1.

Which one of the following statements

about the treatment of depression is
correct:
A. Selective serotonin reuptake inhibitors (SSRIs)
should be used with caution in the first few weeks of
treatment because they have been associated with an
increased rate of completed suicides
B.SSRIs are associated with more adverse effects than
tricyclic antidepressants.
C. Venlafaxine is more effective than tricyclic
antidepressants.
D. Cognitive therapy has been shown to effectively
improve depressive symptoms.

The answer is:

D
Treatment: Always start with an SSRI
SSRI increase the risk of Suicide (Ideation,
attempted, complete)
First Neurovegetative Sx 1-3 weeks next
Emotional Sx
Serotonin Syndrome, switching from an SSRi to
MAOIHyperthermia, Myoclonus, rigor and
Hypertonicity
Other Treatments: ECT (Study The indications),
Psychotheray: Cognetive Therapy

2. In treating manic episodes, which of the

following is most useful in the first three
days of treatment?
A. Haloperidol 5 mg bd
B. Chlorpromazine 10 mg po bd
C. Lithium 300 mg od
D. Carbamazepine 200 mg bd
E. A quit, dimly-lit room to decrease stimulation

The answer is:

A

Mood Stabilizers:

Lithium: Therapeutic Response within 7-14 days up to 3 weeks, 600-1500

mg/day - ) 0.5 -1.2 mmol/L (1.0-1.25 mmol/L Acute) Monitoring: Biweekly or
Monthly, q2months Thyroid and Creatinine 6 months, UA annual
Carbamazepine (Tegretol): 750-3000 mg/day

Rapid cycling, Severe sleep problems, Can't take Depakote

lamotrigine/Lamictal: Depression is the dominant symptom, Dysphoric mood
Valproic Acid (Depakene-Epival)
valproate/Depakote: Need something strong and fast, Male gender, and not
afraid of weight gain risk Rapid cycling, Significant manic symptoms

Antipsychotics:

Haloperidol: 0.5-5 PO b/tid,

Chlorpromazine (largactil): 10-15 PO b/tid FDA:To control the

manifestations of the manic type of manic-depressive illness, low
potency

Olanzapine/Zyprexa: Emergency-level symptoms, Need help really

fast,Can use on "as-needed" basis

3. A 22 yr old girl with history of vomiting,

loss of weight and amenorrhea. History
compatible with anorexia nervosa. At
present what are the investigations you
will do, except:
A. Serum electrolyte
B. Liver function test
C. Gonadotrophin levels.
D. ECG
E. bone densitometry

The answer is:

E
A chemistry panel should be assessed for hypokalemic,
hypocalcemic metabolic alkalosis caused by vomiting.
Ionized calcium levels should detect hypocalcemia
Liver function tests may be slightly elevated, but albumin
and protein levels are usually normal
Thyroid function tests, prolactin, and serum folliclestimulating hormone levels can differentiate anorexia
nervosa from alternative causes of primary amenorrhea.
ECG is helpful in evaluating the severity of malnutrition
and risk for dysrhythmias in patients with metabolic
abnormalities
Imaging is rarely necessary in the emergency department

4.Pregnant woman on SSRI-what will you

do?

A. Continue
B. Switch to something else
C. Discontinue
D. Tell her the risk is low

The answer is:

A

Advisory
2006-11
March 10, 2006
For immediate release
OTTAWA - Health Canada is advising women who are taking antidepressants known as
Selective Serotonin Re-uptake Inhibitors (SSRI) and who are pregnant or intend to
become pregnant to discuss the situation with their doctor due to potential risks to the
baby.
Health Canada stresses that patients should not stop taking SSRI medication without
first consulting their doctors, as they could experience serious side effects.

Generally, SSRI treatment should only be continued if the benefits to the individual
patient are thought to outweigh the risks to the unborn child, while also considering the
benefits and risks of switching to another treatment option or stopping treatment
altogether. These precautions and the possibility of adverse health effects in newborns
are mentioned in the current Canadian prescribing information and consumer information
for SSRIs
SSRI are Class C = risk to fetus cannot be ruled out
Electroconvulsive therapy has been used to treat depression in pregnancy for over 50
years. This technique has been reported to be relatively safe in pregnant women with
severe, refractory depression

5.What is the minimum age that you can

start an insight-psychoanalysis with a
child?

A.6Y
B.10Y
C.14Y
D.17Y

The answer is:

A
Anna Freud Centre, 21 Maresfield Gardens, London NW3 5SD.
After a discussion of some of the theoretical issues raised in the past
about the concept of insight, the authors go on to track changes in the
internal representations of two young patients during the course of a
session with each of them. Their argument is that in the attention to
the detail of these sessions there is evidence of a gradual
development of knowledge about internal relationships in the patient,
which is reflected in movements in the narrative of the play. The need
for congruence between heightened affect in the patient and the
analyst conveying understanding is stressed and compared with early
mother-infant relationships. They argue that the 5-year-old child can
use his developing capacity to mentalise most safely in the
context of pretend play and that the analyst's communications
should remain as close as possible to that context, typically in
displacement. They conclude that their sessions give evidence
that children of this age are capable of a form of insight that
could be said to be the equivalent of that of adults in analysis,
but that their mode of expression and of communication of their
self-knowledge through their play is very different.

6.Concerning childhood psychiatric disorder

each of the following is correct except:
A. Children with mild MR are identifiable at 2-3
years of age
B. Children with developmental reading disorder
have a normal intelligence
C. Presence of autism in siblings of autistic
children is 50 times higher than in general
population
D. Diagnosis of encopresis can be made when a
child is 4 year old
E. Children with gender identity disorder rarely
develop transsexualism in adult life

The answer is:

A
For clinically referred children, onset of crossgender interests and activities is usually between
ages 2 and 4 years, and some parents report that
their child has always had cross-gender interests.
Only a very small number of children with Gender
Identity Disorder will continue to have symptoms
that meet criteria for Gender Identity Disorder in
adolescence or adulthood
most children with mental retardation do not
develop symptoms that are noticeable until the
preschool period. Symptoms become apparent at a
younger age in those more severely affected.
Usually, the first problem parents notice is a delay
in language development.

7.An 18 yrs girl with good health previously,

seeks helps at an emergency room for
lightheadedness, headaches and nausea. She
appears anxious and is tremulous. sweating
and breathing heavily. While waiting for doctor
she began to complain of tingling around her
mouth and her fingers. which one 1st step of
management?

A. Ask her breath into a paper bag

B. Immediate IV glucose solution.
C. Order a urine drug screen
D. Give oxygen with mask
E. 2mg of SL lorazepam (ativan)

The answer is:

A

Panic Attack: Abruptly and peak within 10

min.
Management:

Box-Breathing, Relaxation Techniques

Supportive Psychotherapy, CBT
BZD (Alprazolam), SSRI, SNRI except
Wellbutrin

8.Which of the following is correct to

anorexia nervosa:
A. Significant depression usually occurs
B. Appetite is not initially lost
C. Pursuit of thinness becomes the only
priority
D. Loosing weight becomes associated
with an escalation of anger
E. Purging often develops later in the
course of the illness

The answer is:

C
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)
Intense fear of gaining weight or becoming fat
Disturbance in the way one's body weight or
shape is experienced, with denial of current low
body weight
Amenorrhea in postmenarcheal females of at
least 3 menstrual cycles
Restricting Type
Binge-Eating-Purging Type

9.All of the following conditions are

included in the DDE of anxiety disorder
except:

A. Schizophrenia
B. Hypothyroidism
C. Panic Disorder
D. DM

The answer is:

A
DDE of anxiety Disorders
Endocrine: Hypo- or Hypothyroidism,
Pheocromocytoma, hypoglacemia,
hyperadrenalism, Hyperpara
CVS: MVP, CHF, PE, Arrhythmia
Respiratory: Astham, Pneumonia, Hyperventilation
Metabolic: Vit B12 Def., Porphyria
Neurologic: Neoplasm, Vestibular Dysfunction,
Encephalitis
Substance Abuse, Withdrawal

 9.65 yr old woman living alone in a dilapidated

house, although her family members have tried in
vain to move her to a better dwelling. She wears
odd clothes, rummages in the garbage cans of
neighbors to look for redeemable cans and
bottles. she is very suspicious of her neighbors
and is convinced that they were trying to end her.
she believes in the "power of crystals" and had
them scattered all over her house. diagnosis:

A. Schizophrenia, paranoid
B. Schizotypal personality disorder
C. Avoidant personality disorder
D. Schizoid personality disorder
E. Borderline disorder

The answer is:

B

Schizotypal PD: Odd Thinking and Speech Patterns,

Odd and eccentric Behavior. Paranoid Ideation and
magical thinking or odd beliefs
Avoidant PD: Avoids occupational activities that
involves significant criticism or rejection
Schizoid PD: Neither Desires nor enjoys close
relationships
Borderline PD: Unstable Affect, mood Swings,
Marked Impulsivity, unstable relationship
Schizophrenia, paranoid: Delusions of persecution
and Grandeur. In late 20s or 30s, best prognosis

10.A patient presents to your office with a

history of ongoing excessive alcohol use
and associated depression. Best
recommendations could include all of
the following EXCEPT:
A. Disulfiram 250mg po qdaily
B. Brief intervention for alcohol
C. Naltrexone 50mg po qhs
D. Cognitive behavioral therapy
E. Increased follow-up

The answer is:

A

The first step in treatment is brief intervention. The physician states unequivocally that
the patient has a problem with alcohol and emphasizes that this determination stems
from the consequences of alcohol in that patient's life, not from the quantity of alcohol
consumed. Emphasizing the effects on family, friends, and occupation, as well as any
physical manifestations, is important. Pointing out that loss of control and compulsive
use indicate alcohol dependence also is important.

Naltrexone blocks opiate receptors and works by decreasing the craving for alcohol,
resulting in fewer relapses. Most, but not all, studies found that naltrexone decreases
relapses but the effect is modest (12-20%). Combining naltrexone therapy with cognitive
behavioral therapy enhanced benefit. One study showed benefit with an intensive
primary care intervention. Studies suggest that virtually all placebo patients who sampled
alcohol relapsed, while only half the naltrexone patients who sampled alcohol relapsed.

A number of medications have been tried in the treatment of alcoholism. Disulfiram

(Antabuse) has been used as an adjunct to counseling and AA with motivated patients to
reduce the risk of relapse. Patients are reminded of the risks of adverse effects when
tempted to drink. Disulfiram causes nausea, vomiting, and dysphoria with coincident
alcohol use. In a large trial, disulfiram did not increase abstinence. If a patient asks for
disulfiram and thinks it will help, it might be worth considering.

Disulfiram produces a sensitivity to alcohol which results in a highly unpleasant reaction

when the patient under treatment ingests even small amounts of alcohol.
Disulfiram plus even small amounts of alcohol produces flushing, throbbing in head and
neck, throbbing headache, respiratory difficulty, nausea, copious vomiting, sweating, thirst,
chest pain, palpitation, dyspnea, hyperventilation, tachycardia, hypotension, syncope,
marked uneasiness, weakness, vertigo, blurred vision, and confusion. In severe reactions,
there may be respiratory depression, cardiovascular collapse, arrhythmias, myocardial
infarction, acute congestive heart failure, unconsciousness, convulsions, and death.
As an aid in the management of selected chronic alcoholic patients who want to
remain in a state of enforced sobriety so that supportive and psychotherapeutic
treatment may be applied to best advantage.
Used alone, without proper motivation and without supportive therapy, disulfiram is
not a cure for alcoholism, and it is unlikely that it will have more than a brief effect
on the drinking pattern of the chronic alcoholic.
Contraindications
Patients who are receiving or have recently received metronidazole, paraldehyde, alcohol,
or alcohol-containing preparations such as cough syrups, elixirs, should not be given
disulfiram. Severe myocardial disease or coronary occlusion; diabetes mellitus; hepatic
cirrhosis or insufficiency; hypothyroidism; epilepsy; cerebral damage; chronic and acute
nephritis; psychoses
Warnings
Disulfiram should never be administered to a patient without his full knowledge or when he
is in a state of alcohol intoxication. The attending physician should instruct those tending
the patient accordingly.
Patients must be fully informed about the disulfiram-alcohol reaction. They must be
strongly cautioned against surreptitious drinking while taking the drug and must be fully
aware of possible consequences. They should be warned to avoid alcohol in disguised
form, i.e., in sauces, vinegars, cough and cold mixtures, and even aftershave lotions or
liniments. They should also be warned that reactions may occur with alcohol up to 14
days after ingestion of disulfiram.

11. Loosening of associations is most

often found in;

A. depression.
B. schizophrenia.
C. bipolar disorder.
D. drug-induced delirium.
E. transient global amnesia

The answer is:

B
loosening of association
A manifestation of a severe thought disorder characterized by the
lack of an obvious connection between one thought or phrase and
the next, or with the response to a question.

Transient global amnesia

A memory disorder seen in middle aged and elderly persons
characterized by an episode of amnesia and bewilderment that
persists for several hours; during the episode the patient has a
memory defect for present and recent past events, but is fully alert,
oriented, capable of high-level intellectual activity, and has a normal
neurological examination. Typically, these amnesic episodes occur
spontaneously, and most patients experience only one; of uncertain
etiologyprobably ischemic, but not due to atherosclerosis.

12.In the emergency room you are asked

to assess a 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 (Valium)

B. nitrazepam (Nitrazedon)

C. chlordiazepoxide (Librium)

D. lorazepam (Ativan)

E. clonazepam (Rivotril)

The answer is:

D
Because of rapid onset, prolonged duration of effects, and high
therapeutic index, Diazepam is drug of choice. Volumes of literature
exist regarding usage of diazepam for ethanol withdrawal. Onset of
action is within a couple of min after IV administration. Has active
metabolite (desmethyl-diazepam) that has longer duration of action
than diazepam.
Severe Liver Disease, severe asthama, respiratory failure present
Lorazepam
Although diazepam and chlordiazepoxide Both diazepam and
chlordiazepoxide undergo hepatic metabolism and produce
pharmacologically active metabolites. Both parent drug and
metabolites result in prolonged half-lives and may accumulate in the
elderly or patients with liver disease. Lorazepam and midazolam have
the advantages of short action and ease of titration, and they produce
no active metabolites. Lorazepam offers many advantages over
diazepam and chlordiazepoxide, especially in elderly and
hepatically dysfunctional patients

13.Patient comes to your office brought by her

spouse after surviving a mugging where she
was punched in the face. Three weeks later, her
contusions are better but she is afraid to leave
the house out of fear of another attack. Her
sleep is disrupted by recurrent intrusive dreams
of further attack. She is on edge, startles easily,
and is easily moved to tears. The most likely
diagnosis is?

A. Panic disorder with agoraphobia

B. Specific phobia
C. Post traumatic stress disorder
D. Transient stress induced anxiety
E. Generalized anxiety disorder

The answer is:

D
A) Panic Disorder: are recurrent unexpected panic attacks, with four of the 13
symptoms that could be present, reach a peak within 10 minutes in the presence of
intense fear. And, at least one of the attacks has been followed by one month of
persistent concern about having additional attacks and/ or worry about the implications
of the attack, such as fear of having a heart attack or going crazy.
B) Specific Phobia: Marked and persistent fear that is excessive or unreasonable, that
is caused by the presence or anticipation of a specific object or situation. Usually, they
dont have anxiety the rest of the time. And, in individuals under 18, the duration must
be at least six months.
C) Post-Traumatic Stress Disorder: Occurs after an individual has been exposed to a
traumatic event that is associated with intense fear or horror. The patient rR-experiences
the event through intrusive recollection or nightmares, flashbacks, or intense distress
when exposed to reminders of the event. And, the symptoms have been present for at
least one month.
D) Transient stress induced anxiety or Acute Stress Disorder: Symptoms occur after
an individual has been exposed to a traumatic event that is outside the realm of normal
human experience. Re-experiences the event as in PTSD. But the symptoms occur
within one month of a stressor and last between 2 days and four weeks.
E) Generalized Anxiety Disorder: The excessive anxiety or worry is present most days
during at least a six-month period.

14.The best treatment for the patient in the

above question is?
A. Fluoxetine 20mg po qdaily
B. Link the assault to the patients anxiety
symptoms and support them in talking about
the assault
C. Imovane 7.5mg po qhs
D. Clonazepam 0.5mg po tid
E. Dynamic psychotherapy relate the
assault and current symptoms to issues
from their past

The answer is:

B

Link the assault to the patients anxiety

symptoms and support them in talking
about the assault

15. Tardive Dyskinesia can be

suppressed initially by;

A. anticholinergics
B. stopping the antipsychotic
C. MAOI
D. increasing the antipsychotic
E. TCA

The answer is:

B
1. All neuroleptics, with the exception of Clozapine,
produce tardive dyskinesia. The risk of tardive dyskinesia
with atypical antipsychotics is substantially decreased
compared to typical agents
2. Antiparkinsonian drugs are of no benefit for tardive
dyskinesias and may exacerbate symptoms.
3. When tardive dyskinesia symptoms are observed, the
offending drug should be discontinued. Patients who
require continued neuroleptic therapy should be switched
to an atypical agent or Clozapine (if severe).
4. The risk of tardive dyskinesia increases with the duration
of neuroleptic exposure, and there is an incidence of 3%
per year with typical agents.
5. Most patients have relatively mild cases, but tardive
dyskinesia can be debilitating in severe cases. Tardive
dyskinesias not always improve with discontinuation or
lowering of the does of neuroleptic

16. 62 YO woman is admitted to a medical unit

because of a 20lb wt loss over the
Previous two months. She also reports
anorexia, fatigue and sever constipation.
Physical examination, blood work and
sigmoidoscopy are all normal.
Which of the following would be the most
appropriate management?
A. Continuing physical investigations to rule out
organic causes
B. Amitriptyline
C. Lorazepam
D. High fiber diet
E. Desipramine

The answer is:

E
The symptomatic presentations of depression in late life are by and
large similar to the presentations throughout adulthood. The
differences in symptom presentation that often are attributed to
increased age, such as pseudodementia and depression masked as
physical illness, are usually secondary to comorbidity (i.e., depression
associated with dementia or physical illness and therefore not related
to age). However, depressed older adults may differ from the
depressed in middle age in that they more often experience weight
loss and less often report feelings of worthlessness and guilt. Although
elderly people suffering from major depression perform less well on
objective tests of cognitive functioning, they are no more likely to
complain of memory problems and concentration than middle-aged
depressives.
Ref: Kelley's Textbook of Internal Medicine. Part 11. Geriatrics,
Chapter 460 - Approach to the Elderly with Depression.
In the Elderly the first choice of pharmacotherapy are tricyclic
antidepressants (Nortriptyline or Desipramine). The SSRI are second
line agents because of their long half-life and side effects (agitation,
insomnia, weight loss
Desipramine Agent of Choice in patients over 75
Amitriptyline CVS side effects in Older patients

17.You have a pt. with stimulant overdose,

in his follow up which is the most helpful
in preventing recurrence ....

A. Naloxone
B. methadone
C. supporting him by psychotherapy
D. supportive family

The answer is:

C
Cognitive-behavioral therapy is focused on the delivery of information
and development of skills that, in theory, enable a patient to
discontinue drug use and avoid relapse. The techniques used within
the designation of the cognitive-behavioral therapy include
psychoeducation, identification of high-risk situations and warning
signs for relapse, development of coping skills, development of new
lifestyle behaviors, increased self-efficacy, and dealing with relapse.
Cognitive-behavioral therapy has been applied successfully across
many different substances of abuse. Cognitive-behavioral therapy
seems to be particularly effective among patients at higher levels of
addiction severity.
Ref: Sadock, Benjamin J., Sadock, Virginia A. Kaplan & Sadock's
Comprehensive Textbook of Psychiatry, 8th Edition, 2005. 11
Substance-Related Disorders
Naloxene to Extinguish drug-seeking behavior

18.27-year-old woman seeks evaluation for her

"depression" in an out-patient clinic. She reports
episodic feelings of sadness since adolescence.
Occasionally she feels good, but these periods seldom
last more than 2 weeks. She is able to work but thinks
she is not doing as well as she should. In describing
her problems she seems to focus more on repeated
disappointments in her life and her low opinion of
herself than on discrete depressive symptoms. In your
differential diagnosis at this point, Which one of the
following is the most likely diagnosis?

A.
B.
C.
D.
E.

major depression with melancholia

adjustment disorder with depressed mood
cyclothymia
childhood depression
dysthymia

The answer is:

E
In dysthymic disorder, depressive symptoms
typically begin insidiously in childhood or
adolescence and pursue an intermittent or lowgrade course over many years or decades; major
depressive episodes may complicate it (double
depression). In pure dysthymia, depressive
manifestations occur at a subthreshold level and
overlap considerably with those of a depressive
temperament: habitually gloomy, pessimistic,
humorless, or incapable of fun; passive and
lethargic; introverted; skeptical, hypercritical, or
complaining; self-critical, self-reproaching, and selfderogatory; and preoccupied with inadequacy,
failure, and negative events.

19. 29-year-old, previously successful woman was climbing

stairs in her new home about a month ago, when the whole
house fell apart. She ended up in a hospital with a fractured
left femur. The psychiatry team was consulted because the
patient complained of nightmares and flashbacks and was
afraid to go to sleep as a result. During the interview, she is
tearful, and afraid that her fear of falling is preventing her
from participating enough in her rehabilitation, and that the
team will discharge her from hospital. Which of the following
is the most appropriate treatment for this patient?
A. Insight-oriented psychotherapy
B. No therapy because the patient needs to take responsibility for her
treatment
C. Put a sitter to stay in the patient's room 24 hours a day to calm her
anxiety
D. Start an antidepressant
E. Start benzodiazepines

The answer is:

D

The diagnosis in this patient is Post-Traumatic Stress Disorder

Post- Traumatic Stress Disorder Diagnostic Criteria:
The person has experienced or witnessed or was confronted with an unusually
traumatic event that has both of these elements:
The event involved actual or threatened death or serious physical injury to the
person or to others, and the person felt intense fear, horror or helplessness.
The person repeatedly relives the event in at least 1 of these ways:
- Intrusive, distressing recollections - thoughts, images.
- Repeated, distressing dreams.
- Through flashbacks, hallucinations or illusions, acts or feels as if the event
were recurring.
- Marked mental distress in reaction to internal or external cues that symbolize
or resemble the event.
- Physiological reactivity - such as rapid heart beat, elevated blood pressure in
response to these cues.
The above symptoms have lasted longer than one month.
The treatment is CBT (that is not mentioned in the options provided) and
Antidepressants
patients may experience guilt because they behaved aggressively and
destructively during armed combat or because they survived a traumatic
experience in which family members or close associates perished--so-called
survivor guilt. In such cases, psychodynamic or insight-oriented
psychotherapy aimed at helping patients understand and modify their selfcritical and punitive psychologic attitudes may be helpful

20. an 84 year old man presents to the ER .his son tells

the physician that his father has been very depressed
in the past few months ,has been eating poorly,
sleeping restlessly and complaining of decreased
energy, Particularly in morning .3 days ago the man's
family physician prescribed amitrptyline 75 mg for the
first night and 100 mg on the second. This evening ,the
son says, his father has been increasingly restless
,shouting incoherently and screaming ''get these things
off me' the most likely diagnosis that accounts for his
deterioration is

A. worsening depression
B. paranoid disorder
C. schizophrenia of old age
D. delerium
E. dementia

The answer is:

D
Older adults are especially liable to certain
side effects of Elavil, including rapid
heartbeat, constipation, dry mouth, blurred
vision, sedation, and confusion, and are in
greater danger of sustaining a fall.

 21. which one of the following

medications given IV would confirm the
present diagnosis in this man?

A .atropine
B. amitriptyline
C. physostigmine
D. diazepam

The answer is:

C

It has been reported that i.v. administration of physostigmine salicylate may reverse
some of the CNS and cardiovascular effects of tricyclic antidepressants. The dosage that
has been recommended for adults is 1 to 2 mg in very slow i.v. injection. Since
physostigmine has a short duration of action, administration may have to be repeated at
30 to 60 minute intervals particularly in life-threatening signs such as arrhythmias,
convulsions, and deep coma recur or persist after the initial dose of physostigmine.
Ref: http://www.mentalhealth
Benzodiazepines remain the agents of choice in treating seizures. Phenytoin is no longer
recommended because of its limited efficacy and possible pro-dysrhythmic effects.
Phenobarbital may be used as a long-acting anticonvulsant.
Benzodiazepines are also the treatment of choice for the extreme agitation or
delirium that occasionally are observed because of the anticholinergic effects of
TCAs.
Physostigmine, an acetylcholinesterase inhibitor, is contraindicated in patients with TCA
overdoses. Although physostigmine was previously advocated for relief of anticholinergic
effects, it may cause bradycardia and asystole in TCA cardiotoxicity.
Flumazenil, a benzodiazepine antagonist, is contraindicated, even in the presence of a
benzodiazepine co-ingestion. Several case reports exist of patients with concomitant
TCA overdoses who had seizures after the administration of flumazenil.

 22. 19yo woman with 2 previous

episodes of mania develops a major
depressive episode.Which of the
following is the most appropriate initial
pharmacologic management?

A. imipramine
B. lithium
C. divalproex
D. venlafaxine
E. venlafaxin&diva

The answer is:

B

the patient has had manic episodes and now has a depressive episode, it is a Bipolar
Disorder. The initial treatment in Bipolar Disorder is always a mood stabilizer.
Remember that in these cases if you give monotherapy with an antidepressant, the
antidepressant could trigger a manic episode. So, the answer is B or C. According to the
American Psychiatric Association:
The first-line pharmacological treatment for bipolar depression is the initiation of
either lithium or lamotrigine
Antidepressant monotherapy is not recommended
As an alternative, especially for more severely ill patients, some clinicians will initiate
simultaneous treatment with lithium and an antidepressant. In patients with lifethreatening inanition, suicidality, or psychosis, ECT also represents a reasonable
alternative. ECT is also a potential treatment for severe depression during pregnancy.

Ref: Am J Psychiatry 159:4, April 2002 Supplement

Lithium :Classic bipolar I symptom pattern: euphoric mania and severe depressions
Significant manic symptoms
Need all the antidepressant you can get
Suicide risk
Very inexpensive
valproate/Depakote :
Need something strong and fast
Male gender, and not afraid of weight gain risk
Rapid cycling
Significant manic symptoms

 23. A patient presents to your office who

has a history of bipolar disorder. He is
currently depressed and on no
medications. He is otherwise well. The
most appropriate treatment is?

A.
B.
C.
D.
E

Electroconvulsive therapy
Valproic acid
Lithium carbonate
Fluoxetine
Desipramine

The answer is:

C

Lithium Carbonate. In this case the patient is without treatment, so he should be treated as a
patient not yet in treatment.
Acute Depression

Goals of Treatment:
Achieve remission of the symptoms of major depression and return the patient to the usual levels of
psychosocial functioning.
Avoid precipitating a manic or hypomanic episode.
For patients not yet in treatment for bipolar disorder, initiate either lithium or lamotrigine.
lamotrigine/Lamictal
Depression is the dominant symptom
Rapid cycling
Need all the antidepressant you can get
afraid of weight gain
As an alternative, especially for more severely ill patients, consider initiating treatment with both
lithium and an antidepressant simultaneously (although supporting data are limited).
Antidepressant monotherapy is not recommended because of the risk of precipitating a manic or
hypomanic episode.
Consider ECT for:
- Patients whit life-threatening inanition, suicidality, or psychosis or
- Severe depression during pregnancy
For patients who suffer a breakthrough depressive episode while on maintenance treatment,
optimize the medication dosage
Ref: Quick Reference to the American Psychiatric Association Practice Guidelines for the Treatment
of Psychiatric Disorders. Compendium 2004.

 24. -what is true with respect to infantile

autism?
A. it is more common than huntington's
chorea
B. about half of these children show
symptoms of organic brain disorder
C. incidence is highest among females of
ashkenazy jews
D. despite delay in language development
intelligence is usually normal
E. more prevalent in lower SES

The answer is:

B

Prevalence of HD in the United States is 5.15 cases per 100,000 persons.

Autistic disorder and related conditions affect up to 10-15 people per 10,000.
2) Approximately 10% of children with a pervasive developmental disorder exhibit a
known medical condition.
3) The male-to-female ratio is 3-4:1. Japanese studies often indicate the more common
occurrence of autism in Japan than in other countries. The high rates of autism reported
in many Japanese studies may reflect higher incidence and prevalence in Japan.
Alternatively, since Japanese clinicians are highly skilled to diagnose autism, they may
identify cases that are overlooked in other countries.
4) Most individuals with autism also manifest mental retardation, typically moderate
mental retardation with intelligence quotients (IQs) between approximately 35 and
approximately 50. Although often difficult to evaluate with intelligence tests, three
quarters of children with autism function in the mentally retarded range.
5) Although autistic disorder was initially reported in children of high social class,
subsequent research has established that autistic disorder afflicts all social classes
equally.

 25.You are counselling a 64-year-old woman who is

concerned about her husband's increasing disinterest
in sexual activity. Which one of the following
statements about sexual function is correct?
A. Age impairs sexual capacity equally in men and
women.
B. Women remain clitorically responsive throughout their
lifespan.
C. Decreased sexual activity occurs as men age even
though androgen levels remain stable.
D. Most antihypertensive drugs will increase erectile
function by promoting vasodilation.
E. Thresholds for male sexual arousal are unchanged
with age.

The answer is:

B

1) An estimated 70 percent of men and 20 percent of women over age 60 years are sexually
active; sexual activity is usually limited by the absence of an available partner. Longitudinal
studies have found that the sex drive does not decrease as men and women age; in fact, some
report an increased sex drive. Masters and Johnson reported sexual functioning among those in
their 80s.
Ref: Kaplan & Sadock.
2) The physical changes resultant from both ageing and declining estrogen levels, affect female
sexuality. In addition to circulating estrogen levels falling at menopause, the nervous system
and vascular system also decline with age. Loss of fat and glandular tissue, combined with
lessened muscle tone and tissue elasticity, makes the breasts and other body regions more
drooping and flabby. The cervix, uterus and ovaries shrink, the vagina becomes dry and the
lining tissue thinner, and the clitoris, which retains its sensitivity, decreases in size.
http://womenshealth.med.monash.edu.au/documents/female-sexuality-and-changes-with-age.pd
f
3) Testosterone levels decline gradually in men, starting from approximately age 30, and this
decline continues throughout life.
Ref: http://www.cenegenics.com/abstracts/abs2.html
4) About 25% of cases of erectile dysfunction are caused by drugs, especially antihypertensives
(most notably reserpine, -blockers, guanethidine, and methyldopa), alcohol, cimetidine,
antipsychotics, antidepressants, lithium, sedative-hypnotics, leuprolide, and hormones such as
estrogen and progesterone.
Ref: http://www.merck.com/mrkshared/mmg/sec14/ch114/ch114a.jsp
5) With normal aging, persons require more time to become sexually aroused. Although some
persons perceive this gradual slowing as a decline in function, others do not consider it an
impairment because it merely results in men and women taking more time to achieve orgasm.
Ref: http://www.merck.com/mrkshared/mmg/sec14/ch114/ch114a.jsp

 26.A previously healthy, 68-year-old woman

develops auditory hallucinations. She cannot
provide many details but believes her mother
is speaking to her. She has difficulty
cooperating during the interview and physical
examination, which is unremarkable. Which
one of the following is the most likely
diagnosis?

A. complex partial seizures

B. Alzheimer's disease
C. adverse medication effect
D. hyperthyroidism
E peduncular hallucinosis

The answer is:

B

She is healthy, they don't mention any diagnosis or treatment in this patient.
A Complex Partial Seizure is an epileptic attack that involves a greater degree of
impairment or alteration of consciousness/awareness and memory than a simple partial
seizure. It may involve automatisms (the unconscious repetition of simple actions,
gestures or verbal utterances), and/or sensory changes. There can be some loss or
memory (amnesia) surrounding the seizure event. Other patients may report a feeling of
tunnel vision or dissociation, which represents a diminishment of awareness without full
loss of consciousness. Still other patients can perform complicated actions, such as travel
or shopping, while in the midst of a complex partial seizure.
Hyperthyroidism major clinical features are weight loss (often accompanied by a
ravenous appetite), fatigue, weakness, hyperactivity, irritability, apathy, depression,
polyuria, and sweating. Additionally, patients may present with a variety of symptoms such
as palpitations and arrhythmias (notably atrial fibrillation), dyspnea, loss of libido, nausea,
vomiting, and diarrhea. In the elderly, these classical symptoms may not be present and
they may present only with fatigue and weight loss leading to apathetic hyperthyroidism
Neurological manifestations are tremor, chorea, myopathy, and periodic paralysis. Stroke
of cardioembolic origin due to coexisting atrial fibrillation may be mentioned as one of the
most serious complications of hyperthyroidism.
Peduncular Hallucinations are formed visual images often associated with sleep
disturbance and are caused by lesions in the midbrain, pons and diencephalon.

27.each of the following is true about post

partum psychosis except;
A. most likely to occur after first child
B. may be characterized by homicidal
thoughts
C. occurs in less than 1% of women
D. often characterized by severe
depression
E. may require psychiatric hospitalization

The answer is:

D

In the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR), the diagnosis of brief psychotic disorder with postpartum onset is given
when psychosis occurs within 4 weeks of delivery and mood symptoms are not present. If
the psychosis lasts longer than 1 month, then other diagnoses, such as schizophreniform
disorder, should be considered. More typically, postpartum psychosis occurs together with
mood symptoms. In such situations, the patient is given a diagnosis of a mood disorder
with the specifier of postpartum onset.
The incidence of postpartum psychosis is approximately 1 to 2 per 1,000 births, with
psychotic symptoms appearing within the first week after childbirth in most individuals.
The most important risk factor for developing a postpartum psychosis is previous history.
The risk of puerperal relapse is as high as 70 percent. Other risk factors include
primigravida, being unmarried, cesarean section, having a female child, and previous
personal or family history of psychiatric illness. Fetal distress and offspring abnormalities
(neurological abnormalities, cyanosis, neonatal polycythemia, thrombocytopenia) have
also been identified as risk factors.
There may be obsessional thoughts regarding violence to the child. However, infanticide is
rare. Although rare, infanticide is more likely to occur in postpartum psychosis than in other
postpartum psychiatric disorders.
Ref: Sadock, Benjamin J., Sadock, Virginia A. Kaplan & Sadock's Comprehensive
Textbook of Psychiatry, 8th Edition. Lippincott Williams & Wilkins 2005.

 28. young patients comes to you with

new development of tremors after taking
antipsychotic medication .How will you
treat?

A. Lorazepam
B. Lorazepine
C. Amantadine
D. Benzodiazepine

The answer is:

C
Anticholinergic and Antiparkinsonian agents are used to
control the extra pyramidal side effects of antipsychotic
agents, including acute dystonic reactions, neuroleptic
induced parkinsonism, and akathisia.
The anticholinergics are drugs of choice for acute
dystonias and for drug-induced parkinsonism.
Agents used:
Anticholinergics: Benztropine, Biperiden, Trihexyphenidyl.
Antihistamine/Anticholinergic: Diphenhydramine
Dopamine/Agonist: Amantadine
Benzodiazepines aren't useful in the treatment of EPS.

 29.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.
B.
C.
D.
E

delusional disorder
paranoid schizophrenia
anxiety disorder
antisocial personality disorder
schizoid personality disorder

The answer is:

A

For the Differential Diagnosis, remember that the patients with Delusional Disorders
have non-bizarre Delusions and no other symptoms.
In Schizophrenia for a material part of at least one month (or less, if effectively treated)
the patient has had 2 or more of:
- Delusions (only one symptom is required if a delusion is bizarre, such as being
abducted in a space ship from the sun)
- Hallucinations (only one symptom is required if hallucinations are of at least two voices
talking to one another or of a voice that keeps up a running commentary on the patient's
thoughts or actions).
- Speech that shows incoherence, derailment or other disorganization
- Severely disorganized or catatonic behavior Any negative symptom such as flat affect,
reduced speech or lack of volition.
In Personality Disorders the Personality Traits consist of enduring patterns fo
perceiving, relating to, and thinking about the environment, other people and oneself.
Personality patterns must be stable and date back to adolescence or early adulthood.
Anxiety Disorders: several disorders fall into this category, including: Panic Disorder,
Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, Phobias (including
Social Phobia also known as Social Anxiety Disorder), and Generalized Anxiety Disorder.
These disorders can result in extensive anxiety and fear for an individual, are chronic
and may become worse if not treated. Delusions are not a prominent part

 30-26YO student has been well controlled on

lithium for five years. His last hospitalization
was for a severe psychotic depression. He is
now complaining of a six-week history of
dysphoria, low energy, lack of drive and
sleepiness. Your most appropriate initial
intervention should be:

A. Stop lithium
B. Do thyroid function test
D. Start an antidepressant
E. Start an antidepressant and neuroleptic
F. Check his hemoglobin

The answer is:

B

Lithium Side Effects:

Among the side effects may be nausea, loss of appetite, & mild diarrhea. They are common during the early
weeks, but usually diminish with time. Patients may also experience dizziness & a fine tremor of the hands. Other
potential side effects include weight gain, hypothyroidism, increased white blood cell count, skin rashes, & birth
defects.
The following are symptoms of Hypothyroidism:
- Fatigue, loss of energy, lethargy, Weight gain, Decreased appetite, Cold intolerance, Dry skin, Hair loss,
Sleepiness, Muscle pain, joint pain, weakness in the extremities, Depression, Emotional lability, mental
impairment, Forgetfulness, impaired memory, inability to concentrate, Constipation, Menstrual disturbances,
impaired fertility, Decreased perspiration, Paresthesia and nerve entrapment syndromes, Blurred vision,
Decreased hearing, Fullness in the throat, hoarseness
Lithium Toxicity:
Toxic levels of lithium in the blood can cause vomiting, severe diarrhea, extreme thirst, weight loss, muscle
twitching, abnormal muscle movement, slurred speech, blurred vision, dizziness, confusion, stupor, or pulse
irregularities.
Anemia:
The symptoms and signs of anemia represent cardiovascular-pulmonary compensatory responses to the severity
and duration of tissue hypoxia. Severe anemia (eg, Hb < 7 g/dL) can be associated with weakness, vertigo,
headache, tinnitus, spots before the eyes, fatigability, drowsiness, irritability, and even bizarre behavior.
Amenorrhea, loss of libido, GI complaints, and sometimes jaundice and splenomegaly can occur. Finally, heart
failure or shock can result.
The answers provided are:
a) Stop Lithium you should stop lithium if the patient had toxic levels of it, but the symptoms in this patient arent
concordant with that diagnosis.
b) Do Thyroid function test among the side effects of lithium therapy is hypothyroidism.
c) Start an antidepressant this patient doesnt meet the criteria for a Major Depressive Episode.
d) Start an antidepressant and neuroleptic the same as in c)
e) Check his hemoglobin there is no reason to think that this patient could have anemia.

31. A 33-year-old patient. A panic disorder

with agoraphobia Which one of the
following drugs is LEAST likely to be
useful in preventing panic attacks?

A.
B.
C.
D.
E.

clonazepam
paroxetine
alprazolam
buspirone
desipramine

The answer is:

D
Buspirone is not effective for Panic
Disorder. The efficacy of buspirone HCl has
been demonstrated in controlled clinical trials
of outpatients whose diagnosis roughly
corresponds to Generalized Anxiety Disorder
(GAD). Many of the patients enrolled in
these studies also had coexisting depressive
symptoms and buspirone HCl relieved
anxiety in the presence of these coexisting
depressive symptoms

32. A 25-year-old woman with depression

repeatedly talks about irrelevant topics
when being interviewed by a
psychiatrist. Which one of the following
symptoms is the patient demonstrating?

A.
B.
C.
D.
E.

suppression
denial
introjection
resistance
repression

Suppression
Conscious act of controlling and inhibiting an unacceptable impulse, emotion,
or idea; differentiated from repression in that repression is an unconscious
process. Dealing with emotional stressors by deferred dealing with the
stressor. For example, a worker finds that he is letting thoughts about a date
that evening interfere with his duties; he decides not to think about plans for
the evening until he leaves work.
Denial
Defense mechanism in which the existence of unpleasant realities is
disavowed; refers to keeping out of conscious awareness any aspects of
external reality that, if acknowledged, would produce anxiety. Dealing with
emotional stressors by failing to recognize obvious implications or
consequences of a thought, act, or situation. For example, a disabled person
plans to return to former activities although it is evident it is virtually
impossible.
Used To avoid becoming aware of some painful aspect of reality

Introjection:
The process of assimilation of the picture of an object (as the individual
conceives the object to be). For example, when a person becomes depressed
due to the loss of a loved one, his feelings are directed to the mental image he
possesses of the loved one. Dealing with emotional stressors by internalizing
the values or characteristics of another person; usually someone who is
significant to the individual in some way. For example, adopting the ideals of a
charismatic leader in order to deal with feelings of one's own inadequacy.
Features of External World ar taken and made part of the self.

The answer is:

D
Resistance:
This defense mechanism produces a deep-seated opposition to the
bringing of repressed (unconscious) data to awareness. Through its
operation, the individual seeks to avoid memories or insights which
would arouse anxiety.
Repression
Freud's term for an unconscious defense mechanism in which
unacceptable mental contents are banished or kept out of
consciousness; important in normal psychological development and in
neurotic and psychotic symptom formation. Freud recognized two kinds
of repression: (1) repression proper, in which the repressed material
was once in the conscious domain, and (2) primal repression, in which
the repressed material was never in the conscious realm. Moving
thoughts unacceptable to the Ego into the unconscious, where they
cannot be easily accessed.
Unconscious Forgetting

33. 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 answer is:

C

NMS is a heterogeneous syndrome that spans a broad severity continuum. The

diagnosis is made on clinical grounds based on the presence of certain
historical, physical, and laboratory findings. The diagnosis is confirmed, but not
necessarily excluded, by the presence of the following criteria:

Recent treatment with neuroleptics within past 1-4 weeks

Hyperthermia (above 38C)

Muscular rigidity

At least 5 of the following:

+ Change in mental status
+ Tachycardia
+ Hypertension or hypotension
+ Diaphoresis or sialorrhea
+ Tremor
+ Incontinence
+ Increased creatinine phosphokinase (CPK) or urinary myoglobin
+ Leukocytosis
+ Metabolic acidosis
+ Exclusion of other drug-induced, systemic, or neuropsychiatric illness

 35. 24-year-old man was recently hospitalized in a

psychiatric unit, where he was started on olanzapine. Upon
visiting his new primary care physician for a routine physical
examination prior to participating in a vocational
rehabilitation program, his physician notices that his
thoughts are quite illogical. For example, when she asks the
young man what sort of employment he hopes to work
toward, he answers, "if you subtract some yellow from the
sky, it becomes greener." After a brief silence, he then
states, "telephone bills should never exceed twenty
dollars ... according to the Book of Numbers." Which mental
status examination finding most accurately describes this
patient's thought processes?

A. Clang associations
B. Concrete thinking
C. Loose associations
D. Tangential thoughts
E. Thought blocking

clang association
Association or speech directed by the sound of a word rather than by its
meaning; words have no logical connection; punning and rhyming may
dominate the verbal behavior. Seen most frequently in schizophrenia or mania.
"I'm not trying to make noise. I'm trying to make sense. If you can't make sense out of
nonsense, well, have fun".

concrete thinking
Thinking characterized by actual things, events, and immediate experience,
rather than by abstractions; seen in young children, in those who have lost or
never developed the ability to generalize (as in certain cognitive mental
disorders), and in schizophrenic persons.
loosening of associations
Characteristic schizophrenic thinking or speech disturbance involving a
disorder in the logical progression of thoughts, manifested as a failure to
communicate verbally adequately; unrelated and unconnected ideas shift from
one subject to another. Loose of associations: the patient makes statements
that lead to other statements in a very loose way, so that the associative leaps
are unclear. There are clearly associations going somewhere in your patients
mind, but you cant make them out.

The answer is:

C
tangentiality
Oblique, digressive, or even irrelevant manner of speech in
which the central idea is not communicated.

"What city are you from?", "Well, that's a hard question. I'm from Iowa. I
really don't know where my relatives came from, so I don't know if I'm
Irish or French".

blocking
Abrupt interruption in train of thinking before a thought or
idea is finished; after a brief pause, the person indicates no
recall of what was being said or was going to be said (also
known as thought deprivation or increased thought latency).
Common in schizophrenia and severe anxiety. Your patient
begins to say something, then stops in midthought and
forgets what he was going to say

36. YOUNG WOMAN SWALLOWED 18 TABS

OF BDZ AFTER A FIGHT WITH HER
BOYFRIEND
SHE WAS DIZZY, AFTER 6hrS SHE IS OK
AND WANT TO LEAVE:

A.OBSERVE FOR 24 HRS.

B.ADMIT HER AGAINST HER WILL
C.LET HER GO
D.SEND HER TO ADDICTION CLINIC

The answer is:

C
Toxicity, Benzodiazepine
* Admit patients with hemodynamic instability, coma, or
respiratory depression to the ICU.
* Watch for signs of withdrawal in patients who have
been taking BZDs chronically before overdose.
* Patients may be discharged if they remain
asymptomatic 4-6 hours post ingestion. Those with mild
toxicity may be observed in the emergency department
until they recover.
* Transfer patients who may require more advanced
care than is available in either the ED or inpatient setting.

37.What is the most common comorbid

psychiatric diagnosis in patients with
chronic pain?

A.
B.
C.
D.
E.

anxiety disorder
depressive disorder
substance abuse disorder
somatization disorder
conversion disorder

The answer is:

B
Mortality/Morbidity: Chronic Pain Syndrome (CPS) can affect patients in
various ways. Major effects in the patient's life are depressed mood,
fatigue, reduced activity and libido, excessive use of drugs and alcohol,
dependent behavior, and disability out of proportion to impairment.
* Sternbach's 6 D's of CPS are as follows:
* Dramatization of complaints
* Drug misuse
* Dysfunction/disuse
* Dependency
* Depression
* Disability

P a tie n ts w ith M o o d D is o rd e rs

Presence of Unexplained
Physical Symptoms is Highly
Correlated
with Mood
Disorders
80
Depressed
patients often present
with numerous physical complaints.

60%

60
44%

As the number of physical

complaints increases, so does the
likelihood of a mood disorder.1

30% of patients with depression

experience physical symptoms for
more than 5 years before proper
diagnosis.2

40
23%

20

12%
2%

0
0-1

2-3

4-5

6-8

9+

Number of Physical Symptoms

N=1000
1. Kroenke K, et al. Arch Fam Med. 1994;3:774-779.
2. Lesse S. Am J Psychother. 1983;37:456-475.

Chronic Painful Physical

Conditions (CPPCs) Comorbid
with MDD
Patients with CPPCs

Patients without MDD

10%

Patients with MDD

43%
Odds Ratio=4.0
p<.001

Ohayon MM, Schatzberg AF. Arch Gen Psychiatry. 2003;60:39-47.

 38.A 36-year-old business consultant, married

for 8 years, gainfully employed with a
Masters in Business Administration (MBA)
states that he has had, No interest in sex for
the past six months. His medical, physical,
and neurological examinations are
unremarkable. Given the absence of any recent
crises in his life, the most reasonable
cause of his sexual disinterest is

A. Catatonic schizophrenia
B. Trichotillomania
C. Sexual addiction
D. Impotence
E. Depression

The answer is:

E

The symptoms of this patient are classified as Sexual Desire Disorder.

DSM-IV-TR divides Sexual Desire Disorders into two classes: hypoactive sexual
desire disorder, characterized by a deficiency or lack of sexual fantasies and
desire for sexual activity, and sexual aversion disorder, characterized by an
aversion to and avoidance of genital contact with a sexual partner. The former
condition is more common than the latter.
Patients with desire problems often have good ego strengths and use inhibition
of desire defensively to protect against unconscious fears about sex. Lack of
desire can also result from chronic stress, anxiety, or depression. Abstinence
from sex for a prolonged period sometimes suppresses the sexual impulse.
Desire problems may also be an expression of hostility toward the partner or
signal a deteriorating relationship.
Impotence is classified as Male Erectile Disorder, and its essential feature is a
persistent or recurrent inability to attain, or to maintain until completion of the
sexual activity, an adequate erection. This patient doesnt refer this problem.
Depressive disorders are often associated with low sexual desire, and the onset
of depression may precede, co-occur with, or be the consequence of the
deficient sexual desire.
Trichotillomani :A compulsion to pull out one's own hair

39.DOUGHTER DOES'NT WANT TO EAT OR GO

TO NURSEY , ALL MAKE A DIAGNOSIS
OF SEPARATION ANXIETY EXCEPT:

A. HER MOTHER WENT TO HOSP. BEFORE

AND LEFT HER.
B. HER FATHER HAS AGAROPHOBIA WHEN HE
WAS YOUNG ND HE IS OVERANXIOUUS
ABOUT HER
C. HER BABY SITTER PUT HER IN DARK ROOM
ALONE ONCE.

The answer is:

C
essential feature of Separation Anxiety Disorder is excessive anxiety
concerning separation from the home or from those to whom the
person is attached.
Separation anxiety disorder may develop after some life stress.
Separation from Primary Caregiver Present from 1-3 / Averge 7.5 at
Onset Prominent Physical symptoms, unrealistic Phobias an Fears,
Sometimes evidence of nail biting and scratching (Self Mutilation)
Treatment: Family Therapy, CBT, SSRI and BZD
Children of parents with panic disorder have more than a threefold
increase in the risk for SAD.
In this case a) mother went to hospital and left her, constitute life stress
for the child. b)The fact that her father has had agoraphobia and is
overanxious is a risk factor for Separation Anxiety Disorder.

 40.19-year-old college student broke up with

her boyfriend 72 hours ago. She now
complains of depressed mood, anxiety,
difficulty concentrating on studies, and
preoccupation with "mistakes" she made in
the relationship. Which one of the following is
the most appropriate treatment at this time?

A. desipramine
B. diazepam
C. phenelzine
D. psychotherapy
E. thioridazine

The answer is:

D
There are typically 5 stages of grief. These reactions do not occur in a specific order, and may
(at times) show simultaneously. Not all of these emotions are necessarily experienced:
* Denial, disbelief, numbness
* Anger, blaming others
* Bargaining (e.g., "If I am cured of this cancer, I will never smoke again.")
* Depressed mood, sadness, and crying
* Acceptance, coming to terms
Individuals who are grieving will frequently report crying spells, some trouble sleeping, and
difficulty being productive at work.
Starts within 3 months and less than 6 months
Grief is a healthy response to loss that should not be prevented. Rather, it should be
respected, and support should be provided to the grieving.
Emotional support for the grieving process is usually provided by family and friends.
Sometimes outside factors can influence the normal grieving process, and outside help
from clergy, social workers, mental health specialists, or self-help groups may be
indicated.
The acute phase of grief can usually last up to 2 months, but some residual milder
symptoms may extend a year or longer. Psychological counseling may benefit a person
suffering from absent grief reaction, or from depression associated with grieving
Treatment: Brief Psychotherapy, Crisis Intervention
BZD, SSRI

 1. 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) counter phobic behavior.
D) reaction formation.
E) isolation of affect

The answer is:

D
1) Projection: Attributing to others one's own unacceptable thoughts, feelings,
impulses, etc. So, the white person with repressed sexual urges may believe
that all blacks are preoccupied with sex. The moralistic spouse, who is tempted
to have an affair, begins to suspicion that his/her partner has been unfaithful. A
slightly different form of paranoid projection is when a self-critical feeling or idea
is attributed to others. Suppose a young woman from a religious family has
strong feelings against any sexual urges she might have and, thus, almost never
has them. She might start to believe, however, that others are critical of her
whenever she wears a dress that shows her shape.
2) Denial: the individual deals with emotional conflict or internal or external
stressors by refusing to acknowledge some painful aspect of external reality or
subjective experience that would be apparent to others. Refusing to admit or
face a threatening situation. Denial can be when a dying person refuses to admit
what is going to happen or when a person with a heart condition denies that their
overeating or smoking is of any consequence. In denial the individual cannot or
will not face emotional conflict or turmoil related to internal or external stressors
and based on this inability refuses to acknowledge aspects or the entire situation
or event because it is too painful

3) Counter phobic behavior: This defense mechanism

involves deliberate approach of the object of one's fear or
phobia.
4) Reaction formation: the individual deals with emotional
conflict or internal or external stressors by substituting
behavior, thoughts, or feelings that are diametrically
opposed to his or her own unacceptable thoughts or
feelings (this usually occurs in conjunction with their
repression). Its a denial and reversal of our feelings.
Love turns into hate or hate into love. The feelings and
actions resulting from a reaction formation are often
excessive, for instance the loud, macho male may be
concealing (from himself) sexual self-doubts or
homosexual urges. Or, the person who is unconsciously
attracted to the same sex may develop an intense hatred
of gays. People, such as TV preachers, who become
crusaders against "loose morals" may be struggling with
their own sexual impulses.

The answer is:

D
5) Isolation of Affect: the individual deals
with emotional conflict or internal or external
stressors by the separation of ideas from
the feelings originally associated with them.
The individual loses touch with the feelings
associated with a given idea (e.g., a
traumatic event) while remaining aware of
the cognitive elements of it (e.g., descriptive
details).

2. Most characteristic in HIV dementia is....

A) seizures and rigidity..

B) cognitive impairment
C) ataxia and confusion
D) pseudobulbar palsy

The answer is:

B
AIDS affect cognitive, behavioral, and motor function.
Patients often present with the insidious onset of
reduced work productivity, poor concentration, mental
slowness, decreased libido, and forgetfulness.
Apathy and withdrawal from hobbies or social activities
are common and must be differentiated from depression.
Rare features include sleep disturbances, psychosis
(with mania), and seizures.
Motor problems include imbalance, clumsiness, and
weakness.
Early signs and symptoms are subtle and may be
overlooked.
Later, these symptoms evolve into a global dementia
with memory loss and language impairment. This can lead
to a vegetative state.

3.In panic disorder , the most effective and

long lasting treatment is :

A)
B)
C)
D)
E)

behavior treatment
psychoanalysis
imipramine
diazepam
hypnotherapy

Nowadays Cognitive Behavioral Therapy (CBT) is the most effective treatment in

Panic Disorder.
The Ontario Guidelines for the management of anxiety disorders in primary care
says:
No consistent differences have been shown in the efficacies of CBT,
medications, and their combination over the short term. While many trials do not
look at long term outcomes, there is a growing literature that supports better
long term outcomes with fewer relapses with CBT compared to medications
(Barlow, 2000; Marks, 1993). Little is known about the best way to sequence
different treatments. If agoraphobia is present it is more important to include
exposure as part of the CBT regimen. Antidepressants may enhance the
effectiveness of exposure therapy. Including spouses in CBT improves
response.
Ref: http://gacguidelines.ca/pdfs/PDF_anxiety.pdf
Cognitive behavior therapy (CBT) is more effective and more cost-effective than
medication. Tricyclic antidepressants (TCAs) and serotonin selective reuptake
inhibitors are equal in efficacy and both are to be preferred to benzodiazepines.
Treatment choice depends on the skill of the clinician and the patients
circumstances. Drug treatment should be complemented by behavior therapy.

The answer is:

A or C?
Panic Disorder Treatment:
Psychotherapy
Supportive Psychotherapy, relaxation techniques (BoxBreathing, visualization), CBT

Pharmacotherapy
BZD (short term, low dose, regular schedule, long halflife, NO PRN)
SSRI/SNRI
MAOIS
Avoid Bupropion

 4. 35 YO woman presents with the recent belief

that since Kim Campbell was defeated she must
take over as Prime Minister of Canada. She
requires two hours of sleep per night, and feels
wonderful and energetic.
Which of the following symptoms is she LEAST
likely to show?

A)
B)
C)
D)
E)

Auditory hallucinations
Disorganized thinking
Disorientation for time and place
Easily angered and irritated
Poor insight

The answer is:

C
DDE of this Case;
Schizoaffective Disorder
Manic episode with Psychotic features
Schizophrenifom Disorder
Bipolar I disorder with Psychotic features

 5.The following therapies may be used in

the management of chronic pain,
EXCEPT :

A) operant conditioning.
B) cognitive therapy.
C) biofeedback.
D) systematic desensitization.
E) relaxation therapy.

 Operant conditioning is a process of behavior

modification in which a subject is encouraged to
behave in a desired manner through positive or
negative reinforcement, so that the subject comes
to associate the pleasure or displeasure of the
reinforcement with the behavior.
Cognitive Therapy is a direct form of
psychotherapy based on the interpretation of
situations (cognitive structure of experiences) that
determine how an individual feels and behaves. It
is based on the premise that cognition, the process
of acquiring knowledge and forming beliefs, is a
primary determinant of mood and behavior. The
therapy uses behavioral and verbal techniques to
identify and correct negative thinking that is at the
root of the aberrant behavior.

 Biofeedback uses electronic devices to measure

physiological processes such as breathing rate; heart rate; skin
temperature; skin conductance (which varies with perspiration);
and muscle tension, which is measured by a process called
surface electromyography (EMG). A biofeedback unit processes
the electronic signals and feeds back the information to the user
in the form of sounds, or graphs on a computer screen. There is
no magic here; simply by practice a client can learn to alter these
various physiological processes. The goal usually is to change
them from a state of nervous arousal to a state of deep relaxation.
Systematic Desensitization, used primarily to treat phobias
related to one particular issue, is also a simple process whose
effectiveness depends on practice. Essentially you create an
anxiety hierarchy (a graded list of anxiety-provoking items) and
then proceed to pair each item with the feeling of being deeply
relaxed. Eventually this training process allows the patient to
remain relaxed even when thinking about the anxiety-provoking
situation. Finally, the patient learns to confront the real situation
while remaining calm and relaxed.

The answer is:

A
Relaxation techniques: the patient learns to
recognize the feeling of tension in his/her body
and then he/she learns to release the tension. Its
a simple process, but it takes practice. There are
three kinds of relaxation: Progressive Muscle
Relaxation (in which the patient tense and relax
various muscles, progressively, through his/her
body), Guided Imagery (in which the patient
visualizes relaxing images and situations), and
Autogenics (in which the patient learns to create a
feeling of warmth and heaviness throughout
his/her body).

 6 .30 years old being treated for his 1st episode

of schizophrenia with haloperidol 10 mg daily
and benzotropine 2mg daily is still feeling
nervous and restless despite a reduction in his
auditory hallucination what's your next step:
A) increase the dose of haloperidol
B) decrease the dose of haloperidol
C) change to different class of antipsychotics
D) increase the dose of benzotropine
E) do supportive psychotherapy to help decrease
his anxiety associated with stress of having such a
serous illness

The answer is:

B
Akathisia is a drug induced reaction. The anticolinergic
agents (as Benzotropine) are drug of choice for acute
dystonias and for drug induced Parkinsonism.
Anticholinergic are less effective for drug induced
Akathisia, which often requires addition of a beta blocker.
Acute within 10 days and tardive >90days
benzotropine - For use as an adjunct in the therapy of all
forms of parkinsonism. Useful also in the control of
extrapyramidal disorders (except tardive dyskinesia) due to
neuroleptic drugs (e.g. phenothiazines).
Treatment: Lorazepam, Propanolol, diphenhydramine,
reduce or change neuroleptice to lower potency

 7-which of the following is the best

treatment for agoraphobia with panic?

A)
B)
C)
D)
E)

Lorazepam 1mg tid

Fluxetine 20mg od
Fluphenazine 20mg od
Cognitive therapy
Lithium 330mg qid

The answer is:

B
Selective serotonin reuptake inhibitors and tricyclic
antidepressants are equally effective in the
treatment of panic disorder. The choice of
medication is based on side effect profiles and
patient preferences. Strong evidence supports the
effectiveness of cognitive behavior therapy in
treating panic disorder
Benzodiazepines are effective in treating panic
disorder symptoms, but they are less effective than
antidepressants and cognitive behavior therapy
Imipramine and clomipramine are considered firstline treatment options for panic disorder

 8. Which one of the following types of

hallucination is normal?

A)
B)
C)
D)
E)

hypnagogic
lilliputian
tactile
olfactory
auditory

The answer is:

A
Lilliputian: hallucination of reduced size of objects or
persons.
Hypnagogia (also spelled hypnogogia) and hypnopompia
are experiences a person can go through when falling
asleep in the case of hypnagogia, or waking up, in the case
of hypnopompia. When in a hypnagogic or hypnopompic
state a person can have lifelike auditory, visual, or tactile
hallucinations (collectively known as hypnagogic
hallucinations), perhaps even accompanied by full body
paralysis. The individual is aware that these are
hallucinations; the frightening part, in many cases, is the
inability to react to them, even being unable to make a
sound. In other cases one may enjoy truly vivid
imaginations.

 9-The most characteristic EEG finding in

delirium is.............

A) Normal EEG
B) Generalized low frequency, high
amplitude theta waves
C) Periodic complexes
D) Focal, paroxysmal spikes
E) Generalized 3-Hz spike and wave
complexes

The answer is:

B
In EEG characteristics of delirium include
slowing or dropout of the posterior dominant
rhythm, generalized theta or delta slowwave activity, poor organization of the
background rhythm, and loss of reactivity of
the EEG to eye opening and closing.
Toronto Notes: Generally Abnormal, slowing
or fast activity

 10.A 30-year-old male has been referred to a psychiatrist by his

physician. The patient describes a constantly depressed mood with
decreased interest in pleasure for the last 3 years. He is
preoccupied by his state of mind, and he would like to have a
prescription so that he can return to his normal mood. Although the
patient describes about 2 or 3 episodes on feeling high and
increased libido, he then returned to the constantly depressed
mood after each of these episodes. He is an engineer and his mood
did not cause interferences with his work. During the interview, the
patient denies any suicidal thoughts or disturbances in appetite or
sleep. His weight is in normal limits and there were no variations for
the last 3 years. The patient also denies the use of drugs or
medications. Physical examination and lab results are in normal
limits. The
most likely diagnosis is
A) Major depressive disorder
B) Bipolar I disorder
C) Bipolar II disorder
D) Dysthymic disorder
E) Cyclothymic disorder

 Bipolar I At least one manic or

mixed episode, could be
accompanied by MDE but not
necessary for DX
Bipolar II at least 1 MDE and at
least 1 Hypomanic No past manic
or mixed episode

The answer is:

E
Numerous episodes of hypomanic and
depressive Sx (not meeting criteria for
MDE) for more than 2 years; never
without Sx for more than 2 months
The symptoms cause clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning.
Treatment anticonvulsants; psychotherapy

 11.Which one of the following is the most

common psychiatric complication of
insulin-dependent diabetes mellitus?
A. Hypochondriacally over-concern in later
stages
B. Major affective disorder
C. Initial adjustment disorder with
depressed mood
D. Suicide attempts with the emergence of
diabetic retinopathy
E. Panic attacks

 Adjustment disorders: Impact of adjustment disorders in

those diagnosed with diabetes is most marked in case of
children and adolescents with type 1 diabetes.
Anxiety disorders: Anxiety is associated with poor glycemic
control and treatment of anxiety is associated with
improved glycemic control particularly in the subset of
patients with more severe anxiety
Sexual dysfunction: Data on sexual dysfunction in diabetes
is complex. Apart from the organic erectile dysfunction
(attributable to complications of diabetes like neuropathy
and vascular disease), other aspects of sexual functioning
like desire, arousal, ejaculation, orgasm and satisfaction
are also impaired in patients with diabetes.

The answer is:

C
Eating disorders: A recent large multi-site case-controlled
study demonstrated that the prevalence rates of both full
syndrome and sub-threshold eating disorders among
adolescent and young adult women with diabetes are
twice as high as in their non-diabetic peers.
Factitious disorders: Factitious hypoglycemia as a
manifestation of Munchausens syndrome, was assessed .
in a study which detected a second generation of the
sulfonylurea oral hypoglycemic agent in 17% of 129
patients who had unexplained severe hypoglycemia
(Trenque et al., 2001). Similar situations relevant to
diabetes treatment wherein patients present with
hypoglycemic episodes (by voluntary overdosage of
hypoglycemic drugs) or ketoacidosis (skipping insulin
doses) have been reported

 12-20-year-old college student presents to you with a

history of intermittent chest pain for about 6 months.
He states that the pain can occur at any time, but often
occurs late in the day. The pain can be sharp, dull, or
aching and may last for hours. He is physically active
and is carrying a full academic load. The pain is
unrelated to exercise and does not restrict his
activities. His father and paternal uncle have both had
myocardial infarctions within the past year. Physical
examination is normal, although the patient appears
restless and has a heart rate of 100/min. Which one of
the following is the most likely diagnosis?

A)
B)
C)
D)
E)

Reflux esophagitis
generalized anxiety disorder
transient myocardial ischemia
myocardial infarction
costochondritis

The answer is:

B
this young patient has multiple documented
sources of anxiety dating back to last 6 months,
e.g. full academic load, relatives having major
diseases. He is also s/s of anxiety.........
restlessness, increased heart rate etc.
3 or more of the following

Restlessness or on edge
Sleep disturbance
Irritability
Difficulty concentrating or mind going blanc
Being easily fatigued
Muscle Tension

 13. 52-year-old man with a long history of

alcohol use comes to the emergency room of a
general hospital. He is confused and on
examination is noted to have palsies of
conjugate gaze, horizontal nystagmus, and
ataxia. Which one of the following is the most
likely diagnosis?

A)
B)
C)
D)
E)

conversion reaction
alcohol intoxication
alcohol hallucinosis
delirium tremens
Wernicke's encephalopathy

DT is more common in patients with a long history of ethanol use and a prior
history of significant withdrawal. Manifestations of ethanol withdrawal may start
several hours to days after cessation or diminution of ethanol intake. Ethanol
withdrawal seizures typically occur 6-48 hours after the last drink. DT usually
begins 24-72 hours after cessation or reduction of ethanol use.
Symptoms may include the following:

Tremors
Irritability
Insomnia
Nausea/vomiting (frequently secondary to gastritis or pancreatitis)
Hallucinations (auditory, visual, or olfactory)
Confusion
Delusions
Severe agitation

Physical:

Tachycardia
Hyperthermia
Hypertension
Tachypnea
Diaphoresis
Tremor
Mydriasis
Diaphoresis
Ataxia
Altered mental status
Hallucination
Cardiovascular collapse

 Consideration for Wernicke encephalopathy should be given to patients

with any evidence of long-term alcohol abuse or malnutrition and any of
the following: acute confusion, decreased conscious level, ataxia,
ophthalmoplegia, memory disturbance, hypothermia with hypotension,
and delirium tremens.
Ocular abnormalities are the hallmarks of Wernicke encephalopathy.
The oculomotor signs are nystagmus, bilateral lateral rectus palsies,
and conjugate gaze palsies reflecting cranial nerve involvement of the
oculomotor, abducens, and vestibular nuclei. Less frequently noted are
pupillary abnormalities such as sluggishly reactive pupils, ptosis,
scotomata, and anisocoria.
Encephalopathy is characterized by a global confusional state,
disinterest, inattentiveness, or agitation. Stupor and coma are rare.
Gait ataxia is likely to be a combination of polyneuropathy, cerebellar
damage, and vestibular paresis. Vestibular dysfunction without hearing
loss is a common finding. In less severe cases, patients walk slowly
with a broad-based gait. However, Hypothermia is common because of
the involvement of the temperature-regulating center in the brainstem.
Hypotension, caused by a defect in efferent sympathetic outflow and
decreased peripheral resistance, may be present. Hypotension can
also be the result of significant alcoholic liver disease.
Coma is rarely the sole manifestation of Wernicke encephalopathy.

 14.The initial management of a bipolar

patient in the manic phase could include
all of the following, EXCEPT

A)
B)
C)
D)
E)

neuroleptic
low-stimulation environment.
antidepressant
lithium carbonate
electroconvulsive therapy.

Mood Stabilizers:

Lithium: Therapeutic Response within 7-14 days up to 3 weeks, 600-1500

mg/day - ) 0.5 -1.2 mmol/L (1.0-1.25 mmol/L Acute) Monitoring: Biweekly or
Monthly, q2months Thyroid and Creatinine 6 months, UA annual
Carbamazepine (Tegretol): 750-3000 mg/day

Rapid cycling, Severe sleep problems, Can't take Depakote

lamotrigine/Lamictal: Depression is the dominant symptom, Dysphoric mood
Valproic Acid (Depakene-Epival)
valproate/Depakote: Need something strong and fast, Male gender, and not
afraid of weight gain risk Rapid cycling, Significant manic symptoms

Antipsychotics:

Haloperidol: 0.5-5 PO b/tid,

Chlorpromazine (largactil): 10-15 PO b/tid FDA:To control the

manifestations of the manic type of manic-depressive illness, low
potency

Olanzapine/Zyprexa: Emergency-level symptoms, Need help really

fast,Can use on "as-needed" basis

 The first-line pharmacological treatment for bipolar depression is

the initiation of either lithium or lamotrigine
Antidepressant monotherapy is not recommended
As an alternative, especially for more severely ill patients, some
clinicians will initiate simultaneous treatment with lithium and an
antidepressant. In patients with life-threatening inanition, suicidality, or
psychosis, ECT also represents a reasonable alternative. ECT is also
a potential treatment for severe depression during pregnancy.

Lithium :Classic bipolar I symptom pattern: euphoric mania and

severe depressions
Significant manic symptoms
Need all the antidepressant you can get
Suicide risk
Very inexpensive
valproate/Depakote :
Need something strong and fast
Male gender, and not afraid of weight gain risk
Rapid cycling
Significant manic symptoms

The answer is:

C
Acute Depression of Bipolar

Goals of Treatment:
Achieve remission of the symptoms of major depression and return the patient to the
usual levels of psychosocial functioning.
Avoid precipitating a manic or hypomanic episode.
For patients not yet in treatment for bipolar disorder, initiate either lithium or
lamotrigine.
lamotrigine/Lamictal
Depression is the dominant symptom
Rapid cycling
Need all the antidepressant you can get
afraid of weight gain
As an alternative, especially for more severely ill patients, consider initiating treatment
with both lithium and an antidepressant simultaneously (although supporting data are
limited).
Antidepressant monotherapy is not recommended because of the risk of
precipitating a manic or hypomanic episode.
Consider ECT for:
- Patients whit life-threatening inanition, suicidality, or psychosis or
- Severe depression during pregnancy
For patients who suffer a breakthrough depressive episode while on maintenance
treatment, optimize the medication dosage

 15.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. Mental status examination
shows the woman to be dishevelled, mildly
agitated, and delirious. Which one of the
following is the most useful next step in this
woman's evaluation?

A) identifying her medications

B) eliciting a family history
C) ordering serum electrolytes
D) obtaining a CT scan of the head
E) prescribing haloperidol for agitation

The answer is:

A
Dis-inhibition, impairment in ADL/IADL, personality
changes, loss of social graces.
ADL IADL
Activities of daily living
Dressing, Eating, Ambulating, Toileting, Hygiene

Instrumental Activities of daily living

Shopping, Housekeeping, accounting, food preparation, transportation

Toxin, MEDS: BZD, Beta Blockers, anticholinergics, heavy

metals
Indication for Head CT in dementia:
Age<60
Rapid onset (unexplained decline in cognition or function over 1-2
months)
Recent significant head trauma
Unexplained neurological symptoms (new onset f several
headaches/seizures)

 16. 28-year-old female has insomnia,

irritability, increased psychomotor
activity, and impulsivity. Which one of
the following is the most likely
diagnosis?

A)
B)
C)
D)
E)

Schizophrenia
Antisocial personality disorder
Major depressive disorder
Hypomania
Hyperthyroidism

The answer is:

D
Hypomanic episodes are characterized by the following:
The patient has an elevated, expansive, or irritable mood of at least
4 days' duration.
Three or more of the following symptoms are present:

Grandiosity or inflated self-esteem

Diminished need for sleep
Pressured speech
Racing thoughts or flight of ideas
Clear evidence of distractibility
Psychomotor agitation at home, at work, or sexually
Engaging in activities with a high potential for painful consequences

The mood disturbance is observable to others.

The mood is not the result of substance abuse or a medical
condition
No psychotic features
NOT SEVERE ENOUGH to cause social or occupational
impairment, or to necessitate hospitalization

 17.32-year-old man is brought into the

emergency department by a friend because of
a heroin overdose. After the administration of
naloxone and a complete physical
examination, which of the following laboratory
studies is most important in the evaluation of
this patient to provide long-term follow-up
care?

A. Albumin level
B. Echocardiogram
C. Electroencephalogram
D. HIV antibody test
E. Plasma liver enzyme levels

The answer is:

D
Major risk factors associated with the use of
contaminated needles; Increased risk of
Hep. B & C, Bacterial endocarditis, HIV
Treatment:

ABC
IV Glucose
Narcan : 0.4 mg up to 2 mg IV for diagnsis
Intubation and mechanical ventilation, naloxene
drip

 18. A young boy was found behind a bar,

delirious and agitated. Examination showed
hypertension, tachycardia, muscle rigidity and
loss of sensation to painful stimuli. The most
likely diagnosis is

A)
B)
C)
D)
E)

LSD
Alcohol
Heroin
Cocaine
PCP

The answer is:

E
Clinical Features of Phencyclidine Abuse:
1. Behavior changes include violence, belligerence,
hyperactivity, catatonia, psychosis, anxiety, impairment of
attention or memory, difficulty communicating.
2. Perceptual disturbances include paranoia,
hallucinations, and confusion
3. Physical Examination: Fever, diaphoresis, mydriasis
Diagnostic Criteria for Intoxication:
1. Behavioral Changes
2. At least two of the following: nystagmus, hypertension or
tachycardia, slurred speech, ataxia, decreased pain
sensitivity, muscle rigididy, seizure or coma, hyperacusis
(Abnormal hearing sensitivity)

 19.Drug that is most associated with

amnesia?

A) Phenytoin
B) Lithium
C) Lorazepam

The answer is:

C
Benzodiazepines (Valium, Diazepam) are a class of drugs
which are primarily used to treat anxiety and insomnia.
Benodiazepines are one of the most commonly prescribed
classes of drugs sold. One of the problems associated
with long-term use of these drugs, particularly in the
elderly, is memory loss. Because aging is inherently
associated with some degree of increasing memory
impairment and because the elderly population is prone to
insomnia, prescribing benzodiazepines is inadvisable. In
fact, benzodiazepines are specifically administered to
patients prior to surgery because they cause anterograde
amnesia. Patients who have not been given a
benzodiazepine drug preoperatively have complained
about remembering their surgery, which leads to lawsuits.

 20.Which one of the following is the

most effective method of treatment for
patients with pathological gambling
disorders?

A)
B)
C)
D)
E)

activity group therapy

self-help group therapy
family therapy
psychodrama
individual therapy

 Central to the problem and treatment of pathologic

gambling is helping the patient overcome irrational
thoughts. Pathologic gamblers believe they have the ability
to control random or chance events by relying on
superstitious behavior or methods.
Treatment goals for patients who are pathologic gamblers
or patients who are being treated for depression or
alcoholism tend to be similar in that they focus on restoring
a normal way of thinking and living to patients. A variety of
approaches are used in the treatment of the pathologic
gambler. Modeled after Alcoholics Anonymous, Gamblers
Anonymous is the primary self-help group and uses a 12step, abstinence-based treatment program. The efficacy of
Gamblers Anonymous has not been demonstrated in
controlled studies and, unlike alcoholism, some
researchers have discovered that complete abstinence
from gambling may not be necessary for successful
treatment.

The answer is:

E
Behavioral, cognitive and cognitivebehavioral therapy appear to be the most
successful treatment approaches.
Pharmacotherapy appears to have a role in
the treatment of coexisting depression,
rather than as a primary treatment for
pathologic gambling.
According with this publication, the most
effective method of treatment for patients
with pathological gambling disorders would
be individual psychotherapy. Ref:
http://www.aafp.org/afp/20000201/741.html

 21.Which of the following characteristics

would be helpful in differentiating
attention deficit hyperactivity disorder
from conduct disorder in children?

A.
B.
C.
E.
F.

Resistance to discipline
Temper tantrums
Distractibility
Aggressiveness
Truancy

The answer is:

C

 22.75ys man, hypertensive on methyldopa,

diuretics and KCl supplement, benzotropine,
and vitamins (including vitamin E), he was
brought to the hospital. The nurse said that he
was complaining of sleep disturbance for the
last two days, and impaired memory, and he
was brought now because of agitation. O/E he
was disoriented, and confused, which drug is
responsible for his confusional state?

a)
b)
c)
d)
e)

methyldopa
vitamine E
benzotropine
diuretics
none of the above

The answer is:

C
Toxins, substance use, medication

Alcohol or alcohol withdrawal

Anesthetics
Anticholinergic
Narcotics especialy morphine
Sedative or sedative withawal
Agents for Parkinsons
Anticonvulsants
Steriods
Insulin
Glyburide
Antibiotics, specially quinolones, NSAIDS

SIDE EFFECTS - Benzotropines

Nervous System: Toxic psychosis, including confusion, disorientation,
memory impairment, visual hallucinations; exacerbation of pre-existing
psychotic symptoms; nervousness; depression; listlessness: numbness
of fingers

 23.38-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)
B)
C)
D)
E)

offer psychotherapy
prescribe benzodiazepines
perform a physical examination
refer the patient to a psychiatrist
teach relaxation techniques

The answer is:

C
Panic disorder with or without agoraphobia must be differentiated from
a number of medical conditions that produce similar symptomatology.
Panic attacks are associated with a variety of endocrinological
disorders, including both hypo- and hyperthyroid states,
hyperparathyroidism, and pheochromocytomas. Episodic hypoglycemia
associated with insulinomas can also produce panic-like states, as can
primary neuropathological processes. These include seizure disorders,
vestibular dysfunction, neoplasms, or the effects of both prescribed and
illicit substances on the central nervous system (CNS). Finally,
disorders of the cardiac and pulmonary systems, including arrhythmias,
chronic obstructive pulmonary disease, and asthma, can produce
autonomic symptoms and accompanying crescendo anxiety that can be
difficult to distinguish from panic disorder. Clues of an underlying
medical etiology to panic-like symptoms include the presence of
atypical features during panic attacks, such as ataxia, alterations in
consciousness, or bladder dyscontrol; onset of panic disorder relatively
late in life; and physical signs or symptoms indicative of a medical
disorder.

 24. Chronic schizophrenic patient, on

antipsychotic and antiparkinson therapy,
develops tardive dyskinesia. What is the
next step of management:
a) Continue antipsychotic and increase
antiparkinson drug
b) Decrease and stop antipsychotic drug
c) Continue anyipsychotic and decrease
antparkinson drug
d) Increase antipsychotic and stop
antiparkinson drug

The answer is:

B
1. All neuroleptics, with the exception of Clozapine,
produce tardive dyskinesia. The risk of tardive dyskinesia
with atypical antipsychotics is substantially decreased
compared to typical agents
2. Antiparkinsonian drugs are of no benefit for tardive
dyskinesias and may exacerbate symptoms.
3. When tardive dyskinesia symptoms are observed, the
offending drug should be discontinued. Patients who
require continued neuroleptic therapy should be switched
to an atypical agent or Clozapine (if severe).
4. The risk of tardive dyskinesia increases with the duration
of neuroleptic exposure, and there is an incidence of 3%
per year with typical agents.
5. Most patients have relatively mild cases, but tardive
dyskinesia can be debilitating in severe cases. Tardive
dyskinesias not always improve with discontinuation or
lowering of the does of neuroleptic

 25.which of the following is correct about child

abuse
a) Children dont lie about sexual or physical
abuse
b) The parents were often victims of abuse
themselves
c) It occurs is usually somebody the child does
not know
d) It occurs mainly in the lower socio-economic
class
e) You should not report your suspicions to the
Childrens Aid Society unless there is ample
evidence of abuse

The answer is:

B
The parents were often victims of abuse
themselves

 26- 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)
B)
C)
D)
E)

an illusion
a delusion
a hallucination
a perseveration
a projection

The answer is:

B
Illusion: misperception of a real external stimulus.
Delusion is a belief about the world that most people would agree is
impossible. A fixed false belief that is out of keeping with a persons
cultural or religious background and is firmly held despite
incontrovertible proof to the contrary.
Hallucination: sensory perception in the absence of external stimuli
that is similar in quality to a true perception.
Perseveration: your patient talks but dwells on a single idea or
preoccupation over and over. This can be seen in both OCD and
dementia, as well as in psychosis.
Projection: is a defense mechanism, projection is falsely attributing to
another his or her own unacceptable feelings, impulses or thoughts.

 27. Common side effects of

antipsychotics include all except

A) slurred speech
B) anxiety and restlessness
C) blurred vision
D) nausea vomiting
E) tremors

Patients ingesting antipsychotic medications, either short-term or long-term, often present to the ED
with complaints of involuntary movement disorders.
Dystonia, primarily manifesting as involuntary movement of the tongue, face, neck, or mouth
Torticollis
Oculogyric crisis
Opisthotonus
Hypotension and dysrhythmias may produce syncope, near syncope, orthostatic dizziness, and
generalized weakness.
Occasionally, patients present with a new onset seizure or are discovered in a postictal state.
Dysrhythmia
Phenothiazines are notorious for causing prolongation of the QT interval on the ECG and are
associated with torsade de pointes. Other ECG findings include prolongation of the PR and QRS
intervals and blocks.
Similar to the anticholinergic effects of these medications, alpha blockade and postural
hypotension may result in reflex tachycardia.
Phenothiazines are associated with priapism caused by alpha blockade.
Phenothiazines may cause photosensitivity, resulting in a blotchy red or purple discoloration of skin
when it is exposed to sunlight.
Anticholinergic syndrome: Toxic psychosis, agitation, confusion, mydriasis, urinary retention, ileus, hot
flushed dry skin, and tachycardia may occur.
Movement disorders
Increased muscle tone, extrapyramidal symptoms, akathisia, restless legs, parkinsonism, or
dystonia may occur.
After chronic use of these medications (>24 mo), certain patients develop irreversible TD that
consists of characteristic involuntary movements of the face, lips, and tongue.
A disorder associated with intravenous use of prochlorperazine (Compazine) has been noted.
Patients with this disorder become intensely anxious and restless and occasionally elope from
the ED. These patients describe this acute dysphoric reaction as being very uncomfortable and
creating the urge to crawl out of their skin. Whether this is an intense form of akathisia or a new
movement disorder is unclear.

The answer is:

B

Neuroleptic malignant syndrome.

Miscellaneous abnormalities include metabolic acidosis, pulmonary edema, acute
respiratory distress syndrome (ARDS), acute myocardial infarction, renal failure,
pulmonary embolus, and disseminated intravascular coagulation (DIC).
Virtually all neuroleptics produce some degree of extrapyramidal (EP) dysfunction
because of inhibition of dopaminergic transmission in the basal ganglia. Several
forms of extrapyramidal symptoms (EPS) are associated with neuroleptic toxicity.

Acute dystonia
Parkinsonism
Akathisia: Motor restlessness and the urge to move are dose-related and occur in up to
20% of cases.
Tardive dyskinesia

All neuroleptics lower the seizure threshold to some degree, although certain ones
(eg, chlorpromazine, clozapine, loxapine) have greater convulsant effects than
others (eg, haloperidol, fluphenazine). The epileptogenic effect is dose-dependent,
and the most common type of convulsion observed is a generalized tonic-clonic
seizure.
Adverse effects associated with chronic neuroleptic use include galactorrhea,
priapism, cholestatic jaundice, skin photosensitivity, lens discoloration, and
agranulocytosis.

 28.the most dangerous withdrawl

symptoms can be expected from:

A)diazepam
B)clonazepam
C)chlordiazepoxide
D)lorazepam
E)oxazepam

The answer is:

E
Half-lives:
Diazepam
20 90
Clonazepam
18 - 50
Clordiazepoxide 50 - 100
Lorazepam
10 20
Oxazepam
4 14
Management: Tapering with long-acting BZD

 29. 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 messages
D) disorientation to time and place
E) an unfounded suspicion that others are plotting against
the government

The answer is:

C
A delusion of control or influence.The
patient with delusions of control believes he
is being controlled by some outside force

30.Affect is disturbed in all of the

following except

A) Dysthymia
B) hebephrenic schitzophrenia
C) melancholic
D) paranoid delusional psychosis

The answer is:

D
Dysthymia A chronic disturbance of mood lasting at least two years in adults
or one year in children, characterized by recurrent periods of mild depression
and such symptoms as insomnia, tearfulness, and pessimism.

Hebephrenic schitzophrenia - A form of schizophrenia in which affective

changes are prominent, delusions and hallucinations fleeting and fragmentary,
behaviour irresponsible and unpredictable, and mannerisms common. The
mood is shallow and inappropriate, thought is disorganized, and speech is
incoherent. There is a tendency to social isolation. Usually the prognosis is poor
because of the rapid development of "negative" symptoms, particularly
flattening of affect and loss of volition. Hebephrenia should normally be
diagnosed only in adolescents or young adults.
A syndrome characterized by shallow and inappropriate affect, giggling, and
silly, regressive behavior and mannerisms; a subtype of schizophrenia now
renamed disorganized schizophrenia.

Melancholia - A mental disorder characterized by depression, apathy, and

withdrawal.

Paranoid delusional psychosis Disturbances of affect, volition and speech,

and catatonic symptoms, are either absent or relatively inconspicuous.