Block 16 Explanations
1) A 35-year-old woman is referred by her dermatologist to a psychiatrist. For the past several years, she has had a compulsive need to wash her hands after shaking hands with someone. Since she is in the public relations business, hiding her problem while still performing her ritual have become increasingly difficult. She knows that if she doesn’t do it, she becomes nervous and tense. Which of the following is the most appropriate treatment?
A. Buspirone
B. Clonazepam
C. Fenfluramine
D. Fluvoxamine
E. Risperidone
Explanation:
The correct answer is
D. Fluvoxamine is an SSRI that has been approved for the treatment of obsessive-compulsive disorder (OCD). Its efficacy has been established in several 10-week trials. Buspirone (choice A) is an nonbenzodiazepine antianxiety agent. It is indicated for anxiety disorders and relief of tension associated with everyday life. It is not approved for the treatment of OC
D. Clonazepam (choice B) is a long-acting benzodiazepine that can be used to treat anxiety if it is associated with OC
D. However, it is not approved for the treatment of OC
D. Fenfluramine (choice C) is an amphetamine congener that was used in the past for weight loss purposes. It is not approved for the treatment of OC
D. Risperidone (choice E) belongs to the group of atypical antipsychotics. It can be used in schizophrenia and other psychotic disorders with obsessive-compulsive symptoms. It is not approved for the treatment of OC
D.
2) A 69-year-old woman presents to her primary care physician for her routine yearly examination. This year, her daughter drove her to the appointment. When asked about this, the daughter whispers to the physician that her mother has gotten lost while driving to the supermarket on two occasions over the past six months. It becomes clear during the history that the woman does not remember the physician’s name and seems to have some word-finding difficulties. The daughter also mentions to the physician that she has recently begun managing her mother’s checking account and other finances, due to forgetfulness. The patient has osteoarthritis of the knees, but is otherwise healthy. Vital signs are within normal limits, and physical examination is unremarkable. Mental status examination reveals slow thinking and impaired attention. Which of the following is the most appropriate next step for evaluating this patient’s memory decline?
A. Mini-Mental Status Examination
B. Laboratory studies
C. Referral for neuropsychological testing
D. Computed tomography (CT) scan of the brain
E. Lumbar puncture
Explanation:
The correct answer is
A. The Mini-Mental Status Examination (MMSE) is a brief instrument designed to grossly assess cognitive functioning. It assesses orientation, memory, calculation, reading and writing capacity, visuospatial ability, and language. The maximum score is 30. This tool is widely used as a simple, quick assessment of possible cognitive deficits. The MMSE can give the clinician a crude measurement of cognitive decline, and the tool can be re-administered periodically to follow progression of dementia. Laboratory studies (choice B) are an important part of the work-up for dementia, and should be ordered after a full history is gathered and cognition is assessed with the MMS
E. Important laboratory studies in the work-up of dementia include basic chemistries, complete blood counts, liver, renal, and thyroid function studies, syphilis serology, serum folate and vitamin B12 levels, erythrocyte sedimentation rate, and HIV screening. Other studies may be included if indicated by history and physical examination. Neuropsychological testing (choice C) may be beneficial in differentiating dementia from other neuropsychiatric syndromes, for assessing the degree of functional impairment, and for assessing specific areas of significant cognitive decline. Neuroimaging studies, such as a CT scan (choice D) may be obtained as part of the work-up for dementia, especially to rule-out reversible causes of dementia, such as intracranial mass lesions, recurrent cerebrovascular accidents, and normal pressure hydrocephalus. A lumbar puncture (choice E) may be indicated if serum syphilis testing is reactive or in the evaluation of normal pressure hydrocephalus.
3) A 50-year-old female politician has an “extreme, paralyzing fear” before walking to a podium to give a speech. She is so anxious about these situations that it is beginning to impair her professional activities. She is terrified of stuttering and “making a fool” of herself in front of unfamiliar people. Which of the following is the most likely diagnosis?
A. Agoraphobia
B. Generalized anxiety disorder (GAD)
C. Panic disorder
D. Posttraumatic stress disorder (PTSD)
E. Social phobia
Explanation:
The correct answer is
E. This patient has a social phobia (performance anxiety). Social phobia is a fear of social or performance situations when the individual may be exposed to unfamiliar individuals or may be evaluated by others. It is a common disorder that affects men and women. It impairs everyday activities and relationships. Blushing, shaking, hypertension, and tachycardia occur when the individual is exposed to the feared situation. Beta-blockers are effective in preventing the symptoms. Agoraphobia (choice A) is an irrational fear of places where escape may be difficult. It leads to avoidance of these situations and often causes the individual to be homebound. Systematic desensitization may be helpful. Generalized anxiety disorder (GAD; choice B) is characterized by persistent intense worry over many events and activities that is present for at least 6 months. The individual finds it difficult to control the worry. Three of the following symptoms must be present: restlessness, difficulty concentrating, irritability, muscle tension, sleep disturbance, and easy fatigability. It usually begins before age 20. Treatment includes benzodiazepines, buspirone, and psychotherapeutic interventions. Panic disorder (choice C) is characterized by unpredictable panic attacks that include palpitations, trembling, sweating, dizziness, dyspnea, chest pain, and the fear of losing control or dying. Tricyclic antidepressants, selective serotonin reuptake inhibitors, benzodiazepines, and psychotherapeutic interventions are helpful. Posttraumatic stress disorder (PTSD; choice D) is an anxiety disorder characterized by exposure to a traumatic event, persistent re-experiencing of the event, avoidance of stimuli associated with the event, and increased arousal. It impairs important activities and relationships. Psychotherapy and medications are directed at the individual’s specific symptoms.
4) A 14-year-old boy is brought in by his mother after the police caught him stealing a neighbor’s bicycle. In addition, the boy is doing poorly in school, and he is suspected of being involved in a recent arson fire in the adjacent neighborhood. Neighbors report that they have often seen him lighting fires and burning trash in vacant lots, and they suspect him in two other burglaries that occurred in the past year. The boy has a history of fighting and truancy at school since the age of 10. Which of the following is the most likely diagnosis?
A. Antisocial personality disorder
B. Attention deficit/hyperactivity disorder
C. Conduct disorder
D. Kleptomania
E. Pyromania
Explanation:
The correct answer is
C. Conduct disorder is defined as a repetitive pattern of behavior in which the basic rights of others, or major age-appropriate societal rules or norms are violated, often with accompanying aggression to people and animals, destruction of property, deceitfulness, or theft. This diagnosis is usually given to individuals younger than 18 years. Antisocial personality disorder (choice A) is not diagnosed before adulthood and consists of many of the same criteria that are used to diagnose conduct disorder. It is also usually accompanied by reckless disregard for the safety of self or others. Attention deficit/hyperactivity disorder (choice B) is a diagnosis requiring inattention and hyperactivity before the age of 7, making it an unlikely diagnosis in this case. Kleptomania (choice D) is the recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value. The stealing is not committed to express anger or vengeance and is not in response to a delusion or hallucination. Pyromania (choice E) is the deliberate and purposeful setting of fire on more than one occasion. This diagnosis requires that the fire setting is not better accounted for by conduct disorder, or antisocial personality disorder.
5) A 15-year-old boy is referred to a psychiatrist by his school counselor, and is brought in by his mother for increasing hostility and argumentativeness with his teachers and toward his parents over the last school year. He often loses his temper and often blames his classmates when his misbehavior causes him to receive punishment in class. He had done well previously with his schoolwork. He has no history of theft, destruction of property, or physical violence. Which of the following is the most likely diagnosis?
A. Attention deficit/hyperactivity disorder (ADHD)
B. Conduct disorder
C. Dysthymic disorder
D. Mental retardation
E. Oppositional defiant disorder
Explanation:
The correct answer is
E. Oppositional defiant disorder is a pattern of negativistic, hostile, or defiant behavior lasting at least 6 months, characterized by losing one’s temper, arguing with adults, and the deliberate annoyance of people or blaming of others for mistakes or misbehavior. It occurs in the absence of conduct disorder (choice B), which is characterized by the breaking of age-appropriate social norms, with associated destruction of property, physical violence, and theft. Attention deficit/hyperactivity disorder (ADHD) (choice A) is characterized by attention deficit and restlessness. It is an unlikely new diagnosis in a 15-year-old who has previously done well in school. Dysthymic disorder (choice C) is a disorder of depressed mood, more often than not, over the course of at least 2 years. Mental retardation (choice D) is a disorder requiring psychological testing to make a diagnosis. It is not supported by this patient’s previous academic record.
6) The mother of a 35-year-old man calls her primary care physician for advice on a drug treatment program for her son. She states that he lives with her since the loss of his job and apartment four months ago. She reports that he goes out on weekends and uses drugs heavily. When he returns home, usually on Monday mornings, he sleeps for the entire day and seems very depressed. He is also very irritable and anxious over the course of the next day. She knows of no other withdrawal symptoms. She believes that he uses the drug throughout the week, but with more intense binges on the weekends. On several occasions, he has called her from the local psychiatric emergency center after admitting himself for suicidal ideation after use of the drug. Which of the following drugs is most likely responsible for this man’s withdrawal state?
A. Alcohol
B. Benzodiazepines
C. Cannabis
D. Cocaine
E. Heroin
Explanation:
The correct answer is
D. The use of cocaine, especially crack cocaine (an extremely potent, freebase form that is sold in small, ready-to-smoke amounts) is associated with the withdrawal symptoms described in this case. After cessation of the use of cocaine, or after acute intoxication, a post-intoxication depression (crash) often occurs. This depression is associated with dysphoria, anhedonia, anxiety, irritability, fatigue, hypersomnolence, intense craving, and suicidal ideation. Alcohol (choice A) is associated with a potentially dangerous set of withdrawal phenomena. These range from mild withdrawal (mild tremulousness) to a full withdrawal syndrome (tremulousness, diaphoresis, hyperreflexia, elevated vital signs, and anxiety) to the very dangerous withdrawal state known as delirium tremens (altered mental status, hallucinations, autonomic instability, seizures, and possibly death). Alcohol withdrawal should be treated in a medical setting with close observation and a detoxification regimen. Benzodiazepines (choice B) can cause dependence and a wide range of withdrawal phenomena very similar to those of alcohol withdrawal. Benzodiazepine withdrawal should also be managed with medical supervision. Cannabis (choice C) may be associated with a withdrawal state including irritability, insomnia, increased or decreased appetite, restlessness, tremor, increased reflexes, and changes in vital signs. The withdrawal phenomena of cannabis are less well defined than many other drugs, and do not lead to dangerous medical sequelae. Heroin (choice E) dependence leads to a characteristic withdrawal syndrome that is very uncomfortable. Symptoms include myalgias, nausea, vomiting, diarrhea, lacrimation, rhinorrhea, piloerection, anxiety, insomnia, irritability, and intense craving.
7) A 48-year-old man is discharged after an uncomplicated myocardial infarction. Several weeks later, he visits his primary care physician complaining of insomnia, anorexia, and depressed mood. He appears to be clinically depressed. Which of the following would be the most appropriate medication to initiate for this patient?
A. Methylphenidate
B. Nortriptyline
C. Phenelzine
D. Sertraline
E. Thioridazine
Explanation:
The correct answer is
D. In a patient with cardiac complications, a selective serotonin reuptake inhibitor (SSRI), such as sertraline, has been demonstrated to be the safest and most effective medication for the treatment of clinical depression. Methylphenidate (choice A) is a stimulant medication that would have the potential to increase heart rate and sympathetic tone, which would not be advantageous in the post-myocardial infarction period. Nortriptyline (choice B) is a tricyclic antidepressant that has the potential for producing cardiac arrhythmias in overdose. Phenelzine (choice C) is a monoamine oxidase inhibitor, which would be contraindicated with a history of recent myocardial infarction, as the ingestion of tyramine with an MAO inhibitor could induce a hypertensive crisis. Thioridazine (choice E) is an low-potency dopamine antagonist antipsychotic medication that is not indicated for the treatment of depression.
A 68-year-old man is admitted to the hospital for delirium associated with a urinary tract infection. Upon adequate treatment of the infection, the patient’s mental status improves significantly, though he is noted to remain partly disoriented. He also has an impairment in short-term memory, difficulties in naming simple objects, and impaired concentration. His family members confirm an 8-month history of gradual progressive decline in cognitive abilities, which they attribute to old-age. However, the man is no longer able to manage his finances and has gotten lost while driving to the grocery store on two occasions. Prior to discharge from the hospital, the nursing staff reports that the patient continues to have urinary incontinence, though his infection has resolved. He is also noted to have a very unsteady gait, requiring assistance when walking. No other obvious signs or symptoms are present. Which disorder most likely accounts for this patient’s dementia?A. Creutzfeldt-Jakob disease
B. Huntington disease
C. Normal pressure hydrocephalus
D. Parkinson disease
E. Pick disease
Explanation:
The correct answer is
C. Normal pressure hydrocephalus is a potentially reversible cause of dementia that causes gait disturbances (unsteady or shuffling gait), urinary incontinence, and dementia. Enlargement of the ventricles with increased cerebrospinal fluid (CSF) pressure is found, and therapeutic lumbar punctures may significantly improve symptoms. Creutzfeldt-Jakob disease (choice A) is a rare diffuse degenerative disease that usually affects people in their 50s, and the usual course is about one year. The terminal stage is characterized by severe dementia, generalized hypertonicity, and profound speech disturbances. It is one of several diseases presumably caused by prions. Huntington disease (choice B) is a hereditary disease associated with progressive degeneration of the basal ganglia and the cerebral cortex. It is transmitted in an autosomal dominant pattern. The onset of Huntington disease occurs between 35 and 50 years of age, or later in rare cases. This disease is characterized by progressive dementia, muscular hypertonicity, and bizarre choreiform movements. Parkinson disease (choice D) is characterized primarily by motor dysfunction, but dementia may be a part of the disorder. The characteristic motor symptoms (bradykinesia, flat facies, resting tremor, shuffling gait, etc) are caused by degeneration of the nigrostriatal dopaminergic tract. Pick disease (choice E) causes a slowly progressive dementia. It is associated with focal cortical lesions, primarily of the frontal lobe. Pathological examination of the brain reveals intraneuronal inclusions called Pick bodies.
9) A 37-year-old man with chronic paranoid schizophrenia is being interviewed by a 4th-year medical student. In the middle of describing how he feels that other people are out to kill him, the patient suddenly stops talking and begins staring into space. Approximately 20 seconds later, he starts talking about how his mother was not a very good parent and was excessive in her discipline during his childhood. Which of the following terms best describes this behavior?
A. Echolalia
B. Echopraxia
C. Mutism
D. Satyriasis
E. Thought blocking
Explanation:
The correct answer is
E. Thought blocking is the sudden repression of anxiety-provoking thoughts in mid-sentence. It is a common finding in many individuals with schizophrenia. Often, when the patient begins speaking again, it is concerning something unrelated to the topic before the pause in conversation and thought. Echolalia (choice A) is the psychopathologic repetition of words or phrases of one person by another, and tends to be repetitive and persistent. Echopraxia (choice B) is the pathologic imitation of movements of one person by another. Mutism (choice C) is psychopathologic voicelessness of a patient over an extended period of time, in the absence of phonetic structural abnormalities. Satyriasis (choice D) is the excessive and compulsive need for coitus in a man. Its corollary in a female is termed nymphomania.
10) A 32 year-old male with a history of panic disorder who works as a salesman presents to his psychiatrist after several weeks of treatment with paroxetine. While he has noted significant improvement in his symptoms, he still notes residual anxiety when put into social situations in which he has to speak in public or become the center of attention. Given that he had some improvement on his current medication regimen, which of the following would be the most appropriate next step in management?
A. Cognitive-behavior therapy
B. Electroconvulsive therapy
C. Medication change
D. Psychoanalysis
E. Seeing the patient more often for supportive psychotherapy
Explanation:
The correct answer is
A. In many cases of panic disorder, effective treatment involves the use of cognitive behavior therapy, which incorporates exposing the patient to disturbing stimuli in an attempt to develop coping mechanisms in response to the stimuli. Electroconvulsive therapy (choice B) is not indicated for use in panic disorder. Medication change (choice C) is not indicated when the current regimen leads to significant symptom relief, as the amount of time necessary to achieve adequate response on a new medication does not justify a medication switch. Psychoanalysis (choice D) is a long term, time consuming process that is not indicated to treat the acute residual anxiety of this patient’s panic disorder. Seeing the patient more often for supportive psychotherapy (choice E) would not be as effective a treatment as cognitive behavioral therapy, according to research on panic disorder.
11) A 29-year-old woman presents to her new primary care physician requesting medication to help with her recent spells of anxiety and depression. She wishes to be started on a medication that will not cause too much sedation. Examination of the patient’s old records reveals two previous suicide attempts by overdose, once with acetaminophen at age 16 and another, with aspirin, during college. Given this history, which of the following antidepressant medications would most likely be contraindicated for this patient?
A. Buspirone
B. Fluoxetine
C. Nortriptyline
D. Paroxetine
E. Sertraline
Explanation:
The correct answer is
C. Nortriptyline is a tricyclic antidepressant, which is lethal in overdose and is the leading cause of overdose-related deaths in the psychiatric population. Overdose is associated with prolongation of the QT interval, leading to cardiac arrhythmia and death. Given this patient’s history of previous overdoses, a tricyclic antidepressant would be contraindicated. Buspirone (choice A) is an antidepressant medication whose pharmacologic action is not well understood, but which is not known to be lethal in high doses. Fluoxetine (choice B), paroxetine (choice D), and sertraline (choice E) are all selective serotonergic reuptake inhibitors (SSRIs). These antidepressant medications are generally safe and effective and are not lethal except in extremely high doses.
12) A 78-year-old woman is complaining to the doctor in her nursing home about her new problems. She reports that her old boyfriend from 50 years ago called her and is now harassing her by controlling her blood pressure, movements, and thoughts. She is convinced that he was initially doing this through the phone by sending special signals with a device that the CIA uses, but now he is able to control her through his thoughts. She stated that she couldn’t tell the police because they probably would not believe her. This patient most likely has which of the following thought disorders?
A. Clang associations
B. Ideas of influence
C. Ideas of reference
D. Noesis
E. Obsessions
Explanation:
The correct answer is
B. Ideas of influence constitute a type of delusion in which a person believes that he or she is being controlled by another person or external force. Clang associations (choice A) are disorders of thought in which the associations of words are similar in sound but not in meaning. Words have no logical connection, but there may be rhyming. Ideas of reference (choice C) are delusions in which a person has a false belief that others (including people on TV or radio) are talking about him or her. In a broader sense, the behavior of others refers to oneself, other persons, or objects that have special significance and meaning. Noesis (choice D) refers to the feeling of revelation in which a person experiences illumination associated with a sense of being chosen as a leader. Obsessions (choice E) are pathologically persistent intrusive thoughts or impulses that cannot be eliminated from consciousness by logical effort and thus cause anxiety. The person is aware that they are not imposed from the outside but are a product of his or her own mind.
13) A woman in her forties is referred to a psychiatrist because of depression. During the initial evaluation sessions, she states that she always had to work hard, and make many sacrifices all her life to achieve goals. She says she loves helping others, but people always seem to “make their problems her problems”. She was in an abusive marriage with an alcoholic husband but finally divorced him. She recently had another relationship with a man who left her after she helped him monetarily. Which of the following personality traits does this person most likely have?
A. Dependent
B. Histrionic
C. Masochistic
D. Narcissistic
E. Obsessive
Explanation:
The correct answer is
C. Masochistic traits are frequently seen in the hospital setting, as well as outpatient treatment programs. Even though the sadomasochistic personality disorder has been excluded from the DSM IV classification, it is frequently seen in everyday practice. The traits include long suffering, complaining, and a self-deprecatory character with an excessive demand for love. Dependent traits (choice A) are seen in persons who avoid positions of responsibility or decision making because of self-doubt. They are dependent on others and prefer to have a submissive position. Histrionic traits (choice B) are seen in persons who display seductive, flirtatious, and attention-seeking behavior. These persons tend to be superficial, vain, and self-absorbed. Narcissistic traits (choice D) are seen in persons with a sense of self-grandiosity and self-importance. There is a pronounced sensitivity to criticism and low self-esteem. The sense of entitlement and the lack of empathy for others are the most striking features. Obsessive traits (choice E) are seen in persons who are controlling, rigid, indecisive, stingy, and distrustful. The traits themselves do not necessarily constitute a disorder.
14) A 64-year-old man is undergoing chemotherapy and has occasional nausea and vomiting, which are treated with IV prochlorperazine. After several days of therapy, the patient complains that he feels very restless and agitated and he cannot stop moving his legs. Which of the following medications, if given during his initial regimen, might have best prevented this reaction?
A. Chlorpromazine
B. Haloperidol
C. Lorazepam
D. Paroxetine
E. Sertraline
Explanation:
The correct answer is
C. This patient has evidence of akathisia, the feeling of restlessness that sometimes occurs as a reaction to use of neuroleptic medications, such as prochlorperazine and haloperidol. Prevention of akathisia is most reliably maintained by use of a benzodiazepine medication, such as lorazepam given IV during administration of the neuroleptic drug. This is particularly important in a patient whose immune system and metabolic capacity may show signs of compromise. Chlorpromazine (choice A) and haloperidol (choice B) are both neuroleptic medications that would exacerbate akathisia rather than prevent it. Paroxetine (choice D) and sertraline (choice E) are both antidepressant medications that are specific serotonergic reuptake inhibitors (SSRIs). These agents have no effect on the prevention of neuroleptic-induced akathisia.
15) A 52-year-old man is being evaluated in the emergency department for a recent fall and blow to his head. A CT scan is normal, and his injuries involve only a small laceration over the right eye. On evaluation of his laboratory values, it is discovered that he has an elevated mean corpuscular erythrocyte volume. This laboratory finding most likely suggests chronic abuse of which of the following substances?
A. Alcohol
B. Cocaine
C. Heroin
D. Marijuana
E. Nicotine
Explanation:
The correct answer is
A. Elevated mean corpuscular erythrocyte volume (MCV) is associated with the chronic abuse of alcohol, which can lead to a deficiency in both folate and thiamine in the diet, leading to a megaloblastic anemia. Cocaine (choice B), heroin (choice C), marijuana (choice D), and nicotine (choice E) are all substances of abuse, but none of them are suggested by an elevated MCV on a laboratory finding.
16) A patient with a long history of bipolar disorder, mixed type, was recently started on an anticonvulsant that he was told would help with his mood swings. He had been on it for 5 weeks when he developed skin changes that looked like burns. He was rushed to the hospital and diagnosed with Stevens-Johnson syndrome. Which of the following medications did this patient most likely take?
A. Carbamazepine
B. Clonazepam
C. Gabapentin
D. Lamotrigine
E. Valproate
Explanation:
The correct answer is
D. Lamotrigine is approved as an adjunct in the treatment of refractory seizures. Its effectiveness in bipolar disorder has been demonstrated in open trials. The most serious side effect of lamotrigine is rash. When the dose is titrated up too quickly, the potentially fatal Stevens-Johnson syndrome can occur. Carbamazepine (choice A) is an anticonvulsant that is also effective in the treatment of acute mania in patients with rapid cycling or mixed bipolar disorder. Its most serious side effects include aplastic anemia and agranulocytosis, as well as liver failure. Clonazepam (choice B) is a high-potency benzodiazepine approved for the treatment of seizures. It is used as an adjunct in the treatment of manic patients or those with anxiety disorders. The most common side effects include sedation and ataxia, as well as the potential for dependency. Gabapentin (choice C) is approved as an adjunct in the treatment of partial and generalized seizures. It has been also used to treat bipolar disorders, pain syndromes, and anxiety disorders. The most common side effects are somnolence, dry mouth, dizziness, and ataxia. Valproate (choice E) is an anticonvulsant that is also effective in the treatment of acute mania, mixed states, and rapid cycling bipolar disorder. Its most serious side effects include hepatotoxicity and thrombocytopenia. In pregnancy, it can cause neural tube defects. It can also lead to polycystic ovarian disease.
17) A grandmother brings her 13-year-old grandson, who is in her custody, to a psychiatrist. He has been talking back to his teachers and not complying with school rules. When asked to stop, he gets angry and blames others, usually his classmates. In addition, his grades are deteriorating. The grandmother has been struggling with him in the past year and thinks he needs “structure and control.” The boy says she doesn’t let him do anything, and he resents having to live with her. Psychological testing shows no indications of a learning disorder. Which of the following is the most likely diagnosis?
A. Adjustment disorder with disturbance of conduct
B. Attention deficit/hyperactivity disorder
C. Conduct disorder
D. Cornelia de Lange syndrome
E. Oppositional defiant disorder
Explanation:
The correct answer is
E. Oppositional defiant disorder belongs to the group of disruptive behaviors characterized by a pattern of negativistic hostile behavior lasting at least 6 months and including four or more of the following: arguing with others, blaming others for own mistakes, being angry and resentful, being vindictive, refusing to comply with adults’ requests, and being easily annoyed by others. The disorder is not due to a mood or psychotic disorder. It causes significant impairment in functioning. Adjustment disorder with disturbance in conduct (choice A) represents a maladaptive response to a stressor within 3 months of an exposure and does not meet the criteria for oppositional disorder. Attention deficit/hyperactivity disorder (choice B) includes either inattention, presenting with six or more associated symptoms for 6 months, or six of the hyperactivity-impulsivity symptoms that are inconsistent with developmental level. Conduct disorder (choice C) is a repetitive pattern of behavior in which the basic rights of others or social rules are violated. The criteria include aggression to animals, destruction of property, violation of rules, deceitfulness, and theft. Three of the criteria need to be present at least for 12 months, and at least one needs to be present in the past 6 months, to make this diagnosis. Cornelia de Lange syndrome (choice D) is characterized by mental retardation, short stature, continuous eyebrows, thin downturning lip, microcephaly, small and malformed hands, and hirsutism.
18) A 41-year-old man with a long history of schizophrenia, paranoid type, has been on the inpatient unit for almost 2 weeks. This is his third admission in the past 6 months, and each time he seems to be less responsive to treatment. In the past, he has been on typical antipsychotics and then tried on different combinations, including some atypical ones, with limited success. His family is supportive and makes sure he takes his medication. Given his most recent poor response, which of the following is the most appropriate next step in treatment?
A. Clozapine
B. Droperidol
C. Electroconvulsive treatment
D. Lamotrigine
E. Topiramate
Explanation:
The correct answer is
A. Clozapine is an atypical agent that has been proven to be more effective than conventional antipsychotics in the treatment of patients with resistant schizophrenia. It exerts an antagonistic effect on D1 and D4 receptors, as well as on the alpha-adrenergic, histaminergic, serotonergic, and cholinergic systems. It is 30% effective in the treatment of patients with resistant schizophrenia in the first 6 weeks. However, it produces troublesome side effects. The most serious one is agranulocytosis. Clozapine requires regular blood count monitoring because of this serious but rare side effect. Droperidol (choice B) is a butyrophenone that has been approved as adjunctive treatment with anesthetics. It can be used in emergency settings because of its strong sedative potential and parenteral form. It is not approved for the treatment of resistant schizophrenia. Electroconvulsive treatment (choice C) is indicated in treatment of schizophrenia only after medication treatment failed. Lamotrigine (choice D) is an anticonvulsant approved as adjunctive treatment for refractory partial seizures. It has been used lately in treating bipolar disorder and pain disorders, but these instances have been reported only in open trials and case reports. Topiramate (choice E) belongs to the group of anticonvulsants approved as adjunctive in the treatment of partial epilepsy in adults. It has not been approved for treatment of schizophrenia, but there have been anecdotal reports of its use as a mood stabilizer.
19) A patient is talking to his psychiatrist about a conflict he has with his partner. They argue because the partner complains that the patient is inefficient and procrastinates doing things that are his responsibility. He never completes a task the way in which he was asked to do it, but in his own way and usually much later. Which of the following types of defense mechanism is this patient exhibiting?
A. Acting out
B. Blocking
C. Passive-aggressiveness
D. Regression
E. Splitting
Explanation:
The correct answer is
C. With passive-aggressiveness, aggression toward others is expressed indirectly, usually through procrastination, stubbornness, passivity, and forgetfulness. The manifestations usually affect others more than the person who is doing it. Acting out (choice A) is a defense by which a person expresses an unconscious wish through action to avoid being conscious of the strong accompanying affect. Blocking (choice B) is a transient inhibition of thinking that usually involves strong affects and impulses that are being inhibited. Regression (choice D) is a defense mechanism in which a person returns to an earlier stage of libidinal development to avoid tension at the present level of development. Splitting (choice E) is a defense mechanism by which external objects are divided into “all good” and “all bad.” It is accompanied by abrupt shifting of an object from one category to the other.
20) A 12-year-old boy is brought to his pediatrician due to failing grades in school. The boy failed last year and is repeating the sixth grade. His parents have suspected for several years that the boy may have low intelligence due to repeated difficulties in school. The family is referred to a psychologist for psychological testing, including an assessment of intelligence. Which of the following tests would be most appropriate for evaluating the boy’s intelligence and to assist with possible placement in special classes in his school?
A. Millon Clinical Multiaxial Inventory
B. Minnesota Multiphasic Personality Inventory
C. Rorschach Test
D. Stanford-Binet Test
E. Thematic Apperception Test
Explanation:
The correct answer is
D. The Stanford-Binet Test is a comprehensive intelligence test that is used in psychiatry and education. Another widely used intelligence test is the Wechsler Adult Intelligence Scale. Such tests are routine intelligence tests in the assessment of borderline intellectual functioning, mental retardation, and specific learning disorders. The Millon Clinical Multiaxial Inventory (choice A) is a 175-item, true-false personality inventory. This test would not be appropriate for assessing intelligence. The Minnesota Multiphasic Personality Inventory (choice B) contains over 500 true-false items, with 17 scales including most major areas of psychopathology. This personality test provides a wide range of data on numerous personality variables and is supported by a strong research base. The Rorschach test (choice C) contains a standard set of 10 inkblots that serve as stimuli for associations. Five of the cards are in black and white, and the other five include colors. A record of the patient’s verbatim response, along with initial reaction times and total time spent on each card allows for interpretation. This test is referred to as a projective test. The Thematic Apperception Test (choice E) is also a projective test that consists of a series of 30 pictures and one blank card. After looking at the card, the patient is instructed to create a story. This test is more useful as a technique for inferring motivational aspects of behavior than as a basis for making a diagnosis. It would not be appropriate for assessing intelligence.
21) A 36-year-old woman comes to a psychiatrist for an initial appointment after relocating from her home several states away due to a transfer of her job. She is on lithium for bipolar disorder, and has been stable for several years after two manic episodes in her early 30′s. She was previously seen by a psychiatrist every two months and had blood drawn for routine monitoring related to her lithium treatment every six months. Since it has been about eight months since her last appointment, the psychiatrist decides to order lab-work and to see the patient back in one week to finish gathering history, to review the lab results, and to provide the patient with another prescription. Which of the following laboratory studies would be most appropriate for the physician to order?
A. Liver transaminases
B. Platelet count
C. Thyroid-stimulating hormone
D. Urinalysis
E. Vitamin B12 level
Explanation:
The correct answer is
C. Lithium affects thyroid function and thyroid-stimulating hormone (TSH) levels should be monitored every 6-12 months. Lithium often causes a generally benign and often transient decrease in the concentration of thyroid hormones. About 30% of patients receiving long-term treatment with lithium will have elevated TSH levels. If symptoms of hypothyroidism emerge, treatment with levothyroxine may be indicated. During routine monitoring of lithium maintenance treatment, lithium plasma concentration and serum creatinine should also be measured periodically. Liver transaminases (choice A) are not affected by lithium treatment. Lithium is almost entirely eliminated by the kidneys. During treatment with valproate, another mood stabilizer, liver transaminases are monitored. A significant portion of patients treated with valproate will have an elevation in liver transaminases, which is usually asymptomatic and resolves with discontinuation of the drug. Platelet count (choice B) is not affected by lithium treatment. However, treatment with valproate may cause thrombocytopenia and platelet dysfunction. Platelet count is usually monitored during treatment with valproate. Urinalysis (choice D) would not be helpful in the routine monitoring of maintenance treatment with lithium. Lithium may cause polyuria and diabetes insipidus, which should be monitored clinically. When polyuria is significant, renal function should be evaluated and followed up with a 24-hour urine collection for creatinine clearance and with consultation with a nephrologist. Vitamin B12(choice E) is often ordered in the evaluation of dementia, psychosis, and mood disorders. It would not be a routine part of lithium maintenance monitoring.
22) A young woman comes to her primary care physician describing extreme irritability and conflicts with her boyfriend a week or so before her period. At times, she also becomes tearful and depressed without a reason and cannot focus on what she is doing. She noticed that she starts overeating or craving chocolate and sweets. This used to happen occasionally, but it has happened each month for the past 4 months. The symptoms resolve with menses. Which of the following is the most likely diagnosis?
A. Adjustment disorder with depressed mood
B. Cyclothymic disorder
C. Depressive personality disorder
D. Major depressive disorder with atypical features
E. Premenstrual dysphoric disorder
Explanation:
The correct answer is
E. Premenstrual dysphoric disorder is a constellation of physical and emotional symptoms occurring during the late luteal phase of the menstrual cycle. The symptoms must be present during most cycles in the past year and during at least two subsequent cycles. Patients have at least five of the following symptoms: depressed mood, marked anxiety, affective lability, decreased interest, decreased energy, sleep disturbance, craving food, feeling overwhelmed, and difficulties concentrating. The symptoms interfere with social or occupational functioning and are not due to other psychiatric or medical disorders. Adjustment disorder with depressed mood (choice A) involves as a criterion a major stressor to which an individual is reacting within 3 months after the exposure. It also involves the continuous presence of symptoms that do not resolve with the onset of follicular phase of the cycle. Cyclothymic disorder (choice B) requires the presence of numerous episodes of hypomanic and depressive symptoms that do not meet the criteria for major affective disorder. The person must have at least 2 continuous months of these symptoms in a 2-year period. The disorder is not due to another psychiatric disorder or medical condition. Depressive personality disorder (choice C) is characterized by pessimism, anhedonia, low self-esteem, and moralistic self-denigrating features. Major depressive disorder with atypical features (choice D) is characterized by mood reactivity, significant weight gain and increased appetite, hypersomnia, leaden paralysis or heavy feeling in arms and legs, and a long-standing pattern of sensitivity to interpersonal rejection. Other criteria for major depressive disorder, including a 2-week period of depressed mood and anhedonia in the past month and significant impairment in functioning, must be met to establish the diagnosis.
23) An intern is examining a patient who was brought by his family to the emergency department for coughing, fever, nausea, and generalized weakness. The patient has been diagnosed and treated in the past for schizophrenia, described by the family as “the type with negative symptoms.” Which of the following symptoms would this patient most likely have?
A. Apathy
B. Audible thoughts
C. Delusions
D. Hallucinations
E. Thought broadcasting
Explanation:
The correct answer is
A. Negative symptoms of schizophrenia are diagnosed in so-called type II schizophrenia, with the predominant presence of flattened affect, poverty of speech or speech content, thought blocking, poor grooming, lack of motivation, anhedonia, social withdrawal, cognitive deficits, and attentional deficits. Audible thoughts (choice B) belong to the core symptoms of schizophrenia per Emil Kraepelin’s, as well as Kurt Schneider’s criteria, which include them in first-rank symptoms. The patient has a feeling that his or her own thoughts are louder or are spoken by voices inside the patient’s head. Delusions (choice C) are positive symptoms and are false beliefs firmly maintained even though contradicted by reality. They are most common in schizophrenia. Hallucinations (choice D) are examples of positive or productive symptoms of schizophrenia. These are sensory perceptions for which there is no external stimulus. They can be of any sensory modality; however, in schizophrenia auditory hallucinations are the most common ones. Thought broadcasting (choice E) is a sense that other people can read a patient’s thoughts, or vice versa, and is typically seen in schizophrenia. This is part of the loss of ego boundaries seen in patients with schizophrenia. Thought broadcasting is an example of the Schneiderian first-rank symptoms, which are productive symptoms in the other classification.
24) A 27-year-old successful businesswoman has developed a fear of flying after an extremely rough landing. She is paralyzed with fear and unable to travel for business. Her physician tried giving her lorazepam to take during the flight, but it didn’t help. Which of the following is the most commonly used treatment for this disorder?
A. Exposure therapy
B. Hypnosis
C. Insight-oriented psychotherapy
D. Medication
E. Supportive therapy
Explanation:
The correct answer is
A. Exposure therapy, a type of behavior therapy, is the most commonly used treatment of specific phobia. The therapist usually desensitizes the patient by a gradual exposure to the phobic stimulus. Relaxation and breathing control are important parts of the treatment. Hypnosis (choice B) is used to enhance the therapist’s suggestions that the phobic object is not dangerous. At times, self-hypnosis can be taught so that the patient uses it as a method of relaxation when confronted with the phobic stimulus. Insight-oriented psychotherapy (choice C) was initially used to treat phobias, but analyzing unconscious conflicts didn’t resolve phobic symptoms. It does help the patient understand the origins of the phobia and how to deal with anxiety-provoking stimuli. Medication (choice D) is used in the treatment of a specific phobia only if it is associated with panic attacks and generalized anxiety. The pharmacologic treatment is then directed toward the panic attacks. Supportive therapy (choice E) may be used in helping the patient actively confront the phobic stimulus during treatment. It is usually used in addition to an ongoing treatment.
25) An 18-year-old woman presents to her doctor along with her mother, who states that she doesn’t know what to do with her daughter. Ever since the daughter started modeling, she became concerned about being fat. Over the past 6 months, she has lost 25 pounds. The daughter states that she has a fear of gaining weight. She had not had her menstrual period for 5 months. She denies use of laxatives or diuretics. On examination, she is thin and has fine hair all over her body. Her weight is about 20% below her expected body weight. Her blood pressure is 90/70 mm Hg, and her pulse is 54/min and regular. Which of the following is the most appropriate next step in management?
A. Admit her to the hospital to reestablish weight and correct abnormalities
B. Refer the patient for psychodynamic psychotherapy
C. Send the patient for evaluation for electroconvulsive treatment
D. Start the patient on hormone therapy to induce her menstrual cycle
E. Tell the mother not to worry and send them home
Explanation:
The correct answer is
A. This patient has lost a significant amount of weight in a short period of time. As indicated by her vital signs and percentage of weight loss, she may need a full evaluation of her physical status to determine and correct abnormalities because her refusal to eat has placed her in a potentially life-endangering situation. Even though the patient may have psychological issues, psychodynamic psychotherapy (choice B) has not proven to be the therapy of choice for anorexic patients. Electroconvulsive therapy (choice C) is not indicated for the treatment of anorexia nervosa per se, and is certainly not appropriate in this case before all other things are done. Starting hormone therapy to induce her menstrual period (choice D) would be inappropriate since the evaluation and treatment of the underlying cause of the condition has not been addressed. Telling the mother not to worry and sending the patient home (choice E) would be a completely inappropriate and inadequate professional assessment of the situation, as this patient may be in a life-threatening condition.
26) A 35-year-old woman comes to the physician for a periodic health maintenance examination. She has no physical complaints, however she is concerned that she hardly ever feels happy. She says that she has basically been “down” for at least 3 years. She rarely goes out with friends and basically keeps to herself at work. She states that her work performance has been stable, but she usually feels tired and “blah”. Which of the following is the most likely diagnosis?
A. Antisocial personality disorder
B. Cyclothymic disorder
C. Depression
D. Dysthymic disorder
E. Schizoaffective disorder
Explanation:
The correct answer is
D. This patient has dysthymia, which is a milder, chronic form of depression. The diagnosis requires 2 years of a depressed mood. It may be associated with changes in appetite, sleep, and concentration, and with fatigue and hopelessness. Treatment is psychotherapy and antidepressant therapy. Antisocial personality disorder (choice A) is a pattern of behavior that is characterized by a complete disregard of the rules of society. These individuals lie, steal, and endanger others. They rarely feel remorse and typically end up in prison. Cyclothymic disorder (choice B) is characterized by recurrent and chronic episodes of hypomania and dysthymia. It is a less severe form of bipolar disease. Depression (choice C) is characterized by a depressed mood, changes in sleep, energy, concentration, and appetite. Other findings are guilt, hopelessness, anhedonia, and psychomotor agitation or retardation. A major depressive episode requires five or more of these symptoms for at least 2 weeks. There is severe distress and functional impairment. It is more severe than dysthymia. Patients with schizoaffective disorder (choice E) have psychotic episodes with a mood disturbance. This patient is not experiencing psychotic episodes.
27) A 38-year-old woman presents to her primary care physician with complaints of fatigue and insomnia. Review of systems reveals no medical symptoms, but the patient does endorse several symptoms on the psychiatric review of systems. She describes feeling tired most of the day, having difficulty falling asleep as well as waking up too early, poor appetite, frequent crying spells, poor concentration, and a recent loss of interest in her hobbies. Physical examination and routine laboratory studies including thyroid stimulating hormone, are within normal limits. Which of the following is the most appropriate initial pharmacological intervention?
A. Alprazolam
B. Buspirone
C. Imipramine
D. Paroxetine
E. Phenelzine
Explanation:
The correct answer is
D. Paroxetine is a selective serotonin reuptake inhibitor (SSRI). Along with other newer antidepressants, the SSRIs are currently the first-line agents for the treatment of depression. This patient has a symptom profile consistent with major depressive disorder, and treatment should be initiated with a goal of complete remission of symptoms. SSRIs are safe in overdose and have a relatively mild side effect profile. Alprazolam (choice A) is a short-acting benzodiazepine used in the short-term treatment of anxiety, such as during initiation treatment for panic disorder while an SSRI is being started. Due to the significant risk of dependence and withdrawal, such short-acting benzodiazepines should be used very sparingly. Buspirone (choice B) is an anxiolytic agent that acts as an agonist or partial agonist on serotonin 1A (5-HT1A) receptors. When used in the treatment of conditions causing anxiety, the full clinical response may take two to four weeks, without immediate anxiolytic effects. Imipramine (choice C) is a tricyclic antidepressant (TCA) that is efficacious in the treatment of depression. However, TCAs are not currently first-line agents due to their potential lethality in overdose, need for pre-treatment electrocardiographic monitoring, and significant side effect profile (due to antiadrenergic, antihistaminic, and antimuscarinic effects). Phenelzine (choice E) is a monoamine oxidase inhibitor (MAOI) antidepressant agent. These agents are rarely used and would never be considered a first-line agent. Patients taking MAOIs (phenelzine, tranylcypromine, isocarboxazid) must follow a diet that restricts tyramine due to the potential for a hypertensive crisis when ingested with tyramine-containing foods. Potential lethality in overdose is also a concern.
28) An emergency room intern is attempting to evaluate a 32-year-old Caucasian male patient with a long history of schizophrenia, disorganized type. In obtaining the history, the physician asks the patient to describe any auditory hallucinations he hears and the patient responds by saying “killin, chillin, and thrillin.” Which of the following most accurately describes this type of response?
A. Clanging
B. Flight of ideas
C. Looseness of associations
D. Neologism
E. Thought blocking
Explanation:
The correct answer is
A. When a patient associates words similar in sound but not in meaning, this is known as a clang association. In this case the words have no logical connections but sometimes rhyme or have similar phonetic phrasing. Flight of ideas (choice B) is a rapid verbalization of a constant shifting of ideas which tend to be connected; it is often found in a patient in a state of mania. Looseness of associations (choice C) is the flow of thoughts and ideas that shift from one topic to another in completely unrelated ways; this is found most often in paranoid schizophrenics who are not actively thought blocking. A neologism (choice D) is a new word created by a patient by combining the syllables of other words, and is usually idiosyncratic in its origin. Thought blocking (choice E) is the abrupt interruption of thought before a thought or idea is finished in being expressed. Usually it is indicated by the patient’s not being able to recall what was previously said or what was going to be said, and usually is accompanied by pauses in conversation.
29) A patient is brought to a psychiatrist after being persuaded by her family to get help. She describes that she thought she was depressed. She feels empty and guilty for not having any feelings for her children. She notices that mornings are the worst. Later in the day, she is able to do some things. In the mornings, however, she stays in bed late and, even though she has never been lazy, she is unable to do anything. She falls asleep quickly at night, but wakes up at 4 AM and is unable to get back to sleep. She is sure there isn’t anything that could cheer her up, even for a short time. Which of the following is the most likely diagnosis?
A. Catatonia
B. Cotard’s syndrome
C. Dysthymia
D. Major depression with atypical features
E. Major depression with melancholic features
Explanation:
The correct answer is
E. Major depression with melancholic features is characterized by a depressed mood most of the time and a lack of reactivity to pleasurable stimuli during episodes. In addition, three or more of the following criteria must be met: distinct quality of depressed mood, worse depression in the morning, early morning awakening, psychomotor retardation or agitation, weight loss, and inappropriate guilt. Catatonia (choice A) can be applied to any of the episodes of major depressive or bipolar disorder. In the clinical picture, the most dominant feature is motoric immobility, as evidenced by waxy flexibility, excessive motor activity, extreme negativism, peculiar voluntary movements, and echolalia or echopraxia. Cotard’s syndrome (choice B), or nihilistic delusional disorder, is diagnosed when patients complain of not only having lost their possessions, status, or strength but also their inner organs. It can be seen in schizophrenic or depressive episodes. Dysthymia (choice C) involves depressed mood for most of the time in the past 2 years and the presence of two or more of the following: changes in appetite, changes in sleep, fatigue, low self-esteem, poor concentration, and feelings of hopelessness. The symptoms do not meet the criteria for major depressive episode. Major depression with atypical features (choice D) can be applied when, in the most recent 2 weeks, there is mood reactivity (the patient brightens to positive events) and two or more of the following are present: weight gain or increased appetite, hypersomnia, leaden paralysis, and sensitivity to rejection from others.
30) Three hours after an uneventful appendectomy, a previously healthy (except for appendicitis) 78-year-old man becomes disoriented and confused. He repeatedly asks the nurses where he is, and his speech pattern is disorganized and rambling. His temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, pulse is 70/min, and respirations are 18/min. The patient is uncooperative, but shows no physical abnormalities. Mental status examination is not possible because of an altered level of consciousness. Laboratory studies show no abnormalities. Which of the following is the most likely diagnosis?
A. Adjustment disorder
B. Brief psychotic disorder
C. Delirium
D. Delusional disorder
E. Dementia
Explanation:
The correct answer is
C. This patient has delirium, which is also called acute confusional state. It is very common in hospitalized and institutionalized elderly individuals. It is characterized by a rapid onset of impaired cognition, altered level of consciousness, disturbances in attention and psychomotor activity, and altered sleep-wake cycles. The symptoms tend to fluctuate and it is usually reversible when the underlying disorder is identified and treated. Common causes include psychologic and physical stress (for example, surgery), metabolic disturbances, neoplasms, infections, medications, cerebral and cardiovascular diseases, and withdrawal from alcohol and prescription medications. Adjustment disorder (choice A) is a maladaptive response to a stressful event. The symptoms include mood disturbances, behavioral changes, and impaired functioning. It usually resolves within 6 months. Brief psychotic disorder (choice B) is characterized by the abrupt onset of psychotic symptoms, including hallucinations, delusions, and disorganization with impaired functioning. It is present for more than 1 day, but less than 1 month. It is usually preceded by a stressful life event. Delusional disorder (choice D) is characterized by the presence of nonbizarre delusions that last for more than 1 month. Functioning is not usually impaired. Antipsychotic agents and psychotherapy may be necessary. Dementia (choice E) refers to the slow and insidious onset of cognitive and intellectual deficits with no changes in consciousness. The symptoms are stable and irreversible. The most common causes are Alzheimer disease and multi-infarct dementia.
31) A 54-year-old woman presents to her primary care physician for her routine yearly health maintenance examination. She denies any new problems. Her only significant medical history includes a 25-year history of schizophrenia, which has been well-controlled with antipsychotic agents, and a 5-year history of hypertension for which she takes a diuretic. Vital signs and physical examination are within normal limits. However, the patient is noted to have occasional irregular puckering and lip-smacking movements. She denies having noticed the abnormal movements, and her speech is normal. Which of the following is the most likely diagnosis?
A. Acute dystonia
B. Akathisia
C. Pseudoparkinsonism
D. Tardive dyskinesia
E. Tardive dystonia
Explanation:
The correct answer is
D. Tardive dyskinesia (TD) is a syndrome characterized by abnormal choreiform and athetoid movements occurring late in onset in relation to initiation of antipsychotic treatment. TD usually develops after months to years of treatment with antipsychotic agents, and is presumably much less likely to occur with the use of atypical antipsychotics. Risk factors for TD include older age, longer duration of antipsychotic treatment, and presence of an affective disorder. The abnormal involuntary movements usually involve orofacial muscles but may include the trunk and extremities. Regular examinations should be done to ensure that patients treated with these medications do not develop signs of T
D. Acute dystonia (choice A) is an abrupt reaction consisting of abnormal positioning or spasm of the muscles of the head, neck, limbs, or trunk. This form of extrapyramidal side effect (EPS) associated with antipsychotic medications can be terminated with administration of an anticholinergic agent. Akathisia (choice B) occurs in approximately 50% of patients taking conventional antipsychotic agents. This form of EPS consists of the experience of a subjective feeling of restlessness. Patients may rock, pace, tap, or move restlessly while sitting. This side effect may be confused with anxiety, agitation, tardive dyskinesia, or worsening of psychosis. Treatment includes reducing the antipsychotic dose, switching to another agent, and the use of beta-blockers or benzodiazepines. Pseudoparkinsonism (choice C) is a form of EPS consisting of some or all of the following: bradykinesia, masklike facial expression, slow speech, tremor, cogwheel rigidity, stooped posture, and shuffling gait. Tardive dystonia (choice E) is a late-occurring dystonia that is a rare adverse event associated with antipsychotic treatment.
32) A 62-year-old woman is brought to the emergency department by her daughter, who is concerned her mother had a “stroke.” According to the daughter, the woman woke up that morning not knowing where she was. She was confused and did not remember what had happened the day before. She recently saw her primary care physician, who started her on a new medication. The workup for stroke is negative, and the physician suspects that the episode is related to the new medication. Which of the following medications would most likely cause cognitive impairment?
A. Alprazolam
B. Bupropion
C. Selegiline
D. Sertraline
E. Vitamin E
Explanation:
The correct answer is
A. Alprazolam belongs to the group of short-acting benzodiazepines. Even though it has a short half-life, it can produce confusion, disinhibition, and amnestic problems like blackouts in the elderly population. The risk is increased if it is combined with CYP3A inhibitors. Bupropion (choice B) is an antidepressant with dopaminergic and noradrenergic properties and minimal anticholinergic properties. Cognitive functions are usually improved and not impaired with bupropion. Selegiline (choice C) is a selective MAO B inhibitor that, when metabolized, has three active metabolites, including amphetamine and methamphetamine, that stimulate the release of norepinephrine and dopamine, thus improving some cognitive functions. Sertraline (choice D) is an SSRI, but it also has some dopaminergic properties and is currently being marketed as a product to improve cognitive functioning. SSRIs is usually not associated with cognitive impairments. Vitamin E (choice E) has been used in elderly population as a scavenger of free oxygen radicals to improve cognitive functions. There are no reports of vitamin E related cognitive impairment.
33) A 32-year-old African American male with a history of chronic paranoid schizophrenia is brought to his psychiatrist after failing courses of treatment with both haloperidol and olanzapine. His psychiatrist would like to start him on clozapine. Which of the following parameters should the psychiatrist monitor carefully in this patient?
A. Blood pressure
B. Platelet count
C. Pulse
D. Respiratory rate
E. White blood cell count
Explanation:
The correct answer is
E. Of all the indicators listed, white blood cell count should concern the physician most, as there is a documented risk of agranulocytosis associated with the use of the antipsychotic clozapine. Most patients on clozapine require weekly monitoring of the CBC in order to prevent the risk of severe infection associated with agranulocytosis. Blood pressure (choice A) should be monitored, as there is some chance for orthostasis while on clozapine, but such orthostatic changes are usually transient and not life-threatening. Platelet count (choice B), pulse (choice C), and respiratory rate (choice D) are not known to be adversely affected by the use of clozapine.
34) A 37-year-old female with a history of bipolar disorder presents to her physician for a medication check. She has been taking the same dose of lithium carbonate daily for over 3 years. She is in generally good health, does not smoke, and has not had a manic episode for several years. Given this patient’s history, the values of which of the following routine laboratory tests is most likely to have remained the same over time?
A. Serum blood urea nitrogen level (BUN)
B. Serum creatinine level
C. Serum lithium level
D. Thyroid stimulating hormone level (TSH)
E. White blood cell count
Explanation:
The correct answer is
C. In general, lithium reaches a steady state level in the blood stream once a dosage is maintained over a given period of time, and does not change unless there are conditions such as dehydration that interfere with this equilibrium. Lithium has been reported to be associated with possible kidney damage with long-term use, which necessitates following kidney function on a regular basis, including BUN (choice A) and creatinine (choice B) levels. Lithium has a thyroid-suppressing effect, so TSH levels (choice D) must be checked on a regular basis. Lithium sometimes causes leukocytosis, so white blood cell counts must also be checked regularly (choice E).
35) A 65-year-old woman presents to a primary care physician with a complaint of poor memory. Her husband died six months ago and she has recently decreased her church involvement and interest in her hobbies. She complains of feeling tired and worried, and has difficulty with attention and memory. She has a history of a major depressive episode approximately ten years ago, which required hospitalization. She was treated with an antidepressant for two years until it was tapered and discontinued. She currently denies depressed mood. She states that her mother died of Alzheimer’s disease, and that she finds her memory loss particularly worrisome in light of this family history. Which of the following factors would be more likely if this patient has a pseudodementia of depression rather than a true dementia?
A. The patient appears unconcerned
B. The patient emphasizes disability related to memory loss
C. The patient has more difficulty with recent memory than remote memory
D. The patient tends to conceal the difficulty
E. The patient tries hard to answer questions about orientation and registration
Explanation:
The correct answer is
B. Distinguishing a pseudodementia of depression from a true dementia is an important task requiring examination of subtle aspects of the mental status examination. Although these individual factors may be used in the assessment of depression-related cognitive dysfunction, the entirety of the mental status examination must be considered when making diagnostic decisions. Treatment for the two conditions would be very different, and memory loss in this woman should not be automatically presumed to be related to a primary dementia. In pseudodementia of depression, the patient often tends to emphasize disability related to memory loss much more than patients experiencing true dementia. If the patient appears unconcerned (choice A) about the memory loss, this would be more characteristic of dementia. Usually in pseudodementia of depression, the patient communicates a strong sense of distress. If the patient has more difficulty with recent memory than remote memory (choice C) true dementia should be considered. In pseudodementia of depression, significant memory loss for both recent and remote events usually occurs. If the patient tends to conceal the difficulty (choice D), this would be more characteristic of dementia. If the patient tries hard to answer questions about orientation and registration (choice E) dementia should be considered, since pseudodementia of depression is often accompanied by little effort to perform even simple tasks.
36) A 48-year-old obese woman with a history of psychotic depression is brought to the psychiatric emergency department following a suicide threat. She is difficult to interview because she feels tired and sleepy and states she is on a continuous positive airway pressure (CPAP) machine at home secondary to having obstructive sleep apnea. She reports that she has been on Prozac and other medications, which she got for “the voices.” During the interview, the psychiatrist learns she has gained 20 pounds in the past several months. Which of the following medications most likely caused this significant weight gain?
A. Amoxapine
B. Lorazepam
C. Molindone
D. Olanzapine
E. Risperidone
Explanation:
The correct answer is
D. Olanzapine is an atypical antipsychotic indicated for the management of psychotic disorders. In placebo-controlled, 6-week studies, 29% of olanzapine-treated patients gained greater than 7% of their baseline weight compared with 3% of placebo-treated patients. Among patients on long-term treatment with olanzapine (more than 238 days of exposure) 56% gained more than 7% of baseline weight. Amoxapine (choice A) is a potent antipsychotic drug with antidepressant activity. Its side effects are related to dopaminergic postsynaptic blockade, as well as norepinephrine selectivity. Weight gain is similar to other comparable antipsychotics. Because of newer antipsychotics and antidepressants with more tolerable side-effect profiles, amoxapine is now used less often. Lorazepam (choice B) is a short-acting benzodiazepine and is not indicated for the treatment of psychotic symptoms. It can be used for sedation, as well as for anxiolytic purposes. Molindone (choice C) is structurally unrelated to other antipsychotics and has a rather favorable profile. It is not widely used. Studies suggest that it is significantly less associated with weight gain compared with other antipsychotics. Weight loss is sometimes rather common with its use. Risperidone (choice E) is an atypical antipsychotic indicated for the treatment of psychotic disorders. In placebo-controlled trials, the proportion of patients with an increase of more than 7% of weight has been about 18% compared with 9% of placebo-treated patients.
37) A 42-year-old man who is HIV-positive is being treated for his first episode of Pneumocystis carinii pneumonia on an inpatient medical ward when he begins to become increasingly disoriented, combative, and agitated. Pulse oximetry shows that he is oxygenating at 93% on room air. He is currently receiving nortriptyline for depression and gabapentin for pain due to peripheral neuropathy. He has a history of alcohol abuse for the past several years before hospitalization and a remote history of opioid abuse. Which of the following is the most likely diagnosis?
A. Alcohol withdrawal
B. HIV dementia
C. Hypoxemic encephalopathy
D. Major depressive disorder
E. Multifactorial delirium
Explanation:
The correct answer is
E. In a patient such as this with a medical illness, a history of the acute onset of agitation, disorientation, and confusion is consistent with and most suggestive of the diagnosis of delirium. Alcohol withdrawal (choice A) is something to consider, but this patient has a history of alcohol abuse, not dependence, in the distant past. Therefore, this diagnosis is less likely. HIV dementia (choice B) is not likely, as this is the patient’s first opportunistic infection, and most patients with HIV dementia are well into the course of their illness before the dementia presents. Hypoxemia (choice C) is often a cause of delirium. In this patient, however, his alteration in orientation and level of consciousness make delirium the more appropriate diagnosis. Major depressive disorder (choice D) is excluded as a diagnosis when medical complications, such as delirium, limit the ability to accurately assess alterations in mood.
38) A 35-year-old woman is in long-term, weekly, insight-oriented psychotherapy. She has been in psychotherapy for one and a half years, and has explored issues related to her depressive symptoms and her tendency to use physical attractiveness to get close to men-even those for whom she has no romantic interest. She is also exploring her past relationships with her parents, and the past importance to her family of her success in beauty pageants in high school and college. During the course of psychotherapy, subtle seductive tendencies have arisen toward the psychotherapist, which often mask her desire for him to find her acceptable and interesting. One day she comes to her psychotherapy session without wearing any make-up. Throughout the session, the patient has a sense of depression and views herself as inadequate and disappointing to the therapist. The therapist makes the following comment, “I notice that on a day without your make-up, you fear that I will find you inadequate, probably much like you perceived your father’s disappointment if you didn’t win the beauty contest. It seems difficult for you to feel accepted if you do not feel attractive. ” Which psychotherapeutic technique best describes the therapist’s comment?
A. Clarification
B. Confrontation
C. Empathic validation
D. Resistance interpretation
E. Transference interpretation
Explanation:
The correct answer is
E. An interpretation involves making something conscious that was previously unconscious, such as the connection between the patient’s sense of depression and her lack of make-up as well as the correlation between her relationship styles with her father and with her therapist. An interpretation is an explanatory statement that links a feeling, thought, behavior, or symptom to its unconscious meaning. In this case, the interpretation directly deals with the transference (the patient’s feelings and behavior toward the therapist that are based on earlier wishes with important figures). Clarification (choice A) involves a reformulation of what the patient has expressed in order to convey a coherent view of what is being communicated. A clarification can help the patient articulate something that is difficult to verbalize. Confrontation (choice B) addresses something that the patient does not want to accept. The patient’s avoidance or minimization of a denied or suppressed feeling is identified. Empathic validation (choice C) demonstrates the therapist’s attunement with the patient’s internal state to show the patient that he or she is understood on an emotional level. This technique is more often used in a supportive type of psychotherapy than in an insight-oriented approach. Resistance interpretation (choice D) is an interpretation that directly deals with the patient’s unconscious use of resistance to avoid painful or conflictual issues.
39) A 59-year-old African American woman, who has been HIV positive for the past 12 years, is brought to the emergency department following an episode of combativeness at home. Her family reports that, over the past couple of days prior to admission, she has been talking “out of her head,” stating that her daughter-in-law had been putting poison into the food. She refuses to eat or take medication in the hospital, stating that the physicians are also against her. Her last CD4 count, done 6 months prior to this admission, was 85/mm3. Physical and neurologic examinations are unremarkable and nonfocal. The current workup for HIV-related infection is negative, and laboratory tests are otherwise unremarkable. On Folstein’s Mini Mental Status Examination she scores 21/30, missing on delayed recall, 3-stage command, writing, and copying, as well as orientation to year. Which of the following is the most likely diagnosis?
A. Amok
B. Delirium
C. Delusional disorder
D. Dementia
E. Schizophrenia
Explanation:
The correct answer is
D. HIV dementia is characterized by affective, cognitive, behavioral, and motor symptoms and signs. It presents as a subcortical process and is most likely to occur in patients with a CD4 count below 200/mm3. It usually has a slow onset, and, after a period of stability, there can be a precipitous decline. The diagnosis is made when other causes of delirium are excluded; the disease may present with psychosis within HIV dementia. The symptoms are controlled with low doses of neuroleptics. Amok (choice A) is a culture-bound syndrome. It is seen among Malayans and presents as unprovoked outbursts of wild rage, causing the person to run madly and attack others or commit suicide. There is a period of amnesia afterward. Delirium (choice B) is the most common cause of mental status changes in patients with HIV/AIDS. It may be related to the primary effects of HIV infection in the CNS, the secondary effects of systemic HIV disease, or side effects of medications. It may also be a result of other usual causes of delirium (e.g., endocrine, metabolic, seizures, trauma, neoplasms). Typically, the clinical picture includes a waxing and waning level of consciousness and fluctuations in cognitive functions, as seen in delirium associated with other causes. Delusional disorder (choice C) is defined as a psychotic disorder with persistent nonbizarre delusions that are firmly held and may be of persecution, somatic nature, grandeur, or jealousy, for example. Schizophrenia (choice E) is a psychosis with the onset of symptoms typically in young adulthood. Patients with schizophrenia can develop dementia and, if they are HIV positive, also develop symptoms related to HIV. Typical schizophrenic symptoms include delusions and hallucinations of at least 1 month’s duration and a significant duration of illness and impairment of more than 6 months.
40) A medical student is interviewing a 78-year-old patient brought from the nursing home to the emergency department. He has been talking to him almost 30 minutes and gotten very little information. Every time he asks a question, the patient starts talking and goes into unnecessary details, eventually answering the question but only after he had told his story to the medical student. This is an example of which of the following?
A. Circumstantiality
B. Glossolalia
C. Logorrhea
D. Perseveration
E. Tangentiality
Explanation:
The correct answer is
A. Circumstantiality refers to speech that is delayed from reaching the point, characterized by overinclusion of details. Eventually, it does get to the original goal. Glossolalia (choice B), also known as speaking in tongues, refers to the expression of a revelatory message through unintelligible words. It may be considered normal and part of some religious practices. Logorrhea (choice C) is a disturbance of speech and is characterized by to copious, coherent speech. Perseveration (choice D) is manifested as a persisting response to a prior stimulus even though a new stimulus has been presented. It can be verbal or motor, and is seen in cognitive disorders. Tangentiality (choice E) is the inability to provide a goal-directed association to the given thought. The patient never gets to the desired goal from the starting point of discussion.
41) A 30-year-old male presents to his physician for a refill of his antipsychotic medication. The patient has been taking his medication for 5 years, after several hospitalizations for bizarre behaviors associated with psychosis. He has been diagnosed with schizophrenia, disorganized type, and has chronic refractory milder psychotic symptoms that are evident only upon engaging him in conversation. Which of the following mental status examination findings is most likely present?
A. Decreased fund of knowledge
B. Disorientation to month
C. Impaired short-term memory
D. Loosening of associations
E. Phobias
Explanation:
The correct answer is
D. Patients with disorganized type schizophrenia are likely to exhibit disorganized speech, disorganized behavior, and flat or inappropriate affect. Examples of disorganized thoughts and speech include: loosening of associations or derailment, flight of ideas, tangentiality, circumstantiality, word salad, neologisms, and clang associations. Such disordered thought processes are not always evident during closed-ended questioning, but frequently become more obvious with open-ended questions and during unstructured conversation. Decreased fund of knowledge (choice A) is not a usual characteristic of schizophrenia. Although patients with schizophrenia may have difficulty learning due to intrusion of psychotic symptoms, and may have subtle cognitive impairments later in the course of the illness, intellectual impairment is not an inherent symptom of the disease. Disorientation to month (choice B) is not a usual characteristic of schizophrenia. Any patient with disorientation must be further assessed for delirium. Chronic disorientation in older patients may suggest dementia. Impaired short-term memory (choice C) is not a usual feature of schizophrenia. Memory difficulties should alert the physician to assess for cognitive disorders including amnesia, delirium, and dementia. Phobias (choice E) are persistent, irrational, exaggerated, and pathological fears of some specific stimulus or situation, resulting in a compelling desire to avoid the feared stimulus. A phobia is not a feature of schizophrenia. Depending on the feared and avoided stimulus, patients with phobias may be diagnosed with a specific phobia or social phobia.
42) A 36-year-old woman comes to her gynecologist because of a three-month history of amenorrhea. Until this time, her menstrual periods had been regular. She also complains of decreased sex drive, worsening over the past couple of months. The patient denies any other symptoms. She has no significant medical history, although she started seeing a psychiatrist five months ago after a brief hospitalization during which she was diagnosed with major depressive disorder, severe, with psychotic features. Her depressive symptoms are resolving. Which of the following medications is most likely responsible for the patient’s presenting complaints during her visit to her gynecologist?
A. Fluoxetine
B. Quetiapine
C. Risperidone
D. Trazodone
E. Venlafaxine
Explanation:
The correct answer is
C. Risperidone is an atypical antipsychotic agent. Conventional antipsychotics are clearly associated with elevations in plasma prolactin concentrations due to blockade in the tuberoinfundibular dopaminergic pathway. Dopamine binds to pituitary lactotrophs to inhibit the release of prolactin. Conventional antipsychotics block dopamine receptors, which releases this inhibition. The newer atypical antipsychotics have minimal, if any effect on plasma prolactin concentrations, except for risperidone, which is associated with elevated prolactin. Antipsychotic-induced hyperprolactinemia may cause side effects including amenorrhea and infertility, sexual dysfunction, galactorrhea, and weight gain. Given this patient’s non-contributory medical history and lack of other symptoms, the onset of her complaints correlates with the initiation of treatment for psychotic depression. A morning plasma prolactin level should be obtained. Fluoxetine (choice A) is a selective serotonin reuptake inhibitor (SSRI). It does not cause significant elevations in serum prolactin. Although SSRIs are commonly associated with sexual side effects, including diminished libido, but especially delayed orgasm, they are not associated with amenorrhea. Quetiapine (choice B) is an atypical antipsychotic agent that is not associated with significant or persistent elevations in plasma prolactin concentrations, unlike risperidone. Trazodone (choice D) is an older antidepressant agent that is commonly used for insomnia associated with depression. Although it may cause sexual side effects, it does not interfere with menstruation. Venlafaxine (choice E) is a serotonin and norepinephrine reuptake inhibitor that may cause sexual side effects, but does not cause amenorrhea.
Tags: Psychiatry
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