EXAM 2 SUBSTANCE ABUSE
14) A 32-year-old woman who has a chronic psychiatric disorder, multiple medical problems, and alcoholism comes to the physician because her breasts have started leaking a whitish fluid. Which of the following is the most likely cause of this symptom? a) Haloperidol b) Oral contraceptives c) Hypothyroidism d) Cirrhosis e) Pregnancy
A - (Rationale Below)
17) A 53-year-old woman has consumed over 1 pint of bourbon per day for the past 24 years. She presents with severe cognitive deficits and is diagnosed with Korsakoff's syndrome. Which of the following is she most likely to display on mental status examination? a) Impaired recent memory and anterograde amnesia b) Hypermnesia c) Both anterograde and retrograde memory deficits d) Retrograde amnesia e) Retrospective falsification
A -- Korsakoff psychosis is characterized by both anterograde and retrograde memory deficits. Patients cannot form new memories, and they have difficulties recalling past personal events, with the poorest recall for events that took place closest to the onset of the amnesia. Remote memories are usually preserved.
23) 388. A 19-year-old man is brought to the emergency room by his distraught parents, who are worried about his vomiting and profuse diarrhea. On arrival, his pupils are dilated, his blood pressure is 175/105 mm Hg, and his muscles are twitching. His parents report that these symptoms started 2 hours earlier. For the past few days he has been homebound because of a sprained ankle, and during this time he has been increasingly anxious and restless. He has been yawning incessantly and has had a runny nose. Which of the following drugs is this man most likely to be withdrawing from? a) Heroin b) Alcohol c) PCP d) Benzodiazepine e) Cocaine
A --- Craving, anxiety, dysphoria, yawning, lacrimation, pupil dilatation, rhinorrhea, and restlessness are followed in more severe cases of withdrawal from short-acting drugs such as heroin or morphine by piloerection (cold turkey), twitching muscles and kicking movements of the lower extremities (kicking the habit), nausea, vomiting, diarrhea, low-grade fever, and increased blood pressure, pulse, and respiratory rate. Untreated, the syndrome resolves in 7 to 10 days. With longer-acting opiates, such as methadone, the onset of symptoms is delayed for 1 to 3 days after the last dose; peak symptoms do not occur until the third to eighth day, and symptoms may last for several weeks. Although very distressing, the opioid withdrawal syndrome is not life-threatening in healthy adults, but deaths have occurred in debilitated patients with other medical conditions.
27) After ensuring adequate ventilation for the patient in the previous vignette, which of the following interventions should be next? a) Intravenous naloxone b) Intravenous phenobarbital c) Intravenous diazepam d) Forced diuresis e) Intramuscular haloperidol
A --- Naloxone, an opiate antagonist, is used to reverse the effects of opiates. The first treatment intervention, however, is to ensure that the patient is adequately ventilated. Tracheopharyngeal secretions should be aspirated, and the patient should be mechanically ventilated until naloxone is administered and a positive effect on respiratory rate is noticed. The usual initial dose of naloxone is 0.8 mg slowly administered intravenously. If there is no response, the dose can be repeated every few minutes. In most cases of opiate intoxication, 4 to 5 mg of naloxone (total dose) is sufficient to reverse the CNS depression. Buprenorphine may require higher doses. Diazepam is used to treat alcohol withdrawal symptoms. Forced diuresis is used in the treatment of salicylates and acetaminophen overdoses, not opiate intoxication. Haloperidol, an antipsychotic medication, is not used for the acute treatment of opiate intoxication.
5) Every morning on school days, an 8-year-old girl becomes tearful and distressed and claims she feels sick. Once in school, she often goes to the nurse, complaining of headaches and stomach pains. At least once a week, she misses school or is picked up early by her mother due to her complaints. Her pediatrician has ruled out organic causes for the physical symptoms. The child is usually symptom-free on weekends unless her parents go out and leave her with a babysitter. Which of the following is the most likely diagnosis? a) Separation anxiety disorder b) Major depression c) Somatization disorder d) Generalized anxiety disorder e) Attachment disorder
A --- Separation anxiety disorder is characterized by manifestations of distress when the child has to be separated from loved ones. The distress often leads to school refusal, Disorders of Childhood and Adolescence Answers 85 refusal to sleep alone, multiple somatic symptoms, and complaints when the child is separated from loved ones, and at times may be associated with full-blown panic attacks. The child is typically afraid that harm will come either to loved ones or to him- or herself during the time of separation. This is normal behavior in children 1 to 3 years old, after which it is thought to be pathological.
29) A college freshman, who has never consumed more than one occasional beer, is challenged to drink a large quantity of alcohol during his fraternity house's party. In a nontolerant person, signs of intoxication usually appear when the blood alcohol level reaches what range? a) 20 to 30 mg/dL b) 100 to 200 mg/dL c) 300 mg/dL d) 400 mg/dL e) 500 mg/dL
A ---- Behavioral changes, slowing of motor performance, and decrease in the ability to think clearly may appear with a blood alcohol level as low as 20 to 30 mg/dL. Most people show significant impairment of motor and mental performance when their alcohol levels reach 100 mg/dL. With blood alcohol concentration between 200 and 300 mg/dL, slurred speech is more intense and memory impairment, such as blackout and anterograde amnesia, becomes common. In a nontolerant person, a blood alcohol level over 400 mg/dL can produce respiratory failure, coma, and death. Because of tolerance, chronic heavy drinkers can present with fewer symptoms, even with blood alcohol levels greater than 500 mg/dL.
28) A 22-year-old man arrives at an emergency room accompanied by several friends. He is agitated, confused, and apparently responding to frightening visual and auditory hallucinations. The patient is put in restraints after he tries to attack the emergency room physician. The patient's friends report that he had "dropped some acid" 6 or 7 hours earlier. How much longer will intoxication with this substance last? a) 1 to 6 hours b) 8 to 12 hours c) 14 to 18 hours d) 20 to 24 hours e) 26 to 30 hours
A ---- Most cases of intoxication with a hallucinogen are over within 8 to 12 hours, but prolonged drug-induced psychoses may occur, especially with phencyclidine (PCP), from which the psychosis may last several weeks
36) A 36-year-old woman comes to the emergency room after she is found unresponsive at a party. Urine toxicology is positive for cocaine. Upon awakening, the patient is interviewed and is found to have a history consistent with cocaine abuse. Which of the following is this patient at an increased risk for having? a) Death by suicide b) Avoidant personality disorder c) ADHD d) Bipolar disorder--mania e) Mild mental retardation
A ---- People who abuse substances are almost 20 times as likely to die by suicide compared to those in the general population who do not abuse substances. Depressive symptoms are very common in patients with cocaine abuse or dependence, especially in the withdrawal phase of the illness.
41) 406. A woman swallows two amphetamines at a party and quickly becomes disinhibited and euphoric. Afterward, she slaps a casual acquaintance because she takes a benign comment as a major offense and starts raving about being persecuted. What mechanism is most responsible for these behaviors? a) Increased release of dopamine and norepinephrine in the synaptic cleft b) Inhibition of catecholamine reuptake c) Activation of NMDA receptors Blockade of dopamine receptors d) Sensitization of GABA receptors
A ---- The main mechanism of action of amphetamines is the release of stored monoamines in the synaptic cleft. Cocaine inhibits the reuptake of the neurotransmitters released in the synapse. Benzodiazepines and barbiturates act by increasing the affinity of GABA type A receptors for their endogenous neurotransmitter, GABA. NMDA aspartate receptors are activated by PCP. Antipsychotic medications act by blocking dopamine receptors.
2nd matching-Match each vignette with the correct term describing it. Each lettered option may be used once, more than once, or not at all. a. Tolerance b. Potentiation c. Withdrawal d. Dependence e. Addiction f. substance abuse\ 1) A 36-year-old cocaine user notices that the longer he uses the drug, the more of it he requires to achieve the same effect.
A ---- Tolerance RATIONALE ----- #52, #53, #54 These terms are commonly confused or used ambiguously. · Tolerance refers to the pharmacological adaptation because of which a larger dose of a drug becomes necessary over time to achieve the same effect.
30) A 27-year-old man is seen in the emergency room after getting into a fight at a local bar and being knocked unconscious. Upon his arrival in the emergency room, he is alert and oriented X 3. He states that he smokes marijuana 2 to 3 times per week and has done so for years. The last time he smoked was 2 days prior to admission to the emergency room. He also admits using PCP 5 days previously, and he took some of his wife's alprazolam the day prior to coming to the emergency room. Which of the following test results would likely be seen if the patient's urine were tested for substances of abuse in the emergency room?
A ----- The patient has admitted taking marijuana, PCP, and alprazolam (a benzodiazepine). These substances can be tested in the urine for, respectively, 3 days to 4 weeks (depending on use), 8 days, and 3 days. Thus, all three of these substances should show up as positive in this patient's urine.
45) A 35-year-old man comes to the psychiatrist for treatment of his heroin addiction. He has been an addict for over 6 years, and has been injecting heroin for 5 of those 6 years. Three previous attempts at quitting have all been unsuccessful. Which of the following medications is the best option for this man? a) Methadone b) Levomethadyl c) Buprenorphine d) Naloxone e) Naltrexone
A ----- This patient is likely to do better with methadone as he attempts to get rid of his heroin addiction. Methadone has the advantage that it frees addicts from needing to inject opioid substances, reducing the chance of HIV infection. It produces less drowsiness and less euphoria, so addicts can be functional and thus become employed, rather than spending their lives searching for enough cash for their next injection. The patient will still be dependent on a narcotic, but it is a more likely successful treatment regimen than quitting narcotics completely after three previously unsuccessful attempts
20) A 23-year-old woman presents to her physician with the chief complaint that she is anxious about the way she looks. She notes that for "as long as she can remember," she has been obsessed about the fact that something must be wrong with her face. She notes that her eyes are too far apart and her nose is misshapen. She states that this concern is "ruining her life" because she spends all her time isolated from others so that they cannot see her face. The physician did not notice anything unusual about the patient's face, but the patient cannot be consoled by this statement. Which of the following is the most likely diagnosis? a) Body dysmorphic disorder b) Delusional disorder c) Obsessive-compulsive disorder d) Somatization disorder e) Hypochondriasis
A — Body dysmorphic disorder is characterized by a preoccupation with an imagined defect in appearance (in this case, the patient believes that her eyes and nose are malformed). The preoccupation must interfere with normal daily functioning and cause clinically significant distress. It cannot be better accounted for by another mental disorder (such as anorexia nervosa). This disorder has an approximately equal distribution between men and women, and most patients are 20 to 40 years old at time of diagnosis.
38) A 64-year-old man is admitted to the emergency room after he was witnessed having a seizure on the sidewalk. Postictally, the patient was noted to be agitated and disoriented. Vital signs include: blood pressure 165/105 mm Hg, pulse 120 beat/min. From the following list, which is the most likely diagnosis? a) Cocaine intoxication b) Alcohol withdrawal c) PCP withdrawal d) Cocaine withdrawal e) Alcohol intoxication
B --- (Rationale below with #39)
22) A young woman presents to the emergency room vomiting bright red blood. Once she is medically stable, the intern who performs her physical examination notices that the enamel of her front teeth is badly eroded and her parotid glands are swollen. Which of the following best describes the source of these medical complications? a) Inadequate caloric intake b) Purging c) Laxative abuse d) Diuretic abuse e) Ipecac toxicity
B --- Chronic exposure of gastric juices through vomiting (purging) can cause severe erosion of the teeth and pathological pulp exposure in bulimic patients. Parotid Personality Disorders Answers 221 gland enlargement is commonly observed in patients who binge and vomit. Esophageal tears, causing bloody emesis, can be a consequence of self-induced vomiting. The toxic effects of ipecac are cardiomyopathy and cardiac failure
3) A 13-year-old boy is brought to the emergency room by his parents after he set fire to their home. He has been seen in the emergency room on multiple occasions for a variety of symptoms, including suicidality, homicidality, uncontrollable tantrums, and pica. Of those symptoms, which is most commonly seen by psychiatrists in the emergency room in children under the age of 12? a) Arson b) Suicidality c) Homicidality d) Uncontrollable tantrums e) Pica
B --- Suicidal behavior is the most common reason for a psychiatrist to see an adolescent in an emergency room setting. Important in the evaluation of these children is an assessment of the stability and supportiveness of the home environment, and the caregiver's competence in taking care of the adolescent. These factors will figure in to a clinician's decision as to whether a potentially suicidal adolescent must be admitted to an inpatient unit or may be released home to be closely monitored.
51) A 16-year-old girl was brought to the emergency department by her mother, after the girl admitted that she had taken an unknown drug at a neighborhood party. The drug was identified as 3,4-methylenedioxymethamphetamine (MDMA), often known as Ecstasy. Which of the following side effects should the physician tell the patient's mother is common with use of this drug? a) Anhedonia b) Bruxism c) Hypotension d) An increased appetite e) Suspiciousness and paranoia
B ---- MDMA (Ecstasy) was tried in the 1970s as an adjunct to psychotherapy and later became popular as a recreational drug. After ingestion, there is an initial phase of disorientation, followed by a "rush" that includes increased blood pressure and pulse rate as well as sweating. Users experience euphoria, increased self-confidence, and peaceful feelings of empathy and closeness to other people; effects usually last 4 to 6 hours. MDMA decreases appetite. It has been associated with bruxism (grinding of the teeth), shortness of breath, cardiac arrhythmia, and death.
47) A 22-year-old man is brought to the emergency room after his friends noted he became agitated and was "acting crazy" at a party. The patient was belligerent and agitated in the emergency room as well. On physical examination, vertical nystagmus, ataxia, and dysarthria were noted. The patient has no previous mental or physical disorders. Which of the following is the best treatment option to give immediately? a) Continuous nasogastric suction b) Minimization of sensory inputs c) Urinary acidification d) Thorazine PO e) Naltrexone IM
B ---- PCP disrupts sensory input, so those intoxicated with it can be extremely unpredictable with regard to any environmental stimuli. Thus, the best immediate treatment option for this patient is the minimization of such stimuli. Continuous NG suction can be overly intrusive and cause electrolyte imbalances. Urinary acidification can increase the risk of renal failure secondary to rhabdomyolysis, and so is both ineffective and potentially dangerous.
37) Three policemen, with difficulty, drag an agitated and very combative young man into an emergency room. Once there, he is restrained because he reacts with rage and tries to hit anyone who approaches him. When it is finally safe to approach him, the resident on call notices that the patient has very prominent vertical nystagmus. Shortly thereafter, the patient has a generalized seizure. Which of the following substances of abuse is most likely to produce this presentation? a) Amphetamine b) PCP c) Cocaine d) Meperidine e) LSD
B ---- Phencyclidine (PCP) intoxication is characterized by neurological, behavioral, cardiovascular, and autonomic manifestations. Intoxicated patients are often agitated, enraged, aggressive, and scared. Because of their exaggerated and distorted sensory input, they may have unpredictable and extreme reactions to environmental stimuli. Nystagmus and signs of neuronal hyperexcitability from increased deep tendon reflexes to status epilepticus) and hypertension are typical findings.
3rd matching--Match each vignette with the correct term describing it. Each lettered option may be used once, more than once, or not at all. a. Tolerance b. Potentiation c. Withdrawal d. Dependence e. Addiction f. substance abuse\
B ---- Potentiations RATIONALE ----- #52, #53, #54 These terms are commonly confused or used ambiguously Withdrawal refers to a substance-specific syndrome that occurs after the cessation of the substance whose use has been heavy and prolonged. An example of the use of potentiation for clinical benefit is the coadministration of a benzodiazepine and an antipsychotic to an agitated psychotic patient. Both medications can be administered at lower doses when used together than either could if used alone
58) A 4-year-old boy is brought to the emergency room by his mother secondary to a fracture of his left femur. The mother states that the boy fell down the stairs at home, and that he has "always been clumsy." X-rays of the boy's leg confirm the fracture, and physical examination reveals bruises of various ages on the boy's chest and abdomen. Which of the following should the physician do first? a) Arrange for a comprehensive psychiatric evaluation of the child b) Ensure the child's safety c) Report the case to the appropriate child-family social service department d) Order a complete skeletal survey (x-rays) of the child e) Request social work intervention
B ---- The first and foremost action that should be taken in this situation is to make sure that the child is safe. This may mean that the child must be removed from the family. All the other options as answers to this question may at some time
1) An emaciated and lethargic 16-year-old girl arrives at the emergency room. Her blood pressure is 75/50, her heart rate is 52 beats per minute, her potassium is 2.8 mEq/L, and her bicarbonate is 40 meq/L. The girl's parents report that she has lost 35 lb in 3 months but is still convinced that she is overweight. She eats only very small amounts of low-calorie food, and she runs 2 to 3 hours every day. What other activities is this patient most likely to have engaged in? a) Sexual promiscuity b) Ethanol abuse c) Purging d) Wearing tight clothes e) Shoplifting
C -- Anorexia nervosa is characterized by the refusal to maintain a minimal normal weight for height and age, intense fear of gaining weight, distorted body image, and amenorrhea. Body weight is controlled by drastic reduction of caloric intake, but most anorectic patients also use diuretics and laxatives. Purging, which causes hypokalemic alkalosis, can also be present but is not as frequent as in bulimia. The other listed behaviors are not characteristic of patients with anorexia.
11) An emaciated and lethargic 16-year-old girl arrives at the emergency room. Her blood pressure is 75/50, her heart rate is 52 beats per minute, her potassium is 2.8 meq/L, and her bicarbonate is 40 meq/L. The girl's parents report that she has lost 35 lb in 3 months but is still convinced that she is overweight. She eats only very small amounts of low-calorie food, and she runs 2 to 3 hours every day. What other activities is this patient most likely to have engaged in? a) Sexual promiscuity b) Ethanol abuse c) Purging d) Wearing tight clothes e) Shoplifting
C --- Anorexia nervosa is characterized by the refusal to maintain a minimal normal weight for height and age, intense fear of gaining weight, distorted body image, and amenorrhea. Body weight is controlled by drastic reduction of caloric intake, but most anorectic patients also use diuretics and laxatives. Purging, which causes hypokalemic alkalosis, can also be present but is not as frequent as in bulimia. The other listed behaviors are not characteristic of patients with anorexia.
21) A 47-year-old man with a master's degree in chemistry lives alone in a halfway house and subsists on panhandling and collecting redeemable cans. Ten years ago he lost his job in a large firm because he was found to have repeatedly stolen company money and used it to bet on horse racing. Afterward, he had several other jobs but always lost them because he stole money. He also stole and borrowed money from friends and relatives. When asked about this behavior, the patient stated that he felt very guilty about it but "couldn't seem to stop" himself. Which of the following diagnoses best fits this patient's symptoms? a) Antisocial personality disorder b) Conduct disorder c) Pathological gambling d) Fugue state e) Kleptomania
C --- Pathological gambling is found in the diagnostic category called impulse control disorders, together with pyromania, intermittent explosive disorder, trichotillomania, kleptomania, and impulse control disorder not otherwise specified. The DSM-IV criteria for pathological gambling are quite similar to the criteria for substance abuse disorders: preoccupation with gambling; need to gamble increasing amounts of money to obtain the same effects; unsuccessful efforts to stop or cut back; using gambling to escape problems or relieve dysphoric mood; after money losses, returning to gambling the next day to "break even"; lying to family and friends to conceal losses and the extent of the involvement in gambling; committing illegal acts to finance the habit; and jeopardizing important relationships or losing jobs because of gambling. The vast majority of compulsive gamblers are men. The prevalence is estimated to be 0.2% to 3% of the general population, varying with the number of gaming venues available. The diagnosis in this case is not an antisocial personality disorder because the patient feels guilty about these actions, and not kleptomania because the stealing is not the primary symptom (the gambling is, which has led to a need to steal to support himself).
4) A 7-year-old boy avoids sleepovers because he wets his bed one to two times per week and is afraid his friends would tease him. He has never achieved a year-long period of dryness throughout the night. A physiologic work-up shows no evidence of an organic cause for this problem, and there is no evidence of a psychiatric disorder in any other category. Which of the following treatments is likely to be effective and should be tried first? a) Pharmacotherapy with imipramine b) Bladder training (reward for delaying micturition during daylight hours) c) Classic conditioning with a bell-and-pad apparatus d) Pharmacotherapy with desmopressin e) Psychotherapy
C --- This child has enuresis of a nonorganic type (he had a negative organic work-up). Nocturnal enuresis is not diagnosed before age 5, an age at which continence is usually expected. The incidence in boys is somewhat higher than in girls. This disorder is often associated with daytime (diurnal) wetting. Nocturnal enuresis usually is diagnosed in childhood, although adolescent onset does occur. The treatment of choice for enuresis is the use of classic conditioning with a bell (or buzzer) and a pad. This is generally the most effective treatment, with success in over 50% of all cases. Successful responses with this treatment also tend to be maintained over time. It also does not have the side effects of the pharmacotherapies. Bladder training, while sometimes effective, is decidedly less so than the bell and pad. Likewise, psychotherapy has not been shown to be effective in treating this disorder, though it may be helpful in dealing with the emotional difficulties that arise secondary to the disorder
40) A 20-year-old man is admitted to the emergency department after an automobile accident, in which his friend drove their car into a light pole. In the emergency department, the man smells strongly of alcohol, and his blood alcohol level is 300 mg/dL. However, he does not show any typical signs of intoxication. His gait is steady, his speech is clear, and he does not appear emotionally disinhibited. Which of the following is the most likely explanation for such a presentation? a) The adrenaline generated in the patient because of the effects of the car crash has counteracted the alcohol in his system. b) A value of 300 mg/dL is below the intoxication level. c) The man has developed a tolerance to the effects of alcohol. d) There has been a laboratory error. e) The man has recently used cocaine, whose effects counteract the effects of alcohol intoxication.
C ---- After prolonged use, most drugs of abuse (and some medications) produce adaptive changes in the brain that are manifested by a markedly diminished responsiveness to the effects of the substance that has been administered over time, a phenomenon called tolerance. Anyone who does not show signs of intoxication with an alcohol level of 150 mg/dL has developed a considerable tolerance.
43) A 22-year-old woman comes to the physician with complaints of problems in sleeping. She notes that she has a hard time falling asleep, and when she does finally get to sleep, she awakens multiple times during the night. The patient says that this problem has been getting worse over the last 2 months. She states that she has also noted that she feels both nervous and fatigued during the day. Her mental status examination is otherwise normal. Toxicology screen is negative. Which of the following is the most likely diagnosis? a) Sleep apnea b) Marijuana intoxication c) Caffeine-induced sleep disorder d) ADHD e) Major depression
C ---- Caffeine is a stimulant that can cause a sleep disorder when it is used in excess. Patients may not recognize caffeine as a "drug" so may answer negatively to questions about drug use. Therefore, a question about caffeine use should be asked specifically to all patients presenting with difficulty sleeping. The sleep disorder caused by caffeine can produce a delay in falling asleep, an inability to remain asleep, and/or early morning awakening.
6) A 1-year-old girl has been hospitalized on numerous occasions for periods of apnea. Each time, her mother called an ambulance after her daughter had stopped breathing suddenly. All work-ups in the hospital have been negative, and the patient has never had an episode in front of anyone but her mother. The patient's mother seems very involved with the child and the staff on the unit, and she does not seem hesitant about consenting to lab tests on her daughter, even if the tests are invasive. Which of the following statements is true about the disorder described in this case? a) It is usually self-limited. b) The father is usually the perpetrator. c) It constitutes a form of child abuse. d) Usually only one child in a family is victimized. e) The caregiver's motivation is watching the child suffer.
C ---- In Munchausen syndrome by proxy, a caregiver, usually the mother, fabricates or produces symptoms of illness in a child. The caregiver's motive is to vicariously receive care and attention from health providers through the sick child. The severity of the disorder varies from cases in which symptoms are completely fabricated to cases in which the mother causes serious physical harm to or even the death of the child. Mothers in cases of Munchausen by proxy are extremely attentive to their children and often are considered model parents. These mothers are not cognitively impaired or psychotic; on the contrary, they are often quite accomplished and knowledgeable and frequently work or have worked in the medical field. Not infrequently, more than one child is victimized in a family, particularly in cases of suffocation disguised as sudden infant death syndrome (SIDS) or apnea. A very pathological relationship develops between the mother and the victimized child, to the point that older children often collude with the mother in producing the symptoms.
7) A social worker makes a routine visit to a 3-year-old boy who has just been returned to his biological mother after spending 3 months in foster care as a result of severe neglect. The child initially appears very shy and clings fearfully to his mother. Later on, he starts playing in a very destructive and disorganized way. When the mother tries to stop him from throwing blocks at her, he starts kicking and biting. The mother becomes enraged and starts shouting. Which of the following is the most likely diagnosis for this child? a) Oppositional defiant disorder b) ADHD c. Reactive attachment disorder c) Posttraumatic stress disorder (PTSD) d) Major depression
C ---- Reactive attachment disorder is the product of a severely dysfunctional early relationship between the principal caregiver and the child. When caregivers consistently disregard the child's physical or emotional needs, the child fails to develop a secure and stable attachment with them. This failure causes a severe disturbance of the child's ability to relate to others, manifested in a variety of behavioral and interpersonal problems. Some children are fearful, inhibited, withdrawn, and apathetic; others are aggressive, disruptive, and disorganized, with low frustration tolerance and poor affect modulation. This condition is often confused with ODD or ADHD.
26) A 50-year-old man is brought to the emergency department by ambulance. His respirations are shallow and infrequent, his pupils are constricted, and he is stuporous. He was noted to have suffered a grand mal seizure in the ambulance. Which of the following drugs is this man most likely to have overdosed on? a) Cocaine b) LSD c) Meperidine d) PCP e) MDMA (Ecstasy)
C ---- Severe opiate intoxication is associated with respiratory depression, stupor or coma, and sometimes pulmonary edema. Less severe intoxication is associated with slurred Substance-Related Disorders Answers 237 speech, drowsiness, and impaired memory or attention. Early on, the pupils are constricted, but they dilate if the patient becomes anoxic because of the respiratory depression. Blood pressure is typically reduced. Meperidine intoxication in a chronic user is often complicated by delirium or seizures caused by the accumulation of normeperidine, a toxic metabolite with cerebral irritant properties.
50) A 29-year-old man is brought to the psychiatrist by his wife because she is concerned about his increasing anger, irritability, and hostility over the past 4 months. The patient denies that any of these symptoms are problematic. On physical examination, the patient is noted to have bilateral muscle hypertrophy, especially in the upper body area, and an elevated fat-free mass index. Which of the following substances is most likely being abused by this man? a) Amphetamines b) Alcohol c) Anabolic-androgenic steroids d) Cocaine e) PCP
C ---- Steroids may cause a variety of mood effects, including euphoria and hyperactivity. However, they can also cause irritability, increased anger, hostility, anxiety, and depression. There is also a correlation between steroid use and violence. These substances are addictive, and when addicts stop taking steroids, they may become depressed, anxious, and concerned about their bodies' appearance
24) The physician tells this patient from the vignette above that the withdrawal symptoms will peak how long after stopping the use of this substance? a) 6 hours b) 5 hours c) 48 hours d) 3 days e) 1 week
C ---- Withdrawal symptoms from short-acting drugs such as heroin or morphine can start within 8 to 12 hours after the last dose and generally reach peak severity 48 hours after the last dose.
1) A 35-year-old man stumbles into the emergency room. His pulse is 100 beats per minute, his blood pressure is 170/95 mm Hg, and he is diaphoretic. He is tremulous and has difficulty relating a history. He does admit to insomnia the past two nights and sees spiders walking on the walls. He has been a drinker since age 19, but has not had a drink in 3 days. Which of the following is the most likely diagnosis? a) Alcohol-induced psychotic disorder b) Wernicke's psychosis c) Alcohol withdrawal delirium d) Alcohol intoxication e) Alcohol idiosyncratic intoxication
C ----- Alcohol withdrawal delirium (delirium tremens) is the most severe form of alcohol withdrawal. In this syndrome, coarse tremor of the hands, insomnia, anxiety, agitation, and autonomic hyperactivity (increased blood pressure and pulse, diaphoresis) are accompanied by severe agitation, confusion, and tactile or visual hallucinations. When alcohol use has been heavy and prolonged, withdrawal phenomena start within 8 hours of cessation of drinking. Symptoms reach peak intensity between the second and third day of abstinence and are usually markedly diminished by the fifth day. In a milder form, withdrawal symptoms may persist for weeks as part of a protracted syndrome. Wernicke's psychosis is an encephalopathy caused by severe thiamine deficiency, usually associated with prolonged and severe alcohol abuse. It is characterized by confusion, ataxia, and ophthalmoplegia. In alcohol hallucinosis, vivid auditory hallucinations start shortly after cessation or reduction of heavy alcohol use. Hallucinations may present with a clear sensorium and are accompanied by signs of autonomic instability less prominent than in alcohol withdrawal delirium.
15) Which of the following endogenous substances is likely to have caused this phenomenon from the vignette above? a) Estrogen b) Thyroid hormone c) Progesterone d) Prolactin e) Alcohol dehydrogenase
D - (Rationale Below) Neuroleptic medications can produce hyperprolactinemia even at very low doses and are the most common cause of galactorrhea in psychiatric patients. Hyperprolactinemia with neuroleptic use is secondary to the blockade of dopamine receptors with these drugs. (Dopamine normally inhibits prolactin, and with dopamine's blockade, hyperprolactinemia can result.) Amenorrhea and galactorrhea are the main symptoms of hyperprolactinemia in women, and impotence is the main symptom in men, although men can also develop gynecomastia and galactorrhea. Other causes of hyperprolactinemia include severe systemic illness such as cirrhosis or renal failure, pituitary tumors, idiopathic sources, and pregnancy
12) A 37-year-old alcoholic is brought to the emergency room after he was found unconscious in the street. He is hospitalized for dehydration and pneumonia. While being treated, he becomes acutely confused and agitated. He cannot move his eyes upward or to the right, and he is ataxic. Which of the following is the most likely diagnosis? a) Alcohol intoxication b) Korsakoff syndrome c) Alcohol delirium d) Wernicke encephalopathy e) Alcohol seizures
D -- (Rationale below)
55) A 25-year-old man is brought to the emergency room after he became unconscious at a party. In the emergency room, the patient's respirations are 8/min. and he is unresponsive. Eye witnesses at the party state the patient was observed taking several kinds of pills, drinking alcohol, and snorting cocaine. The patient is given a total of 1.5 mg of flumazenil, at which time he gradually awakens. Which of the following drugs was most likely the agent in this patient's unconsciousness? a) An opioid b) Cocaine c) Alcohol d) A benzodiazepine e) A barbiturate
D ---- Flumazenil is used to counteract the effects of benzodiazepine receptor agonists. It is administered via IV and has a half-life of approximately 10 to 15 minutes. Common adverse side effects of its use include: nausea, vomiting, dizziness, agitation, emotional lability, fatigue, impaired vision, and headache. The most serious adverse effect is the precipitation of seizures, most likely to occur when given to a person with a preexisting seizure disorder
48) A 16-year-old male with a long record of arrests for breaking and entering, assault and battery, and drug possession is found dead in his room with a plastic bag on his head. For several months he had been experiencing headaches, tremors, muscle weakness, unsteady gait, and tingling sensations in his hands and feet. These symptoms (and the manner in which the boy died) suggest that he was addicted to which of the following substances? a) PCP b) Cocaine c) Methamphetamine d) An inhalant e) Heroin
D ---- Inhalant abuse is associated with very serious medical problems. Hearing loss, peripheral neuritis, paresthesias, cerebellar signs, and motor impairment are common neurological manifestations. Muscle weakness caused by rhabdomyolysis, irreversible hepatic and renal damage, cardiovascular symptoms, and gastrointestinal symptoms such as vomiting and hematemesis are also common with chronic severe abuse.
9) A 15-year-old boy is arrested for shooting the owner of the convenience store he tried to rob. He has been in department of youth services custody several times for a variety of crimes against property, possession of illegal substances, and assault and battery. He is cheerful and unconcerned during the arrest, more worried about losing his leather jacket than about the fate of the man he has injured. Which of the following is the most likely diagnosis in this case? a) Oppositional defiant disorder b) Antisocial personality disorder c) Narcissistic personality disorder d) Conduct disorder e) Substance abuse
D --- Children with conduct disorder display a persistent disregard for rules and other people's rights that lasts at least 1 year. Aggression toward people and animals, destruction of property, deceit and illegal activities, and frequent truancy from school are the main characteristics of the disorder. Approximately one-third of children diagnosed with conduct disorder proceed to become delinquent adolescents, and many are diagnosed with antisocial personality disorder in adulthood. Patients with antisocial personality disorder display a pervasive pattern of disregard for and violation of the rights of others since the age of 15 years, with evidence of a conduct disorder before age 15. Substance abuse is just one facet of conduct disorder. Children with oppositional defiant disorder are problematic and rebellious but do not routinely engage in aggressive, destructive, or illegal activities. Also, they do not present with the lack of empathy for others and the disregard for other people's rights that are typical of conduct disorder.
25) A 28-year-old woman is seen for postpartum blues by the psychiatrist. She states she is depressed because she "did this to her child." The infant has growth retardation, microphthalmia, short palpebral fissures, midface hypoplasia, a short philtrum, a thin upper lip, and microcephaly. Which is the most likely diagnosis of the mother (besides the postpartum blues)? a) Bipolar disorder b) Major depression c) Hypochondriasis d) Alcohol dependence e) Cocaine dependence
D --- This woman is likely suffering from alcohol dependence, because her child is showing the classic signs of a fetal alcohol syndrome. This syndrome affects approximately one-third of all infants born to women afflicted with alcoholism. Besides the signs this infant has, one can see delayed development, hyperactivity, attention deficits, learning disabilities, intellectual deficits, and seizures in these children.
33) A 45-year-old housewife has been drinking in secret for several years. She started with one or two small glasses of Irish cream per night to help her sleep, but, over time, her nightly intake has increased to four to five shots of hard liquor. Now she needs a few glasses of wine in the early afternoon to prevent shakiness and anxiety. During the past year, she could not take part in several important family events, including her son's high school graduation, because she was too ill or she did not want to risk missing her nightly drinking. She is ashamed of her secret and has tried to limit her alcohol intake but without success. Which of the following is the most likely diagnosis? a) Alcohol abuse b) Alcohol addiction c) Addictive personality disorder d) Alcohol dependence e) Alcohol-induced mood disorder
D ---- A diagnosis of alcohol dependence requires the presence of compulsive drinking with ineffective attempts to stop or cut down (the housewife in this vignette has tried to "limit her alcohol intake but without success"); evidence of severe impairment of occupational, social, and family life because of the great amount of time the patient spends procuring and consuming alcohol or recovering from its effects (she has not been able to take part in several important family events because she was too ill or did not want to miss her nightly drinking); persistent excessive drinking despite the problems alcohol causes (she has continued to drink despite these issues); and physical symptoms and signs of withdrawal and tolerance (shakiness and anxiety when she misses a drink).
46) A 55-year-old man comes to his physician because he wants to stop smoking. He tells the physician that he is desperate to stop because his wife was just diagnosed with emphysema. The patient is willing to work with the physician on behavioral strategies to quit smoking but would also like some medications to help. Which of the following medications should the physician prescribe for this patient? a) Lithium b) Clonazepam c) Methylphenidate d) Bupropion e) Amitriptyline
D ---- A variety of psychopharmacologic agents, including clonidine, antidepressants, and buspirone, have been used with some success in the treatment of nicotine dependence. Bupropion (Zyban) was approved by the FDA in 1996 for this use. Nicotine replacement patches and gum can also be used and then tapered off Substance-Related Disorders Answers 241 slowly to reduce the symptoms of nicotine withdrawal. A new drug, varenicline (Chantix) has also been released to the market. It is a non-nicotine prescription medicine specifically developed to help adults quit smoking. Chantix contains no nicotine, but targets the same receptors that nicotine does. Chantix is believed to block nicotine from these receptors.
32) Which of the following is the most appropriate initial treatment for the patient from the previous vignette? a) Intramuscular haloperidol b) Intramuscular chlorpromazine c) Oral lithium d) Oral chlordiazepoxide e) Intravenous naloxone
D ---- Benzodiazepines are the preferred treatment for alcohol withdrawal delirium, with diazepam and chlordiazepoxide (Librium) the most commonly used. Elderly patients or patients with severe liver damage may better tolerate intermediate-acting benzodiazepines such as lorazepam and oxazepam. Thiamine (100 mg) and folic acid (1 mg) are routinely administered to prevent CNS damage secondary to vitamin deficiency. Thiamine should always be administered prior to glucose infusion, because glucose metabolism may rapidly deplete patients' thiamine reserves in cases of long-lasting poor nutrition. When the patient has a history of alcohol withdrawal seizures, magnesium sulfate should be administered.
34) A 26-year-old woman presents to the psychiatrist with a 1-month history of severe anxiety. She states that before 1 month ago she was a 'normal, laid-back person." Since that time she rates her anxiety as an 8 on a scale of 1-10. She notes she is afraid to leave the house unless she checks that the door is locked at least 5 times. Which of the following substance-related conditions would most likely cause these kinds of symptoms? a) Alcohol intoxication b) Nicotine withdrawal c) Caffeine withdrawal d) Cocaine intoxication e) PCP intoxication
D ---- Cocaine-induced anxiety disorder can present with any of the symptoms occurring in this patient. Other symptoms of anxiety that can occur, and must be ruled out from the corresponding disorder, are panic disorder symptoms, or symptoms of phobias or obsessive-compulsive disorder.
57) A 47-year-old man comes to a physician for treatment of his impotence. He has had a 20-year history of IDDM, well-controlled, and a 12-year history of alcohol dependence, though he has been sober for 3 years. He is prescribed sildenafil. Which of the following adverse effects is most commonly associated with this drug? a) Hypoglycemia b) Ketoacidosis c) Liver failure d) Myocardial infarction e) Arteritic anterior ischemic optic neuropathy (NAION)
D ---- The most important adverse side effect associated with sildenafil is myocardial infarction. While the drugs themselves do not posed an increased risk of death in this manner, the increased oxygen demand and stress placed on the heart by sexual activity, in a heart that is already affected by an underlying condition such as atherosclerotic disease may precipitate a heart attack. Non-arteritic anterior ischemic optic neuropathy (NAION) is a very rare but serious condition which may occur in men taking sildenafil. It causes restriction of blood flow to the optic nerve and can result in permanent blindness.d
13) Which of the following is the most appropriate treatment for the patient in the vignette above? a) Dilantin b) Valium c) Haloperidol d) Amobarbitol e) Thiamine
E - (Rationale below) Wernicke encephalopathy occurs in nutritionally deficient alcoholics and is because of thiamine deficiency and consequent damage of the thiamine-dependent 114 Psychiatry brain structures, including the mammillary bodies and the dorsomedial nucleus of the thalamus. It presents with mental confusion, ataxia, and sixth-nerve paralysis. Wernicke encephalopathy is a medical emergency and can rapidly resolve with immediate supplementation of thiamine. This diagnosis should be considered in any patient brought into the emergency room unresponsive.
39) In the vignette above, which of the following medications is most likely to be helpful to this patient postictally? a) Librium IM b) Haloperidol PO c) Clonidine po d) Haloperidol IM e) Lorazepam IM
E --- (Rationale below) Alcohol withdrawal delirium is a medical emergency, since untreated, as many as 20% of patients will die, usually as a result of a concurrent medical illness such as pneumonia, hepatic disease, or heart failure. Symptoms of this delirium include: autonomic hyperactivity, hallucinations, and fluctuating activity levels, ranging from acute agitation to lethargy. The best treatment for this delirium is, of course, prevention. However, once it appears, chlordiazepoxide should be given orally, or if this is not possible (as in this case), lorazepam should be given IV or IM. Antipsychotic medications should be avoided, since they may further lower the seizure threshold.
56) A 7-year-old boy who wets the bed at least three times a week and has not responded to appropriate behavioral interventions is diagnosed with ADHD. Which of the following medications is indicated to treat both disorders? a) Bupropion b) Dextroamphetamine c) Clonidine d) Risperidone e) Imipramine
E ---- Imipramine is effective in the treatment of nocturnal enuresis, through a still unknown mechanism. Its beneficial effects in this disorder may be related to its anticholinergic properties or an effect on the sleep process. Imipramine is also used with good results in the treatment of children and adults with ADHD, although it is not as effective as the stimulants. Imipramine can be helpful for patients with comorbid anxiety or tics, patients who do not tolerate stimulants, or patients who have a history of substance abuse
8) A first-grade teacher is concerned about a 6-year-old girl in her class who has not spoken a single word since school started. The little girl participates appropriately in the class activities and uses gestures and drawings and nods and shakes her head to communicate. The parents report that the little girl talks only in the home and only in the presence of her closest relatives. Which of the following is the most likely diagnosis? a) Autism b) Expressive language disorder c) Oppositional defiant disorder d) School phobia e) Selective mutism
E --- In selective mutism, a child voluntarily abstains from talking in particular situations (usually at school) while remaining appropriately verbal at home. Some children speak only with their parents and siblings and are mute with relatives and friends. Children with selective mutism do not have a language impediment, nor do they display the lack of social interactions, lack of imagination, and 86 Psychiatry stereotyped behavior characteristic of autism. On the contrary, they can be quite interactive and communicative in a nonverbal way, using drawing, writing, and pantomime. Children with school phobia refuse to go to school but do not have problems communicating through language. Oppositional defiant disorder is characterized by persistent refusal to follow rules and defiance toward authorities, not by failure to speak.
10) A 24-year-old previously healthy man is brought to the emergency room after he began yelling that people on the bus were out to hurt him. In the emergency room, he is agitated, hypervigilant, and anxious. He is unable to give much history other than to say that he is a graduate student and nothing like this has ever happened before. Which of the following is the most likely cause of this behavior? a) Delirium b) Pick disease c) Dissociative disorder d) Vitamin B12 deficiency e) Cocaine intoxication
E --- The agitation, hypervigilance, and anxiety that this man presents with are common in cocaine-intoxicated states. The man's history indicates that nothing like this has ever happened before, and he is a young graduate student, making Pick disease unlikely. Similarly, the lack of any obvious other medical condition in a previously Cognitive Disorders Answers 107 healthy patient makes delirium unlikely. Vitamin B12 deficiency would not have presented with these signs and symptoms, nor would dissociative disorder.
2) A 17-year-old boy is brought to the emergency room by his friends after he "took a few pills" at a party and developed physical symptoms, including his neck twisting to one side, his eyes rolling upward, and his tongue hanging out of his mouth. The patient responds immediately to 50 mg of diphenhydramine intramuscularly with the resolution of all physical symptoms. Which of the following substances is most likely to have caused the symptoms? a) Methamphetamine b) Meperidine c) Alprazolam d) Methylphenidate e) Haloperidol
E --- The boy in question experienced an acute dystonic reaction, an adverse effect of neuroleptic medications secondary to blockage of dopamine receptors in the nigrostriatal system. Dystonic reactions are sustained spasmodic contractions of the muscles of the neck, trunk, tongue, face, and extraocular muscles. They can be quite painful and frightening. They usually occur within hours to 3 days after the beginning of the treatment and are more frequent in males and young people. They are also usually associated with high-potency neuroleptics. Occasionally, dystonic reactions are seen in young people who have ingested a neuroleptic medication, mistaking it for a drug of abuse. Administration of anticholinergic drugs provides rapid treatment of acute dystonia.
44) A 22-year-old Asian woman becomes flushed and nauseated immediately after drinking half a glass of wine. She is noted to have slurred speech, ataxia, and nystagmus as well. She is brought to the emergency department by her concerned friends. Which of the following is the most likely diagnosis? a) Conversion disorder b) Panic disorder c) Histrionic personality disorder d) Factitious disorder with physical symptoms e) Alcohol intoxication
E ---- Among Asian men and women, 10% lack the form of acetaldehyde dehydrogenase responsible for metabolizing low blood concentrations of acetaldehyde (they are homozygous for an inactive form of the enzyme). Approximately 40% of Asian men and women are heterozygous for this specific enzyme variation. Because of the rapid accumulation of acetaldehyde, homozygous individuals develop facial flushing, nausea, and vomiting after ingestion of small quantities of alcohol, which are the common side effects of alcohol intoxication and occur much earlier than the norm. Heterozygous individuals can tolerate some alcohol but are more sensitive to its effects. This enzyme variation is found only in people of Asian descent.
35) A 37-year-old woman is admitted to an inpatient treatment program for withdrawal from heroin. Eighteen hours after her last injection of heroin, she becomes hypertensive, irritable, and restless. She also has nausea, vomiting, and diarrhea. Which medication would be best to treat some of the symptoms of opioid withdrawal? a) Chlordiazepoxide b) Haloperidol c) Paroxetine d) Phenobarbital e) Clonidine
E ---- Clonidine, an alpha 2-adrenergic receptor agonist, is used to suppress some of the symptoms of mild opioid withdrawal. Clonidine is given orally, starting with doses of 0.1 to 0.3 mg three or four times a day. In outpatient settings, a daily dosage above 1 mg is not recommended because of the risk of severe hypotension. Clonidine is more effective on symptoms of autonomic instability, but is less effective than methadone in suppressing muscle aches, cravings, and insomnia. Clonidine is particularly useful in the detoxification of patients maintained on methadone.
42) A 25-year-old woman is dropped on the doorstep of a local emergency room by two men who immediately leave by car. She is agitated and anxious, and she keeps brushing her arms and legs "to get rid of the bugs." She clutches at her chest, moaning in pain. Her pupils are wide, and her blood pressure is elevated. Which of the following substances is she most likely using? a) Alcohol b) Heroin c) Alprazolam d) LSD e) Cocaine
E ---- Cocaine intoxication is characterized by euphoria but suspiciousness. Agitation, anxiety, and hyperactivity are also typical presenting symptoms. Signs of sympathetic stimulation, such as tachycardia, cardiac arrhythmias, hypertension, pupillary dilatations, perspiration, and chills are also present. Visual and tactile hallucinations, including hallucinations of bugs crawling on the skin, are present in cocaine-induced delirium. Among the most serious acute medical complications associated with the use of high doses of cocaine are coronary spasms, myocardial infarcts, intracranial hemorrhages, ischemic cerebral infarcts, and seizures
49) A 13-year-old girl is brought to the emergency department by her mother because the girl thinks she is "going crazy." The girl states that at a friend's party several hours previously she was given a white tablet to take, which she did. She is now agitated and restless and convinced that she can fly. She also notes that she is having visual, auditory, and tactile hallucinations. On examination, she is noted to have tachycardia, tremors, hypertension, and mydriasis. Which of the following substances did she most likely ingest? a) Cannabis b) Heroin c) Cocaine d) MDMA (Ecstasy) e) LSD
E ---- Patients ingesting LSD may have a wide variety of sensory disturbances, and because of the sympathomimetic effects of the drug, may experience tremors, hypertension, tachycardia, mydriasis, hyperthermia, sweating, and blurry vision. Patients may die when they act on their false perceptions (in this case, the belief that the patient can fly) or accidentally kill themselves. When the subject is not clear about which drug was taken, the unexpected sensory disturbances can be quite terrifying, and patients can fear losing their minds, as in this case.
Match each vignette with the correct term describing it. Each lettered option may be used once, more than once, or not at all. a. Tolerance b. Potentiation c. Withdrawal d. Dependence e. Addiction f. substance abuse\ 52) A 22-year-old man continues to use alcohol on a once-weekly basis, despite the fact that every time he uses it he does something embarrassing, which he regrets. This has led him to lose some of his friends because they do not want to be around him when such behavior occurs.
F ---- Substance Abuse RATIONALE ----- #52, #53, #54 These terms are commonly confused or used ambiguously. · Substance abuse describes a maladaptive behavioral pattern characterized by recurrent use in spite of academic, social, or work problems; use in situations in which changes in mental status may be dangerous (driving); and recurrent substance-related legal problems.
