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Psychology

The most effective way to diagnose chronic alcoholism is to

a) Ask the patient directly if he/she is an alcoholic


b) Obtain a careful history of alcohol intake from the patient
c) Inquire about problems resulting from drinking
d) Confront the patient when he/she is intoxicated
The correct answer is C

Explanation
Because denial is a key aspect of alcoholism, eliciting examples of loss
of control as a consequence of drinking is an effective interview
strategy. Little can be accomplished when the patient is intoxicated.
Which one of the following is the medical treatment of choice for acute
delirium in the intensive care unit?

a) Intravenous haloperidol (Haldol) in increasing doses every 30


minutes as needed
b) Intravenous droperidol (Inapsine) every 6-8 hours
c) Intravenous lorazepam (Ativan)
d) Intramuscular chlorpromazine (Thorazine)
e) Intramuscular diphenhydramine (Benadryl)
The correct answer is A

Explanation
Intravenous haloperidol has been found to be more effective than
lorazepam and has minimal physiologic side effects. Chlorpromazine can
worsen confusion and lower blood pressure. Droperidol can cause
akathisia. Diphenhydramine can increase confusion due to its
anticholinergic effects.
Once the diagnosis of anorexia nervosa is established, the most
important initial goal of treatment is

a) To prevent the patient from dying from complications of malnutrition


b) To treat the patient’s depression in order to prevent death by suicide
c) To rapidly correct problems with body image and performance-driven
perfectionist behavior, using intense psychotherapy
d) To correct dysfunctional family system dynamics that are at the
heart of the problem, using intense family therapy
The correct answer is A

Explanation
Once the diagnosis of anorexia nervosa is confirmed, the initial goal of
treatment is to prevent death by starvation. Depression, a common
finding in anorexia nervosa, is usually alleviated with nourishment. In
cases that are refractory to proper nutrition, an antidepressant may be
helpful. Psychotherapy, using a combination of behavioral and cognitive
techniques, is an important adjunctive therapy. It begins when the
diagnosis is established and continues after the patient has returned to
normal weight. Family therapy is also recommended in younger patients.
It facilitates recovery in the individual by addressing problems in the
family environment and also often continues for years after the
patient’s return to normal weight.
A 22 year old male presents to the emergency department after taking an
overdose of fluoxetine (Prozac). His symptoms include fever, tremor,
diarrhea, shivering, and sweats. On examinagion the patient has a
temperature of 38.3C (100.9F) is diaphoretic, and is hyperreflexic
with inducible clonus.

Which one of the following is recommended for treatment of this syndrome?

a) Propranolol
b) Bromocriptine
c) Dantrolene
d) Valproate
e) Cyproheptadine
The correct answer is E

Explanation
There are many seratonergic agents that can cause serotonin syndrome,
including SSRIs. The severity of the symptoms varies, and therapy should
be adjusted accordingly. Mild cases, with hyperreflexia and tremor but
no fever, can usually be managed with supportive care, discontinuation
of the precipitating drugs, and benzodiazepines. Moderately ill patients
should have all cardiorespiratory and thermal abnormalities aggressively
corrected, and may benefit from a 5-HT2A antagonist such as
cyproheptadine. Hyperthermic patients (temperature >41.1C) are severely
ill and should receive all of these treatments, as well as immediate
sedation, neuromuscular paralysis, and orotracheal intubation.

Propranolol, a 5-HT1A antagonist with a long duration of action, may


cause hypotension and shock in patients with autonomic instability.
Furthermore, propranolol can eliminate tachycardia, which can be used to
determine the duration and effectiveness of therapy. Bromocriptine, a
dopamine antagonist, and dantrolene are not useful therapies; case
reports citing their use probably involved a misdiagnosis of another
condition as the serotonin syndrome. Bromocriptine has actually been
implicated in the development of the serotonin syndrome, as has valproate.
A 50 year old woman with a past history of recurrent major depressive
disorder is currently on a maintenance dose of an antidepressant. She
has been well for the past 2 years. She is complaining to her
psychiatrist about her decreased ability to reach orgasm. Which of the
following medications has most likely caused her anorgasmia?

a) Amitriptyline
b) Bupropion
c) Mirtazapine
d) Nefazodone
e) Paroxetine
The correct answer is E

Explanation
Paroxetine, along with other selective serotonin reuptake inhibitors,
can cause decreased libido and difficulties reaching orgasm. In studies,
the incidence of these side effects was 1% to 2% in patients on
paroxetine, compared with those on placebo.
An anxious and agitated 18 year old white male presents to your office
with a 2 hour history of severe muscle spasms in the neck and back. He
was seen 2 days ago in a local emergency department with symptoms of
gastroenteritis, treated with intravenous fluids, and sent home with a
prescription for prochlorperazine /Compazine) suppositories. The best
therapy for this problem is intravenous administration of

a) Benztropine
b) Hydroxyzine
c) Haloperidol (Haldol)
d) Succinylcholine
e) Carbamazepine (Tegretol)

The correct answer is A

Explanation
While rarely life threatening, an acute dystonic reaction can be
frightening and painful to the patient and confusing to the treating
physician who may be unaware of what medications the patient is taking.
Dystonia can be cause by any agent that blocks dopamine, including
prochlorperazine, metoclopramide, and typical neuroleptic agents such as
haloperidol.

The treatment is to discontinue the offending agent. For the relief of


an acute dystonic reaction, 1-2 mg of benztropine mesylate may be given
IV, followed by 1-2 mg orally twice daily to prevent recurrence.
Which of the following defense mechanisms is used in borderline
personality disorder?

a) Splitting
b) Reaction formation
c) Displacement
d) Avoidance
The correct answer is A

Explanation
Splitting, is a way to divide the world in "all good" "all bad". It is a
black and white way to see the world without "grey". Splitting is one of
the defense mechanism used.

Black-or-white, all-or-nothing perceptions or thinking, in which people


are divided into all-good idealized saviors or all-bad evildoers.

Such patients will avoid the discomfort of feeling ambivalent (ie,


having loving and angry feelings for the same person) uncertainty and
helplessness. This defense mechanism is typical of borderline
personality disorder.
A 68-year-old man is asked to reproduce the face to a clock correctly,
demonstrating the hours from 1 to 12. Which one of the following
neuropsychiatric disorders is most consistent with his drawing?
a) Subcortical dementia and parkinsonism
b) Schizophrenia
c) Attention deficit disorder
d) Pseudodementia of depression
e) Multiple sclerosis
The correct answer is A

Explanation
Poor planning and perseveration with micrographia are most consistent
with a subcortical dementing process and parkinsonism.
Which of the following have not been beneficial in treating tardive
dyskinesia?

a) Clozapine
b) Vitamin E
c) Propranolol
d) Haloperidol
e) Tetrabenazine
The correct answer is D

Explanation
Haloperidol may mask the dyskinetic movements associated with TD, but
ultimately this relatively pure D2 blocking agent will worsen the
condition. There is no universally effective treatment for TD, but the
atypical antipsychotic clozapine with serotonergic and D4 affinities has
been helpful for some individuals with TD. Some patients who have had TD
for a short duration benefit from the antioxidant vitamin E. Propranolol
as a beta blocking agent and tetrabenazine as a monoamine depleting
agent have been helpful.
A 20 year old white male states that he was physically abused by his
natural parents, and as a result of running away from home on several
occasions was placed in a series of foster homes. His schooling was
sporadic, and he was frequently in trouble for truancy, vandalism,
initiating fights, and stealing. He dropped out of school at the age of
16, and during that year he was arrested for car theft and driving while
intoxicated. He has not worked at any job for more than 6 months, and
has had frequent changes of address due to failure to pay rent and other
financial obligations. He brags that he has fathered three children by
three different women, but has not provided any support of many any
contact with any of them since their pregnancies. IQ testing is normal
and there is no history of a psychotic break. The most accurate
diagnosis of this patient’s condition is

a) Borderline personality disorder


b) Unipolar manic disorder
c) Antisocial personality disorder
d) Abused child reaction formation
e) Schizotypal personality disorder with psychoactive substance abuse
The correct answer is C

Explanation
This patient meets the criteria for antisocial personality disorder,
including age over 18, evidence of conduct disorder in childhood; a
pattern of irresponsible and antisocial behavior since age 15, and
absence of schizophrenia or manic episodes. Although the patient has
some features of borderline personality disorder, such as unstable
relationships, the persistently aggressive nature and lack of remorse
are much more typical of antisocial personality. Although the boasting
quality of the patient might appear somewhat grandiose, there are no
other features to suggest mania. Abused child reaction formation is not
a recognized diagnosis in the Diagnostic and Statistical Manual of
Mental Disorders. Schizotypial personality disorder is not usually
associated with such pervasive antisocial behavior and violence.
A 56 year old woman presents with sudden onset of aphasia. Considering
the possibility of conversion disorder, which aspect of her history is
least likely to be helpful in confirming the diagnosis’

a) Childhood history of stammering


b) History of previous episodes of conversion disorder
c) History of recent stress
d) History of recent onset of sexual dysfunction
e) Family history of conversion disorder
The correct answer is A

Explanation
Conversion disorder consists of symptoms or deficits that develop
unconsciously and nonvolitionally and usually involve motor or sensory
function. Manifestations resemble a neurologic or other general medical
condition but rarely conform to known pathophysiologic mechanisms or
anatomic pathways. Onset and maintenance of conversion symptoms are
typically attributed to mental factors, such as stress.

Diagnosis is based on history after excluding physical disorders.


Treatment begins by establishing a consistent, supportive
physician-patient relationship; psychotherapy can help, as may hypnosis
or drug-facilitated interviews.
A 6-month-old Hispanic female has had itching and irritability for 4-5
weeks. There is a family history of atopy and asthma. Physical
examination reveals an excoriated dry rash bilaterally over the
antecubital and popliteal fossae, as well as some involvement of the
face. In addition to maintenance therapy with an emollient, which one of
the following topical medications would be appropriate first-line
treatment for flare-ups in this patient?

a) A calcineurin inhibitor such as pimecrolimus (Elidel)


b) An anesthetic
c) An antihistamine
d) An antibiotic
e) A corticosteroid
The correct answer is E

Explanation
This child has atopic dermatitis (eczema). It is manifested by a
pruritic rash on the face and/or extensor surfaces of the arms and/or
legs, especially in children. There often is a family history of atopy
or allergies. In addition to the regular use of emollients, the mainstay
of maintenance therapy, topical corticosteroids have been shown to be
the best first-line treatment for flare-ups of atopic dermatitis.
Topical calcineurin inhibitors should be second-line treatment for
flare-ups, but are not recommended for use in children under 2 years of
age. Antibiotics should be reserved for the treatment of acutely
infected lesions. There is no evidence to support the use of topical
anesthetics or analgesics in the treatment of this disorder.
n agitated 30 year old businessman is brought to the ER by two police
officers.

The patient was trying to get into the governor’s residence and when the
security guards made an attempt to stop him, he was combative and tried
to attack them. When asked about his behavior, he replies “I found the
solution for the Middle East crisis; I am so excited to tell the
governor and Mr. President about it”. The patient is very talkative, his
speech is pressured and jumps from one idea to the other rapidly.

His past medical history is non contributory. Physical exam is within


normal limits except for irritability as the patient feels that you are
wasting his time and there is nothing wrong with him. Lab tests,
including a urine toxicology screen, are normal.

Which of the following is the most likely diagnosis of this patient?

a) Bipolar type I
b) Bipolar type II
c) Cyclocythmia
d) Dysthymia
e) Schizophrenia
The correct answer is A

Explanation
Only one acute attack of mania is enough for the diagnosis of bipolar
disorder type I. An acute manic attack is characterized by an abnormally
elevated and irritable mood for more than 1 week. Mania is often
accompanied by *D*istractibility, *D*ecreased need for sleep,
*I*ncreased energy, *I*ncreased self esteem, *G*randiosity, *F*light of
ideas, *A*gitation, hyper-*S*exuality and *T*alkativeness “remember the
famous mnemonic *DIG FAST*”

Bipolar disorder type II is characterized by the presence of hypomania


and major depression.

Dysthymia is a chronic depressive state for more than 2 years.

Cyclothymia is a slow cycling between hypomania and depressed mood for


more than 2 years.

Schizophrenia is characterized by hallucinations, bizarre delusions,


disorganized behavior and speech for more than 6 months.
A 41 year old man reports that he washes his hands 50 times a day. In
the evening, he will check the doors, windows, and stove at least a
dozen times before retiring for the night. Which one of the following is
the most likely diagnosis’
a) Paranoid disorder
b) Paranoid schizophrenia
c) Schizotypal personality disorder
d) Obsessive-compulsive disorder
e) Presenile dementia
The correct answer is D

Explanation
Obsessive-compulsive disorder (OCD) is characterized by
anxiety-provoking ideas, images, or impulses (obsessions) and by urges
(compulsions) to do something that will lessen that anxiety. The cause
is unknown.

Typically, affected people feel compelled to perform repetitive,


purposeful rituals to balance their obsessions, as in the following:

Washing balances contamination, checking balances doubt, hoarding


balances loss, avoiding people who may provoke them balances fear of
behaving aggressively.

Most rituals, such as hand washing or checking locks, are observable,


but some rituals, such as repetitive counting or statements muttered
under the breath, are not.

Diagnosis is based on history. Treatment consists of psychotherapy, drug


therapy, or, especially in severe cases, both.

A 23-year-old, otherwise healthy, single woman presents to the emergency


center complaining of an episode of lightheadedness, chest discomfort,
shortness of breath, and trembling, which occurred earlier that morning
and lasted nearly 10 minutes. This is the first episode of these
symptoms, but she is very fearful that it will happen again. Each of
the following psychiatric conditions are commonly associated with her
symptoms EXCEPT:

a) Agoraphobia
b) Depression
c) Avoidant personality
d) Substance abuse
e) Mania
The correct answer is E

Explanation
Mania. Comorbid psychiatric conditions exist in the majority of patients
with panic disorders. The most frequent is agoraphobia. Depression may
precede or follow the onset of a panic disorder, but mania and bipolar
disorder has no particular association. A variety of “cluster C”
personality disorders, including avoidant, dependent, and
obsessive-compulsive personality, are associated with panic disorder. A
variety of drugs, including stimulants, can precipitate a panic episode.
A 32 year old woman has a history of general anxiety disorder. Which one
of the following medications is she most likely to develop a physical
dependence to?

a) Trazodone
b) Hydroxyzine
c) Diazepam
d) Venlafaxine
e) Sertraline
The correct answer is C

Explanation
Generalized anxiety disorder is characterized by excessive, almost daily
anxiety and worry for > 6 months about many activities or events. The
cause is unknown, although it commonly coexists in people who have
alcohol abuse, major depression, or panic disorder. Diagnosis is based
on history and physical examination. Treatment is psychotherapy, drug
therapy, or both.

Certain antidepressants, including SSRIs are effective but typically


only after being taken for at least a few weeks. Benzodiazepines (eg
Diazepam) in small to moderate doses are also often and more rapidly
effective, although sustained use usually causes physical dependence.
The most appropriate definition of agoraphobia is

a) Fear of being trapped in small confined spaces


b) Fear of spiders
c) Fear of heights
d) Fear of open spaces where it is difficult to escape
The correct answer is D

Explanation
Agoraphobia is a fear of being in places where it may be difficult or
embarrassing to get out quickly or where you may have a panic attack and
can't get help. Commonly feared places and situations are elevators,
sporting events, lines, bridges, public transportation, driving,
shopping malls and airplanes. The fears can be so overwhelming that some
people are essentially trapped in their own homes, it's the only place
they feel truly safe, so they don't venture out into public at all.

The other choices describe claustrophobia, arachnophobia and acrophobia


respectively.
A 36-year-old female with moderate depression desires treatment, but
prefers a plan that does not include pharmacologic therapy. She asks
about cognitive therapy.

Which one of the following statements is true about cognitive treatment


for depression?

a) It is not effective in patients who have not responded to


pharmacologic therapy
b) It is a valid alternative to antidepressants in treating moderate
depression
c) It is not effective in preventing relapse
d) It provides little benefit in treating severe depression
e) It is effective in adults but not in adolescents
The correct answer is b

Explanation
Numerous studies and meta-analyses convincingly demonstrate that
cognitive therapy effectively treats patients with unipolar major
depression. The evidence suggests that it is a valid alternative to
antidepressants for patients with mild to moderate depression and in
combination with antidepressants for patients with more severe
depression. Cognitive therapy is recommended for patients who do not
respond appropriately to medication, and should be considered for
adolescents with mild to moderate depression. Cognitive therapy can
decrease the risk of relapse.
Which one of the following is least likely to cause discontinuation
syndrome if stopped abruptly?

a) Fluoxetine (Prozac)
b) Sertraline (Zoloft)
c) Paroxetine (Paxil)
d) Citalopram (Celexa)
The correct answer is A

Explanation
Stopping an SSRI, or forgetting doses, can cause a discontinuation
syndrome with a range of symptoms including asthenia, anxiety,
agitation, GI distress, myalgias, or a sensation of ‘electrical shocks’
through the arms and legs. The likelihood of the discontinuation
syndrome occurring is inversely proportional to the half-life of the
medication and the presence of active metabolites.

Fluoxetine is the least likely of the drugs to produce a discontinuation


syndrome on abrupt cessation of use, due to both its long half-life (4-6
days) and a long-acting metabolite (t1/2: 4-16 days). Paroxetine has the
shortest half-life (21 h) and therefore is most likely to cause symptoms.

Sertraline and citalopram have intermediate half-lives (26 h and 35 h


respectively) and sertraline has an active metabolite (t1/2: 21/2-41/2).
These agents have an intermediate likelihood of precipitating
discontinuation symptoms.
Neuropsychological effects of hallucinogens may include all of the
following, except

a) Miosis
b) Tremor
c) Hyper-reflexia
d) Uncoordination
e) Blurred vision
The correct answer is A

Explanation
Hallucinogens can produce physiological effects including elevated heart
rate, increased blood pressure, and dilated pupils. These drugs are
often unpredictable and a user may experience different effects compared
to other users or past usage. Users often experience changes in
perception, thought, and mood.
Children of an elderly man who suffers from Alzheimer’s disease are
bothered by his wandering and pacing behaviors. You have started
treatment with a cholinesterase inhibitor, but the behavior persists.
They ask you to prescribe additional drug therapy. You would recommend
which one of the following?

a) No additional drug therapy


b) Risperidone (Risperdal)
c) Citalopram (Celexa)
d) Lorazepam (Ativan)
e) Valproic acid (Depakote)
The correct answer is A

Explanation
Behavioral symptoms such as agitation and wandering become common as
Alzheimer’s disease progresses. Cholinesterase inhibitors may improve
some of these symptoms. If they persist, use of a psychotropic agent may
be necessary. Atypical agents can help control problematic delusions,
hallucinations, severe psychomotor agitation, and combativeness. Typical
agents help control these same problems, but are used more as
second-line therapy in those who do not respond to atypical agents.
Mood-stabilizing drugs can help control these symptoms as well, and may
also be useful alternatives to antipsychotic agents for controlling
severe agitated, repetitive, and combative behaviors. Benzodiazepines
are used to manage insomnia, anxiety, and agitation. Some behaviors,
such as wandering and pacing, are not amenable to drug therapy.
An old man whose wife recently died is brought to you by his daughter.
He is depressed, always crying and telling you that he's already dead
and that his internal organs have been eaten by worms. What is he likely
having?

a) Nihilistic delusion
b) Hallucination
c) Deja vu
d) Hypnopompic delusion
The correct answer is A

Explanation
A nihilistic delusion is a delusion that nothing exists, or that a
significant aspect of the self (such as one's brain or the outside
world) does not exist.

Nihilistic delusions center on the nonexistence of self or parts of


self, others, or the world. A person with this type of delusion may have
the false belief that the world is ending.
In Anorexia Nervosa all of the following are present, except
a) Bradycardia
b) Hypertension
c) Parotid gland hypertrophy
d) Atrophic breast
e) Dental crown
The correct answer is b

Explanation
A refusal to maintain body weight at or above a minimally normal weight
for age and height (usually less than 85% of ideal body weight). Patient
will have an intense fear of gaining weight or becoming fat.

Physical examination may reveal hypothermia, peripheral edema, thinning


hair, and obvious emaciation. Behaviorally, a patient may demonstrate a
flat affect and display psychomotor retardation, especially in the later
stages of the disease.

Vital sign abnormalities may include hypothermia, bradycardia, and


hypotension. Cardiac examination may reveal the mid-systolic click of
mitral valve prolapse. Patients with purging behavior may have parotid
gland hypertrophy, dental enamel erosion and, in extreme cases, seizures
from electrolyte disturbances. Dermatologic examination reveals dry
skin, lanugo (a fine, downy covering of hair on the extremities), and
poor skin turgor.
In a patient taking a selective serotonin reuptake inhibitor (SSRI),
addition of bupropion (Welbutrin) should be considered if the patient
develops with one of the following side effects’

a) Dystonia
b) Nausea
c) Headache
d) Sexual dysfunction
The correct answer is D

Explanation
Antidepressants that inhibit serotoneric reuptake have been reported to
interfere with sexual function. Bupropion is a norepinephrine and
dopamine reuptake inhibitor with essentially no direct serotonergic
activity. Improvement in sexual functioning has been reported when
sustained-release bupropion was either substituted for other
antidepressants or added to a regimen of SSRIs.

Two recent studies have also shown that sustained-release bupropion was
well tolerated in the treatment of sexual dysfunction in non-depressed
women.
The correct answer is D

Explanation
Antidepressants that inhibit serotoneric reuptake have been reported to
interfere with sexual function. Bupropion is a norepinephrine and
dopamine reuptake inhibitor with essentially no direct serotonergic
activity. Improvement in sexual functioning has been reported when
sustained-release bupropion was either substituted for other
antidepressants or added to a regimen of SSRIs.

Two recent studies have also shown that sustained-release bupropion was
well tolerated in the treatment of sexual dysfunction in non-depressed
women.
The correct answer is A

Explanation
Buspirone is indicated for the treatment of anxiety. Its advantages
include the absence of addictive potential and sedation: like
antidepressants, the onset of benefit is often delayed for several
weeks. However, it is not an established antidepressant. Its use with
other agents for depression has yielded questionable benefit, and used
alone it is not an effective therapy for depression.

The other agents listed have both antidepressant and antianxiety effects
and were originally marketed for their antidepressant effect.
Nortriptyline shares the risks of tricyclic agents, but historically it
was one of the better tolerated tricyclics. The newer agents have
serotonin-norepinephrine reuptake inhibition (SSRI activity). They have
shown benefit in the treatment of anxiety as well as depression.

Postpartum depression may be distinguished from the ‘baby blues’ by


which one of the following characteristics’

a) Episodes of crying
b) Feelings of sadness
c) Irritability
d) Anxiety
e) Duration of symptoms
The correct answer is E

Explanation
Crying, sadness, and confusion are common to both postpartum depression
and ‘baby blues’. ‘Baby blues’ usually lasts for 1-2 weeks post partum,
not long enough for antidepressants to work. Postpartum depression lasts
for months, and may not be evident for up to a month after delivery.
A 19 year old male college student is brought to your office in a state
of agitation. He claims that people have been calling him a homosexual,
even though his best friend, who brought him in, states he is not aware
of that. Although he has been attending classes, his academic
performance has been poor for the past several months. He admits he
cannot focus and does not try hard since his new 'friends' told him his
purpose in life was to keep close contact between aliens and humans. On
examination, he is found to be well-oriented in all spheres. Memory and
immediate recall are good. This clinical picture is most compatible with
which one of the following?

a) Alcoholic hallucinosis
b) Schizophrenia
c) Phencyclidine intoxication
d) Marijuana intoxication
e) Adolescent turmoil
The correct answer is b

Explanation
Schizophrenia is characterized by psychosis (loss of contact with
reality), hallucinations (false perceptions), delusions (false beliefs),
disorganized speech and behavior, flattened affect (restricted range of
emotions), cognitive deficits (impaired reasoning and problem solving),
and occupational and social dysfunction.

The cause is unknown, but evidence for a genetic component is strong.


Stressors may be primarily biochemical (eg, substance abuse, especially
marijuana) or social (eg, becoming unemployed or impoverished, leaving
home for college, breaking off a romantic relationship, joining the
Armed Forces). Symptoms usually begin in adolescence or early adulthood.
One or more episodes of symptoms must last > 6 months before the
diagnosis is made. Treatment consists of drug therapy, psychotherapy,
and rehabilitation.
Psychic structure that relate desire to external environment is

a) ID
b) Ego
c) Superego
d) Self
e) Personality
The correct answer is b

Explanation
In Sigmund Freud’s psychoanalytic theory of personality, personality is
composed of three elements known as the id, the ego, and the superego,
that work together to create complex human behaviors.

The “id” is the only component of personality that is present from


birth. This aspect of personality is entirely unconscious and includes
of the instinctive and primitive behaviors.

The “ego” operates based on the reality principle, which strives to


satisfy the id's desires in realistic and socially appropriate ways.

The “superego” is the aspect of personality that holds all of our


internalized moral standards and ideals that we acquire from both
parents and society, our sense of right and wrong.
A 26 year old man is brought to the emergency department by his family
because he says that he is being followed by gangsters and that they are
going to kill him. Temperature is 37.8°C (100.0°F), pulse is 110/min and
blood pressure is 160/95 mm Hg. His pupils are dilated. The remainder of
the physical examination is normal. The family states that he has a
history of drug abuse. Which of the following drugs most likely caused
this reaction?

a) Alcohol
b) Cocaine
c) Diazepam
d) Heroin
The correct answer is b

Explanation
This patient shows symptoms of paranoia and sympathetic stimulation.
Common symptoms of cocaine use include the classic ones associated with
sympathetic stimulation, such as tachycardia, hypertension, mydriasis,
and sweating. Paranoia, suspiciousness, and psychosis may occur with
prolonged use.

Although at low levels alcohol induces some behavioral stimulation, it


is a CNS depressant. Occasionally chronic alcohol use induces paranoia,
but dementia and memory loss are more common symptoms.

Diazepam, sold under the trade name Valium, is commonly prescribed as an


antianxiety drug or muscle relaxant, and does not produce the symptoms
noted. Heroin, like most opioids, is also a CNS depressant, and symptoms
associated with its use include drowsiness, slurred speech, memory
impairment, occasional perceptual disturbances, and pinpoint pupils.
Of the following, which one is the most effective treatment for bulimia
nervosa?

a) Fluoxetine (Prozac)
b) Buspirone (BuSpar)
c) Prochlorperazine (Compazine)
d) Omeprazole (Prilosec)
e) Metoclopramide (Reglan)
The correct answer is A

Explanation
A number of placebo-controlled, double-blind trials have demonstrated
the effectiveness of a variety of antidepressants in the treatment of
bulimia nervosa. Fluoxetine has FDA approval for this indication. The
other agents are not used for treating bulimia.
Which of the following would you typically not find in anorexia nervosa?

a) Hyperthermia
b) Bradycardia
c) Hypotension
d) Lanugo hair
e) Cachetic appearance
The correct answer is A

Explanation
Anorexia nervosa is characterized by a relentless pursuit of thinness, a
morbid fear of obesity, a refusal to maintain a minimally normal body
weight, and, in women, amenorrhea.

Common physical findings include bradycardia, low BP, hypothermia,


lanugo hair or slight hirsutism, and edema. Even patients who appear
cachectic tend to remain very active (including pursuing vigorous
exercise programs), are free of symptoms of nutritional deficiencies,
and have no unusual susceptibility to infections.

Diagnosis is clinical. Treatment is with cognitive-behavioral therapy;


olanzapine may help with weight gain, and SSRIs, especially fluoxetine,
may help prevent relapse.
A 52 year old woman who has had low back pain for several years is
admitted to the hospital because the pain has suddenly worsened. Her
current medications include oxycodone, amitriptyline, perphenazine,
fluoxetine and trazodone. On physical examination, the patient is 10%
below her ideal body weight, pupils are constricted and skin turgor is
poor. She seems sluggish and her speech is slow. Results of neurologic
examination and x-ray films of the lumbosacral spine are normal. If a
medication is responsible for her mental condition, the medication is
most likely to be which of the following?

a) Amitriptyline
b) Fluoxetine
c) Oxycodone
d) Perphenazine
e) Trazodone
The correct answer is C

Explanation
The question gives you the classic sign of opiate use: constricted
pupils. Prolonged use of opiates may also induce depression.
Amitriptyline can cause weight gain, and does not cause pupil
constriction. Fluoxetine may result in mild weight loss of two to five
pounds, but does not cause pupil constriction. Neither perphenazine nor
trazodone cause pupillary constriction.
A 60 year old female patient comes in with a complaint of multiple
episodes of abnormally elevated energy levels and sudden mood changes in
one week, followed by one or more depressive episodes, the next week.
According to this description, you think she is suffering from bipolar
disorder. A number of reasons exist to obtain all of the following
laboratory studies,*except*

a) Substance and alcohol screen


b) Electrolytes
c) MRI
d) CBC
e) VDRL test
The correct answer is C

Explanation
CBC count with differential: This test is used to rule out anemia as a
cause of depression.

Electrolytes: This test is used to diagnose electrolyte problems,


especially with sodium, that are related to depression. Hyponatremia,
ie, low sodium can manifest as a depression. Treatment with lithium can
lead to renal problems and electrolyte problems.

A number of infections, especially chronic infections, can produce a


presentation of depression in the patient. Any of the encephalitides can
dramatically manifest as changes in mental status.
HIV test: AIDS causes changes in mental status, including dementia and
depression.
VDRL test: Syphilis, especially in its later stage, alters mental status.

Substance and alcohol screen: Alcohol abuse and abuse of a wide variety
of drugs can present as either mania or depression. For example, speed
(ie, amphetamines) and cocaine abuse can present as a manialike
disorder, and barbiturate abuse can present as a depressionlike disorder.

The total value of performing an MRI in a patient with bipolar disorder


remains unclear.
You have diagnosed tardive dyskinesia in a 72 year old white female with
schizophrenia. She resides in a nursing home and has been treated with
haloperidol (Haldol), 1 mg twice a day, for 5 years. She also has a
hiatal hernia. Which one of the following statements is true regarding
this patient?

a) The chances of symptoms remission after withdrawal of the


haloperidol are better than for a younger patient
b) Quickly reducing the dosage of haloperidol will lead to prompt
worsening of her tardive dyskinesia
c) Long-term metoclopramide (Reglan) would bet the best treatment for
her hiatal hernia
d) Risperidone (Risperidal) would be most likely than haloperidol to
cause tardive dyskinesia
The correct answer is b

Explanation
Symptom remission is more likely to occur after neuoleptic withdrawal in
young patients than in the elderly. Tardive dyskinesia is initially
exacerbated by a reduction in neuroleptic dosage, and dyskinesias
decrease following an increase in the dosage. Metoclopramide has been
shown to cause tardive dyskinesia with long-term treatment, and
therefore would not be the best drug for the patient’ hiatal hernia.
There is no convincing evidence that any of the traditional
antipsychotic drugs is less likely to produce tardive dyskinesia than
any other, but the newer atypical agents such as clozapine, risperidone,
and olanzapine offer some hope for a reduced incidence.
Piaget’s preoperational thought stage of development includes all of the
following EXCEPT:

a) Development of symbolic functions


b) Use of language
c) Deductive reasoning
d) Egocentrism
e) Observational learning
The correct answer is C

Explanation
Deductive reasoning is developed during the later adolescent years
during the formal operations stage. Preoperational development typically
occurs in the pre-school years and also includes thinking by intuition
and differentiation between signs and symbols.
A 27 year old man is brought to the emergency department by his wife
because he has been vomiting for the past 24 hours. He has used
prochlorperazine suppositories for relief of nausea and vomiting. He now
has severe muscle spasms in his neck. On physical examination there is
sustained spasm of the sternocleidomastoid and trapezius muscles with
twisting of his head to the right. Which of the following is the most
appropriate pharmacotherapy at this time?

a) Chlorzoxazone
b) Dantrolene
c) Diazepam
d) Diphenhydramine
e) Methocarbamol
The correct answer is D

Explanation
The trick to this question is recognizing that that prochlorperazine is
a directive of the antipsychotic medications (neuroleptics) such as
chlorpromazine, thioridazine, and fluphenazine. Thus, it is capable of
causing similar dystonic reactions, including sustained twisting of the
head to the right (torticollis), impaired breathing (laryngospasm), and
eyes deviated up, down, or sideways (oculogyric crisis).
Diphenhydramine, 25-50 mg given intramuscularly, will relieve the
symptoms of a dystonic reaction.
The focus of dialectical behavioral therapy (DBT) for patients with a
borderline personality disorder includes each of the following EXCEPT:

a) Accepting the patients the way they are while trying to teach them
to change
b) Encompassing cognitive and behavioral therapy approaches
c) Identifying alternative responses to stressful events
d) Uncovering unconscious conflicts
e) Skills training in the areas of interpersonal effectiveness and
emotional regulation
The correct answer is D

Explanation
Uncovering unconscious conflicts is a component of psychoanalytic or
psychodynamic psychotherapy. DBI is a more practical type of therapy
developed by Marsha Linehan and her colleagues aimed at reducing
inappropriate behaviors and teaching skills to handle surges of emotion.
Strategies include teaching the patient to do a chain analysis of what
led up to an identified problematic event and identifying what
alternatives could have been taken to avoid the event. Both individual
and classroom group scenarios are utilized in DBT.
Hypertensive encephalopathy is a serious complication of treatment with

a) Phenothiazines
b) Tricyclic antidepressants
c) Lithium carbonate
d) MAOI antidepressants
e) Benzodiazepines
The correct answer is D
Explanation
The most common cause of hypertensive encephalopathy is abrupt blood
pressure elevation in the chronically hypertensive patient. Other
conditions predisposing a patient to elevated blood pressure can cause
the same clinical situation. For example, ingestion of
tyramine-containing foods or tricyclic antidepressants in combination
with monoamine oxidase inhibitors (MAOIs).
A 35 year old female complains that her nose is too large, even after
having cosmetic surgery on her nose three times. She has a minimal
social life because of her concern about the appearance of her nose. A
physical examination, including her appearance, is normal.

a) Social phobia
b) Obsessive-compulsive disorder
c) Delusional disorder
d) Body dysmorphic disorder
The correct answer is D

Explanation
The diagnostic criterion for body dysmorphic disorder is preoccupation
with an imagined defect in appearance which causes significant distress
of impairment in social, occupational, or other areas of function, and
which is not better accounted for by another disorder.
Obsessive-compulsive disorder, delusional disorder, and social phobia
may accompany body dysmorphic disorder, but the history given is not
specific for these disorders. Also, these disorders do not include
preoccupation with a physical defect in their diagnostic criteria.
Regarding the epidemiology of attention deficit hyperactivity disorder
(ADHD) all of the following are true EXCEPT:

a) DSM-IV prevalence rates are in the 3%-5% range for school age children
b) Male to female sex ratio of 1:3
c) High rate of comorbidity for other psychiatric disorders
d) Risk factors of lower socioeconomic status
e) High incidence of alcoholism as adults
The correct answer is b

Explanation
ADHD is far more common in boys than girls, with a sex ratio of
approximately 3:1. Although prevalence rates can be affected by changing
the threshold number and severity of symptoms, most experts agree on the
3-5% range. Comorbid psychiatric conditions may include conduct,
oppositional, and anxiety disorders. Half of Tourette’s patients have
comorbid ADHD which usually precedes the tics. Many with ADHD later
develop alcohol and drug problems.
The initial management of a bipolar patient in the manic phase could
include all of the following, except

a) Lamotrigine
b) Low-stimulation environment
c) Valproate
d) Lithium carbonate
e) Electroconvulsive therapy
The correct answer is E

Explanation
Bipolar disorders are characterized by mania and depression, which
usually alternate. Exact cause is unknown, but heredity, changes in the
level of brain neurotransmitters, and psychosocial factors may be
involved. Diagnosis is based on history. Treatment consists of drugs (eg
lithium, neuroleptics), sometimes with psychotherapy. The first-line
drugs for treating a manic episode during the acute phase are lithium
and valproate. The newer anticonvulsants (lamotrigine, gabapentin, and
topiramate) are often best reserved as back-up medications to add to
firstline medications for mania, or to use instead of the first-line
group if there have been difficult side effects.
ECT is not indicated in the initial management of bipolar disorder.
A 25 year old woman with a several year history of binging and purging
presents to a psychiatrist complaining of a lack of energy, poor sleep,
and decreased ability to concentrate. She is very concerned about weight
gain. Which of the following medications would be the most appropriate
to initiate?

a) Bupropion
b) Fluoxetine
c) Haloperidol
d) Lithium carbonate
e) Valproic acid
The correct answer is b

Explanation
This patient appears to have symptoms of major depression in the context
of bulimia. She should therefore be treated with an antidepressant
medication, and a selective serotonin reuptake inhibitor (SSRI), such as
fluoxetine, would be most appropriate.

A nurse with a known psychiatric history has multiple ER visits for


hypoglycemia. Upon measurements she is found to have a normal C-peptide
level. What is the most likely reason?

a) Exogenous insulin administration


b) Increase in endogenous insulin
c) Pancreatic tumor
d) Drug interaction
The correct answer is A

Explanation
This is likely a case of self administration of insulin to purposely
create hypoglycemia for the sake of hospital visits and admissions. The
fact that she is a nurse suggests that she may have easier access to
such drugs.

This is known as munchausen syndrome, a severe and chronic form of


factitious disorder, consists of repeated production of feigned physical
symptoms without an external incentive; the motivation for this behavior
is to assume the sick role. Symptoms are usually acute, dramatic, and
convincing and are accompanied by a tendency to wander from one
physician or hospital to another for treatment.

The exact cause is unknown, although stress and borderline personality


disorder are often implicated.
Which one of the following populations is at greatest risk of completed
suicide?

a) Males over 45 years of age


b) Females over 45 years of age
c) Females under 14 years of age
d) Females age 14 to 18
e) Males age 14 to 18
The correct answer is A

Explanation
Men > 75 years have the highest rate of death by suicide. Among all age
groups, male deaths by suicide outnumber female deaths by 4:1. About 3
females attempt suicide for every male that makes an attempt.

Risk factors and warning signs for a potential completed suicide


include: male sex, age > 65 years, previous suicide attempt, making
detailed suicide plans, taking steps to implement plan (obtaining gun,
pills), taking precautions against being discovered, personally
significant anniversaries, family history of suicide or of affective
disorder, unemployment or financial difficulties, particularly if
causing a drastic fall in economic status, recent separation, divorce,
or widowhood and social isolation with real or imagined unsympathetic
attitude of relatives or friends.
A 43 year old male patient presenting with hallucinations and delusions
was prescribed chlorpromazine. He woke up early in the morning with
acute hyperpyrexia, rigidity and confusion. Three hours later he became
unconscious and did not respond to painful stimuli. What is the most
likely diagnosis’

a) Acute dystonias
b) Serotonin syndrome
c) Seizure
d) Tardive dyskinesia
e) Neuroleptic malignant syndrome
The correct answer is E

Explanation
Neuroleptic malignant syndrome (NMS) refers to the combination of
hyperthermia, rigidity, and autonomic dysregulation that can occur as a
serious complication of the use of antipsychotic drugs. Criteria for the
diagnosis of neuroleptic malignant syndrome are based on clinical
features. Cardinal features are the development of severe muscular
rigidity, hyperthermia, autonomic instability, and changes in the level
of consciousness associated with the use of an antipsychotic medication.
Which one of the following benzodiazepines has the shortest half-life?
a) Nitrazepam
b) Alprazolam (Xanax)
c) Clorazepate (Tranxene)
d) Diazepam (Valium)
e) Clonazepam (Klonopin)
The correct answer is b

Explanation
Alprazolam (Xanax) has a half-life of about 12 hours, versus 25 hours
for clonazepam and nitrazepam and 50 hours for clorazepate, and diazepam.
A 17 year old girl presents to the ER. On exam she has pinpoint pupils
and abnormal behavior. What is the most appropriate test to order at
this time?

a) Urine drug test


b) CT head scan
c) BHCG
d) Psych consult
The correct answer is A

Explanation
This teenage girl is likely abusing drugs, in particular heroin.

Opioids have many effects. They are strong sedating drugs and cause
people to become quiet and introspective. Opioids may also produce
euphoria, sometimes simply because severe pain has finally been
relieved. The dull pain may enhance sexual pleasure.

They also cause constipation, flushed or warm skin and lowered blood
pressure, itching, constricted pupils, slow, shallow breathing, a slow
heart rate, and low body temperature. Opioids may cause confusion,
especially in older people.

Many complications can arise from opioid addiction, especially if the


drugs are injected with shared unsterilized needles. For example, viral
hepatitis, which causes liver damage, can be spread through shared
needles. Infections can occur at the site of injection or be carried
through the bloodstream (sepsis), causing infections in the brain and bones.

A 45-year-old man is evaluated for insomnia and anxiety. He dates the


onset of his symptoms to one year ago, when he received a concussion in
a car accident while working. In spite of a normal MRI scan of his brain
taken on the day of the accident, he has suffered from headaches,
dizziness, difficulty concentrating, poor memory, fatigue, insomnia,
anxiety, and depressed mood. Once asleep, he frequently awakens with
nightmares about the accident. He feels ‘jumpy’, and is short-tempered
with his wife and coworkers. Driving, especially, is an ordeal for him,
making him feel tense and irritable. He has missed six months of work in
the past year because of these symptoms. Which of the following
diagnoses would be the LEAST likely?
a) Post-traumatic stress disorder
b) Post-concussional disorder
c) Malingering
d) Acute stress disorder
e) Chronic subdural hematoma
The correct answer is D

Explanation
Acute stress disorder is similar to post-traumatic stress disorder, but
by DSM-IV definition, lasts a maximum of 4 weeks.

A & B. With this history, the patient meets criteria for both
post-traumatic stress disorder and post-concussional disorder as
proposed by DSM-IV. The latter diagnosis is recognized by most
neurologists and is believed to be attributable to diffuse microscopic
shearing injuries to axons, which show up better on post-mortem
dissection specimens than they do on MRI.
C. Unfortunately, more so than with most injuries, one must consider
malingering when assessing work-related injuries.
E. Subdural hematoma may take weeks to accumulate after head injuries,
and thus may not show up on brain imaging done at the time of the accident.

A 49 year old male is diagnosed with Obsessive-Compulsive Disorder.


Which of the following is considered the first line treatment for this
patient?

a) Clonazepam
b) Clomipramine
c) Haloperidol
d) Venlafaxine
e) Phenelzine
The correct answer is b

Explanation
Selective Serotonin Reuptake Inhibitors represent the first-line
treatment for OCD.
The two medications proven to be most effective in the treatment of OCD
are tricyclic antidepressants (TCAs) and selective serotonin reuptake
inhibitors (SSRIs). Serotonin is a chemical in the brain called a
neurotransmitter that may be imbalanced in people with OCD.

While both drugs are very effective, SSRIs have generally become the
preferred medication for anxiety disorders, including OCD. SSRIs have
less side effects than other forms of antidepressants, less withdrawal
symptoms, less danger in the event of an overdose and overall are
considered safer that other types of drugs (TCAs and SSRIs are both very
safe drugs, however). Common SSRIs include fluoxetine (Prozac),
fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), citalopram
(Celexa), and escitalopram (Lexapro).

There are other drugs that can be used to treat OCD, or even to augment
SSRIs and TCAs. These drugs include monoamine oxidase inhibitors (MAOIs)
and atypical antidepressants. (MAOIs are not to be combined with SSRIs.)
A - benzodiazepine
C - antipsychotic
D - SNRI
E - MAOI

Which one of the following is a clinical feature of somatization disorder?

a) Onset in middle age


b) A history of multiple surgical operations
c) An organized, precise presentation of the medical history
d) A generally well-adjusted individual
e) An organic etiology for most complaints
The correct answer is b

Explanation
The clinical features of somatization disorder include an onset in the
teens or 20s, multiple unexplained symptoms, frequent concurrent
psychiatric symptoms, drug and alcohol abuse, dramatic and emotional
presentations, a history of multiple surgical operations, and providing
imprecise and often inaccurate medical histories.
A 60 year old female patient comes in with a complaint of multiple
episodes of abnormally elevated energy levels and sudden mood changes in
one week, followed by one or more depressive episodes, the next week.
According to this description, the most likely diagnosis is bipolar
disorder and she is started on lithium. Which of the following could be
caused by this medication?

a) Hyperthyroidism
b) Decreased WBC count
c) EKG changes
d) Decrease in TSH
e) Decrease in BUN and creatinine
The correct answer is C

Explanation
Treatment with lithium may cause:
> a reversible increase in the WBC count.
> renal problems and electrolyte problems. Low sodium levels can lead to
higher lithium levels and lithium toxicity. Hence, in screening
candidates for lithium therapy as well as those on lithium therapy,
checking electrolytes is indicated.
> hypothyroidism.
> can affect urinary clearances, and serum creatinine and BUN can
increase. Therefore, carefully and regularly monitor these levels.
> can lead to changes such as reversible flattening or inversion of T waves.

Electroconvulsive therapy (ECT) is a treatment in which one of the


following conditions’

a) Obsessive compulsive disorder


b) Paranoid schizophrenia
c) Generalized anxiety disorder
d) Acute mania
e) Major depression with psychotic features
The correct answer is E

Explanation
Electroconvulsive therapy (ECT) is indicated in severe suicidal
depression, depression with agitation or psychomotor retardation, or
depression during pregnancy is often treated with ECT if drugs are
ineffective. Patients who have stopped eating may need ECT to prevent
death. ECT is also effective for psychotic depression. Response to 6 to
10 ECT treatments is usually dramatic and may be lifesaving. Relapse
after ECT is common, and drug therapy is often maintained after ECT is
stopped.

A 51-year-old healthy female sees you for a routine examination. On a


screening questionnaire she reports having two alcoholic drinks per day
on average, but never more than three drinks on any occasion. She denies
problems or symptoms associated with alcohol use.

To reduce the risk of this patient suffering adverse effects from


alcohol use you should

a) refer her to Alcoholics Anonymous


b) prescribe naltrexone (ReVia)
c) advise her to quit drinking
d) inform her that her pattern represents at-risk drinking
The correct answer is D

Explanation
A brief intervention is a short-term counseling intervention based on
motivational interviewing techniques. It is designed to reduce at-risk
or problem drinking. The Public Health Service, Preventive Services Task
Force, and the Society of Addiction Medicine define at-risk drinking for
women (and all those over 65 years of age) as more than seven drinks per
week or more than three drinks per occasion. For men, at-risk drinking
is defined as more than 14 drinks per week or more than four drinks per
occasion.

A referral to Alcoholics Anonymous or prescribing naltrexone would be


more appropriate for an alcohol-dependent person, which this patient is not.
Which one of the following is a major advantage of second-generation
(atypical) antipsychotics compared with first-generation antipsychotics’

a) Less tardive dyskinesia


b) Less monitoring for major side effects
c) The availability of deport (intramuscular) formulations
d) Lower cost
e) Simpler dosing schedules
The correct answer is A

Explanation
A recent expert consensus panel endorsed the use of second-generation
antipsychotics rather than first-generation drugs. Tardive dyskinesia is
much less common with the use of second-generation antipsychotics.
Several of the second-generation drugs require monitoring for major side
effects, however. For example, clozapine, shown by studies to be the
most efficacious of the new class, causes granulocytopenia or
agranulocytosis, requiring weekly and later biweekly monitoring of blood
counts. Both classes have depot formulations for intramuscular
administration every 2-4 weeks. Oral dosing of drugs from both classes
varies from 1 to 3 times daily. First-generation antipsychotics cost
less than second-generation drugs.
A 4 year old boy, is found to be checking and playing with his genitals
more often than before. Which of the following stages of Freud’s
psychosexual development is this child in?

a) Oral phase
b) Anal phase
c) Phallic phase
d) Latency phase
e) Genital phase
The correct answer is C

Explanation
The concept of psychosexual development, developed by Sigmund Freud at
the end of the nineteenth, consists of five separate phases: oral, anal,
phallic, latency, and genital. Here is an explanation of each phase:

Oral phase: occurs at age 0-18 months, involves an obsession with


stimulating the mouth. A child in this age category will likely want to
put anything in their mouth.

Anal phase: occurs at age 18-36 months, in which a child's pleasure and
conflict centers are in the anal area. This stage is exemplified by a
toddler's pleasure in controlling his or her bowels.

Phallic phase: occurs at age 3-6 years, when awareness of and


manipulation of the genitals is supposed to be a primary source of pleasure.

Latency phase: occurs at 6 years-puberty, the child begins to make


connections to siblings, other children, and adults.

Genital phase: occurs at puberty and beyond, allowing the child to


develop opposite sex relationships with the libidinal energy again
focused on the genital area.

A 32 year old man with schizophrenia is brought to the hospital by his


sister because he has become incoherent and locks himself in his room
for days at a time. His family is concerned because he has tried many
antipsychotic agents and none of them seem to have worked. Physical
examination is normal. He is placed on clozapine and scheduled for a
visit to the clinic in 1 week. One week later, he arrives at the clinic
for his appointment. Which of the following is the most appropriate test
at this time?

a) Complete blood count


b) Electroencephalogram
c) Electrocardiogram
d) Prolactin levels
e) Thyroid-stimulating hormone levels
The correct answer is A

Explanation
Clozapine is an atypical antipsychotic that may produce agranulocytosis,
requiring weekly monitoring of the CBC. Clozapine blocks both dopamine
and serotonin receptors and causes only minimal extrapyramidal side
effects. It is effective in treating the negative symptoms of
schizophrenia and is often used in treatment-resistant cases. In
addition to causing agranulocytosis (1% incidence), clozapine therapy
has a 5-10% incidence of seizures, but weekly EEGs are not performed. It
does not increase the prolactin level.
Clozapine is the neuroleptic of choice for schizophrenia when

a) The patient shows no evidence of tardive dyskinesia


b) The patient has not improved with conventional antipsychotics
antipsychotics

c) The patient is under fifteen years of age


d) The patient has a WBC count of >10 000
e) The patient is very sensitive to anticholinergic side effects
The correct answer is b

Explanation
Second-generation antipsychotics - SGA’s (eg Clozapine) act by blocking
both dopamine and serotonin receptors (serotonin-dopamine receptor
antagonists). SGAs tend to alleviate positive symptoms; may lessen
negative symptoms to a greater extent than do conventional
antipsychotics (although such differences have been questioned); may
cause less cognitive blunting; are less likely to cause extrapyramidal
(motor) adverse effects; have a lower risk of causing tardive
dyskinesia; and for some SGAs produce little or no elevation of prolactin.

Clozapine is the only SGA demonstrated to be effective in up to 50% of


patients resistant to conventional antipsychotics. Clozapine reduces
negative symptoms, produces few or no motor adverse effects, and has
minimal risk of causing tardive dyskinesia, but it produces other
adverse effects, including sedation, hypotension, tachycardia, weight
gain, type 2 diabetes, and increased salivation. It also may cause
seizures in a dose-dependent fashion. The most serious adverse effect is
agranulocytosis, which can occur in about 1% of patients. Consequently,
frequent monitoring of WBCs is required, and clozapine is generally
reserved for patients who have responded inadequately to other drugs.
Which of the following treatment interventions would be LEAST likely to
alleviate panic symptoms’

a) Decrease her caffeine intake


b) Paroxetine
c) Amitryptyline
d) Haloperidol
e) Alprazolam
The correct answer is D

Explanation
Haloperidol is an antipsychotic with dopamine antagonist properties.
Paroxetine and amitryptyline are both serotonergic agents very helpful
in preventing panic episodes, as is the potent benzodiazepine
alprazolam. The patients should abstain from stimulants like caffeine.

Dysfunction within the pictured darkened areas of the brain are


associated with which psychiatric disturbance?

a) Short-term memory impairment


b) Remote memory impairment
c) Anomia
d) Attention deficits
e) Emotional disturbance
The correct answer is E

Explanation
The darkened areas represent the cortical components of the limbic
system. The common features shared by limbic system. The common feature
shared by limbic system dysfunction is an emotional disturbance.
Psychosis, mood disorders, obsessive-compulsive behavior, personality
alternations, and disturbances of sexual behavior are linked to limbic
system dysfunction.
Which one of the following statements regarding antidepressant drug
therapy is true?

a) The response rate to most antidepressants is 90%-95%


b) Patients unimproved after 2 weeks should receive a different drug
c) Patients unresponsive after 6 weeks should have their treatment altered
d) Patients unresponsive to one class of drugs are unlikely to respond
to another class
e) In patients who have not improved after 6 weeks of drug therapy,
depression is unlikely to be the cause of their symptoms
The correct answer is C

Explanation
An adequate trial of antidepressant therapy is 4-6 weeks. Patients who
are unresponsive to treatment may respond to another antidepressant with
a different mechanism of action. Patients who are partially responsive
may benefit from dosage titration or the addition of a second
antidepressant in combination. Electroconvulsive therapy is the most
effective treatment in patients with severe resistance to medical
antidepressant therapy of those with psychotic depression.
A 45 year old business executive with advanced cirrhosis of the liver
and a history of alcohol abuse says that he drinks only because of the
constant nagging of his wife. This is an example of which of the
following defense mechanisms’
a) Rationalization
b) Repression
c) Sublimation
d) Reaction formation
e) Intellectualization
The correct answer is A

Explanation
Offering a socially acceptable and apparently more or less logical
explanation for an act or decision actually produced by unconscious
impulses. The person rationalizing is not intentionally inventing a
story to fool someone else, but instead is misleading self as well as
the listener. Examples: a man buys a new car, having convinced himself
that his older car won't make it through the winter. A woman with a
closet full of dresses buys a new one because she doesn't have anything
to wear.
Of the following antidepressants, which one is least likely to cause
drug interactions’

a) Citalopram (Celexa)
b) Fluoxetine (Prozac)
c) Paroxetine (Paxil)
d) Mirtazapine (Remeron)
The correct answer is A

Explanation
Like all drugs, SSRIs have significant side effects, including
inhibition of the cytochrome P-450 system. However, citalopram is least
likely to inhibit this system, making it a preferred SSRI for patients
taking multiple medications for other illnesses.
A patient who has been placed on an antipsychotic drug for schizophrenia
develops symptoms of tardive dyskinesia. He has lip smacking and tongue
protrusion and muscular movements of his face. What is the treatment for
this side effect?

a) Give a beta blocker


b) Give an anticholinergic
c) Give a benzodiazepine
d) Stop the antipsychotic drug
The correct answer is D

Explanation
The side effects of antipsychotic medications are as follows:

Parkinsonism: involves tremor, increased muscle tone, bradykinesia or


akinesia, drooling, postural instability, loss of spontaneity,
micrographia, seborrhea.
Treatment of this side effect: Lower dose or change to low-potency or
atypical agent. Add anticholinergic agent.

Akathisia: motor restlessness accompanied by a feeling of inner


restlessness (sometimes described as anxiety), an urge to move, and an
inability to sit still, patients may pace or continuously move their
feet and legs.
Treatment of this side effect: Lower dose. Add benzodiazepine or beta
blocker.

Dystonia: sustained contraction of muscles, twisting postures and may be


visible only when the patient is moving. Neck and arm muscles are most
commonly affected.
Treatment of this side effect: Add anticholinergic agent or
antihistamine. Lower dose or change to low-potency or atypical agent.

Tardive dyskinesia: hyperkinesia, involuntary body movements most often


of the muscles of the face, mouth, and tongue.
Treatment of this side effect: Lower dose or discontinue agent or change
to low-potency or atypical agent.
Which of the following statements about attention deficit and
hyperactivity disorders (ADHD) is incorrect?

a) ADHD is more commonly seen in boys than girls


b) Deafness and seizure disorders must be excluded before the diagnosis
of ADHD is made
c) Three characteristic features of ADHD are inattention,
hyperactivity, and mental retardation
d) Ritalin is effective in the treatment of about 70% of cases of ADHD
e) Side effects of Ritalin include poor growth, insomnia, and tics
The correct answer is C

Explanation
Symptoms of attention-deficit/hyperactivity disorder (ADHD) are present
in as many as 9 percent of school-age children. ADHD-specific
questionnaires can help determine whether children meet diagnostic
criteria for the disorder. The recommended evaluation also includes
documenting the type and severity of ADHD symptoms, verifying the
presence of normal vision and hearing, screening for comorbid
psychologic conditions, reviewing the child's developmental history and
school performance, and applying objective measures of cognitive function.

The stimulants methylphenidate (Ritalin) and dextroamphetamine remain


the pharmacologic agents of first choice for the management of ADHD.
These agents are equally effective in improving the core symptoms of the
disorder, but individual children may respond better to one stimulant
medication than to another. Achievement of maximal benefit may require
titration of the initial dosage and dosing before breakfast, before
lunch and in the afternoon.

Mental retardation is not a component of ADHD.


A patient with a fear of heights is brought to the top of a tall
building and required to remain there as long as necessary for the
anxiety to dissipate. This is an example of

a) Graded exposure
b) Participant modelling
c) Positive reinforcement
d) Flooding
e) Relationship therapy
The correct answer is D

Explanation
Flooding is a psychotherapeutic technique used to help patients heal
their traumatic memories. It works by exposing the patient to their
painful memories, with the goal of reintegrating their repressed
emotions with their current awareness.

'Flooding' is an effective form of treatment for phobias amongst other


psychopathologies. It works on the behaviourist principles of classical
conditioning. According to classical conditioning we learn through
associations so if we have a phobia it is because we associate the
feared object or stimulus with something negative.

If we were using flooding to treat a phobia we would expose a person to


vast amounts of the feared stimulus. Example, if a person was scared of
spiders we might lock them in a room full of spiders. The idea is that
whilst a person will be initially very anxious, the body cannot stay
anxious forever. When nothing bad happens the person will begin to calm
down and so from that moment on associate a feeling of calm with the
previously feared object.
A 61 year old man who manages his own accounting firm has a 5 year
history of malignant melanoma that has been treated with local excision
and immunotherapy. He now is admitted to the hospital for evaluation of
constant pain in his back and left hip and an 11 kg (24 lb) weight loss.
He and his wife of 35 years are worried that "the cancer may be back."
Pelvic and abdominal CT scans show multiple bony metastases. He tells
you, "I just want to die. I can't bear this." Which of the following
symptoms would be most suggestive of a major depressive syndrome in this
patient?

a) Anorexia
b) Expressions of discouragement
c) Insomnia
d) Low energy
e) Withdrawal from family
The correct answer is E

Explanation
There is no question that anorexia, expressions of discouragement,
insomnia, and low energy are symptoms of depression. Expressions of
discouragement are less intense than the hopelessness seen in major
depression. However, as patients become more depressed, they cling even
tighter to the family for support, and become more dependent on them,
making withdrawal from the family more significant. In addition,
anorexia, insomnia, and low energy may be secondary to the malignant
melanoma. As the support of family members is the mainstay of most
terminally ill patients, withdrawal from this support would be strong
evidence of depression, or possibly even of suicidal intent. All of the
rest are either appropriate behaviors or could be the side effects of
the disease or treatment, such as low energy, insomnia, or anorexia.
Which one of the following statements concerning insomnia is correct

a) There is little correlation between insomnia and depression


b) Daytime drowsiness, excessive snoring, and confusion if awakened
from sleep are associated with restless legs syndrome
c) Getting up at the same time every day can increase the restfulness
of sleep
d) Patients must take hypnotic drugs for a prolonged period to cure
insomnia
e) Insomnia rarely occurs in the elderly
The correct answer is C

Explanation
Getting up at the same time every day stabilizes the sleep-wake schedule
and improves the restfulness of actual sleep in bed. Insomnia is more
prevalent among the elderly and is associated with depression. Daytime
drowsiness, excessive snoring, and confusion when awakened are
associated with sleep apnea. Hypnotics should be prescribed only for
short-term use.
A 32 year old female with a history of depression presents with
restlessness, nausea and unstable vital signs. She was recently switched
from citalopram (SSRI) to phenelzine (MAOI). On examination her blood
pressure is 140/90 mmHg and she is tachycardic and tachypneic. Her
neurological examination is normal aside from hyperreflexia and
myoclonous. What is the most likely diagnosis’

a) Neuroleptic malignant syndrome


b) Serotonin syndrome
c) Akathisia
d) Hypertensive crisis
e) SSRI withdrawal
The correct answer is b

Explanation
The most common severe adverse effect associated with SSRIs is the
development of serotonin syndrome. This syndrome was first described in
patients treated with MAOIs who were given other drugs that enhance
serotonergic activity. However, ingestion of an MAOI is not required for
this syndrome to develop, and its development is unpredictable.

Drug interactions resulting in serotonin syndrome can occur while


switching serotonergic pharmacologic agents when an insufficient time
lag occurs before initiating the alternative therapy. Residual
pharmacologic effect, receptor downregulation or upregulation, and the
presence of active metabolites may be causative in these circumstances.

Symptoms of serotonin syndrome include altered mental status, agitation,


myoclonus, hyperreflexia, diaphoresis, tremor, diarrhea, incoordination,
muscle rigidity, and hyperthermia. The clinical manifestations of
serotonin syndrome are diverse, and minor manifestations are common
after initiation of SSRI and atypical antidepressant therapy.
Differential Diagnosis of the Serotonin Syndrome from the Neuroleptic
Malignant Syndrome: In addition to the associated medications, the time
courses of the two syndromes are substantially different. Signs and
symptoms of the serotonin syndrome develop within minutes to hours after
exposure to the offending agents, whereas NMS typically develops days to
weeks after daily exposure to the drug in question. In addition, after
symptoms develop and offending drugs are discontinued, NMS can last for
as long as 2 weeks, whereas the serotonin syndrome usually resolves
quickly, coinciding with the offending drug's pharmacokinetic
metabolism. A review of the literature indicates that patients
presenting with serotonin syndrome were more likely to exhibit
agitation, hyperactivity, clonus and myoclonus, ocular oscillations,
shivering, tremors, and hyperreflexia, whereas patients presenting with
NMS were more likely to exhibit bradykinesia and lead pipe rigidity.
Which one of the graphed curves best reflects the relationship between
clinical response and the plasma levels for nortriptyline?

a) Curvilinear
b) Sigmoidal
c) Straight line
d) None of the above
e) All of the above
The correct answer is A

Explanation
There is a curvilinear relationship between clinical response and
nortriptyline plasma levels. The clinical response increases with the
plasma level but plateaus in the 50-150 ng/ml range. This range is
called the therapeutic window. The decreased clinical response above 150
ng/ml is not due to side effects.
A 43-year-old female seeks treatment for depression, which has begun to
seriously interfere with her ability to function. Her only other medical
condition is hypertension.

Which one of the following antidepressants would be most likely to


exacerbate her hypertension?

a) Escitalopram (Lexapro)
b) Bupropion (Wellbutrin)
c) Venlafaxine (Effexor)
d) Duloxetine (Cymbalta)
e) Mirtazapine (Remeron)
The correct answer is C

Explanation
Of all of the antidepressants, only venlafaxine is known to exacerbate
hypertension, and would therefore be a poor choice for this patient.
Erotomania is a psychiatric syndrome which includes each of the
following features EXCEPT:

a) A subtype of the broader DSM-IV classification delusional disorders


b) The attraction to another person is purely sexual
c) Is more common in females in clinical settings
d) May escalate to violence when there is perceived rejection
The correct answer is b

Explanation
The central theme of erotomania is a delusional belief that another
person is in love with them in an idealized, romantic way rather than a
pure sexual attraction. Most mental health experts believe erotomania is
underdiagnosed because people with this condition do not seek
psychiatric treatment. Stalking behavior can occur in erotomania.
Violence is more common in males with erotomania and occurs more
frequently when there are multiple objects of the delusional fixation
and a history of antisocial behavior. The erotomaniac stalks to gain the
idealized relationship and can react violently when the delusional
beliefs are threatened.

All of the following drugs cause depression as a side effect, except

a) Prednisone
b) Warfarin
c) Cimetidine
d) Propranolol
The correct answer is b

Explanation
A very long list of medicines cause depression as a side effect. Some of
those medicines are:

Anticholinergics - A group of medicines used to relieve cramps or spasms


of the stomach, intestines, and bladder. Examples include Bentyl, Levbid
and Symax.
Corticosteroids - A group of medicines that decrease inflammation
(swelling) and reduce the activity of the immune system (cells that
fight infection). Examples include Prednisone, hydrocortisone and
triamcinolone.
Cyclosporine - A drug used to suppress the immune system to prevent the
rejection of transplanted organs.
Propanolol - A medicine used to treat high blood pressure.
Cimetidine - This drug is used to prevent and treat ulcers, heartburn,
acid indigestion, and sour stomach.
Antabuse - A medicine used to treat alcoholism.
Synthroid - A drug commonly prescribed as a thyroid hormone replacement.
Ritalin - This drug is used to treat attention-deficit hyperactivity
disorder (ADHD).
Opioids - A group of narcotics used to relieve moderate to severe pain.
These drugs have a high potential for abuse and addiction. Examples
include codeine, morphine, Demerol, Darvocet and Percodan.
Yohimbine - A drug used to treat male impotence.

Warfarin does not have depression as part of its side effect profile. It
does have the following side effects: bleeding and necrosis (gangrene)
of the skin, rash, hair loss, bloating, diarrhea, and jaundice.
A 23-year-old unemployed female who is four months pregnant is brought
to an emergency room by police after they had found her standing on a
bridge over a freeway threatening to jump. She tells the doctor that for
the last six weeks she has felt severely anxious and depressed, waking
in the early hours of the morning. She has not eaten or drunk for four
days because she is extremely worried that demons have poisoned her food
and water. She admits to frequent use of IV heroin and cocaine until
four weeks ago. She is dehydrated and disheveled, wearing soiled
clothing and displays considerable psychomotor retardation. Which of the
following is the MOST appropriate treatment option to initiate at this time?

a) Clonazepam, 0.5 mg tid


b) Electroconvulsive therapy
c) Carbamazepine, 200 mg bid
d) Intensive cognitive-behavioral therapy
e) Intensive chemical-dependency treatment
The correct answer is b

Explanation
Electroconvulsive therapy (ECT) is considered by many clinicians to be
the treatment of choice for severely depressed pregnant women,
especially if they are putting themselves and their fetus at high risk
by refusing oral intake. ECT is also considered to be particularly
effective for psychotic depression, for patients who are acutely
suicidal, and for patients with marked psychomotor agitation or
retardation.

A. This would be likely to worsen the patient’s psychomotor retardation.


It would also interfere with ECT, because of its anticonvulsant activity.
C. This is inappropriate for the same reason as clonazepam.
Additionally, both carbamazepine and clonazepam are known teratogens.
D & E. A patient this ill is not likely to be able to participate in
these therapies. They would be useful as part of her continuing care,
however.
Which one of the following is associated with an increased risk of
developing Alzheimer’s disease?

a) A positive homozygous genotype for apolipoprotein E4


b) Elevated serum aluminum
c) Elevated serum alpha-tocopherol
d) Decreased serum Beta-carotene
e) A low-fiber diet
The correct answer is A

Explanation
Recent genetic work has demonstrated a high risk for the development of
Alzheimer’s disease in patients with the apolipoprotein E4 genotype.
Other predictors of the disease have been elusive. Serum aluminum is not
predictive, although higher than normal brain aluminum levels have been
studied for many years. Eating a low-fiber diet has no known
correlation, and serum levels of Beta-carotene and vitamin E are not
useful for predicting the development of Alzheimer’s disease, although
supplementation is considered helpful by some sources.
The most frequently reported side effect of tricyclic antidepressants is
a) Peripheral neuropathy
b) Photosensitivity
c) Agranulocytosis
d) Jaundice
e) Dry mouth
The correct answer is E

Explanation
Physicians use tricyclic antidepressants in the treatment of severe
depression or depression that occurs with anxiety. Several also have
broad anti-obsessional and anti-panic effects.

The anticholinergic effects of dry mouth, blurred vision, constipation,


and difficulty in urination, postural hypotension, tachycardia, loss of
sex drive, erectile failure, increased sensitivity to the sun, weight
gain, sedation (sleepiness), increased sweating.
A 43 year old male patient presenting with hallucinations and delusions
was prescribed chlorpromazine, a phenothizine derivative for reduction
of the positive symptoms of schizophrenia. What is its mechanism of
action as an antipsychotic?

a) Blockade of serotonin receptors


b) Acts as histamine receptors agonist.
c) Blockade of dopamine receptors
d) Blockade of insulin receptors
e) Acts as an adrenergic receptors agonist.
The correct answer is C

Explanation
Chlorpromazine is an aliphatic phenothiazine antipsychotic which blocks
postsynaptic mesolimbic dopaminergic receptors in the brain. Basically,
it is a dopamine inhibitor, increases dopamine turnover in the brain,
and stimulates prolactin release.

Chlorpromazine works on a variety of receptors in the central nervous


system, producing anticholinergic, antidopaminergic, antihistaminic, and
weak antiadrenergic effects.

Alcohol-induced amnestic disorder is associated with each of the


following EXCEPT:

a) Also known as Korsakoff’s syndrome


b) Related to thiamine deficiency
c) Associated with diffuse brain lesions of the prefrontal cortex
d) Usually picked up with a mental status examination
e) May result in permanent psychosis
The correct answer is C

Explanation
At autopsy, patients with Korsakoff's syndrome show hemorrhage and
sclerosis of the mammillary bodies and thalamic nuclei along with
diffuse lesions of the brain stem, cerebellum and limbic system.
Thiamine treatment is usually successful in treating this condition,
which can be diagnosed clinically by the presence of cognitive deficits
and confabulation. One-fourth of patients with this condition remain
impaired chronically.
A 45 year old business executive with advanced cirrhosis of the liver
and a history of alcohol abuse claims that he does not have a problem
with drinking and can quit any time he wants to. Eventually he quits
drinking but continues to have the symptoms of advanced cirrhosis of the
liver. Despite the obvious discomfort caused by his illness, he tells
everyone how happy he is to have cirrhosis because it has led to the
cessation of his drinking. The defense mechanism he is using is best
identified as

a) Projection
b) Denial
c) Counterphobic behaviour
d) Reaction formation
e) Isolation of affect
The correct answer is D

Explanation
Reaction formation involves going to the opposite extreme;
overcompensation for unacceptable impulses. Examples include: a man
violently dislikes an employee; without being aware of doing so, he
"bends overbackwards" to not criticize the employee and gives him
special privileges and advances. Another example is a married woman who
is disturbed by feeling attracted to one of her husband's friends treats
him rudely.

Intentional efforts to compensate for conscious dislikes and prejudices


are sometimes analogous to this mechanism.
In most patients, anti-depressant treatment should be carried on for how
long a period of time?

a) 2 weeks
b) 6 weeks
c) 9 months
d) Indefinite time
The correct answer is C

Explanation
Anti-depressant medications usually for 2-6 weeks at a therapeutic dose
level are needed to observe a clinical response. After this period
patients will continue to take the medicines until symptoms have
completely resolved.

Most physicians will likely suggest that you take your antidepressants
for at least 6-12 months, even after you feel better. Most patients may
be able to discontinue their antidepressant medications without relapse,
therefore life long use may not be necessary.
A depressed patient is most likely to commit suicide when
a) The depression is most profound
b) The patient is starting to recover from the depression
c) The patient receives bad news or a disappointment
d) The patient becomes physically ill
e) The patient has completed a course of electroconvulsive treatments
The correct answer is b

Explanation
Experts believe there’s an association between early recovery and
increased likelihood of suicide. As depression begins to lift, a
person's energy and planning capabilities may return before the suicidal
thoughts disappear, increasing the chances of a suicide attempt. Studies
show that the period six to 12 months after hospitalization is when
patients are most likely to consider, or reconsider, suicide.

A 32-year-old female singer in a rock group is evaluated for “mood


Swings”. She says that her mood has gone from the “depths of blackness”
to “floating on air with happiness” and back several times a day every
day for the past twenty years. She also complains of constant anxiety,
which is relieved only when she is performing on stage. She denies any
history of substance abuse. She has had an extensive number of
relationships with men, none lasting more than a few months. She brags
about her ability to get men to buy her whatever she wants. On
examination, she wearing heavy make-up and a low-cut shirt, and refers
to the doctor as ‘honey’. Her affect is labile, shifting rapidly from
tears to laughter and back. What is the most likely diagnosis’

a) Histrionic personality disorder


b) Narcissistic personality disorder
c) Borderline personality disorder
d) Bipolar I disorder
e) Substance abuse
The correct answer is A

Explanation
The attention-seeking behavior of patients with histrionic personality
disorder manifests in a number of ways: through exaggerated displays of
emotion, use of dramatic expressions in speech, use of their physical
appearance to draw attention to themselves, and inappropriate
familiarity and seductiveness. Because they are uncomfortable in
situations where they are not the center of attention, they sometimes
gravitate toward the entertainment industry.

B. Patients with narcissistic personality disorder share histrionic


Patients’ need for admiration, but their presentation is dominated by a
grandiose sense of self-importance.
C. Borderline personality disorder is also notable for affective
instability and dramatic, unstable relationships, but identity
disturbance is a key feature and the characteristic affect displayed is
one of inappropriate anger.
D. Many psychiatrists would consider this patient to have a bipolar
spectrum illness because of her mood lability. However, the bipolar I
diagnosis rests on the presence of a history of a full-blown manic
episode, a seven-day period of elevated or irritable mood, along with
symptoms of neurovegetative disturbance.
E. Substance abuse is possible despite her denial. However, the history
overall is characteristic for histrionic personality disorder, so that
remains the most likely diagnosis.
Which one of the following is the leading risk factor for delirium?

a) Alcohol abuse
b) Depression
c) Dementia
d) Malnutrition
e) Stroke
The correct answer is C

Explanation
The cause of delirium is typically multifactorial. The development of
delirium involves the complex interaction between the vulnerable patient
(one with predisposing factors) and exposure to precipitating factors.

Delirium affects 10%-30% of hospitalized patients who are medically ill.


The prevalence is even higher in certain subgroups. For example, 25% of
hospitalized patients with cancer, 30%-40% of hospitalized patients with
HIV infection, and more than 50% of postoperative patients develop
delirium during hospitalization. Among nursing-home residents older than
75, up to 60% may have delirium at any time.

Dementia is the leading risk factor for delirium, and fully two-thirds
of delirium cases occur in patients with dementia. The underlying
vulnerability of the brain in patients with dementia may predispose them
to the development of delirium as a result of insults related to acute
medical illnesses, medications, or environmental changes.

Unless the physician recognizes that dementia is a risk factor for


delirium, the confusion and agitation associated with delirium can
mistakenly be attributed to preexisting dementia. This can lead to a
failure to search for underlying medical conditions or to discontinue
medications that may be causing the delirium.

The most appropriate initial pharmacologic treatment of panic disorder is

a) An SSRI
b) A tricyclic antidepressant
c) Valproic acid (Depakene)
d) Lithium
The correct answer is A

Explanation An SSRI is the treatment of choice for patients who have


never had pharmacolotherapy for panic disorder.
An initial episode of depression has responded to pharmacologic
treatment. Treatment should be continued for a minimum of

a) 1 month
b) 2 months
c) 6 months
d) 12 months
e) 24 months
The correct answer is C

Explanation Pharmacologic treatment of depression should last for a


minimum of 6 months after an initial episode.
In the emergency room you are asked to assess a 67 year old man with
alcoholic cirrhosis and recent alcohol cessation. He is agitated,
confused and hallucinating. You make a presumptive diagnosis of delirium
tremens. What is the best treatment for his condition?

a) Diazepam
b) Nitrazepam
c) Chlordiazepoxide
d) Lorazepam
e) Clonazepam
The correct answer is D

Explanation
Delirium tremens (DT), a very serious set of symptoms, may result if
alcohol withdrawal is left untreated. Delirium tremens usually does not
begin immediately; rather, it appears about 2 to 10 days after the
drinking stops. In delirium tremens, the person is initially anxious and
later develops increasing confusion, sleeplessness, nightmares,
excessive sweating, and profound depression. The pulse rate tends to
speed up. Fever typically develops.

DT is treated with benzodiazepines. Among the benzodiazepines, diazepam


offers the most rapid time to peak clinical effects, which limits
oversedation that may occur following the administration of drugs with
slower onset to the peak drug effect, such as lorazepam. Because of the
delayed peak clinical effect of lorazepam of approximately 10-20
minutes, several doses may be administered in rapid succession with
little clinical effect, followed by the appearance of the sedative
effect of the cumulative doses.

If >65 years old or severe liver disease, severe asthma, or respiratory


failure are present, use short acting benzodiazepine - lorazepam PO/SL/IM.
Each of the following statements about tobacco use is true EXCEPT:

a) 55% of the population experiment with tobacco


b) The mesolimbic system is involved in the reinforcing effects of nicotine
c) 30% of smokers succeed in quitting smoking
d) Smoking is more common among depressed patients
e) Genetic influences predispose to smoking persistence
The correct answer is C

Explanation
Only 2-3% of dependent smokers succeed in quitting smoking. Tobacco use
for many is a classical addictive disorder with the behavior pattern of
compulsive drug use despite adverse psychosocial and health
consequences. Dopamine is the key neurotransmitter of the mesolimbic
system reinforced by nicotine stimulation. Some research suggests that
the effects of nicotine may have similar results to antidepressants.
This may explain the shared benefit of cessation. Both genetic and
environmental factors are important to develop regular tobacco use.
Those who persist smoking have a .70 genetic predisposition.
A homeless 30 year old man dressed in tattered clothes is brought into
the Emergency Room by police after he was found haranguing passersby.
Which one of the following is most suggestive of psychosis’

a) Hyper-religiosity and ascetic living habits


b) Rumination about the meaninglessness of material things
c) A belief that his thoughts are controlled via secret television
d) Disorientation to time and place
e) An unfounded suspicion that others are plotting against the government
The correct answer is C

Explanation
Psychosis is a loss of contact with reality. Some people with psychosis
have false beliefs that can best be described as fearfulness and
suspiciousness (paranoia). They may have vague fears or complaints about
others controlling their lives, but many describe consistent suspicions
of very specific, elaborate, and persistent plots against them. Very
often, these beliefs are directed at family members or friends. For
example, people with psychosis may believe that their spouse or children
have deserted them or that their family or friends are scheming to
obtain control of their finances or property.

Hallucinations”seeing or hearing things that no one else sees or


Hears”are sometimes experienced by people with psychosis. These
hallucinations may seem dangerous and threatening to the person,
although in some cases they are taken in stride.

People with psychosis may lose the ability to take care of their
personal hygiene. They may seem withdrawn and without any emotions.
However, when a psychotic disorder, such as paraphrenia, develops during
old age, it is common for a person to communicate and function quite
well despite delusions or hallucinations.
A 40-year-old man presents with problems remembering things at work. His
children have told him that they find themselves having to repeat
information in conversations with him. He has never had memory problems
before but has had a stressful year since the death of his father. He is
an otherwise very healthy man. He has had loss of appetite, insomnia,
and a lot of guilt concerning his father’s death from a stroke. What is
the most likely cause of this patient’s memory problems’

a) Vascular dementia
b) Alzheimer's dementia
c) Encephalopathy
d) Pseudodementia of depression
e) None of the above
The correct answer is D

Explanation
This patient, who has no known medical problems and is exhibiting
symptoms of depression, is likely having memory problems as a result of
a mood disorder. If concentration is impaired by a mood disorder, the
patient will have difficulty getting new information into his or her
short-term memory. This results in information not making it into
long-term memory. Treatment of his mood should resolve his memory problems.

A. Though his father had a stroke, this is an unlikely cause due to his
age and the absence of other physical findings.
B. This is a diagnosis of exclusion that requires a mood component to be
ruled out, as well as other possible causes of dementia.
C. No medical conditions are present to support this.
A patient with previously-known psychiatric disorder is admitted after
multiple physical trauma, with impending hypovolemic shock and violent
behavior. He refuses all treatments. Initial treatment is to

a) Wait for shock to develop further, then commence aggressive treatment


b) Sedate and medicate to a level of patient compliance and treat
c) Obtain a psychiatric opinion before any intervention
d) Certify insanity quickly and administer chlorpromazine
e) Commence immediate treatment, using restraints if necessary
The correct answer is E

Explanation
The competent patient has the right to refuse treatment to the extent
permitted by law, and to be informed of the medical consequence of
his/her decision. However if the patient is not competent (eg
psychiatric disorder) it is the physicians duty to treat, especially in
an emergency situation.
A patient with depression would like to switch her current medicine, an
MAOI to an SSRI. What is the most appropriate way to do this’

a) Stop the MAOI and start the SSRI after 2 weeks


b) Stop the MAOI then start the SSRI the next day
c) Start the SSRI now then 2 weeks later stop the MAOI
d) Start the SSRI now then 1 day later stop the MAOI
The correct answer is A

Explanation
Serotonin syndrome is a condition characterized by dangerously high
levels of serotonin in your body. It occurs when you take certain
combinations of prescription medications that affect serotonin levels.

Signs and symptoms of serotonin syndrome range from restlessness and


rapid heartbeat to muscle rigidity and seizures. These go away quickly
with treatment, which may include discontinuing use of the medications
causing the symptoms along with taking other drugs such as muscle
relaxants and serotonin-production blocking agents. If not treated
quickly, serotonin syndrome can become life-threatening.

Serotonin syndrome generally occurs when you take multiple drugs that
affect serotonin levels in your body. In particular, taking a selective
serotonin reuptake inhibitor (SSRI) along with triptans, a class of
migraine medications, may cause the condition, potentially raising
serotonin to dangerous levels.

However, serotonin syndrome can also occur when you start a single new
drug that affects serotonin levels or when you take an increased dose of
such a drug that you've previously used.

Therefore it is recommended that when changing from an MAOI to an SSRI,


a two week gap should be allowed before starting the SSRI.
A 4 year old boy is brought to the office because he has become
unmanageable at his day-care center. He constantly interrupted
situations, seeking his mother's attention. She now reports that during
the past few months his fighting, refusal to obey the day-care workers
and violations of "time out" have become much worse. The boy has a
6-month-old sister who also attends the same day-care center. The most
likely cause for this child's worsening behavior is

a) Aggressiveness to compensate for a poor self-image caused by short


stature
b) Attention-deficit/hyperactivity disorder
c) A reaction to his father's drinking
d) Reduction in his mother's attention because of his new sibling
e) A toxic reaction to organic fumes from his father's clothes and work
materials
The correct answer is D

Explanation
This question inquires about what may have caused the behavior to worsen
in the “past few months”. A stressor coinciding with the changes in
behavior would be most likely, although numerous stressors may have been
listed. In this case, the birth of the sister six months previously
corresponds to the worsening in the behavior. The needy infant competes
for already scarce attention with the four-year-old boy.

A 38 year old woman tells her physician that for several months she has
been experiencing palpitations, dizziness, shortness of breath, a
feeling of impending doom and a fear of dying. Which of the following
would be the most appropriate initial step in managing this patient?

a) Offer psychotherapy
b) Prescribe benzodiazepines
c) Perform a physical examination
d) Refer the patient to a psychiatrist
e) Teach relaxation techniques
The correct answer is C

Explanation
The patient is exhibiting symptoms of panic disorder, which can include
fear of dying, fear of going crazy or of losing control, feelings of
unreality, strangeness, or detachment from the self (depersonalization),
dizziness, unsteady feelings, or faintness, nausea or abdominal
distress, palpitations or accelerated heart rate, sensations of
shortness of breath or smothering and trembling or shaking.

Panic disorder is diagnosed after physical disorders that can mimic


anxiety are eliminated. Therefore a complete physical exam should be
performed on this patient.
A woman who is found unconscious at home is rushed to the ER. A STAT ABG
(arterial blood gas) done shows acidosis and low po2, high pco2. What is
the most likely diagnosis’

a) Acetaminophen poisoning
b) Tricyclic antidepressant poisoning
c) Carbon monoxide poisoning
d) Hyperventilation
The correct answer is b

Explanation
With tricyclic antidepressant (TCA) overdose, symptoms typically occur
within 2 hours of ingestion, which corresponds to the peak tricyclic
antidepressant serum level, which may range from 2-12 hours.

Symptoms include: palpitations, chest pain, hypotension, decreased


mental status and respiratory depression. ABG will show of acidosis and
hypoxia.

Carbon monoxide poisoning and hyperventilation would show an alkalosis


on ABG.
A 40 year old male professional consults you about his recent onset of
depression. He generally feels well, but sometimes feels ‘high and out
of control’. This is followed by significant depression which usually
remits after a long weekend of sleep at his cabin on the lake. He also
complains of persistent nasal congestion and a 10-lb weight loss. His
psychiatric history is negative, but he is suspicious and feels that
people are against him. His mental status otherwise reveals normal
thought content and processes. His physical examination is normal except
for inflamed nares and enlarged nasal turbinates. The most likely
diagnosis is

a) Schizophrenia
b) Generalized anxiety disorder
c) Panic disorder
d) Alcohol abuse
e) Cocaine abuse
The correct answer is E

Explanation
A chronic user of cocaine, like the chronic user of alcohol, does not
always fit the classic description of dependence, and the physician must
therefore consider the diagnosis in all patients with episodic
depression and peculiar mood swings. Organic symptoms are like those of
amphetamine use, mainly hyperpyrexia, tachycardia, and even cardiac
arrhythmias. Routine, continued cocaine ‘snorting? often leads to nasal
mucosal congestion and occasional septal perforation. Paranoid ideation
is sometimes seen with the use of cocaine and other stimulants. The
patient’s age and normal mental status make schizophrenia unlikely.
Panic disorder is not complicated by paranoid behavior.
Patients with which one of the following conditions are at increased
risk for complications from electroconvulsive therapy for depression?

a) Pregnancy
b) Seizure disorder
c) Cardiac pacemaker implantation
d) Depression unresponsive to oral medications
e) Recent cerebral hemorrhage
The correct answer is E

Explanation
There are no absolute contraindications to electroconvulsive therapy
(ECT), but more complications are seen in patients with a history of
recent cerebral hemorrhage, stroke, or increased intracranial pressure.
The efficacy of ECT may be reduced in patients who have not responded to
oral antidepressants.
Psychiatric symptoms associated with multiple sclerosis include each of
the following EXCEPT:

a) Depression
b) Mania
c) Compulsions
d) Reduced information processing
e) Memory impairment
The correct answer is C

Explanation
Compulsions are not particularly associated with MS. Depression is the
most common psychiatric symptom associated with this population, with a
lifetime prevalence of 40-50%. Suicide risk is also elevated. The
coexistance of mania and MS is as high as 13 times what would be
expected in a normal population. Steroid therapy may precipitate manic
episodes, but there is evidence that underlying organic changes in the
brain play a role. Cognitive deficits such as memory impairment, slowed
information processing, and concentration problems become present in
60-70% of MS patients.
A 30-year-old man is admitted to a locked psychiatric unit for
court-ordered treatment, after threatening to kill himself. He gives a
three-week history of irritable mood, sleep fragmentation, high energy,
loss of appetite, a ten pound loss of weight, and racing thoughts. He
states that he has had six episodes like this in the past year. He has a
five-year history of bipolar disorder and is currently taking valproic
acid and paroxetine. On examination, he is restless, his speech is
pressured, and his affect is labile. Which of the following would NOT be
an appropriate intervention at this time?

a) Urine drug screen


b) Stopping the paroxetine
c) Stopping the valproic acid
d) Electroconvulsive therapy
e) Milieu therapy
The correct answer is C

Explanation
The patient is currently having an episode of mania, for which the
treatment of choice is a mood stabilizer, such as valproic acid.
Stopping it would likely worsen his condition. A blood level should be
measured and the dosage optimized. His bipolar disorder is also a rapid
cycling one, defined as four or more episodes of a mood disturbance in
the past year.

A. Despite his known history of bipolar disorder, abuse of illicit drugs


may be playing a role in his current presentation.
B. Antidepressants can initiate mania and they can initiate or worsen
rapid cycling. In manic patients and in most patients with rapid
cycling, they should be discontinued.
D. Studies suggest that ECT may be more effective than medication for
the treatment of mania.
E. Milieu therapy is an important part of inpatient psychiatric
treatment and refers to the use of the hospital environment itself as a
therapeutic intervention. It includes such techniques as behavioral
reinforcement, peer support, and structured scheduling of daily activities.
A 40 year old patient is on an typical antipsychotic drug. She is
started on 20mg once a day. A few weeks later the dose changed to 40mg
once daily. She then reports that she has become agitated, aggressive.
The initial proper management of this is

a) Increase dose of drug


b) Decrease dose of drug
c) Add anticholinergic drug
d) No treatment available, this is irreversible
e) Add propranolol
The correct answer is b

Explanation The following table lists the side effects of


antipsychotic drugs:

Side Effect

Symptoms

Treatment options
Parkinsonism

Tremor, increased muscle tone, bradykinesia or akinesia, drooling,


postural instability, loss of spontaneity, micrographia.

Lower dose
Change to low-potency or atypical agent
Add anticholinergic agent
Akathisia
Restlessness, anxiety

Lower dose
Add benzodiazepine or beta blocker
Dystonia

Sustained muscle contractions

Add anticholinergic agent or antihistamine


Lower dose
Change to low-potency or atypical agent
Tardive dyskinesia

Hyperkinesia, involuntary body movements (usually choreiform)

Lower dose or discontinue agent


Change to low-potency or atypical agent
Raise dose to mask effects

This patient likely has developed akathisia. Patients with akathisia


will be very restless, constantly getting up and then sitting back down,
inability to sit still and anxious feelings. This has been caused
because of increasing her dose and her dose should be lowered. Initially
reduce the dose or the potency of the drug, perhaps considering a newer
(atypical) antipsychotic. If this is of no benefit consider an
anticholinergic drug and if this fails to help, a beta blocker. Next a
trial of a benzodiazepine (diazepam up to 15mg or clonazepam, 0.5-3mg)
should be considered.

A 33 year old man is unable to leave his city to do his business because
of fear. This has affected his job as an executive. What is the most
likely diagnosis’

a) Anxiety disorder with agoraphobia


b) Pseudodementia
c) Depression
d) OCD
The correct answer is A

Explanation
Agoraphobia is fear of and anticipatory anxiety about being trapped in
situations or places without a way to escape easily and without help if
intense anxiety develops. The situations are avoided or they may be
endured but with substantial anxiety. Agoraphobia can occur alone or as
part of panic disorder.

Common examples of situations or places that create fear and anxiety


include standing in line at a bank or at a supermarket checkout, sitting
in the middle of a long row in a theater or classroom, and using public
transportation, such as a bus or an airplane. Some people develop
agoraphobia after a panic attack in a typical agoraphobic situation.
Others simply feel uncomfortable in such a situation and may never or
only later have panic attacks there. Agoraphobia often interferes with
function and, if severe enough, can cause people to become housebound.
In bulimia nervosa all of the following can occur, except

a) Dental caries
b) GI reflux
c) Parotid enlargement
d) Stomach rupture
e) Metabolic acidosis
The correct answer is E

Explanation
Bulimia nervosa is recurrent episodes of binge eating followed by
self-induced vomiting, laxative or diuretic abuse, vigorous exercise, or
fasting.

Patients typically describe binge-purge behavior. Binges involve rapid


consumption of food, especially high-calorie foods, such as ice cream
and cake. Binges vary in amount of food consumed, sometimes involving
thousands of calories. They tend to be episodic, are often triggered by
psychosocial stress, may occur as often as several times a day, and are
carried out in secret.

Most symptoms and physical complications result from purging.


Self-induced vomiting leads to erosion of dental enamel of the front
teeth and to painless salivary gland enlargement. Serious fluid and
electrolyte disturbances, especially hypokalemia and metabolic
alkalosis, occur occasionally due to vomiting potassium and protons.

A 49 year old male presents with depressed mood that has been going on
for 6 months now. He has lost interest in the things he used to enjoy,
feels sleepy all the time and skips work frequently. He admits that this
mood change impairs his ability to function daily. The patient is taking
phenelzine (2 months) but does not see any improvement. You would like
to switch it to paroxetine.
What is the safest way to do it?

a) Stop phenelzine today and start paroxetine


b) Stop phenelzine today and start paroxetine in two weeks.
c) Start paroxetine today - both paroxetine and phenelzine can be
continued concomitantly
d) Full dose of paroxetine can be started today with gradual decrease
of phenelzine
e) Stop phenelzine today and gradually increase the dose of paroxetine
The correct answer is b

Explanation
Before changing the therapy from phenelzine to paroxetine, two weeks
wash out time should be allowed in order to prevent the adverse effects
of serotonin accumulation. If caution is not taken while changing the
anti-depression therapy it may result in serotonin syndrome. Both
phenelzine (MAOI) and paroxetine (SSRI) are serotonin increasing agents;
it results in accumulation of the levels of serotonin, which on the
other hand would increase risk of psychosis.
A 68 year old man with documented alcohol abuse returns to the office
because of abdominal pain and bloating. When you meet with him, he
appears dejected and his eye contact is poor. Physical examination is
normal. Since his last visit, he has moved from the neighborhood where
he had lived for 40 years. In addition, he mentions that approximately 6
months ago breast cancer was diagnosed in his wife; she is currently
receiving radiation therapy for bony metastases. The most important next
step in management of his symptoms is evaluation for

a) Delirium tremens
b) Gastrointestinal bleeding
c) Pancreatic carcinoma
d) Situational anxiety disorder
e) Suicidal ideation
The correct answer is E

Explanation
Notice in this question that you are being informed of numerous
psychosocial stressors for the patient, including growing old, a move
from his home of 40 years, and a potentially terminal illness in his
wife. A question that enumerates a list of life stressors is most often
related to a developing depression and/or suicidal ideation. Suicidal
ideation is consistent with the picture of a depressed patient as
described in this question, namely ‘dejected... .poor eye contact... .’
A patient who is alcohol-intoxicated is 50 times more likely to commit
suicide. The first step in the management of depression is always an
assessment for suicidal ideation.
A patient who is evaluated 1 week after the death of her father
describes many memories of her father and says that she is tearful
occasionally and having some trouble falling asleep. She returned to
work 4 days after her father's death. Proper treatment for this patient
should consist of which of the following?

a) Administration of antidepressant agents


b) Long-term psychotherapy
c) Referral for further psychiatric evaluation
d) A longer period of time away from work
e) Conservative, supportive treatment
The correct answer is E

Explanation
The treatment of a normal grief reaction involves conservative,
supportive treatment. Most of the support that people receive after a
loss comes from friends and family. Doctors and nurses may also be a
source of support. For people who experience difficulty in coping with
their loss, grief counseling or grief therapy may be necessary.

Grief counseling helps mourners with normal grief reactions work through
the tasks of grieving. Grief counseling can be provided by
professionally trained people, or in self-help groups where bereaved
people help other bereaved people. All of these services may be
available in individual or group settings.

The goals of grief counseling include: Helping the bereaved to accept


the loss by helping him or her to talk about the loss. Helping the
bereaved to identify and express feelings related to the loss (for
example, anger, guilt, anxiety, helplessness, and sadness). Helping the
bereaved to separate emotionally from the person who died and to begin
new relationships.
A 40 year old male is brought to the emergency department in a confused
state.

His past medical history is unremarkable. He is not taking any


medications. He is complaining of severe, weakness and lightheadedness
that began an hour ago.

A STAT glucometer reveals a value of 2.5 mmol/L. The patient improved


dramatically upon Dextrose 50% infusion. After careful history and
physical exam, you ordered some lab tests that return abnormal for an
elevated insulin levels and decreased C-Peptide. Which of the following
is the most likely diagnosis’

a) Chronic pancreatitis
b) Factitious disorder
c) Glucagonoma
d) Insulinoma
e) Sulphonylurea overdose
The correct answer is b

Explanation
Our patient has classic symptoms of hypoglycemia (confusion, weakness,
lightheadedness’), documented by lab test, then improved dramatically
with glucose administration (Whipple’s triad).

This patient is likely injecting insulin surreptitiously for a primary


gain (factitious disorder or Munchausen syndrome). The exogenous
industrial insulin is purified and does not have the C-peptide as a
component; thus in a person who is injecting insulin, expect low
glucose, high insulin and low C-peptide.

Insulinoma would give high levels of both insulin and C-peptide


(endogenous insulin).

Sulphonylurea drugs make the Beta cells of the pancreas secrete insulin
thus the lab tests will be similar to insulinoma; a urine toxicology
screen for sulphonylurea drugs will clench the diagnosis.

Glucagonoma presents with hyperglycemia and a characteristic rash


(Necrolytic migratory erythema).

Chronic pancreatitis may present with hyperglycemia and diabetes because


of insulin deficiency.

Please remember that the C-peptide is an endogenous substance which is


not present in pharmaceutical insulin and you will answer all the tricky
questions around this issue correct.
A 16 year old girl complains weight loss of 10 Kg. All of the following
suggest non- organic cause, except

a) Does not worry about weight loss


b) Engaged in athletic activity
c) Family history of eating disorder
d) Persistent complain of fatigue
The correct answer is D

Explanation
An organic cause of weight loss would be related to an organ in the
body. The most common cause of non-organic (psychiatric) weight loss is
anorexia nervosa.

Anorexia nervosa is characterized by a relentless pursuit of thinness, a


morbid fear of obesity, a refusal to maintain a minimally normal body
weight, and, in women, amenorrhea.

Anorexia is a misnomer, because appetite remains until the patient


becomes cachectic. Patients are preoccupied with food: They study diets
and calories; hoard, conceal, and waste food; collect recipes; and
prepare elaborate meals for others. Patients are often manipulative,
lying about food intake and concealing behavior, such as induced
vomiting. Binge eating followed by induced vomiting and the use of
laxatives and diuretics occurs in 50%. The others simply restrict their
food intake. Most anorectics exercise excessively to control weight.

Diagnosis is clinical. Treatment is with cognitive-behavioral therapy;


olanzapine may help with weight gain, and SSRIs, especially fluoxetine,
may help prevent relapse. Anorexia nervosa may be mild and transient or
severe and long-standing. Most patients are lean yet are concerned about
body weight and restrict food intake. Preoccupation and anxiety about
weight increase, even as emaciation develops.
Fragile X syndrome is associated with each of the following
characteristics EXCEPT:

a) More common in females


b) Most common form of inherited mental retardation
c) Involves the long arm of the X chromosome
d) Can be diagnosed with a blood test
e) Treatment is limited to symptomatic management
The correct answer is A

Explanation
Fragile X syndrome is more common in males than females, affecting 1 in
2000 and 1 in 4000, respectively. It is the most common inherited form
of mental retardation and second only to Down’s syndrome as a cause of
mental impairment. As the name implies, the syndrome is the result of a
fragile site on the long arm of the X chromosome attributed to the
excess amplification of the trinucleotide CGG sequence. It is thought
that the protein produced by this gene is responsible for guiding the
connections between neurons involved in learning and memory. The
symptoms of this pervasive developmental disorder include mental
retardation ranging from learning disabilities to severe intellectual
impairment, hyperactivity, unstable mood, and autistic-like behaviors.
The diagnosis can now be made by a DNA probe to pinpoint the defective
gene. Presently gene repair is not possible, so treatments include
behavioral and pharmacologic management of the symptoms.
Which one of the following is a common early side effect of fluoxetine
(Prozac)?

a) Constipation
b) Loss of appetite
c) Orthostatic hypotension
d) Atrioventricular block
e) Skin rash
The correct answer is b

Explanation
Fluoxetine, a selective serontonin reuptake inhibitor, has no effect on
the norepinephrine system; therefore, it does not produce the side
effects common to the tricyclic antidepressants. These include
anticholinergic side effects (dry mouth, constipation), orthostatic
hypotension, cardiac conduction disturbances, and drowsiness. Loss of
appetite is often seen in patients who take fluoxetine, and can be
especially troublesome in the elderly. Skin rash is uncommon.
Which is true regarding suicide in adolescents’

a) More common in summer


b) Females attempt suicide more than males
c) Females commit suicide more than males
d) Those of high socioecomonic status commit suicide more
The correct answer is b

Explanation
Statistics and epidemiology associated with suicide is as follows:

Males commit suicide successfully at a greater rate than females. But


females attempt suicide more.

Most suicides occur in the spring. The month of May has been noted for
its high rate of suicide. The speculation is that during the winter and
early spring when people are depressed. Lack of daylight correlates with
depression and suicide.

Poverty and low income, with concomitantly fewer options and


opportunities, correlate with suicide.
The husband and daughter of a 65 year old female report recent changes
in her behavior, including decreased energy, lack of motivation,
difficulty making decisions, decreased appetite, and insomnia of 4
weeks’ duration. The patient is not on any new medications, and has no
previous medical problems. Over the past 2 days, she has become
concerned about memory loss for both recent and remote events. This
patient most likely has
a) Depression
b) Dementia
c) A brain tumor
d) Hypoglycemia
e) Myocardial infarction
The correct answer is A

Explanation
The diagnosis of depression requires the presence of at least five of
the following: depressed mood, sleep disturbance, lack of interest or
pleasure in activities, guilt and feelings of worthlessness, lack of
energy, loss of concentration and difficulty making decisions, anorexia
or weight loss, psychomotor agitation or retardation, and suicidal
ideation. The symptoms must be present nearly every day during a 2-week
period. Because dementia may cause similar symptoms, distinguishing
between the two is important. Dementia is insidious, with a long
duration of symptoms including fluctuating mood and memory impairment
for recent events. Memory loss often precedes mood changes. Organic
problems such as brain tumor, hypoglycemia, and myocardial infarction
may cause similar symptoms, but are far less likely to be the cause.
Regarding suicide, all of the following are associated with increased
risk of a successful attempt, except

a) Depression
b) Malignancy
c) Female gender
d) Hopeless elderly man
The correct answer is C

Explanation
Men commit suicide far more frequently than women. However, women make
far more attempts than men. Risk factors for suicide include: history of
suicide attempts, severe hopelessness and depression, alcohol/substance
abuse, loss/separations, severe medical illness.
A 30 year old man presents in emergency with right lower quadrant
abdominal pain. His wife reports that he had been drinking heavily in
response to marital problems and had never had such pain before.
Appendicitis was diagnosed and an appendectomy was successfully
performed. Four days later the patient was anxious, restless, unable to
sleep and claimed his wife was a stranger trying to harass him. The most
likely diagnosis is

a) Paranoid reaction
b) Delirium tremens
c) Mania
d) Schizophreniform reaction
e) Post-operative delerium
The correct answer is b

Explanation
Delirium tremens (DTs), a very serious set of symptoms, may result if
alcohol withdrawal is left untreated. Delirium tremens usually does not
begin immediately; rather, it appears about 2 to 10 days after the
drinking stops. In delirium tremens, the person is initially anxious and
later develops increasing confusion, sleeplessness, nightmares,
excessive sweating, and profound depression. The pulse rate tends to
speed up. Fever typically develops.

The episode may escalate to include fleeting hallucinations, illusions


that arouse fear and restlessness, and disorientation with visual
hallucinations that may incite terror. Objects seen in dim light may be
particularly terrifying, and the person becomes extremely confused. The
floor may seem to move, the walls fall, or the room rotates. As the
delirium progresses, the hands develop a persistent tremor that
sometimes extends to the head and body, and most people become severely
uncoordinated. Delirium tremens can be fatal, particularly when untreated.
Which one of the following is more characteristic of anxiety disorder
than of depressive disorder?

a) Early morning awakening


b) Loss of interest in usual activities
c) Difficulty in making decisions
d) Feelings of dread and apprehensive expectations
e) Slowed speech and thought process
The correct answer is D

Explanation
Trying to distinguish between anxiety and depression can be difficult
because there is a high incidence of depressive symptoms in patients
with anxiety disorders, and a significant number of individuals with
major depression have anxiety symptoms. A number of symptoms are
characteristic of both disorders, such as sleep disturbance, appetite
changes, difficulty concentrating, irritability, fatigue, thoughts of
suicide or death, and nonspecific gastrointestinal or cardiac complaints.

Features that are more characteristic of anxiety include difficulty


falling asleep, apprehensive expectations or feelings of dread, tremors
or palpitations, phobic avoidance behavior, rapid pulse and other
autonomic hyperactivity, breathing disturbances, sweating spells,
feeling faint or dizzy, depersonalization (feelings of detachment from
one’s body), or derealization (a sensation that the immediate
environment is unreal or unfamiliar). Findings more characteristic of
depression include early morning awakening, diurnal variation (feeling
worse in the mornings), sad and downcast facial expressions, psychomotor
retardation (slowed speech, slowed thought processes), chronic
unexplained pain, sadness, feeling guilty, hopelessness, feelings of
worthlessness, despair, loss of interest in usual activities, anhedonia
(inability to experience pleasure), and difficulty in making decisions.
A 72 year old woman enters the hospital having lost 7 kg and saying she
has no interest in eating. Her physical examination and laboratory
findings are normal. She has been awakening at 5 a.m. for several months
and cannot fall back to sleep. She says she has been feeling anxious and
helpless since her husband died 3 years ago. Which one of the following
is a reasonable medication to prescribe for her?

a) Olanzapine
b) Sertraline
c) Clonazepam
d) Quetiapine
e) Risperidone
The correct answer is b

Explanation
Many people with depression cannot experience emotions, including grief,
joy, and pleasure, in a normal way; in the extreme, the world appears to
have become colorless and lifeless. Thinking, speech, and general
activity may slow down so much that all voluntary activities stop.
Depressed people may be preoccupied with intense feelings of guilt and
self-denigration and may not be able to concentrate. They may experience
feelings of despair, loneliness, and low self-esteem. They can be
withdrawn, speak little, stop eating, and sleep little. They are often
indecisive and withdrawn, feel progressively helpless and hopeless, and
think about death and suicide.

Selective serotonin reuptake inhibitors (SSRIs) (eg Fluoxetine (Prozac),


Sertraline (Zoloft), Paroxetine (Paxil), Escitalopram (Lexapro),
Citalopram (Celexa))) are now the most commonly used class of
antidepressants. SSRIs are effective in treating depression and
dysthymia as well as other mental health disorders that often coexist
with depression. Although SSRIs can cause nausea, diarrhea, tremor,
weight loss, and headache, these side effects are usually mild or go
away with continued use. Most people tolerate the side effects of SSRIs
better than the side effects of tricyclics. SSRIs are safer than the
tricyclics in their side effects on the heart.
A 27 year old female complains of palpitations. Your clinical evaluation
finds no abnormalities. You recommend that she discontinue her daily
regimen of 3-4 cups of regular coffee. Which one of the following
symptoms is the most likely to develop?

a) Anxiety
b) Depression
c) Headache
d) Fatigue
e) Flu-like illness
The correct answer is C

Explanation
In a study of patients with low to moderate caffeine intake,
discontinuing caffeine resulted in moderate to severe headache in 52%.
About 10% had depression or anxiety, and less than 10% had fatigue or
flu-like symptoms.
A 19 year old female patient used to be an A student in high school. Now
that she's in college she has manifestations of irritability, paranoia,
declining grades, and not desiring to go out with friends and preferring
to stay home in her room. The parents don't think that she's taking any
drugs. Which of the following is the most likely problem?

a) Cocaine withdrawal
b) Normal teenager
c) Cannabis abuse
d) Schizophrenia
The correct answer is D

Explanation
Schizophrenia is characterized by psychosis (loss of contact with
reality), hallucinations (false perceptions), delusions (false beliefs),
disorganized speech and behavior, flattened affect (restricted range of
emotions), cognitive deficits (impaired reasoning and problem solving),
and occupational and social dysfunction.

The cause is unknown, but evidence for a genetic component is strong.


Symptoms usually begin in adolescence or early adulthood. One or more
episodes of symptoms must last > 6 months before the diagnosis is made.
Treatment consists of drug therapy, psychotherapy, and rehabilitation.

Worldwide, the prevalence of schizophrenia is about 1%. The average age


at onset is 18 years in men and 25 years in women. Onset is rare in
childhood, but early adolescent or late-life onset (when it is sometimes
called paraphrenia) may occur.

This is a typical presentation of schizophrenia, where a promising


teenager goes off to college or university then declines drastically
with no apparent cause.
A 64-year-old white male appears to be depressed 2 weeks after hospital
discharge for a myocardial infarction. He experienced short runs of
ventricular tachycardia during his hospitalization, and echocardiography
revealed an ejection fraction of 40% at the time of discharge, with no
symptoms of heart failure. He has a history of depression in the past.
His current symptoms include depressed mood, sleep disturbance, feelings
of hopelessness, and anhedonia. He denies suicidal ideation. Which one
of the following would be most appropriate at this point?

a) Low-dose amitriptyline at bedtime


b) Sertraline (Zoloft)
c) Referral for electroconvulsive therapy
d) Referral for intense interpersonal psychotherapy
The correct answer is b

Explanation
Several studies have demonstrated that SSRIs are safe and effective in
treating depression in patients with coronary disease, particularly
those with a history of previous episodes of depression. Medications
have performed significantly better than intensive interpersonal
psychotherapy in this setting. Electroconvulsive therapy is not
considered first-line therapy in the absence of severe symptoms. While
it may be effective for sleep disturbance, amitriptyline has potential
cardiac side effects and is unlikely to be effective for the treatment
of depression in low doses.
Compared to children with attention-deficit/hyperactivity disorder
(ADHD), adults with ADHD

a) Tend to be more hyperactive


b) Tend to be less impulsive
c) Are less likely to have corroboration of symptoms by family members
d) Are less likely to complain of inattention difficulties
The correct answer is b

Explanation
Longitudinal studies of young people diagnosed with
attention-deficit/hyperactivity disorder (ADHD) show that symptoms of
hyperactivity and impulsivity may decrease with age, but inattention
tends to persist. Studies of clinically referred adults with ADHD show
that about half have clinically important levels of hyperactivity and
impulsivity and up to 90% have prominent attentional symptoms. Like some
youth with ADHD, adults with ADHD tend to have additional cognitive
deficits, specifically executive function deficits, which include
problems encoding and manipulating information and difficulties with
organization and time management.

Research shows that using retrospective self-reports of adults is a


valid method of diagnosing ADHD. Studies have shown that the consistent
reporting of childhood ADHD symptoms by both adults and their parents is
highly correlated. Research has also found strong agreement between the
self-reports of adults and their partners regarding ADHD symptoms.

A 53 year old housewife presents with depression marked by early morning


wakening, diminished energy and poor concentration. She is treated with
supportive psychotherapy and celexa 20 mg. After four weeks she is no
better. You would next

a) Reassure her that antidepressants take 5-6 weeks to be effective


b) Begin intensive psychotherapy
c) Switch to a different SSRI
d) Increase the dose to 40 mg
The correct answer is D

Explanation
Depressive disorders are characterized by sadness severe enough or
persistent enough to interfere with function and sometimes by decreased
interest or pleasure in activities. Exact cause is unknown but probably
involves heredity, changes in neurotransmitter levels, altered
neuroendocrine function, and psychosocial factors. Diagnosis is based on
history. Treatment usually consists of drugs, psychotherapy, or both,
and sometimes electroconvulsive therapy. Improvement may require 1 to 4
weeks of taking drugs as prescribed. If no response is seen after this
time it is appropriate to raise the dose.
A 23-year-old male student presents with a six-month history of extreme
daytime fatigue and repeatedly falling asleep in classes, on the bus,
and other inappropriate places. On review of systems, he admits to
sometimes ‘fainting’ when he is upset. He describes these fainting
spells as a sudden feeling of weakness, causing him to fall down, but
with preserved consciousness throughout. On further questioning which of
the following symptoms are also likely to be present in this patient?
a) Somnambulism (sleepwalking)
b) Hallucination-like dreams
c) Cogwheel rigidity
d) Loud snoring
e) Palpitations
The correct answer is b

Explanation
Hallucination-like dreams occurring at sleep onset (hypnogogic
hallucinations) or on waking (hypnopompic hallucinations) are often
associated with narcolepsy. The most common presentation of narcolepsy
is of excessive daytime fatigue and irresistible attacks of refreshing
sleep. Cataplexy is also common, and is defined as the sudden loss of
muscle tone, usually precipitated by intense emotions.

A. This is a separate sleep disorder.


C. Cogwheel rigidity occurs in parkinsonism.
D. Loud snoring is characteristic of obstructive sleep apnea, which also
presents with excessive sleepiness, but is not associated with cataplexy.
E. Palpitations might be associated with syncope, which by definition
involves loss of consciousness.
Which one of the following side effects induced by traditional
neuroleptic agents responds to treatment with Beta-blockers’

a) Akathisia
b) Rigidity
c) Dystonia
d) Sialorrhea
e) Stooped posture
The correct answer is A

Explanation
Rigidity, sialorrhea, and stopped posture are parkinsonian side effects
of neuroleptic drugs. These are treated with anticholinergic drugs such
as benztopine or amantadine. Dystonia, often manifested as an acute
spasm of the muscles of the head and neck, also responds to
anticholinergics. Akathisia (motor restlessness and an inability to sit
still) can be treated with either anticholinergic drug or Beta-blockers.
After one of many inappropriate late-night phone calls from the same
patient, you review in your mind recent problems of his that you have
dealt with. You have treated him four times over the past 2 years for
sexually transmitted diseases and he has been to your office three times
in the past year for job-related injuries. More than once you have felt
anger at the patient for manipulating you, and he caused a scene in your
waiting room 2 months ago over a 10-minute delay for his appointment. He
often has episodes of unexplained blues or anxiety. Six months ago you
saw in the newspaper that he was arrested for shoplifting.

You have started to wonder if the patient has an unrecognized underlying


psychopathology. If he does indeed have a psychiatric disorder, which
one of the following diagnoses is most likely?
a) Bipolar disorder
b) Borderline personality disorder
c) Masochistic personality disorder
d) Anxiety neurosis
e) Schizo-affective psychosis
The correct answer is b

Explanation
Borderline personality disorder (BPD) is defined in the Diagnostic and
Statistical Manual of Mental Disorders as the presence of at least five
out of eight criteria that include impulsivity, unstable interpersonal
relationships, difficulty in regulation of anger unstable mood, a
tendency towards self-damaging acts, difficulty in accepting loss, and a
feeling of boredom or emptiness. While the other diagnoses listed are
not excluded by the information provided, they are not directly
suggested by the history.
Which would not be considered a risk factor for suicide in patients
presenting with suicidal ideation

a) Substance abuse
b) Male gender
c) Lack of social supports
d) Unsuccessful attempt at suicide in the past
e) Childless marriage
The correct answer is E

Explanation
More than 1-2 of suicidal behaviors stem from depression. Other
predisposing factors include a history of suicide in family members or
close friends, a recent death in the family, substance abuse, and
conduct disorder. More immediate precipitating factors can include loss
of self-esteem (eg, resulting from family arguments, a humiliating
disciplinary episode, pregnancy, school failure); loss of a boyfriend or
girlfriend; and loss of familiar surroundings (eg, school, neighborhood,
friends) due to a geographic move.

Other factors may be a lack of structure and boundaries, leading to an


overwhelming feeling of lack of direction, or intense parental pressure
to succeed accompanied by the feeling of falling short of expectations.
A frequent motive for a suicide attempt is the effort to manipulate or
punish others with the fantasy ‘You will be sorry after I am dead.’ A
rise in suicides is seen after a well-publicized suicide (eg, of a rock
star) and among self-identified populations (eg, a high school, a
college dormitory), indicating the power of suggestion.
You are treating an 89 year old white male who has lived alone since his
wife died 5 years ago. His niece found him helpless in his apartment.
The patient is filthy, listless, and weak, and complains of thirst. He
is orientated to self, but he is sure that you are his pastor and that
Nixon is president. His general physical examination reveals
cardiomegaly and peripheral edema. Findings on neurologic examination
include horizontal and vertical nystagmus, weakness of lateral recti,
ataxia, and peripheral areflexia. Plantar responses are downpointing. A
CBC is pending; electrolyte, BUN, and glucose levels obtained in the
emergency department reveal hypertonic dehydration for which 5% dextrose
in 1/2-normal saline is running at 200 cc/hr. The patient’s drowsiness
increases during your examination. You order which one of the following?

a) Cyanocobalamin (vitamin B12)


b) Thiamine
c) Methylprednisolone sodium succinate (Solu-Medrol)
d) A stat carboxyhemoglobin determination
The correct answer is b

Explanation
Alcoholism, while less frequent in the elderly, is often masked by
isolation. Elderly widowers are in the highest risk group. Several
features of this case, including the long-term inattention to self, gaze
disturbance, cerebellar signs, confabulation (confidence in the face of
confusion), and better past that present memory, all suggest Wernicke’s
encephalopathy. The presence of signs of wet beriberi related to the
same nutritional deficiency support the diagnosis. The patient is at
immediate risk and thiamine should be administered right away. Other
diagnosis are less likely. Pernicious anemia causes no prominent eye
motor signs; temporal arteritis, lupus, and Takayasu’s vasculitis causes
lateralizating signs; lead poisoning doesn’t generally cause
cardiomegaly; and carbon monoxide intoxication is more acute, causing
headache and nonselective confusion.
Depression is associated with which of the following sleep patterns’

a) Decreased rapid-eye movement latency


b) Decreased rapid-eye movement
c) Decreased stage 2 rapid-eye movement
d) Decreased stage 4 rapid-eye movement
The correct answer is A

Explanation
A normal sleep cycle involves five stages of sleep: rapid-eye movement,
or REM, and four non-REM stages. During REM sleep, the brain is about as
lively as when it's awake, and the body burns lots of energy. In non-REM
sleep, the brain slows down and the body conserves energy. Healthy
people alternate between REM and non-REM sleep throughout the night.

Normally, the first REM cycle begins about 90 minutes after falling
asleep, but in a depressed sleeper, it may begin after just 60 minutes.
A person who enters REM too early will cut short the deep sleep,
necessary for biological restoration and repair, that precedes the first
REM cycle.
A 25-year-old female with a longstanding history of depression is doing
well on her current medication. She and her husband are planning a
pregnancy. Her psychiatrist has recommended that she continue taking an
SSRI.

Which one of the following poses the greatest risk during pregnancy?

a) Sertraline (Zoloft)
b) Escitalopram (Lexapro)
c) Citalopram (Celexa)
d) Fluoxetine (Prozac)
e) Paroxetine (Paxil)
The correct answer is E

Explanation
A recent update by the College of Obstetricians and Gynecologists
Committee on Obstetric Practice recommends that SSRI use during
pregnancy be individualized. Most SSRIs are pregnancy category C, which
means that these drugs have been found to cause teratogenic effects in
animals, but there are no adequate studies in humans. However, recent
data has shown that paroxetine in the first trimester of pregnancy may
increase congenital cardiac defects, such as atrial septal defect and
ventricular septal defect, and it now has been changed to pregnancy
category D (found to be harmful to human fetuses). If at all possible,
this drug should be avoided in pregnant women and those planning a
pregnancy.

SSRIs used late in pregnancy has also been associated with neonatal
complications that include jitteriness, mild respiratory distress,
transient tachypnea of the newborn, weak cry, poor tone, and admission
to the neonatal intensive-care unit. One study showed that 30% of
neonates exposed to SSRIs during late pregnancy develop a neonatal
abstinence syndrome identified by a formal scoring system. A large
case-controlled study found a sixfold increase in the risk of persistent
pulmonary hypertension for newborns whose mothers used SSRIs after 20
weeks gestation. While there are potential risks associated with SSRI
use, they must be balanced with the risks associated with stopping the
medicine. Women who discontinue antidepressants during pregnancy have
five times the risk of relapse compared to those who take the
medications. Untreated depression may increase the risk of low weight
gain, sexually transmitted disease, and alcohol and substance abuse,
which all may put the fetus at risk. It is important for the risks and
benefits of treatment with SSRIs to be weighed and thoroughly discussed
with the patient prior to treatment so she can make an informed decision.
A 17 year old boy is brought to the office by his mother who says that
he has been increasingly withdrawn and preoccupied for several weeks. He
has been sleeping poorly and has refused to leave the house for the past
week because he believes he is being followed. When his father insisted
he attend school this morning, the patient threatened him with a knife.
On examination, the patient is sweating, has dilated pupils and is
obviously fearful.

Rapport with this patient can best be established by asking which of the
following?

a) "Are you hearing voices’"


b) "Do you have a special mission to accomplish?"
c) "Do you think you are being persecuted?"
d) "How do you feel others are treating you?"
e) "Who do you think is following you?"
The correct answer is D
Explanation
Rapport is defined as an empathic and trusting working relationship
between a psychiatrist and patient. Rapport is usually best established
by addressing the feelings of the patient. Most patients respond best to
a doctor who first attempts to understand a person’s emotional state and
clarifies symptoms afterwards.

Asking about symptoms may give you information, but it does not
establish rapport. Similarly, asking about specific thoughts the patient
is having will give you information, but will not establish a
collaborative relationship.
A young mother is very focused on the health of her 16 month old. She
keeps her house immaculate for fear that dirt will harm her baby, she
checks the lock on the door at least ten times before retiring to bed,
and she has to get up and check that her child is still breathing at
least 3 times every night. She knows that her fears are irrational but
persists with these behaviors. The most likely diagnosis is

a) Paranoid delusions not otherwise specified


b) Post-partum depression
c) Obsessive compulsive disorder
d) Generalized anxiety disorder
e) Paranoid personality disorder
The correct answer is C

Explanation
Obsessive-compulsive disorder (OCD) is characterized by
anxiety-provoking ideas, images, or impulses (obsessions) and by urges
(compulsions) to do something that will lessen that anxiety. The cause
is unknown. Diagnosis is based on history. Treatment consists of
psychotherapy, drug therapy, or, especially in severe cases, both.
Which one of the following medications is associated with the highest
risk for falls in elderly patients’

a) Ibuprofen
b) Atorvastatin (Lipitor)
c) Sertraline (Zoloft)
d) Pseudoephedrine
e) Fludrocortisone (Florinef)
The correct answer is C

Explanation
Most falls result from interactions between predisposing factors and
precipitating factors in a person’s environment. The use of four or more
prescription medications increases fall risk, as does the use of certain
individual classes of medications, including SSRIs (such as sertraline),
tricyclic antidepressants, neuroleptics, benzodiazepines,
anticonvulsants, and class IA antiarrhythmic agents.

The other agents listed have not been associated with falls in the
elderly. Ibuprofen and fludrocortisone cause salt and water retention
and may reduce the risk of orthostatic hypotension, a cause of falls in
the elderly. Pseudoephedrine stimulates adrenergic receptors and tends
to raise blood pressure as well. Statin drugs have no known association
with falls.

A 33-year-old male has had a one-month history of depressed mood. He


tells you he had an increase in his appetite with an 8-pound weight
gain. He is sleeping most of the day. He reports the evenings being the
most difficult time of day for his mood. His concentration is impaired,
and he no longer enjoys watching television or reading like he used to.
He feels guilty about how his work has suffered, and is hopeless about
being able to recover from this in time to save his job. He denies
feeling suicidal, but has had more thoughts of death in the past week.
You diagnose him with atypical depression based on which of the
following symptoms being present?

a) Increased appetite and sleep


b) Poor concentration and guilt
c) Thoughts of death without suicidal ideation
d) Anhedonia
e) Reversal of diurnal variation in mood
The correct answer is E

Explanation
Other findings would be mood reactivity to positive events, leaden
paralysis, and a pattern of interpersonal rejection sensitivity.
Increased appetite and sleep don’t distinguish atypical depression,
though they are often present. In typical depression the patients
describe feeling the worst in the morning and better as the day
progresses, which is termed a diurnal variation. This patient shows a
reversal of that pattern. Diagnosing atypical features can be helpful
because it is one of the few indications to specially choose a monoamine
oxidase inhibitor. All of the other answers are findings in ‘typical’
depression.

A 65-year-old male presents for a follow-up visit for severe depression.


His symptoms have included crying episodes, difficulty maintaining
sleep, and decreased appetite. He has suicidal ideations and states that
he has a gun in his home. He also thinks his wife is having an affair,
but she is present and is adamant that this is not true. His symptoms
have not been relieved by maximum doses of sertraline (Zoloft),
venlafaxine (Effexor), or citalopram (Celexa). He currently is taking
duloxetine (Cymbalta), which also has failed to relieve his symptoms.
Which one of the following would most likely provide the quickest relief
of his symptoms’

a) Counseling
b) Bupropion (Wellbutrin)
c) Stopping duloxetine and starting an MAO inhibitor
d) Electroconvulsive therapy
The correct answer is D
Explanation
This patient has psychotic depression with suicidal ideations and has
not responded to maximum doses of several antidepressants. He is more
likely to respond to electroconvulsive therapy than to counseling or a
change in medication.
All of the following statements about depression in the elderly are
true, except

a) Somatic symptoms are frequently substituted for emotional symptoms


b) Tricyclic antidepressants should not be used due to cardiotoxicity
c) Precipitating events are often related to loss
d) Certain cases may benefit from a course of electroconvulsive therapy
e) May present with abnormalities of cognitive functioning
The correct answer is b

Explanation
Tricyclic antidepressants such as amitriptyline and imipramine have been
reported to be effective in depressed geriatric patients, but because of
their potential for side effects, it is not advisable to use them in the
elderly. Desipramine has a less toxic side effect profile, especially
with respect to anticholinergic effects, but its efficacy has not been
well studied. This does not mean, however, that it is not an effective
drug for the elderly depressed.

Nortriptyline is the tricyclic that has been the most studied. The
results of those studies show that it should be recommended as an
antidepressant for older patients. It is effective in both the acute and
continuation treatment of depression in the elderly. As far as its use
in maintenance treatment, the results are mixed but at this moment there
is nothing with which to compare it. It has a favorable side effect
profile: low anticholinergic activity; relatively few cardiac side
effects, even in patients with preexisting cardiac disease; and
relatively less orthostatic hypotension.
Each of the following statements about cannabis use is true EXCEPT:

a) Regular use will not lead to dependence


b) Delirium can occur with long-lasting usage
c) Cannabis-induced anxiety is a common effect
d) Decreased libido is associated with regular usage
e) Delta-9-tetrahydrocannabinol causes the psychoactive effects
The correct answer is A

Explanation
Cannabis or marijuana used regularly can lead to dependence and
withdrawal. Persistent use despite psychological and physical impairment
as well as developing tolerance are hallmarks of such. The delirium seen
with cannabis is similar to what is seen with the hallucinogens and
psychomimetics and can last up to 10 days. Decreased libido, ataxia,
increased reaction time, perceptual distortion, and restlessness are
also associated with cannabis usage. Anxiety is common during acute
intoxication, especially for inexperienced users, and is often provoked
by paranoid thoughts. Although there are approximately 60 active
substances in cannabis, THC is thought to be the key chemical
responsible for the psychoactive effect.
You see a 32 year old white female for her first visit. She presents
with numerous complaints which do not conform to patterns seen in
organic disease. She states that she has seen several physicians and
describes a changing set of symptoms. Although she appears to be well,
she claims to have been ‘sickly’ for years. From her affect, you suspect
that she is depressed. The most likely diagnosis is

a) Conversion reaction
b) Chronic somatization disorder
c) Schizophrenia with multiple somatic delusions
d) Histrionic personality
e) Primary hypochondriasis
The correct answer is b

Explanation
Conversion disorder usually involves a single symptom which is
neurologic or pain-related. Symptoms of chronic somatization differ from
psychoses in that the symptoms of the psychotic patient are bizarre and
more vivid, persist over time, are unaltered by reasoned argument, and
are not congruent with the patient’s social or cultural background. The
delusional nature of psychotic somatic symptoms usually unfolds as the
patient talks.

The essential feature of the histrionic (hysterical) personality is a


pervasive pattern of excessive emotionality and attention seeking.
People with this disorder constantly seek to be the center of attention.
Emotions are often expressed with inappropriate exaggeration. People
with this disorder tend the be very self-centered and have little
tolerance for delayed gratification. These people are typically
attractive and seductive, often to the point of looking flamboyant and
acting inappropriately.

Features of primary hypochondriasis include the patient’s fixed


conviction that he or she is ill, the interpretation of all somatic
changes as confirmation of this, and a relentless pursuit of medical
assistance despite persistent dissatisfaction with the results. The
patient’s symptoms remain consistent for years.

Physicians frequently feel overwhelmed when initially presented with a


patient with somatization disorder. This disorder begins before age 30
and is rarely seen in males. The patient complains of multiple symptoms
which involve many organ systems and do not readily conform to patterns
seen in organic diseases. The patient skips back and forth from symptom
to symptom during the interview. Anxiety and depressed mood are frequent
in this disorder, and suicide attempts are common.
You see a 25 year old woman with a history of paranoid schizophrenia
maintained on haloperidol shots. She is stiff, cannot swallow or talk,
and appears tremulous. On examination, her temperature is 38.7 C (101.7
F), blood pressure is 157/104 mm Hg, pulse is 122/min, and respirations
are 24/min. She has increased tone in her neck and extremities, and
appears tremulous, diaphoretic, and confused. Her leukocyte count is
19,600/mm3 and the serum creatine phosphokinase is markedly elevated.
Which of the following is the most likely diagnosis’
a) Acute dystonic reaction
b) Lethal catatonia
c) Malignant hyperthermia
d) Neuroleptic malignant syndrome
e) Serotonin syndrome
The correct answer is D

Explanation
Neuroleptic malignant syndrome (NMS) is a rare complication of
neuroleptic therapy that confers high mortality if not recognized and
treated promptly. It is defined by the development of severe muscle
rigidity and elevated temperature in association with at least two or
more of the following: dysphagia, tremor, diaphoresis, tachycardia,
change in level of consciousness, leucocytosis, elevated or labile blood
pressure, and elevated creatine phosphokinase as an indicator of muscle
injury. The predisposing factors include high neuroleptic doses,
intramuscular injections, and lithium treatment.
An 8 year old child eats glue and pencils etc. His teacher has tried to
control his behavior by placing vegetables on his table but the boy
refused to eat them. His teacher describes him as one of the most
stubborn and disobedient students in his class. This is an example of?

a) Oppositional Defiant Disorder


b) Conduct disorder
c) Autism
d) ADHD
The correct answer is A

Explanation
Oppositional defiant disorder is a recurring pattern of negative,
defiant, and disobedient behavior. Children with oppositional defiant
disorder are stubborn, difficult, and disobedient without being
physically aggressive or actually violating the rights of others. Most
often, children develop this disorder by age 8.

Typical behaviors of children with oppositional defiant disorder include


arguing with adults, losing their temper, actively defying rules and
instructions, blaming others for their own mistakes, and being angry,
resentful, and easily annoyed. These children do know the difference
between right and wrong and feel guilty if they do anything that is
seriously wrong.

Conduct disorder is characterized by a repetitive pattern of behavior in


which the basic rights of others are violated. Children with a conduct
disorder engage in bullying, threatening, and frequent fights and may be
cruel to animals. Other children with conduct disorder damage property,
especially by setting fires. They may be deceitful or engage in theft.
Seriously violating rules is common and includes running away from home
and frequent truancy from school.

Choice a) is the most appropriate choice to this question.


A 75 year old white male complains of a tremor which has been
progressive over the past 2 years. The tremor interferes with writing,
pouring liquids, and eating soup. He has no other medical problems. He
abstains from alcohol and tobacco products. Physical examination is
remarkable for an action tremor of the upper extremities and a head
tremor. No rigidity or gait disorder is noted. Of the following agents,
which one is most appropriate as initial drug therapy for this problem?

a) Alprazolam (Xanax)
b) Clonazepam (Klonopin)
c) Carbamazepine (Tegretol)
d) Propranolol (Inderal)
e) Theophylline
The correct answer is D

Explanation
Essential tremor is the most likely cause of a disabling action tremor
in this age group. A resting tremor, rigidity, and other associated
problems are seen with Parkinson’s disease.

Propranolol and primidone are the agents of choice. Alprazolam may have
beneficical effects, but it is not a first-line agent because of the
risk of sedation and habituation. Clonazepam has not been found to be
effective in this disorder. Low doses of theophylline have been found to
be somewhat beneficial, but it is considered a second-line agent for
essential tremor. Selective Beta-blockers such as metoprolol are not as
effective as propranolol.
You are considering treating a 21 year old female with a history of
anorexia nervosa and depression with an antidepressant. Which one of the
following should you avoid?

a) Desipramine
b) Citalopram
c) Venlafaxine
d) Phenelzine
The correct answer is D

Explanation
Phenelzine is a monoamine oxidase inhibitor (MAOI). It can interact with
certain foods that have a high tyramine content (such as wine, cheese)
and cause severe side effects such as a hypertensive crisis.

Therefore, dietary restrictions must be made for a patient placed on an


MAOI. This would not be appropriate in a patient already suffering from
anorexia nervosa.
Behavior therapy has been shown to be the best treatment for which one
of the following?

a) Obsessive-compulsive disorders
b) Somatization disorders
c) Substance abuse
d) Acute schizophrenia
e) Phobic disorders
The correct answer is E

Explanation
Because many phobic disorders involve avoidance, exposure therapy, which
is a form of psychotherapy, is the treatment of choice. With structure
and support from a clinician who prescribes exposure homework, patients
seek out, confront, and remain in contact with what they fear and avoid
until their anxiety is gradually relieved through a process called
habituation. Exposure therapy helps > 90% of those who carry it out
faithfully and is almost always the only treatment needed for specific
phobias. Cognitive-behavioral therapy is effective for agoraphobia and
social phobia.

Cognitive-behavioral therapy involves teaching patients to recognize and


control their distorted thinking and false beliefs as well as
instructing them on exposure therapy. For example, patients who describe
acceleration of their heart rate or shortness of breath in certain
situations or places learn by being repeatedly exposed to those
situations that their worries about having a heart attack are unfounded
and are taught to respond instead with slow, controlled breathing or
other methods that promote relaxation.
A 28 year old female has insomnia, irritability, increased psychomotor
activity, and impulsivity. Which one of the following is the most likely
diagnosis’

a) Schizophrenia
b) Antisocial personality disorder
c) Major depressive disorder
d) Hypomania
e) Hyperthyroidism
The correct answer is D

Explanation
Mania is characterized by excessive physical activity and feelings of
extreme elation that are grossly out of proportion to any positive
event. Hypomania is a less severe form of mania. Manic symptoms
typically develop rapidly over a few days. In the early (milder) stages
of mania, the person feels better than normal, exuberant, and energetic.

A person who is manic may be irritable, cantankerous, or hostile. He


typically believes he is quite well. A lack of insight into his
condition, along with a huge capacity for activity, can make the person
impatient, intrusive, meddlesome, and aggressively irritable when
crossed. Mental activity speeds up (a condition called flight of ideas).
The person is easily distracted and constantly shifts from one theme or
endeavor to another.

The person may believe he is being assisted or persecuted by others or


have hallucinations, hearing and seeing things that are not there. The
need for sleep decreases. A manic person is inexhaustibly, excessively,
and impulsively involved in various activities (such as risky business
endeavors, gambling, or perilous sexual behavior) without recognizing
the inherent social dangers. In less severe mania, hospitalization may
be needed during periods of overactivity to protect the person and his
family from ruinous financial or sexual behavior.
Which of the following defense mechanisms is the most mature
psychological strategy to cope with a reality?

a) Projection
b) Sublimation
c) Regression
d) Displacement
The correct answer is b

Explanation
Defense mechanisms are our way of distancing ourselves from a full
awareness of unpleasant thoughts, feelings and desires.

Projection is the attribution of one's undesired impulses onto another.


For example, a jealous man accuses his wife of cheating.

Sublimation is a defense mechanism that allows us to act out


unacceptable impulses by converting these behaviors into a more
acceptable form. For example, a person experiencing extreme anger might
take up kick boxing as a means of venting frustration.

Regression is the reversion to an earlier stage of development in the


face of unacceptable impulses. For an example an adolescent who is
overwhelmed with fear, anger and growing sexual impulses might become
clinging and begin thumb sucking or bed wetting.

Displacement is the redirecting of thoughts feelings and impulses from


an object that gives rise to anxiety to a safer, more acceptable one.
Being angry at the boss and kicking the dog can be an example of
displacement.
A 43-year-old chronically mentally ill man was admitted to the medical
floor for ketoacidosis. His previously prescribed antipsychotic
haloperidol was stopped and not restarted when he was transferred to an
extended care facility several weeks later. A routine follow-up
examination by his primary care physician finds the patient with
tic-like movements of his face and tongue and lip smacking. Based on
this information, what is the most likely diagnosis’

a) Diabetic neuropathy
b) Tourette's disorder
c) Parkinson's disease
d) Akathisia
e) Tardive dyskinesia
The correct answer is E

Explanation
Tardive dyskinesia is a common side effect to prolonged antipsychotic
medication usage. More advanced cases may exhibit choreoathetoid
movements of the limbs and trunk.
A generally healthy 35-year-old female has mild generalized anxiety, but
is not depressed. She does not want to take a prescription medication,
and asks if an herbal or dietary supplement might be helpful. Which one
of the following botanical medications has the best clinical evidence of
potential benefit for anxiety disorders when used for a short time (up
to 24 weeks)?

a) St. John’s wort


b) Valerian
c) Fava beans
d) Kava
e) Chamomile
The correct answer is D

Explanation
The use of herbal and nutritional supplements has become commonplace in
Canada. Unfortunately, there is insufficient research for most herbal
remedies, in terms of both efficacy and safety. However, there is a
significant body of evidence from randomized, controlled trials and
various meta-analyses showing benefit from the use of kava in the
short-term treatment of anxiety disorders (up to 24 weeks), including
generalized anxiety disorder. The other remedies listed have only single
studies or anecdotal evidence attesting to benefit for patients with
anxiety. At best, information about them is limited, and there are often
conflicting results.

Safety concerns about kava have been addressed by recent randomized,


controlled trials demonstrating that kava has a safety profile similar
to those of FDA-approved treatments for anxiety disorders. Care should
be taken with any concurrent use of kava and medications metabolized by
the liver, and patients should be discouraged from using alcohol while
taking kava.

Physicians should be aware of all remedies their patients are taking,


even if they are not prescribed. In addition, it is important to be
aware of remedies that have evidence supporting their use.

Patients with conversion disorders will show each of the following, except

a) Conscious faked symptoms


b) Loss of special sense function
c) Severe psychological stress
d) Paralysis of voluntary muscles
The correct answer is A

Explanation
In conversion disorder, physical symptoms that are caused by psychologic
conflict are unconsciously converted to resemble those of a neurologic
disorder. Conversion disorder, once referred to as hysteria, is caused
by psychologic stress and conflict, which people with this disorder
unconsciously convert into physical symptoms. Although conversion
disorder tends to occur during adolescence or early adulthood, it may
first appear at any age. The disorder is generally believed to be
somewhat more common in women than in men.

The symptoms of conversion disorder are limited to those that suggest a


nervous system dysfunction, usually paralysis of an arm or leg or loss
of sensation in a part of the body. Other symptoms may include simulated
seizures and the loss of one of the special senses, such as vision or
hearing.

Generally, the onset of symptoms is linked to some distressing social or


psychologic event. A person may have only a single episode in his
lifetime or sporadic episodes, but usually the episodes are brief. If
people with conversion symptoms are hospitalized, they generally improve
within 2 weeks. However, 20 to 25% of those people who are hospitalized
have recurrences within a year, and for some people, symptoms become
chronic.
In patients with bipolar depression, monotherapy with which one of the
following may trigger a manic episode?

a) Valproic acid (Depakene)


b) Lithium
c) Fluoxetine (Prozac)
d) Lamotrigine (Lamictal)
e) Carbamazepine (Tegretol)
The correct answer is C

Explanation
Bipolar depression is characterized by unpredictable mood swings ranging
from episodes of depression to periods of mania (psychomotor activity,
euphoria, impaired judgment, impulsivity, grandiose ideas, and
irritability). Specific classification and criteria for diagnosis are
available in the DSM-IV. Depressive symptoms can be controlled with an
SSRI-type antidepressant such as fluoxetine, but if used alone the drugs
can trigger a manic episode in some patients. Mood stabilizers such as
lithium carbonate, valproic acid, carbamazepine, and lamotrigine are
used to control and prevent mania. Antipsychotics such as olanzapine can
also be used to control mania, particularly when psychotic features are
clinically presented.

A 28 year old man presents with symptoms of constant blinking. He has


had it for several years, but lately it has worsened. He also has
recently had some inappropriate loud outbursts at work. Which of the
following disorders is likely?

a) Tourette
b) Schizophrenia
c) Tic douloureux
d) Panic disorder
The correct answer is A

Explanation
Tourette's syndrome is a hereditary tic disorder that begins in
childhood. Symptoms include simple, complex, and vocal tics. The
movement disorder may begin with simple tics (eg, facial grimacing, head
jerking, blinking, sniffing) that progress to multiple complex tics,
including respiratory and vocal ones (eg, loud, irritating
vocalizations; snorting). Vocal tics may begin as grunting or barking
noises and evolve into compulsive utterances that are often loud or shrill.

Patients may voluntarily suppress tics for seconds or minutes.


Coprolalia (involuntary scatologic or obscene utterances) occurs in a
few patients. Severe tics and coprolalia are physically and socially
disabling. Echolalia (immediate repetition of one's own or another
person's words or phrases) is common. Diagnosis is clinical. Treatment
may include clonidine or antipsychotics.
A 36-year-old female has been seen multiple times in the past several
months for various pain-related complaints. On each occasion, no
physical or laboratory findings were found to explain the symptoms. The
patient is involved in a worker’s compensation case and could make a
significant amount of money if it is demonstrated that her physical
complaints are related to work conditions. Which one of the following
diagnoses characterizes her unexplained physical symptoms’

a) Somatization disorder
b) Conversion disorder
c) Hypochondriasis
d) Malingering
The correct answer is D

Explanation
This patient most likely is malingering, which is to purposefully feign
physical symptoms for external gain. Factitious disorder involves
adopting physical symptoms for unconscious internal gain, such as
deriving comfort from taking on the role of being sick. Somatization
disorder is related to numerous unexplained physical symptoms that last
for several years and typically begin before 30 years of age. Conversion
disorder involves a single voluntary motor or sensory dysfunction
suggestive of a neurologic condition, but not conforming to any known
anatomic pathways or physiologic mechanisms.
Which one of the following is true regarding dysthymic disorder?

a) Antidepressant medications are not helpful in the management of this


problem
b) The prognosis for eventual remission is generally excellent
c) There is a strong association with other psychiatric and medical
conditions
d) The onset is typically abrupt following an identifiable life stress
The correct answer is C

Explanation
Dysthymic disorder, also known as dysthymia, is a depressive disorder
characterized by mild to moderate symptoms with a duration of 2 or more
years. It has an insidious onset and a waxing and waning course. There
is a strong association between dysthymia and other psychiatric
disorders (especially major depression, personality disorders, and
social phobia) and medical conditions (cerebrovascular accidents,
multiple sclerosis, AIDS, premenstrual syndrome, hypothyroidism).
Long-term treatment with selective serotonin reuptake inhibitors is
often necessary.
The son of a 79 year old woman wants a psychiatric evaluation for his
mother because she has been more confused and lethargic during the past
6 months. She takes several medications daily, although her son doesn't
know what they are. The patient seems to be disheveled, mildly agitated,
and delirious. Which one of the following is the most useful next step
in this woman's evaluation?

a) Mental status evaluation


b) Ordering serum electrolytes
c) Obtaining a CT scan of the head
d) Prescribing haloperidol for agitation
e) No further evaluation is needed
The correct answer is A

Explanation
In most cases, the symptoms of dementia occur gradually, over a period
of years. Symptoms of dementia caused by injury or stroke occur more
abruptly. Difficulties often begin with memory, progressing from simple
forgetfulness to the inability to remember directions, recent events,
and familiar faces and names. Other symptoms include difficulty with
spoken communication, personality changes, problems with abstract
thinking, poor personal hygiene, trouble sleeping, and poor judgment and
decision making. Dementia is extremely frustrating for the patient,
especially in the early stages when he or she is aware of the
deficiencies it causes.

Dementia is diagnosed through a study of the patient’s medical history


and a complete physical and neurological exam. You will speak with those
close to the patient to document a pattern of behavior. You will also
evaluate the patient’s mental functioning with tests of mental status,
such as those that require the patient to recall words, lists of
objects, names of objects, and recent events. Diagnostic tests, such as
blood tests, x-rays, or magnetic resonance imaging (MRI), positron
emission tomography (PET), or computed tomography (CT) scans, can help
determine the cause of the dementia.
Josh is a 3 year old child brought by his mother to your office because
of speech problems.

The mother reports that Josh speaks occasionally and when he does his
words are difficult to understand. He stays all day playing with a
puzzle game, trying repetitively to make pictures with it. He stays to
himself and does not hug her or show emotions to the family members. Her
pregnancy was uncomplicated, delivery was normal and he is growing well.
His vaccinations are up to date. Which of the following is most likely
diagnosis’

a) Asperger’s disease
b) Attention deficit hyperactivity disorder
c) Autism
d) Conduct disorder
e) Rett syndrome
The correct answer is C

Explanation
This child is most likely having autism. Autism is a pervasive
developmental disorder characterized by social impairment, speech and
language delay, minimal emotion expression and repetitive stereotypical
behaviors.

Asperger’s disorder is another pervasive disorder that is very close to


autism. However, language is usually normal.

Rett syndrome is a neurodevelopmental disorder of the brain that affects


girls almost exclusively. The clinical features include small hands and
feet and a deceleration of the rate of head growth.

ADHD is characterized by impulsiveness, hyperactivity and inattentiveness.

Conduct disorder is a psychiatric disease marked by a pattern of


repetitive behavior wherein the rights of others or social norms are
violated.
All of the following are classified as paraphilias, except

a) Fetishism
b) Homosexuality
c) Exhibitionism
d) Sexual sadism
e) Transvestism
The correct answer is b

Explanation
Paraphilias are recurrent, intense, sexually arousing fantasies, urges,
or behaviors that are distressing or disabling and that involve
inanimate objects, children or other nonconsenting adults, or suffering
or humiliation of oneself or the partner. Paraphilias include fetishism,
exhibitionism, sexual sadism and transvestism.

Homosexuality has not been considered a disorder or paraphilia for > 3


decades. About 4 to 5% of the population identify themselves as
exclusively homosexual for their entire lives. Like heterosexuality,
homosexuality results from complex biologic and environmental factors
leading to an ability to become sexually aroused by people of the same sex.
Which one of the following types of hallucination is normal?

a) Hypnagogic
b) Tactile
c) Olfactory
d) Auditory
The correct answer is A

Explanation
Hypnagogic phenomena are particularly vivid auditory or visual illusions
or hallucinations that may occur when just falling asleep or, less
often, immediately after awakening. They are difficult to distinguish
and are somewhat similar to vivid dreams, which are normal in REM sleep.
Hypnagogic phenomena occur in about 1-3 of patients with narcolepsy, are
common among healthy young children, and occasionally occur in healthy
adults.
Which is not a part of normal grief reaction after the death of a loved
one?

a) Physical symptoms
b) Preoccupation with suicide
c) Insomnia
d) Consider oneself responsible
e) Anorexia
The correct answer is b

Explanation
A normal reaction to loss, grief is unique in its impact, course and
meaning to each of us. While every change brings about a loss,
experiencing the loss of a partner, a parent or sibling, or a lifelong
friend, with whom we share history, often has special meaning to us and
hits us even harder.

Physical Symptoms: Fatigue, palpitations, trouble sleeping and a change


in appetite.

Emotional Symptoms: Sadness, anger, anxiety, helplessness, self blame


and guilt.

Behavioral/Psychological Symptoms: forgetfulness, difficulty


concentrating, dreams of the deceased, hallucinations of the deceased,
sensing their presence (visual or auditory).

Preoccupation with suicide is not normal and needs immediate


medical/psychiatric intervention.
Identify the type of schizophrenia that is marked by psychomotor
disturbances during which the patient may demonstrate rigidity,
immobility or posturing. Patient may get excited and shout or be silent
and withdrawn.

a) Disorganized schizophrenia
b) Catatonic schizophrenia
c) Paranoid schizophrenia
d) Residual schizophrenia
e) Undifferentiated schizophrenia
The correct answer is b

Explanation
Answer: B ‘ Catatonic schizophrenia is the type of schizophrenia that is
marked by psychomotor disturbances during which the patient may
demonstrate rigidity, immobility or posturing and may also be silent and
withdrawn and may even get excited and shout. This is recognized as
motor disturbances either psychological or physiological. Due to the
rigidity the body fails to move for long periods. This also involves the
slowdown of motor activity. Human thinking, feeling and behavior are
affected by the catatonic schizophrenia. This affects the interpersonal
relationship of the patient with others.

A. Disorganized schizophrenia is marked by inappropriate responses or


unresponsiveness. Even the hallucinations and delusions would be
fragmented. Hypochondriacal behavior may be present.
C. Paranoid schizophrenia is the schizophrenia during which the patient
would be very anxious, excited, aggressive and argumentative.
D. Residual schizophrenia is associated with vague associations,
illogical thinking and withdrawal.
E. Undifferentiated schizophrenia may be characterized by prominent
hallucinations, delusions, incoherence and disorganized behavior.

Each of the following personality disorders is followed by correct


descriptions of expected associated behaviors EXCEPT:

a) Paranoid: wariness, suspicion, jealousy, and violence


b) Schizoid: submissive, clinging, and indecisive
c) Antisocial: deceiving, manipulative, and seeking secondary gains
d) Borderline: impulsive, angry, and poor sense of reality
e) Narcissistic: entitled, vicious, and competitive
The correct answer is b

Explanation
Schizoid personality disorder is associated with behaviors of withdrawal
and seeking isolation and privacy. A dependent personality disorder is
unusually submissive, clinging, and indecisive with a childlike need to
be taken care of by others.
A 30 year old white female returns to your office for a 6 week follow-up
for depression. Six weeks ago, she started fluoxetine (Prozac) and se
now complains that her libido, which was decreased when she started the
drug, has become significantly worse. Which one of the following is
appropriate?

a) Continue fluoxetine and tell her that her libido will improve
b) Continue fluoxetine but increase the dosage
c) Stop fluoxetine and start imipramine (Tofranil)
d) Stop fluoxetine and start bupropion (Wellbutrin)
e) Stop fluoxetine and start sertraline (Zoloft)
The correct answer is D

Explanation
Fluoxetine and other SSRIs (e.g. sertraline) can cause or worsen loss of
libido. This is also true with tricyclics such as imipramine. Bupropion
does not inhibit libido.
A 35 year old man presents to the emergency room with suicidal ideation.
He describes significant stress due to recent job loss and financial
hardship. Further inquiry reveals a history of repeated job loss, fraud
charges, and frequent arm slashing to decrease stress. The man was not
disruptive as a child. The most likely diagnosis is

a) Borderline personality disorder


b) Antisocial personality disorder
c) Adjustment disorder
d) Dysthymic disorder
e) Schizophrenia
The correct answer is A

Explanation
Borderline personality is marked by unstable self-image, mood, behavior,
and relationships. Affected people tend to believe they were deprived of
adequate care during childhood and consequently feel empty, angry, and
entitled to nurturance. As a result, they relentlessly seek care and are
sensitive to its perceived absence. Their relationships tend to be
intense and dramatic. When feeling cared for, they appear like lonely
waifs who seek help for depression, substance abuse, eating disorders,
and past mistreatments. When they fear the loss of the caring person,
they frequently express inappropriate and intense anger.

These mood shifts are typically accompanied by extreme changes in their


view of the world, themselves, and other people’eg, from bad to good,
from hated to loved. When they feel abandoned, they dissociate or become
desperately impulsive. Their concept of reality is sometimes so poor
that they have brief episodes of psychotic thinking, such as paranoid
delusions and hallucinations. They often become self-destructive and may
cut themselves (self-mutilate) or attempt suicide.

NOTE: To receive a diagnosis of antisocial personality disorder (B), a


person must have shown behaviors of conduct disorder during childhood.

A 21 year old man presents with a recent suicide attempt. You are asked
to assess him in the emergency room. Which one of the following
statements concerning the suicide assessment of this patient is true?

a) Discussing suicide with persons suspected of feeling suicidal may


increase their risk of suicide
b) Persons with a recent suicide attempt are at less risk for
eventually killing themselves
c) Depressed persons who commit suicide can do so as they begin to improve
d) Persons with schizophrenia are at less risk for suicide
e) Persons with schizophrenia do not usually communicate their intentions
The correct answer is C

Explanation
In the assessment of suicide it is important to assess the following
indicators:

Previous attempts: 50% to 80% of those who commit suicide have


previously attempted it.

Depression: This symptom combined with problems sleeping and eating


increases the risk approximately 500 times. People are more likely to be
at risk when they are coming out of a depression rather than when they
are profoundly depressed.

The presence of psychotic thinking: Often severely disturbed people


believe death to be a temporary rather than permanent state. They fully
expect to return tomorrow after committing suicide today. Confusion and
disorientation also adds significantly to the risk factors.
A 25 year old male visits your office for follow-up 3 weeks after
beginning fluoxetine (Prozac) for newly diagnosed major depression. He
has experienced gastrointestinal discomfort, increased agitation,
worsening insomnia, and sexual dysfunction since beginning the drug.
Together you agree to discontinue fluoxetine and begin a different
medication. Which one of the following would be the best choice to avoid
agitation and sexual dysfunction?

a) Bupropion (Wellbutrin)
b) Clonazepam (Klonopin)
c) Sertraline (Zoloft)
d) Mirtazapine (Remeron)
e) Venlafaxine (Effexor)
The correct answer is D

Explanation
Many patients stop taking antidepressants within the first month of
therapy, often citing side effects as the reason. Fluoxetine, an SSRI,
is frequently associated with gastrointestinal irritation, sexual side
effects, and agitation. Sertraline is an SSRI with a similar side-effect
profile. Bupropion does not have the sexual side effects of the SSRIs
but can cause significant agitation. Clonazepam is a benzodiazepine and
likely would not cause many of this patient’s side effects, but is not
appropriate as the primary treatment for major depression. The mechanism
of action for venlafaxine includes both serotonin and epinephrine
reuptake inhibition, and it can cause some of the same symptoms as the
SSRIs. Mirtazapine, however, would help this patient sleep, usually does
not cause appetite suppression, and infrequently causes sexual disturbance.
Which of the following types of psychotherapy is most efficacious for
treating panic disorder?

a) Psychodynamic psychotherapy
b) Cognitive-behavioral therapy
c) Interpersonal psychotherapy
d) Psychoanalytic psychotherapy
e) None of the above
The correct answer is b

Explanation
Cognitive-behavioral therapy (CBT) can be very helpful in treating panic
disorders. Some studies found an equal efficacy to pharmacologic
interventions. CBT is based on the premise that panic is a learned
response. Cognitive misinterpretations of environmental and internal
cues result in a conditioned response, which can be unlearned.
Insight-oriented therapies based on underlying unconscious conflicts of
unresolved relationship issues tend not to alleviate the specific
symptoms of a panic disorder.
A 26-year-old female consults you because she becomes quite anxious in
many social situations, often panicking when she must lead discussions
at work. She states that she is increasingly uncomfortable in social
situations and is spending more time alone at home. She has asthma and
notes that her symptoms increased when she used albuterol.
Which one of the following would be the most appropriate therapy?

a) Sertraline (Zoloft)
b) Bupropion (Wellbutrin)
c) Alprazolam (Xanax)
d) Hydroxyzine (Vistaril)
e) Propranolol (Inderal)
The correct answer is A

Explanation
SSRIs, SNRIs, and other pharmacologic therapies are useful in
generalized social anxiety disorders, and often require higher doses to
be effective. This patient meets the criteria for a performance-type
social anxiety disorder with significant impairment, and an SSRI such as
sertraline is indicated. Buproprion is an antidepressant that is not
useful in managing anxiety disorders. A benzodiazepine or a ß-blocker
could be used for mild, intermittent performance anxiety, but would not
be appropriate in this situation. ß-blockers might also worsen her
asthma. Hydroxyzine is an antihistamine with sedating properties that is
not useful for treating anxiety disorders of this type.
In transvestitism disorder all of the following are true, except

a) Dressing in clothes of opposite gender for sexual excitement


b) More common males
c) Begins in late childhood
d) Most will present for treatment
The correct answer is D

Explanation
In transvestic fetishism, heterosexual males dress in women's clothing.
They generally begin such behavior in late childhood. This behavior is
associated, at least initially, with sexual arousal.

Cross-dressing per se is not a disorder. Personality profiles of


cross-dressing men are generally similar to age- and race-matched norms.
When their partners are cooperative, these men have intercourse in
partial or full feminine attire. When their partners are not
cooperative, they may feel anxiety, depression, guilt, and shame
associated with the desire to cross-dress.

Most transvestites do not present for treatment. Those who do are


brought in by unhappy spouses, are referred by courts, or are
self-referred out of concern about experiencing negative social and
employment consequences. Some cross-dressers present for treatment of
comorbid gender dysphoria, substance abuse, or depression. Social and
support groups for cross-dressers are generally helpful.
What is the most common side effect of lithium?

a) Renal insufficiency
b) Tremors
c) Hypothyroidism
d) Nephrogenic diabetes insipidus
The correct answer is b

Explanation
Lithium is commonly used to treat mania and bipolar depression
(manic-depression or bipolar disorder).

Tremor is the most common neurological side effect. Lithium tremor is an


irregular, non-rhythmic twitching of the arms and legs that is variable
in both intensity and frequency. Lithium-induced tremor occurs in
approximately half of persons taking this medication. The chance of
tremor decreases if the dose is reduced. Acute lithium toxicity
(poisoning) can result in neurological side effects, ranging from
confusion and coordination impairment, to coma, seizures, and death.
Other neurological side effects associated with lithium therapy include
lethargy, memory impairment, difficulty finding words, and loss of
creativity.

About 30 to 35% of patients experience excessive thirst and urination,


usually due to the inability of the kidneys to retain water and sodium.
However, lithium is not known to cause kidney damage.

Lithium inhibits the synthesis of thyroid hormone. About 10 to 20% of


patients treated with lithium develop some degree of thyroid
insufficiency, but they usually do not require supplementation with
thyroid hormone tablets.
Which one of the following historical features is specifically required
for the diagnosis of adult attention-deficit/hyperactivity disorder (ADHD)?

a) Difficulty with maintaining attention and focus


b) Affective lability with frequent mood swings
c) Impulsivity and hyperactivity
d) Symptoms present since childhood
e) Sporadic episodes of symptoms
The correct answer is D

Explanation
Of the criteria listed, the feature most critical to the diagnosis of
adult attention-deficit/hyperactivity disorder (ADHD) is the presence of
symptoms since childhood. An extended, consistent pattern of ADHD
symptoms, dating back to childhood, should be uncovered during history
taking. The recent onset of symptoms or sporadic episodes of symptoms
should raise concern about the appropriateness of the diagnosis of ADHD.

The other features listed are seen with ADHD, but are also seen with
other psychiatric disorders. Difficulty maintaining attention and focus
is seen with major depression, bipolar disorder, and substance abuse.
Affective lability occurs with bipolar disorder, substance abuse, and
personality disorders (e.g., borderline and antisocial personality).
Impulsivity and hyperactivity are characteristic of personality
disorders and bipolar disorder.
In healthy adults, performance on the Folstein Mini-Mental State
Examination is affected by which one of the following?
a) Educational attainment
b) Socioeconomic status
c) Gender
d) Race
The correct answer is A

Explanation
The Mini-Mental State Examination, developed by Folstein in 1975, has
become a standard tool for rapid clinical assessment of cognitive
impairment. The score is known to be affected by the patient’s
educational attainment. given the same level of cognitive impairment,
those with higher education levels score somewhat better than those with
less education. Race, sex, and socioeconomic status per se do not affect
patient’s scores.
A 23-year-old female was recently diagnosed with bipolar disorder after
experiencing her first episode of acute severe mania. After initial
stabilization, which one of the following would be appropriate for
maintenance therapy of her condition?

a) Gabapentin (Neurontin)
b) Olanzapine (Zyprexa)
c) Valproate (Depakene)
d) Lorazepam (Ativan)
e) No medication unless she has a second severe episode
The correct answer is C

Explanation
Of the agents listed, only valproate has been useful in maintenance
therapy for bipolar disorder. Patients should be maintained on
preventive therapy after a severe manic episode. Olanzapine is useful in
the management of severe mania, but is not as helpful for maintenance.
Lorazepam may be useful as adjunctive therapy. Gabapentin has not been
shown to be helpful.

An 82 year old male resident of a nursing home has developed symptoms of


depression including withdrawal and sadness. The staff also reports that
he doesn’t want to leave his room, and often expresses a desire to stay
in bed all day. After performing an appropriate evaluation and
recommending nonpharmacologic interventions, you also decide that
pharmacologic treatment is indicated. Which one of the following would
be the most appropriate antidepressant for this patient’

a) Amitriptyline (Elavil)
b) Doxepin (Sinequan)
c) Trazodone (Desyrel)
d) Sertraline (Zoloft)
e) Olanzapine (Zyprexa)
The correct answer is D

Explanation
Amitriptyline, doxepin, MAO inhibitors, and clomipramine should be
avoided in nursing-home patients. SSRIs are the most appropriate
first-line pharmacologic treatment for depression in nursing-home
residents. Other classes of non-tricyclic antidepressant may be
effective and appropriate, but the evidence for this is not as good as
the evidence for SSRIs.
The following therapies may be used in the management of chronic pain,
except

a) Cognitive therapy
b) Biofeedback
c) Systematic desensitization
d) Relaxation therapy
e) Physical therapy
The correct answer is C

Explanation
Treatment of chronic pain usually involves medicines and therapy.
Several types of therapy can help ease pain. Physical therapy (such as
stretching and strengthening activities) and low-impact exercise (such
as walking, swimming or biking) can help reduce the pain. However,
exercising too much or not at all can hurt chronic pain patients.
Occupational therapy teaches how to pace yourself and how to do ordinary
tasks differently so you won't hurt yourself. Behavioral therapy can
reduce pain through methods (such as meditation and yoga) that help you
relax. It can also help decrease stress.

Biofeedback, a method of consciously controlling a body function that is


normally regulated automatically by the body, such as skin temperature.
Biofeedback is a method that uses the mind to control a body function
that the body normally regulates automatically, such as skin
temperature, muscle tension, heart rate, or blood pressure.

Lifestyle changes such as getting daily exercise, eating a healthy diet,


getting enough sleep, and trying complementary therapies and
cognitive-behavioral therapy may help you reduce the pain or prevent it
from getting worse. Cognitive-behavioral therapy (CBT) teaches
relaxation techniques, stress management, and other ways to help you
cope with pain. Physical, psychological, and social factors all play a
role in pain management.

Systematic desensitization is a type of behavioral therapy used in the


field of psychology to help effectively overcome phobias and other
anxiety disorders.
A 40 year old man presents with sporadically occurring behaviour
automatisms and olfactory hallucinations. Which one of the following is
the most likely diagnosis’

a) Schizophrenia
b) Schizophreniform psychosis
c) Hysterical personality disorder
d) Nondominant parietal lobe lesion
e) Temporal lobe lesion
The correct answer is E
Explanation
Olfactory hallucinations are related to lobe lesions throughout the
entire brain, though mainly to the temporal lobe. Complex automatic
behaviorisms are related to lesions of the temporal lobe.

Visual hallucinations (formed images) are related to lesions of the


posterior temporal lobe or amygdala-hippocampus. Visual hallucinations
(unformed images) are related to lesions of the occipital lobe.

A 23-year-old black female visits your office because a home pregnancy


test was positive. You confirm that she is pregnant, at 6 weeks gestation.

She has a several-year history of moderate to severe depression which is


well controlled with fluoxetine (Prozac), and is concerned about the
drug’s effect on her pregnancy. You advise her that she should

a) Continue fluoxetine
b) Discontinue fluoxetine and substitute a tricyclic antidepressant
c) Discontinue fluoxetine and substitute valproic acid (Depakene)
d) Discontinue fluoxetine and substitute lithium
e) Add bupropion (Wellbutrin) to the fluoxetine
The correct answer is A

Explanation
Fluoxetine has been shown to be safe and effective throughout pregnancy.
Tricyclic antidepressants are not safer. Valproic acid and lithium can
cause significant teratogenic effects in the first trimester. There is
limited data on bupropion, and its use is therefore not recommended
during pregnancy.
A 37-year-old factory worker comes to your office because his wife
thinks he has a problem. He takes no drugs and has no significant past
medical history other than an episode of depression several years ago.
He is not currently depressed. He says that he feels ?great,? has plenty
of energy, and is the ‘fastest assembler in the plant.’ However, he does
admit to being more irritable than usual and often feeling restless. On
weekends and holidays he goes 48 hours without sleeping, choosing
instead to spend time on the Internet, ‘looking at stuff I shouldn’t see
and buying stuff I can’t afford.’ He admits that he sometimes oversteps
social boundaries by calling friends at inappropriate times of the day
or expounding on his intense religious convictions.

Which one of the following is the most likely diagnosis’

a) Attention deficit disorder


b) Bipolar II disorder
c) Generalized anxiety disorder
d) Borderline personality disorder
e) Schizophrenia
The correct answer is b
Explanation
This patient’s symptoms are most consistent with bipolar II
disorder/hypomania. According to the DSM-IV, bipolar II disorder is
characterized by one or more major depressive episodes accompanied by at
least one hypomanic episode. Hypomanic episodes consist of an elevated
mood, often with expansive or irritable qualities. Patients with
hypomania feel like they have abundant energy and often speak rapidly or
interrupt others repeatedly. They usually are convinced of their own
talent and often have intense religious and/or sexual interests. They
usually have a decreased need for sleep, spend money beyond their means,
and take unnecessary risks. Their intense social interest may cause them
to call friends at inappropriate times, especially late at night.

A diagnosis of bipolar II disorder requires a history of depression and


a hypomanic state at some time in the past that caused impaired
relationships or function and that is not explained by a medical
condition, drugs, or other psychiatric diagnosis (i.e., schizophrenia).
However, if symptoms have ever been fully manic, the diagnosis would be
bipolar I disorder.

Symptoms of attention deficit disorder (ADD) persist into adulthood in


up to 50% of children diagnosed with ADD, and can be similar to those in
this patient. There is insufficient information from his history
regarding childhood symptomatology to support a diagnosis of ADHD.
Although the patient notes irritability and restlessness, he does not
report excessive anxiety and worry, which are the central symptoms of
generalized anxiety disorder. Borderline personality disorder is
characterized by a similar pattern of marked impulsivity and poor social
boundaries. However, it is diagnosed primarily in women (75%), and this
patient apparently has been able to maintain a stable marital
relationship up to this point, which would be unusual.
Which of the following is the most accurate description of tardive
dyskinesia?

a) An acute extrapyramidal side effect of antipsychotic


b) An acute anticholinergic side effect of tricyclic antidepressants
c) A type of Parkinson’s disease
d) A side effect of excessive ECT treatments
e) A complication of long-term dopaminergic antagonist medications.
The correct answer is E

Explanation
Tardive dyskinesias (TDs) are involuntary movements of the tongue, lips,
face, trunk, and extremities that occur in patients treated with
long-term dopaminergic antagonist medications. People with schizophrenia
and other neuropsychiatric disorders are especially vulnerable to
developing TDs after exposure to conventional neuroleptics,
anticholinergics, toxins, substances of abuse, and other agents. TDs are
most common in patients with schizophrenia, schizoaffective disorder, or
bipolar disorder who have been treated with antipsychotic medication for
long periods, but TDs occasionally occur in other patients as well.
Tardive dyskinesia may persist after withdrawal of the drug for months,
years or even permanently.
TDs may be differentiated from acute movement disorders that commonly
occur in the same patient groups. The acute movement disorders that
occur as manifestations of effects of neuroleptics and other dopamine
antagonists include akathisia, acute dystonia, and other hyperkinetic
dyskinesias. Acute effects of dopamine antagonists also include
Parkinsonian syndromes manifested by bradykinesia, rigidity, and pill
rolling tremor. The acute movement disorders resulting from exposure to
dopamine antagonists are commonly termed extrapyramidal syndromes (EPS).

A 34-year-old female presents to the emergency department with a severe


migraine headache unresponsive to tramadol (Ultram) and sumatriptan
(Imitrex) at home. She takes fluoxetine (Prozac) for depression. Soon
after being given an injection of meperidine (Demerol), she develops
agitation, diaphoresis, tremor, diarrhea, fever and incoordination.

The most likely cause of the patient’s symptoms is

a) Serotonin syndrome
b) Thyrotoxic storm
c) Sepsis
d) Viral encephalitis
e) Panic attack
The correct answer is A

Explanation
Physicians who prescribe SSRIs such as fluoxetine should be aware of
potential drug interactions. Several of the SSRIs may increase the
effects of warfarin and raise tricyclic antidepressant levels.
Combination of an SSRI with a drug that increases serotonin
concentrations may induce the potentially life-threatening serotonin
syndrome, with mental status changes, agitation, myoclonus,
hyperreflexia, diaphoresis, shivering, tremor, diarrhea, incoordination,
and fever.

These drugs include monoamine oxidase inhibitors, tramadol, sibutramine,


meperidine, sumatriptan, lithium, St. John’s wort, ginkgo biloa, and
atypical antipsychotic agents.
You have recently begun caring for a 25-year-old white female who has
multiple complaints. You have seen her 3 times for walk-in office visits
over the past month. She has shown appreciation for your work during the
encounter, but has been critical of your care when talking to office
staff. At times she has been kind and charming, and at other times she
has been rude and verbally abusive to your staff. She has a string of
multiple relationships in the past, none of which has lasted very long.
During times of intense stress, she has sometimes engaged in
self-mutilation. She frequently changes jobs and living arrangements.

Which one of the following strategies would be most appropriate in the


care of this patient?

a) Strive to develop a close relationship with the patient


b) Ignore verbal attacks on staff members
c) Prescribe lorazepam (Ativan)
d) Schedule frequent office visits for follow-up
e) Provide detailed, technical explanations for any therapies provided
The correct answer is D

Explanation
This patient demonstrates features of borderline personality disorder.
These patients often demonstrate instability in interpersonal
relationships and self-image, and may be impulsive. They can present
with a wide range of symptoms, including depression, anger, paranoia,
extreme dependency, self-mutilation, and alternating idealization and
devaluation of their physicians. Their lives are often chaotic.

Treatment strategies include maintaining a caring but somewhat detached


professional stance. A close personal relationships is typically not
therapeutic for these patients. Angry outbursts will often have to be
tolerated, but limit-setting is necessary with respect to appropriate
behaviors. SSRIs, atypical antipsychotics, and mood stabilizers may be
of help at times, but anxiolytics are often abused and may be associated
with self-mutilating behaviors. These patients tend to respond best to
clear, simple, non-technical explanations related to their medical care.

A 27 year old man is suspicious of others, superstitious, believes he


possesses telepathic powers, and has no friends. Which one of the
following is most likely to be associated with this clinical description?

a) Passive-aggressive personality disorder


b) Histrionic personality disorder
c) Schizotypal personality disorder
d) Avoidant personality disorder
e) Obsessive-compulsive personality disorder
The correct answer is C

Explanation
Those with schizotypal personality disorder may share symptoms of
schizophrenia, but they are generally not so severe as to meet the
criteria for psychosis. People with this disorder tend to be shy and to
isolate themselves and may show mild suspiciousness and other
disturbances in thinking. Genetic studies indicate that schizotypal
personality disorder may be a mild form of schizophrenia.

A. Passive-aggressive personality disorder is a long-term (chronic)


condition in which a person seems to actively comply with the desires
and needs of others, but actually passively resists them. In the
process, the person becomes increasingly hostile and angry. People with
this disorder resent responsibility and show it through their behaviors,
rather than by openly expressing their feelings. They often use
procrastination, inefficiency, and forgetfulness to avoid doing what
they need to do or have been told by others to do.
B. Histrionic personality disorder is one of a group of conditions
called dramatic personality disorders. People with this disorder have
intense, unstable emotions and distorted self-images. They have an
overwhelming desire to be noticed, and often behave dramatically or
inappropriately to get attention.
D. People with avoidant personality disorder are preoccupied with their
own shortcomings. They form relationships with others only if they
believe they will not be rejected. Loss and rejection are so painful
that these people will choose to be lonely rather than risk trying to
connect with others.
E. Obsessive-compulsive personality disorder is a condition in which a
person is preoccupied with rules, orderliness, and control.

A 26-year-old law student is referred to a psychiatrist by her family


physician for treatment of symptoms of severe anxiety, frequent
handwashing, and hoarding. She relates to the consulting psychiatrist
that she has experienced a variety of obsessions and compulsions since
age 10. Which of the following statements about obsessive-compulsive
(OCD) is INCORRECT?

a) Concordance between monozygotic twins is negligible


b) The condition affects between 2% and 3% of the population
c) Presents at a younger age in males than females
d) Symptoms most commonly include cleaning, arranging, counting, and
checking
e) Patients are often secretive regarding the nature and extent of
their obsessions and compulsions
The correct answer is A

Explanation
Various twin studies have calculated concordance rates greater than 80%
in monozygotic twins. This indicates non-shared or environmental factors
play a role as the concordance rate is not 100%. Nonetheless genetics
have become increasingly implicated in the etiology of the disease.
Which one of the following predisposing factors for tardive dyskinesia
(TD) is INCORRECT?

a) Advanced age
b) Male gender
c) Mood disorders
d) Family history of affective disorders
e) Exposure to several antipsychotic medications
The correct answer is b

Explanation
Males can develop tardive dyskinesia, but females have a higher risk of
developing this condition. Both the prevalence and severity of TD
increase with age. Unipolar depression as well as positive family
history of affective disorder in relatives of schizophrenic patients are
predisposing factors.
Monoamine oxidase inhibitor drugs are used in the treatment of
depression because they increase synaptic levels of

a) Gamma-aminobutyric acid (GABA)


b) Histamine
c) Acetylcholine
d) Norepinephrine
e) Somatostatin
The correct answer is D

Explanation
Once the brain's three neurotransmitters, known as monoamines
(serotonin, norepinephrine, and dopamine), have played their part in
sending messages in the brain, they get burned up by a protein in the
brain called monoamine oxidase, a liver and brain enzyme.

Antidepressants known as monoamine oxidase inhibitors work by blocking


this cleanup activity. When the excess neurotransmitters don't get
destroyed, they start piling up in the brain. And since depression is
associated with low levels of these monoamines, increasing the
monoamines ease depressive symptoms.
A patient who is charming, manipulative, does not learn from experience
and shows lack of remorse or guilt has which of the following
personality disorders’

a) Antisocial
b) Borderline
c) Histrionic
d) Narcissistic
The correct answer is A

Explanation
Antisocial personality is marked by the callous disregard for the rights
and feelings of other people. Affected people exploit others for
materialistic gain or personal gratification. They become frustrated
easily and tolerate frustration poorly. Characteristically, they act out
their conflicts impulsively and irresponsibly, sometimes with hostility
and violence.

They usually do not anticipate the consequences of their behaviors and


typically do not feel remorse or guilt afterward. Many of them have a
well-developed capacity for rationalizing their behavior or blaming it
on others.

Dishonesty and deceit permeate their relationships. Punishment rarely


modifies their behavior or improves their judgment. Antisocial
personality often leads to alcoholism, drug addiction, promiscuity,
failure to fulfill responsibilities, frequent relocation, and difficulty
abiding by laws. Life expectancy is decreased, but the disorder tends to
diminish or stabilize with aging.
Which one of the following is most likely to induce withdrawal symptoms
if discontinued abruptly?

a) Venlafaxine (Effexor)
b) Divalproex (Depakote)
c) Fluoxetine (Prozac)
d) Olanzapine (Zyprexa)
e) Donepezil (Aricept)
The correct answer is A
Explanation
The abrupt discontinuation of venlafaxine, or a reduction in dosage, is
associated with withdrawal symptoms much more severe than those seen
with other SSRIs such as fluoxetine. Although more pronounced with
higher dosages and prolonged administration, they also occur at lower
dosages. These symptoms include agitation, anorexia, confusion, impaired
coordination, seizures, sweating, tremor, and vomiting. To avoid this
withdrawal symptom, dosage changes should be instituted gradually.

Abrupt discontinuation of mood stabilizers such as divalproex, and


atypical antipsychotics such as olanzapine, can result in the return of
psychiatric symptoms, but not severe physiologic dysfunction. Similarly,
stopping anticholinesterase inhibitors such as donepezil will not cause
a withdrawal syndrome.
From among the drugs listed below, which would be the cause for most
concern in an overdose

a) Paroxetine (SSRI)
b) Amitriptyline (tricyclic)
c) Diazepam (benzodiazepine)
d) Chlorpromazine (phenothiazine)
e) Fluoxetine (SSRI)
The correct answer is b

Explanation
Tricyclic antidepressant overdose is a significant cause of fatal drug
poisoning. The severe morbidity and mortality associated with these
drugs is well documented and due to their cardiovascular and
neurological toxicity. Additionally, they are a serious problem in the
pediatric population due to their inherent toxicity and the availability
of these in the home when prescribed for bed wetting and depression.

The central nervous system and heart are the two main systems that are
affected. Initial or mild symptoms include drowsiness, a dry mouth,
nausea, and vomiting. More severe complications, include hypotension,
cardiac rhythm disturbances, hallucinations, and seizures.
Electrocardiogram (ECG) abnormalities are frequent and a wide variety of
cardiac dysrhythmias can occur, the most common being sinus tachycardia
and intraventricular conduction delay (QRS prolongation). Seizures and
cardiac dysrhythmias are the most important life threatening complications.

While performing the Mini-Mental State Exam the PCP asks her patient to
copy the following design. What cognitive function is being assessed by
this request?

a) Language
b) Orientation
c) Registration
d) Recall
e) Visual-motor integrity
The correct answer is E
Explanation
While each possible choice listed is assessed during the Mini-Mental
State Exam, the specific request to copy the given design screens for
visual-motor integrity. A correct response includes correctly copying
all ten angles, two of which must intersect. The correct response is
awarded a score of 1 point on this 30-point screening exam.

An 18-year-old female presents with a fear of having run over someone


when she is driving. She has had to stop her car and get out to see if
there is a body in the road every time she drives over a bump. When you
ask her about other worries, she states she checks her stove, iron, and
coffee pot multiple times a day to ensure they are turned off. She has
tried to stop doing these things because she feels they don’t make
sense, but feels intense anxiety if she doesn’t stop and check. The
medications used to treat this disorder work primarily through which
neurotransmitter?

a) GABA
b) Serotonin
c) Glutamate
d) Norepinephrine
e) None of the above
The correct answer is b

Explanation
Obsessive-compulsive disorder is thought to occur due to serotonin
dysregulation. The areas of the brain that are thought to be involved
are the frontal lobes, the basal ganglia, and the cingulum. Treatment
includes selective serotonin reuptake inhibitors such as fluvoxamine or
fluoxetine, or the tricyclic agent clomipramine.
A patient with bipolar disorder has been well controlled on lithium for
3 years. He has had severe symptoms in the past. If lithium is
discontinued, the most likely result would be

a) Prolonged remission with a low risk of relapse


b) An episode of depression preceding any recurrence of mania
c) Recurrent mania within 6 months
d) Recurrent mania 1-2 years after discontinuation
e) A significant reduction in the risk of recurrence if psychotherapy
is begun
The correct answer is C
Explanation
All available studies indicate a high risk of recurrence of bipolar
illness after termination of lithium therapy. In one survey of 14
articles, the computed time to 50% failure of remission was 5 months,
with the time of recurrence of mania being 5.2 times earlier than for
depression. Mania tended to recur within 2.7 months, whereas depression
was delayed for as long as 14 months. More than 50% of new episodes of
illness occurred within 10 weeks of stopping therapy. In patients with
mean cycle lengths before treatment of almost 12 months, their time to a
new episode when off lithium therapy was less than 2 months. Studies
indicate that the risk of early recurrence of bipolar illness,
especially mania, evidently is increased following discontinuation of
lithium use and may exceed that predicted by the course of the untreated
disorder.
A 35 year old woman with a history of alcohol abuse and depression
presents in an obtunded state after an overdose of alcohol,
benzodiazepines and a MAOI. Which of the following represents the most
serious threat under these circumstances’

a) Delirium tremens
b) Respiratory arrest
c) Status epilepticus
d) Cerebrovascular accident
The correct answer is b

Explanation
Alcohol overdose may cause slurred speech, confusion and aggression and
puts the patient at risk of aspiration of vomit. Wernicke’s
encephalopathy requires immediate referral for urgent thiamine infusion.

Benzodiazepine overdose leads to drowsiness, ataxia and nystagmus to


hypotension, respiratory depression and coma.

Monoamine oxidase inhibitors (MAOIs) overdose symptoms include: tremor,


sweating, agitation, tachycardia and hyperthermia. Hyper or hypotension
may occur and in severe cases the patient may have seizures, respiratory
depression and/or cardiac arrest.
Each of the following is associated with conversion disorder EXCEPT:

a) Extreme concern by the patient for the disability


b) Not intentionally produced
c) Higher incidence in women
d) Frequent history of sexual abuse
e) Symptoms end abruptly
The correct answer is A

Explanation
Many conversion disorder patients exhibit la belle indifference, a lack
of concern regarding an apparent extreme decline in their health. This
condition often presents in late adolescence or early adulthood and is
more common in women with histrionic personality disorder and past
history of sexual abuse during childhood. In contrast to malingering or
factitious disorder, the symptoms of a conversion disorder are not
intentionally produced, but rather the ego defense mechanisms of
repression and dissociation are unconsciously at work. The symptoms
generally begin suddenly following a period of psychological stress and
in most cases end abruptly and are of a short duration.
A 23-year-old man who is struggling with finishing college is diagnosed
with schizophrenia. He eventually drops out of college and loses contact
with his family. He is found 5 years later living in a homeless shelter.
This illustrates the concept of:

a) Downward drift
b) Dissociation
c) Antisocial behavior
d) Malingering
e) Somatization
The correct answer is A

Explanation
The downward drift hypothesis is based on the belief that persons with
mental illness tend to drift into a lower socioeconomic class because
their illness interferes with skills needed to maintain a higher
socioeconomic status. There is a slow drift downward as living skills
become more and more impaired.
Which of the following is NOT considered a potential treatment for NMS’

a) Dantrolene
b) Discontinue all antipsychotic medications
c) Bromocriptine
d) Amantadine
e) Valproic acid
The correct answer is E

Explanation
Valproic acid has no particular use in the treatment of NMS. Dantrolene
blocks the release of calcium from the sarcoplasmic reticulum, producing
muscle relaxation. Of course, the offending antipsychotic should be
stopped. Bromocriptine acts as a dopamine receptor agonist, and
amantadine enhances the synthesis, release and reuptake of dopamine.
Symptomatic treatment of fever, correcting electrolyte imbalance, and
managing any cardiovascular instability are necessary as well. Some
studies indicate a mortality rate of nearly 12% for NMS.
A patient is taking St John’s wort for depressive symptoms. Which of the
following drugs would be contraindicated?

a) Phenelzine
b) Atenolol
c) Metformin
d) Niacin
The correct answer is A

Explanation
St John- wort is an herbal medicine used in the treatment of depression.
St. John's wort contains substances that appear to have an
antidepressant effect. Although the exact causes of this potential
interaction are not understood, the antidepressant effects of drugs like
phenelzine may be increased, decreased, or erratic when taken at the
same time that St. John's Wort is being used. In general, it is not
advisable to use St. John's wort or any other herbal supplement while
one is taking phenelzine.
Which of the following symptoms of schizophrenia responds best to
anti-psychotic medication?

a) Anti-social behavior
b) Flat affect
c) Paranoid delusions
d) Lack of motivation
The correct answer is C

Explanation
In schizophrenia symptoms are categorized as positive or negative.
Positive symptoms are characterized by an excess or distortion of normal
functions; negative symptoms, by diminution or loss of normal functions.
Positive symptoms can be further categorized as delusions and
hallucinations or thought disorder and bizarre behavior. Negative
symptoms include blunted affect, poverty of speech, anhedonia, and
asociality.

Antipsychotic drugs can be effective in reducing or eliminating positive


symptoms, such as delusions, hallucinations, and disorganized thinking.
After the immediate symptoms have cleared, the continued use of
antipsychotic drugs substantially reduces the probability of future
episodes.
A 28-year-old woman presents to a psychiatrist for evaluation of ‘bad
thoughts’. She relates that for the past three years, she has been
plagued by thoughts of harming her husband. Every day, many times
throughout the day, she experiences detailed visual images of stabbing
him repeatedly with a kitchen knife, or of him lying bloody and mangled
as she runs him over with her car. She is very upset about and ashamed
of these images, as she states that she loves her husband, does not want
to hurt him, and would never act on these images. She attempts to ignore
or suppress them, but they are completely beyond her control. She
identifies them as her own thoughts, however. She denies auditory
hallucinations, thought insertion, broadcasting, or withdrawal,
delusions of control, or other paranoid phenomena. She denies any
repetitive behaviors or mental acts which she feels driven to perform
and she denies a history of violent behavior. On examination, she
appears extremely distressed and anxious but her thought process is
organized and logical. What is the most likely diagnosis’

a) Schizophrenia, undifferentiated type


b) Sexual sadism
c) Partner relational problem
d) Dissociative disorder, not otherwise specified
e) Obsessive-compulsive disorder
The correct answer is E

Explanation
Obsessions are defined as recurrent intrusive thoughts, impulses, or
images that are recognized as inappropriate and are distressing to the
patient. This woman is one of the approximately 10% of patients who have
only obsessions, without compulsions.

A. The images are experienced as being her own thoughts, and so do not
qualify as hallucinations.
B. In sexual sadism, fantasies of injuring or humiliating other evoke
sexual excitement, which is not present in this case.
C. This DSM-IV diagnosis is used when the clinical focus is a
maladaptive pattern of interaction between spouses. This does not appear
to be the case here.
D. In dissociative disorders, there is a loss of a unitary sense of self
or identity. There is no evidence for dissociation here.
A 28-year-old unemployed white female presents to a psychiatrist for the
treatment of anxiety. She states that for the last ten years, she has
felt anxious in social situations because other women stare at her. When
asked why they stare at her, she states ‘I’m not sure, but they might be
jealous of my beautiful hair.’ She denies auditory or visual
hallucinations, thought broadcasting, insertion, or withdrawal, but
admits that she has ‘a sixth sense’ about people, and that she can
sometimes make events happen by thinking about them. She has no friends,
though she wishes she did, and in fact has no social contacts other than
her mother. As she relates this, she is smiling. She speaks with a
British accent, though she states she grew up in Ohio and has never been
outside the Midwest. Her speech is organized and coherent, however. What
is the likely diagnosis’

a) Schizophrenia, undifferentiated type


b) Paranoid personality disorder
c) Social phobia, generalized type
d) Schizotypal personality disorder
e) Schizoid personality disorder
The correct answer is D

Explanation
Individuals with schizotypal personality disorder appear eccentric, with
their odd ideas, magical thinking, inappropriate affect, and persistent
social anxiety. They are usually socially isolated, but may gravitate
toward fringe groups or subcultures, where their personality style may
appear less unusual.

A. Schizophrenia by DSM-IV definition must include two or more symptoms


of delusions, hallucinations, disorganized speech or behavior, and
negative symptoms (affective flattening, avolition, etc.). The patient
is uncertain of her belief that other women might be jealous of her
hair, and therefore this does not qualify as a delusion.
B. Patients with paranoid personality disorder are suspicious of others
without basis, but do not have the odd ideas, magical thinking, and
other eccentricities of schizotypal patients.
C. In social phobia, anxiety is associated with negative evaluations of
the self, rather than with the paranoid fears about others typically
seen with schizotypal personality disorder.
E. Unlike this patient, schizoid patients do not desire to have friends.
Which one of the following statements is true regarding the use of light
therapy to treat seasonal affective disorder?

a) It generally is most effective when administered in the morning


b) Duration of exposure to light is the main determinant of efficacy
c) It is not known to precipitate mania
d) Any light source may be used for treatment
The correct answer is A

Explanation
Light therapy generally is most effective when administered in the
morning. Early morning light helps regulate the circadian pattern of
melatonin secretion, whereas light in the evening can delay the normal
melatonin phase shift. The dosage of light therapy most often found to
be effective is 5000 lux daily. This can be given as 2500 lux for 2
hours or 10,000 lux for 30 minutes. Like drug therapy for depression,
light therapy does carry a risk of precipitating mania. Patients should
be instructed to use light therapy units that are specifically designed
for treatment of seasonal affective disorder. Other light sources may
not provide adequate brightness or ultraviolet light filtration.
Patients treated with which one of the following require regular
hematologic monitoring for the development of granulocytopenia?

a) Olanzapine (Zyprexa)
b) Haloperidol (Haldol)
c) Clozapine (Clozaril)
d) Fluphenazine (Prolixin)
e) Risperidone (Risperdal)
The correct answer is C

Explanation
Clozapine is one of the so-called second-generation antipsychotics,
which are believed to be less likely to cause extrapyramidal side
effects than the first-generation drugs such as haloperidol or the
phenotiazines (e.g., fluphenazine). A 2003 meta-analysis concluded that
clozapine was the most efficacious second-generation antipsychotic,
followed by risperidone and olanzapine. However, clozapine use is
associated with an approximately 1% incidence of granulocytopenia or
agranulocytosis. Early detection by monitoring blood counts every 1-2
weeks has led to a reduction in agranulocytosis-related death, but
clozapine is generally considered second-line therapy, to be used in
cases unresponsive to other drugs.
The predominant symptom associated with dysthymic disorder is

a) Incoherence
b) Loosening of associations
c) Delusions
d) Depression
The correct answer is D

Explanation
The predominant symptom associated with dysthymic disorder is
depression. Other names commonly used for this disorder are depressive
neurosis, characterological depression, and minor depression. The
depression associated with dsthymic disorder lacks the severity of major
depression is sustained over a 2-year period. Delusions, loosening of
associations, and incoherence are not associated with dysthymic disorder.
Schizophrenia is most commonly associated to

a) Monozygotic twins
b) Dizygotic twins
c) Siblings
d) Family history
The correct answer is A

Explanation
Schizophrenia is a mental disorder characterized by loss of contact with
reality (psychosis), hallucinations (usually, hearing voices), delusions
(false beliefs), abnormal thinking, flattened affect (restricted range
of emotions), diminished motivation, and disturbed work and social
functioning.

The genetic inheritance of this disorder is illustrated in the graph


above. Identical twins have clearly the highest rate of association.
A 40 year old man presents to the emergency room with rapid speech,
grandiose delusions, insomnia, and hypersexual behaviour of several
weeks duration. The history reveals similar past episodes interspersed
with periods of psychomotor retardation, hypersomnia, weight gain, and
poor job performance. Which one of the following drugs is most likely to
be of long-term benefit for this patient?

a) Thioridazine
b) Desipramine
c) Lithium
d) Chlordiazepoxide
The correct answer is C

Explanation
A manic episode is defined as > 1 week of a persistently elevated,
expansive, or irritable mood, accompanied by > 3 additional symptoms:
inflated self-esteem or grandiosity, decreased need for sleep, greater
talkativeness than usual, persistent elevation of mood, flight of ideas
or racing of thoughts, distractibility, increased goal-directed
activity, and excessive involvement in pleasurable activities with a
higher risk of undesirable consequences (eg, injury, loss of money).
Symptoms impair functioning.

Typically, mood stabilizers are used to induce remission in patients


with acute mania or hypomania. Lithium, acts as a mood stabilizer and is
similarly effective.
Which of the following statements concerning anorexia nervosa and
bulimia nervosa is false

a) Patients with either of these eating disorders are preoccupied with


weight, food, and body shape

b) Both of these eating disorders are more common in females than in males
c) Bulimia nervosa often presents earlier in adolescence than does
anorexia nervosa
d) Bulimic symptoms may occur in both bulimia nervosa and anorexia nervosa
The correct answer is C

Explanation
Anorexia nervosa is characterized by a relentless pursuit of thinness, a
morbid fear of obesity, a refusal to maintain a minimally normal body
weight, and, in women, amenorrhea. Diagnosis is clinical. Treatment is
with cognitive-behavioral therapy; olanzapine may help with weight gain,
and SSRIs, especially fluoxetine, may help prevent relapse.

Bulimia nervosa is recurrent episodes of binge eating followed by


self-induced vomiting, laxative or diuretic abuse, vigorous exercise, or
fasting. Diagnosis is based on history and examination. Treatment is
with psychotherapy and SSRIs, especially fluoxetine.

In anorexia, the illness begins between early adolescence (13-18 y) and


early adulthood, earlier-onset and later-onset are encountered. In some
patients with early-onset (ie, age 7-12 y).

In bulimia, eating disorders usually develop in adolescence, but about


5% of people develop the disorder when they are older than 25 years.
Peak onset of bulimia nervosa occurs at 18 years.
Potential complications of long-term therapy with lithium include which
one of the following?

a) Tardive dyskinesia
b) Agranulocytosis
c) Acquired nephrogenic diabetes insipidus
d) Hyperprolactinemia
The correct answer is C

Explanation
Late-onset polyuria in patients on chronic lithium therapy may indicate
the development of acquired renal tubular unresponsiveness to
antidiuretic hormone (nephrogenic diabetes insipidus) and is usually
reversible with discontinuation of the drug. Tardive dyskinesia is
mainly associated with the use of neuroleptic agents and has not been
reported in association with lithium therapy; in fact, lithium has been
used experimentally in the management of tardive dyskinesia. Chronic use
of lithium induces a mild, benign increase in the number of circulating
polymorphonuclear leukocytes, which has led to its experimental use in
the treatment of neutropenia. Hyperprolactinemia has not been reported
with lithium therapy, and the cardiovascular effects of lithium include
hypotension, not hypertension.
Which one of the following anticonvulsant medications is preferred for
the treatment of mania or hypomania in patients with bipolar disorder?

a) Phenytoin (Dilantin)
b) Phenobarbital
c) Valproic acid (Depakene)
d) Gabapentin (Neurontin)
e) Clonazepam (Klonopin)
The correct answer is C

Explanation
Anticonvulsant medications are used in the treatment of various
psychiatric disorder. Valproic acid is FDA-approved for the treatment of
manic episodes associated with bipolar disorder. It has been shown in
controlled studies to be significantly more effective than placebo. The
initial dosage is 750 mg daily given in divided doses, and most
individuals require between 1000 and 2500 mg daily. Carbamazepine has
also been used to treat mania and is an alternative for individuals who
cannot tolerate lithium or valproic acid. Clonazepam is used in the
treatment of panic attacks, and gabapentin is used to treat anxiety.
Both phenytoin and gabapentin are also used to treat peripheral
neuropathy. The primary use of Phenobarbital is as an anticonvulsant.
A 23-year-old patient presents to your office with complaints of
depression. He has trouble sleeping, poor appetite, feelings of
hopelessness, and passive suicidal ideation with no plan. He recently
lost his job because he has been chronically late or missing many days
of work. The patient reports that he would be late because he would need
to check the parking brake on his car several times to make sure it was
locked. He was embarrassed to admit that he missed work on days that he
knew his coworkers had cold symptoms. He was fearful that he would catch
their germs and become violently ill as a result. You also notice that
patient’s hands are dry and irritated. The patient explains that he
washes his hands frequently throughout the course of the day to avoid
contamination. Which of the following would be the best form of
medication treatment for the patient?
a) Bupropion
b) Desipramine
c) Nefazodone
d) Fluvoxamine
e) Nortriptyline
The correct answer is D

Explanation
The patient exhibits symptoms of obsessive-compulsive disorder and would
benefit from treatment with an antidepressant with serotonergic
properties. Fluvoxamine is a selective serotonin reuptake inhibitor that
has been FDA approved for treatment of OCD.

A. Bupropion is an antidepressant with dopaminergic and noradrenergic


properties and has not been shown to be effective in treatment of OCD.
B. Desipramine is a tricyclic antidepressant with highly noradrenergic
properties. Clomipramine is an alternative tricyclic antidepressant with
serotonergic properties shown to be effective for OCD.
C. Nefazodone antagonizes the 5-HT2 receptor but shows modest blockade
of 5-HT reuptake. Studies are lacking that show its effectiveness for
treatment of OCD.
E. Nortriptyline is another noradrenergic tricyclic antidepressant.

Electroconvulsive therapy (ECT) is generally contraindicated in the


presence of

a) Brain tumor
b) Cardiac rhythm disturbance
c) Impaired liver function
d) Chronic obstructive pulmonary disease
e) Osteoporosis
The correct answer is A

Explanation
ECT can be administered to persons with severe medical conditions.
Although some medical conditions may alter the risk of treatment, there
are no ‘absolute’ medical contraindications to the use of ECT. In some
medically ill patients ECT may be preferred because of its efficacy and
safety profile.

Providers should assure review of medical conditions that may


substantially increase risk during the delivery of ECT. A medical
history and physical examination are essential before prescribing of ECT
to determine risk factors and minimize risks. Factors that significantly
increase risk may include: unstable or severe cardiovascular conditions,
aneurysm or vascular malformation, increased intracranial pressure (eg
brain tumor), cerebral infarction and pulmonary insufficiency.
A 62-year-old male recently moved and presents to your office for an
initial examination. He has bipolar disorder that has been treated with
lithium for many years. Which one of the following should be monitored
at regular intervals in patients taking lithium?

a) Adrenal and thyroid function


b) Liver and adrenal function
c) Liver and thyroid function
d) Renal and thyroid function
e) Renal and liver function
The correct answer is D

Explanation
Lithium is a mood-stabilizing agent that is used to treat acute manic
episodes of bipolar disorder. Long-term complications include the
potential for renal impairment and hypothyroidism. It is recommended
that renal function be tested every 2-3 months for 6 months and every
6-12 months thereafter. Thyroid function should be evaluated once or
twice during the first 6 months of treatment and every 6-12 months
thereafter.
A 33 year old white female comes to your office accompanied by her
spouse. In the last 9 months she has withdrawn from a master’s degree
program and has requested a leave of absence from her job as a teacher.
Her husband says that she no longer will accept social engagements, and
that she was formerly highly active in church and teaching Sunday
school, but has also withdrawn from these activities. Her marriage
remains strong, she sleeps well, and she continues independent running
and cycling. Which one of the following would be appropriate as initial
treatment?

a) Lithium
b) Paroxetine (Paxil)
c) Haloperidol (Haldol)
d) Alprazolam (Xanax)
e) Trazodone (Desyrel)
The correct answer is b

Explanation
Paroxetine has emerged as the drug of choice for treatment of social
phobias. Also known as social anxiety disorder, social phobias
characteristically cause fear of situations that may lead to
embarrassing scrutiny. Patients learn to avoid situations where they
fell others may notice them such as church gatherings, classroom
settings, and other group events. Lithium and haloperidol are used for
more severe psychiatric disturbances, while alprazolam would be best
reserved for secondary use because of the possibility of dependency.
Trazodone is approved for treatment of depression, but its strong
sedative properties make it inappropriate in this scenario.
Which one of the following is contraindicated in a patient taking an SSRI?

a) Phenothiazines
b) Electroconvulsive therapy
c) Alpha-Receptor blocking agents
d) Monoamine oxidase inhibitors
e) Benzodiazepines
The correct answer is D

Explanation
Combining serotonergic medications such as SSRIs and MAO inhibitors can
lead to the serotonin syndrome, a potentially fatal metabolic reaction.
When switching from an SSRI to an MAO inhibitor, a washout period of
five half-lives of the SSRI is recommended.
Cognitive therapy helps to correct which of the following ?

a) Depersonalization
b) Psychotic thinking
c) Over-generalizations
d) Selective inference
e) Posttraumatic stress disorder
The correct answer is E

Explanation
Cognitive Behavioral Therapy (CBT) is a psychotherapy based on modifying
cognitions, assumptions, beliefs and behaviors, with the aim of
influencing disturbed emotions. The general approach, developed out of
behavior modification, CBT has become widely used to treat various kinds
of neurosis and psychopathology, including mood disorders and anxiety
disorders. The particular therapeutic techniques vary according to the
particular kind of client or issue, but commonly include keeping a diary
of significant events and associated feelings, thoughts and behaviors;
questioning and testing cognitions, assumptions, evaluations and beliefs
that might be unhelpful and unrealistic; gradually facing activities
which may have been avoided; and trying out new ways of behaving and
reacting.

Relaxation and distraction techniques are also commonly included. CBT is


widely accepted as an evidence- and empiricism-based, cost-effective
psychotherapy for many disorders and psychological problems.

In recent years, CBT has been used to treat symptoms of schizophrenia,


such as delusions and hallucinations.

An intensive form of cognitive-behavioral therapy that requires patients


to imagine themselves being exposed to the traumatic event is highly
effective for rape-related PTSD.This technique produces significant
reduction in all symptom clusters of the disorder in most patients.
A 28 year old female complains of generalized headache, dizziness
(characterized as lightheadedness), and generally not feeling well for 3
days. This started at the same time as her menses and coincided with a
major examination in a college class she is taking. Her review of
symptoms is otherwise negative. Her past medical history includes a
recent acute onset of low back pain related to lifting, and a recent
depressive episode which responded well to medication. Her current
medications include an oral contraceptive which she has taken for 2
years, a corticosteroid nasal spray, and ibuprofen for the past 2 weeks.
She was on paroxetine (Paxil), 30 mg/day, for 7 months, but this was
stopped 5 days ago because of sexual dysfunction. Because of her
symptoms she has not taken any medications for the past 2 days. Since
then the headache has eased substantially, but the feeling of
lightheadedness has remained. A physical examination is unremarkable.
Which one of the following is the most likely cause of her symptoms’
a) Allergic rhinitis
b) Paroxetine withdrawal
c) Serotonin syndrome
d) Viral infection
e) Stress
The correct answer is b

Explanation
The timing of the symptoms (starting about 2 days after paroxetine was
stopped) and the symptoms (headache, light-headedness) are consistent
with SSRI discontinuation syndrome. This syndrome is more likely with
abrupt withdrawal, after prolonged treatment, at higher doses.
A 25 year old female is brought to the ER after ingesting a bottle of
aspirin tablets in a suicidal attempt.

She is complaining of confusion and tinnitus. On examination she has RR:


25/min, temp is 38.5C, BP is 132/80 mmHg and PR: 90/min. Which of the
following would best describe the acid base status of this patient?

a) pH (7.24), PaCO2 (35mmHg), HCO3 (13 meq/L)


b) pH (7.30), PaCO2 (50mmHg), HCO3 (24 meq/L)
c) pH (7.36), PaCO2 (22mmHg), HCO3 (12 meq/L)
d) pH (7.40), PaCO2 (40mmHg), HCO3 (23 meq/L)
e) pH (7.45), PaCO2 (30mmHg), HCO3( 20 meq/L)
The correct answer is C

Explanation
Aspirin toxicity can cause dramatic changes in the acid base status. In
adults, it stimulates the respiratory center and thus leads to
respiratory alkalosis. However, it also uncouples oxidative
phosphorylation leading to a metabolic acidosis state (lactic acidosis
caused by hypoxia). So in adults, you expect mixed respiratory alkalosis
and metabolic acidosis.

Answer 1 suggests primary metabolic acidosis without compensation

Answer 2 suggests acute respiratory acidosis without compensation.

Answer 4 is a normal acid base status.

Answer 5 suggests respiratory alkalosis with metabolic compensation.

Aspirin toxicity is a hot topic! On the exam, you may not see the same
scenario; you may see a clinical scenario describing a young child with
aspirin toxicity! Expect the acid base status to be different, in young
children the respiratory center stimulation is not there; look for
metabolic acidosis alone i.e. answer 1 would be correct.

A 38 year old man is taking medications for psychoses. You would like to
change his treatment from his current antipsychotic agent to
risperidone. What is the best way to do it?

a) Discontinue his current antipsychotic agent abruptly and start


risperidone
b) Gradually reduce the dose of his current antipsychotic agent before
initiating risperidone
c) Use both his current antipsychotic agent and risperidone for better
control
d) Start risperidone at full dose and then gradually reduce the dose of
his current antipsychotic agent until discontinued.
e) Increase the dose of the current antipsychotic agent, initiate
risperidone and then adjust the dosage of both.
The correct answer is b

Explanation
When treating patients with psychoses, you must often consider changing
their treatment from one antipsychotic agent to another. A principal
problem in changing antipsychotic agents is the potential for withdrawal
symptoms resulting from discontinuation of the existing therapy. These
syndromes can manifest as reemergence or worsening of psychosis, rebound
or unmasked dyskinesia, and cholinergic-rebound symptoms. Withdrawal
signs and symptoms may include insomnia, nausea, vomiting, anxiety, and
agitation.
When switching a patient to the new antipsychotic agent risperidone, you
can keep withdrawal symptoms to a minimum. Usually, the dose of the
previous medication must be gradually reduced before risperidone is
initiated. However, in many cases, the transition is best made by
overlapping the existing therapy and risperidone.
A patient with bipolar disorder is being treated with lithium. Of the
following, which one is the most likely side effect of this therapy?

a) Hypoparathyroidism
b) Hypoaldosteronism
c) Hypothyroidism
d) Diabetes insipidus
The correct answer is C

Explanation
Lithium is used as a mood stabilizer in bipolar disease and can be used
as monotherapy, especially when the depression is mild. A
well-recognized side effect lithium is hypothyroidism. It is recommended
that TSH be monitored in patients treated with lithium.
Hyperparathyroidism, but not hypoparathyroidism, has been reported, but
it is not common as hypothyroidism. Nephrogenic diabetes insipidus has
been reported only rarely. Hypoaldosteronism is not a side effect of
lithium therapy.
Psychotherapy is superior to medication in the management of

a) Schizophrenia
b) Bipolar disorder
c) Alcoholic withdrawal
d) Dysthymia
The correct answer is D

Explanation
Dysthymia is defined as low-level or subthreshold depressive symptoms.
Symptoms typically begin insidiously during adolescence and follow a
low-grade course over many years or decades (diagnosis requires a course
of ? 2 years). Dysthymia may intermittently be complicated by episodes
of major depression. Affected patients are habitually gloomy,
pessimistic, humorless, passive, lethargic, introverted, hypercritical
of self and others, and complaining.

Both cognitive behavior therapy and interpersonal psychotherapy have


been demonstrated in controlled studies to be effective in the treatment
of depression and dysthymia.
A 59-year-old female presents to the emergency room after coming to work
very confused. She had difficulty answering questions, and her coworkers
saw her stumbling. Her coworkers are puzzled because she doesn?t seem to
smell of any alcohol. They report repeated episodes of the patient
coming to work intoxicated and state she has been alcoholic for most of
her life. On exam you find her disoriented with a disconjugate gaze and
staggering gait. The diagnosis that is most consistent with this
presentation and most worrisome is:

a) Acute alcohol intoxication


b) Transient ischemic attack
c) Wernicke's encephalopathy
d) Korsakoff's syndrome
The correct answer is C

Explanation
Wernicke’s encephalopathy is characterized by acute confusion, sixth
nerve palsy, and unsteady gait. Though the triad is characteristic, it
may occur with very subtle eye or gait findings that are initially
missed. Since this is potentially reversible it is important to be
actively looking for these findings to ensure the diagnosis is not missed.

A. Though it can appear as if the patient is intoxicated, remember that


most intoxicated people are not disoriented, nor do they have
ophthalmoplegia on exam.
B. Patients with thiamine deficiency may have cardiovascular disease,
but this would not be a typical TIA presentation. The more worrisome
diagnosis is Wernicke’s, which can be treated if recognized quickly.
D. Korsakoff’s syndrome is a persistent form of thiamine deficiency. It
presents more slowly and is characterized as a failure in short-term
memory. The patient may confabulate her history to conceal her memory
deficits. If Wernicke’s encephalopathy progresses to Korsakoff’s
syndrome, the chances of recovery diminish to only 20%.

A 30 year old woman presents with depression. She has had no prior
episodes, but did see a psychiatrist one year ago because of bulimia.
She states she still occasionally purges. You decide that she does need
antidepressant treatment and discuss many options with her. The one
medication that you would hesitate to recommend in this patient would be:

a) Buspirone
b) Nefazodone
c) Sertraline
d) Bupropion
e) Fluoxetine
The correct answer is D

Explanation
The most serious potential side effect of bupropion is seizures. The
risk of having a seizure is increased when there is an eating disorder
such as bulimia or anorexia. The mechanism is not understood at this
time, but if possible an alternative agent should be used in this
patient. The other options listed do not have a contraindication with a
history of eating disorders.
[Nefazodone (Serzone, Nefadar) is an antidepressant that was
discontinued in May, 2004 in the United States and Canada due to the
rare incidence of hepatotoxicity (liver damage), which could lead to the
need for a liver transplant, or even death.]
Difficult patients include those who make repeated visits without
apparent medical benefit, those who do not seem to want to get well,
those who engage in power struggles, and those who focus on issues
seemingly unrelated to medical care. Which one of the following
strategies is recommended for managing such patients’

a) Ignore the problem behavior


b) Refer the patient to another physician
c) Confront the patient directly about the negative behavior and the
reality that there is nothing physically wrong
d) Schedule regular visits at 2- to 3-week intervals
e) Prescribe an SSRI
The correct answer is D

Explanation
Ignoring the problem or exporting it to another physician does not make
the difficulty disappear. Accusing the patient of being problematic may
provoke patient anger and counter-blaming. Telling the patient that
there is nothing wrong or that there is nothing you can do for him or
her may trigger persistent attempts to prove that a problem exists.
Attempts to solve problems with psychopharmacology, unless carefully
introduced and targeted to a specific diagnosis, may also prove
problematic. One of the best suggestions for better management of these
patients is to schedule regular follow-up visits at 2- to 3-week
intervals, especially if high dependency needs are suspected.

A 26-year-old single woman is referred by her primary care physician to


a psychologist for testing. An MMPI is performed resulting in a
?conversion V? profile as reported on the 1, 2, and 3 scales. Which one
of the following conditions is most closely associated with this profile
on the MMPI?

a) Psychosis
b) Somatoform disorder
c) Invalid profile
d) Normal profile
e) None of the above
The correct answer is b
Explanation
Conversion ?V? is a profile seen on the MMPI when there are elevations
of hypochondriasis (1) and conversion hysteria (3) scales both higher
than the elevated depression (2) scale, resulting in a ?V?
configuration. This suggests that the patient is depressed but unable or
unwilling to interpret the experience psychologically. Distress is
typically experienced physically, resulting in nonspecific somatic
preoccupations.
Which one of the graphed curves best reflects the relationship between
clinical response and the plasma levels for imipramine?

a) Straight line
b) Sigmoidal
c) Curvilinear
d) None of the above
e) All of the above
The correct answer is b

Explanation
A sigmoidal relationship exists between response and imipramine plus its
therapeutic metabolite desipramine levels. This clinical response
increases with a plasma level up to approximately 250 ng/ml and then
levels off. The antidepressant nortriptyline is associated with a
curvilinear clinical response-plasma level relationship.
A 34-year-old woman presents to her obstetrician’s office accompanied by
her spouse three weeks after delivering a healthy infant son. Her
husband relates that soon after leaving the hospital his wife has become
increasingly irritable, tearful, and is having trouble sleeping. The
past week she has become extremely indecisive and expresses concerns
that she is not capable of caring for her newborn even though this is
her third child. Which one of the following is the likely diagnosis’

a) Postpartum blues
b) Puerpal psychosis
c) Postpartum major depression
d) Adjustment disorder with mixed emotional features
e) Bipolar disorder
The correct answer is C
Explanation
Postpartum major depression. The postpartum period is a time of
increased risk for development of mood disturbances in women. Postpartum
depressive disorders are divided into three classifications: postpartum
blues, postpartum depression, and puerperal psychosis. Postpartum blues
is the most common and is separated from postpartum depression by the
severity of symptoms in the latter condition and typically peaking
within the first week after delivery. Postpartum or puerperal psychosis
is relatively rare, with the onset for the majority of cases within 2
weeks postpartum. Psychotic symptoms would include delusions,
hallucinations, and bizarre, disorganized behavior. There is an
association between postpartum psychosis and bipolar disorder. This
patient’s symptoms are too severe to classify as an adjustment disorder.
Her mood disturbance warrants psychiatric consultation and likely will
require pharmacologic treatment.
A 30-year-old male smoker with an 18-pack-year history comes to your
office complaining of a dry, hacking cough. You perform a physical
examination and obtain a chest X-ray to confirm that he does not have an
active infection. You wish to educate the patient about smoking
cessation and advise the patient to stop smoking. Which of the following
would be the most appropriate first step for intervention?

a) Confront the patient about his smoking behavior and associated


health risks
b) Educate the patient about physiological and psychosocial therapies
available for smoking cessation
c) Establish a therapeutic alliance with the patient
d) Make a referral to a psychiatrist for nicotine dependence
e) Give the patient pamphlets on smoking cessation
The correct answer is C

Explanation
Establishing a therapeutic relationship is important due to the chronic,
relapsing nature of nicotine dependence. Advising a patient to stop
smoking is best done in a supportive and non-judgmental manner. There
are currently no studies to support that confrontational styles are
effective for smoking cessation. Often smokers are ambivalent about
quitting, and giving more personalized information and feedback on
smoking cessation can increase motivation to change.
Psychogenic amnesia may be characterized by all of the following, except

a) Depression
b) Moderate to severe anterograde amnesia
c) Inconsistent memory loss
d) Loss of a sense of personal identity
e) Sudden onset of amnesia for personally significant memories
The correct answer is b

Explanation
Dissociative amnesia is an inability to recall important personal
information that is too extensive to be explained by normal
forgetfulness. The cause is usually trauma or severe stress. The
information lost would normally be part of conscious awareness that
could be described as autobiographic memory, eg, who one is; what one
did; where one went; to whom one spoke; what was said, thought,
experienced, and felt. The forgotten information sometimes continues to
influence behavior.

The incidence is unknown, but dissociative amnesia is most commonly


diagnosed in young adults. The amnesia appears to be caused by traumatic
or stressful experiences endured or witnessed (eg, physical or sexual
abuse, rape, combat, abandonment during natural disasters, death of a
loved one, financial troubles) or tremendous internal conflict (eg,
turmoil over guilt-ridden impulses, apparently unresolvable
interpersonal difficulties, criminal behaviors).

The main symptom is memory loss. Characteristically, one or more


episodes are experienced, in which some patients forget some, but not
all, events that occurred during a period of time; others cannot recall
any information. These periods, or gaps in memory, may represent only a
few hours or can encompass years or even an entire lifetime. Usually the
forgotten period of time is clearly demarcated.
Two middle aged brothers moved back into their parent’s house, in order
to take care of the family business. The eldest brother was diagnosed
with paranoid schizophrenia, and was not compliant with his medication.
He would constantly tell his younger brother that the neighbors were
plotting against their family, and would be contaminating the water
supply with arsenic. He would also stress the importance of not trusting
anyone in the community, and because harm would come to them. The
younger brother did believe these things that his elder brother would
tell him. When the elder brother left the home, the younger brother
started to let go of these beliefs. What is the younger brother’s diagnosis’

a) Folie a deux

b) Capgras syndrome

c) Paranoid delusions

d) Fregoli delusion

e) Mirrored self misidentification


The correct answer is A

Explanation
Folie a deux is where symptoms of a delusional belief is transmitted
from one individual to another individual. This syndrome is most
commonly diagnosed when the two or more individuals concerned live in
proximity and may be socially or physically isolated and have little
interaction with other people.
Capgras syndrome is where a person holds a delusion that a friend,
spouse, parent or other close family member has been replaced by an
identical-looking impostor.
Fregoli delusion is a delusional belief that different people are in
fact a single person who changes appearance or is in disguise. May be
related to a brain lesion, and is often of a paranoid nature with the
delusional person believing themselves persecuted by the person they
believe is in disguise.
Mirrored self-misidentification is the delusional belief that one's
reflection in a mirror is some other person (often believed to be
someone who is following them around). Often people who suffer from this
delusion are not delusional about anything else.

A high risk of suicide is associated with which one of the following factors

a) Female aged less than 30 years


b) Married male less than 30 years
c) Public setting
d) Secondary gain from attempt
e) Single male aged more than 60 years
The correct answer is E

Explanation
In most countries, women continue to attempt suicide more often, but men
tend to complete suicide more often. Although the frequency of suicides
for young adults has been increasing in recent years, elderly Caucasian
males continue to have the highest suicide rate. Other risk factors for
taking one's life include single marital status, unemployment, low
income, mental illness, a history of being physically or sexually
abused, a personal history of suicidal thoughts, threats or behaviors,
or a family history of attempting suicide.

Data regarding mental illnesses as risk factors indicate that


depression, manic depression, schizophrenia, substance abuse, eating
disorders, and severe anxiety increase the probability of suicide
attempts and completions. Nine out of 10 people who commit suicide have
a diagnosable mental illness and up to three out of four individuals who
take their own life had a physical illness when they committed suicide.
Behaviors that tend to be linked with suicide attempts and completions
include violence against others and self-mutilation, like slitting one's
wrists or other body parts, or burning oneself.
A 68-year-old black female is brought to your office by her daughter,
who tells you that her mother has recently been exhibiting short-term
memory loss and confusion. For example, she has difficulty remembering
how to get dressed appropriately and sometimes forgets to turn off the
oven after using it. These symptoms developed fairly abruptly. The
patient’s medical problems include type 2 diabetes mellitus,
hypertension, hypercholesterolemia, and osteoarthritis. She had a stroke
last year and has residual mild hemiparesis.

A physical examination is normal except for mild hemiparesis. On


cognitive testing she is able to recall only one of three words, and all
the numbers are on one side on the clock-drawing test.

Which one of the following types of dementia is most likely in this


patient?

a) Alzheimer’s disease
b) Dementia with Lewy bodies
c) Vascular dementia
d) Frontotemporal dementia
e) Multisystem atrophy
The correct answer is C

Explanation
This patient's history and examination meet the criteria for vascular
dementia published by the National Institute of Neurological Disorders
and Stroke, and the Association Internationale pour la Neurosciences
(NINDS-AIREN). Significant findings include cognitive decline from a
previously higher level of functioning, manifested by impairment of
memory and of two or more cognitive domains, and evidence of
cerebrovascular disease by focal signs on neurologic examination,
consistent with stroke. To fully meet the NINDS-AIREN criteria, she
would need to have neuroimaging that demonstrates characteristic
vascular dementia lesions.

A 28-year-old white female sees you for preconception counseling. For


the past 3 years she has been successfully treated with fluoxetine
(Prozac) for depression, and she asks if she can continue taking it when
she becomes pregnant. It is labeled by the FDA as category C for use in
pregnancy.

Which one of the following would you advise?

a) There is evidence of harm to the human fetus, and she should


discontinue it
b) Controlled studies in women fail to demonstrate risk to the fetus;
it is safe to continue it
c) Animal studies do not indicate any risk to the fetus; there are no
studies in women
d) Animal studies demonstrate some risk to the fetus; there are no
studies in women
e) There is evidence of risk to the human fetus
The correct answer is D

Explanation
Physicians are often asked to advise women on the use of medicines
during pregnancy, even if they are not providing the primary obstetrical
care. FDA category C means that animal studies demonstrated teratogenic
or embryocidal effects, but there are not controlled studies in women.
Fluoxetine caused a higher incidence of stillbirths in rat reproductive
studies, but the surviving litter mates showed no evidence of
neurotoxicity. There are no controlled studies in humans, although there
are no reports of major malformations in babies born to mothers who took
fluoxetine in the first trimester.

Category A medications are those for which controlled studies in women


show no risk to the fetus. Category B indicates that animal studies have
shown no risk but there are no controlled human studies. Category D
agents have ?positive evidence? of human fetal risk but their use is
allowed in situations where the benefit outweighs that risk. Category X
medicines are those which have evidence of harm ot human fetuses and
should not be used at all during pregnancy.

Loosening of association is associated with which of the following?

a) Schizophrenia
b) Mania
c) Bipolar
d) Depression
The correct answer is A

Explanation
Loosening of association (derailment) is pattern of speech in which a
person's ideas slip off one track onto another that is completely
unrelated or only obliquely related. In moving from one sentence or
clause to another, the person shifts the topic idiosyncratically from
one frame of reference to another and things may be said in
juxtaposition that lack a meaningful relationship.

This disturbance occurs in schizophrenic patients.


A 26 year old man with schizophrenia comes to the emergency department
with a 2 hour history of involuntary contractions of the muscles in his
neck. He states that he was watching television and "all of a sudden I
turned my head and my neck locked". He began taking a high-potency
antipsychotic agent 3 days earlier. Examination shows no abnormalities
except torticollis. Which of the following is the most appropriate
pharmacotherapy?

a) Amantadine
b) Benztropine
c) Bromocriptine
d) Clonidine
e) Propranolol
The correct answer is b

Explanation
This patient has acute dystonia. Dystonia is characterized by
involuntary muscle spasms, which in this patient, are due to a high
potency antipsychotic agent. Dystonia is most common in young men, and
often begins within days of starting the drug therapy. It usually
involves the muscles of the head and neck, leading to torticollis and
blepharospasm. It can produce a life-threatening laryngospasm requiring
intubation. The treatment of acute dystonia is with anticholinergic
medications, such as benztropine or diphenhydramine.
Which of the following drugs would be the best to use in a patient with
obsessive compulsive disorder?

a) Imipramine
b) Amitriptyline
c) Fluvoxamine
d) Buspirone
e) Clonazepam
The correct answer is C
Explanation
Obsessive-compulsive disorder is characterized by recurring, unwanted,
anxiety-provoking, intrusive ideas, images, or impulses (obsessions)
that may even seem silly, weird, nasty, or horrible to the person
experiencing them. The person also has urges (compulsions) to do
something that will relieve the discomfort caused by the obsessions.

Rituals used to control an obsession include the following:

Washing or cleaning to be rid of contamination


Checking to eliminate doubt (for example, checking to make sure a door
is locked)
Hoarding to prevent loss
Avoiding the people who might become objects of aggression

Mainstay of treatment for OCD is with a Selective serotonin reuptake


inhibitors such as fluoxetine and fluvoxamine, and with clomipramine
which is a tricyclic antidepressant. Many experts believe that a
combination of exposure therapy and drug therapy is the best treatment.

A 37 year old white male comes to your office for evaluation of multiple
complaints. He has seen three other physicians but has been dissatisfied
with their treatment. He states that he has been in poor health for most
of his adult life, and lists the following complaints: difficulty
swallowing, palpitations, shortness of breath, impotence, difficulty
urinating, vomiting, diarrhea, bloating, muscle weakness, joint pains,
dizziness, fainting, poor vision, and headaches. A thorough physical
examination reveals no physical cause for any of his complains. He
sleeps well and has not lost any weight recently. The most likely
diagnosis is

a) Panic attacks
b) Conversion disorder
c) Masked depression
d) Somatization disorder
e) Hysteria
The correct answer is D

Explanation
Somatization disorder is the most likely diagnosis in problem patients
who are not depressed or anxious. These patients claim to have been in
poor health all their lives, but have not had any outward signs of
disease or abnormal physical findings. They must have at least 13
specific complaints lasting for at least 2 years and starting before the
age of 30, with no evidence for other psychological disease such as
panic attacks. Frequently seen complaints include vomiting, abdominal
pain, painful extremities, shortness of breath, palpitations, amnesia,
difficulty swallowing, a burning sensation in the sex organs, and
painful menstruation.
A 30-year-old female patient, who visits the urgent care clinic
frequently, complains of a ?burning sensation? during sexual
intercourse. She has no pregnancy history and has a normal physical and
pelvic exam. Her medical record indicates that she has been in for
multiple physical complaints with no evidence of disease by repeated
examinations. In order to make the diagnosis of somatization disorder,
her complains over the past several years should consist of the
following EXCEPT:

a) At least one sexual or reproductive symptom


b) Complaints related to a medical condition that are in excess of what
would be expected from history, exam, and laboratory findings
c) History of depression or anxiety
d) Significant impairment in social, occupational, or other significant
areas of functioning
e) At least one neurological symptom
The correct answer is C

Explanation
Individuals with somatization disorder may experience symptoms of
depression or anxiety; however, these symptoms are not always present
and are not necessary for the diagnosis. Other criteria needed for the
diagnosis of somatization disorder include a history of at least two
gastrointestinal symptoms other than pain and four pain symptoms related
to four different anatomical sites or functions. Symptoms cannot be
explained by a known medical condition or effects of a chemical
substance, and symptoms are not intentionally produced or feigned.
A 28 year old woman presents with a history of sudden onset of
palpitations, feelings she cannot get enough air and that she is going
to die. She has had several of these episodes in the last two months.
She has been to the emergency department on three occasions and was told
that her blood pressure, ECG and chest x-ray are normal. Which one of
the following would you recommend as part of her treatment?

a) Propranolol
b) Clonidine
c) Lithium
d) Paroxetine
e) Verapamil
The correct answer is D

Explanation
People with panic disorder are more receptive to treatment if they
understand that the disorder involves both physical and psychologic
processes and that treatment must address both. Drug therapy and
behavior therapy can generally control the symptoms.

Drugs that are used to treat panic disorder include antidepressants and
antianxiety drugs such as benzodiazepines. Most types of
antidepressants, tricyclic antidepressants, monoamine oxidase inhibitors
(MAOIs), selective serotonin reuptake inhibitors (SSRIs) (eg
Paroxetine), and serotonin/norepinephrine reuptake inhibitors (SNRIs),
are effective .

Benzodiazepines work faster than antidepressants but can cause drug


dependence and are probably more likely to cause sleepiness, impaired
coordination, and slowed reaction time. SSRIs are the preferred drugs
because they are as effective as the other drugs but usually have fewer
side effects.
A 17 year old girl has a history of fighting and breaking up with her
friends. On occasion, she has attempted suicide in an effort to get her
boyfriend to reconsider a relationship with her. Last year she
contracted gonorrhea and delayed getting medical help. Which one of the
following is the most likely diagnosis’

a) Narcissistic personality disorder


b) Oppositional defiant disorder
c) Schizophrenia
d) Borderline personality disorder
e) Bipolar disorder
The correct answer is D

Explanation
People with a borderline personality, most of whom are women, are
unstable in their self-image, moods, behavior, and interpersonal
relationships. Their thought processes are more disturbed than those of
people with an antisocial personality, and their aggression is more
often turned against the self. They are angrier, more impulsive, and
more confused about their identity than are people with a histrionic
personality. Borderline personality becomes evident in early adulthood
but becomes less common in older age groups.

People with a borderline personality often report being neglected or


abused as children. Consequently, they feel empty, angry, and deserving
of nurturing. They have far more dramatic and intense interpersonal
relationships. When they fear being abandoned by a caring person, they
tend to express inappropriate and intense anger. People with a
borderline personality tend to see events and relationships as black or
white, good or evil, but never neutral.

When people with a borderline personality feel abandoned and alone, they
may wonder whether they actually exist (that is, they do not feel real).
They can become desperately impulsive, engaging in reckless promiscuity,
substance abuse, or self-mutilation. At times they are so out of touch
with reality that they have brief episodes of psychotic thinking,
paranoia, and hallucinations.
Which one of the following is most important in the assessment and
diagnosis of sexual dysfunction in women?

a) A detailed history
b) A physical examination
c) An estradiol level
d) A prolactin level
e) A testosterone level

The correct answer is A

Explanation
A detailed history is the main tool for the assessment and diagnosis of
sexual dysfunction, and is usually obtained from both partners. A
physical examination, including a pelvic examination, is part of routine
care, but it infrequently identifies a cause of sexual dysfunction. The
possibility that laboratory testing will identify causes of sexual
dysfunction is low.
A 30-year-old female presents to your office after being evaluated in
the Emergency Room for chest pain. She reports that her medical workup
for heart disease was negative, but that she continues to have episodes
of chest pain and fears she is going to have a heart attack. On further
evaluation, you identify her episodes as lasting usually 10 minutes and
associated with shortness of breath, sweating, lightheadedness, tingling
in her extremities, and an intense feeling of doom. After educating the
patient about the symptoms of panic disorder, you suggest medication
treatment. All of the following medications may be useful in treating
her symptoms EXCEPT:

a) Bupropion
b) Alprazolam
c) Sertraline
d) Imipramine
e) Phenelzine
The correct answer is A

Explanation
Bupropion has not been shown to be effective in treatment of panic
disorder and does not appear to have antipanic properties. Tricyclic
antidepressants, particularly imipramine, and benzodiazepines such as
alprazolam have been shown to be effective in treating panic disorder.
Selective serotonin reuptake inhibitors, such as sertraline, have
valuable antipanic properties and are useful to treat panic disorders.
MAOIs such as phenelzine are also very effective in treatment of panic
disorder.

Which one of the following is the preferred treatment for patients with
obsessive-compulsive disorder?

a) Lithium carbonate
b) Alprazolam (Xanax)
c) Fluoxetine (Prozac)
d) Amitriptyline (Elavil)
e) Valproic acid (Depakene)
The correct answer is C

Explanation
Obsessive-compulsive disorder is characterized by obsessive thoughts and
compulsive behaviors that impair everyday functioning. SSRIs such as
fluoxetine and fluvoxamine are FDA-approved and considered first-line
agents in the treatment of this condition. None of the other agents
listed is recommended for the treatment of obsessive-compulsive
disorder. Lithium is useful in bipolar disorder and depression,
alprazolam is used in generalized anxiety and panic disorder, and
amitriptyline is used in depression and chronic pain syndromes. Valproic
acid is primarily an anti-epileptic agent.
Which one of the following antidepressants is LEAST likely to cause
sexual dysfunction?

a) Bupropion (Wellbutrin)
b) Sertraline (Zoloft)
c) Fluoxetine (Prozac)
d) Imipramine (Tofranil)
e) Trazodone (Desyrel)
The correct answer is A

Explanation
Sexual dysfunction, including decreased libido, ejaculatory disturbance,
and anorgasmia, is common with the SSRIs (e.g. sertraline and
fluoxetine). Tricyclic antidepressants such as imipramine also cause
sexual dysfunction. Trazodone can cause priapism. Only bupropion is
relatively free of sexual side effects.

The criteria for diagnosis of a Munchausen syndrome include all of the


following, except

a) Intentional production or feigning of physical signs or symptoms


b) Absence of secondary gain
c) Possibility of economic gain
d) Desire to assume the sick role
The correct answer is C

Explanation
Munchausen syndrome, a severe and chronic form of factitious disorder,
consists of repeated production of feigned physical symptoms without an
external incentive; the motivation for this behavior is to assume the
sick role. Symptoms are usually acute, dramatic, and convincing and are
accompanied by a tendency to wander from one physician or hospital to
another for treatment. The exact cause is unknown, although stress and
borderline personality disorder are often implicated.
A 28-year-old male comes to your office with concerns that he may have
attention-deficit/hyperactivity (ADHD). He says he was a “bad student”
and was frequently told he was “hyper” as a child. His adult life is
characterized by uncompleted projects and he has difficulty focusing on
details of his work. He has had difficulty keeping jobs, and a career
counselor suggested he talk with a doctor about the possibility of
“getting on Ritalin”.

Which one of the following is true in this situation?

a) ADHD cannot be diagnosed because the patient is over 18 years of age


b) He is unlikely to respond to stimulant medications because he is an
adult
c) The presence of symptoms since early childhood meets one of the
criterion for the diagnosis of ADHD
d) The criteria for diagnosing ADHD in adults are different than those
for children
e) The diagnosis of ADHD in adults is decreasing in frequency
The correct answer is C

Explanation
Adult attention-deficit/hyperactivity disorder (ADHD) is becoming more
widely recognized. Attention deficit is a genetic disorder that is
present from birth, and should not be diagnosed in a person who has not
had a history of symptoms since childhood. The criteria for diagnosing
ADHD do not differ for children and adults, and there is no mention in
the DSM-IV of age, except that there must have been some symptoms prior
to age 7. Self-reporting of symptoms has been found to be very reliable
in adults and is often required. The most commonly used category of
medications for adult ADHD is stimulants.
A 24 year old man is brought to the emergency room after being found
unresponsive in a city park. Physical examination reveals pinpoint
pupils unresponsive to light and a respiratory rate of 7 breaths per
minute. Which one of the following is the most likely cause?

a) Tricyclic antidepressant overdose


b) Morphine overdose
c) Arsenic poisoning
d) Lead intoxication
e) Alcohol intoxication
The correct answer is b

Explanation
Morphine is the principal constituent of opium.

Morphine is highly addictive. Tolerance (the need for higher and higher
doses to maintain the same effect) and physical and psychological
dependence develop quickly. Morphine activates the brain’s reward systems.

A Morphine overdose happens when you consume more Morphine than your
body can safely handle. Morphine users are constantly flirting with
Morphine overdose, and the difference between the high they're seeking
and serious injury or death is often quite small.

Symptoms of a Morphine overdose include: cold clammy skin, flaccid


muscles, lowered blood pressure, "pinpoint" or dilated pupils,
sleepiness, stupor, coma, slowed breathing (respiratory depression),
difficulty breathing and slow pulse rate.
A 38 year old alcoholic male has successfully completed outpatient
alcohol detoxification and has plans to participate in Alcoholics
Anonymous. Which one of the following pharmacologic agents can aid in
relapse prevention?

a) Naltrexone (ReVia)
b) Naloxone (Narcan)
c) Bupropion (Wellbutrin)
d) Mirtazapine (Remeron)
e) Flumazenil (Romazicon)
The correct answer is A
Explanation
Pharmacological agents can be useful adjunct to counselling in
preventing relapse in patients with alcohol dependence. Naltrexone and
disfulfiram are currently approved by the FDA for treatment of
alcohol-dependent patients. Bupropion is of value for smoking cessation
and mirtazaphine is an antidepressant. Naloxone is used to treat opioid
overdose and fluazmenil to treat benzodiazaphine overdose.

Side effects of methylphenidate (Ritalin) therapy for hyperactivity


include each of the following, except

a) Anorexia
b) Insomnia
c) Tachycardia
d) Dependence (addiction)
e) Growth suppression
The correct answer is D

Explanation
Ritalin is the most frequently prescribed stimulant drug for Attention
Deficit Disorder. Possible side effects of Ritalin include reduced
appetite, headache, sleep difficulty, anxiety, increased blood pressure
and heart palpitations. Furthermore, growth suppression represents a
common long-term side effect of Ritalin use.
At a routine follow-up visit, a 30-year-old male with depression that
has been well-controlled for 12 months on extended-release paroxetine
(Paxil) discusses stopping the medication because of delayed ejaculation
that has become more problematic. He calls your office 5 days later
because of a 3-day history of influenza-like symptoms, insomnia, nausea,
and dizziness, which were moderately severe initially but are now improving.

Which one of the following would be most appropriate at this time?

a) Wait to see if the symptoms completely resolve


b) Prescribe an antiviral medication
c) Restart the paroxetine
d) Restart the paroxetine at twice the previous dosage
e) Hospitalize the patient
The correct answer is A

Explanation
This patient has developed antidepressant discontinuation syndrome.
Proposed criteria for SSRI discontinuation syndrome include the presence
of anxiety, diarrhea, dizziness, fatigue, gait/balance disturbance,
gastrointestinal upset, hyperarousal, insomnia, instability,
lightheadedness, paresthesia, tremor, vertigo and visual disturbance.
Two or more of these must be present within 7 days of discontinuation of
an SSRI after at least 1 month’s use.

Because this patient’s symptoms are resolving quickly, it is unlikely to


be influenza and does not warrant hospitalization. The patient could
restart the SSRI, but if this were a relapse of his depression the
symptoms would not be resolving. Doubling the dosage of the medication
is inappropriate because the patient was doing well on the original
dosage, and the symptoms do not indicate worsening depression.
Which one of these constitute a part of mature ego defense mechanism?

a) Displacement
b) Sublimation
c) Suppression
d) Regression
e) Projection
The correct answer is b

Explanation
Displacement: taking out impulses on a less threatening target, for
example, slamming a door instead of hitting as person, yelling at your
spouse after an argument with your boss.

Sublimation: acting out unacceptable impulses in a socially acceptable


way, for example, sublimating your aggressive impulses toward a career
as a boxer; becoming a surgeon because of your desire to cut; lifting
weights to release 'pent up' energy.

Suppression: pushing into the unconscious, for example, trying to forget


something that causes you anxiety.

Regression: returning to a previous stage of development, for example,


sitting in a corner and crying after hearing bad news; throwing a temper
tantrum when you don't get your way.

Projection: placing unacceptable impulses in yourself onto someone else,


for example, when losing an argument, you state "you're just stupid?.

Of the above the most mature method is sublimation.


Which one of the following is true concerning the treatment of patients
with obsessive-compulsive disorder (OCD)?

a) Behavioral therapy fails to improve OCD


b) SSRIs are ineffective for OCD in children
c) Tricyclic antidepressants are more effective than SSRIs for treating OCD
d) Discontinuing SSRIs is associated with a high rate of relapse
The correct answer is D

Explanation
Stopping SSRIs causes a high rate of relapse of obsessive-compulsive
symptoms. Obsessive-compulsive patients are usually very aware that
their behavior is illogical, and behavioral therapy is very effective in
treating obsessions. SSRIs are effective in both adults and children,
and are more effective than tricyclic antidepressants for treating
obsessive-compulsive disorder.
You evaluate an 80 year old white male who is a heavily medicated
chronic schizophrenic. You note constant, involuntary chewing motions
and repetitive movements of his legs. Which one of the following is the
most likely diagnosis’
a) Neuroleptic malignant syndrome
b) Acute dystonia
c) Huntington’s disease
d) Tardive dyskinesia
e) Oculogyric crisis
The correct answer is D

Explanation
The patient has classic signs of tardive dyskinesia. Repetitive movement
of the mouth and legs is caused by antipsychotic agents such as
phenothiazides and haloperidol. Neuroleptic malignant syndrome consists
of fever, autonomic dysfunction, and movement disorder. Acute dystonia
involves twisting of the neck, trunk, and limbs into uncomfortable
positions. Huntington’s disease causes choreic movements, which are
flowing, not repetitive. Oculogyric crisis involves the eyes.
A 75-year-old male is brought in by his family due to concerns about
memory loss. Which one of the following is best for determining whether
or not he has dementia?

a) A Mini-Mental State Examination (MMSE)


b) Non-contrast-enhanced CT of the head
c) MRI of the head
d) A lumbar puncture
e) An electroencephalogram
The correct answer is A

Explanation
There are no biologic markers for Alzheimer’s disease or most other
dementias; the diagnostic criteria include elements obtained only from a
history and physical examination, including results from a Mini-Mental
State Examination (MMSE) or other cognitive testing. Brain imaging is
recommended for evaluation, but cannot confirm the diagnosis of
dementia. An EEG should be ordered if there is history to suggest
seizures, and a lumbar puncture is indicated is infection or cancer is a
concern.
A 43 year old male patient presenting with hallucinations and delusions
was prescribed chlorpromazine, a phenothizine derivative for reduction
of the positive symptoms of schizophrenia. Identify one of the
extrapyramidal side effects caused by this medication that involves
torticolis and retroclois:

a) Acute dystonias
b) Akathisia
c) Pseudoparkinsonism
d) Tardive dyskinesia
e) Neuroleptic malignant syndrome
The correct answer is A

Explanation
Answer: A ? Acute dystonias is marked by sudden muscle spasms in the
form of torticolis and retrocolis and trismus. These symptoms would be
very distressing to the patient. This is most common in the young
patients and especially in men receiving high doses of chlorpromazine.
The best medication for the control of acute dystonias is
anti-cholinergic drugs, which reduce the symptoms for large extent if
given through IV route. Acute dystonias can also be controlled by
switching the medication to atyptical medication.

B. Akathesia is marked by restlessness, agitation and inner tension.


C. Pseudoparkinsonism is the side effect of the antipsychotic drugs,
like pehothizine derivatives.
D. Tardive dykinesia is marked by abnormal movements of the body, which
can occur in any part of the body.
E. Neuroleptic malignant syndrome is characterized by hyperthermia,
altered consciousness and autonomic changes.

A 34 year old woman who takes antipsychotic medication, develops


stiffness in her arms and neck. Which of the following side affects of
does she have?

a) Parkinsonism
b) Akathisia
c) Dystonia
d) Tardive dyskinesia
The correct answer is C

Explanation
The side effects of antipsychotic medications are as follows:

Parkinsonism: involves tremor, increased muscle tone, bradykinesia or


akinesia, drooling, postural instability, loss of spontaneity,
micrographia, seborrhea.

Akathisia: motor restlessness accompanied by a feeling of inner


restlessness (sometimes described as anxiety), an urge to move, and an
inability to sit still, patients may pace or continuously move their
feet and legs.

Dystonia: sustained contraction of muscles, twisting postures and may be


visible only when the patient is moving. Neck and arm muscles are most
commonly affected.

Tardive dyskinesia: hyperkinesia, involuntary body movements most often


of the muscles of the face, mouth, and tongue.
A 30-year-old female presents with a complaint of years of recurrent
insomnia. She often lies awake with her mind ?racing,? so she uses
alcohol nightly to help her fall asleep. She also has trouble focusing
at work. She has been treated for depression several times since age 22,
but she does not improve with antidepressant therapy. She has no family
history of psychiatric disorders.

Which one of the following statements is true regarding this patient?

a) She most likely suffers from obstructive sleep apnea


b) Although she does not have a family history of bipolar disorder, her
presentation is
compatible with hypomania
c) She should begin taking venlafaxine (Effexor) to treat her depression
d) Once her sleep issues are addressed, stimulant therapy for
attention-deficit disorder
should be considered
The correct answer is b

Explanation
This patient has many features of bipolar II disorder, which is defined
as hypomania plus at least one episode of depression. While the patient
does not have a family history suggestive of bipolar disorder (which is
highly heritable), his insomnia, racing thoughts, and trouble focusing
are compatible with hypomania. Unresponsiveness or worsening with
antidepressant treatment also suggests bipolar disorder; therefore,
trying another antidepressant without a concomitant mood stabilizer is
inappropriate. Stimulant therapy also is inappropriate, at least until
the mania is controlled, especially with a history of alcohol misuse.
This patient has many psychiatric clues that make obstructive sleep
apnea unlikely.
A 50 year old female with a history of paroxysmal atrial fibrillation
has been successfully treated for depression with sertraline (Zoloft).
However, she has persistent insomnia, and a 10-day trial of zolpidem
(Ambien) has yielded minimal improvement. The most appropriate addition
to her current medication would be

a) Trazodone (Desyrel) each evening


b) Lorazepam (Ativan) daily
c) Zaleplon (Sonata) at night
d) Amitriptyline (Elavil) at night
The correct answer is A

Explanation
Trazodone has been found useful for its sedative and hypnotic effects,
and is often used in combination with another antidepressant.
Benzodiazepines are not recommended for long-term use. Zaleplon is more
short-acting than zolpiden and therefore would not be more effective.
Amitriptyline could be used for its antidepressant and sedative effects,
but its chronotropic side effects make it less preferable for someone
with a disposition to cardiac arrhythmia.
The following are common side effects of SSRIs, except

a) Headache
b) Sexual dysfunction
c) Vomiting
d) Anorexia
e) Orthostatic hypotension
The correct answer is E

Explanation
The most common side effects when taking SSRIs include headache, nausea,
somnolence (drowsiness), weight/appetite fluctuations, changes in sexual
behavior and increased feelings of anxiety or depression. These side
effects are mostly present during the initial 1-4 weeks while the body
adapts to the drug.

It is well documented that SSRIs can cause various sexual dysfunctions


such as anorgasmia (inability to reach orgasm), diminished libido (sex
drive) and erectile dysfunction or difficult/premature ejaculation in
men. Such side effects have been found present in between 41% and 83% of
patients responding to physician inquiry. These side effects
occasionally disappear spontaneously without discontinuing use of the
drug, and in most cases resolve themselves after stopping taking the SSRI.
A 60 year old female patient comes in with a complaint of multiple
episodes of abnormally elevated energy levels and sudden mood changes in
one week, followed by one or more depressive episodes, the next week.
According to this description, you think she is suffering from bipolar
disorder. In regards to medical treatment of this condition, which of
the following is true?

a) Ziprasidone and other atypical antipsychotics are never used in


bipolar disorder.
b) Clonazepam is contraindicated for an acute manic episode
c) Lithium and Aripiprazole can be used for the maintenance.
d) Lamotrigine can be given to a patient presenting with manic episodes
only
e) Valproate is commonly used for mixed episodes (manic + depression)
The correct answer is C

Explanation
Appropriate medication depends on the stage of the bipolar disorder the
patient is experiencing. A number of drugs are indicated for an acute
manic episode, primarily the antipsychotics, valproate, and
benzodiazepines (eg, lorazepam, clonazepam).
Atypical antipsychotics are being used increasingly for treatment of
both acute mania and mood stabilization. These include ziprasidone,
quetiapine, risperidone, aripiprazole, olanzapine, and asenapine.
Patients with disorders of gender identity often have a history of

a) Previous homosexual behavior


b) Cross-dressing in childhood
c) Genetic disturbances
d) Biologic disorder
e) Late onset of puberty
The correct answer is b

Explanation
Gender identity disorder is a strong, persistent cross-gender
identification condition in which people believe they are victims of a
biologic accident and are cruelly imprisoned in a body incompatible with
their subjective gender identity. Those with the most extreme form of
gender identity disorder are called transsexuals.

Childhood gender identity problems are usually present by age 2. For


some people, however, gender identity disorder does not manifest until
adulthood. Children experiencing difficulty with gender identity
commonly prefer cross-dressing, insist that they are of the other sex,
intensely and persistently desire to participate in the stereotypical
games and activities of the other sex, and have negative feelings toward
their genitals.
A patient is convinced that an intravenous (IV) injection he received
has made him immortal. This is an example of which one of the following?

a) An illusion
b) A delusion
c) A hallucination
d) A perseveration
e) A projection
The correct answer is b

Explanation
A delusion is a belief that is pathological (the result of an illness or
illness process). As a pathology it is distinct from a belief based on
false or incomplete information or certain effects of perception which
would more properly be termed an apperception or illusion.

An illusion refers to a specific form of sensory distortion. For


example, an optical illusion is always characterized by visually
perceived images that, at least in common sense terms, are deceptive or
misleading. Therefore, the information gathered by the eye is processed
by the brain to give, on the face of it, a percept that does not tally
with a physical measurement of the stimulus source.
A 40 year old white male is having rapid mood changes, and his speech is
pressured and difficult to interpret. These findings suggest

a) Obsessive-compulsive disorder
b) Manic episode
c) Paranoid schizophrenia
d) Borderline personality
e) Antisocial personality
The correct answer is b

Explanation
Rapid mood swings and speech that is typically pressured and difficult
to interpret are characteristics of a manic episode. These features are
not characteristic of the other psychiatric conditions listed.
Hypertensive encephalopathy may be precipitated in patients taking
monoamine oxidase inhibitors with the ingestion of foods containing high
levels of which one of the following?

a) Tyramine
b) Tryptophan
c) Serotonin
d) Tyrosine
e) Dopamine
The correct answer is A

Explanation
Antidepressants known as monoamine oxidase inhibitors work by blocking
the breakdown of neurotransmitters (NT’s). When the excess NT’s don't
get destroyed, they start piling up in the brain. And since depression
is associated with low levels of these NT’s, increasing the NT’s ease
depressive symptoms.

Unfortunately, monoamine oxidase doesn't just destroy those


neurotransmitters; it's also responsible for mopping up another amine
called tyramine, a molecule that affects blood pressure. So when
monoamine oxidase gets blocked, levels of tyramine begin to rise, too.
And that's when the trouble starts.
While a hike in neurotransmitters is beneficial, an increase in tyramine
is disastrous. Excess tyramine can cause a sudden, sometimes fatal
increase in blood pressure so severe that it can burst blood vessels in
the brain.

Every time you eat chicken liver, aged cheese, broad-bean pods, or
pickled herring, tyramine floods into your brain. Normally, MAO enzymes
take care of this potentially harmful tyramine excess. But if you're
taking an MAO inhibitor, the MAO enzyme can't stop tyramine from
building up. This is exactly what happened when the drugs were
introduced in the 1960s. Because no one knew about the tyramine
connection, a wave of deaths from brain hemorrhages swept the country.
Other patients taking MAO inhibitors experienced severe headaches caused
by the rise in blood pressure.
Which of the following is not a symptom of barbiturate withdrawal?

a) Convulsion
b) Low pulse
c) Tremor
d) Anxiety
The correct answer is b

Explanation
Barbiturates are prescribed as anticonvulsants, sedatives, and general
anesthetics. They can also mimic some of the characteristics of alcohol
intoxication (including euphoria, elation, and uninhibited behavior),
which make them candidates for abuse. These drugs depress the
respiratory and nervous system functions, and because abusers rapidly
build up a tolerance to the effects of the drug, fatal overdose or coma
can easily occur.

Symptoms of withdrawal syndrome appear 12-20 hours after the last dose,
they include anxiety, irritability, elevated heart and respiration rate,
muscle pain, nausea, tremors, hallucinations, confusion, and seizures.
Death is a possibility if the condition is left untreated. Major
withdrawal symptoms (convulsions and delirium) may occur within 16 hours
and last up to 5 days after abrupt cessation of these drugs.
A 7 year old girl hospitalized for a tonsillectomy awakens and cries out
in fright that a "big bear" is in her room. She is relieved when a
nurse, responding to her cry, enters the room and turns on the light,
revealing the bear to be an armchair covered with a coat. This
experience would be an example of

a) A delusion
b) A hallucination
c) An illusion
d) Déjà vu
e) Dissociative reaction
The correct answer is C

Explanation
A delusion is a belief that is pathological (the result of an illness or
illness process). As a pathology it is distinct from a belief based on
false or incomplete information or certain effects of perception which
would more properly be termed an apperception or illusion.

An illusion refers to a specific form of sensory distortion. An optical


illusion is always characterized by visually perceived images that, at
least in common sense terms, are deceptive or misleading. Therefore, the
information gathered by the eye is processed by the brain to give, on
the face of it, a percept that does not tally with a physical
measurement of the stimulus source.
A 75-year-old female presents to the emergency room with a broken hip
and is given an analgesic for pain relief. Her medications include a
monoamine oxidase inhibitor, phenelzine, which she has taken for many
years. Shortly after receiving the analgesic she becomes nauseated,
diaphoretic, and her blood pressure increases to 190/110. What analgesic
was responsible for this reaction?

a) Meperidine
b) Ibuprofen
c) Morphine
d) Codeine
e) Acetaminophen
The correct answer is A

Explanation
Meperidine (Demerol) is contraindicated in patients taking monoamine
oxidase inhibitors. It can result in a serotonin syndrome that can
include severe hypertensive crisis, occipital headache, stiff neck,
sweating, nausea, restlessness, muscle twitches, seizures, and high
fever. Morphine and codeine in high doses or in a patient on other
potentiating medications could lead to this syndrome as well, but
meperidine is the most likely culprit.
A 40 year old man states that he is feeling somewhat down and in
conflict with his wife. You elicit that he has always been somewhat
rigid; he is a conscientious hard worker at his employment. You note
that he is dressed very neatly and that, while giving his personal
history, he rambles and gives you all the details. The most likely
personality type is

a) Self-defeating (masochistic)
b) Passive-aggressive
c) Dependent
d) Narcissistic
e) Obsessive-compulsive
The correct answer is E

Explanation
Obsessive-compulsive disorder (OCD) is characterized by
anxiety-provoking ideas, images, or impulses (obsessions) and by urges
(compulsions) to do something that will lessen that anxiety. The cause
is unknown. Diagnosis is based on history. Treatment consists of
psychotherapy, drug therapy, or, especially in severe cases, both.
A 76-year-old white male with a history of recurrent depression has
recently become more depressed and developed psychotic features. His
symptoms have not responded to antidepressants and antipsychotic agents,
prescribed by his psychiatrist. The psychiatrist has recommended
electroconvulsive therapy (ECT) for the patient. The patient’s family
visits you to ask for your opinion and recommendations regarding ECT in
this individual.

In your consultation with this family, which one of the following would
be accurate advice regarding ECT?

a) It is efficacious and safe


b) There is evidence that it injures the brain
c) It causes irreversible short-term memory loss
d) There is evidence that it predisposes to the development of dementia
e) It has a low response rate
The correct answer is A

Explanation
Electroconvulsive therapy (ECT) has a more than 60-year history for the
treatment of severe depression. There has been no evidence of brain
damage secondary to ECT. The most common side effect is reversible
short-term memory loss. Dementia is not listed as a side effect.
Response rates are generally in the 60%-90% range.

In which one of the following situations, would it be unethical for a


psychiatrist to break confidentiality, and notify the authorities’

a) The psychiatrist believes that the patient will probably commit murder
b) The psychiatrist believes that the patient is actively suicidal
c) The patient has severely impaired judgement and is in a responsible
position, e.g. an airline pilot
d) The patient has aggressive fantasies
The correct answer is D

Explanation
A physician may break confidentiality in the following situations:

Concern for public welfare - it is required by law to report certain


communicable or infectious diseases to the public health authorities.

Concern for the safety of other specific persons - clinicians have a


duty to protect identifiable individuals from any serious threat of harm
if they have information that could prevent the harm.

A 25-year-old female is new to your practice. She left her last


physician after 6 months because ‘she didn?t take me seriously?. While
providing her personal history she tells you that she has been in and
out of at least five ‘serious’ relationships in the past 18 months. She
attempted suicide on at least one occasion when she was angry with her
parents. She started college after high school, but says she has not
graduated yet because she has changed her major at least six times.
You suspect that she has which one of the following personality disorders’

a) Antisocial
b) Borderline
c) Schizotypal
d) Dependent
e) Narcissistic
The correct answer is b

Explanation
This patient displays many of the characteristics associated with
borderline personality disorder, including instability in interpersonal
relationships, marked impulsivity, emotional instability, and mood
lability. Antisocial patients display a persistent pattern of
deceitfulness, impulsivity, and disregard for the rights of others.
Narcissistic patients display a grandiose sense of self-importance, tend
to be demanding, appear haughty and self-absorbed, and insist on special
status and treatment in the physician-patient relationship. Patients
with dependent personalities struggle with the self-perception that they
are unable to function adequately without the help of others. They have
trouble with decision-making, motivation, and assuming responsibility,
and fear abandonment. Schizotypal patients are uncomfortable in
interpersonal siturations, emotionally distant, difficult to engage, and
isolative, and exhibit strange or quasi-delusional beliefs.
A 45 year old woman comes to the office for the first time because of
recurrent abdominal pain. Review of her extensive medical chart, which
she has brought with her, discloses that she has a long history of
varying physical complaints. Definitive causes for these complaints have
not been found despite extensive diagnostic studies, consultations with
many physicians and several surgical explorations. She gives dramatic
and exaggerated descriptions of her present and past symptoms, and she
makes conflicting statements about her history. She has been
hospitalized at least 23 times since age 18 years. Which of the
following is the most likely diagnosis’

a) Borderline personality disorder


b) Conversion disorder
c) Histrionic personality disorder
d) Occult medical disorder
e) Somatization disorder
The correct answer is E

Explanation
This patient is over the age of 30, has a history of multiple
hospitalizations, and presents with multiple physical complaints, the
central feature of somatization disorder. Persons with borderline
personality disorder are dramatic; however, the central presentation is
not physical complaints but mood lability and intense personal
relationships.

In conversion disorder there is a stated stressor, and the conversion


symptoms are circumscribed and short in duration. Persons with
histrionic personality disorder typically seek attention with seductive
behavior and emotions, but their central presentation is not usually
with physical complaints. Multiple hospitalizations and surgeries are
uncommon in individuals with this disorder. After 23 hospitalizations
and 32 years of illness, the patient has had enough work-ups to rule out
an occult medical disorder.
A 44 year old man comes to the office for the first time for routine
medical care. He has been referred to you by his psychiatrist who has
informed you that the patient has paranoid personality disorder. He is
unmarried, lives alone and has no close friends, but he occasionally
attends family gatherings. Which of the following is the best way to
structure the physician-patient relationship with this patient?

a) Avoid giving him excessive details about possible, but infrequent,


side effects and complications in order to avoid triggering his paranoia
b) Explain the rationale for any diagnostic procedures and treatment
regimens in some detail, adopting a professional, but not overly
friendly stance
c) Go out of your way to be warm and friendly so that he can develop
trust in you
d) Have his psychiatrist, with whom he has been working for several
years, take the lead in presenting medical treatment options
e) Try to communicate with his family or medical personnel when he is
not present in order to overcome his withholding information because of
distrust
The correct answer is b

Explanation
The history of psychiatric illness in this patient is meant to be a red
herring of sorts. The physician-patient relationship is the concept at
the core of this question specifically, does the personality of the
patient play a role in how a physician behaves’ The answer generally
speaking is no, it does not. Each patient should be approached in the
same professional and courteous manner. All patients should be informed
about issues concerning their care and they should be made to feel
comfortable.

This standard approach may not be “effective” for all patients in that
some patients may report that their physician is “cold” or “aloof” while
others might report that the physician is “friendly” or “quite
personable.” This is common when dealing with a diversity of patient types.
A 12 year old boy is brought into the office by his mother for symptoms
of anxiety and checking behaviors. His mother gives a normal birth
history and states that the boy’s developmental milestones were normal
from birth. From age 4, she notes that he has been easily distracted and
extremely overactive for his age. At age 7 he was given the diagnosis of
ADHD and was treated with methylphenidate. His anxiety was noted only
recently and appears to be associated with the need for symmetry and
counting rituals. On evaluation, the boy displayed motor tics of
excessive blinking, head turning, and repetitive foot stomping. He would
frequently clear his throat and repeatedly grunt or sniff. When these
behaviors were brought to the attention of the mother, she stated, ?Oh
yes, he does that all the time, but so does his father.? Which of the
following medications would be most helpful to treat the patient’s motor
and vocal tics’

a) Haloperidol
b) Clonazepam
c) Fluoxetine
d) Dextroamphetamine
e) Clomipramine
The correct answer is A

Explanation
Tourette’s syndrome is characterized by chronic motor and vocal tics
that being in childhood. Comorbid psychiatric disorders that are often
seen with Tourette’s syndrome include obsessive-compulsive disorder
(OCD) and attention deficit disorder. Tourette’s disorder is up to nine
times more common in male children than female children, and family
studies suggest that tic disorders share a common genetic etiology.
Dopamine, antagonists, typically given in low doses, such as haloperidol
or pimozide, have been most effective in treating the tics of Tourette’s
syndrome.

B. Although clonazepam may cause improvement of tics in some patients


with Tourette’s disorder, it is not the most effective form of treatment.
C. Fluoxetine may be helpful for comorbid symptoms of OCD, but is not
known to be helpful for treatment of tics.
D. Stimulants, such as methylphenidate and dextroamphetamine, may
actually worsen the tics seen in Tourette’s syndrome.
E. Like other serotonin agents, clomipramine has not been shown
effective in treatment of tics but may be helpful for comorbid symptoms
of OCD.
The principles of sleep hygiene management include each of the following
EXCEPT:

a) Take a nap during the day


b) Regular exercise
c) Wake up at your usual time
d) Go to bed at your usual time
e) Abstain from stimulants
The correct answer is A

Explanation
Good sleep hygiene includes following a regular sleep schedule,
maintaining a bedtime routine and a proper sleep environment, and using
the bedroom primarily as a place for sleep. Regular exercise, relaxation
strategies such as a warm bath, and avoiding any substances that
interfere with sleep are important as well. Daytime napping may delay
the expected return to sleep later that night, disrupting many of these
beneficial patterns.
A 25 year old surgical nurse is concerned that she is loosing her mind.
For the past 6 months she has been preoccupied with contamination on her
ward. She has not been touching any doorknobs washing her hands
excessively. Which of the following is the most appropriate treatment of
her disorder?
a) Fluoxetine
b) Lorazepam
c) Neurosurgical treatment
d) Lithium
e) Alprazolam
The correct answer is A

Explanation
Obsessive-compulsive disorder (OCD) is characterized by
anxiety-provoking ideas, images, or impulses (obsessions) and by urges
(compulsions) to do something that will lessen that anxiety. The cause
is unknown. Diagnosis is based on history. Treatment consists of
psychotherapy, drug therapy, or, especially in severe cases, both.

Many experts believe that combining psychotherapy and drug therapy is


best, especially for severe cases. Medications used are selective
serotonin reuptake inhibitors (eg fluoxetine) and clomipramine.

Neurosurgical treatment of OCD is performed at a limited number of


centers and is reserved for patients with severe and refractory
symptoms. The most common small series use a specific small lesion (eg,
cingulotomy) or deep brain stimulation.
A 37-year-old female presents with concerns about difficulty initiating
and maintaining sleep for the past 3?4 months. She is irritable and
feels fatigued and sleepy during the day. After further evaluation, she
is diagnosed with chronic insomnia. She asks about alternatives to
hypnotic drug treatments. Which one of the following management options
is best supported by current evidence?

a) Diphenhydramine (Benadryl)
b) Cognitive behavior therapy
c) St. John’s wort
d) 4 oz of red wine 30 minutes before bedtime
e) Vigorous aerobic exercise 30?45 minutes before bedtime
The correct answer is b

Explanation
Routine use of over-the-counter antihistamines should be discouraged
because they are only minimally effective in inducing sleep, may reduce
sleep quality, and can cause residual drowsiness.

Cognitive-behavioral therapy helps change incorrect beliefs and


attitudes about sleep (e.g., unrealistic expectations, misconceptions,
amplifying consequences of sleeplessness). Techniques include
reattribution training (goal setting and planning coping responses),
decatastrophizing (balancing anxious automatic thoughts), reappraisal,
and attention shifting. Cognitive-behavioral therapy is recommended as
an effective, nonpharmacologic treatment for chronic insomnia (SOR A).

Many herbs and dietary supplements have been promoted as sleep aids.
However, with the exceptions of melatonin and valerian, there is
insufficient evidence of benefit.
Alcohol acts directly on GABA-gated channels, reducing sleep-onset
latency, but it increases wakefulness after sleep onset and suppresses
rapid eye movement (REM) sleep. It also has the potential for abuse and
should not be used as a sleep aid.

Moderate-intensity exercise can improve sleep, but exercising just


before bedtime can delay sleep onset.
A 29 year old female presents with a 15-year history of drinking. She
recently lost her job and is facing DUI charges for the 3rd time in the
past 5 years. She asks you to prescribe disulfiram for her because she
has met many people in A.A. who have stayed sober after using it. In
reviewing the side effects with her you explain that if she ingests any
alcohol she may experience flushing, tachycardia, nausea, diaphoresis,
or severe anxiety. These symptoms occur because disulfiram causes:

a) An accumulation of acetaldehyde
b) A sudden increase in the release of endogenous opioids
c) A sudden decrease in serotonin levels resulting in a panic attack
d) None of the above
The correct answer is A

Explanation
The fear of the unpleasant symptoms of disulfiram is used as a deterrent
to future drinking in those patients who are willing to take the
medication. It works by causing a shift in the chemical reaction
involved in metabolizing alcohol in the liver. The result is a shift
toward the production of acetaldehyde. Severe reactions can occur if a
patient drinks despite taking her disulfiram. In those cases an
alternative method must be used.

The toxic effects of disulfiram are not a result of serotonin level changes.
An alternative agent to disulfiram is naltrexone, an opiate antagonist,
which works by decreasing cravings and rates of relapse.
Though the sensation after ingesting alcohol is described like a panic
attack, the mechanism of action of disulfiram is not thought to be
through serotonin pathways.
A 79-year-old male has psychosis secondary to dementia associated with
Parkinson’s disease. After exhausting all other options you decide to
prescribe an antipsychotic agent. Which one of the following would be
the best choice in this situation?

a) Haloperidol
b) Olanzapine (Zyprexa)
c) Risperidone (Risperdal)
d) Quetiapine (Seroquel)
e) Thioridazine
The correct answer is D

Explanation
Quetiapine is an atypical antipsychotic that has no clinically
significant effect on the dopamine D2 receptor, which is responsible for
the parkinsonian side effects of antipsychotic medications. Because of
this, it is considered the antipsychotic of choice in patients with
dementia associated with Parkinson’s disease, although its use has not
been studied extensively in this clinical situation. The other atypical
antipsychotics listed, olanzapine and risperidone, have some D 2receptor
effect. Thioridazine and haloperidol are typical antipsychotics and have
more side effects, including parkinsonian side effects; they are not
recommended in this clinical situation.
What is the treatment of choice for Tourettes syndrome?

a) Haloperidol
b) Fluoxetine
c) Lithium
d) Cognitive behavioral therapy
The correct answer is A

Explanation
Tourette's syndrome is a hereditary tic disorder that begins in
childhood. Symptoms include simple, complex, and vocal tics. Diagnosis
is clinical. Treatment may include clonidine or antipsychotics (eg
haloperidol).
A 44 year old housewife and mother of four children (ages 6 to 13 years)
has been coming to you for management of tension headaches that have not
improved with trials of several appropriate medications. She has been
married to a police officer for the past 6 years. You ask if she has
been under extra stress, and she begins to cry. You notice bruises on
her arms. On further questioning, you learn that her husband hits her
whenever he is drunk, which is at least 2 nights per week. Her husband
is also a patient of yours. Which of the following is the most
appropriate intervention?

a) Advise her to leave her home with her children and move in with her
relatives
b) Contact her husband's supervisor to discuss recent stress levels on
the job
c) Gather more information while remaining neutral, since both the
husband and wife are your patients
d) Refer her to a domestic violence program
e) Seek a restraining order against her husband on her behalf
The correct answer is D

Explanation
In this case the physician must act as an advocate for this woman. The
question clearly describes evidence of physical abuse and an ongoing
risk of possible physical harm from this husband. In this regard the
physician should refer the patient to a battered women’s program much in
the same way that a pediatrician would contact the bureau of child
welfare if he suspected child abuse. Choices a), c) and e) offer
logistical advice that do not directly address protection of the woman.
Contacting her husband’s supervisor would violate confidentiality.
Although both the husband and wife may be patients of this physician,
the woman is clearly the individual who is at ongoing risk.
An 88 year old white female nursing-home resident with a primary
diagnosis of Alzheimer’s disease develops a pattern of behavioral
symptoms consisting of significant physical and verbal aggression toward
staff and other residents on at least three occasions. In addition, she
has experienced hallucinations that have been very stressful to her.
After secondary causes have been excluded, you decide to treat her
abnormal behavior pharmacologically. Which one of the following would be
the most appropriate choice?

a) Hydroxyzine (Atarax)
b) Risperidone (Risperdal)
c) Donepezil (Aricept)
d) Alprazolam (Xanax)
e) Divalproex (Depakote)
The correct answer is b

Explanation
Secondary causes of behavioral symptoms includes adverse medication
effects, metabolic causes, infections, dehydration, pain, delirium,
fecal impaction, and injury. Appropriate first-line pharmacologic
treatment of nursing-home residents who have severe behavioral symptoms
with psychotic features, such as hallucinations and delusions that are
causing distress, consists of atypical antipsychotics such as
risperidone. The other choices listed are not atypical antipsychotics.
A patient was diagnosed by a psychiatrist as a case of depression and
was prescribed an antidepressant for 8 months. Now, you are the family
physician to see him and the symptoms have already been subsided
completely. Which of the following should you NOT do?

a) Continue treatment for another 4 months


b) Stop therapy abruptly
c) Reduce therapy slowly & stop
d) Give therapy for life
e) Continue therapy for another year
The correct answer is b

Explanation
In order to avoid antidepressant withdrawal symptoms, never stop your
medication ?cold turkey.? Instead, gradually taper your dose, allowing
for at least 1-2 weeks between each dosage reduction. This tapering
process may take up to several months, and should be monitored under a
doctor's supervision.

Continuation of antidepressant therapy for depression beyond the acute


phase of treatment is widely recommended as a means of consolidating
treatment response and reducing the risk of relapse.

Frequent conditions appearing comorbidly with ADHD include all of the


following, except

a) Oppositional defiant and conduct disorders


b) Anxiety disorder
c) Learning disabilities
d) Autism
e) Language disorders
The correct answer is D

Explanation
Core symptoms and signs of ADHD are inattention, hyperactivity, and
impulsivity that are more pronounced than expected for the child's
developmental level; impaired academic or social function is common.

Inattention tends to appear when a child is involved in tasks that


require vigilance, rapid reaction time, visual and perceptual search,
and systematic and sustained listening. Inattention and impulsivity
impede development of academic skills and thinking and reasoning
strategies, motivation for school, and adjustment to social demands.
Children who have predominantly inattentive ADHD tend to be hands-on
learners who have difficulty in passive-learning situations that require
continuous performance and task completion. Overall, about 30% of
children with ADHD have learning disabilities.

Behavioral history can reveal low frustration tolerance, opposition,


temper tantrums, aggressiveness, poor social skills and peer
relationships, sleep disturbances, anxiety, dysphoria, depression, and
mood swings.
What is the treatment of choice for bipolar disorder?

a) SSRI
b) Haloperidol
c) Benzodiazepine
d) Lithium
The correct answer is D

Explanation
Mood stabilizers are the most commonly prescribed medications for
bipolar disorder. These medications help regulate and stabilize mood so
that you don't swing between depression and mania. Lithium has been
widely used as a mood stabilizer and is generally the first line of
treatment for manic episodes.

Anti-seizure medications: the medications are used to prevent mood


swings, especially in people with rapid cycling bipolar disorder. These
medications, such as valproic acid (Depakene), divalproex (Depakote) and
lamotrigine (Lamictal), also are widely used as mood regulators.

The use of antidepressants in bipolar disorder, although once common, is


now controversial.
Over the past year, a 27-year-old female has had marked feelings of
anxiety, tension and irritability during the week preceding most
menstrual cycles, accompanied by extreme fatigue and insomnia. She has
regularly missed several days of work each month because of fatigue. She
has no previous history of any health or mental problems, and within a
few days of the onset of her period she is back to normal.

Which one of the following is true concerning this condition?


a) Neither biologic nor psychological factors play a part in this condition
b) This condition is a variation of a depressive disorder
c) Oral contraceptive pills are consistently effective in the treatment
of this condition
d) This problem can be effectively treated with serotonergic
antidepressants
e) Alprazolam (Xanax) is an effective first-line agent for treatment of
this condition
The correct answer is D

Explanation
Women with premenstrual dysphoric disorder (PMDD) experience a cluster
of mood, cognitive, and physical symptoms that recur in the luteal phase
of the menstrual cycle and remit in the follicular phase. Multiple
rigorously conducted, placebo-controlled, randomized trials have
consistently shown the value of SSRIs, especially if administered during
the luteal phase of the menstrual cycle. Among women whose mothers have
been affected by PMS, 70% have PMS themselves, compared with 37% of
women whose mothers have not been affected. Because many patients with
PMDD do not have depressive symptoms, this disorder should not be
considered as simply a depressive variant. Some studies have shown that
symptoms actually worsen with administration of oral contraceptive
pills. Because of the potential for drug dependence, high-potency
benzodiazepines such as alprazolam should be used only as second-line
drug therapy if an optimal response is not achieved with an SSRI.

A male patient has diabetes and hypertension for which he takes


propranolol. He comes in with complaint of progressive impotence. He
states that because of this he has not had sexual intercourse with his
wife for more than 6 months. He admits to you privately that he has had
morning erection and also erections when he views adult magazines. What
is the appropriate explanation?

a) He will need a penile tumescence test


b) Marital psychotherapy
c) Stop propranolol
d) Impotence due to diabetes (vascular problem)
The correct answer is b

Explanation
The most frequent physical causes of erectile dysfunction are vascular
(blood vessel) diseases. Vascular diseases may cause problems involving
blood flow into the penis to make it erect. They can also cause problems
with holding the blood in the penis to maintain the erection. Thus,
hardening of the arteries and other diseases that affect the vascular
system are risk factors for erectile dysfunction.

However this patient is able to achieve erections. Therefore a


psychological cause is likely. This includes stress and anxiety due to
marital, financial or other personal problems. For example, a man who
has lost interest in his spouse may suddenly find himself unable to have
an erection with her. It is possible for the man's stress and anxiety to
interfere with nerve impulses from his brain when he attempts sexual
intercourse.
Which of the following could be associated with attention deficit
hyperactivity disorder (ADHD) ?

a) Social withdrawal and substance abuse


b) Parental abuse
c) Normal adult functioning
d) Accident proneness
e) All of the above
The correct answer is E

Explanation
In addition to the primary symptoms of inattention, hyperactivity, and
impulsivity, ADHD can cause secondary problems. Poor attention to social
cues can cause a child to be unpopular and rejected by peers. Parental
frustration in repeatedly disciplining the child can result in abuse.
Hyperactivity combined with impulsiveness and inattention to danger and
warnings makes children with ADHD accident-prone. The adult outcome of
ADHD is variable. At least one-third are not significantly different in
adulthood from a matched normal control group.
You diagnose depression in a 27 year old white male and prescribe
bupropion (Wellbutrin). He returns for a follow-up visit 4 weeks later.
He now reports less despondency, but says he has developed severe
insomnia. He also tells you that his mind ?races’ all the time, and that
he has received two speeding tickets in the past 2 weeks. Which one of
the following would be appropriate now?

a) Substitute sertraline (Zoloft) for the bupropion


b) Add valproate (Depakote)
c) Add alprazolam (Xanax)
d) Add imipramine (Tofranil) at bedtime
The correct answer is b

Explanation
Some depressed patients develop mania or hypomania when exposed to
antidepressants. This variant is sometimes called bipolar III disorder.
Medication is the key to stabilizing bipolar disorder. The initial
treatment of mania usually includes lithium or valproic acid. If the
patient is psychotic, a neuroleptic medication may also be given.
Long-acting benzodiazephines may be used initially to treat agitation,
but short-acting agents are not recommended. Tricyclic antidepressants
should be avoided, as they may include rapid cycling of symptoms in
these patients.
A 27 year old female patient is brought to the ER with chest pain,
sweating and palpitations.

She was entrapped in an elevator for 10 min. Her past medical history is
significant for claustrophobia. Vital signs show: pulse is 110/min, RR
is 26/min, temp is 37C and BP is 125/75 mmHg. Her EKG is normal, her
pulse oxymetry is 98 % on room air and her arterial blood gases
measurement is significant for respiratory alkalosis. What should you do
next?

a) Haloperidol IM
b) Intubation
c) Let the patient breath in a paper bag
d) Lorazepam IV
e) Tell her to stop malingering
The correct answer is C

Explanation
This patient is experiencing a panic attack as characterized by
tachypnea, tachycardia, chest pain, sweating and palpitations in the
absence of EKG abnormalities. In this patient with a panic attack, the
underlying cause of alkalosis is the increased respiratory rate.
Therefore, the best intervention is to calm the patient and let her
breathe in a closed bag. This will allow a high concentration of carbon
dioxide and thus will reduce her respiratory drive and decrease her
respiratory rate, thus correcting the underlying cause.

Lorazepam administration would be appropriate when the conservative


measures fail.

Haloperidol would be appropriate for acute hallucinations or psychosis.

Intubation is inappropriate in this well oxygenated hyperventilating woman.

The patient does not seem to be malingering. Even if she is, it is


inappropriate to tell the patient to stop malingering; you should talk
to the patient and try to know the cause of her attitude in order to
help her.
Which of the following neurological symptoms is NOT produced by
antipsychotic drugs’

a) Akathisia
b) Shuffling gait
c) Oculogyric crisis
d) Tremor at rest
e) Urinary incontinence
The correct answer is E

Explanation
Conventional antipsychotics produce several adverse effects, such as
sedation, cognitive blunting, dystonia and muscle stiffness, tremors,
elevated prolactin levels, and weight gain. Akathisia (motor
restlessness) is particularly unpleasant and may lead to noncompliance.
These drugs may also cause tardive dyskinesia, an involuntary movement
disorder most often characterized by puckering of the lips and tongue
and/or writhing of the arms or legs. The incidence of tardive dyskinesia
is about 5%/year of drug exposure among patients taking conventional
antipsychotics. In about 2%, tardive dyskinesia is severely disfiguring.
In some patients, tardive dyskinesia persists indefinitely, even after
the drug is stopped.
A male patient comes to you for follow-up. His depression is well
controlled with his medications however, now he tells you that he sees
aliens just when he is about to sleep. What is the problem?

a) Hypnopompic illusion
b) Hallucination
c) Schizophrenia
d) Deja vu
e) Hypnagogic illusion
The correct answer is E

Explanation
The hypnagogic experience occurs as one is falling asleep, while the
hypnopompic experience occurs as one is waking up.

Experienced qualities vary, and include fear, awareness of a "presence,"


chest or back pressure, and an inability to breathe, a falling sensation
or a feeling of tripping, but sometimes also of joy.

Which one of the following neuropsychiatric conditions is best reflected


by the sleep stage histogram depicted below?

a) Alzheimer's disease
b) Healthy young adult
c) Parkinson's disease
d) Depression
e) None of the above
The correct answer is b

Explanation
The depicted histogram is that typically seen in a healthy young adult.
REM sleep (darkened area) occurs cyclically through the night, and
stages 3 and 4 (slow wave sleep) are concentrated earlier during sleep.
Alzheimer’s disease is typically marked by frequent interruptions in
sleep throughout the night. Parkinson’s disease is plagued by an
increased number of awakenings throughout the night, as well, with
decreased REM sleep. Sleep disturbances are seen in most patients with
major depression and are characterized by sleep fragmentation and a
redistribution of REM sleep into the first half of the night.
A 19-year-old receptionist presents to her gynecologist with mild
symptoms of anxiety and shyness. On physical examination she notices
that the patient has only penciled-in eyebrows and no eyelashes. The
remainder of the physical examination is normal. The most likely
diagnosis is which of the following?

a) Conversion disorder
b) Stereotypical movement disorder
c) Schizophrenia
d) Factitious disorder
e) Trichotillomania
The correct answer is E

Explanation
Trichotillomania is the irresistible urge to pull out one’s hair. There
is some gratification or relief upon pulling out the hair, but the
disturbance causes distress or impairment socially. Onset of this
condition usually occurs in the teenage years and is four times more
common in females. Some mental health experts consider trichotillomania
a variant obsessive-compulsive disorder, and it is not uncommon to
uncover other ritualistic behaviors or obsessions. The clinical course
is varied and since the hair pulling may result in chewing or swallowing
hair, trichbezoars may be present in the GI tract, resulting in
abdominal complaints, iron deficiency anemia, and hair in the stools.
A 30-year-old female presents to your office for follow-up on her
obsessive-compulsive disorder and depression. She has decided to try to
get pregnant and wants to know if she has to stop taking her fluoxetine.
She had a severe suicide attempt 1 year ago and has had severe
peripartum depression in the past. You recommend:

a) Continue the fluoxetine since the risks of harm to the baby from the
medication are small
b) Continue the fluoxetine despite the risks of heart or neural tube
defects since her history is so concerning
c) Stop the fluoxetine and watch for a recurrence of symptoms
d) Stop the fluoxetine and if depression occurs she will have to
receive electroconvulsive treatments
e) None of the above
The correct answer is A

Explanation
Fluoxetine is second only to the tricyclic agents in studies of
antidepressants in the setting of pregnancy. There are no known
teratogenic effects with its use throughout the pregnancy or in
breastfeeding despite its being present in the breast milk.

B. Lithium is associated with Ebstein’s anomaly in the heart, and the


anticonvulsants are associated with neural tube defects. These patients
must be taken off their medications if found to be pregnant unless
symptom severity is severe. Certainly they should be counseled about
continuing on these medications if they are trying to get pregnant.
C. Her history is concerning and predicts another episode of peripartum
depression is likely, and often the episodes will become more severe
with successive pregnancies. Unless she has objections to being on the
medication, she should be maintained on her current dose.
D. Electroconvulsive treatments are generally safe in pregnancy, but
they are not the only treatment option she has available to her.
An 11 year old girl has become markedly withdrawn during the past 8
months and has complained of persistent abdominal pain and constipation,
for which no organic cause has been found. Which one of the following is
the most likely diagnosis’

a) Depressive disorder
b) Schizophrenia
c) Conduct disorder
d) Attention deficit hyperactivity disorder
e) Infantile autism
The correct answer is A

Explanation
Depressive disorders in children and adolescents are characterized by a
pervasive and abnormal mood state consisting of sadness or irritability
that is severe or persistent enough to interfere with functioning or
cause considerable distress. Decreased interest or pleasure in
activities may be as or even more apparent than the mood abnormalities.

The basic manifestations of childhood depression are similar to those


seen in adults but are related to typical concerns of children, such as
schoolwork and play. Children may be unable to explain inner feelings or
moods. Depression should be considered when a previously well-performing
youth does poorly in school, withdraws from society, or commits
delinquent acts.

Somatic complaints include headaches, abdominal pain, insomnia,


anorexia, weight loss, sleep disruption (including nightmares),
despondency, and suicidal ideation.

Diagnosis is by history and examination. Treatment is with


antidepressants, psychotherapy, or both.
A 24-year-old male, new to your practice, presents for a mental health
evaluation. The patient has a past history of schizophrenia, diagnosed
several years ago. Which one of the following, if present, would lead to
a reconsideration of this diagnosis’

a) Auditory hallucations
b) Loose associations
c) Elated mood
d) Social dysfunction
e) Incoherent speech
The correct answer is C

Explanation
Schizophrenia can be very difficult to definitively diagnose, and there
are many subtypes. There are many sets of diagnostic criteria, but most,
including DSM-IV, include the presence of thought disorders such as
hallucinations, delusions, and loose associations; disorganized speech,
catatonic behavior; and apathy or flat affect. (Two of these must be
present to meet DSM-IV criteria). Additionally, there must be social or
occupational impairment and a minimum duration of symptoms (6 months for
DSM-IV). Mood disorders, including depression, mania, and
schizoaffective disorder, must be excluded in order to diagnose
schizophrenia. Obviously, treatment of these disorders is very different
from that of schizophrenia
A 30 year old man is described by his wife as a procrastinator who
avoids obligations by claiming to have "forgotten". His co-workers
mention that he obstructs their efforts and resents useful suggestions.
This is most likely

a) Schizophreniform disorder
b) Depersonalization disorder
c) Passive-aggressive behavior
d) Borderline personality disorder
e) Social phobia
The correct answer is C

Explanation
Passive-aggressive behavior refers to passive, sometimes obstructionist
resistance to following authoritative instructions in interpersonal or
occupational situations. It can manifest itself as resentment,
stubbornness, procrastination, sullenness, or repeated failure to
accomplish requested tasks for which one is assumed, often explicitly,
to be responsible.

It is a defense mechanism and, more often than not, only partly


conscious. For example, people who are passive-aggressive might take so
long to get ready for a party they do not wish to attend, that the party
is nearly over by the time they arrive. Alternatively, leaving notes to
avoid face-to-face discussion/confrontation is another form of
passive-aggressive behavior.
An 18 year old high school student presents to the ER with sudden onset
of fever and gustatory hallucinations.

His roommate says that his friend is having bizarre behavior. Vital
signs show a BP of 125/80 mm Hg, pulse is 105/min, Temperature is 40.5C
and RR is 18/min.

He is confused and disoriented. Physical exam is negative for meningeal


signs and for focal neurologic deficit. You order a LP which reveals:
CSF protein: 90mg/dL, Glucose is 70 mg/dl, Cell count is 200/mm3 and too
many red blood cells to count. An MRI of the brain shows enhancement of
the temporal area. Which of the following is the most likely diagnosis
of this young patient?

a) Brain tumor
b) HSV encephalitis
c) Measles encephalitis
d) Meningitis
e) Substance abuse
The correct answer is b

Explanation
Herpes simplex virus encephalitis is the most likely diagnosis in our
patient. HSV usually affects the temporal area of brain resulting in
bizarre behavior and gustatory hallucinations. The presence of RBCs in
the CSF fluid is highly suggestive of HSV encephalitis. The diagnosis is
confirmed by PCR for HSV in the CSF.

The evidence of brain parenchymal involvement (hallucination,


confusion?) and the absence of meningeal signs make meningitis unlikely.

The negative CT scan excludes brain tumor as a diagnosis.

Measles encephalitis would not explain the temporal enhancement on MRI


and the presence of RBCs in the CSF.

The hallucinations of drug abuse are usually visual or tactile and not
gustatory. Moreover, the high fever suggests infectious etiology of the
condition.

>Know this: High fever, confusion, gustatory hallucination and RBCs in


the CSF means HSV encephalitis; order PCR of the CSF looking for HSV
then start IV Acyclovir immediately without waiting for the results of
the PCR!
A 68-year-old Mexica-Canadian female is brought to your office by her
son with a complaint of headaches. The patient speaks English
adequately, but diverts her eyes to look at her son when answering your
questions. Which one of the following is the most likely reason for this
patient not making eye contact?

a) Her son is overly controlling


b) She is a victim of abuse
c) She is being untruthful
d) She is showing respect to you
e) She is depressed
The correct answer is D

Explanation
Nonverbal communication is important for identifying issues that a
patient may be hiding or is unwilling to divulge. Some nonverbal clues,
however, are culturally biased. Many older or less-educated
Mexican-Canadians consider direct eye contact to be disrespectful.
Because a physician is held in high regard, these patients will often
either look down or look at another, more ?equal? person in the room
while being interviewed. Many Canadians, on the other hand, may consider
a lack of eye contact to be negative, implying that a patient is unsure
of the information they are providing, has poor self-esteem, or is
hiding something.
A 10-year-old boy is brought to your office by his mother. He has had
stomachaches, headaches, and crying spells since school started in the
fall. His mother reports this being most severe on Monday mornings while
getting ready for school. He feels fine in the afternoons, evenings, and
over the weekends, but continues to have physical complaints on school
mornings, requesting to stay home from school. He has good friends at
school and has never been a discipline problem. After further medical
history is obtained and a physical exam is done there is no obvious
medication explanation for his symptoms. The most likely diagnosis is:
a) Major depressive disorder
b) Truancy
c) School phobia
d) Antisocial personality disorder
e) Conduct disorder
The correct answer is C

Explanation
School phobia is characterized by symptoms being most severe in the
morning while getting ready for school. Typically the child’s somatic
symptoms and feelings of distress are most severe after a long weekend
away from school, and they tend to reduce as the child progresses
through their day at school. It is necessary to determine if there is a
justified fear such as the child being bullied or teased. If no medical
or situational explanation is found, it is important to keep the child
attending school as much as possible. If the child faces the anxiety
consistently, it will likely extinguish and the school phobia will resolve.

A. Depression may lead to a school avoidance over time, but other


symptoms of depression should be present throughout the day and on weekends.
B. Truant children will readily leave the home claiming they are going
to school.
D. Antisocial personality disorder cannot be diagnosed before the age of
18 and is characterized by a disregard for and a violation of others’
rights.
E. Conduct disorder is the appropriate term for antisocial
characteristics before the age of 18; however, the history doesn?t
support a discipline problem.

A 50-year-old male with a history of methamphetamine abuse requests


medication to treat this problem. According to evidence-based studies,
which one of the following would be most likely to help this patient
overcome methamphetamine dependence?

a) Fluoxetine (Prozac)
b) Amlodipine (Norvasc)
c) Imipramine (Tofranil)
d) Bupropion (Wellbutrin)
e) Cognitive therapy
The correct answer is E

Explanation
Methamphetamine dependence is very difficult to treat. No medications
have been approved by the FDA for the treatment of this problem, nor
have any studies shown consistent benefit to date. The standard therapy
for methamphetamine dependence is outpatient behavioral therapies,
especially with case management included. Therapy must be
individualized. Support groups and 12-step drug-treatment programs may
be helpful.
Which one of the following is considered both an effective and safe
treatment for seasonal affective disorder?
a) Melatonin
b) Fluticasone (Flonase)
c) Phototherapy
d) Lithium
e) Electroconvulsive therapy (ECT)
The correct answer is C

Explanation
Seasonal affective disorder is defined as recurrent depressive episodes
that occur during the autumn and winter, with cessation of symptoms
during spring and summer. Typical symptoms include sleep disturbance,
loss of interest in daily activities, and decreased libido. It is more
common in North America than in Europe. Both SSRIs and tricyclic
antidepressants are effective; however, phototherapy, with exposure of
the eyes, not the skin, it is also effective and has less potential for
side effects. Melatonin may induce symptoms of winter depression in
patients successfully treated with phototherapy. Lithium is primarily
used in the treatment of bipolar disorder, and has the potential for
significant side effects. Electroconvulsant therapy is used to treat
major depression, often with psychotic features. Fluticasone is used in
the treatment of seasonal allergic rhinitis.

A 6-year-old male is brought in by his mother for evaluation of


behavioral problems. The boy lives at home with his mother and
8-year-old sister. His mother says that he is frequently disruptive both
at home and at school. The child speaks out of turn at school and has
trouble following his teacher’s instructions. His mother reports that he
bickers constantly with his sister and rarely completes his daily
chores. In addition, he won?t sit still for longer than 2-3 minutes at a
time.

To make a diagnosis of attention-deficit/hyperactivity disorder (ADHD),


it is important to keep in mind which one of the following?

a) Reporting of symptoms by the parents or caregivers is not necessary


b) Symptoms must have begun before age 10
c) Depression or a conduct disorder often coexists with ADHD
d) ADHD is more commonly diagnosed in girls than boys
e) Behavioral difficulties both at home and school make ADHD less likely
The correct answer is C

Explanation
Attention-deficit/hyperactivity disorder (ADHD) is a persistent pattern
of inattention and/or hyperactivity. It can involve inattention and
hyperactivity combined, or it can be predominantly one or the other. The
symptoms must result in some impairment in at least two setting (home,
school, or on the job). Some of the symptoms must have begun before age
7, although the condition may persist into adulthood. A key source of
information is the parents, caregivers, and school. Boys are diagnosed
at least four times more frequently than girls. Psychiatric disabilities
can coexist with ADHD, making diagnosis and treatment more difficult.
Which one of the following criteria is most likely to signify that an
individual has bulimia nervosa rather than anorexia nervosa?

a) The absence of at least three consecutive menstrual cycles in a


postmenarchal nonpregnant female
b) Recurrent episodes of binge eating
c) Refusal to maintain a body weight greater than normal for age and height
d) Intense fear of weight gain or becoming fat, even though underweight
e) Denial of the seriousness of the current low body weight
The correct answer is b

Explanation
The key clinical finding in bulimia nervosa is not, as is often assumed,
vomiting. Binge eating is the sine qua non for bulimia. Temporary relief
of the associated depressed mood and self-deprecating thoughts is
achieved by methods intended to rid the body of the effects of calories.
More than 80% of patients with bulimia nervosa engage in self-induced
vomiting or laxative or diuretic abuse for this purpose. The other
options listed are DSM-IV criteria used to establish the diagnosis of
anorexia nervosa
Which one of the following agents would be best when rapid relief of
symptoms is required in a severely distressed patient with panic disorder?

a) Imipramine (Tofranil)
b) Clomipramine (Anafranil)
c) Phenelzine (Nardil)
d) Fluoxetine (Prozac)
e) Alprazolam (Xanax)
The correct answer is E

Explanation
All the agents listed are effective in the management of panic disorder.
However, only alprazolam has an onset of action measured in hours
instead of weeks, making it the most appropriate choice for managing
acutely distressed patients. Because of the difficulty in discontinuing
benzodiazepines, their most common use is to stabilize severe initial
symptoms until another treatment becomes effective.
A 37 year old white male comes to your office for evaluation of multiple
complaints. He has seen three other physicians but has been dissatisfied
with their treatment. He states that he has been in poor health for most
of his adult life, and lists the following complaints: difficulty
swallowing, palpitations, shortness of breath, impotence, difficulty
urinating, vomiting, diarrhea, bloating, muscle weakness, joint pains,
dizziness, fainting, poor vision, and headaches. A thorough physical
examination reveals no physical cause for any of his complains. He
sleeps well and has not lost any weight recently. The most likely
diagnosis is

a) Panic attacks
b) Conversion disorder
c) Masked depression
d) Somatization disorder
e) Hysteria
The correct answer is D

Explanation
Somatization disorder is the most likely diagnosis in problem patients
who are not depressed or anxious. These patients claim to have been in
poor health all their lives, but have not had any outward signs of
disease or abnormal physical findings. They must have at least 13
specific complaints lasting for at least 2 years and starting before the
age of 30, with no evidence for other psychological disease such as
panic attacks. Frequently seen complaints include vomiting, abdominal
pain, painful extremities, shortness of breath, palpitations, amnesia,
difficulty swallowing, a burning sensation in the sex organs, and
painful menstruation.
After a minor but distressing automobile accident, a patient is unable
to move one leg. Careful physical examination demonstrates no obvious
injury that might have caused the paralysis. His reflexes are intact. A
CT of the spine demonstrates no back injury. The patient is reassured,
and the paralysis resolves over a 2 week period. Which of the following
is the most likely diagnosis’

a) Body dysmorphic disorder


b) Conversion disorder
c) Munchausen syndrome
d) Pain disorder
e) Somatization disorder
The correct answer is b

Explanation
This case illustrates conversion disorder. In this condition, physical
symptoms are caused by psychological conflict. The symptoms develop
unconsciously and are, by definition, limited to those that mimic a
neurologic disorder, such as impaired coordination, weakness, paralysis,
loss of sensation, blindness, deafness, or inability to speak. The onset
is usually abrupt and linked to a stressful event. In most patients,
symptoms improve within 2 weeks, although some patients will have
persistent or recurrent problems.
A previously healthy 27-year-old female has had a progressive decline in
social and occupational functioning over the past year, along with a
withdrawal from activities. In addition, her family notes that over the
past 4 months she has had paranoid delusions, exhibited disorganized
speech, and heard voices. She has not had any major depressive or manic
episodes. A physical examination reveals a disheveled female with a flat
affect, poor eye contact, and loosely-associated speech. A toxicology
screen and basic laboratory analysis are unremarkable. She is not on any
medications.

Which one of the following is the most likely diagnosis’

a) Brief psychotic disorder


b) Delirium
c) Schizophrenia
d) Mood disorder with psychotic features
e) Delusional disorder
The correct answer is C

Explanation
The diagnosis of schizophrenia requires two or more of the following
characteristic symptoms (each present for a significant portion of time
during a 1-month period): delusions, hallucinations, disorganized
speech, grossly disorganized or catatonic behavior, and negative
symptoms (i.e., affective flattening, alogia, or avolition). In
addition, one or more major areas of functioning, such as work,
interpersonal relationships, or self-care, should be markedly below the
level seen prior to the onset of symptoms. Schizoaffective and mood
disorders, substance abuse, medical illness or medication-induced
disorders, and pervasive developmental disorders should be ruled out.

Brief psychotic disorder is characterized by the presence of delusions,


hallucinations, disorganized speech, or grossly disorganized or
catatonic behavior lasting at least 1 day but less than 1 month.
Delirium may present with psychotic symptoms but is the direct
physiologic consequence of a general medical condition and usually has a
much shorter course. Mood disorders with psychotic features can be ruled
out if no major depressive, manic, or mixed episodes have occurred
concurrently with the active-phase symptoms, or if the duration of mood
disturbance is brief compared to the overall duration of active and
residual symptoms. Delusional disorder does not cause bizarre delusions
and also lacks other characteristic symptoms of schizophrenia such as
hallucinations, disorganized speech or behavior, or prominent negative
symptoms.
You are treating a 34 year old white male for anxiety, panic disorder,
and a history of alcoholism. He has been abstinent from alcohol for 6
years. Which one of the following treatment options carries the greatest
risk of physical dependence?

a) Alprazolam (Xanax)
b) Imipramine (Tofranil)
c) Buspirone (BuSpar)
d) Sertraline (Zoloft)
e) Phenelzine (Nardil)
The correct answer is A

Explanation
Alprazolam is a benzodiazepine. It is capable of producing physical
dependence, and the risk is substantially elevated in a patient with a
history of alcohol dependence.

Imipramine is a tricyclic drug and does not carry a risk of physical


addiction or dependence. Buspirone is in the azapirone class. It does
not produce sedation or euphoria. There is no withdrawal syndrome or
dependence. Propranolol is a Beta-blocker and may be useful for
controlling somatic symptoms of anxiety. While Beta-blockers are not
addictive, abrupt withdrawal may be hazardous due to potential
cardiovascular side effects. Phenelzine is an MAO inhibitor. Physical
dependence is not a problem with this drug class.
A 23-year-old single male with the diagnosis of chronic undifferentiated
schizophrenia is brought to the emergency center by the paramedics with
hyperthermia, severe muscle rigidity, autonomic instability, and
delirium. Which class of psychiatric medications has this patient most
likely been recently exposed to, causing these clinical symptoms’

a) Benzodiazepines
b) Tricyclic antidepressants
c) Selective serotonin reuptake inhibitors
d) Monoamine oxidase inhibitors
e) Antipsychotics
The correct answer is E

Explanation
Antipsychotics. The blockade of dopamine and other monoamine
neurotransmission in the pathways that regulate thermal and
neuromuscular homeostasis is associated with the neuroleptic malignant
syndrome (NMS). Other signs and symptoms of NMS include diaphoresis,
dysphagia, tremor, incontinence, mutisms, tachycardia, leukocytosis, and
laboratory evidence of muscle injury resulting in an elevate CPK.
A 34 year old white female comes to the office for a Papanicolaou (Pap)
test. On a review-of-system checklist, she checks ?yes’ to depressive
symptoms, insomnia, and anxiety. On questioning, she admits to feeling
depressed for about 4 months, after a recent job change. She is not
suicidal. With probing, she admits that she repeatedly checks her locks
and constantly worries about cleanliness; she has been this way ?all of
her life?, but finds it very time-consuming. Which one of the following
drugs is the best choice for this patient?

a) Risperidone (Risperdal)
b) Clorazepate (Tranxene)
c) Clonazepam (Klonopin)
d) Imipramine (Tofranil)
e) Fluoxetine (Prozac)
The correct answer is E

Explanation
The patient most likely has obsessive-compulsive disorder (OCD) with a
depressive episode. SSRIs are most frequently used. Risperidone and
clonazepam are considered second-line drugs and are used as augmentation
drugs when there I a partial response to an SSRI. There is no evidence
that clorazepate or imipramine is effective in OCD.

A 73 year old white male nursing-home resident has Alzheimer’s dementia


and hypertension. He has been weaker and less responsive over the last
week and has gained 8 lb. On physical examination he has normal vital
signs with a heart rate of 110 beats/min, but is noted to have marked
lower extremity edema and presacral edema. Laboratory evaluation shows a
serum sodium level of 122 mmol/L (N 135-145). Which one of the following
is the most likely cause of his hyponatremia?
a) Diuretic use
b) Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
c) Addison’s disease
d) Congestive heart failure
e) Psychogenic polydipsia
The correct answer is D

Explanation
Most decision tress for the evaluation of hyponatremia begin with an
assessment of volume status; edema reflects volume overload and
increased total body sodium caused by congestive heart failure,
cirrhosis, or renal failure. If edema is absent, plasma osmolality
should be determined. SIADH, Addison’s disease (hypoadrenalism),
diuretic use, and renal artery stenosis all lower serum osmolality.
Urine electrolytes help distinguish the other conditions: psychogenic
polydipsia causes low urine sodium, while SIADH and hypoadrenalism cause
inappropriately elevated urine sodium. Diuretic use, a very common cause
of hyponatermia in the geriatric population, causes hypovolemic
hyponatremia and can be associated with either high or low urine sodium,
but there is often concomitant hypokalemia.

A 40 year old woman has had multiple tests done for her symptoms of
abdominal pain, including abdominal CT, colonoscopy, pelvic ultrasound
and laparoscopy. All tests have been normal. Despite assurance she still
is continually scared that she may have something serious. Which of the
following disorder does she likely have?

a) Antisocial
b) Borderline
c) Histrionic
d) Narcissistic
e) Hypochondriasis
The correct answer is E

Explanation
Hypochondriasis is a fear of having a serious disease based on
misinterpretation of physical symptoms or normal bodily functions.
Hypochondriasis is nonvolitional; the exact cause is unknown. Diagnosis
is confirmed when fears and symptoms persist for ? 6 months despite
reassurance after thorough medical evaluation. Treatment includes
establishing a consistent, supportive physician-patient relationship;
psychotherapy and drug therapy may help.
What is the drug of choice for the treatment of obsessive compulsive
disorder?

a) Imipramine
b) Fluoxetine
c) Chlorpromazine
d) Lithium
The correct answer is b
Explanation
Obsessive-compulsive disorder (OCD) is characterized by
anxiety-provoking ideas, images, or impulses (obsessions) and by urges
(compulsions) to do something that will lessen that anxiety. The cause
is unknown. Diagnosis is based on history. Treatment consists of
psychotherapy, drug therapy, or, especially in severe cases, both. SSRIs
(eg fluoxetine) and clomipramine are most commonly used.
A 62 year old man with a history of depression has been self-treating
his symptoms with St. John's wort for one week. His medical history
includes hyperlipidemia, congestive heart failure, atrial fibrillation,
and hypertension, for which he is taking atorvastatin (Lipitor),
digoxin, warfarin, and verapamil (Calan). Which one of the following
statements is correct?

a) The patient's digoxin level should be checked immediately because


St. John's wort has been suspected to increase the digoxin level and
cause toxicity
b) The patient's warfarin dosage should be decreased because St. John's
wort can cause an increase in INR
c) The patient's atorvastatin dosage should be decreased because of
increased blood levels
d) The patient's verapamil dosage should be increased if blood pressure
is not well controlled
The correct answer is D

Explanation
St. John’s Wort may increase the breakdown of verapamil in the stomach,
causing a decreased effect of verapamil. It is best to avoid using St.
John’s Wort while taking Verapamil. If these products must be used
together, you may need to adjust the dose of verapamil especially when
St. John’s Wort is either started or stopped.

St John's Wort may decrease verapamil levels, therefore caution is


advised when these two medicines are used together.
Considering the patient’s long history of OCD symptoms, the consulting
psychiatrist also recommends psychotherapy for her. Which of the
following choices is likely to be most helpful?

a) Cognitive-behavioral therapy
b) Psychodynamic psychotherapy
c) Group therapy
d) Interpersonal psychotherapy
e) Existential therapy
The correct answer is A

Explanation
Cognitive-behavioral therapy (CBT) is a helpful adjunct to
pharmacotherapy of OCD. Some studies show that the long-term gains
achieved with CBT exceed and are more durable than SSRIs alone.
A woman presents with hair loss. See picture:
She denies any family history of premature balding. She does state that
she has been under severe stress and she has been taking medications for
obsessive compulsive disorder. Which of the following is likely?

a) Telogen effluvium
b) Trichotillomania
c) Alopecia areata
d) Tinea capitus
The correct answer is b

Explanation
Trichotillomania is a psychiatric condition in which an individual has
an uncontrollable desire to pull out their own body hair. It is
generally considered to be an impulse control disorder but is sometimes
classified as either a subtype or variant of obsessive-compulsive
disorder (OCD).
A 32 year old married woman describes experiencing panic attacks every
time she goes to the local store. These have been getting more frequent
and she is finding it increasingly difficult to leave her home. Which
one of the following should form part of her treatment?

a) Psychodynamic therapy
b) Interpersonal psychotherapy
c) Family therapy
d) Crisis intervention
e) Cognitive behavioral therapy
The correct answer is E

Explanation
A panic attack is the sudden onset of a discrete, brief period of
intense discomfort, anxiety, or fear accompanied by somatic or cognitive
symptoms. Panic disorder is occurrence of repeated panic attacks
typically accompanied by fears about future attacks or changes in
behavior to avoid situations that might predispose to attacks.

Diagnosis is clinical. Isolated panic attacks may not require treatment.


Panic disorder is treated with drug therapy, psychotherapy (eg, exposure
therapy, cognitive-behavioral therapy), or both.

Cognitive-behavioral therapy involves teaching patients to recognize and


control their distorted thinking and false beliefs and to modify their
behavior so that it is more adaptive. For example, if patients describe
acceleration of their heart rate or shortness of breath in certain
situations or places and fear that they are having a heart attack, they
are taught the following: not to avoid those situations, to understand
that their worries are unfounded and to respond instead with slow,
controlled breathing or other methods that promote relaxation.
A 25 year old man is hospitalized after weeks of worsening psychosis. He
is given thiothixene, an antipsychotic medication. Five days later, he
develops a fever of 39.8 °C, becomes delirious and lies stiffly in his
bed. His family reports that he had been physically well prior to his
admission. Which of the following diagnosis is of most immediate concern?

a) Tardive dyskinesia
b) Viral meningitis
c) Neuroleptic malignant syndrome
d) Ruptured cerebral aneurysm
e) Unsuspected opioid dependence
The correct answer is C

Explanation
Neuroleptic malignant syndrome is a hypermetabolic reaction to
antipsychotics, particularly dopamine-receptor antagonists (eg
thiothixene), although any antipsychotic can be involved. This syndrome
usually occurs early in treatment or after an increase in dosage and
rarely during maintenance treatment unless other physical conditions
such as dehydration occur. It develops in up to 3% of patients started
on antipsychotics. Risk is increased in agitated males who have received
large and rapidly increased doses. No genetic component is apparent. Its
pathophysiologic basis is believed to be blockade of dopamine D2 receptors.

Characteristic signs are ?lead pipe? muscle rigidity, hyperpyrexia,


tachycardia, hypertension, tachypnea, change in mental status,
confusion, and diaphoresis. Common complications include MI, aspiration
pneumonia, respiratory failure, acidosis, and rhabdomyolysis. Less
common complications include thromboembolism and renal failure.
Mortality approaches 30%.

Diagnosis is based on clinical findings. Treatment is usually


administered in an ICU with the dopamine agonist bromocriptine or
dantrolene.
The negative symptoms of schizophrenia include each of the following EXCEPT:

a) Anhedonia
b) Apathy
c) Asociality
d) Attentional impairment
e) Auditory hallucinations
The correct answer is E

Explanation
Auditory hallucinations are considered positive symptoms of
schizophrenia, along with ideas of reference, thought broadcasting, and
delusional thinking. Although successful treatment of positive symptoms
will keep patients out of the hospital, the negative symptoms can be a
tremendous handicap to the patients, their families, and society.
Converse to the hyperdopaminergic hypothesis of positive symptoms,
negative symptoms may involve hypodopaminergic activity in the frontal
lobes of the brain.
A 36 year old woman with a long history of alcoholism presents to the
emergency department intoxicated. On physical examination, she is
disoriented and confused, and has ataxia, dysarthria, and oculomotor
paralysis. Which of the following intravenous substances should most
likely be administered first?

a) Glucose
b) Haloperidol
c) Lorazepam
d) Thiamine
e) Valproic acid
The correct answer is D

Explanation
This patient appears to have Wernicke encephalopathy, which is due to a
deficiency of thiamine that is quite common in chronic alcoholics.
Symptoms of Wernicke encephalopathy include oculomotor disturbances,
cerebellar ataxia, and mental confusion. Treatment consists of giving
thiamine, 100 mg IV or IM, along with magnesium sulfate given before
loading with glucose.
A 48-year-old female nurse was recently admitted for evaluation of
recurrent skin infections and sepsis. On review of her medical records,
she has been treated for a non-healing abscess on her left forearm as
well as her right calf. The medical staff has been particularly
suspicious of her recurring infections and noted that she has missed
many days of work as a result of needed hospitalizations. Nursing staff
later uncovered a syringe that was concealed by the patient in her
personal belongings. It was suspected that the patient has been
injecting foreign material under the surface of her skin. Which of the
following statements is true about a patient with factitious disorder?

a) The symptoms are not intentionally produced by the patient


b) The patient tends to be overly compliant with medical staff
c) The motivation for the patient’s behavior is to assume the sick role
d) The motivation for the patient’s behavior is to avoid legal
responsibility, such as going to work
e) None of the above
The correct answer is C
Explanation
Factitious disorder is characterized by intentional production or
feigning of physical or psychological symptoms of a medical condition.
Motivation for the behavior is to assume the sick role.

A. Symptoms that are not intentionally produced by a patient to assume


the sick role would be more characteristic of a somatoform disorder.
B. A patient with factitious disorder is more often demanding and
disruptive with medical staff. These individuals will often dispute lab
results and sign out against medical advice when confronted with a
negative medical workup.
D. External incentives such as avoiding legal obligations,
responsibilities, or just seeking a room for the night are absent in
factitious disorder. Malingering would be the proper term for this
behavior.
Patients being treated with clozapine (Clozaril) for treatment-resistant
schizophrenia should be monitored with which one of the following?

a) Weekly WBC counts


b) A monthly EEG
c) Monthly clozapine levels
d) Monthly examinations for early signs of extrapyramidal side effects
e) Monthly examinations for early signs of tardive dyskinesia
The correct answer is A

Explanation
Clozapine is an antipsychotic agent which can be used to treat patients
with schizophrenia resistant to standard phenothiazines. Drug levels are
not usually monitoring for clozapine. Although seizures occur in 4% of
cases, EEG monitoring is impractical and is not recommended.
Extrapyramidal side effects and tardive dyskinesia do not occur with
this drug.

Agranulocytosis, although rare, can be fatal. Therefore, it is


recommended that patients on clozapine be monitored with weekly CBC counts.
A 74-year-old male comes to your office for a routine checkup. He has
been a patient of yours for many years and has never been a management
problem. Near the end of the visit he tells you he is very angry at his
neighbor. He has been able to hear all of his neighbor’s thoughts for
the past week and believes the man has been monitoring him with hidden
cameras. He further informs you that he has bought a shotgun and intends
to shoot the man the next time he comes out to complain about his yard.
When you ask him if he is serious about this he replies, ?You bet I am.?
After a prolonged discussion about this and repeated efforts to resolve
the problem otherwise, he tells you, ?I don?t care what happens to me
legally, I?m going to shoot him in the leg and teach him a lesson.? You
are obligated to:

a) Respect the patient’s confidentiality and do nothing


b) Try to talk him out of it, and document that clearly in the chart
before you let him leave the office
c) Obtain an outpatient evaluation of the patient by a psychiatrist
later that week
d) Arrange an emergency evaluation
e) None of the above
The correct answer is D

Explanation
According to the Tarasoff decision you must report threats of violence
where the patient has shown intent toward a specific person or persons.
Every reasonable effort should be made to keep the patient in the office
until the appropriate safe disposition is made. One should not put
oneself in danger, however, to achieve this.

A. Reasons to break confidentiality include homicidal ideation, suicidal


ideation, and report or evidence of child abuse.
B. You still have an obligation to protect public safety.
C. The patient could act on his plan by the time the consultation
occurs, even if that was the very next day.

An 11 year old boy has developed a hand washing ritual. He has been
noticed to wash his hands up to 35 times a day. His mother is very
worried but does not want treatment with any medication. Which one of
the following non-pharmacological treatments is best?

a) ECT
b) Counseling
c) Cognitive behavioral therapy
d) Family therapy
The correct answer is C

Explanation
Studies show that cognitive-behavioral therapy (CBT) is a highly
successful form of treatment for children and adolescents with both
obsessive-compulsive disorder (OCD).

CBT is often used interchangeably with cognitive therapy and behavior


therapy, there are distinctions between these interventions.

At the core of the behavior therapy program is a technique known as


exposure and ritual prevention (ERP). ERP is based on the process of
habituation, in which individuals habituate to stimuli they don't like.
We all experience this process in our daily lives. An example would be
jumping into cold water. The water feels cold initially, but gradually
feels warmer as our body becomes habituated to it. A person can become
habituated to smells, sounds, physical sensations, and emotions. In
persons with anxiety related to OCD, habituation is a decrease in
anxiety that occurs with the simple passage of time.

During cognitive therapy/restructuring, the therapist tries to identify


and correct errors in the patient's thinking that generate anxiety.
Patients with OCD usually have 2 types of erroneous thinking. One is a
probability overestimation error, in which they overestimate the
probability of a bad event, such as becoming infected with HIV by
touching a doorknob. The second is a catastrophe error, in which the
patient magnifies the severity of a likely event, such as observing
someone using the toilet and not washing his hands. Persons with OCD can
best learn to identify and self-correct these errors in thought by going
through a series of steps that we call ?thought challenging.?
An 87 year old black female is admitted to your hospital with a hip
fracture. She lives alone and has been self-sufficient. She has been
able to drive, go to the grocery, and balance her own checkbook. She
does well in the hospital until the second postoperative day, when she
develops agitated behavior, tremor, and disorientation. She attempts to
remove her Foley catheter repeatedly. She exhibits alternating periods
of somnolence and agitation, and describes seeing things in the room
that are not there. Which one of the following is the most likely diagnosis’

a) Delirium
b) Alzheimer’s disease
c) Senile dementia
d) Schizophrenia
e) Psychosis
The correct answer is A

Explanation
This individual is exhibiting symptoms of delirium. Diagnostic criteria
for delirium, according to the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV-TR), include the following:
A. Disturbance of consciousness (i.e., reduced clarity of awareness
about the environment) with reduced ability to focus, sustain, or shirt
awareness.
B. A change in cognition (e.g., memory deficit, disorientation, language
disturbance) or development of a perceptual disturbance that is not
better accounted for by established, or evolving dementia
C. Development over a short period of time (usually hours to days) with
a tendency to fluctuate during the course of a day
D. Evidence from the history, physical examination, or laboratory
findings that indicates the disturbance is caused by direct physiologic
consequences of a general medical condition.

In the case described, the patient’s history does not indicate


preexisting problems and she had a relatively abrupt onset of
disturbance of consciousness and change in cognition, related to the
hospitalization for hip fracture.
A patient taking lithium for bipolar develops weakness, lethargy and
cold intolerance. What investigation should be done at this time?

a) Lithium level
b) Blood pressure
c) TSH
d) CBC
The correct answer is C

Explanation
Chronic lithium use may precipitate thyroid disorders, particularly when
there is a family history of hypothyroidism. Therefore, TSH levels
should be monitored when lithium is started and at least annually if
there is a family history or if symptoms suggest thyroid dysfunction or
at least biannually for all other patients.
A psychiatrist is consulted to see a 29-year-old woman who is being
treated in an ICU for complications resulting from her intentionally
overdosing on her medication. This is her fourteenth overdose in the
past five years. All of them have been desperate attempts to stop
various boyfriends from leaving her. Several of the ICU nurses complain
that she is being mistreated by other nurses. They accuse these nurses
of labeling her a ?problem patient? despite her ‘sweet and vulnerable
nature?, and of punishing her by ignoring many of her requests for care,
and otherwise being rude to her. The accused nurses admit that she is
indeed a difficult patient, but that despite her constant verbal abuse
and hostility toward them, they have at all times been very polite to
her. What would be the most appropriate management of the situation?

a) Report to the head of nursing that the ICU nursing team is


unprofessional and unable to work together
b) Tell the patient that next time she overdoses, she will have to go
to another hospital
c) Call a meeting for the nurses, and invite a professional conflict
mediator to help resolve their dispute
d) Call a meeting for the nurses, and explain the concept of splitting
e) Establish a token economy for the patient as a behavioral treatment
The correct answer is D

Explanation
Splitting, a primitive defense mechanism where external objects are
divided into categories of ?all good? or ?all bad?, is
characteristically employed by patients with borderline personality
disorder. When hospital staff are unwittingly coopted into these
patients’ defensive strategies, they may become divided against each
other. The ICU nurses should be advised regarding the psychological
dynamics of the patient, and on how to manage the countertransference
(i.e., the feelings toward her) she provokes.

A. Most nurses do not receive much training regarding psychological


defense mechanisms; thus, this situation does not reflect on their
professionalism.
B. Refusing emergency treatment would be inappropriate and would violate
federal EMTALA regulations.
C & E. These more elaborate options might be appropriate if the dispute
still continued after full education regarding the psychological
dynamics of the patient and advice on how to manage transference and
countertransference.
Seventy-two hours after being admitted the patient develops delirium
tremens. Which one of the following statements about delirium tremens
is NOT true?

a) Confusion, obtundation, and delirium are the hallmarks of delirium


tremens
b) Auditory hallucinations are more common than visual hallucinations
c) Only 5% of patients with ethanol withdrawal progress to DT
d) The mortality rate for delirium tremens may be as high as 35% if
untreated
e) Typically occurs 3-7 days after the patient stops drinking
The correct answer is b

Explanation
Delirium tremens (DT) usually occurs 3-7 days after the last drink. It
is differentiated from the less severe forms of withdrawal by altered
sensorium and autonomic instability. Confusion, obtundation, and
delirium are the hallmarks of delirium tremens. Other findings include
severe agitation, hyperpyrexia, tachycardia, hypertension, and diaphoresis.
Only 5% of patients with ethanol withdrawal progress to DT.
The mortality rate for delirium tremens may be as high as 35% if
untreated but is less than 5% with early recognition and treatment.

Visual hallucinations are more common than auditory hallucinations.


Auditory hallucinations can be prolonged and disturbing, sometimes
lasting months and no particularly responsive to antipsychotic medications.
A 42-year-old man is admitted to a psychiatric ward and gives a
six-month history of severely depressed mood, loss of appetite and
weight, insomnia, and auditory hallucinations commanding him to hang
himself. While on the ward, he spends his time joking and socializing
with other patients, smoking heavily, eating double portions, and
sleeping soundly without hypnotic medication. Despite this, he continues
to complain of hallucinations and a severely depressed mood, and states
he will kill himself if discharged. It is noted that he is homeless,
that the weather has been unseasonably cold recently, and that he admits
he does not care to live in homeless shelters, citing how dangerous they
can be. What would be the most appropriate option for management of this
patient?

a) Start an MAOI, because he has an atypical depression as evidenced by


his reactive and apparently normal affect
b) Order MMPI testing
c) Restrict smoking privileges until he leaves voluntarily
d) Have him arrested for fraud
e) Supply him with a one-way bus ticket to a warmer state
The correct answer is b

Explanation
The Minnesota Multiphasic Personality Inventory assesses a wide range of
personality variables, and also rates responses on a ?lie scale?, an
?infrequency scale?, and a ‘suppressor scale?, which can be useful in
identifying malingering. It would not make a final determination of the
patient’s degree of truthfulness, but would provide supporting evidence.

A. Patients taking MAOIs must be reliable in following certain dietary


restrictions. Since there is some question as to this patient’s
reliability, an MAOI would be inadvisable.
C, D & E. These would be risky and questionable ethically. Nicotine
withdrawal particularly is extremely uncomfortable ? even genuinely ill
patients may leave the hospital if smoking is denied them.
For the past 6 months, an 18 year old man has withdrawn to the basement
of his house, because he believes he is the subject of a conspiracy to
kill him and that the home is "bugged". Which one of the following is
the most likely diagnosis’

a) Bipolar disorder - manic phase


b) Antisocial personality disorder
c) Obsessive-compulsive disorder
d) Schizophrenia
e) Delirium
The correct answer is D

Explanation
Schizophrenia is characterized by psychosis (loss of contact with
reality), hallucinations (false perceptions), delusions (false beliefs),
disorganized speech and behavior, flattened affect (restricted range of
emotions), cognitive deficits (impaired reasoning and problem solving),
and occupational and social dysfunction. The cause is unknown, but
evidence for a genetic component is strong.

Symptoms usually begin in adolescence or early adulthood. One or more


episodes of symptoms must last ? 6 months before the diagnosis is made.
Treatment consists of drug therapy, psychotherapy, and rehabilitation.
A 19 year old man comes home late at night from a party. He starts
hallucinating and is taken to the ER. On exam, nystagmus is found. What
was the substance he likely was abusing that night?

a) Marijuana
b) Cocaine
c) Phencyclidine
d) Fingernail polish remover
The correct answer is C

Explanation
Nystagmus can be found with the abuse of the following illicit drugs:
Lysergic acid diethylamide (LSD) and Phencyclidine (PCP).

Marijuana causes red eyes and weight loss. Phencyclidine (PCP) can cause
psychosis, slurred speech, confusion and agitation. Cocaine causes
hypertension, anxiety, nasal damage, loss of appetite and sleeplessness.
Inhalants such as fingernail polish remover, insecticides and paint
thinner can cause nausea, nosebleeds, headache and lightheadedness.

The only antidepressant with demonstrated efficacy in childhood and


adolescent depression is

a) clozapine (Clozaril)
b) fluoxetine (Prozac)
c) lithium
d) imipramine (Tofranil)
e) mirtazapine (Remeron)
The correct answer is b
Explanation
Fluoxetine is the only antidepressant with demonstrated efficacy in
childhood and adolescent depression. Other SSRIs, tricyclic agents, and
newer antidepressants have not been shown to be effective for treating
depression in this age group. Fluoxetine is the only SSRI currently
approved for pediatric use.
Each of the following statements about the designer drug Ecstasy is true
EXCEPT:

a) Hyperthermia and electrolyte imbalance are side effects


b) The dosage of the drug is indicative of the outcome
c) Is closely related to methamphetamine
d) Is often mixed with heroin and ketamine
e) Frequent use decreases the experience of euphoria
The correct answer is b

Explanation
The dosage of Ecstasy (3,4 methylenedioxymethamphetamine or MMDA) is not
always indicative of the outcome. Small amounts have resulted in
hyperthermia and near death. This drug can cause a serotonin-like
syndrome requiring rapid cooling of the body. The associated dancing in
a warm environment at a ?rave party? can result in severe electrolyte
imbalance as well. Frequent users may develop tolerance to the pleasant
or euphoric effects of MMDA. Other drugs may be added to produce or
augment the psychotropic effect being sought.
Which one of the following is true regarding panic disorder?

a) It is associated with major depression


b) It is more common in men than in women
c) It is best treated with anti-epileptic drugs
d) It is exacerbated by benzodiazepines
e) Relapses are rare
The correct answer is A

Explanation
Ninety percent of patients with panic disorder will have at least one
other psychiatric disorder during their lifetime. Conditions commonly
reported include major depression, generalized anxiety disorder,
agoraphobia, post-traumatic stress disorder, bipolar disorder, and
alcohol abuse. The risk of suicidal behavior is likely to be increased
among patients with panic disorder and coexisting major depression.

Panic disorder is more common in women than in men. Anti-epileptic drugs


are not indicated for panic disorder. Relapse occurs within 2 years in
at least one-third of patients with the disorder. The most effective
medications for panic disorder include SSRIs, SNRIs, and tricyclic
antidepressants, as well as benzodiazepines.
An elderly woman is admitted to a psychiatric unit for workup of
possible depression. Her symptoms consist primarily of lethargy and
indifference. She appears to ignore the left side of her body in her
daily activities, and when questioned about this, she denies any
difficulties. This patient should be suspected of having a
a) Bilateral frontal lobe lesion
b) Right parietal lobe lesion
c) Right temporal lobe lesion
d) Left pontine lesion
e) Left cerebellar lesion
The correct answer is b

Explanation

The parietal lobes can be divided into two functional regions. One
involves sensation and perception and the other is concerned with
integrating sensory input, primarily with the visual system. The first
function integrates sensory information to form a single perception
(cognition). The second function constructs a spatial coordinate system
to represent the world around us. Individuals with damage to the
parietal lobes often show striking deficits, such as abnormalities in
body image and spatial relations.

Damage to the left parietal lobe can result in what is called


"Gerstmann's Syndrome." It includes right-left confusion, difficulty
with writing (agraphia) and difficulty with mathematics (acalculia). It
can also produce disorders of language (aphasia) and the inability to
perceive objects normally (agnosia).

Damage to the right parietal lobe can result in neglecting part of the
body or space (contralateral neglect), which can impair many self-care
skills such as dressing and washing. Right side damage can also cause
difficulty in making things (constructional apraxia), denial of deficits
(anosagnosia) and drawing ability.
A 29 year old school teacher who lives alone is brought to the emergency
room because she has become increasingly suspicious, hyperactive, and
anorexic over the past two days. She believes that ?people in the
neighbourhood are out to get me?. She has not slept in 2 nights. She
reports seeing snakes crawling on the wall. Based on this information,
the most likely diagnosis of the woman’s problem is

a) Anorexia nervosa
b) Cocaine withdrawal
c) Paranoid personality
d) Psychostimulant abuse
e) Shared paranoid disorder
The correct answer is D

Explanation
In toxic doses, the psychostimulants begin to produce unpleasant CNS
symptoms including anxiety, agitation, hallucinations, delirium,
seizures, and death. High-dose, long-term use of stimulants can induce
an acute psychotic state in previously healthy individuals. CNS-induced
abnormalities, seizures, or muscular hyperactivity may induce
hyperthermia. secondary rhabdomyolysis may also be seen. Cardiovascular
manifestations include hypertension, tachycardia, arrhythmias, and
myocardial ischemia. Cerebrovascular accidents are precipitated by
elevated blood pressure or drug-induced vasospasms.

The clinical picture of stimulant intoxication also includes a wide


array of psychiatric symptoms including schizophrenic symptoms,
manic-like states, psychoses, depressions (especially during
withdrawal), and various types of anxiety conditions including panic
states. Psychotic symptoms usually arise with chronic abuse but may also
appear acutely with large doses of stimulants. With high doses of
stimulants, symptoms of extreme anger in conjunction with aggressive
behavior can also be a catalyst for both violence and murder and is
especially seen in cases of methamphetamine and cocaine intoxication.
A 46 year old man admitted to the psychiatric ward is given haloperidol.
He then develops restlessness. Constantly gets up, then sits back down,
and cannot sit still for any period of time. Which of the following side
effects of haloperidol has he developed?

a) Parkinsonism
b) Akathisia
c) Dystonia
d) Tardive dyskinesia
The correct answer is b

Explanation
The side effects of antipsychotic medications are as follows:

Parkinsonism: involves tremor, increased muscle tone, bradykinesia or


akinesia, drooling, postural instability, loss of spontaneity,
micrographia, seborrhea.
Akathisia: motor restlessness accompanied by a feeling of inner
restlessness (sometimes described as anxiety), an urge to move, and an
inability to sit still, patients may pace or continuously move their
feet and legs.

Dystonia: sustained contraction of muscles, twisting postures and may be


visible only when the patient is moving. Neck and arm muscles are most
commonly affected.

Tardive dyskinesia: hyperkinesia, involuntary body movements most often


of the muscles of the face, mouth, and tongue.
A woman brings in her son to your office saying that he is an alcoholic
who denies it. Among the questions you could ask him, what question is
least relevant?

a) Do you need a drink when you first get up in the morning


b) Do you hate criticism about your drinking
c) Do you drink only on social occasions
d) Do you drink and then feel guilty about it
e) Have you ever tried to cut down on your drinking
The correct answer is C

Explanation The C.A.G.E. questionnaire is an important tool in


evaluating potential alcoholics. The questions are as follows:

C: Have you ever tried to Cut down on drinking?


A: Have you ever felt Annoyed at criticism of your drinking?
G: Have you ever felt Guilty about your drinking?
E: Have you ever needed a drink first thing in morning? Eye opener?

The development of a bipolar mood disorder is frequently associated with


a history of

a) Loss of a parent before age 11


b) Repetitive experiences of "learned helplessness"
c) Night terrors
d) Sibling suffering from hypothyroidism
The correct answer is A

Explanation
Bipolar disorders are characterized by mania and depression, which
usually alternate. Exact cause is unknown. Heredity plays some role.
There is also evidence of dysregulation of serotonin and norepinephrine.
Psychosocial factors may also be involved. Stressful life events are
often associated with initial development of symptoms and later
exacerbations, although cause and effect have not been established.

A 32 year old engineer has been uncharacteristically active for several


weeks. He spends most of his time at work and gets little sleep. He has
told another engineer that he is involved ?in a research project that
will earn me the Nobel Prize?. The engineer is irritable, and it is hard
to hold his attention. A classmate from graduate school recalls that the
patient behaved in a similar manner twice during stressful periods at
school. Long term drug therapy for this patient would likely include

a) Lithium
b) Clozapine
c) Ascorbic acid
d) Chlordiazepoxide
The correct answer is A

Explanation
Mania is descibed by the following:

1. Inflated self-esteem or grandiosity,


2. Decreased need for sleep,
3. Excessive talking,
4. Racing thoughts,
5. Distractibility,
6. Increased goal-directed activity,
7. Excessive involvement in pleasurable activities with potentially
painful consequences, such as sexual indiscretions or spending sprees.

Mania and hypomania usually develop before the patient reaches age 40,
unless the patient has had prior depressive episodes. The differential
diagnosis of new-onset mania in a younger person should include
drug-induced mental disorders and brief reactive psychosis. If thought
disorder is prominent, a primary thought disorder in the schizophrenic
spectrum must be considered. If the patient is confused or disoriented,
agitated delirium is a relevant consideration.
The primary treatment for mania or hypomania is therapy with a
mood-stabilizing drug, of which lithium was the first and is the
best-studied. Patients who do not respond to lithium, those with rapid
cycles between depression and mania, and those with a mixture of manic
and depressive symptoms may respond well to a mood-stabilizing
antiepileptic drug. These drugs are given at typical antiepileptic
dosages. The effects of valproate and carbamazepine are well-established
by clinical trials; gabapentin has shown mood-stabilizing effects when
used as an anticonvulsant and may eventually be used as a psychiatric
drug. Functionally impaired patients with prominent paranoid features,
and those who fail to respond to both lithium and antiepileptic drugs,
should be treated with neuroleptics.
A 68 year old man develops acute renal failure after surgery for
ruptured aortic aneurysm. He refuses dialysis. Psychiatric consultation
reveals him to be fully alert and oriented, cognitively intact, and not
psychotic or clinically depressed. He says he is refusing dialysis
because he has "lived a full life" and does not want to be "tied to a
machine, even if this means I'll die." The psychiatrist should tell the
man's internist that the man

a) Is temporarily incompetent to decide on treatment, so treatment


should be started
b) Is competent to decide on treatment, but his refusal should be
overruled because of the existence of a medical emergency
c) His refusal of dialysis must be respected because he is competent to
decide on treatment
d) Is behaving in a self-destructive manner, so he should be committed
for treatment against his will
e) Shows no evidence of a major psychiatric illness but assessment of
competency is required
The correct answer is C

Explanation
The Supreme Court of Canada has said that the ?right to refuse unwanted
medical treatment is fundamental to a person’s dignity and autonomy.?
There are a number of reasons why a patient may wish to reject his
doctor’s recommended treatment: religious grounds, concern about side
effects, or concern about risks. In fact, the law protects the right of
a competent patient to make foolish decisions.

Under the law, a patient has the right to refuse treatment if he has the
ability ?to understand the information that is relevant to making a
decision about the treatment?and to appreciate the reasonably
foreseeable consequences of a decision or lack of decision.? He must be
able to understand the information, apply it to his circumstances, and
weigh the risks and benefits of the proposed treatment.
Which of the following is not considered a panicogenic?

a) Alcohol
b) Phobias
c) Ritalin
d) Carbon dioxide
e) Clonazepam
The correct answer is E

Explanation
Various provocative agents, including sodium lactate, carbon dioxide
(CO2), caffeine, yohimbine and cholecystokinin (CCK), have been shown to
be panicogenics.

People will often experience panic attacks as a direct result of


exposure to a phobic object or situation.

Sometimes panic attacks may be a listed side effect of medications such


as Ritalin (methylphenidate) or even fluoroquinolone type antibiotics

Serotonin reuptake inhibitors and benzodiazepines have an antipanic effect.

A 63-year-old retired teacher shared with his primary care physician


(PCP) during a routine office visit that he has noticed increasing
difficulty with his memory. Otherwise he is in good health and requiring
no medication. Which one of the following psychological tests is a
valuable screening device to be used by primary care physicians in this
type of situation?
a) MMPI
b) WAIS
c) Thematic Apperception Test
d) Mini-Mental State Exam
e) Rorschach Tests
The correct answer is D

Explanation
Mini-Mental State Exam. Answers A, B, C, and E are time-consuming and
except for choice B not directly pertinent in screening for memory or
cognitive deficits.
The best way to prevent benzodiazepine dependence is

a) Use benzodiazepines with short half-lives


b) Use for short duration only
c) Use at nighttime only
d) Use more than one benzodiazepine
The correct answer is b

Explanation
Benzodiazepine have addictive properties. If a benzo with shorter
half-life is used, there is more dependency since the patient will see
the effect of the drug wear off faster. The better option is to counsel
against long term use of such medicines.

When prescribing benzodiazepines the following guidelines should be used:

Do not prescribe benzodiazepines in someone with a history of drug


misuse and dependence.
Prescribe the lowest possible doses of benzodiazepines and only
prescribe for a few weeks. It is important to remember that patients can
get withdrawal symptoms between doses if they are given short-acting
benzodiazepines.
Elderly patients are particularly prone to adverse effects of
benzodiazepines therefore, need to be careful.
An IQ in the 40-54 range would be categorized by which one of the
following labels’

a) Profound retardation
b) Severe retardation
c) Moderate retardation
d) Mild retardation
e) Borderline retardation
The correct answer is C

Explanation
Moderate retardation is the correct answer. The IQ is a standardized
score of the Wechsler Adult Intelligence Scale (WAIS) with a population
mean of 100 and a standard deviation score of 15. A score less than 25
is labeled profound retardation; 25-39, severe retardation; 55-70, mild
retardation; and 70-80, borderline retardation. The WAIS is designed for
people 16 years and older. The Wechsler Intelligence Scale for Children
and a Wechsler Preschool and Primary Scale of Intelligence are used for
younger individuals.
A 49 year old male presents with depressed mood that has been going on
for three months now. He has lost interest in the things he used to
enjoy, feels sleepy all the time and skips work frequently. He admits
that this mood change impairs his ability to function daily.
What is this patient's condition most likely related to?

a) Depletion of norepinephrine and serotonin


b) Increase in serotonin and dopamine
c) Increase in norepinephrine and dopamine
d) Depletion serotonin and histamine
e) Depletion of serotonin and heparin
The correct answer is A

Explanation
Depression has been linked to problems or imbalances in the brain with
regard to the neurotransmitters serotonin, norepinephrine, and dopamine.
The neurotransmitter serotonin is involved in regulating many important
physiological (body-oriented) functions, including sleep, aggression,
eating, sexual behavior, and mood. Current research suggests that a
decrease in the production of serotonin can cause depression in some
people, and more specifically, a mood state that can cause some people
to feel suicidal.
Deficiency of the neurotransmitter norepinephrine in certain areas of
the brain was responsible for creating depressed mood. More recent
research suggests that there is indeed a subset of depressed people who
have low levels of norepinephrine.
Dopamine plays an important role in regulating our drive to seek out
rewards, as well as our ability to obtain a sense of pleasure. Low
dopamine levels may in part explain why depressed people don't derive
the same sense of pleasure out of activities or people that they did
before becoming depressed.

Histamine is a biogenic amine related to allergies.


Heparin is an anti-coagulant

A 37 year old female has been having problems at work for about 30
months now. She admits having occasional episodes of hyperactivity and
euphoria. These were preceded by episodes of sadness and inability to
cooperate with her colleagues in spite of trying hard to do her best.
What is the most likely diagnosis’

a) Bipolar disorder
b) Dysthymia
c) Cyclothymia
d) Masked depression
e) Factitious disorder
The correct answer is C

Explanation
Cyclothymic disorder is characterized by the presence of numerous
periods with hypomanic symptoms and numerous periods with depressive
symptoms that do not meet criteria for a Major Depressive Episode, for
at least 2 years (in children and adolescents, the duration must be at
least 1 year). During this 2-year period (1 year in children and
adolescents), the patient does not go without the symptoms for more than
2 months at a time.

Compared to more serious mood disorders, the mood symptoms of


cyclothymia are mild. Depressive symptoms in cyclothymic disorder never
reach the criteria for major depression. Elevated mood never reaches the
definition for mania.

Diagnosis is clinical and based on history. Management consists


primarily of education, although some patients with functional
impairment require drug therapy

In Bipolar disorder (manic-depressive illness) episodes of depression


alternate with episodes of full mania or lesser degrees of joyousness or
elation.

Dysthymic Disorder is a chronic condition characterized by depressive


symptoms that occur for most of the day, more days than not, for at
least 2 years.
A 31 year old man is shy, socially withdrawn, low in self-esteem, yet
eager to please when called on by persons in authority. Which one of the
following personality disorders is most likely to be associated with
this clinical description?

a) Passive-aggressive personality disorder


b) Histrionic personality disorder
c) Schizotypal personality disorder
d) Avoidant personality disorder
e) Compulsive personality disorder
The correct answer is D

Explanation
Avoidant personality is marked by hypersensitivity to rejection and fear
of starting relationships or anything new because of the risk of failure
or disappointment. Because affected people have a strong conscious
desire for affection and acceptance, they are openly distressed by their
isolation and inability to relate comfortably to other people. They
respond to even small hints of rejection by withdrawing.
A 45 year old woman who is well controlled on lithium for bipolar
disorder becomes hypothyroid. What is the appropriate intervention?

a) Reduce dose of lithium to 50%


b) Start levothyroxine
c) Stop lithium
d) Monitor and check TSH/FT4 in 3 months
The correct answer is b

Explanation
It is well established that lithium therapy can cause hypothyroidism in
about 2-3 % of patients. Once hypothyroidism is diagnosed, treatment of
the condition should be instigated rapidly with thyroxine.
Discontinuation of lithium therapy is an option but in most cases the
psychiatric indication for continuing it is strong as in this patient.
Once treatment is begun, regular monitoring of TSH and FT4 will be required.
A 22 year old male is admitted to a psychiatric unit for stabilization
of an acute episode of psychosis. He has been started on an
antidepressant, an antipsychotic, and has required additional
medications on several occasions for agitation. On the fifth day of his
hospitalization, he develops a sustained muscular contraction involving
his left neck muscles, with associated pain and distress. Which of the
following medications is most likely responsible for this acute reaction?

a) Fluoxetine
b) Haloperidol
c) Lorazepam
d) Olanzapine
e) Sertraline
The correct answer is b

Explanation
This patient is experiencing neuroleptic-induced acute dystonia. About
10% of patients experience dystonia as an adverse effect of
antipsychotics, usually within the first few days of treatment. Dystonia
can involve the neck (torticollis), the jaw, the tongue, the eyes, other
specific muscle groups, and the entire body. Dystonias are most common
with high potency conventional antipsychotics, such as haloperidol.
Pseudoparkinsonism and akathisia are other forms of acute extrapyramidal
side effects.
Which one of the following would justify a patient's being declared
incompetent with respect to self care?

a) The patient has a major mental disorder


b) The patient has been admitted to hospital
c) The patient is undergoing psychotherapy
d) The patient is unable to understand the consequences of his/her
decisions
e) The patient is unable to work because of a mental disorder
The correct answer is D

Explanation
Incompetence is determined by establishing the inability to understand
the risks, benefits, and alternatives of particular activities.
The diagnosis of mental illness lies in the hands of medical and
psychiatric personnel. On the other hand, the determination of mental
incompetence lies with a court of law.
A 25-year-old male presents to your clinic concerned that he may have
cancer. He has noted palpitations, abdominal cramps, and weight loss
over the past 3 months. He has begun to avoid eating breakfast because
his symptoms seem to occur only in the morning as he is driving to work.
He admits to some stressors at work, mainly because he cannot
concentrate well. He also is having problems with his marriage. He
blames this on difficulty adjusting since returning 6 months ago from
military service in Iraq. He also wonders if he could have picked up a
parasite or been exposed to chemicals during patrols in his armored vehicle.

He notes problems with sleep, night sweats, and daytime irritability. He


has a family history of hyperthyroidism, depression, and irritable bowel
syndrome. A physical examination is normal.

The most likely cause of this patient’s symptoms is

a) Hyperthyroidism
b) Posttraumatic stress disorder
c) Depression
d) /Giardia/ infection
e) Irritable bowel syndrome
The correct answer is b

Explanation
Many veterans returning from Iraq are expected to develop posttraumatic
stress disorder (PTSD). In this patient, driving his car triggers an
intense physiologic reactivity, as he subconsciously relives the stress
of driving his vehicle in battle zones.

PTSD is more common in people with a family history of mental illness.


The fact that it began 3 months after the patient’s return from Iraq and
that it happens mainly at only one time of day makes it unlikely to be a
parasite. A delay in symptom onset can be seen with PTSD.

With irritable bowel syndrome, diarrhea is often worse in the morning,


but this diagnosis does not account for his other problems. A normal
physical examination would tend to rule out hyperthyroidism, although
this possibility should still be explored. Irritability and difficulty
concentrating are related to symptoms of increased arousal seen with
PTSD. Depression could account for some of this patient’s symptoms, but
it not the most likely diagnosis given the history.
An 18 year old female visits you because she is having difficulty
sleeping, cannot concentrate, and is more irritable. She also says that
people around her remark on how overly alert and wary she seems to be
and how easy it is to startle her. With gentle probing you discover that
6 months ago she was driving a car that was involved in an accident in
which a close friend was killed.

Since that time she avoids driving and always tries to avoid the
intersection where the accident occurred. In spite of trying to put it
out of her mind, she still dreams about the event, and even during the
day may relieve the accident. Her mother is concerned because she has
begun to withdraw from participation in school and church activities and
just broke off a relationship with her long-term boyfriend. The most
probable primary diagnosis in this patient is which one of the following?

a) Acute stress disorder


b) Adjustment reaction with depressed mood
c) Major depression
d) Generalized anxiety disorder
e) Post-traumatic stress disorder
The correct answer is E

Explanation
This patient’s findings include all four categories of criteria for the
diagnosis of post-traumatic stress disorder (PTSD). First, a traumatic
event occurred in which the patient witnessed or experienced actual or
threatened death or serious injury and responded with intense fear,
horror, or helplessness. Second, on exposure to memory cues, the patient
has re-experiencing symptoms such as intrusive recollections,
nightmares, flashbacks, or psychological distress. Third, the patient
avoids trauma-related stimuli and feels emotionally numb. Finally, the
patient has increased arousal, manifested by hypervigilance,
irritability, or difficulty sleeping. The symptoms must also be
persistent for at least 1 month and significantly disturb the patients
social or occupational functioning, or both.

Acute stress disorder also occurs after exposure to a traumatic event,


but symptoms appear within 4 weeks of the trauma and last from 2 days to
4 weeks. Patients with this disorder also have more dissociative
symptoms, describing themselves as feeling ?in a daze? or having
temporary amnesia about the event. PTSD increases the risk of later
developing comorbid psychiatric problems. The most common diseases that
occur with PTSD are major depression, dysthymia, generalized anxiety
disorder, substance abuse, somatization, panic disorder, bipolar
disorder and dissociative disorders.
A 25 year old female comes to your clinic with the complaint of heat
intolerance.

The symptoms started 3 weeks ago. She also complains of weight loss,
increased appetite and occasional palpitations. Her vital signs are
significant for a pulse of 110/min and a BP of 150/60 mmHg. On physical
exam, her thyroid gland is normal in size.

You order a thyroid workup which reveals low TSH, high T4, high T3,
minimal uptake on radioactive iodine scan and undetectable thyroglobulin
levels.

Based on the described scenario, which of the following is the most


likely diagnosis’

a) Acute thyroiditis
b) Factitious disorder
c) Grave’s disease
d) Hypothyroidism
e) Toxic multinodular goiter
The correct answer is b

Explanation
The patient is most likely ingesting thyroid medications
surreptitiously. The symptoms and thyroid function tests point to
hyperthyroidism however the low uptake scan with the low thyroglobulin
level denotes an exogenous source of the thyroid hormones. Patients with
factitious disorder deliberately create or exaggerate symptoms of an
illness in several ways. They may lie about or mimic symptoms, hurt
themselves to bring on symptoms, or alter diagnostic tests (such as
contaminating a urine sample). People with factitious disorders seek
internal, primary (psychological) gain.

Grave’s disease would give a diffusely enlarged thyroid with a diffuse


high uptake scan of the thyroid.

Hypothyroidism is neither suggested clinically nor by lab tests.

Toxic multinodular goiter would give a big nodular thyroid along with
hot toxic nodules on the iodine uptake scan.

Acute thyroiditis may give thyrotoxic symptoms initially due to the


inflamed follicles releasing thyroid hormones; however, the
thyroglobulin levels would be very high.
A 34 year old white male presents with a history and findings that
satisfy DSM-IV criteria for bipolar disorder. Which one of the following
treatment options is the most effective for long-term management of the
majority of patients with this disorder?

a) Electroconvulsive therapy (ECT)


b) Tricyclic antidepressants
c) SSRIs
d) Monoamine oxidase (MAO) inhibitors
e) Lithium
The correct answer is E

Explanation
Electroconvulsive therapy (ECT) is as effective as medication for the
acute treatment of the severe depression and/or mania of bipolar
disorder. However, ECT should be reserved for patients with severe mood
syndromes who may be unable to wait for mood-stabilizing drugs to take
effect. Neuroleptic (antipsychotic) drugs are effective in acute mania,
but are not recommended for long-term use because of side effects.
Bipolar depression generally responds to tricyclic antidepressants,
SSRIs, and MAO inhibitors, but when used as long-term therapy these
drugs may induce episodes of mania.

Anticonvulsants, such as carbamazepine, valproic acid, and


benzodiazepines, have been useful adjuncts combined with lithium in
patients with breakthrough episodes of mania and/or depression. Lithium
is the classic mood stabilizer. It has been shown to have antimanic
efficacy, prophylactic efficacy in bipolar disorder, and some efficacy
in prophylaxis against bipolar depression. Lithium remains the drug of
choice for long-term treatment of the majority of patients with bipolar
illness.
Each of the following regarding alcohol abuse in the elderly is true EXCEPT:

a) Community prevalence for men is in the 3% range


b) Increased prevalence of mood disorders
c) Respond as well as middle-aged alcoholics to treatment
d) Is differentiated from alcohol dependence by tolerance
e) Commonly has its onset after retirement
The correct answer is E

Explanation
Although 30% of people with alcoholism older than age 65 began their
abuse after age 60, the majority established their pathological use
earlier. The 3% prevalence rate typically includes institutionalized
elderly patients. Alcoholism is associated with higher prevalence of
both mood and cognitive disturbances. Tolerance is seen with continuous
alcohol use, leading to a dependence on increased consumption. The
principles of treatment for elderly alcoholics are similar to younger
patients. Late-onset drinkers have a better response rate to treatment.

The basic mechanism of defense in phobic reactions is

a) Displacement
b) Projection
c) Avoidance
d) Sublimation
e) Isolation
The correct answer is C

Explanation
Avoidance is a defense mechanism consisting of refusal to encounter
situations, objects, or activities because they represent unconscious
sexual or aggressive impulses and/or punishment for those impulses;
avoidance, according to the dynamic theory, is a major defense mechanism
in phobias.
Several studies have indicated that, in large urban areas, there is a
higher prevalence of schizophrenia in the lower socioeconomic class.
Epidemiologic studies tend to support the hypothesis that

a) Unsatisfactory social circumstances "breed" an excess incidence of


schizophrenia
b) The fathers of schizophrenics also tend to come from a lower
socioeconomic class
c) People with schizophrenia tend to "drift" down the social scale,
because of their illness
d) Both intelligence and schizophrenia are negatively associated with
social class
e) Schizophrenia "runs" in families and is primarily an inherited disorder
The correct answer is C

Explanation
Schizophrenia is characterized by psychosis (loss of contact with
reality), hallucinations (false perceptions), delusions (false beliefs),
disorganized speech and behavior, flattened affect (restricted range of
emotions), cognitive deficits (impaired reasoning and problem solving),
and occupational and social dysfunction.

The cause is unknown, but evidence for a genetic component is strong.


Symptoms usually begin in adolescence or early adulthood. One or more
episodes of symptoms must last ? 6 months before the diagnosis is made.
Treatment consists of drug therapy, psychotherapy, and rehabilitation.

The concept of ‘schizophrenia drift? refers to the fact that as people


develop the illness they tend to sort of migrate to cities and then sort
of drift down the food chain and become the urban poor. So that evidence
does not suggest that being poor and urban is a cause of the illness,
rather that’s where patients end up.
Jennifer is a 24 year old lady that presents to your office with the
complaint of stomach pain.

When asked about the duration, she replies that the pain has been there
constantly for the past 5 years. The pain is located around the
umbilicus, not relieved with medications, not related to foods and does
not increase or decrease with movement.

She also complains of a chronic back pain, nausea, bloating,


dysmenorrhea, dysphagia, dyspareunia, headaches and an episode of
deafness. When asked about any past interventions regarding all these
problems, she said that she underwent two upper endoscopies, one
colonoscopy and two CT-scans and no abnormalities were detected. Her
physical exam is normal. Which of the following is the most likely
diagnosis’

a) Chronic fatigue syndrome


b) Fibromyalgia
c) Hypochondriasis
d) Pain syndrome
e) Somatization disorder
The correct answer is E

Explanation
The most likely diagnosis of this patient is somatization disorder. It
usually presents with multiple somatic complaints involving different
organ systems (2 GIT symptoms, 4 pain symptoms, sexual and neurologic
symptoms) with a negative workup. It is seen predominantly in women and
usually presents before the age of 30.

Hypochondriasis is the major differential of somatization. Be careful!


The hypochondriatic patient will also complain of multiple symptoms;
however, she will name only one disease and will try to convince you
with this diagnosis. In other words, the patient will tell you ?I think
I have brain tumor, heart attack??

Pain syndrome patients will complain of multiple pain symptoms and only
pain.

Chronic fatigue syndrome is a condition causing persistent fatigue that


lasts for at least 6 months and is not due to another medical condition
(e.g., hypothyroidism).

Fibromyalgia is a chronic condition that presents with pain, stiffness,


and tenderness of the muscles, tendons, and joints with a characteristic
tenderness involving specific points in the body. Fibromyalgia is also
characterized by restless sleep, chronic fatigue, anxiety, and depression.
A 27 year old woman comes to the office because of concerns about sexual
function. The patient recently has remarried after being divorced from
an abusive partner. She is currently unable to complete intercourse with
her new husband due to intense vaginal pain on attempts at penetration.
She was able to have intercourse successfully early in her first
marriage. She is orgasmic with other stimulation but cannot tolerate
digital or other penetration. Which of the following is the most likely
mechanism for this condition?

a) Change in vaginal flora because of a new partner


b) Conversion disorder
c) Inadequate lubrication
d) Inflammation of vestibular glands
e) Vaginal muscle spasm
The correct answer is E

Explanation
The successful completion of intercourse depends on both psychologic and
physical factors. Although this patient is the victim of spousal abuse,
there is no indication that she is unable to achieve sexual
gratification (quite the opposite is true) suggesting that she is
physically and psychologically able to achieve orgasm. The issue is
rather pain with a specific form of sexual activity: vaginal
intercourse. In the absence of other findings such as blood (cervical
cancer), this is most likely due to vaginal muscle tension or spasm.

A change in vaginal flora may occur depending on the stage of


menstruation, infection, antibiotic usage or diet, but this change is
not associated with vaginal pain in the absence of vaginal discharge or
smell. A conversion disorder is a psychiatric illness whereby physical
symptoms are manifest solely as a function of mental illness. As
mentioned above, this patient appears to be quite able psychologically
to attain orgasm. In addition, conversion disorder, according the DSM
IV, has specific diagnostic criteria. Among these is that the symptom or
deficit is not limited to pain or sexual dysfunction.
Each of the following patients comes to your office asking if they can
stop their medications. Which patient would you feel most comfortable
tapering off the medication mentioned?

a) A man with bipolar disorder who is taking valproic acid and has had
no episodes for the past year
b) A woman with major depression with psychotic features who has had no
psychotic symptoms for the past 3 months on haloperidol and intends to
stay on her antidepressant
c) A man with schizoaffective disorder treated with olanzapine who has
had no psychotic symptoms for the past 3 months
d) A schizophrenic man on risperidone who has just gotten a job after 3
years of minimal psychotic symptoms
The correct answer is b

Explanation
This is a case where you should actively be working with the patient to
eventually stop the antipsychotic. The psychotic symptoms should resolve
once the condition is adequately treated with an antidepressant. Usually
the patient can be tapered off the haloperideol fairly quickly while
continuing on the antidepressant. The risk of tardive dyskinesia is
reduced by using the antipsychotic for as short a time period as
possible, and using an atypical antipsychotic whenever possible.

A. Most bipolar patients will require indefinite treatment with a mood


stabilizer to prevent future episodes. If this is not done, it is
believed that a ?kindling phenomenon? occurs. This refers to the
observation that future episodes will occur with progressively less time
between them, more severe symptoms, and less of a response to treatment.
C. This patient is at higher risk for a recurrence of symptoms since
stabilization of mood is not sufficient to prevent psychosis.
D. His treatment may be more necessary if his stress level is about to
increase.
A 53 year old white female visits your office for her annual
examination. During the last year she has stopped having menstrual
periods and has had moderately severe sleep disturbance. She has been
waking up at night with sweats. She denies other problems or complaints.
She has a previous history of depression and her family history is
significant for osteoporosis, heart disease, and Alzheimer’s disease in
older members of her family. There is no family history of breast
cancer. The patient is concerned about her future and current health and
wants to know the benefits and risks of hormone replacement therapy
(HRT). Which one of the following statements about HRT is correct?

a) It protects against coronary heart disease


b) It slows progression of Alzheimer’s disease
c) It improves symptoms of depression
d) It improves vaginal dryness
e) It improves urinary incontinence
The correct answer is D

Explanation
Hormone replacement therapy (HRT) improves the urogenital symptoms of
menopause, such as vaginal dryness and dyspareunia. However, recent
research regarding HRT has not shown a benefit for reducing coronary
events, slowing the progression of Alzheimer’s disease, improving
depression, or improving urinary incontinence.
A 42 year old man is diagnosed by his primary care physician as having
major depressive disorder. The patient tells his physician that he is
extremely concerned about his sexual performance, as he is worried that
he is getting older and that he is having some marital difficulties with
his wife. Which of the following antidepressants would be the best
choice for initial treatment?

a) Bupropion
b) Fluoxetine
c) Imipramine
d) Paroxetine
e) Sertraline
The correct answer is A

Explanation
Bupropion is the antidepressant of the choices listed that has the
fewest adverse sexual side effects. Selective serotonin reuptake
inhibitors, such as fluoxetine, paroxetine , and sertraline are all
known to be associated with erectile and orgasmic disturbances, such as
delayed ejaculation and anorgasmia. Because imipramine also has effect
on the serotonin levels in the brain, it too has sexual side effects,
although to a somewhat lesser degree than the SSRIs.
Which one of the following antipsychotic medications is most likely to
cause agranulocytosis’

a) Clozapine (Clozaril)
b) Aripiprazole (Abilify)
c) Risperidone (Risperdal)
d) Olanzapine (Zyprexa)
The correct answer is A

Explanation
Clozapine was the first atypical antipsychotic drug, so designated
because it has antipsychotic effects without the adverse effects on
movement seen with first-generation agents, in addition to having
enhanced therapeutic efficacy compared with first-generation drugs.
Because of these advantages, it was introduced into clinical practice in
Canada despite a serious known adverse effect: an increased incidence of
agranulocytosis. Although only clozapine causes agranulocytosis in a
substantial proportion of patients, many second-generation drugs produce
clinically significant weight gain.
A previously-healthy 70 year old man made a nearly successful attempt at
suicide by hanging. His depression has been effectively treated with a
tricyclic antidepressant. On examination, he has an impairment of short
and long-term memory. He is well-nourished, and routine hematologic and
biochemical tests are normal. The most likely cause of his memory
deficit is

a) Psychogenic amnesia
b) Alzheimer disease
c) Posttraumatic stress disorder
d) Cerebral anoxia
e) Thiamine deficiency
The correct answer is D

Explanation
Hanging or strangulation account for 15% of all suicides yearly with
hanging being the most common method of suicide amongst inmates. The
male to female ratio is 4:1. Death is caused by cerebral anoxia caused
by compression of the nerves and vessels in the neck. Occlusion of the
upper airway by constriction of the neck is thought to be rare, however
closure of the airway is caused by upward displacement of the tongue and
epiglottis. Cardiac arrest may ensue from pressure on the vagus nerve or
carotid sinus.
Most survivors of the initial trauma later die of pulmonary edema,
aspiration pneumonia, or ARDS. Delayed airway obstruction has been
observed secondary to hemorrhage or edema formation or to fracture of
the hyoid bone. Survivors often exhibit memory loss, restlessness, and
confusion.
Under certain circumstances, it may be legitimate to detain individuals
in an institution against their wishes, for their own good and to
protect others. This situation may arise when

a) A person has bizarre fantasies and actions


b) Persons are mentally incompetent and unable to manage their own affairs
c) A close relative submits a petition that an individual is insane
d) The individual's continued liberty poses a danger
e) A person has visual and aural hallucinations
The correct answer is D

Explanation
Involuntary admission to a hospital is allowed when a person:

1) has a mental disorder and


2) needs inpatient care or treatment and
3) presents a danger to the life or safety of the person or others and
4) is unable or unwilling to be admitted voluntarily and
5) there is no available less restrictive form of intervention that is
consistent with their welfare and safety.
Which of the following is true of the biopsychosocial model of
approaching illness’

a) It emphasizes the structural and chemical nature of disease


b) It emphasizes the cognitive, psychodynamic, and personality factors
affecting disease
c) It emphasizes the role of one’s culture, support system, and living
environment on disease
d) All of the above
e) None of the above
The correct answer is D

Explanation
The biopsychosocial model is an attempt to approach all patients in a
comprehensive manner - approach that posits that biological,
psychological (which entails thoughts, emotions, and behaviors), and
social factors, all play a significant role in human functioning in the
context of disease or illness. Reviews of their past medical history,
family medical history, physical symptoms, the physical exam, and any
laboratory or pathology findings are included in the biologic
assessment. Reviews of coping skills, current motivations and goals, and
personality traits that may affect the intensity or ability to adapt to
the illness are included in the psychological assessment. The person’s
family and community influences are included in the social assessment.
Combined, these factors offer a better sense of how to understand and
subsequently treat the problem that the patient is bring to the physician.
The syndrome of delirium tremens is associated with each of the
following, except

a) Rapidly fluctuating level of consciousness


b) Dehydration
c) Visual hallucinations
d) Renal failure
e) Polyneuropathy
The correct answer is D

Explanation
Delirium tremens (DTs), a very serious set of symptoms, may result if
alcohol withdrawal is left untreated. Delirium tremens usually does not
begin immediately; rather, it appears about 2 to 10 days after the
drinking stops. In delirium tremens, the person is initially anxious and
later develops increasing confusion, sleeplessness, nightmares,
excessive sweating, and profound depression. The pulse rate tends to
speed up. Fever typically develops. The episode may escalate to include
fleeting hallucinations, illusions that arouse fear and restlessness,
and disorientation with visual hallucinations that may incite terror.
Objects seen in dim light may be particularly terrifying, and the person
becomes extremely confused. The floor may seem to move, the walls fall,
or the room rotates.

Other problems are directly related to the toxic effects of alcohol on


the brain and liver. Prolonged use of excessive amounts of alcohol can
lead to alcoholic liver disease. An alcohol-damaged liver is less able
to rid the body of toxic substances, which can cause hepatic coma. A
person developing hepatic coma becomes dull, sleepy, stuporous, and
confused and usually develops an odd flapping tremor of the hands.
Hepatic coma is life threatening and needs to be treated immediately.
Which one of the following is the most effective drug for the treatment
of alcohol dependence?

a) Disulfiram (Antabuse)
b) Diazepam (Valium)
c) Amitriptyline (Elavil)
d) Fluoxetine (Prozac)
e) Naltrexone (ReVia)
The correct answer is E

Explanation
Drug therapy should be considered for all patients with alcohol
dependence who do not have medical contraindications to the use of the
drug and who are willing to take it. Of the several drugs studied for
the treatment of dependence, the evidence of efficacy is strongest for
naltrexone and acamprostate. Naltrexone is currently available;
acamprosate and tiapride are currently available in Europe but not in
Canada.
In a bulimic patient, what medication is likely to help the most?

a) Lithium
b) Haloperidol
c) Clomipramine
d) Fluoxetine
The correct answer is D

Explanation
Bulimia nervosa is recurrent episodes of binge eating followed by
self-induced vomiting, laxative or diuretic abuse, vigorous exercise, or
fasting.

Most symptoms and physical complications result from purging.


Self-induced vomiting leads to erosion of dental enamel of the front
teeth and to painless salivary gland enlargement. Serious fluid and
electrolyte disturbances, especially hypokalemia, occur occasionally.

The diagnosis is suspected when patients express marked concern about


weight gain and have wide fluctuations in weight, especially with
excessive laxative use or unexplained hypokalemia. Swollen parotid
glands, scars on the knuckles (from induced vomiting), and dental
erosion are danger signs.

Treatment is with psychotherapy and SSRIs, especially fluoxetine.


A 66 year old white male is brought to your office for evaluation of
progressive memory loss over the last several months. The problem seems
to wax and wane significantly over the course of days and weeks. At
times when he is more confused, he tends to have visual and auditory
hallucinations that he is back fighting in Vietnam, thinking a ringing
telephone is calling in fighter jets. He has also been falling occasionally.

On physical examination, he has a resting tremor in his left leg, and


rigidity of his upper body and face. A full medical workup, including
standard blood work and a CT scan, shows no abnormalities that suggest
delirium, stroke, or other primary etiologies. Which one of the
following is the most likely diagnosis’

a) Alzheimer’s disease
b) Dementia with Lewy bodies
c) Fronto-temporal dementia
d) Multi-infarct dementia
e) Pseudodementia
The correct answer is b

Explanation
Dementia with Lewy bodies is currently considered one of the most common
etiologies of dementia in elderly patients, representing up to 20%-30%
of those with significant memory loss. The clinical presentation
consists of parkinsonian symptoms (rigidity, tremor), fluctuating levels
of alertness and cognitive abilities, and behavior sometimes mimicking
acute delirium. Significant visual hallucinations are common, and
delusions and auditory hallucinations are seen to a lesser degree. On
pathologic examination, Lewy bodies (seen in the substantia nigra in
patients with Parkinson’s disease) are present diffusely in the cortex.
There is currently no specific treatment.
A 23-year-old female presents to her employee health services
complaining of severe anxiety. She reports symptoms of shortness of
breath, sweaty palms, shakiness, and lightheadedness over the past few
weeks. She states that she has a work-related presentation scheduled
that week as well as an office holiday party that she is expected to
attend. She admits that she worries excessively that she will do
something to embarrass herself in either of these situations. She has
avoided office parties in the past because she thinks others will
scrutinize her appearance or behavior. She is distressed because she has
few friends and prefers to stay at home rather than go out and meet new
people.

a) Social phobia
b) Depression
c) Paranoia
d) Simple phobia
e) Agoraphobia
The correct answer is A

Explanation
Social phobia is an anxiety disorder of persistent fear that one or more
social situations will result in humiliation of the individual or
scrutiny by others. Affected individuals avoid social or performance
situations in fear they will embarrass themselves or be judged as
anxious or stupid. Individuals with social anxiety usually experience
physical symptoms of anxiety and marked anticipatory anxiety far in
advance of upcoming social situations.

B. Social withdrawal is common with depression but is usually associated


with a lack of interest rather than fear of social situations.
C. Paranoia is marked by fear that someone will do something untoward to
the individual, not that they will be humiliated.
D. Simple phobia is marked and persistent fear of a clearly discernible,
circumscribed object or situation, and exposure leads to immediate
anxiety response, for example, social situations related to crowds or
being in an enclosed space.
E. Agoraphobia is characterized by avoidance of situations due to fear
the individual will have incapacitating panic-like symptoms or fear of
losing control.
A 47-year-old man has presented to his primary care doctor eight times
in the last year with concerns over a variety of minor symptoms such as
dry skin, vague abdominal discomfort, and so on. He states he was in
good health prior to the age of 46. At each visit, full history,
examination, and appropriate lab testing reveal no physical abnormality.
His doctor repeatedly reassures him of this. When the doctor does this
the patient believes him, but before long he again becomes concerned
about a new symptom. The symptoms themselves are less troubling to him
than is the fear he feels that he might have some serious, unknown
medical illness which the doctor has missed finding. On questioning, he
has no other psychiatric symptoms. Though this concern about having an
unknown illness is obviously genuine and very distressing to him, he
never requests time off work, hospitalization, or inquires about medical
disability payments. What is the likely diagnosis’
a) Delusional disorder, somatic type
b) Somatization disorder
c) Hypochondriasis
d) Malingering
e) Major depressive disorder
The correct answer is C

Explanation
Hypochondriasis is characterized by a preoccupation with fears that one
has a serious disease due to an unrealistic assessment of one’s
symptoms. This fear persists despite reassurance, and is distressing to
the patient.

A. In hypochondriasis, the fear of having a serious disease is not of


delusional intensity, as seen in patients with delusional disorder,
somatic type, who cannot be convinced even briefly that their beliefs
are inaccurate.
B. Somatization disorder is characterized by a variety of unexplained
symptoms occurring over many years and by definition must being before
age 30.
D. Malingering is the intentional simulation of symptoms and/or signs of
illness in order to gain some external incentive, like insurance
benefits or time off work.
E. Major depressive disorder by definition includes symptoms of
depressed mood or loss of interest or pleasure in life, along with a
variety of other symptoms such as sleep disturbance, loss of appetite,
and so on.
A teenage boy is very aggressive, angry and always getting in fights.
Through the help of his teachers and counselors he decides to join the
wrestling team and within a few months is one of the best wrestlers on
his high school team. This is an example of which defense mechanism?

a) Sublimation
b) Regression
c) Splitting
d) Projection
The correct answer is A

Explanation
In Sigmund Freud’s psychoanalytic theory, defense mechanisms are
psychological strategies used by individuals to cope with reality and to
maintain self-image.

There are numerous defense mechanisms here are explanations of the above
4 choices:

Sublimation: transformation of negative emotions or instincts into


positive actions, behavior, or emotion. For example, rageful person who
is accustomed to lashing out might rechannel their passion through a
positive hobby.

Regression: is a defense mechanism leading to a return to earlier,


especially to infantile, patterns of thoughts or behavior, or stage of
functioning. For example, an adult woman who is told that her father
just died, will react by throwing a temper tantrum and crying like a child.

Splitting: when a person thinks purely in extremes. Everything is either


all good or all bad.

Projection: is a defense mechanism in which one attributes to others


one’s own unacceptable or unwanted thoughts or/and emotions. For
example, a man who has thoughts of cheating on his wife, becomes very
jealous of his own wife and phone calls or letters that she receives.

A 44-year-old female comes to your office for a second opinion. She says
she is being treated for bipolar disorder but doesn?t understand why she
is hearing voices even when she is no longer depressed or manic. On
reviewing her records you discover that she has auditory hallucinations
and paranoia that never clear completely despite being without any mood
symptoms for long periods of time. You inform the patient that your
diagnosis would be:

a) Schizoaffective disorder
b) Schizophrenia, residual type
c) Schizophrenia, paranoid type
d) Schizophrenia, disorganized type
e) Major depression with psychotic features
The correct answer is A

Explanation
A bipolar patient has psychosis only during a depression or mania. If
psychotic symptoms are present despite full treatment of mood symptoms,
the diagnosis is schizoaffective disorder. This impacts your treatment
because the patient may need indefinite antipsychotic treatment.

B. This is the term for a chronic schizophrenic who has predominantly


negative symptoms such as disorganization, flattened affect, or
vegetative symptoms.
C. This is the term for the schizophrenic with the typical spectrum of
hallucinations and delusions.
D. This is the term for the schizophrenic who has very disorganized
speech, is difficult to understand, and has inappropriate emotional
responses.
E. If psychotic symptoms are present when the patient is not depressed,
this cannot be the diagnosis.
A 36-year-old male presents to your office with rapid speech, elevated
mood, increased energy, poor sleep, and increased appetite. You consult
a psychiatrist who recommends initiating medication treatment with
lithium. The psychiatrist asks you to perform some baseline tests before
starting the medication. All of the following tests should be done to
appropriately monitor the patient taking lithium EXCEPT:

a) Baseline EKG
b) CBC
c) Liver enzyme panel
d) TSH
e) BUN and creatinine level
The correct answer is C

Explanation
Liver enzymes should be monitored in individuals who are taking valproic
acid or carbamazepine, but not lithium, which is excreted primarily
through the kidney.

A. Lithium may cause EKG changes such as flattening or inversion of T


waves or, more seriously, sinus node dysfunction.
B. Elevation of white blood count is possible while taking lithium.
D. Hypothyroidism secondary to lithium can be detected by elevation of TSH.
E. Renal function should be monitored every 3 months
A 30-year-old man presents with the typical findings of depression and
is started on an antidepressant medication. At the time of presentation
he was having suicidal thoughts, but he had no plan to act on them and
felt hopeful about improving with medication. He sees you in your office
for a follow-up visit the following week and reports improvement in
appetite, sleep, and concentration. He reports having more energy to get
up and go to work in the mornings. He still has suicidal thoughts, but
they are much less frequent. He still feels he won?t act on them. One
week later the patient commits suicide. What is the most likely reason
that this patient committed suicide after getting treatment?

a) Antidepressant medications can cause some patients to act on


suicidal thoughts
b) The patient has overly stressed by his work and should have been
given a work release
c) Patients are at highest risk for suicide when they begin to regain
their energy
d) Patients frequently feel more hopeless after seeing a psychiatrist
and will overdose on the medications they are given
e) None of the above
The correct answer is C

Explanation
In a severe depression there is characteristically a loss of drive,
concentration, and energy to carry out any plans. As these factors
improve, it become possible that the patient will develop and carry out
a plan for suicide.

A. This is a misperception because of the effect that they have on


improving the patients’ vegetative symptoms.
B. That is not necessarily so, since some patients do better if they are
distracted and still involved in their normal activities.
D. Patients frequently report more hope after seeing a psychiatrist,
which is part of the placebo response seen in antidepressant medications
and therapy.
Which of the following is NOT a common side effect seen with SSRIs’

a) Delayed ejaculation
b) Headache
c) Nausea
d) Extrapyramidal symptoms
e) Anorgasmia
The correct answer is D

Explanation
Extrapyramidal symptoms are rarely seen with SSRIs. Many of the side
effects associated with SSRIs are similar to those experienced with the
older tricyclic antidepressants but typically not so severe.
A 15-year-old male is brought in to the Adolescent Clinic by his mother.
The mother complains that he had recently been put on suspension from
school for frequent fights he initiated with other peers and vandalism
of school property. He frequently takes his mother’s money from her
purse without permission and then denies that he has stolen the money.
He has been grounded for staying out past curfew, but sneaks out of the
home to see friends. The patient states his mother is ?overreacting?.
The mother feels his behavior has been unmanageable since he was 10
years old. Which of the following is the most likely diagnosis’

a) Oppositional defiant disorder


b) Autistic disorder
c) Conduct disorder
d) Antisocial personality disorder
e) Attention deficit disorder
The correct answer is C

Explanation
There is a persistent pattern of behavior that violates the basic rights
of other or societal norms or rules. Behaviors include either aggression
toward others, destruction of property, deceitfulness or theft, and
serious violations of rules, beginning in childhood.

A. ODD consists of a pattern of negativistic, hostile, and defiant


behaviors. Opposition toward authority figures is demonstrated by
persistent disobedience, argumentativeness and violation of major rules.
Legal violations are more characteristic of conduct disorder.
B. In autistic disorder, aggressive behavior does not necessarily lead
to a violation of the basic rights of other.
D. Antisocial personality disorder develops in adolescence but is
diagnosed when the individual is 18 years or older.
E. Although attention deficit disorder may be seen in such an
individual, impulsive behavior does not necessarily lead to a violation
of rules or the basic rights of others.
A 32 year old man is in twice-weekly insight-oriented psychotherapy with
a psychiatrist. Recently, the patient has been exploring his thoughts
and feelings around his wife's complaint that he is too restricted and
inhibited in their sexual activity. The patient admits that he wishes to
be more sexually available for his wife, but finds himself maintaining a
restricted stance. Which of the following defense mechanisms would best
describe this patient's tendency in his sexual relationship with his wife?

a) Projection
b) Reaction formation
c) Sexualization
d) Somatization
e) Sublimation
The correct answer is b

Explanation
Reaction formation, often seen in obsessional characters, is the term
for the defense mechanism in which an unacceptable impulse is
transformed into its opposite. In this case, during insight-oriented
psychotherapy, the patient realizes his wish to be freer in his sexual
relationship with his wife (an impulse which he finds unacceptable on
some level) but finds himself responding in the opposite way
(maintaining a restricted stance). Inhibition may also partly account
for this man's difficulty, in that a renunciation is used to evade
anxiety arising out of impulses.
Each of the following statements about anorexia nervosa is true EXCEPT:

a) Anorexia nervosa is present in all cultures


b) The rate of this illness is higher in women than men
c) Amenorrhea may precede significant weight loss
d) Depression is a frequent comorbid illness
e) Lack of insight is frequent
The correct answer is A

Explanation
Interestingly, anorexia nervosa occurs primarily in industrialized
societies where the incidence of starvation is almost nonexistent. The
illness is much more common in women, especially in social and
vocational environments demanding thinness, such as dancing, modeling,
and athletics. Typically reluctant or secretive about their illness, the
presence of amenorrhea may be a suspicious clue for the primary care
physician to pursue other associated symptoms and behaviors.
Obsessive-compulsive traits and depression are common comorbid
conditions. It is not unusual for family or friends to bring the
anorectic for evaluation due to family concerns rather than the
patient’s concern.
Which one of the following is the most appropriate adjunct medication
for treating patients with post-traumatic stress disorder?

a) Alprazolam (Xanax)
b) Haloperidol (Haldol)
c) Methylphenidate (Ritalin)
d) Quetiapine (Seroquel)
e) Temazepam (Restoril)
The correct answer is D

Explanation
PTSD Pharmacotherapy includes:
-SSRI
-benzodiazepines (for acute anxiety)
-first line adjunct - atypical antipsychotics (quetiapine, olanzapine,
risperidone)
Which of the following is correct about depression in children
a) Family therapy should be avoided because it scapegoats a child who
is already vulnerable
b) Symptoms may manifest as antisocial behaviour
c) Antidepressants generally are not effective in children
d) The suicide rate in children aged 8-13 is higher than it is in older
adolescents
e) Depression in children has been shown to be a prodrome to the later
development of schizophrenia
The correct answer is b

Explanation
Depression among children and adolescents is common but frequently
unrecognized. It affects 2 percent of prepubertal children and 5 to 8
percent of adolescents. The clinical spectrum of the disease can range
from simple sadness to a major depressive, bipolar disorder or
antisocial disorder. Risk factors include a family history of depression
and poor school performance. Evaluation should include a complete
medical assessment to rule out underlying medical causes. A structured
clinical interview and various rating scales such as the Pediatric
Symptom Checklist are helpful in determining whether a child or
adolescent is depressed.

Psychotherapy appears to be useful in most children and adolescents with


mild to moderate depression. Tricyclic antidepressants and selective
serotonin reuptake inhibitors are medical therapies that have been
studied on a limited basis. The latter agents are better tolerated but
not necessarily more efficacious. Because the risk of school failure and
suicide is quite high in depressed children and adolescents, prompt
referral or close collaboration with a mental health professional is
often necessary.
A 19 year old male complains of a six month history of worrying about
his health, increased desire to sleep, demoralization, and difficulty
focusing attention on tasks. Which one of the following is the most
likely diagnosis’

a) Schizoid personality disorder


b) Somatization disorder
c) Generalized anxiety disorder
d) Depression
e) Chronic fatigue syndrome
The correct answer is D

Explanation
Depressive disorders in children and adolescents are characterized by a
pervasive and abnormal mood state consisting of sadness or irritability
that is severe or persistent enough to interfere with functioning or
cause considerable distress. Decreased interest or pleasure in
activities may be as or even more apparent than the mood abnormalities.

Common symptoms include a sad appearance, excessive irritability, apathy


and withdrawal, reduced capacity for pleasure (often expressed as
profound boredom), feeling rejected and unloved, somatic complaints (eg,
headaches, abdominal pain, insomnia), and persistent self-blame. Others
include anorexia, weight loss (or failure to achieve expected weight
gain), sleep disruption (including nightmares), despondency, and
suicidal ideation. Diagnosis is by history and examination. Treatment is
with antidepressants, psychotherapy, or both.
A 31 year old male prisoner with a self-described history of physical
abuse is brought to the emergency department by prison staff. The
patient states that he has severe leg pain after falling out of his bunk
bed and that he is unable to walk. Neurologic examination shows normal
deep tendon reflexes, but the patient has decreased sensation to pain
and pinprick. The following morning, the patient is seen walking, but
complains that he is unable to pass urine, and he is told by the nurse
that he will have to have a catheter inserted. As his physician walks in
unexpectedly on rounds, the patient is seen sneaking back into bed from
the direction of the restroom. Which of the following is the most likely
diagnosis’

a) Antisocial personality disorder


b) Conversion disorder
c) Drug dependence
d) Factitious disorder
e) Schizophrenia
The correct answer is D

Explanation
Factitious disorder presents with physical symptoms that are consistent
with true illness but are under the voluntary control of a patient. It
is often dependent on a patient's need to fulfill the "sick role" and be
under the care of a physician. Often, multiple invasive procedures or
examinations are done at the request of the patient before a diagnosis
is reached.
A pattern of unstable but intense interpersonal relationships,
impulsivity, inappropriately intense anger, identity disturbance,
affective instability, and problems with being alone suggest a diagnosis of

a) Antisocial personality disorder


b) Narcissistic personality disorder
c) Histrionic personality disorder
d) Schizoid personality disorder
e) Borderline personality disorder
The correct answer is E

Explanation
Borderline personality is marked by unstable self-image, mood, behavior,
and relationships. Affected people tend to believe they were deprived of
adequate care during childhood and consequently feel empty, angry, and
entitled to nurturance. As a result, they relentlessly seek care and are
sensitive to its perceived absence. Their relationships tend to be
intense and dramatic. When feeling cared for, they appear like lonely
waifs who seek help for depression, substance abuse, eating disorders,
and past mistreatments. When they fear the loss of the caring person,
they frequently express inappropriate and intense anger.
These mood shifts are typically accompanied by extreme changes in their
view of the world, themselves, and other people?eg, from bad to good,
from hated to loved. When they feel abandoned, they dissociate or become
desperately impulsive. Their concept of reality is sometimes so poor
that they have brief episodes of psychotic thinking, such as paranoid
delusions and hallucinations. They often become self-destructive and may
cut themselves (self-mutilate) or attempt suicide. They initially tend
to evoke intense, nurturing responses in caretakers, but after repeated
crises, vague unfounded complaints, and failures to comply with
therapeutic recommendations, they are viewed as help-rejecting complainers.

A 22 year old woman with anorexia nervosa and a history of depression,


for which she is currently taking bupropion, moves to a new city and
presents to a local psychiatrist to establish care in her new location.
She tells the doctor that she has been on the same dose of bupropion
since she was 18 years old, and that her depression has been stable, but
that she has lost 10 pounds over the last month and weighs only 90
pounds (41 kg) now with a height of 5 feet 5 inches (165 cm). About
which of the following complications should the physician be most
concerned?

a) Cardiac arrhythmia
b) Decreased renal function
c) Hypochondriasis
d) Osteoporosis
e) Seizures
The correct answer is E

Explanation
Bupropion is an antidepressant that can lower the seizure threshold for
some patients, and as a result should be discontinued or carefully
monitored in a patient with anorexia nervosa. Patients with anorexia are
at increased seizure risk related to large fluid shifts and electrolyte
disturbances caused by bingeing and purging behavior.

Risk factors associated with the development of postpartum affective


disorders include each of the following EXCEPT:

a) History of mood disorder


b) Higher socioeconomic status
c) Complicated pregnancy
d) Thyroid dysfunction
e) Difficult delivery
The correct answer is b

Explanation
Higher socioeconomic status. Actually, a lower socioeconomic status with
antecedent chronic stress, inadequate social supports, limited funds for
basic needs such as food, formula, shelter, etc. is a risk factor for
postpartum mood disorders. Women with a history of postpartum affective
disturbances have a recurrence rate as high as 50% in some studies. For
this population, medical and psychologic prevention prior to delivery is
very important. In some cases, prophylactic antidepressants or mood
stabilizing agents are warranted. Thyroid dysfunction itself can cause a
mood disorder, and certainly a complicated delivery can be traumatic
psychologically.
A 60-year-old man has been admitted to the psychiatric unit for
psychosis. After visiting one day with his sisters he reports they have
been replaced with imposters. He asks to see them through the window
before letting them in the unit next time so that he can determine if
they are his ?real? sisters or the imposters. This syndrome is called:

a) Folie a deux
b) Amok
c) Capgras
d) Paranoia
e) None of the above
The correct answer is C

Explanation
Capgras’ syndrome describes a specific delusion that is seen mostly in
schizophrenic patients. The patient believes that a person has been
replaced with an exact double that can act in every way like the
original. It is named after the psychiatrist who first described the
delusion.

A. This describes a delusion that begins in one patient and becomes


incorporated into a significant other’s beliefs and behaviors so that
they eventually share the delusion.
B. This is a Malayan term for a sudden fury and violent behavior
developing in a person.
D. This is a broad term for this type of delusion. The more specific
answer is Capgras’ syndrome.
Each of the following statements about alcohol withdrawal is true EXCEPT:

a) The withdrawal syndrome occurs once the blood alcohol level reaches zero
b) Symptoms typically last 2-7 days
c) Repeated periods of withdrawal may exacerbate the severity of future
episodes of withdrawal
d) The severity of symptoms depends on the amount and duration of
alcohol consumption
e) Seizures can occur in major as well as minor withdrawal states
The correct answer is A

Explanation
The withdrawal syndrome may occur any time after the blood alcohol level
begins to fall.

Which of the following statements regarding clinical depression is TRUE?

a) The age of onset has become later in life over the past several decades
b) The overall rate of depression has decreased in the U.S.
c) The DSM-IV diagnostic criteria include a six-week duration of the
symptoms
d) A relative lack of dietary W-3 fatty acids has been associated with
this condition
e) This condition is equally common in males and females
The correct answer is D

Explanation
Over the past century, the sharp increase in the dietary intake of W-6
(omega) fatty acids and a rapid decline of dietary W-3 (omega) fatty
acids has paralleled the increased rate of depression in the U.S.
Interestingly there has been a progressive earlier age of onset, as
well, while the condition remains more prevalent in women compared to
men. DSM-IV diagnostic criteria include a depressed mood or decreased
interest for at least two weeks with the associated symptoms of sleep
and appetite changes, energy disturbance, guilt, poor concentration, and
suicidal ideation. Clinical depression is thought to affect 11 million
Americans yearly.
A 43-year-old female presents to the Emergency Room with severe anxiety.
She reports that she had been taking alprazolam up to four times a day
for panic attacks. Over the past few days, her anxiety symptoms are
worse and she complains of trouble falling asleep and nausea. On further
evaluation, she admits that she had recently skipped her regular doses
because a friend told her that the medication she is taking is
addicting. Which of the following would be the most appropriate
intervention?

a) Discontinue alprazolam and switch her treatment with a serotonin


reuptake inhibitor
b) Refer patient back to her outpatient physician
c) Switch the patient to a longer-acting benzodiazepine, such as clonazepam
d) Educate patient on proper use of her medication, risks and signs of
benzodiazepine withdrawal
The correct answer is D

Explanation
Discontinuation of benzodiazepines, such as alprazolam, can lead to
relapse or rebound symptoms of anxiety, or more severe withdrawal
symptoms. Rebound symptoms such as anxiety, insomnia, and GI symptoms
are milder and short-lived. However, symptoms of withdrawal are more
serious, such as agitation, tachycardia, palpitations, blurred vision,
muscle cramps, and seizures. In an emergency setting, educating the
patient about risks associated with discontinuation of benzodiazepines
would be most appropriate and prevent more serious effects.
An 84 year old woman is brought to the office by her daughter, who is
your patient. The mother has just moved in with the family because she
can no longer care for herself due to progressive, long-standing
dementia. On physical examination the mother does not respond to your
words or to the physical examination. You notice that she smells of
urine. On examination of the pelvis there is a diffuse erythematous rash
extending over the perineum and the medial thighs bilaterally. You
suspect the rash relates to urinary incontinence. Which of the following
is the most appropriate statement to the daughter?

a) "How long have you left your mother in this condition?"


b) "His is a rash caused by urine. My nurse will insert a Foley catheter."
c) "This rash should respond to cleansing with mild soap and drying
with a clean towel three times a day."
d) "You should take better care of your mother."
e) "Your mother needs to wear diapers."
The correct answer is C

Explanation
This choice demonstrates that the physician is in the position of
offering guidance for care of this elderly woman. Answers a) and d)
indicate that the physician is disapproving of the daughter’s care, and
in admonishing her, demonstrates a lack of empathy. Answers b) and e)
are inappropriate suggestions, but answer c) indicates a safe,
practical, and noninvasive approach to treatment of this patient.
An 88-year-old woman is seen by her primary physician for difficult to
control hypertension and prior cerebral vascular accidents. Her current
blood pressure reading is 160/95 mmHG. She has continued to be depressed
since her last stroke despite an adequate trial of paroxetine. The
physician asks you if the antidepressant he is planning to switch her to
is safe with her medical history. Which medication may need to be
avoided if possible in this patient?

a) Nefazodone
b) Venlafaxine
c) Fluoxetine
d) Sertraline
e) Bupropion
The correct answer is b

Explanation
The most concerning side effect of venlafaxine is a possible sustained
elevation of blood pressure. The diastolic may increase to >90 mmHG, and
the systolic may increase by 10 mmHG or more from baseline. If this
patient’s hypertension was well controlled, venlafaxine could be an
appropriate choice. The other antidepressants listed do not have this
effect.
A 73-year-old white male is brought to your office by his family. He had
uncontrolled hypertension and was found to have renal artery stenosis,
but became normotensive following stent placement. Since then he has
lost 6 kg (13 lb) and has no appetite. He is 165 cm (68 in) tall and
currently weighs 59 kg (130 lb). He has been feeling anxious, and during
a recent home repair he cut a hole in a wall and noticed a white
material, which he believes is asbestos. He is concerned that the news
media will find out about this, that his home will be condemned, and
that the whole world will know. His affect is flat, and his eye contact
is poor. However, he is alert and oriented. The remainder of the
examination is normal. He is given an adequate trial of paroxetine
(Paxil) and venlafaxine (Effexor) with no relief of symptoms, and
continues to lose weight.

Which one of the following would be the most effective treatment at this
time?

a) Fluoxetine (Prozac)
b) Mirtazapine (Remeron)
c) Lorazepam (Ativan)
d) Methylphenidate (Ritalin)
e) Electroconvulsive therapy (ECT)
The correct answer is E

Explanation
This patient has late-life psychotic depression, as indicated by his
delusional thinking. Psychotic depression is often resistant to standard
antidepressant regimens. Aggressive pharmacotherapy is required, with
best results in young adults.

Available evidence suggests that most elderly patients who have


depression with pronounced psychotic features either cannot tolerate
adequate doses of conventional medications or do not respond to them.
For severe depression that is persistent and refractory to psychotherapy
and pharmacotherapy, electroconvulsive therapy (ECT) is the most
effective treatment. ECT has therefore become the standard for treatment
of late-life psychotic depression.
The most significant adverse effect of clozapine (Clozaril) is

a) Agranulocytosis
b) Gastrointestinal bleeding
c) Hyperkalemia
d) Tardive dyskinesia
e) Seizures
The correct answer is A

Explanation
Agranulocytosis is the most significant adverse effect of clozapine.
Weekly WBC counts are mandatory for patients receiving clozapine. The
period is maximal risk is 4-18 weeks after the initiation of therapy.
Older women appear to be at highest risk, and genetic factors may also
be involved. Seizures may occur more often with clozapine than with
other antipsychotic drugs. Clozapine is the only antipsychotic drug for
which the risk of tardive dyskinesia is low or nonexistent. Clozapine
does not cause hyperkalemia or gastrointestinal bleeding.
Which one of the following is true concerning falls in the elderly?

a) Treating depression with SSRIs reduces the risk of falling


b) Patients tend to fall less often immediately after coming home from
the hospital
c) Ambulatory blood pressure monitoring should be ordered for all
patients who fall
d) Arthritis and vision impairment are not associated with an increased
risk of falling
e) Reducing the number of medications a patient takes reduces the risk
of falling
The correct answer is E

Explanation
Falling is one of the most common adverse effects associated with drugs.
The elderly frequently take many mediations; reducing these medications
also reduces the risk of falling. SSRIs, tricyclic antidepressants,
benzodiazepines, and anticonvulsants have the strongest association with
falls in the elderly.

The highest risk for falling occurs immediately after hospital stays and
lasts for about a month. Ambulatory blood pressure monitoring is
associated with so many false-negative and false-positive results that
it cannot be recommended for all patients who fall. Arthritis and vision
problems are both strongly associated with an increased risk of falls.
A 17-year-old male student is uncooperative for his required annual
physical. Though he is willing to give adequate history, he is unwilling
to disrobe for the physical examination. You notice that he avoids eye
contact and appears flushed when you address him for questions. He is
wearing four layers of clothing, despite the warm spring weather.
Hesitantly, he tells you he hates his ?puny? body and does not want
anyone to look at it. He says he feels ?unmanly? and is on a special
diet to ?bulk up?. He spends hours checking himself and ?grooming? in
front of the mirror. He admits that he is preoccupied by his body image
and he is always comparing his body to other peers. Which of the
following would be the most likely diagnosis for this patient?

a) Anorexia nervosa
b) Body dysmorphic disorder
c) Obsessive-compulsive disorder
d) Gender identity disorder
e) Social phobia
Correct Answer:* b)

Explanation
Dysmorphic disorder is characterized by preoccupation with an imagined
defect or excessive concern of appearance. Preoccupation is marked by
distress or impairment in social functioning.

A. Though the patient is preoccupied with the size of his body, the
preoccupation is not limited to fear of ?fatness.? The patient is on a
special diet in order to ?bulk up? or gain weight.
C. Though rituals are commonly seen in BDD, the rituals are limited to
preoccupation with the imagined defect.
D. Preoccupation with primary or secondary sexual defects is
characteristic of gender identity disorder. However, this individual
appears to desire being ?more manly? in his appearance and does not
express desire to be more like the opposite sex.
E. In both disorders there is fear of rejection and humiliation;
however, it is clear that this patient’s fear of humiliation is limited
to his imaged body defect.

An 83-year-old female is admitted to the hospital with an exacerbation


of her COPD. On the second hospital day she is clinically improved but
is quite disorientated, experiencing visual hallucinations, agitation,
and problems with recent memory and attention span. She is noted by the
nursing staff to periodically fall asleep during conversation. Her
previous medical history is notable for emphysema and hypertension, but
there is not history of psychiatric problems. Her blood pressure is
140/82 mm Hg, pulse 88 beats/min, and oxygen saturation 98% on 2 L of
nasal O2.

Which one of the following does this patient most likely have?

a) Dementia
b) Acute depression
c) Mania
d) Delirium
e) Schizophrenia
The correct answer is D

Explanation
The primary distinguishing feature of delirium is a course that is
typically acute, with rapid deterioration over hours or days, rather
than months as with dementia. Also, the severity of delirium tends to
fluctuate over the course of hours, with patients appearing quite normal
at time and wildly agitated with hallucinations at others. Frequently,
extreme changes in psychomotor activity are noted with delirium;
although this may also be seen with dementia, it is typically not seen
until the latter stages. Bipolar disorders are characterized by the
occurrence of mania, which is manifested by a full-blown disturbance of
mood together with elation and irritability. Its onset is generally in
the third or fourth decade of life. Schizophrenia, while often including
hallucinations and delusions, usually starts in late adolescence or
early adulthood, with a prodomal phase showing a gradual deterioration
in function.
A 9-year-old child is brought for evaluation of his throat. He clears
his throat so often that it is disruptive in class and children are
beginning to make fun of him at school. His medical evaluation shows no
abnormalities. In speaking to him you also notice that he blinks very
frequently, but can stop it when asked to. He has already seen a
psychiatrist in the past for treatment of his attention deficit and
obsessive-compulsive disorders. His mother is concerned and asks what
the best treatment for this behavior would be. You make the following
diagnosis and treatment recommendation:

a) Conduct disorder - set up a reward system for appropriate behaviors


b) Tourette syndrome - begin a medication to lessen episodes while the
child is in class
c) Tardive dyskinesia - stop all psychiatric medications
d) Generalized anxiety disorder - refer for psychotherapy to decrease
overall anxiety level
e) None of the above
The correct answer is b

Explanation
The classic triad in children is Tourette’s syndrome,
obsessive-compulsive disorder, and attention deficit disorder. These
three disorders are seen so frequently together that if one is found
during an evaluation, the other two disorders should be screened for as
well.

A. No evidence that this is conduct related.


C. No antipsychotic medications are mentioned, nor are they routinely
used in the treatment of this child’s other psychiatric disorders.
D. No symptoms of generalized anxiety disorder are mentioned.
After being started on thiamine, folate, and multivitamins, the patient
is admitted to the inpatient unit. Laboratory studies are normal except
for several abnormal liver function tests. Which of the following class
of medications is indicated for this type of alcohol-withdrawing patient
to prevent further withdrawal symptoms’

a) Anticonvulsants
b) Beta blockers
c) Antipsychotics
d) Long-acting benzodiazepines
e) Short-acting benzodiazepines
The correct answer is E

Explanation
Benzodiazpines are the mainstay of the treatment for alcohol withdrawal.
This patient’s impaired liver functioning requires a shorter-acting
agent such as lorazepam or oxazepam.
After validating the referring physician’s diagnosis of OCD for this
patient, the consulting psychiatrist recommends a specific
pharmacological treatment. Which is the best class of psychotropic
medications to choose from?

a) Anticonvulsants
b) Benzodiazepines
c) Selective serotonin reuptake inhibitors
d) Antipsychotics
e) Beta blockers
The correct answer is C

Explanation
The selective serotonin reuptake inhibitors (SSRIs) are the first-line
pharmacologic agents used to treat OCD. This class includes the
tricyclic clomipramine as well as the more specific SSRIs such as
fluoxetine, paroxetine, citalopram, sertraline, and fluvoxamine. The
consulting psychiatrist suggests this patient receive fluoxetine at a
starting dose of 20 mg each day.
A 45-year-old male presents to your office in extreme agitation after a
verbal altercation with his boss, during which he was fired. He feels
overwhelmed and very angry, and states that he is going to ?get? his
boss and then ?who knows what.?

Which one of the following is true regarding this situation?

a) Physicians have a responsibility to warn and protect intended


victims of a patient
b) It is dangerous to ask the patient about suicidal tendencies
c) If the patient is at high risk for suicide and needs inpatient care,
but refuses, he may
be allowed to go home if accompanied by a family member
d) You and your staff are not at risk for harm
e) The patient’s family may be reassured that they are not at risk for
harm, as only his
boss has been directly threatened
The correct answer is A

Explanation
It has been legally established that physicians have a duty to warn and
protect intended victims of a patient. Evaluation of suicide and
homicide risks in a crisis situation, including direct questioning of
the patient about suicidal and homicidal tendencies, is important and
does not lead to further harm. If a suicidal or homicidal patient who
needs hospitalization refuses, law enforcement authorities should be
contacted. Policies should be in place to ensure the safety of clinic
staff in crisis situations. The patient’s family may be at risk for
harm, and plans to ensure their safety, if needed, are appropriate.
The mechanism of action of typical antipsychotic drugs is

a) Dopamine receptor agonists


b) Dopamine receptor antagonists
c) Serotonin receptor agonists
d) Serotonin receptor antagonists
The correct answer is b

Explanation
Typical antipsychotic medications include haloperidol, chlorpromazine
and thioridazine. Their mechanism of action is they block the dopamine
(D2) receptors. They treat positive symptoms like hallucination or
delusions.

Atypical antipsychotics include risperdione and clozapine. They work by


blocking both D2 and serotonin (5-HT) receptors. They treat both
positive and negative symptoms.
A 66 year old white female consults you because she has developed a
tremor of her right hand that interferes with her ability to do
needlework. She has noticed that the tremor improves when she rests her
hands in her lap and gets worse when she holds them up against gravity.
She has developed a slight quiver to her voice as well. Her symptoms
started gradually over 6 months ago and have progressed slowly. She
remembers her mother having similar problems in her later years.

She takes no medications, and her physical examination corroborates her


history. No other abnormalities are noted. A multiple chemistry screen
and TSH level are normal. Which one of the following is most likely to
alleviate her tremor?

a) Propranolol (Inderal)
b) Paroxetine (Paxil)
c) Carbidopa/levodopa (Sinemet)
d) Bromocriptine (Parlodel)
e) Carbamazepine (Tegretol)
The correct answer is A

Explanation
This patient has essential tremor, which is frequently a familial
condition. Primidone and propranolol are the drugs most likely to
provide relief of essential tremor. Other Beta-blockers such as atenolol
and metroprolol may not be as effective, although results of trials are
mixed. Antiparkinsonian medications such as carbidopa and bromocriptine
have no effect on essential tremor. Carbamazepine is occasionally
useful, but is much less likely to be effective than primidone.

A 7-year-old boy is brought to a psychiatrist because he is doing poorly


in first grade. He doesn?t seem to pay attention to the teacher, and has
not made any friends. He is fascinated with insects and has spent almost
all of the last two months in class looking at a book with pictures of
insects in it. He had no delay in his language skills and converses
normally, but limits his discussions to details about insects. In the
office, he makes no eye contact and twirls his hair around his finger.
His parents state he has always been like this. What is the likely
diagnosis’

a) Asperger's disorder
b) Autistic disorder
c) Obsessive-compulsive disorder
d) Schizophrenia
e) Childhood disintegrative disorder
The correct answer is A

Explanation
Patients with Asperger’s disorder have impaired social interaction and
restrictive, repetitive behaviors and interests but normal language skills.

B. The features of autistic disorder are similar to Asperger’s disorder,


but also include impaired language skills. Asperger’s disorder is thus
considered to be a less severe variant of autism.
C. In OCD, repetitive behaviors and interests may also be present, but
these are intended to prevent or reduce distress in some way. Social
skills are not primary affected.
D. This patient does not demonstrate psychotic features such as
delusions, hallucinations, or disorganized thought processes, which are
required for the diagnosis of schizophrenia.
E. Childhood disintegrative disorder is a syndrome of loss of previously
acquired skills in language, behavior, bowel or bladder control, play,
or motor skills.
A 53 year old male presents with a 3-month history of despondency,
insomnia, and irritability with family and co-workers. During your
interview you also discover that he is drinking heavily at times and has
several firearms at home. He thinks his life is ?useless’, noting that
he ?would be better off dead?. The most appropriate action at this time
would be to

a) Prescribe an SSRI
b) Arrange immediate hospitalization
c) Have the patient agree to a suicide prevention contract
d) Avoid direct questions regarding suicidal thoughts
Correct Answer:* b)

Explanation
More than 50% of suicides are associated with a major depressive episode
and 25% are associated with a substance abuse disorder. Suicide rates
increase with age and are higher among men. Increased suicide rates also
occur in patients with significant medical illnesses. Because discussing
suicidal ideation may relieve the patient’s anxiety, the physician
should directly ask depressed patients about any suicidal thoughts.
There are no known reliable tools for assessing suicide risk, so the
assessment is subjective, The initial management of suicidal ideation
should establish safety, often by hospitalization. The suicide
prevention contract is of unproven clinical and legal usefulness.
Antidepressant medication has not been shown to reduce suicide rates,
especially on a short-term basis.
The wife of a 45 year old executive says that over the past 6 months her
husband has been accusing her of having an extramarital affair. He has
been phoning her work place, checking her mail and phone calls. She says
that there is absolutely no truth to the allegation, but despite the
efforts of herself and his family to reassure him, he continues to
accuse her. Which one of the following is the likely cause?

a) Delusional disorder
b) Paranoid schizophrenia
c) Anxiety disorder
d) Antisocial personality disorder
e) Schizoid personality disorder
The correct answer is A

Explanation Delusional Disorder is relatively uncommon in clinical


settings, with most studies suggesting that the disorder accounts for
1%-2% of admissions to inpatient mental health facilities.
The essential feature of Delusional Disorder is the presence of one or
more nonbizarre delusions that persist for at least 1 month . Auditory
or visual hallucinations, if present, are not prominent. Tactile or
olfactory hallucinations may be present (and prominent) if they are
related to the delusional theme Apart from the direct impact of the
delusions, psychosocial functioning is not markedly impaired, and
behavior is neither obviously odd nor bizarre. If mood episodes occur
concurrently with the delusions, the total duration of these mood
episodes is relatively brief compared to the total duration of the
delusional periods. The delusions are not due to the direct
physiological effects of a substance (e.g., cocaine) or a general
medical condition (e.g., Alzheimer's disease, systemic lupus erythematosus).
Psychosocial functioning is variable. Some individuals may appear to be
relatively unimpaired in their interpersonal and occupational roles. In
others, the impairment may be substantial and include low or absent
occupational functioning and social isolation. When poor psychosocial
functioning is present in Delusional Disorder, it arises directly from
the delusional beliefs themselves.

Paranoid ideations in substance abuse is associated with what drug?


a) LSD
b) Heroin
c) Cannabis
d) Barbiturates
The correct answer is C

Explanation
The following is a list of the symptoms associated with each drug:

Drug - Presenting signs/symptoms and effects

LSD - Hallucinations, numbness, nausea, and increased heart rate.

Heroin - Needle marks, sleeping at unusual times, sweating, vomiting,


coughing and sniffling, twitching, loss of appetite, contracted pupils
and no response of pupils to light.

Cannabis (marijuana) - Relaxation (a high), tachycardia, conjunctival


injection, and dry mouth, panic reactions, paranoia and increased appetite.

Barbiturates - Patient seems drunk as if from alcohol but without the


associated odor of alcohol, difficulty concentrating, clumsiness, poor
judgment, slurred speech, sleepiness, and contracted pupils.

Of the answer choices, c) fits the question stem the best.


What is the definition of a delusion?

a) A persistent belief that is contradicting


b) A fixed thought
c) The sight of a formed image
d) A brief sensation that acts as a warning
The correct answer is A

Explanation
The Diagnostic and Statistical Manual of Mental Disorders (DS) defines a
delusion as:

A false belief based on incorrect inference about external reality that


is firmly sustained despite what almost everybody else believes and
despite what constitutes incontrovertible and obvious proof or evidence
to the contrary.

A visual hallucination involves sight, which may consist of formed


images, such as of people, or of unformed images, such as flashes of light.

An aura is a premonitory, subjective brief sensation (e.g., a flash of


light) that warns of an impending headache or convulsion.
All of the following have been found in association with manic behavior,
except

a) Sertraline
b) Digitalis
c) Prednisone
d) Methylphenidate
e) Cimetidine
The correct answer is b

Explanation
Mania can occur by chance association during drug treatment,
particularly in patients predisposed to mood disorder. Drugs with a
definite propensity to cause manic symptoms include levodopa,
corticosteroids and anabolic-androgenic steroids. Antidepressants of the
tricyclic and monoamine oxidase inhibitor classes can induce mania in
patients with pre-existing bipolar affective disorder.

Drugs which are probably capable of inducing mania, but for which the
evidence is less scientifically secure, include other dopaminergic
anti-Parkinsonian drugs, thyroxine, iproniazid and isoniazid,
sympathomimetic drugs, chloroquine, cimetidine, baclofen, alprazolam,
captopril, amphetamine and phencyclidine.
A 12 year old boy is brought to the physician because of a pattern of
behavior that has been worsening over the past year. His mother states
that he has been bullying other boys at school, staying out late without
permission, setting small fires in abandoned lots, and physically
abusing neighborhood cats. During the examination, a speculum from the
examination room drawer falls out from underneath his shirt. Which of
the following is the most likely diagnosis’

a) Antisocial personality disorder


b) Attention deficit hyperactivity disorder (ADHD)
c) Conduct disorder
d) Oppositional defiant disorder (ODD)
e) Tourette syndrome
The correct answer is C

Explanation
This patient has conduct disorder. The diagnosis requires a pattern of
behavior that violates societal rules and the basic rights of others.
Common features include lying, stealing, running away, staying out
without permission, setting fires, truancy, vandalism, cruelty to
animals, bullying, physical aggression, and sexual aggression. At least
three of these features must be present to make the diagnosis.
Twenty-five to fifty percent of these patients go on to have antisocial
personality disorder as an adult.
A nurse has been to the ER with repeated attacks of hypoglycemia. Her
stories are inconsistent and she also wishes to be admitted each time.
Further investigation reveals she has an increased serum insulin but low
serum C-peptide. Appropriate management at this time would be

a) Growth Hormone test


b) GTT (glucose tolerance test)
c) Psychiatric assessment
d) B-HCG
e) CT of Pancreas
The correct answer is C
Explanation
Insulin pushes glucose into the cells and high quantities of insulin can
cause hypoglycemia and symptoms associated with it like sweating,
intense hunger, trembling, weakness and palpitations. If the increased
insulin in her body was endogenous then the C-Peptide would be high when
tested. Insulinomas (tumors of the pancreas) can cause this.

C-peptide is a by-product in insulin biosynthesis, produced at the same


rate. So when insulin is high as a result of endogenous production,
C-Peptide will be also. Since her C-Peptide level is low. This means her
insulin has come from an exogenous source.

Since she is a nurse and her stories are inconsistent she is likely
injecting herself with insulin she has obtained at her job to fake
symptoms. This now becomes a psychiatric/social issue and warrants a
psychiatric assessment via consult.
A 50-year-old white male with mildly symptomatic benign prostatic
hyperplasia has been diagnosed with panic disorder. Of the following,
which one would be most appropriate as pharmacotherapy for this individual?

a) Haloperidol (Haldol)
b) Imipramine (Tofranil)
c) Fluoxetine (Prozac)
d) Lithium
e) Carbamazepine (Tegretol)
The correct answer is C

Explanation
SSRIs have been shown to be very effective in the treatment of panic
attacks. For a number of years, imipramine was used to treat panic
attacks. However, a patient with prostatic hyperplasia is likely to
become more symptomatic if given a tricyclic antidepressant. Haloperidol
is not indicated for this problem. Lithium and carbamazepine have not
been shown to be effective in the treatment of panic disorder.

A teenage girl complains that for the past few months she enters into
cycles of elative moods at times that alternate with feelings of loss of
interest and sadness. Which of the following disorders does she likely have?

a) Depression
b) Dysthymia
c) Schizophrenia
d) Cyclothymia
The correct answer is D

Explanation
Cyclothymic disorder is characterized by hypomanic and mini-depressive
periods that last a few days, follow an irregular course, and are less
severe than in bipolar disorder. Diagnosis is clinical and based on
history. Management consists primarily of education, although some
patients with functional impairment require drug therapy.

Cyclothymic disorder is commonly a precursor of bipolar II disorder.


However, it can also occur as extreme moodiness without becoming a major
mood disorder. In chronic hypomania, a form rarely seen clinically,
elated periods predominate, with habitual reduction of sleep to < 6
hours. People with this form are constantly overcheerful, self-assured,
overenergetic, full of plans, improvident, overinvolved, they rush off
with restless impulses and accost people.
You are consulted for medical management of a 45-year-old male,
previously unknown to you, who is hospitalized in the psychiatric unit
with paranoid schizophrenia. His fasting blood glucose level is 180 mg/dL.

Which one of the following medications is the most likely cause of the
hyperglycemia?

a) Alprazolam (Xanax)
b) Haloperidol (Haldol)
c) Chlorpromazine (Thorazine)
d) Olanzapine (Cyprexa)
e) Thiothixene (Navane)
The correct answer is D

Explanation
The atypical antipsychotics include clozapine, olanzapine, risperidone,
ziprasidone, quetiapine, and aripiprazole. As a class, they have fewer
extrapyramidal side effects than the classical antipsychotics
haloperidol, thiothixene, chlorpromazine, and others. Some of the
atypical agents, notably olanzapine and clozapine, have been associated
with hyperglycemia and the development of type 2 diabetes mellitus.
Neither benzodiazepines like alprazolam nor the classical antipsychotics
have been associated with hyperglycemia.

OCD is distinguished from other anxiety disorders by the presence of


which of the following symptoms’

a) Phobias
b) Compulsions
c) Obsessions
d) Exaggerated startle response
e) None of the above
The correct answer is b

Explanation
Compulsions are the best differentiating symptoms within the anxiety
disorders category to make the diagnosis of OCD. Phobias and of course
obsessions are common aspects of OCD. The phobias in OCD tend to become
generalized over time. Obsessional ruminations are seen to some extent
within all the anxiety disorders.
A 28 year old man with a drug addiction presents with rhinorrhea,
tachycardia, dilated pupils and high blood pressure. The most likely
cause is
a) Opiates
b) LSD
c) Heroin
d) Opioid withdrawal
e) Barbiturates
The correct answer is D

Explanation

The following table lists the symptoms associated with each drug:

Drug

Presenting signs/symptoms and effects


Cocaine

Paranoia, constriction of blood vessels leading to hypertension, heart


damage or stroke, irregular heartbeat, and death.
LSD

Hallucinations, numbness, nausea, and increased heart rate.


Heroin

Needle marks, sleeping at unusual times, sweating, vomiting, coughing


and sniffling, twitching, loss of appetite, contracted pupils and no
response of pupils to light.
Opioid withdrawal

Yawning, sweating, lacrimation, rhinorrhea, anxiety, restlessness,


insomnia, dilated pupils, piloerection, chills, tachycardia,
hypertension, nausea/vomiting, crampy abdominal pains, diarrhea, and
muscle aches and pains.
Barbiturates

Patient seems drunk as if from alcohol but without the associated odor
of alcohol, difficulty concentrating, clumsiness, poor judgment, slurred
speech, sleepiness, and contracted pupils.

Of the answer choices, d) fits the question stem the best.


You are asked to assess a 42 year old man with a history of auditory
hallucinations and an admission with a psychotic episode in his early
20's. Which one of the following would be most helpful in distinguishing
between a diagnosis of schizophrenia and bipolar disorder in this man?

a) A history of mania followed by depression


b) A history of repeated hospital admissions
c) A history of grandiose delusions
d) A history of thought disorder
e) Response to antipsychotics
The correct answer is A

Explanation
Bipolar disorders are characterized by mania and depression, which
usually alternate. Exact cause is unknown, but heredity, changes in the
level of brain neurotransmitters, and psychosocial factors may be
involved. Diagnosis is based on history. Treatment consists of drugs,
sometimes with psychotherapy.

Schizophrenia is characterized by psychosis (loss of contact with


reality), hallucinations (false perceptions), delusions (false beliefs),
disorganized speech and behavior, flattened affect (restricted range of
emotions), cognitive deficits (impaired reasoning and problem solving),
and occupational and social dysfunction. The cause is unknown, but
evidence for a genetic component is strong. Symptoms usually begin in
adolescence or early adulthood. One or more episodes of symptoms must
last > 6 mo before the diagnosis is made. Treatment consists of drug
therapy, psychotherapy, and rehabilitation.
Which one of the following is true regarding suicide?

a) Adolescents are a low-risk group for suicide


b) Two-thirds of suicide deaths occur on the first attempt
c) Women have a higher rate of completed suicide than men
d) Men attempt suicide more often than women
e) Among men, blacks have the highest suicide rate
The correct answer is b

Explanation
No evidence that has been found to demonstrate that screening for
suicide risk reduces suicide attempts or mortality. There is limited
evidence regarding the accuracy of screening tools to identify suicide
risk in the primary care setting, including tools to identify those at
high risk. In addition, there is insufficient evidence to show that
treatment of those at high risk reduces suicide attempts or mortality.
Two-third of suicide deaths occur on the first attempt, with higher
completion rates in men than in women. Although men complete suicide
more often than women, women attempt suicide more often than men. Almost
75% of completed suicides are by white males, who have a two-fold higher
risk for suicide than black males. Adolescents and the elderly are
high-risk groups for suicide.
A 43-year-old female secretary is followed by her psychiatrist for
recurrent annual depressive episodes. She recently watched a special on
the local public television channel about seasonal affective disorder
(SAD) and is inquiring what causes this condition. The correct response
would include each of the following EXCEPT:

a) There are many theories regarding the causes of SAD


b) Melatonin may be involved
c) Serotonin may be involved
d) Diminished appetite seen in winter SAD suggests an endocrine problem
e) SAD is more common in the northern latitudes
The correct answer is D

Explanation
Diminished appetite is not typical of SAD. In fact, carbohydrate craving
is common for winter SAD. The theories regarding SAD are numerous,
emanating from observation, clinical research, and patient intuition.
The incidence of pure SAD is much higher in the northern latitudes,
resulting in an interest in the seasonal variations of sunlight exposure
and temperature as possible causes. The administration of melatonin can
cause relapses in patients with SAD. The most accepted theory as to the
etiology of SAD involves serotonin. The more common successful
treatments for SAD affect serotonin in some way. These include the
selective serotonin reuptake inhibitors (SSRIs) and light therapy.
A patient that you are starting on valproic acid has a history of
elevated ammonia levels in the past when taking this medication. There
are no other options at this point in her treatment, so you make the
following recommendation:

a) Follow liver function tests every 2 weeks


b) Place the patient on a stimulant if symptoms return
c) Start lactulose to prevent an elevated ammonia level this time
d) Start carnitine to prevent an elevated ammonia level this time
e) None of the above
The correct answer is D

Explanation
The mechanism that leads to elevated ammonia levels in patients taking
valproic acid is based on a depletion of the vitamin carnitine which is
required in fatty acid transport. If carnitine is depleted by valproic
acid, it can disrupt this process, which results in ammonia formation.
Some patients can prevent this from occurring by taking carnitine as a
supplement. Unfortunately, it does not reverse the process for everyone.
Of note, the degree of ammonia elevation is not an accurate indicator of
expected severity of symptoms.

A. The liver function tests are not indicators of this specific problem.
B. This is the not the treatment for high ammonia levels.
C. Lactulose decreases ammonia levels in alcoholics by increasing
transit time in the bowel, which reduces the amount of ammonia that is
transported across the bowel wall to the serum. This is minimally
helpful in patients with valproic acid induced elevations in ammonia.
A 32 year old woman who is a single mother of two small children comes
to the office saying that she feels "halfway tired all the time." Her
physical examination is normal. Toward the end of the visit she says
anxiously, "My children just don't listen. They make me so angry that I
feel out of control sometimes." She pauses. "Yesterday my 6 year old
daughter talked back to me and I slapped her in the face." Her eyes fill
with tears. Which of the following is the most accurate statement
concerning this patient?

a) She should be reported to child abuse authorities


b) She was clearly a victim of child abuse herself
c) She would benefit from antidepressant medication
d) She would benefit from family counseling
e) She would exhibit better self-control if she were married
The correct answer is D

Explanation
There is insufficient evidence from the information given that the
mother is abusing her child. The patient describes feeling overwhelmed;
engaging the mother and the two children in family therapy may be of
great value in assisting her with coping mechanisms.

There is insufficient evidence from the question to indicate that she


was clearly a victim of child abuse herself or that she would benefit
from antidepressant medication, although this may be a consideration
upon further determination of the patient’s mood and ability to adjust
to her social environment.
A 54 year old man has become forgetful, preoccupied, withdrawn,
irritable and disheveled. His physical examination was normal. The
patient had been with his company for 22 years and was considered an
excellent employee. Which of the following is the most likely diagnosis

a) Multi-infarct dementia
b) Hypothyroidism
c) Schizophrenia
d) Alcoholism
e) Major depression
The correct answer is E

Explanation
Major depression involves periods (episodes) that include ? 5 mental or
physical symptoms and last ? 2 weeks are classified as major depression.
Symptoms must include sadness deep enough to be described as despondency
or despair (often called depressed mood) or loss of interest or pleasure
in usual activities (anhedonia). Other mental symptoms include feelings
of worthlessness or guilt, recurrent thoughts of death or suicide,
reduced ability to concentrate, and occasionally agitation.

Physical symptoms include changes in weight or appetite, loss of energy,


fatigue, psychomotor retardation or agitation, and sleep disorders
(insomnia, hypersomnia, early morning awakening). Patients may appear
miserable, with tearful eyes, furrowed brows, down-turned corners of the
mouth, slumped posture, poor eye contact, lack of facial expression,
little body movement, and speech changes (eg, soft voice, lack of
prosody, use of monosyllabic words).
A 10 year old male comes in for follow-up of his
attention-deficit/hyperactivity disorder (ADHD). At the time of his last
visit 1 month ago he was taking methylphenidate (Ritalin) once daily
each morning. At that time his mother reported that he did extremely
well in class during the morning, but by the end of the day he was
having problems with inattentiveness. This carried over into
difficulties concentrating on homework after school. These problems were
affecting his grades and causing distress to him and his mother. The
child expressed a desire not to have to take medicine during the school
day. You switched his medicine at that visit to a long acting form of
methylphenidate (Concerta).

At this visit the mother reports that her son is now doing well through
the entire school day and is able to get his homework done. However, she
notes that his appetite at dinner has decreased and that he has lost 2
lb. She also reports that it is somewhat more difficult for him to fall
asleep. What is the most appropriate management at this point?

a) Have him take the medication at bedtime


b) Reassure the mother and reevaluate in 1 month
c) Add a dose of a tricyclic antidepressant such as nortiptyline
(Aventyl, Pamelor), to be taken with the evening meal
d) Switch him to a selective serotonin reuptake inhibitor (SSRI) such
as paroxetine (Paxil)
The correct answer is b

Explanation
Anorexia with mild weight loss and difficulty falling asleep are common
side effects of amphetamine treatment for ADHD. In most patients these
side effects are tolerable and transient. While alternative drugs such
as antidepressants can be substituted, these usually do not work as well
and have their own potential side effects.
A patient with schizophrenia is not responding to treatment with
conventional antipsychotics. What will you now try?

a) Clozapine
b) Haloperidol
c) Thioridazine
d) Chlorpromazine
The correct answer is A

Explanation
Schizophrenia is characterized by psychosis (loss of contact with
reality), hallucinations (false perceptions), delusions (false beliefs),
disorganized speech and behavior, flattened affect (restricted range of
emotions), cognitive deficits (impaired reasoning and problem solving),
and occupational and social dysfunction.

The cause is unknown, but evidence for a genetic component is strong.


Symptoms usually begin in adolescence or early adulthood. One or more
episodes of symptoms must last ? 6 months before the diagnosis is made.

Treatment consists of drug therapy with conventional antipsychotics such


as haloperidol, thioridazine and chlorpromazine, psychotherapy, and
rehabilitation.

About 30% of patients with schizophrenia do not respond to conventional


antipsychotics. They may respond to a 2nd-generation antipsychotic such
as clozapine or risperidone.
Which of the following investigations need NOT be tested before starting
treatment with lithium carbonate?

a) Serum creatinine
b) Serum electrolytes
c) Thyroid function studies
d) Serum bilirubin
The correct answer is D

Explanation
Two thirds of patients with uncomplicated bipolar disorder respond to
lithium.

Lithium may precipitate hypothyroidism, particularly when there is a


family history of hypothyroidism. Therefore, TSH levels should be
monitored when lithium is started and at least annually if there is a
family history or if symptoms suggest thyroid dysfunction or at least
biannually for all other patients.

Patients with a history of parenchymal renal disease may be at risk of


structural damage to the distal tubule. Renal function should be
assessed at baseline, and serum creatinine levels should be monitored
over time.
Which one of the following is indicated in the diagnostic workup for
attention-deficit/hyper-activity disorder (ADHD)?

a) A TSH level
b) An EEG
c) A blood lead level
d) Continuous performance testing
e) Home and school specific ADHD rating scales
The correct answer is E

Explanation
The use of rating scales and/or questionnaires has been integral to the
diagnosis of attention-deficit/hyperactivity disorder (ADHD). Continuous
performance testing is designed to obtain samples of the child’s
behaviour, but the sensitivity and specificity are too low to be useful
at this time. Likewise, thyroid testing, EEGs, and blood lead levels are
not indicated in the routine workup for ADHD.
A woman hears of the death of her father and develops several symptoms
including inability to move her arms and legs. Regarding this conversion
disorder, all of the following are true, except

a) La belle indifference
b) Involuntary character of the syndrome
c) Can cause social or professional hindrance
d) Can be induced voluntarily
The correct answer is D

Explanation
Conversion disorder consists of symptoms or deficits that develop
unconsciously and nonvoluntarity and usually involve motor or sensory
function. Manifestations resemble a neurologic or other general medical
condition. Onset and maintenance of conversion symptoms are typically
attributed to mental factors, such as severe stress (eg death of a loved
one).

Symptoms often develop abruptly, and onset can usually be linked to a


very stressful event. Symptoms are limited to those that affect
voluntary motor or sensory function and suggest a neurologic or general
medical condition (eg, impaired coordination or balance, weakness, or
paralysis of an arm or a leg or loss of sensation in a body part).

The symptoms are severe enough to cause distress or disrupt social,


occupational, or other important areas of functioning. A patient may
have a single episode or sporadic repeated ones; symptoms may become
chronic. Typically, episodes are brief.

La belle indifférence is considered a classic feature of conversion


disorder. It is characterized by the inappropriate and paradoxical
absence of distress despite the presence of an unpleasant symptom.
A 19-year-old female is brought by her mother to the emergency room for
dehydration. She appears severely undernourished, and requires
intravenous fluids for orthostatic hypotension. She is currently in a
treatment program for anorexia. Her laboratory values show a critical
hypokalemia. In addition to adding potassium to her fluids, you should:

a) Ask the patient’s permission to contact the facility to verify she


is in treatment
b) Recommend that her belongings be searched with her permission for
pharmaceuticals
c) Prescribe thiamine, folate, and a multivitamin daily until nutrition
is improved
d) All of the above
e) None of the above
The correct answer is D

Explanation
Due to the lethality of this case an effort should be made to ensure
appropriate treatment is actively being pursued. Since many patients
with an eating disorder will abuse laxatives or diuretics that lower
their potassium to critical levels, the facility should be informed, if
the patient permits, to look for contraband. This patient is high risk
for nutritionally based diseases and should be supplemented.