mental health final

A 22-year-old woman is referred to a psychiatrist by her mother because she has few friends and "doesn't socialize like other people her age." Which of the following statements is most consistent with a diagnosis of SPD?

"I have plenty of friends. The stars have told me I should have two friends, and that's exactly what I have."

A 22-year-old single graduate student with narcissistic personality disorder is admitted to a hospital after a car accident in which his right femur is fractured. A medical student has been assigned to follow the patient, but when she enters the room and introduces herself as a medical student, the patient states, "Oh, I wouldn't let a medical student touch me—I need someone with much more experience than you." Which of the following statements by the medical student is most likely to lead to a successful interview with this patient?

"I'm told that you are a very articulate person, so I'm hoping you'll teach me what I need to know."

A 36-year-old woman comes into your office for a new patient evaluation. When reviewing her past medical history, she tells you she has a diagnosis of schizoaffective disorder. Which of the following statements is most consistent with a diagnosis of schizoaffective disorder?

"I've had several psychotic episodes in my life. In between, I sometimes function okay, but I have had a couple times where my mood got really low and I crawled under the covers for weeks."

An epidemiologic survey of the general public showed between 9% and 16% met criteria for one or more personality disorders. In psychiatric samples the prevalence is even higher. What percentage of personality disorders would you expect to find in an outpatient psychiatric sample?

30-50%

A 54-year-old man is admitted to the hospital for elective surgery. He has been through alcohol rehabilitation but has continued to struggle with his drinking. He alerts the primary service taking care of him that he has continued to drink up to the time of his admission. In what time frame after cessation of all drinking is he at most risk for DTs?

48-96 hours

woman with major depressive disorder seen 1 year later for a return visit. She has remained on the citalopram at the same dose, and she is tolerating it well, but she worries about "always having to take medication," and requests it to be discontinued. What is her lifetime risk of reoccurrence if not maintained on medication?

85%

In the patient with ASD who is 4, what statement might best describe the etiology of his disorder?

A complex heritable and in utero environmental influence best explain the etiology of ASD.

A 22-year-old woman is referred for neuropsychological testing after reporting confusion and amnestic episodes. She has received bills in the mail for credit cards she does not remember opening. The woman has found clothing in her closet that she does not recall purchasing. She has been tagged in numerous pictures on Facebook with people she does not know and has been checked into venues unfamiliar to her. What is the most likely diagnosis?

DID

A 38-year-old barista presents to her primary care provider with concern about memory problems. She has had trouble recalling significant personal information and life events. The patient reports that dating has been problematic because during intimate encounters, "I just disconnect. I feel so scared and ashamed. I'm floating above my body, looking down on what's happening." Her current boyfriend has described that sometimes she talks like a "little girl" and other times like a "sophisticated southern belle." He finds it endearing, but news of this behavior frightened the patient, as she has no recollection of acting this way. Her boyfriend has said he loves the way she plays piano, but she cannot remember ever touching the instrument. She drinks socially on the weekends but denies heavy use, blackouts, or withdrawal symptoms. Which of the following is the most likely diagnosis?

DID

In the scenario in Question about the woman with delerium due to UTI, which of the following features most distinguishes delirium from mild neurocognitive disorder (formerly known as dementia)?

Decreased attention

he patient in Question 55.3[woman with NPD] has now been seeing a therapist twice weekly for the last year. The therapist and the patient have a good working alliance. During one therapy session, the therapist comes to the session 4 minutes late. He apologizes to the patient, stating that he had an emergency involving another patient. During the session, the patient notes that the therapist "isn't as sharp as some of the therapists I hear on the talk shows." Which of the following defense mechanisms is the patient using?

Devaluation

A 41-year-old nurse presents to the emergency department with concerns that she has hypoglycemia from an insulinoma. She reports repeated episodes of headache, sweating, tremor, and palpitations. She denies any past medical problems and only takes nonsteroidal anti-inflammatory medications for menstrual cramps. On physical examination, she is a well-dressed woman who is intelligent, polite, and cooperative. Her vital signs are stable except for slight tachycardia. The examination is remarkable for diaphoresis, tachycardia, and numerous scars on her abdomen, as well as needle marks on her arms. When asked about this, she says that she feels confused because of her hypoglycemia. The patient is subsequently admitted to the medical service. Laboratory evaluations demonstrate a decreased fasting blood sugar level and an increased insulin level, but a decreased level of plasma C-peptide, which indicates exogenous insulin injection. When she is confronted with this information, she quickly becomes angry, claims the hospital staff is incompetent, and requests that she be discharged against medical advice.

FACTITITOUS DISORDER

A 32-year-old man and his 28-year-old wife come to a psychiatrist because of problems in their relationship. The wife states that the two have been married for 6 months and that they dated for 2 months prior to that. During all their sexual encounters, the husband insists that the wife wear very high-heeled shoes at all times. Although the wife initially thought that this behavior was sensual, she now worries that it is the shoes that the husband finds attractive and not her. She thinks the behavior is "freaky" and has asked the husband to stop, which he has refused to do. This has led to arguments between them. The husband states that he is unable to achieve an erection or orgasm without the presence of the shoes. He notes that for as long as he can remember, he has needed high-heeled shoes as part of his sexual play. He feels no shame or guilt about this behavior, although he is worried that it is causing problems between him and his wife.

Fetishistic disorder

A patient with schizoid personality disorder comes to his primary care provider with chief complaints of polyuria and polydipsia. He is found to have insulin-dependent diabetes. Which of the following interventions by the provider is likely to be most well received by this patient?

Giving the patient detailed written information about the disease and telling him that the provider will be available to answer any questions.

A 26-year-old woman comes to see a psychiatrist because she has been taking showers for 6 to 7 hours every day. She explains, "It all starts when I wake up. I am sure I am covered in germs, and if I don't wash, I will get sick. If I don't wash, I get paralyzed with anxiety. Once I'm in the shower, I have to shower in a particular order. If I mess up, I have to start over, and this takes hours and hours. My skin is cracking and bleeding because I spend so much time in the water." Which of the following conditions does this patient is most likely have?

OCD

A 28-year-old man is brought to a psychiatrist complaining that he has been hearing voices for the past several weeks. He says that he also heard these voices 3 years ago. He notes that his mood is "depressed" and rates it 3 on a scale of 1 to 10 (with 10 being the best he has ever felt). He does not recall if his mood was depressed the last time he had psychotic symptoms. Which of the following actions should the provider take next?

Obtain more detailed information about the time course of the psychotic symptoms and the mood symptoms.

What is the main difference between obsessive-compulsive personality disorder and OCD?

People with obsessive-compulsive personality disorder don't have true obsessions or compulsions like people with OCD.

A 12-year-old girl with a history of complex trauma is admitted to the inpatient child psychiatry unit for the management of disruptive behaviors. On the unit, she has a verbal altercation with a staff member. She stops responding directly to the staff member and appears very frightened. She turns away and begins wailing, "Don't hurt me, daddy. Please, please don't..." If the patient is forcibly placed into physical restraints, what would be the most likely result?

Retraumatization

A 24-year-old woman was admitted to the obstetrical service for the delivery of a full-term baby boy. One day after the delivery, the obstetrics service requested a consultation from the psychiatrist on duty to "rule out schizophrenia." The psychiatrist interviews the patient and finds out that the pregnancy was because of a rape the patient suffered 9 months previously. The patient is planning to give the baby up for adoption. She claims that she has never seen a psychiatrist and has never felt a need to do so. She speaks at length about how the rape was "written in the stars" for all to see; she is an avid astrologer. She denies having recurrent thoughts or nightmares about the rape itself. She states that she has very few close friends, preferring to study astrology and astral projection at home by herself. She believes strongly in reincarnation, although she knows that her family thinks this belief is strange. She admits that she has worked intermittently as a "crystal ball gazer" but has never held a steady, full-time paying job. During the mental status examination, the patient sits upright in her hospital bed dressed in three hospital gowns and a robe, which she is wearing backward. Her hair is neatly combed, although one side is in braids and the other is not. She is cooperative with the interviewer. She states that her mood is good, and her affect is congruent although constricted. She has tangential thought processes and ideas of reference but no suicidal or homicidal ideation, hallucinations, or delusions.

SCHIZOTYPAl personality disorder

A 42-year-old man comes to his outpatient psychiatrist with complaints of a depressed mood, which he states is identical to episodes of depression he has experienced previously. He was diagnosed with major depression for the first time 20 years ago. At that time, he was treated with imipramine, up to 150 mg/d, with good results. During a second episode that occurred 15 years ago, he was treated with imipramine, and once again his symptoms remitted after 4 to 6 weeks. He denies illicit drug use or any recent traumatic events. The man states that although he is sure he is experiencing another major depression, he would like to avoid imipramine this time because it produced unacceptable side effects such as dry mouth, dry eyes, and constipation. What is the best treatment?

SSRIs

A 23-year-old man comes to his clinician asking for sexual reassignment surgery. He states that for "as long as I can remember," he has felt that he was born in the wrong body. He states that he believes that "truly I am a woman" and is disgusted by his male body habitus. He has been living as a woman since he moved out of his parents' house several years ago. He wishes to have his penis removed and would like female breasts and genitalia. He considers himself a heterosexual because he is attracted to men. When talking with the patient, which of the following should be used to describe this man?

She has gender dysphoria

A 40-year-old man who has been stable on methadone maintenance for the past 10 years approaches you about switching to buprenorphine/naloxone because he is having difficulty attending the methadone clinic daily. He learned that you prescribe buprenorphine/naloxone in your clinic. He has done well on methadone without any relapses on heroin. He uses marijuana several times a week to manage his anxiety because his health care provider told him not to mix benzodiazepines with methadone. How would you counsel him about a potential switch to buprenorphine/naloxone?

Work with the methadone provider to taper him off. Explain that he may experience withdrawal symptoms during the transition to buprenorphine/naloxone.

A 48-year-old woman presents to a psychotherapist. The patient lives a very secluded life, largely consumed by working nights as a janitor at a department store and taking care of her elderly mother. She complains of feeling lonely and is aware that she has a great deal of difficulty relating to other people. Which of the following conditions would most distinguish her issues from a person with schizoid personality disorder?

a desire to engage in interpersonal relationships

Which of the following is required for the diagnosis of gender dysphoria in children but not in adolescents or adults?

a strong desire to be of the other gender or an insistence that one is the other gender

someone with narsissitc personality disorder would likely become depressed after which life event?

aging

A 55-year-old unresponsive woman is brought to the emergency department after an apparent suicide attempt. Earlier that day, she refilled her monthly prescription for lorazepam, which she had been prescribed for panic disorder. The empty pill bottle was found on her nightstand by the paramedics. Concurrent ingestion of which of the following substances is most likely to worsen the prognosis of her overdose?

alcohol

A 28-year-old man is brought into the emergency center for an overdose of prescribed medications, which includes benzodiazepines. He also admits to being habituated to his prescribed medication. After stabilization for the acute problems, he is subsequently transferred to another facility for detoxification. Which of the following benzodiazepines is most likely to cause a withdrawal syndrome?

alprazolam

A 16-year-old adolescent girl is brought into the office due to having suicidal thoughts. The parents report that over the past year, the patient has increasingly been truant from school. She has stolen money from her family and neighbors, and she slashed the tires of a fellow classmate for making fun of her. She often bullies her sister and has slapped her on several occasions. Over the past 2 months, the patient has had increasing problems sleeping and has lost weight. Upon questioning, the patient states that she has low energy. A urine drug screen is negative. Which of the following treatments is best employed to treat this patient?

an antidepressant medication

A 55-year-old man complains of inability to achieve an erection. He has been worried about his health recently and takes antihypertensive medication. Which of the following would most likely differentiate between an organic and psychiatric condition?

an erection on wakening in the morning

A 36-year-old man with narcissistic personality disorder calls your office asking for an appointment with the "best therapist in the clinic." One of his complaints is difficulties in his relationships with his colleagues. The patient states, "They are not giving me the credit I deserve for my accomplishments at the law firm." What is the most likely reason the patient is seeking treatment?

anger

A 17-year-old honors student is brought to the emergency department by his parents. In the last academic quarter, his grades have suddenly dropped, he is irritable with friends and family, has no energy, does not go to bed until 1 AM, and has a poor appetite. He also has auditory hallucinations in which a man's voice tells him that he is a "lazy bastard" and that his family "would be better off with him dead." Which of the following would be the most appropriate initial pharmacologic treatment plan?

antidepressant and antipsychotic medications

A 20-year-old musician comes to his primary care provider's office because he has been feeling depressed, fatigued, and unmotivated for the last few weeks. He wants help getting his "muse" back. Physical examination and laboratory studies are unremarkable. He is prescribed fluoxetine with a plan to follow up in a month. The patient's girlfriend brings him back to clinic 2 weeks later, concerned that he is "acting different." She reports that the patient plays guitar all day and late into the night. She complains that he has spent all their money on new guitars and keyboards. She does not want to "crush his dreams, but he's reaching a bit high trying to book tours with the Rolling Stones." The patient reports feeling "Better than ever!" He talks quickly and informs the clinician that he has to get going so he can keep practicing for "the big gig." What is the most likely diagnosis?

antidepressant induced bipolar disorder

What is the best treatment option for the patient experiencing paranoid delusions

antipsychotic medication

A 10-year-old girl is brought in for treatment by her father because the child is not sleeping well, has lost 7 lb because of a decreased appetite, seems to be tired much of the time, is irritable and tearful most of the time, refuses to go to school or play with her friends, and has been spending most of her time locked in her room. These symptoms gradually began a few months after the sudden death of the girl's mother due to suicide. The father is worried about suicide risk in the girl but does not want to ask her about it, as he fears putting suicidal ideas in her mind. Which is the best way to address suicide risk in this patient?

ask the child about suicidal thoughts

A health care provider is called to see a 42-year-old man who was jailed on a robbery charge 48 hours previously. Twelve hours before the provider arrived, the patient began to complain of feeling anxious. The correctional officers noted that he was nauseous, diaphoretic, and had muscle tics, so they alerted medical personnel. By the time the clinician came to see the patient, the patient had a witnessed, generalized tonic-clonic seizure, 30 seconds in duration. He is now postictal. The results of a subsequent urine toxicology screening are positive for cocaine, opiates, and benzodiazepines.

benzodiazapine withdrawl

A 32-year-old man with a 12-beer-per-day drinking history for the last year is being treated for injuries related to a motor vehicle accident (MVA). On the third day inpatient, the nurse notices the patient shaking and hallucinating. On examination, he is febrile with increased blood pressure. The provider suspects delirium tremens (DTs). What class of medication would be an appropriate first-line treatment for DTs?

benzodiazepine

A 30-year-old woman with an 18-year history of daily intravenous heroin use comes into the community rehabilitation clinic asking to be "detoxed" in order to "kick my heroin habit" for good. Though she is motivated for treatment, she currently is shivering, with rhinorrhea, tearing, gagging, and grabbing her abdomen in pain due to cramps. When questioned about her last use, she states that shortly before arriving, a peer gave her "something different to shoot up." Which of the following substances would be most likely to cause her current symptoms?

buprenophrine

A 30-year-old man presents to his primary care provider's office complaining of being "down" for the last month. He has been suffering from difficulty falling and staying asleep, severe fatigue, guilt, poor appetite, and thoughts of wanting to take his life. He does not ever recall feeling this bad. He has stopped talking to his friends and has no interest in doing anything. He is diagnosed with major depressive disorder. He is open to treatment but has heard that antidepressants cause sexual dysfunction. His concerns are noted, and he is started on an antidepressant medication. He presents to the emergency department 3 days later after an episode of generalized tonic-clonic seizures. Which of the following antidepressants was he most likely prescribed?

bupropion

A 25-year-old man arrives to the emergency department with gastrointestinal distress, muscle aches, rhinorrhea, lacrimation, and an anxious mood. He had become addicted on prescription opioids and now buys pills on the street. He says he works as an accountant and just "wants to kick this thing once and for all." Which of the following medications would be most helpful in ameliorating his symptoms?

clonidine

A 45-year-old man with a history of schizophrenia and alcohol use disorder is brought in by an ambulance after he was found sleeping on the floor of a local homeless shelter. He appears drowsy but arousable, and he mumbles, "The voices are killing me." He admits to taking a bottle of lorazepam because "I just couldn't take it anymore." Which of the following antipsychotics has been associated with decreased suicide attempts?

clozapine

Which of the following features must be present in a patient's history for SPD to be diagnosed?

cognitive and perceptual distortions

During morning prerounds, a medical student finds one of her patients, a 72-year-old man, unresponsive to verbal stimuli. The patient groans to sternal rub but does not otherwise respond. What is the best descriptor for this patient's level of attention and awareness?

coma

A 13-year-old girl is admitted to the pediatric unit for the evaluation of seizures. Her first seizure occurred 1 week ago, and she has had three since then. Episodes are described by her parents as a generalized shaking and jerking of the body, lasting 1 to 2 minutes, with eyes rolled back. During one seizure, there was urinary incontinence. The girl denies feeling depressed but does mention feeling "stressed out" due to school and recently not getting along with her stepmother. There is a history of sexual abuse by her stepfather 5 years ago. She has diagnoses of depressive disorder and anxiety for which she takes fluoxetine 20 mg daily. Her physical examination and neurologic workup are unremarkable. Laboratory studies are also within normal limits. Which of the following is the most likely diagnosis?

conversion disorder

A 23-year-old pregnant woman complains of an inability to feel her legs. She wonders if the fetus is grabbing her spinal cord. Although she does not appear concerned about her condition, on further questioning she admits that her pregnancy was unplanned and that it has been a source of stress for her and her husband. Her neurologic examination is unremarkable except for decreased sensation below her waist. The results of a computed tomography scan and magnetic resonance imaging of her brain and spine are normal.

conversion disorder

A 24-year-old man is admitted to the neurology service with new-onset blindness. The patient awoke on the morning of his admission entirely unable to see. A detailed workup by the neurology service, including physical, laboratory studies, and imaging, revealed no clear medical reason for this abnormality—the patient was found to be otherwise healthy. A psychiatric consultation was subsequently ordered. The patient tells the psychiatrist that he does not know why he is blind. He emigrated from Mexico several years ago, coming to the United States to make money to support his sick mother. She remained ill for several years, but he was unable to send her money because he lost the money gambling. She died recently, and he became despondent because he would never see her again. On mental status examination, the patient is alert and oriented to person, place, and time. His appearance and hygiene are good, and he does not seem to be overly concerned with his blindness. His mood is described as "okay," and his affect is congruent and full range. He has normal thought processes and denies having suicidal or homicidal ideation, delusions, or hallucinations. What is the most likely diagnosis?

conversion disorder

A 26-year-old woman presents to her provider with the chief complaint of "I have epilepsy." She states that for the past 3 weeks she has had seizures almost daily. She describes the episodes as falling on the ground, followed by her arms and legs shaking uncontrollably. These events last for approximately 10 minutes. She is unable to otherwise move during the time, although she denies any loss of consciousness or bladder or bowel functions. The patient seems to be rather indifferent when stating her complaints. She has never injured herself during these episodes, but as a result, she has been unable to continue her job. She is somewhat bothered because she received a promotion 1 month ago. Which of the following is the most likely diagnosis?

conversion disorder

A 29-year-old man presents to his primary care provider with back pain for the past year since he slipped on a wet floor at work. He has been unable to work since the accident. A comprehensive medical workup has been entirely normal, and his only symptom is pain in the middle of his back that is present constantly. He has had multiple visits (more than two dozen) to the emergency department, where he is frequently given opioids and alprazolam to help with the pain. At today's visit, he tells you he is applying for disability designation and benefits. If the patient truly has pain and limitations without a medical physiologic explanation, which of the following is most likely to be present?

conversion disorder

A 19-year-old college freshman is brought to the emergency department by his dorm roommate. The roommate states that his fellow freshman has been up until 4 AM for the last 2 nights, painting for an art final. The roommate complains the patient's behavior precludes him from being able to sleep or work in their shared space. He states that his colleague continuously paces between the easel and the window. He describes his roommate's mood as "obnoxiously happy," especially in the context of finals week. The patient describes a history of good moods, during which he has bursts of energy and creativity while requiring less sleep. These episodes are typically followed by feeling down and depleted, even with sufficient sleep. The patient denies any associated suicidality or psychotic symptoms. He denies substance use, medications, or medical problems. What is the most likely diagnosis?

cyclothymic disorder

The night float psychiatry resident is paged to evaluate a 64-year-old man in the telemetry unit after he began screaming about strange men in his hospital room. The patient has a history of multivessel coronary artery disease (CAD) and underwent a coronary artery bypass graft (CABG) surgery 3 days ago. He claims that he saw several ominous-appearing men standing in his room, glaring at him threateningly. The patient denies ever having any unusual experiences like this before and has no prior psychiatric history. The nurses' notes from the last shift indicate that the patient has been agitated and restless, although at other times he appeared stuporous. On mental status examination, the patient is alert and oriented to person, place, and situation, but the date he reports is off by several months. He denies any current hallucinations, and no delusions were elicited. What is the most likely diagnosis

delerium

A 30-year-old man comes into your clinic after being referred by his primary care provider. He lives with his mother and relies on her to make everyday decisions for him. He has never worked and depends on her for financial support. He lacks self-confidence and is uncomfortable when left alone. Since his mother's diagnosis of cancer, the patient is preoccupied with the fear of his mother dying and being left alone to care for himself. You believe he is suffering from a personality disorder. Which is the most likely disorder?

dependent personality disorder

A 32-year-old man comes to a psychiatrist on his mother's advice with the chief complaint of being depressed since he broke up with his girlfriend 2 weeks ago. The patient explains that although he loves his ex-girlfriend, he broke up with her because his mother did not approve of her and would not allow him to marry her. He says that he cannot go against his mother because she "has taken care of me all these years." He states he could never fend for himself without his mother and alternates between being angry with her and feeling that "maybe she knows best." He has not told her that he is angry with her because he is worried that "she might not love me anymore." He has lived at home his entire life except for one semester away at college. He returned home at the end of the semester because he was homesick and did not go back. The patient reports no loss of appetite, concentration, or energy. The patient claims that he performs "adequately" at work and has no job-related problems. He works for an accounting firm in an entry-level position even though he has been there for several years. He says that he has turned down promotions in the past because he knows that he "couldn't possibly supervise anyone or make decisions for them." The patient has two close childhood friends whom he talks to on the telephone nearly every day and says he "feels lost" when he is not with them. The results of his mental status examination are normal except for a depressed mood (although affect is full range).

dependent personality disorder

A 42-year-old woman is hospitalized for severe abdominal pain. After an extensive evaluation, the clinicians have reached a diagnosis of factitious disorder. Which of the following is most likely the motivation behind this patient's behavior?

desire to take on the patient role

A 22-year-old woman is brought to the clinic by her brother, who voices concern about the patient's strange behavior. He states that his sister struggles with depression and that it acutely worsened after a painful breakup with her abusive boyfriend. She did not return home for several days, after which he finally found her at a bar across town. She had facial bruising and appeared disheveled. His sister acted like a "completely different person" and spoke with a French accent. He was unaware of his sister ever learning French. He finally convinced her to come back home with him that night. Since returning home, the woman has "been her normal self." The brother admits that they had a rough childhood, often suffering from physical abuse at the hands of their father. He states that despite an unstable upbringing, "We have done pretty well for ourselves. Both of us are clean and employed." The patient denies any recollection of the past few days. Her last memory before the episode was her boyfriend yelling at her and his fist flying at her face. She felt herself disconnect from her body and cannot recall what happened next. She states that her boyfriend had been increasingly jealous and possessive of her. He accused her of cheating on him, which she adamantly denied. The patient reports that her boyfriend became abusive over the past few months when she began receiving late night phone calls from strange men asking "for the French girl" to "meet up again." She denies straying in her relationship and feels bewildered about these phone calls. The patient does not remember much of her childhood and has "blocked out" the abuse. On memory testing, the patient is oriented to person, place, and time, and does not exhibit any gross impairment. What is the most likely diagnosis?

dissociative identity disorder

A 27-year-old woman with cyclothymia presents to the obstetrician for a routine prenatal visit. She has continued taking lithium during pregnancy. The risk of which congenital abnormality is increased in her child?

ebstein anomaly

Your patient is a 25 year old man diagnosed with schizophrenia and has been doing well on clozapine. At his next office visit, he reports that his symptoms are returning. He has not missed any doses of clozapine and has not changed any other behaviors. You obtain a clozapine level and find that his level is therapeutic. What is the next line of treatment for this patient?

electroconvulsive therapy [ECT]

Which of the following personality traits is most likely seen in patients with histrionic personality disorder?

emotional lability

A 25-year-old man with SPD comes to his psychiatrist with a chief complaint of a depressed mood. He notes that since losing his job as an astrologer, he has been depressed and unable to sleep. He states that although his mood is usually fairly low (4 out of a possible 10), it has lately been a constant 2. The patient also notes problems with concentration and energy level and has experienced several crying spells. He reports he had premonitions that certain foods could heal him, so he has been mixing "magical potions" and eating "magical foods." A mental status examination reveals an oddly dressed man with constricted affect, ideas of reference, unusual beliefs, and some mild paranoia. Which of the following medications is most likely to be helpful to this patient?

escitalopram for depressive symptoms

A 35-year-old woman has been hospitalized repeatedly for severe diarrhea and dehydration. Multiple extensive evaluations including culture for infectious etiologies, stool analysis, upper and lower gastrointestinal endoscopy, and biopsies have returned negative. During her current hospitalization, the attending physician orders a lab analysis, which reveals the presence of laxative use. Which of the following is the most appropriate next step in approaching this patient?

establishing therapeutic alliance

A 32-year-old woman is admitted for second- and third-degree burns of her right hand, which she attributes to accidentally spilling hot oil while she was cooking dinner. Upon evaluation, the surgeon recognizes the patient as someone he treated for a similar burn on the same hand 3 months ago. Further detailed review of her medical records reveals that this is her sixth burn-related injury in 2 years. Upon further questioning, there does not seem to be an attached secondary gain. Which of the following is the most likely diagnosis?

factitious disorder

A 38-year-old woman comes in for evaluation of an abscess on her thigh. Her chart documents frequent outpatient and hospital visits. She is admitted, her abscess is drained, and she is treated with antibiotics. Culture studies demonstrate microorganisms consistent with fecal matter, and a further physical examination reveals many old scars, presumably self-inflicted.

factitious disorder

A 12-year-old girl is hospitalized with severe abdominal pain that has not responded to numerous medications. The comprehensive evaluation, including blood tests and imaging, has been normal. The patient's mother was noted to be very cooperative with medical personnel, but when a psychiatric evaluation was requested, the mother was very unhappy and stopped the consultation after 5 minutes. Investigation revealed that the patient and her mother had been seen in various emergency departments around the county over the past several years. After separating the mother from the patient for several hours, the patient began to improve. Which of the following is the most likely diagnosis?

factitious disorder imposed on another [munchausen by proxy]

Treatment of the patient in Question 44.1 would likely involve administration of which of the following?

flumazenil

A 14-year-old girl presents to the psychiatrist for a new patient evaluation. She endorses depression, anxiety, and feeling like "there is a pit in my stomach and things are spiraling downward." She states she has a lot she wants to do with her life and does not think she will achieve it. She is a straight-A student and enjoys band and art. She states she has been crying a lot and sometimes it feels as if "I do not exist." She describes herself as a tomboy and states she has always been interested in sports. She states she feels more comfortable in boy's clothing. She states she is uncomfortable with her body, especially the development of her breasts. She feels she should have been born a male. She has felt this way since she was 10 years old but was fearful of telling her family due to their strong religious beliefs. She wishes to wear a binder for her breasts and wants to start hormone therapy. She was attracted to both males and females initially and believed she was bisexual. She now reports an exclusive interest in girls. She states she did some research because she didn't feel she identified with being bisexual or lesbian and now identifies as transgender. She recently disclosed to her family 2 months ago that she identified as a male and states this is stressful because her parents do not understand. She states she prefers the use of male pronouns with regard to herself, and she has picked a male name. She is afraid to disclose these facts to her family. On mental status exam, she is well-groomed and cooperative. She is dressed in boy's clothing brands consisting of jeans and a t-shirt with a button-down shirt over it. Her hair is shortly cropped, and she is wearing a baseball cap. She is alert and oriented to person, place, and time. No abnormalities were found on her mental status examination.

gender dysphoria

A 42-year-old man comes to see a psychiatrist stating that his life is "crashing down around his ears." He explains that since his girlfriend of 2 months left him, he has been "inconsolable." He says that he is having trouble sleeping at night because he is mourning her loss. When asked to describe his girlfriend, the patient states, "She was the love of my life, just beautiful, beautiful." He is unable to provide any further details about her. He says that they had five dates, but that he simply knew she was the one for him. He claims that he was often in the "depths of despair" in his life, but that he also felt "on top of the world." He denies any psychiatric history or any medical problems. On a mental status examination, the patient is dressed in a bright, tropical-pattern shirt and khaki pants. He leans over repeatedly to touch the female interviewer on the arm as he speaks, and he is cooperative during the interview. He sometimes sobs for a short period of time when talking directly about his girlfriend but smiles broadly during the interview when asking the interviewer questions about herself. His speech is of normal rate, although at times somewhat loud. The patient describes his mood as "horribly depressed." His affect is euthymic the majority of the time and full range. His thought processes and thought content are all within normal limits.

histrionic personality disorder

A 36-year-old man presents to his PCP for evaluation of his complaints. He is convinced that he has colon cancer despite being told that it is unlikely because of his young age. He occasionally notices traces of red blood on the toilet paper, which he had previously attributed to hemorrhoids, and abdominal cramps when he eats too much. A review of the records demonstrates numerous prior appointments in connection with the same or similar complaints, including repeatedly negative results from tests for occult fecal blood and normal results from colonoscopies. He continues to be worried about dying of cancer and requests another colonoscopy. Which of the following is the most likely diagnosis?

illness anxiety disorder

A 42-year-old man returns to his internist for the fourth time in 5 months with the same complaints of intermittent numbness of his fingers and indigestion. Although his medical workup has been unremarkable, this has failed to reassure him. He remains anxious and is now concerned that he has celiac disease and requests a gastrointestinal (GI) consultation. Which of the following is the most likely diagnosis?

illness anxiety disorder

Ms. K, a 60-year-old woman, is brought by her sister to see a psychiatrist at a local mental health center with complaints that Ms. K has "changed" over the past year. According to the sister, Ms. K appears anxious all the time and stays by herself in her room, not socializing with anyone. She even quit her "very good" job at the local school. Ms. K has not been eating well and has lost significant weight within the time. She used to be a "fun-loving" person before. The sister wants the physician to "bring her sister back." Ms. K denies that she is sad. She worries about her health because she is convinced that mercury poisoning has caused all her symptoms, but the doctors "do not seem to believe her." She reports that about a year ago, she visited her dentist and was informed that her dental filling had fallen off. That night, her husband jokingly said that she may have mercury poisoning since "silver dental fillings may cause it." Ms. K then began to research mercury poisoning on the Internet. Within several months, she developed all the symptoms of mercury poisoning that were mentioned on various websites. She started to isolate herself in her room to further look up the symptoms on the Internet. She often gets into arguments with her husband because he thinks that "she is getting paranoid." She gets irritable when her sisters visit and refuses to go out to eat with them. Ms. K cannot sleep well because thinking about her illness keeps her awake at night. She reports she cannot eat much. After 6 months of symptoms at home, her family took her to see her primary care provider (PCP), who performed a thorough physical and neurologic exam and ran several tests, including blood and urine tests, to measure mercury levels. All of these tests were within normal limits. Ms. K seemed relieved for few days but the Internet searches began again, and so did all the symptoms. She was taken back to her PCP, who then referred her to the psychiatrist. There is no personal or family history of major psychiatric illnesses or substance abuse. Psychiatric review of systems reveals mild to moderate anxiety, which has never been treated with psychotropic medications. Mental status exam reveals no paranoid thoughts or hallucinations. Ms. K has a calm demeanor with no agitation and very rational thinking. She states, "I know I may be having anxiety for no reason, but I am still having all the symptoms of mercury poisoning."

illness anxiety disorder

A 32-year-old man with a long-standing heroin addiction has recently started maintenance treatment with methadone. Three days since starting the methadone regimen, he is now experiencing some craving, diarrhea, and mild sweating. His urine toxicology screen is negative for any opiates besides methadone. Which of the following is the most appropriate course of action?

increase dose of methadone

A 24-year-old woman is called into the head office of the agency where she works and told that her chronic lateness in completing her assignments will result in her dismissal if she does not change her behavior. The patient really loves her job, and the news comes as a major blow. That night at home, she tells her boyfriend in great detail about each and every step of the meeting and spends the entire night thinking about her job. The boyfriend tells her that she does not "look" particularly upset. Which of the following defense mechanisms is being used by this woman?

intellectualization

A woman with schizoid personality disorder was involved in a motor vehicle accident in which she was rear-ended by another car. The driver of the other car refused to take responsibility for the accident and hired a lawyer to provide his defense. The woman spends hours every day thinking about the specifics of the accident, including such details as the color of the cars involved and what each party to the accident was wearing. Which of the following defense mechanisms, common to patients with schizoid personality disorder, is the woman using?

intellectualization

A patient breathes through a thin straw in order to produce the sensation of not getting enough air; this activity produces or similar sensation to the distressing feeling of getting on an airplane.

interoceptive exposure

A 54-year-old man is being seen for anxiety associated with depression. He has been tried on various medications without success, and the psychiatrist is considering prescribing a benzodiazepine. He also has been diagnosed with chronic hepatitis C infection. Which agent would be safest for this patient?

loreazepam

A 44-year-old woman comes to your office for a follow-up visit. She recently received a diagnosis of major depressive disorder and began treatment with citalopram (an SSRI) 6 weeks ago. She claims to feel "happy again," without further depression, crying spells, or insomnia. Her appetite has improved, and she has been able to focus at work and enjoys time with her family. Although she experienced occasional headaches and loose stools at the beginning of her treatment, she no longer complains of any side effects. Which of the following is the most appropriate next step in her treatment?

maintain current dose of citalopram

Children or adolescents with separation anxiety disorder are at higher risk for which other psychiatric disorder?

major depression

A 20-year-old woman comes to see a psychiatrist at the insistence of her mother, who states that her daughter just "isn't herself." The patient is spending a great deal more time alone in her bedroom, she doesn't seem to be caring for her hygiene as well as usual, and has been missing work a great deal more. She is very clingy and attention seeking with her mother. Which of the following diagnoses best fits this patient's presentation?

major depressive disorder

A 16-year-old student is brought to the emergency department by her parents. She says that for the past 6 weeks, she feels as if she "just can't cope with all the pressure at school." She broke up with her boyfriend 6 weeks ago. Since that time, she cannot sleep more than 3 or 4 hours a night. She has lost 15 lb without trying to, and her appetite is decreased. She says that nothing interests her and that she cannot even concentrate long enough to read a magazine, much less her textbooks. Her energy level is very low. She is not doing things with her friends like she was in the past and says that when she is with them, "things just aren't fun like they used to be." She tends to be irritable and gets angry with slight provocation. On a mental status examination, she is observed to be a well-dressed teenager with good hygiene. She notes that her mood is very sad, 2 on a scale of 1 to 10 (where 10 is the best possible mood). Her affect is dysphoric and constricted. She admits to hearing a voice telling her that she is "no good." She has heard this voice at least daily for the past week. She states she has had thoughts of suicide frequently over the past several days but denies that she would act on these thoughts because it would be a "sin." She does not have a suicide plan. No delusions are present, and she is alert and oriented to person, place, and time. She reports that she has "never felt anything like this before in my life!"

major depressive disorder with pyschotic features

A 19-year-old man presents to a psychiatrist insisting, "I have schizophrenia and need to be admitted." He describes hearing voices telling him to kill himself for the past several days. He says that he is possessed by the devil. The patient denies feeling depressed but insists he will hurt himself if he is not admitted to a hospital immediately. He has vague suicidal plans and says he will find some ways to kill himself but cannot be more specific. He has no prior history of psychiatric treatment or complaints, no medical problems, and is not taking any medication. He drinks one or two beers a week and denies using drugs. At the end of the interview, he again requests hospitalization. He then adds that he is currently on leave from the Navy and is due back on his ship, which is leaving in 2 days. On a mental status examination, the patient is initially cooperative and forthcoming but becomes increasingly irritated when asked to give more details about his symptoms. He has good hygiene and maintains good eye contact. His mood and affect are euthymic and full range. His thought processes are logical, without looseness of association or thought blocking. His thought content is notable for suicidal ideation but no homicidal ideation. He reports having delusions and auditory hallucinations but doesn't seem to be responding to any internal stimuli. His insight seems good considering the severity of his symptoms.

malingering

A 34-year-old woman is admitted to the inpatient psychiatric unit after being brought to the emergency department by police because of an episode of aggression in which she destroyed her brother's house during an argument. She initially states she has no recollection of the incident. She then goes on to provide vague details about how she ended up at her brother's and discloses that she was told she did 5000 dollars' worth of property damage. She verbalizes repeatedly that she is concerned about the legal consequences of her actions. She reports she has never had an episode like this but doesn't appear particularly distressed about it. She refuses to allow consent for collateral information to be gathered. What is the most likely diagnosis?

malingering

A 45-year-old man complains of lower back pain and weakness in his legs after lifting heavy boxes while at work. He says that he has not been able to go to work for several days. He requests treatment and a letter excusing him from work. On examination, he is found to have significant lumbar pain without spasms. The strength in his legs is decreased because of a lack of effort. His reflexes are within normal limits. He was observed to be ambulating without any problem in the waiting area prior to the appointment.

malingering

A 50-year-old man is referred to a clinician because he has ongoing migraine headaches. His headaches are chronic and bilateral, are worse with loud noises and light, and occur without aura or vomiting. His physical examination is unremarkable except that the patient does not appear to be in significant distress. When he is presented with various options for treatment, including nonsteroidal anti-inflammatory medications, he becomes angry, demanding that acetaminophen with codeine is "the only thing that has ever helped" him. When he is told that non-narcotic medications should be tried first, he accuses the provider of not believing him and storms out of the clinic.

malingering

Which evidence-based treatment is likely most effective for the treatment of CD?

multimodal interventions

A 45-year-old man is admitted to a cardiac intensive care unit after suffering a heart attack. Twenty-four hours after admission, the consultation psychiatrist is called in to make an evaluation because the patient is trying to sign himself out against medical advice. When the psychiatrist enters the patient's hospital room, she finds him getting dressed and yelling at the top of his lungs, "I won't be treated in this manner! How dare you!" The patient does agree to sit down and speak with the psychiatrist, however. He tells the psychiatrist that staff members are simply rude and do not treat him "in the manner to which he is accustomed." He says that he is a small business owner, but that he is on the way up and "as soon as people realize my full potential, I will be a millionaire." He cannot understand why the staff will not bring food up from an outside cafeteria for him because the food in the hospital is so bad. He asks the psychiatrist whether, after the interview, she will get some food for him, and he becomes angry when she declines. He then eyes her new, expensive watch enviously. On a mental status examination, the psychiatrist finds no disorders of thought process or content, and the patient is found to be oriented to person, place, and time

narcissistic personality disorder

A 50-year-old man with a past history of chronic, treatment-resistant schizophrenia was admitted last night after reemergence of command AHs telling him to "do bad things." He had been recently hospitalized and stabilized on clozapine. He denies missing any doses. What addiction is the most common form of substance abuse in patients with schizophrenia and likely contributed to the patient's recent psychotic episode?

nicotine

A 23-year-old medical student makes lists of all the tasks that he must accomplish each day. He spends hours studying and refuses to go out with his colleagues even when there are no tests on the immediate horizon, preferring to spend his time looking at specimens in the laboratory. He keeps meticulous notes during all his classes and attends every lecture, not trusting his colleagues to take notes for him. He is doing well in school and has a girlfriend who is also a medical student. Which of the following conditions does this student most likely have?

obsessive compulsive traits

A 36-year-old man is referred to his employment assistance agency because he has trouble making timely decisions and is often late with important work. The patient has angrily complied with this request although he does not believe that anything is wrong with him. He describes himself as "so devoted to my work that I make others look bad," believing that this is why he has been singled out for attention. The patient says that he has worked at the company for 4 years and during that time has put in anywhere from 10 to 12 hours of work per day. He admits that he often misses deadlines but claims that "they are unreasonable deadlines for the quality of work I provide." He states, "If more people in the country were like me, we would get a lot more done—there are too many lazy slobs and people who don't follow the rules." He points out that his office is always perfectly neat, and he says, "I know where every dollar I ever spent went." On a mental status examination, the patient does not reveal any abnormalities in mood, thought processes, or thought content. His manner is notable for its rigidity and stubbornness.

obsesssive compulsive personality disorder

A 56-year-old divorced, unemployed man with a long-standing history of substance abuse presents to the emergency department with abdominal pain, sweats, diarrhea, and body aches. On initial evaluation, the patient is noted to have a watery nose and eyes, a slightly elevated temperature of 100 °F (37.8 °C), and dilated pupils. His mood is dysphoric, and his affect is irritable and labile. His abdominal examination is benign. Laboratory examinations including electrolytes, complete blood count, liver function tests, amylase, and lipase are all normal. A plain abdominal x-ray showed no clear cause for his abdominal pain.

opiod withdrawl/ use

A 16-year-old adolescent boy is being seen for follow-up after a diagnosis of schizoaffective disorder based on the findings of depressive symptoms and hearing voices. The patient is prescribed olanzapine. Upon returning to the office after 1 week, he has not improved. In fact, he seems to have worsened. Which of the following is your best next step?

order a urine serum toxicology for substances of abuse

A 36-year-old man comes to his primary care provider's office with the chief complaint that "people are out to hurt me." Despite being reassured by his wife that this is untrue, the patient is convinced that people are observing his behavior and actions at home and at work, using telescopic lenses and recording devices. He has torn apart his office on more than one occasion "looking for bugs." The patient's wife says that this behavior is relatively new, appearing somewhat suddenly after the patient was robbed on the way to his car approximately 6 months previously. Which of the following symptoms best describes what the patient is experiencing?

paranoid delusions

A 47-year-old man is referred to a psychiatrist at his employee assistance program because of continuing conflicts on the job. This is the third time the patient has been referred to a psychiatrist under such circumstances. He lost two previous jobs because of conflicts with coworkers. The patient states that people do not like him and would like to see him fail. He cites as an example one instance in which one of his colleagues was late in sending him some material he needed, resulting in the patient being unable to complete his assignment in a timely fashion. Although the colleague apologized for the mistake, the patient says that he knows that this man "is out to get me fired." He has since broken off all contact with this coworker and refuses to speak with him directly, preferring to use only written communication. On a mental status examination, the patient appears somewhat angry and suspicious. He glares intently at the interviewer and sits with his back to the wall. He repeatedly requests a clarification of questions, often asking, "What will this material be used for? I bet you are going to use it against me so that I will be fired." When the interviewer's pager goes off, the patient accuses him of trying to shorten the time allotted to him by arranging to have the pager interrupt them. The patient's mood is described as "fine," but his affect is tense and he appears suspicious and ill at ease. He denies auditory or visual hallucinations and says, "You want to make me look crazy so you can fire me!" The patient's thought processes and thought content are both within normal limits.

paranoid personality disorder

A 65-year-old retired engineer presents to his primary care provider at the insistence of his wife. The patient reports not needing as much sleep as he used to—only a few hours for the last few nights. He is considering going back to work because he wants to share his knowledge with "all the young fledgling engineers—they need my guidance." His wife notes that he has been very irritable and overly talkative lately. The patient has no previous psychiatric or medical history. He denies use of drugs or alcohol. Which of the following is the best next step?

perform a physical exam

Which of the following scenarios is most consistent with factitious disorder?

placing feces in urine to receive treatment for a UTI

Which of the following is a poor prognostic indicator in the treatment of fetishists?

presence of another paraphillia

A 42-year-old woman undergoing psychotherapy storms into her therapist's office for her session and angrily accuses the therapist of "trying to undermine [her] intelligence." After a discussion with the therapist, it becomes clear that it is the patient who is second-guessing herself, thereby "undermining" her own intelligence. Which of the following defense mechanisms is this patient using?

projection

A 27-year-old man is referred to your office by his boss for filing numerous unfounded complaints against his co-workers. The patient tells you "there is nothing wrong with me! In fact, everyone at work is trying to sabotage me constantly! They are the ones who should be sitting here!" He denies any hallucinations or delusions. Which of the following is the best treatment option?

provide supportive psychotherapy

A 35-year-old woman who has been diagnosed with a histrionic personality disorder has seen her psychotherapist once a week for the past year. She has come in the last few visits subtly different. She appears more distracted, is late for appointments, reports an increased amount of arguments with her family, and appears flushed and even sweaty. You asked about use of illicit substances and she denies it. Which of the following is the most important next step in this patient's management?

request urine toxicology screen for substance abuse

A 40-year-old man with schizoaffective disorder has been hospitalized in an inpatient psychiatry unit for the third time in the last 5 years. During each episode prior to hospitalization, he becomes noncompliant in taking his medications, develops manic symptoms and auditory hallucinations, and then becomes violent. In the inpatient unit, he physically threatens other patients and staff and is generally agitated. He is put in isolation to help quiet him. The patient is prescribed a mood stabilizer. Which of the following medications would be most appropriate to help relieve this patient's acute agitation?

risperidone

A 15-year-old adolescent girl is brought to your office by her family after a recent hospitalization for a suicide attempt. She made this attempt shortly after a party she attended the previous weekend. At this party, she reportedly argued with her best friend and left very angry. Her history at admission shows a several-month history of irritability, worsening performance in school, poor sleep, anhedonia, anergia, and isolation from her family and friends. Her discharge summary has an admitting diagnosis of major depression for which she was started on fluoxetine (Prozac). She sees you 2 weeks after her 3-day hospitalization and is quite cheery, energetic, and happy. She reports no problems and dismisses her earlier suicide attempt as a childish act to get attention. She reports that the staff at the hospital were absolutely wonderful and helped her solve all her problems. She says that she was so impressed with them that she has decided to go into psychiatry herself so she can help others. Later, while meeting with the parents, they report that at home she is sleeping well and appears in a good mood. Nevertheless, they are concerned because they also report that she is worried about whether there were cameras in the doctor's office that were recording her. She also reports that she believes she is being stalked by several of the boys at her school.

schizoaffective disorder

A 30-year-old man is brought to a psychiatrist by his parents because they are concerned that he seems to lack ambition. He lives in his parents' basement, never having lived on his own. He has no friends or social contacts. He works from home as a computer programmer, working for the same company since graduating from college online. When asked, he shrugs and tells you he is happy and doesn't need anything else out of life. Which of the following is the most likely diagnosis?

schizoid personality disorder

A 56-year-old man is referred to a psychiatrist from his primary care provider due to restricted affect and concern about possible depression. The patient denies that he is depressed or feeling stressed. He was doing well in his job as a security guard, working the night shift, until he was told that his position was being phased out and that in order to stay with the company, he would need to switch to the day shift. The patient agreed because he did not think that this would be a problem and did not want to lose his insurance benefits and retirement plan. However, after several months in his new position, he admits he is concerned that he is not doing as well in his new position. His previous position allowed him to work on his own for the vast majority of his work hours, while his new job requires almost constant interaction with coworkers, clients, his supervisor, and the general public, which does not agree with him; he describes himself as "not a very sociable person." The patient says that he has almost no friends, except for a cousin to whom he has been close since childhood. He reports that he has never had a significant romantic relationship or sexual encounter, but he does not miss having these experiences or having friends. He states that he most enjoys spending hours surfing the Internet, collecting stamps, or playing computer games by himself. He has never seen a mental health professional before and has presented today only at the insistence of his primary care provider. On mental status examination, the patient appears notably detached and aloof toward the examiner. He exhibits little eye contact. His mood is reported as "stressed," but his affect is not congruent with this. He appears calm, and his emotional range is flat. No other prominent symptoms are noted during the mental status examination.

schizoid personality disorder

A 26-year-old man who is a medical student with no prior psychiatry history is referred to your office by the dean of students. The student's friends came to the Dean with concerns that he has not been going to classes for over a month. They reported that over the past 6 months, he hasn't seemed himself, he's been more withdrawn, and he doesn't seem to be doing as well in his classes. After he stopped going to class, they went to his apartment to check on him. They became scared because his apartment was filthy, he had taped aluminum foil over all the windows, and he kept telling them they had to leave "before they become targets too." The patient appears disheveled as though he hasn't showered or brushed his hair in over a week. He clutches a notebook to his chest with all the "proof of the conspiracy" written inside. When you ask to see the notebook, he quickly opens it to a random page, which you see is covered with words scribbled in no organized fashion. He reports feeling depressed because "they will eventually catch me and torture me for the secrets...who wouldn't be depressed?" He denies changes in sleep or appetite but admits he has run out of food at his apartment and has been too scared to leave to buy more groceries. He would love to play basketball—his favorite hobby—but states, "I don't have time because I have to protect the secrets." On mental status exam, he is unkempt. He has poor eye contact, and his eyes constantly dart around the room. His affect is blunted. He is suspicious, asking several times, "Are you in on it? How do I know you're not in on it?" He denies hearing voices, but you notice him frequently turning to the side and mumbling under his breath. He denies using drugs or alcohol because "I've got to stay sharp!" He denies suicidal or homicidal thoughts.

schizophrenia

A 20-year-old man is brought to a psychiatrist by his parents for odd thinking. He is dressed in clothes consistent with a 1960s hippie, with long unruly hair and marginal hygiene. He was recently fired from his job for not showing up for his shifts and was forced to move back in with his parents. He has artistic aspirations and is very interested in philosophy, metaphysics, magic, and the occult. He talks about his desire for fame and wealth, given his special talents. He has recently gotten into some legal trouble because he produced artwork of fanciful paper currency, which he attempted to use at some local stores. However, he admits that he did not think that this was going to work and describes this as a performance art. Which of the following is the most likely diagnosis?

schizotypal personality disorder

A 13-year-old boy presents to a psychiatrist for the first time and gives a history indicative of gender dysphoria. He states that he wishes to undergo treatment to suspend puberty. Which of the following treatment steps is most appropriate?

screening the patient for psychopathology

Which of the following would be the most useful psychiatric treatment for the patient with dependent personality disorder?

sociotherapies

A 42-year-old woman describes a 20-year history of numerous physical complaints, including joint pain, dysuria, headaches, chest pain, nausea, vomiting, irregular menses, and double vision. Although they do not all occur at the same time, she has been suffering from one or more of these problems throughout her adult life. Many medical evaluations have been performed, and she has undergone repeated hospitalizations, but no specific cause has yet been found. Discussion with her husband confirms no traumatic events in the patient's life. She is extremely anxious and has become significantly disabled as a result. Which of the following is the most likely diagnosis?

somatic symptom disorder

A 53-year-old man pulls a back muscle while doing his usual exercise routine 6 months ago. He sought out several medical opinions with sports medicine, orthopedics, and neurology, all of which assured him that he only experienced an unfortunate muscle strain. However, the patient currently exhibits high levels of anxiety and ascribes any ache or pain to some unknown malady. He is so fearful of reinjury that he no longer exercises, always walks with a cane, and is insistent that someone be with him at all times in case he becomes debilitated.

somatic symptom disorder

A 63-year-old woman returns to her family care provider with continuing headaches for 9 months. She describes the pain as "constant ... always with me," around her entire scalp. She does not appreciate much variation throughout the day, and she cannot name any aggravating or alleviating factors. Although she occasionally feels lightheaded when in severe pain, she denies photophobia, visual changes, nausea, or vomiting. She is especially upset about the headaches, as she retired in the past year and has been unable to travel to visit her infant granddaughter. Complete neurologic examination, computed tomography, magnetic resonance imaging, laboratory studies, and lumbar punctures have been unremarkable. Which of the following is the most likely diagnosis?

somatic symptom disorder with predominant pain

A 42-year-old woman presents to her primary care provider with a chief complaint of back pain for the past 6 months that began after she was knocked down by a man attempting to elude the police. She states that she has extreme pain on the right side of her lower back, near L4 and L5. The pain does not radiate, and nothing makes it better or worse. She says that since the injury she has been unable to function and spends most of her days lying in bed or sitting up, immobile, in a chair. Immediately after the accident, she was taken to an emergency department, where a workup revealed back strain but no fractures. Since then, the patient has repeatedly sought help from a variety of specialists, but the ongoing pain has been neither adequately explained nor relieved. She denies other medical problems, although she mentions a past history of domestic violence that resulted in several visits to the emergency department for treatment of bruises and lacerations. On mental status examination, the patient is alert and oriented to person, place, and time. She is cooperative and maintains good eye contact. She holds herself absolutely still, sitting rigidly in her chair and grimacing when she has to move even the smallest amount. Her mood is depressed, and her affect is congruent. Her thought processes are logical, and her thought content is negative for suicidal or homicidal ideation, delusions, or hallucinations.

somatic symtpom disorder

You are consulted to evaluate a 45-year-old married woman who was admitted to the surgical service 2 days ago for an appendectomy. The procedure went well, but she was found to be tearful, stating, "I wish I were dead." On obtaining further history, she is quite cooperative and talkative. She is questioned about her earlier comments, and she states that she "wanted attention, I guess." She is upset that her husband is not with her in the hospital; she has "never been away from him" for this long since they started dating when the patient was 16 years old. She feels helpless and is having a difficult time being active in her care. She feels overwhelmed regarding her postsurgical and discharge instructions, and the nursing staff has become frustrated with her constant need for reassurance. Although at times she is tearful during the interview, she denies prior or recent pervasive depressive or neurovegetative symptoms and is not actively suicidal. Which of the following is the most appropriate approach to this patient?

spend regular short periods of time with her to discuss discharge planning and aftercare

Which of the following approaches would be the most effective for the patient conversion disorder?

suggestion that the symptoms will improve with time

A 24-year-old woman with a diagnosis of panic disorder is being treated with alprazolam 1 mg twice daily in addition to citalopram 20 mg daily. Since starting the medications, she has noticed a reduction in the number of panic episodes but reports feeling anxious and close to a panic attack when she wakes up each morning, which lasts until she takes her morning dose of medications. What is the next best step in management?

switch alprazolam to clonazepam

A 23-year-old woman with a diagnosis of histrionic personality disorder comes to see her primary care provider for the chief complaint of frequent headaches. As the (male) provider is taking the patient's history, he notices that the patient is frequently reaching across the desk to touch his arm as he talks to her, as well as leaning forward in her seat to be nearer to him. She expresses her gratitude in his listening to her. Which of the following responses is the most appropriate response from the provider during this interview?

tell the patient that he understands her concern but touching him is innapproproate

Psychotic depression is diagnosed in a 14-year-old boy, and he is treated with an antipsychotic agent (risperidone) and an antidepressant. Three months later, his mood symptoms have resolved and he is no longer psychotic. Which of the following best describes the next step?

the antipsychotic medication should be discontinued via a taper

Which of the following is one of the main reasons that many other previously distinct disorders were grouped in ASDs by DSM-5?

the disorders were not as discrete and independent as previously thought

Patients with schizophrenia or other psychotic disorders may present with delusional claims of cross-gender issues. Which of the following pieces of history would suggest that a male patient's claim of cross-gender identity is due to delusions?

the patient actually believes he is a member of the other sex

A married pharmacist comes in for treatment at the insistence of his wife, who was disturbed to find that he was wearing some of her undergarments under his clothes. He admitted to her that he often masturbates when wearing her underwear and fantasizes about wearing it while having intercourse with her. Which of the following best describes this paraphilia?

transvestic behavior

A 35-year-old man being seen for major depression shares that he enjoys dressing as a woman and masturbating in private. He finds cross-dressing very arousing sexually but is married, and his wife has become aware of this. She is very upset, and there have been marital problems over his behavior. At work and in other settings, he functions in typical male roles and activities. He had two sexual experiences with men before he got married. He feels very committed to his marriage and finds his wife sexually attractive. The best diagnosis for this patient would be which of the following?

transvestic fettishism

A 71-year-old woman with a history of early Alzheimer disease is brought to the hospital by her family because "she is just not acting like her normal self" since waking up this morning. She takes no medications. On mental status examination, she is lethargic, easily distractible, and oriented only to person. At baseline, she is oriented to person and place but has difficulty recalling the date and time. Physical examination and diagnostic workup are suggestive of an uncomplicated urinary tract infection (UTI). What is the most important component of treating this patient's delirium?

treat her UTI with antibitoics

A 17-year-old adolescent girl is seen in your office after her friends noticed some strange behavior. The patient reports to you that in addition to some long-term depression issues, she has begun to experience some other disturbing events. She reports that over the last 2 months she has been hearing voices—both at work and at home—of people she does not think are there. She does not recognize these voices. Sometimes they just give a dialogue of what she is doing, but more disturbing to her is when they start saying horrible things about her and tell her to do things she does not want to do. You start her on olanzapine, and when she returns in 1 week, the voices have been gone entirely for 2 or 3 days. However, she continues to experience severe mood symptoms. Her Hamilton Depression Rating Scale score places her in the moderate to severe range for depression. Which of the following should you do next?

treat the patient with fluoxetine [SSRI]

A 29-year-old woman with no medical or psychiatric history is brought to the emergency department (ED) by her husband because of her bizarre behavior. She has been ranting about being a victim of gang stalking ever since she lost her job at the postal service. "I know they are after me," she states repeatedly. Her husband states that since being laid off, the patient has been spending much of her time "with the neighborhood druggies." Which of the following would the initial workup include?

urine drug screen

Acute stress disorder is diagnosed in a 32-year-old woman who witnessed her fiancé being shot to death in a robbery attempt. She has difficulty sleeping and feels that she is not emotionally attached to anything around her. She also has repetitive flashbacks of the event and avoids going near the location where the incident occurred. Which of the following medications might be helpful to this patient over the short term?

zolpidem [hypnotic]

Which of the following is an area of the brain which appears to be most closely related to anxiety based on functional imaging studies?

Amygdala

Atomoxetine is a relatively new drug used for the treatment of ADHD. Which of the following represents the advantage of using atomoxetine over methylphenidate?

Atomoxetine appears to have less of a potential for abuse than does methylphenidate (Ritalin).

A patient with obsessive-compulsive personality disorder may also be categorized in a grouping of disorders named Cluster C personality disorders. Which other personality disorder is part of Cluster C?

Avoidant personality disorder

first line treatment for bulimia

CBT

A patient is asked to imagine his wartime experiences as vividly as possible, in order to confront his memory of the traumatic events.

imaginal exposure

A 24-year-old man presents to a therapist. Which of the following statements made by the patient is most consistent with avoidant personality disorder?

"I have a couple of close friends, but it is very hard to make friends. I'm afraid most people wouldn't want me around."

Which of the following scenarios is most consistent with antisocial personality traits?

A 67-year-old man, who is a CEO, embezzles from his company, is unfaithful to his third wife, and has been involved in covering up corporate malfeasance from federal investigators.

A 9-year-old boy is referred to a psychiatrist because of poor school performance. He has been tested for learning disabilities but none are present, and he has an IQ in the high normal range. The teacher reports that it is hard to hold his attention and that he appears hyperactive and fidgety at school, which disrupts the class. However, he does not purposefully go out of his way to disobey the teacher. His parents have noticed no difficulties at home, but his soccer coach has noticed attention problems during practice, and his Sunday school teacher has trouble teaching him because of distractibility. Which of the following is the most likely diagnosis for this patient?

ADHD combined type

A 16-year-old girl has been admitted with a 3-week history of sudden irritability, impulsive buying, and disappearing at night with older men. Her need for sleep is decreased; she has flight of ideas and grandiose thoughts about being an advisor to a presidential candidate. Test results indicate she is pregnant. Which of the following is the most appropriate statement that should be made to her parents?

An atypical antipsychotic may be the best choice for managing both psychotic features and mood disturbance associated with her bipolar disorder, especially during the first trimester of pregnancy.

A 19-year-old woman is referred to a psychiatrist after her roommates become concerned about her behavior. The patient tells the psychiatrist that for the past 2 years, since beginning college, she has been making herself vomit by sticking her fingers down her throat. This behavior occurs regularly, as many as three or four times a week, and worsens when she is stressed out at school. The patient says that she regularly gorges herself with food and is worried that she will become overweight if she does not vomit it up. She describes her gorging episodes as "eating whatever I can find" in large quantities and mentions one incident in which she ordered three large pizzas and ate them all by herself. The patient states that she feels out of control when she is gorging herself but is unable to stop. She is ashamed of this behavior and goes to great lengths to hide how much she eats. She notes that her sense of self-esteem seems to be very dependent on her weight and whether or not she sees her body image as fat. She agreed to see a psychiatrist after her roommates found out about the self-induced vomiting. A physical examination shows a young woman, 5 ft 6 in tall and weighing 135 lb. Her vital signs are: blood pressure 110/65 mm Hg, respirations 12 breaths per minute, temperature 98.2 °F (36.8 °C), and pulse rate 72 beats per minute (bpm). The rest of her physical examination is within normal limits. What is the most likely diagnosis?

Bulimia nervousa

A 30-year-old man was the recent victim of a tornado. He reports he survived by sitting in the bathtub in his underwear as the tornado went through the town. He reports he had to go to a shelter after that and now is trying to rebuild his life. He has nightmares every night. His mood is sad, and he is hypervigilant. Which of the following approaches might be helpful in preventing the development of PTSD?

CBT

A 35-year-old man is being seen in the office because "I'm afraid to give presentations and I'm going to lose my job." He stated that ever since he could remember, he has had a fear of speaking in public or being the center of attention. He feels awkward in social situations and does not know what to say. During these times, he reports that his heart races and he sweats profusely. Which of the following would be most effective in treating his condition?

CBT

A 37-year-old man is referred to a therapist to begin psychotherapy for his PTSD. Which of the following has been shown to be the most efficacious treatment for his condition?

CBT

A 37-year-old man who works as a college professor and has a history of GAD and major depressive disorder (MDD) has been referred to psychiatry by his primary care provider. His symptoms have been relatively well controlled up until last semester when he received negative reviews from his students. Since this time, he has started to doubt his ability to teach, worry about his career, and ruminate on each lesson plan. He worries that his reputation among the students has been irrevocably damaged, which makes him feel despondent. The professor desperately wants to get help but is hesitant to try any medication that will impair his intellectual prowess. Which of the following is the most effective treatment approach?

CBT and escitalopram [SSRI]

A 10-year-old boy is being seen in the office for flight of ideas and inflated mood. He is diagnosed with mania without psychosis. Which of the following medications would be the best choice for mood stabilization for this patient?

Divalproex [mood stabilizer]

The patient in Question 38.1 is treated appropriately, with normalization of his vitals and laboratory test results, and he is released from the hospital after 8 days. He immediately enrolls in an outpatient rehabilitation program, which he is required to attend three times per week, as well as AA meetings daily. He is quite hopeful about his recovery and denies significant depression, although he is greatly concerned about a possible relapse. While he is interested in medication to minimize his risk, he admits to being "very forgetful" with medications. Which of the following medications would be most appropriate to initiate in this patient?

Naltrexone

A 13-year-old adolescent girl is brought to a psychiatrist by her mother. The patient states that for the past 6 months she has been showering for long periods, up to 5 hours at a time. She says she is unable to stop this behavior although it is distressing to her and causes her skin to crack and bleed. She reports that the symptoms started after she began to have recurrent thoughts of being dirty or unclean. These thoughts occur many times a day. She states that she grows increasingly anxious until she is able to take a shower and clean herself. The patient claims that the amount of time she spends in the shower is increasing because she must wash herself in a particular order to avoid getting the "clean suds" mixed up with the "dirty suds." If this happens, she must start the whole showering process over again. The patient states that she knows she "must be crazy," but she seems unable to stop herself. The patient's mother verifies the patient's history. She claims that her daughter has always been popular in school and has many friends. She emphatically states that her daughter has never used drugs or alcohol. The patient's only medical problem is a history of asthma, which is treated with an albuterol inhaler. The patient's mental status examination is otherwise unremarkable except as noted earlier. What is the most likely diagnosis? What type of therapy should you use for this patient?

Obsessive compulsive disorder Behavioral therapy involving exposure and response prevention

A 32-year-old man is seen in the clinic for a new patient appointment. His chief complaint is "feeling angry and having a temper." He is a veteran who left the military 2 years ago, after three tours of duty in Iraq. He was an army medic and had been involved in the rescue and treatment of severely wounded army personnel. During his last tour of duty, the patient's vehicle was hit by a roadside improvised explosive device (IED). One of his close friends died in that incident. He felt he could not continue in the army after that and has since been discharged. Since coming back to the United States, he has continued to struggle. He has not been in a long-term stable relationship, as his relationships end up having arguments and fights. The 4th of July is hard for him since he feels he needs to fall to the ground and look for cover at the loud sound of fireworks. During those times, he is also extremely anxious. Driving on dirt roads is also a problem for him, and whenever something hits the car and makes a loud noise, he ducks and starts yelling. He reports he has nightmares almost every night, mostly about his experiences in Iraq. He can't sleep and has been drinking every night to the point of passing out. He has avoided going out with his military buddies and doesn't hunt anymore. He feels he cannot connect with any of his friends or family like he did in the past. When asked about the events in Iraq, he becomes loud, upset, and states he doesn't remember anything and insists that he is bad and feels guilty over being alive. He has been involved in several bar fights, sometimes for minor reasons. When going out to eat, he feels the need to sit in a place from which he can see the whole restaurant. Otherwise, he has to leave. He gets startled easily when someone approaches him unannounced. He works at a local gardening center and expresses gratitude to his boss for being understanding. He has to take breaks and go and sit in his car when he feels like crying while on the job. On mental status examination, he appears appropriately dressed and cooperative. He keeps looking around the room and repeatedly at the door and window of the office. His mood is "angry" and affect is irritable, particularly while talking about his past experience in the military. Speech is loud at times, but not pressured. Thought process is linear, but he struggles to tell a coherent story about his experience in war. He denies any suicidal or homicidal ideations but states, "I can't carry on like this." He denies any hallucinations or delusions but states, "No one can be trusted." Cognition is intact, and insight and judgement seem fair. What is the most likely diagnosis?

PTSD

A 34-year-old office clerk was a victim of robbery at his place of work 4 months ago. He was alone at the time when two individuals entered, demanded all the cash at the store, and pointed a gun at him. One of them kicked him to the floor when he was slow to react. Since then he has not been sleeping well, having recurrent nightmares about the robbery. He has thought of going back to work and has been to the parking lot of his workplace but had to leave, as he had panic attacks. He has also been "spacing out." He reports his mood as being sad and angry. He is not eating well. He feels guilty that he was not able to call for help quickly or defend himself. He has started to drink more to get to sleep. Which of the following is the likely diagnosis?

PTSD

A 5-year-old boy was in recent motor vehicle accident in which he fractured his leg. He needed to be flown by helicopter to the nearest hospital. It has been 5 months since the accident, and the boy has never talked much about it. His parents report that he still continues to refuse to get in the car. When playing with his toys he often crashes the cars and seems distressed. He wakes up at night screaming but is only able to say "car." What is the likely diagnosis?

PTSD

Which statement best characterizes the difference between patients with avoidant personality disorder and those with schizoid personality disorder?

Patients with avoidant personality disorder would like to have friends more than patients with schizoid personality disorder.

An 11-year-old boy is brought into the office due to the parents being frustrated with the patient's behavior. The parents report that their son does not want to go to school, doesn't want to study, and becomes angry at small issues. He is found to be deceitful at home and at school. His teachers state that he bullies other children and has stolen other children's property. His physical examination is normal. He is alert and has normal cognition, memory, speech, and language skills. He has no issues with calculations, concentration, or mood. Which of the following medications is most likely to be useful in treating this patient's condition?

Risperidone

A 21-year-old woman comes in for treatment after developing symptoms a few days after she was raped at a college dorm party. She says she has been very anxious, fears returning to school, and is thinking about dropping out. She is also experiencing insomnia, poor concentration, intrusive flashback of the event, nightmares, and a constantly depressed mood. She has refused to talk to her family about the event because she "just wants it to go away." What is the most likely diagnosis?

acute stress disorder

A 35-year-old man is brought to see a psychiatrist by his friend because "ever since the disaster that killed his wife, he has been out of it." The patient states that 1 week previously, the town in which he lived was hit by a tornado. His house was destroyed, and his wife of 2 years was killed. The patient states that he feels as if "I'm living in a fog—this just can't be real." He says that he feels disconnected from everything and everyone—he knows they are trying to help him, but he just feels numb. He says that when he closes his eyes, all he sees is an image of his wife being buried under rubble, and he hears the loud roar of the tornado. The patient admits that since that time, he has isolated himself from others as much as possible so that he does not have to talk about what happened. He has not slept well for several days, and when he hears a loud noise, he thinks the tornado is coming back, which makes him very anxious and jumpy. He has been unable to work and has not called any of his insurance companies to tell them about the disaster. The patient states that he has never been to a psychiatrist before and came today only because his friend insisted. What is the most likely diagnosis? What is the next step in treatment?

acute stress disorder facilitating strength and community/family support

A 40-year-old woman presents with complaints of not being able to leave her house. For the past 5 years, she has had increasing difficulty traveling far from home. She constantly worries that she will not be able to get help if she "freaks out." In fact, when she has ventured out of her neighborhood alone, she has had several episodes of intense fear, associated with shortness of breath, chest pain, diaphoresis, and dizziness, lasting for 20 minutes. She is convinced that if she drives alone or with someone else too far from home, she will have an attack and not be able to obtain help. As a result, she relies on her husband and siblings to do all of her shopping, and when she does travel, she does so with extreme trepidation and anxiety. Which of the following is the most likely diagnosis?

agoraphobia

A 45-year-old married man presents to his primary care provider with a chief complaint of fatigue lasting for the past 9 months. He states that he goes to sleep easily enough but then wakes up repeatedly throughout the night. He has had this problem since he was injured on the job 9 months ago. On further questioning, he reports low mood. He states that his alcohol consumption is 6 to 12 beers a day, as well as several ounces of hard liquor to "take the edge off the pain." He discloses that it takes more alcohol than it used to in order to "get relaxed." The patient states that he has experienced several blackouts caused by drinking during the past 2 months and admits that he often has a drink of alcohol first thing in the morning to keep him from feeling shaky. Despite receiving several reprimands at work for tardiness and poor performance and his wife threatening to leave him, he has been unable to stop drinking. On his mental status examination, the patient is alert and oriented to person, place, and time. He appears rather haggard, but his hygiene is good. His speech is of normal rate and tone, and he is cooperative with the practitioner. His mood is noted to be depressed, and his affect is congruent, although full range. Otherwise, no abnormalities are noted. what is the most likely diagnosis?

alcohol use disorder

Twelve hours after a surgical admission for a broken arm, a 42-year-old woman begins to complain of feeling jittery and shaky. Six hours later, she tells staff members that she is hearing the voice of a dead relative shouting at her, although on admission she denied ever having heard voices previously. She complains of an upset stomach, irritability, and sweatiness. Her vital signs are BP 150/95 mm Hg, pulse 120 beats per minute (bpm), respirations 20 breaths per minute, and temperature 100 °F (37.8 °C). The patient reports no prior significant medical problems and says that she takes no medications. She has not had prior complications due to general anesthesia. what is the most likely diagnosis? what should be done next to treat this patient?

alcohol withdrawl give her a benzo immediately then taper as she recovers

A 17-year-old adolescent girl is brought to see a psychiatrist because her parents have become increasingly alarmed about her weight loss. The patient claims that her parents are "worrying about nothing" and that she has come to the office just to appease them. She states that she feels fine, although her mood is slightly depressed. She denies having problems with sleeping or appetite and denies any kind of drug or alcohol abuse. She says that she thinks she looks "fat," but that if she could lose another couple of pounds, she would be "just right." She notes that her only problem is that she stopped having her period 3 months ago; she is not sexually active and therefore cannot be pregnant. When questioned separately, the parents report that the patient has been steadily losing weight over the past 8 months. They say that she started dieting after one of her friends commented that she "looked a little plump." At that point, they noted that their daughter weighed approximately 120 lb. The patient lost 5 lb and, according to the parents, felt good about the comments made by her friends. Since that time, she has eaten less and less. She now dresses in baggy clothes and does not discuss with her parents how much she weighs. Despite this, she helps her mother cook elaborate meals for party guests when the family entertains. She exercises throughout the day, and her parents say they can often hear her doing jumping jacks and sit-ups in her room in the evening. On physical examination, the patient is found to be 5 ft 2 in tall; she weighs 70 lb and appears cachectic. what is the most likely diagnosis? what are the next therapeutic steps?

anorexia nervosa, restrictive type hospitalization

Despite her protest, the adolescent in the vignettes in Questions early is diagnosed with anorexia. After stabilization of her nutritional status on a specialized inpatient unit, she is discharged home with plans for follow-up therapy as an outpatient. Which of the following treatments have been shown to be effective in treating anorexia nervosa as an outpatient?

family based treatment

A 32-year-old man is seen by a jail psychiatrist after getting into a fight with another inmate over a $5 bet. This is the patient's fourth incarceration, this time for forging bad checks. Previous incarcerations were for assaulting a police officer, stealing from a department store, and at age 13, stealing a car. The patient states that he fought with the other inmate because, "I was bored and felt like it." He admits that the $5 was not really his to begin with, but he shows no remorse either about trying to take the money or about getting into a physical altercation with the other inmate. The patient states that he has seen psychiatrists in the past (always reluctantly and always because of demands made either by his mother or the courts) but states, "There isn't anything wrong with me, so why should I?" He denies using drugs or alcohol while incarcerated but admits that if he were not in jail, he would probably be using both. A mental status examination indicates the patient is alert and oriented to person, place, and time. He cooperates with the examiner. At times, he appears open and engaging, even charming, while at other times he is rude and disrespectful. He is dressed in jail garb. His speech is normal in rate, rhythm, and tone. His mood is described as "fine," and his affect is congruent. He shows no disorders of thought processes or thought content. What is the most likely diagnosis?

antisocial personality disorder

A 14-year-old student is being seen for follow-up after treatment is begun for his OCD. As treatment develops, the parents inform you that he had an infectious episode treated with antibiotics several weeks ago prior to developing these symptoms. Which of the following conditions is most likely to be related to his current symptoms?

associated with streptococcal infections in pediatric patients

Which of the following medications is commonly used in social anxiety that is associated with performance situations, shortly before exposure to a phobic stimulus?

atenolol

A 7-year-old girl is brought to her pediatrician on the suggestion of her second-grade teacher. The patient has been back in school for 3 weeks following a summer break. According to the teacher, the patient has found it very difficult to complete her classroom tasks since returning to school. The child is generally not disruptive but is unable to finish assignments in the allotted time, although her classmates do so without difficulty. She also makes careless mistakes in her work. Although she is still passing her classes, her grades have dropped, and she seems to daydream a great deal in class. The teacher reports that it takes several repetitions of the instructions for the patient to complete a task (eg, in an art class). The patient enjoys physical education and does well in that class. The child indicates that when it appears to others that she is not paying attention she is thinking about other things. Teachers report that her attention wanders constantly and they have to call her name or wave to get her immediate attention. There have been no episodes where she stares blankly or is briefly nonresponsive. Although her parents have noticed some of the same behaviors at home, they have not been particularly concerned because they have found ways to work around them. If they monitor the child and her work directly, she can complete her homework, but they must continually check her work for careless mistakes. She does seem to know the right answer when it is pointed out. The parents also report that the patient does not get ready for school in the mornings without moment-by-moment monitoring. Her bedroom is in shambles, and she loses things all the time. The parents describe their daughter as a happy child who enjoys playing with her siblings and friends. They note that she does not like school, except for the physical education classes. What is the most likely diagnosis?

attention deficit hyperactivity disorder [ADHD] inattentive presentation

Which of the following treatment options would be a contraindicated treatment option for the patient in thw other questions with bulimia

atypical antipsychotic medications

A 2½-year-old boy is brought to a pediatrician by his parents for his regular yearly examination. He is the couple's only child. The parents relate a normal medical history with a single episode of otitis media. They recently placed their son in day care for 2 half-days a week. However, he has not adjusted well, crying and having tantrums during the first hour of day care. Then he usually quiets down, but he does not interact with the rest of the children. The teacher cannot seem to make him follow directions and notes that he does not look at her when she is near him and attempting to interact with him. On further discussion with the parents, the pediatrician finds that the patient has a limited vocabulary of perhaps 10 words. He does not use these words in any greater length than two words in a row and often uses them inappropriately. He did not speak his first clear word until 6 to 9 months. The patient does not interact well with other children but does not seem upset by them either. His favorite toys are often used inappropriately—he performs single, repetitive movements with them for what seems like hours on end. The pediatrician picks the child up to help him onto the examination table and notices that he seems quite stiff, pushing himself away from the examiner with his hands. Although his hearing and eyesight appear to be intact, the child does not respond to requests by the pediatrician and does not make eye contact. All other gross neurologic and physical features are within normal limits. What is the most likely diagnosis?

autism spectrum disorder

A 21-year-old woman comes to the student counseling center with complaints of being depressed and feeling anxious. She states that 2 weeks ago, while in class, she was called on by the teacher and gave the wrong answer. She says that she felt "humiliated" and has not gone back to the classroom since then. She describes a lifelong history of being painfully shy. She admits that she would like to have a boyfriend but is afraid to meet anyone because, "He'll find someone better and dump me." She describes herself as "socially awkward" and avoids going out with anyone new. She has two close friends from junior high school and does go out to dinner with them weekly, which she enjoys. She denies trouble sleeping or with her appetite, although she does admit to feeling ashamed of her social ineptitude. She is worried that she will be unable to finish college because of her problems. what is the most likely diagnosis?

avoidant personality disorder best treatment-- psychodynamic or CBT

n controlled studies, which of the following medications is ineffective for use in childhood anxiety disorders?

benzodiazapines

A 28-year-old woman who is a medical student is brought to the physician by her boyfriend because of unremitting headaches and always "worrying about everything." The patient admits that she has been more "stressed out" than usual over the last year about interview season, the couples match, getting married, moving out of state, and student loans. Her headaches have increased in frequency and intensity. She reports difficulty sleeping through the night and constant fatigue. The patient's boyfriend complains that lately, "She freaks out about every little thing. I can't deal with this anymore. I don't even know if matching together is still a good idea." Which of the following is the most likely diagnosis?

generalized anxiety disorder

A 14-year-old boy is brought to the emergency department after being found in the basement of his home by his parents during the middle of a school day. The parents came home after receiving a call from the school reporting that their son had not attended school for 4 days. The boy was furiously working on a project he claimed would solve the fuel crisis. He had started returning home from school after his parents left for work because his science teacher would no longer let him use the school laboratory other than during regular class time. The patient was involved in an altercation with the school janitor after being asked to leave the school because it was so late. The boy claimed that the janitor was a foreign spy trying to stop his progress. The parents are very proud of their son's interest in science but admit that he has been more difficult to manage lately. He can't stop talking about his project, and others cannot get a word in edgewise. His enthusiasm is now palpable. For the past few weeks, he reads late into the night and gets minimal sleep. Despite this, he seems to have plenty of energy and amazes his parents' friends with detailed plans of how he is going to save the world. His friends have not been able to tolerate his increased interest in his project. His train of thought is difficult to follow. He paces around the examination room saying, "I am anxious to get back to my project before it is too late." Although he has no suspects in mind, he is concerned that his life may be in danger because of the importance of his work. What is the most likely diagnosis?

bipolar 1 disorder, manic episode with congruent mood psychotic features

A 23-year-old woman is admitted to the inpatient psychiatric unit after slashing both wrists when her therapist left for a week's vacation. The cuts were superficial and did not require stitches. The patient says that she is angry with her psychiatrist for "abandoning her." She claims that she is often depressed, although the depressions last "only a couple of hours." When she was first admitted to the hospital, she told the admitting psychiatrist that she heard a voice saying, "I will never amount to anything," but she subsequently denies having heard the voice. This is the patient's fourth hospital admission, and all of them have been precipitated by someone in her life leaving, even temporarily. After 3 days in the unit, the patient's psychiatry resident gets into an argument with the nursing staff. He says that the patient has been behaving very well, responding to his therapy, and is deserving of a privilege. The nurses claim that the patient is not following unit rules, sleeping through her group meetings, and ignoring the limits set. Both parties go to the unit director complaining about the other. What is the most likely diagnosis?

borderline personality disorder

A 16-year-old girl is brought to her primary care provider by her mother, who states that her daughter has been losing weight steadily. The adolescent denies there is a problem and states that she is in no way underweight. The provider determines that the girl is 5 ft 6 in tall and weighs 90 lb. Which of the following would be the next best step to work this patient up?

calculation and assessment of patient's BMI

A 20-year-old college student presents to the ED with acute agitation and psychosis. He has been smoking marijuana since age 16 years, and his use has increased to the point where his roommates note that all he does is "smoke pot." He began distancing himself from others in the dorm over the last year, complaining that they were trying to kill him by poisoning his food. His school grades and self-care have gone downhill considerably. However, he does not feel his cannabis use is problematic and states that "weed is the only thing that has kept me sane!" What is the most likely diagnosis in this patient?

cannabis induced psychosis

A 20-year-old man is brought to the emergency department (ED) by his friends in a scared and agitated state. He had been playing basketball several hours ago with his friends when he suddenly began complaining of being stung by bees. He began behaving erratically and saying that bees were coming out of his ears and mouth. He began accusing one of his friends of plotting against him and blaming him for his condition. He became agitated and ran away from the basketball court, darting in and out of traffic on the adjoining street. His friends had to track him down and force him to come to the hospital. His friends report that some of them had been smoking "weed" prior to the game, and the patient was a "newbie to weed." His friends do not believe he has had any psychiatric problems in the past but cannot be sure. On examination, the patient appears anxious, apprehensive, and fearful. He looks around the room furtively, repeatedly spitting into a cup. He is fully aware of his surroundings, but his attention span is very short. His memory is intact and fully oriented. He no longer suspects his friend and holds out the cup he has been spitting into for the doctor to inspect for bees. He finds it unbelievable that he has bees crawling out of himself but cannot help feeling the sensation. Physical examination reveals redness of eyes and an elevated pulse rate. Otherwise, the physical examination is normal. Neurologic examination is within normal limits. The patient complains of the bees "sucking out all [his] energy making [him] very hungry." What is the most likely diagnosis?

cannibis intoxication

The patient in Question about the 15 year old girl with OCD does not respond to an adequate trial and dose of sertraline in combination with cognitive behavioral therapy. What interventions should be considered next?

change medication to fluvoxamine

Which of the following physical complications would be most likely to occur in the patient with cocaine intoxication?

chest pain

A 50-year-old homeless man is brought to the emergency department by the police for disruptive behavior. On mental status examination, he has an elevated affect, but he also has psychomotor agitation and paranoia; he says he "feels fantastic" but is wary of answering any questions, quickly becoming irritated. On physical examination, the patient exhibits a moderately elevated blood pressure and pulse rate. He is most likely intoxicated with which of the following substances?

cocaine

A 15-year-old girl is brought to a psychiatrist by her parents because they are concerned that she might be depressed. The parents had no complaints until 2 or 3 years ago. Since then, the patient's grades have fallen because she cuts classes. She gets into fights, and her parents claim that she hangs out with the "wrong crowd"; some nights she does not come home until well past her curfew. The patient says that there is "nothing wrong" with her and that she wants her parents to "butt out of [her] life." She claims that she is sleeping and eating well. She says she skips school to hang out with her friends and admits that they frequently steal food from a convenience store and spend time watching movies at one of their homes. She claims that she fights only to prove that she is as tough as her friends but admits that she often picks on younger students. She shows limited guilt or remorse about this. She seems cold and uncaring about how her behavior might affect others. She is not concerned about her grades and just wants her parents to "lay off" and let her enjoy her youth. She denies the use of drugs or alcohol other than occasionally at parties. Her blood alcohol level is zero, and the results of a urinalysis are negative for drugs of abuse. What is the most likely diagnosis?

conduct disorder

A 39-year-old man is evaluated by mental health services in prison. He has a history of multiple arrests as both an adult and as a juvenile. After several interviews, a diagnosis of antisocial personality disorder is confirmed. He has a history of multiple psychiatric hospitalizations after suicide attempts and was in special education programming as a child. Which psychiatric diagnosis is most likely to have occurred comorbidly in such an individual?

conduct disorder

A 60-year-old man is brought to the emergency department by his wife for "confusion." She reluctantly confides to the staff that he is a "heavy drinker" and that he has drunk up to a case of beer almost every day for the past 30 years. Although he has not changed his alcohol intake significantly, over the past year he has eaten less, preferring alcohol to large meals. She has noticed a gradual weight loss as a result. His last drink was earlier that day. Which of the following would be the most likely finding on the mental status examination of this patient?

confabulation

In the patient with ED aggressiveness and such, urine toxicology confirms intoxication with amphetamines. Which of the following withdrawal syndromes would be expected?

crash of mood into depression, lethargy, increased appetite

A 24-year-old woman with BPD is admitted to a psychiatric hospital because of suicidal ideation. The provider on call tells the patient about all the rules and regulations in the unit and that "although it is a great place to get better, it is a lot of work." Which of the following is this provider attempting to do with this patient?

decrease idealization of the unit and the hospitalization

A 34-year-old woman presents with a 10-year history of episodes in which she eats large quantities of food, such as eight hamburgers and three quarts of ice cream, at a single sitting. Because of her intense feelings of guilt, she then repeatedly induces vomiting. This cycle repeats itself several times a week. She is extremely ashamed of her behavior but says, "I can't stop doing it." On examination, which of the following physical findings is most likely to be seen?

dental carries

A 24-year-old woman is seen in the emergency department after superficially cutting both her wrists. Her explanation is that she was upset because her boyfriend of 3 weeks just broke up with her. When asked about other relationships, she says that she has had numerous sexual partners, both male and female, but none of them lasted more than several weeks. Which type of psychotherapy might she be most likely to respond to?

dialectical behavioral therapy

A 35-year-old woman is engaged in psychotherapy to address her avoidant personality disorder. In particular, she is distressed by her inability to maintain a romantic relationship with a man. During the course of treatment, the therapist learns that her father was an alcoholic and was physically abusive to the patient and her mother. Which defense mechanism best describes the patient's behavior?

displacement

An 11-year-old boy is admitted to an inpatient psychiatric unit for increasing aggression toward his peers and teachers at school. During evaluation, the patient states, "I am moody all the time." He has been aggressive toward his younger siblings and recently hit his dad during an argument. He has been diagnosed with ADHD and takes medications irregularly. At home, his mother reports that any small thing makes him erupt in extreme anger every other day for the last 2 years. Which of the following is the most likely diagnosis?

disruptive mood dysregulation disorder

An elderly woman presents to the emergency department due to a hip fracture. She reports that she "hasn't been feeling very well" recently, and she is vague and hard to pin down regarding details. You think that there might be the odor of alcohol on her breath and suspect alcohol use disorder. Which of the following findings would be most supportive of your concern?

elevated gamma-glutamyl transpeptidase

Upon the urging of his supervisor, a 29-year-old man decides to see a counselor at his employee assistance program. The patient was recently promoted to a position that requires increased interpersonal interaction as well as new supervisory responsibilities. Subsequently, his job performance has dropped off significantly. The patient states that since his transfer, he has been so nervous at work that he has not been able to think straight. He reports that his mood at home has been good, but that he knows he will fail at the new job because, "I have always been such a dope when it comes to working with other people." After several sessions, the counselor diagnoses the patient with avoidant personality disorder. Which of the following would be the most helpful in assisting the patient to manage his anxiety regarding his new job?

engage the patient in CBT to help him deal with his distorted thinking

A 27-year-old man, enrolled in law school, presents to his primary care provider's office with increased stress due to his academic workload. He has been having difficulty sleeping at night, is fatigued, and has muscle tension. These symptoms have been persistent over the years but recently have been worsening. He has been in a relationship with his girlfriend since college, and they plan to marry upon his graduation from law school. He is worried about his law boards, successfully completing school, wedding planning, and keeping in touch with his parents. He reported having a difficult childhood, as his parents divorced, and he had to move back and forth between their places. He experienced domestic conflicts between his parents prior to their divorce. He fears that his marriage may end in divorce too, even though his girlfriend loves him very much. He worries about not landing a job and fears having difficulty paying student loans. Due to all these stresses, he has been having difficulty concentrating on schoolwork. He denies any other psychiatric symptoms, past psychiatric history, or medical problems. He denies alcohol use or illicit drug use. He denies any family psychiatric diagnoses but says that "My parents should have sought some professional help." On mental status exam, the patient is casually dressed with good hygiene. He is cooperative but avoids eye contact. When speaking, he appears to choke on his words and then talk faster, but speech is not pressured. His hands tremble, and he tightly crosses the fingers of both hands. He is restless, shaky, and taps his foot on the floor. He reports his mood as being overwhelming. His affect is anxious and restless. His thought process is linear, logical, and goal directed with a perseveration of future worries. His thought content is focused on how he will manage all his worries in life. He denies any suicidal or homicidal thoughts, or any type of hallucination. What is the most likely diagnosis? What is the treatment for the most likley diagnosis?

generalized anxiety disorder therapy, medication with SSRIs

A 26-year-old graduate student is brought to the emergency department after becoming physically aggressive with his best friend. The patient has not been sleeping or eating well, resulting in a weight loss of approximately 10 lb, and has been "studying like a fiend" for his exams. The patient has no medical or psychiatric history. The patient's physical examination shows hypertension and tachycardia, as well as dilated pupils, diaphoresis, and a fine bilateral tremor in his hands. In the emergency department, he is oriented but belligerent and uncooperative. He states that his mood is fine, although he appears angry and tries to elope from the hospital. Several staff members are needed to control the patient, who is psychotic and extremely agitated, requiring placement in four-point restraints. Which of the following pharmacologic interventions is the most appropriate?

haloperidol

The patient with weed psychosis becomes agitated and screams at the staff, claiming that they are trying to kill him and sell his organs to an organ trafficking syndicate. He appears internally stimulated and responding to imaginary voices. He begins throwing things at the treating team and threatening to beat anyone who enters his room, requiring him to be put into four-point restraints. Which of the following pharmacologic interventions is the most appropriate?

haloperidol

A 39-year-old man with antisocial personality disorder, incarcerated for life after murdering a man, has a multitude of somatic complaints over the course of several years. Yearly physical examinations never show anything physically wrong with him, yet he complains of a variety of aches and pains, neurologic symptoms, and gastrointestinal distress. He does not enjoy the time he spends in the jail's infirmary. Speaking to the guards at the facility, there does not seem to be secondary gain from visiting the infirmary. Which of the following is the most likely explanation for this patient's complaints?

he has developed a somatic disorder

A 16-year-old adolescent girl is incarcerated in a juvenile detention facility. She is currently charged with theft, apparently to support her and her boyfriend's drug habit. She has had multiple involvements with child and family services for running away from home, where she apparently had been sexually abused by her mother's boyfriend. She has a diagnosis of posttraumatic stress disorder (PTSD). Prior to the onset of the abuse, she was doing extremely well in school and was in an accelerated program. Which of the following factors speaks most strongly against making a diagnosis of antisocial personality disorder?

her age

Which of the following laboratory abnormalities would most likely be found in the patient in the woman with bulimia?

hypochloremic-hypokalemic alkalosis

A patient is presented with photographs of spiders while practicing various relaxation techniques to overcome fear; gradually he practices relaxation while in the presence of live spiders.

in vivo exposure

A 58-year-old man with hypertension and hyperlipidemia is admitted to the general medicine unit for intravenous antibiotics for treatment of pneumonia. After 2 days he becomes increasingly anxious, with complaints of "shaking" and sweating. His vitals demonstrate a temperature of 100.4 °F, blood pressure of 170/97 mm Hg, pulse of 110 beats per minute, and respiratory rate of 16 breaths per minute. On examination he appears diaphoretic and flushed, with a coarse tremor of his upper extremities bilaterally. Laboratory test results are significant for slightly elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyl transferase (GGT). Review of his chart reveals a long history of daily heavy alcohol use. When confronted with this information, the patient reluctantly admits to drinking "one fifth" of vodka plus several beers daily, with little sobriety. His last drink was the day prior to admission. Administration of which of the following medications would be the most appropriate for this patient?

lorazepam

A 62-year-old man is admitted to the ICU after a motor vehicle accident. The patient was previously healthy per his girlfriend of 3 days, whom he met online. Per his girlfriend, they were at a party prior to the motor vehicle accident. A psychiatrist is called because the patient has become confused, agitated, and diaphoretic and screams that the nurses are trying to euthanize him. He begins pulling out his IV lines and other tubes. He is visibly tremulous, flushed, and diaphoretic. His blood pressure is 168/93 mm Hg, heart rate is 125 bpm, respiratory rate is 20 breaths per minute, and oxygen saturation is 98% on room air. The results of his physical examination are unremarkable, but his laboratory tests show low serum albumin and low protein levels, as well as an elevated prothrombin time/partial prothrombin time. Which of the following medications would be most appropriate in treating this patient?

lorazepam

Treatment of ASD should focus primarily on which of the following?

mobilizing social supports

The patient in the previous two questions with weed problems is treated on the inpatient psychiatric unit with antipsychotic medications, and his symptoms are well controlled after a week of inpatient stay. The patient is still ambivalent about his substance use problem. Which of the following would be the next recommended step in management?

motivational interviewing

A 15 year old adolescent female is diagnosed with OCD and is started on sertraline. Which of the following is the most common side effect to this medication?

nausea and diarrhea

A 25-year-old woman who is a business analyst from Colorado comes to her primary care provider's office for a wellness check. She reports using marijuana occasionally ever since her college days at parties and on the weekends, maybe once or twice a month. She likes the feeling it produces but denies any problems arising from it. She denies other substance use except an occasional glass of wine on the weekend. She is highly regarded at work and recently got engaged to her high school sweetheart. She wants to settle down and start a family and feels her "partying days" are over. What is the likely diagnosis in this patient?

nonproblematic cannabis use

Parents of a 10-year-old boy note that their son does well with his family until he is not allowed to do something he wants to do. When this occurs, he will get irritable, impulsively aggressive, and agitated for several hours. Once he calms down or gets his way, he is happy and pleasant again. At school, he has no trouble focusing, but if he does not want to do something, he becomes argumentative. Which of the following is the most likely diagnosis?

oppositional defiant disorder

Which of the following has the highest rate of comorbidity with ADHD?

oppositional defiant disorder/conduct disorder

A 33-year-old man has the chief complaint of "I'm going to have a heart attack like my father." He explains that his father died of a myocardial infarction at 45 years of age. He is convinced that he is experiencing angina attacks consisting of nervousness, sweating, shortness of breath, palpitations, flushing, and numbness in his hands, each lasting for several minutes. He is anxious about having these symptoms, and despite negative results from a cardiology workup, he remains certain that he will suffer a heart attack. His behavior and lifestyle have not been otherwise affected. Which of the following is the most likely diagnosis?

panic disorder

A 14-year-old boy has been diagnosed with CD based on a history of aggression, destruction of property, and deceitfulness. Which evidence-based treatment is likely most cost effective for treatment of his condition?

parent training

A 17-year-old young woman is being seen in the office for difficulty with coping at school. She confides that she has problems with eating foods. In trying to distinguish the eating disorders, which of the following is most accurate regarding the differences between bulimia and anorexia nervosa?

patients with bulimia may not have any symptoms until early adulthood while anorexia typically begins in early adolescence

A 10-year-old boy presents with episodes of somatic complaints, anxiety, and crying at school which resolves when he is sent home. He won't go anywhere without his mother. Which of the interventions would be an appropriate part of the plan of treatment?

place patient on low dose fluoxetine

A 17-year-old high school senior is referred to a psychiatrist by his counselor because of academic difficulty. Although he had always been an honors student, this past year his grades have dropped, especially in mathematics. When questioned, he reveals the new onset of "superstitions" involving numbers. When presented with certain numbers, he feels compelled to count forward and then backward to and from that number. He becomes anxious about not completing this task, although he is unable to state a particular consequence. If interrupted, he must begin all over again. He realizes that there is "no good reason" for his behavior but is unable to stop it. Because of this, he not only feels "tortured," but he may need to repeat a year in school. He denies any past psychiatric history. You begin treating him with sertraline and cognitive therapy to address the obsessions. He misses appointments with his therapist and feels therapy will not be helpful, and the parents believe he is not taking his medications regularly. What interventions should be considered next?

residential setting to deliver treatment

Which medication has been shown to be effective for serious behavioral problems, such as aggression, tantrums, and self-injurious behaviors, which may be symptoms of autistic spectrum disorders?

risperidone

A 4-year-old boy who is an only child starts preschool. His parents are quite nervous about this and describe themselves as protective and overinvolved. However, they are looking forward to seeing him more involved with school, as he has had little peer interaction prior to this because he has never shown much of an interest in interacting with others. He has never used many words, which the parents attribute to his isolation. They tell the teacher he has always done best with a strict schedule and doesn't tolerate change well. He has always seemed to have a very narrow repertory of play—focusing primarily on spinning objects such as tops and balls. He comes to the classroom for the first time, runs right to these toys, and does not say goodbye to his mother or even acknowledge she is leaving. Other children attempt to play with him, but his response is to either ignore them or get angry at their advances. His focus on spinning objects in play might be considered what type of behavior often seen with ASD?

stereotyped behavior

A 10-year-old boy with chronic asthma is brought to a pediatrician for his 6-month checkup. He has complained of chronic headaches for the past 3 months, as well as increasing gastric upsets, which his family believes are caused by multiple food allergies. The patient has a severe allergy to peanuts, which limits the number of places he can go in public. Thus, he has been home schooled for a year and is doing well. A review of his history shows that he is a highly articulate, thoughtful child who appears to be at or above the educational level of his peers. The child does not agree to be interviewed separately from his mother, stating, "I don't go anywhere without my mother." The two of them are almost never apart. Two years ago, the mother was hospitalized after a serious bout with lupus. She continues to struggle with her disease, and despite having a thriving career before her illness, she can do very little now. She is home all the time, dealing with her own recovery and the management of her illness. During her hospitalization, the patient was quite worried about her illness and even now believes that if he is not around to monitor her condition, she might get sick and require hospitalization again—or even worse. The mother has difficulty sleeping and is most comfortable on the living room couch. The patient no longer uses his own room but sleeps in a chair next to his mother to continue to keep an eye on her. He has very few friends and can be separated from his mother only briefly, and only if he is in the company of his brother or father. After a short period, he becomes anxious and upset and must be reunited with his mother. What is the most likely diagnosis? What might be a useful treatment?

separation anxiety disorder multi-systemic treatment approach is needed- SSRIs can be helpful, relaxation techniques good too

Despite a course of psychotherapy, the above patient who was 37 with PTSD, continues to suffer from depressed mood, recurrent nightmares, flashbacks, hypervigilance, and emotional numbing. Which of the following medications is the first choice in this patient?

sertraline

The college professor described in the previous question follows up with the psychiatrist in 4 weeks after starting the indicated treatment. He reports a decrease in symptoms but states that he does not want to take the medication any longer. When asked why, he blushes and stammers, "It's not working right." Which SSRI side effect is the most common with long-term treatment and often results in nonadherence?

sexual dysfunction

A 28-year-old businessman describes a persistent fear of speaking in public. Although he does not have difficulty with one-on-one situations, he becomes extremely anxious when giving a lecture to a group, worrying that he will be humiliated. He relates one episode when he was forced to speak at the last minute, which resulted in his experiencing panic, shaking, abdominal cramps, and a fear that he would defecate on himself. Because of this problem, he has been held back from promotion at his place of employment. Which of the following is the most likely diagnosis?

social anxiety disorder

A 35-year-old man visits a psychiatrist because he is overwhelmingly anxious about a speech he has to make. The man states that he was recently promoted to a position within his company that requires him to speak in front of an audience of approximately 100 people. He says that the first such speech is coming up in 2 weeks and that worrying about it keeps him from sleeping. He knows that his fear is out of proportion, but he is unable to control it. He explains that he has always had trouble with public speaking because he fears that he might "do something stupid" or otherwise embarrass himself. He has avoided public speaking in the past as much as possible or has spoken in public only before an audience of fewer than 10. Because he knows that he must make the presentation coming up in 2 weeks or he will not be able to keep his new job, he has visited the psychiatrist hoping to find a solution to the problem. What is the most likely diagnosis? What is the treatment of choice?

social anxiety disorder behavioral cognitive therapy [CBT]

A 25-year-old woman describes a lifelong history of being "scared of heights." She becomes uncomfortable when at an elevation higher than three stories, and whenever traveling or shopping, she becomes preoccupied with knowing the exact heights of buildings. Whenever finding herself at a significant distance from the ground, she has severe anxiety symptoms, including trembling, lightheadedness, numbness and tingling, and a fear of dying. Which of the following is the most likely diagnosis?

specific phobia

A 24-year-old single woman is referred to a mental health clinic because of "fear of elevators." She describes being "afraid" of elevators since adolescence, when she was stuck in one for over 1 hour. Since that time, she has attempted to avoid taking them, either walking stairs or using escalators. However, this has become increasingly difficult given her recent employment on the upper floor of a skyscraper downtown. She has tried to use the stairs, but it takes too long and she is winded by the end. As a result, she has been late to meetings and has already been reprimanded. She says, "I forced myself" to ride the elevator several days ago, but she reports having felt extremely anxious, with sweating, hyperventilation, palpitations, nausea, dizziness, and fear that she would suffocate and die. While she understands that the realization of her fears is very unlikely, she is unable to tolerate the elevator. She has decided to come in for help to avoid losing her job. What is the most likely diagnosis? What is the best treatment option?

specific phobia CBT with exposure therapy

The patient in Question 57.1 complains to her psychiatrist that all the nurses on the floor don't know what they are doing and are rude. She later tells her nurse she is the best nurse on the floor and wished her psychiatrist cared about her the way the nurse did. Which of the following defense mechanisms is this patient using?

splitting

A 22-year-old man with BPD patient loses his job at a local restaurant, the first job he has held for longer than a month. His mother dies suddenly 3 weeks later. One month after his mother's death, the patient tells his therapist, whom he has been seeing once a week, that he has trouble sleeping, waking up at 3 AM and then unable to go back to sleep. He has lost 13 lb in 5 weeks without trying to do so. He reports low energy and a decreased interest in his usual hobbies. He states that he feels depressed but then grins and says, "But I'm always depressed, aren't I?" Based on his history, which of the following should the clinician do next?

start treating the patient with an antidepressant such as paroxetine

A 6-year-old boy with an early, ongoing history of distractibility, hyperactivity, and impulsivity is diagnosed with ADHD. He is treated with methylphenidate. Three weeks later he is brought in, and his inattention and hyperactivity are much better. The mother also notes that he has a small bald spot from where he has begun repeatedly rubbing his head. You periodically observe him to suddenly raise his hand to the spot, rub back and forth once, and put his hand down. There is no rash but the area is hairless. The most likely diagnosis is which of the following?

stimulant induced motor tic

A 29-year-old single woman is brought to the emergency department by the police after they picked her up attempting to break into a grocery store. When they apprehended her, they noticed that she "seemed high" and that she was sweating with dilated pupils. The patient admits to "doping" daily for the majority of the past year and losing 30 lb in the past 6 months. She claims that her habit now costs more than $100 per day, although she used to get the "same high" for $20. When intoxicated, she describes her mood as "really good" and that she has "loads" of energy. When she does not use, she craves the drug, becomes very sleepy, feels depressed, and has a large appetite. She has tried to quit on numerous occasions, even entering an inpatient treatment program at one point, but she always quickly begins using again. The patient used to work part-time as a secretary, but she lost her job because she was chronically late and, in fact, stole money in order to pay her dealer. She freely admits that she was trying to rob the grocery store to "pay off my debts." What is the most likely diagnosis?

stimulant intoxication and stimulant use disorder [COCAINE]

A 9-year-old boy has been refusing to leave home. He complains of abdominal pain, nightmares, and fear of getting hurt and losing his mother. Five weeks ago, his mother was in a car accident. He is diagnosed with separation anxiety disorder, and fluoxetine treatment is initiated. The Food and Drug Administration (FDA) recommends the clinician monitor closely for which of the following?

suicidal thoughts

A patient with obsessive-compulsive disorder (OCD) attempts to use public handrails and doorknobs while intentionally refraining from washing her hands afterward.

systemic desensitization

the patient described with anorexia who had her BMI calculated was admitted to an inpatient pediatric unit for initial treatment. She received nutritional support provided to her by the treatment team, which included a dietician. However, the patient wanted to get better faster and started to take one additional 30-g protein shake per meal. On day 4 of treatment, the patient developed signs and symptoms of cardiac failure and a new arrhythmia. What is the most likely cause of this complication?

the patient developed refeeding syndrome

A 48-year-old woman is brought to the emergency department. She is unresponsive to questions, stumbles around the room, and is agitated. On physical examination, you notice that she smells of alcohol, and she is not cooperative during the remainder of the examination. Administration of what medicine would be the most appropriate initial treatment?

thiamine

A 47-year-old man is admitted to a psychiatric unit for depression with suicidal ideation and detoxification. He has a long history of dependence upon both alcohol and cocaine. Which of the following signs is most characteristic of early alcohol withdrawal?

tremor