PSY

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107. A 32-year-old woman is brought to the emergency room when she complains of chest pain. She is noted to be hypervigilant and anxious, with a pulse of 120 beats per minute and BP of 140/97. She has widely dilated pupils. Her toxicology screen is positive. Which of the following drugs is she most likely to have used? a. Cocaine b. Ritalin c. Heroin d. Phencyclidine (PCP) e. Lysergic acid diethylamide (LSD)

108. A 42-year-old woman comes to the psychiatrist with complaints of short-term memory loss. She has lost her way home several times in past weeks. Mini Mental Status Exam scores 18 of 30 points. An MRI shows the loss of brain volume. The patient's mother died of the same disease at age 46. Which of the following genes in this patient (and her mother) are likely to show a mutation on chromosome 14? a. Presinilin 1 b. Presinilin 2 c. β-Amyloid precursor protein (APP) d. Apolipoprotein E (Apo E) e. Human lymphocyte antigen (HLA)

114. A 48-year-old man is being treated for a major depression. He com- plains of depressed mood, anergia, anhedonia, and suicidal ideation with a plan. Which of the following neurochemicals is likely to be abnormal in this patient's CSF? a. 5-Hydroxyindoleacetic acid (5-HIAA) b. GABA c. Dopamine d. Acetylcholine e. Substance P

117. The patient above has never previously reported symptoms as described in the vignette. Which of the following is the most appropriate next step in the management of this patient? a. Reduce the L-dopa b. Increase the L-dopa c. Add haloperidol d. Add Sinemet e. Call a psychiatrist for consultation

128. A 35-year-old man presents to his physician with a slowly develop- ing difficulty of movement and thinking. The patient tells the physician that his father had similar problems. His wife notes that the patient appears depressed and apathetic. On examination, the patient has involuntary choreiform movements of his face, hands, and shoulders. Which of the fol- lowing areas of the brain is likely to show atrophy with this disease? a. Caudate nucleus b. Frontal lobe(s) c. White matter d. Cerebellum e. Pituitary

130. A 28-year-old man with a 6-month history of symptoms is noted to have disinhibition, lability, and euphoria. He is also noted to have a lack of remorse. Which area of the man's brain is likely to be dysfunctional? a. Orbitofrontal region of frontal lobe b. Dorsolateral region of frontal lobe c. Medial region of frontal lobe d. Limbic system e. Parietal lobe

142. Every morning on school days, an 8-year-old girl becomes tearful and distressed and claims she feels sick. Once in school, she often goes to the nurse, complaining of headaches and stomach pains. At least once a week, she misses school or is picked up early by her mother due to her complaints. Her pediatrician has ruled out organic causes for the physical symptoms. The child is usually symptom free on weekends, unless her par- ents go out and leave her with a babysitter. Which of the following is the most likely diagnosis? a. Separation anxiety disorder b. Major depression c. Somatization disorder d. Generalized anxiety disorder e. Attachment disorder

148. A 12-year-old boy is brought to the psychiatrist because his mother says the boy is driving her "nuts." She reports that he constantly argues with her and his father, does not follow any of the house rules, and inces- santly teases his sister. She says that he is spiteful and vindictive and loses his temper easily. Once he is mad, he stays that way for long periods of time. The mother notes that the boy started this behavior only about 1 year previously. While she states that this behavior started at home, it has now spread to school, where his grades are dropping because he refuses to par- ticipate. The patient maintains that none of this is his fault--his parents are simply being unreasonable. He denies feeling depressed and notes that he sleeps well through the night. Which of the following is the most likely diagnosis? a. ODD b. Antisocial personality disorder c. Conduct disorder d. Childhood-onset schizophrenia e. Mania

155. A 69-year-old woman slips on the ice and hits her head on the pave- ment. During the following 3 weeks, she develops a persistent headache, is increasingly distractible and forgetful, and becomes fearful and disoriented at night. Which of the following is the most likely cause of these changes? a. Subdural hematoma b. Frontal lobe meningioma c. Korsakoff disease d. Epidural hematoma e. Multi-infarct dementia

156. A 43-year-old man is admitted to the neurology service after he went blind suddenly on the morning of admission. The patient does not seem overly concerned with his sudden lack of vision. The only time he gets upset during the interview is when he is discussing his mother's recent death in Mexico--he was supposed to bring his mother to the United States, but did not because he had been using drugs and did not save the necessary money. Physical examination is completely negative. Which of the following is the most likely diagnosis? a. Conversion disorder b. Hypochondriasis c. Factitious disorder d. Malingering e. Delusional disorder

159. A 55-year-old man comes to the physician with the chief complaint of daytime drowsiness. He states that although he goes to bed at 10 PM and doesn't get up until 6 AM, he is chronically tired and must take naps dur- ing the day. He wakes up in the morning with a headache and a dry mouth. His wife states that he snores loudly. Which of the following is the most likely diagnosis? a. Obstructive sleep apnea b. Narcolepsy c. Central apnea d. Recurrent hypersomnia e. Major depression

163. A 69-year-old man with a diagnosis of delirium has symptoms of psychosis which include: frightening auditory and visual hallucinations and paranoid delusions. Which of the following medications should be chosen first for this man's symptoms? a. Haloperidol b. Quetiapine c. Valium d. Olanzepine e. Ziprasidone

167. A 72-year-old retired English professor with a long history of hyper- tension has been having difficulties with tasks he used to find easy and enjoyable, such as crossword puzzles and letter writing, because he cannot remember the correct words and his handwriting has deteriorated. He has also been having difficulty remembering the events of previous days and he moves and thinks at a slower pace. These symptoms have been progressing slowly in a step-wise fashion over time. Subsequently, he develops slurred speech. Which of the following is the most likely diagnosis? a. Multi-infarct dementia b. German-Strausser syndrome c. Rett disorder d. Wernicke-Korsakoff syndrome e. Alzheimer disease

178. Which of the following etiologies is most likely underlying the behavior of the woman in the vignette above? a. Primary gain b. Secondary gain c. Psychosis d. Marginal intellectual function e. Drug-seeking behavior

18.A 69-year-old man is brought to see his physician by his wife. She notes that over the past year he has experienced a slow, stepwise decline in his cognitive functioning. One year ago she felt his thinking was "as good as it always had been," but now he gets lost around the house and can't remember simple directions. The patient insists that he feels fine, though he is depressed about his loss of memory. He is eating and sleeping well. Which of the following is the most likely diagnosis? a. Multi-infarct dementia b. Mood disorder secondary to a general medical condition c. Schizoaffective disorder d. Delirium e. Major depression

180. A 32-year-old woman who has a chronic psychiatric disorder, multi- ple medical problems, and alcoholism comes to the physician because her breasts have started leaking a whitish fluid. Which of the following is the most likely cause of this symptom? a. Haloperidol b. Oral contraceptives c. Hypothyroidism d. Cirrhosis e. Pregnancy

186. A 53-year-old woman has consumed over 1 pint of bourbon per day for the past 24 years. She presents with severe cognitive deficits and is diag- nosed with Korsakoff's syndrome. Which of the following is she most likely to display on mental status examination? a. Impaired recent memory and anterograde amnesia b. Hypermnesia c. Both anterograde and retrograde memory deficits d. Retrograde amnesia e. Retrospective falsification

188. A 15-year-old girl develops generalized tonic-clonic seizures after a brain injury. She is started on valproic acid and is well controlled for the next 3 years. She leaves for college at 18, and the seizures are noted to dra- matically increase in frequency, though her valproate levels remain thera- peutic. If administered within 20 minutes after one of these episodes, which of the following tests may help in the differential diagnosis of seizure versus pseudoseizure? a. Prolactin level b. Calcium level c. TSH level d. Cortisol level e. Electromyography

195. A 43-year-old man comes to the physician with the chief complaint of nervousness and excitability for 3 months. He states that he feels this way constantly and that this is a dramatic change for his normally relaxed personality. He notes that on occasion he becomes extremely afraid of his own impending death, even when there is no objective evidence that this would occur. He notes that he has lost 20 lb and frequently has diarrhea. On mental status examination, he is noted to have pressured speech. On physical examination, he is noted to have a fine tremor and tachycardia. Which of the following disorders is this patient most likely to have? a. Hyperthyroidism b. Hypothyroidism c. Hepatic encephalopathy d. Hyperparathyroidism e. Hypoparathyroidism

201. A 28-year-old woman comes to the physician requesting genetic counseling. Her father has been diagnosed with Huntington disease. What is this woman's risk of developing this disease? a. 1in2. b. 1in4. c. 1in16. d. 1in32. e. She will not develop the disease, but will be a carrier.

203. A 32-year-old man is admitted to the hospital after he is hit by a car and breaks his femur. Three days into his hospital stay, he tells the nurse that he is repeatedly hearing the voice of his mother telling him to protect himself from danger. He also notes that he sees movement out of the cor- ners of his eyes. He states that these things have never happened to him previously. His vital signs are BP, 160/92; respirations, 12 breaths per minute; pulse, 110 beats per minute; and temperature, 38°C (100.4°F). Which of the following is the most likely diagnosis for this patient? a. Delirium tremens b. Brief psychotic disorder c. Schizophrenia d. Schizophreniform disorder e. Subdural bleed

204. A 56-year-old retired boxer is brought to the physician by his wife because his memory is "not what it used to be." On examination, he is noted to have a moderately severe cognitive impairment. He shows little facial expression and he walks with small, rigid steps. Which of the follow- ing is the most likely cause of his disorder? a. An idiopathic degenerative process b. Chronic trauma c. An inborn error of metabolism d. A familial disorder e. A vitamin deficiency

210. The patient in question 208 becomes very agitated in the emergency room, screaming that the nurses were there to kill her and that she had to escape. She tried to strike one of the nurses before being restrained. Which of the following treatment options is recommended first? a. Haloperidol and lorazepam IM b. Clozapine PO c. Fluphenazine decanoate IM d. Mellaril IM

214. A 36-year-old woman is brought to the psychiatrist by her husband because for the past 8 months she has refused to go out of the house, believ- ing that the neighbors are trying to harm her. She is afraid that if they see her they will hurt her, and she finds many small bits of evidence to support this. This evidence includes the neighbors' leaving their garbage cans out on the street to try to trip her, parking their cars in their driveways so they can hide behind them and spy on her, and walking by her house to try to get a look into where she is hiding. She states that her mood is fine and would be "bet- ter if they would leave me alone." She denies hearing the neighbors or any- one else talk to her, but is sure that they are out to "cause her death and mayhem." Which of the following is the most likely diagnosis? a. Delusional disorder b. Schizophreniform disorder c. Schizoaffective disorder d. Schizophrenia e. Major depression with psychotic features

215. A 35-year-old woman has lived in a state psychiatric hospital for the past 10 years. She spends most of her day rocking, muttering softly to her- self, or looking at her reflection in a small mirror. She needs help with dressing and showering, and she often giggles and laughs for no apparent reason. Which of the following is the most likely diagnosis? a. Schizophrenia b. Delusional disorder c. Bipolar disorder, manic phase d. Schizoaffective disorder e. Schizophreniform disorder

217. A 21-year-old man is brought to the emergency room by his parents because he has not slept, bathed, or eaten in the past 3 days. The parents report that for the past 6 months their son has been acting strangely and "not himself." They state that he has been locking himself in his room, talk- ing to himself, and writing on the walls. Six weeks prior to the emergency room visit, their son became convinced that a fellow student was stealing his thoughts and making him unable to learn his school material. In the past 2 weeks, they have noticed that their son has become depressed and has stopped taking care of himself, including bathing, eating, and getting dressed. On examination, the patient is dirty, disheveled, and crying. He complains of not being able to concentrate, a low energy level, and feeling suicidal. Which of the following is the most likely diagnosis for this patient? a. Schizoaffective disorder b. Schizophrenia c. Bipolar I disorder d. Schizoid personality disorder e. Delusional disorder

219. A 40-year-old woman is arrested by the police after she is found crawling through the window of a movie star's home. She states that the movie star invited her into his home because the two are secretly married and "it just wouldn't be good for his career if everyone knew." The movie star denies the two have ever met, but notes that the woman has sent him hundreds of letters over the past 2 years. The woman has never been in trouble before and lives an otherwise isolated and unremarkable life. Which of the following is the most likely diagnosis? a. Delusional disorder b. Schizoaffective disorder c. Bipolar I disorder d. Cyclothymia e. Schizophreniform disorder

22. The patient above becomes physically violent in the emergency room, attempting to strike a nurse and struggling with security. Which of the fol- lowing actions should the psychiatrist take now? a. Order full leather restraints b. Admit the patient to the inpatient psychiatry unit c. Offer the patient 5 mg of haloperidol PO d. Attempt to find out why the patient is so upset e. Assist security in restraining the patient

229. A 28-year-old woman is brought to see a psychiatrist by her mother. The patient insists that nothing is wrong with her, but the mother notes that the patient has been slowly but progressively isolating herself from everyone. She now rarely leaves the house. The mother says she can hear the patient talking to "people who aren't there" while she's in her room. On examination, the patient is noted to have auditory hallucinations and the delusional belief that her mother is going to kick her out of the house so that it can be turned into a theme park. Which of the following is the life- time prevalence for this disorder? a. 1% b. 3% c. 5% d. 10% e. 15%

23. The patient in question 21 is eventually placed in full leather restraints. He struggles against them and screams racial slurs repeatedly. What action should the psychiatrist take next? a. Give haloperidol 5 mg IM and lorazepam 2 mg IM b. Start an IV and give diazepam 5 mg IVP c. Isolate the patient so that all visual stimuli are reduced d. Give a loading dose of carbamazepine e. Send the patient for an MRI of his head

233. Families of patients with schizophrenia, who are overtly hostile and overly controlling, affect the patient in which one of the following ways? a. Increased relapse rate b. Decreased rate of compliance c. High likelihood that this behavior led to the patient's first break of the disease d. Increased likelihood that the patient's schizophrenia will be of the paranoid type e. Decreased risk of suicidal behaviour

235. A 23-year-old woman was diagnosed with schizophrenia after a single episode of psychosis (hallucinations and delusions) that lasted 7 months. She was started on a small dose of olanzapine at the time of diag- nosis, which resulted in the disappearance of all her psychotic symptoms. She has now been symptom free for the past 3 years. Which of the follow- ing treatment changes should be made first? a. Her olanzapine should be decreased and then stopped if she remains symptom free. b. Her olanzapine should be decreased, but not stopped. c. Her olanzapine should be maintained at a constant level, but she can stretch out the time between her appointments with the psychiatrist. d. Her diagnosis should be reexamined as she is likely not schizophrenic at all. e. Her olanzapine should be switched to a long-acting depot antipsychotic med- ication such as haloperidol decanoate.

236. A 75-year-old man is being cared for in a hospice setting. He has widely spread prostatic carcinoma and is considered terminal. Which of the following psychiatric symptoms are seen in 90% of all terminal patients? a. Delusions b. Hallucinations c. Flight of ideas d. Anxiety e. Depression

248. A 24-year-old woman with bulimia joins an eating disorder support group on the advice of her psychiatrist. After years of being deeply ashamed of her disorder and keeping it secret, she is relieved to hear that others in the group have binged and purged as she has. Which of the fol- lowing terms best describes this phenomenon, which is common in self- help groups? a. Universalization b. Group cohesion c. Multiple transference d. Shared belief system e. Validation

27. A 59-year-old man goes to a psychiatrist for a 3-month history of panic attacks. He notes for the past 3 months he has experienced "out of the blue," extreme episodes of fearfulness that last about 20 minutes. Dur- ing that time he experiences palpitations, sweating, shortness of breath, and trembling. He denies any substance abuse, and has never had symp- toms like this before these past 3 months. Which of the following signs or symptoms would likely lead the physicians to expect a diagnosis of anxiety secondary to a general medical condition in this case? a. The patient's age b. History of palpitations c. History of sweating d. History of shortness of breath e. History of trembling

94. A young man is often the object of his friends' jokes because he drops to the floor whenever he is having a good laugh. Which of the following is this man most likely suffering from? a. Cataplexy b. Narcolepsy c. Hysteria d. Drop seizures e. Histrionic personality

10.A 23-year-old woman comes to the psychiatrist because she "cannot get out of the shower." She tells the psychiatrist that she has been unable to go to her job as a secretary for the past 3 weeks because it takes her at least 4 hours to shower. She describes an elaborate ritual in which she must make sure that each part of her body has been scrubbed three times, in exactly the same order each time. She notes that her hands are raw and bloody from all the scrubbing. She states that she hates what she is doing to herself but becomes unbearably anxious each time she tries to stop. She notes that she has always taken long showers, but the problem has been worsening steadily for the past 5 months. She denies problems with friends or at work, other than the problems that currently are keeping her from going to work. Which of the following is the most likely diagnosis? a. Attention-deficit hyperactivity disorder b. Obsessive-compulsive disorder c. Obsessive-compulsive personality disorder d. Separation anxiety disorder e. Brief psychotic disorder

103. Monoamine oxidase inhibitors (MAOIs) exert their influence primar- ily by which of the following mechanisms? a. Increasing GABA production b. Blocking inactivation of biogenic amines c. Decreasing norepinephrine d. Decreasing serotonin e. Increasing endorphin production

104. A 36-year-old woman is being evaluated in the sleep laboratory. She is noted to have a decreased latency of REM. Which of the following disor- ders is this woman most likely to be suffering from? a. Schizophrenia b. Major depression c. Panic disorder d. Obsessive-compulsive disorder e. Posttraumatic stress disorder (PTSD)

111. A 50-year-old man notes that several times per week he has a hallu- cination of the smell of burning rubber. He is diagnosed with partial com- plex seizures. Which of the following regions is most likely to show a discharging focus on EEG? a. Parietal lobe b. Temporal lobe c. Frontal lobe d. Thalamus e. Occipital lobe

112. During a study on schizophrenia, a sample of children from 12 to 15 years is recruited. Any child already showing signs of schizophrenia is excluded from the sample. Histories are taken to look for a variety of risk factors for developing schizophrenia. Every year thereafter, the children are evaluated to determine how many have developed schizophrenia. Which kind of study is this? a. Clinical trial b. Cohort study c. Case-control study d. Case-history study e. Crossover study

127. A 54-year-old man is a chronic alcoholic. He has been diagnosed with Korsakoff syndrome (a severe inability to form new memories and a variable inability to recall remote memories). Where in the brain is the damage causing this memory loss likely located? a. Angular gyrus b. Mammillary bodies c. Hypothalamus d. Globus pallidus e. Arcuate fasciculus

129. A 58-year-old man has a brain lesion that causes him to feel euphoric, laugh uncontrollably, and joke and make puns. Where is this brain lesion most likely located? a. Fornix b. Right prefrontal cortex c. Hippocampus d. Left orbitofrontal cortex e. Amygdala

131. A 44-year-old man has had a traumatic injury to his brain. Since the accident, he has appeared inattentive and undermotivated. He tends to linger on trivial thoughts and echoes the examiner's questions. Which area of the man's brain is likely to have been traumatised? a. Orbitofrontal region of frontal lobe b. Dorsolateral region of frontal lobe c. Medial region of frontal lobe d. Limbic system e. Parietal lobe

133. A 5-year-old boy is brought to the psychiatrist because he has diffi- culty paying attention in school. He fidgets and squirms and will not stay seated in class. It is noted that at home he talks excessively and has diffi- culty waiting for his turn. His language and motor skills are appropriate for his age. Which of the following is the most likely diagnosis? a. Oppositional defiant disorder (ODD) b. Attention-deficit hyperactivity disorder (ADHD) c. Pervasive developmental disorder d. Separation anxiety disorder e. Mild mental retardation

134. A 4-year-old girl is brought to her pediatrician because her parents think she does not seem to be "developing normally." The girl's mother states that her daughter seemed normal for at least the first 2 to 3 years of her life. She was walking and beginning to speak in sentences. She was able to play with her mother and older sister. The mother has been noticing that over the past 2 months her daughter has lost these previously acquired abilities. She will no longer play with anyone else and has stopped speak- ing entirely. She has lost all bowel control, when previously she had not needed a diaper for at least a year. Which of the following is the most likely diagnosis? a. Rett disorder b. Childhood disintegrative disorder c. Autism d. Asperger disorder e. Pervasive developmental disorder

135. The parents of an 8-year-old boy with a normal IQ are concerned because he is a very slow reader and does not appear to understand what he reads. When the boy reads aloud, he misses words and changes the sequence of the letters. They also note that he has problems with spelling, though he is otherwise quite creative in his ability to write stories. On examination, the child displays verbal language defects as well, though pri- marily he communicates clearly. His hearing and vision are normal and he has no trouble with motor skills. Which of the following is the most likely diagnosis for this child? a. Developmental expressive writing disorder b. Dyslexia c. Developmental articulation disorder d. Pervasive developmental disorder e. Developmental coordination disorder

137. A 13-year-old boy is brought to the emergency room by his parents after he set fire to their home. He has been seen in the emergency room on multiple occasions for a variety of symptoms, including suicidality, homi- cidality, uncontrollable tantrums, and pica. Of those symptoms, which is most commonly seen by psychiatrists in the emergency room in children under the age of 12? a. Arson b. Suicidality c. Homicidality d. Uncontrollable tantrums e. Pica

146. A 4-year-old boy is brought to the physician by his parents because he experiences episodes of waking in the middle of the night and scream- ing. The parents state that when they get to the boy's room during one of these episodes, they find him in his bed, thrashing wildly, his eyes wide open. He pushes them away when they try to comfort him. After 2 min- utes, the boy suddenly falls asleep, and the next day he has no memory of the episode. Which of the following medications should be the first choice to treat this disorder? a. Haloperidol b. Diazepam c. Methylphenidate d. Amitriptyline e. Valproic acid

152. A 70-year-old man with a dementing disorder dies in a car accident. During the previous 5 years, his personality had dramatically changed and he had caused much embarrassment to his family because of his intrusive and inappropriate behavior. Pathological examination of his brain shows frontotemporal atrophy, gliosis of the frontal lobes' white matter, character- istic intracellular inclusions, and swollen neurons. Amyloid plaques and neurofibrillary tangles are absent. Which of the following is the most likely diagnosis? a. Alzheimer disease b. Pick disease c. Creutzfeldt-Jakob disease d. B12 deficiency dementia e. HIV dementia

157. A 76-year-old woman was admitted to the hospital after she was found lying on the floor of her bedroom by her daughter. In the hospital, the patient was found to be incoherent. She was also hypervigilant and had disorganized thoughts. The woman's medications before hospitalization included digoxin and a benzodiazepine which has been recently started because the patient had been complaining of insomnia. What is the most likely diagnosis? a. Delirium secondary to a general medical condition b. Delirium secondary to substance intoxication c. Dementia of the Alzheimer type d. Vascular dementia e. Pseudodementia secondary to major depression

16.A 23-year-old woman comes to the emergency room with the chief complaint that she has been hearing voices for 7 months. Besides the hal- lucinations, she has the idea that the radio is giving her special messages. When asked the meaning of the proverb "People in glass houses should not throw stones," the patient replies, "Because the windows would break." Which of the following mental status findings does this patient display? a. Poverty of content b. Concrete thinking c. Flight of ideas d. Loose associations e. Delirium

172. A 25-year-old woman is brought to the physician by her boyfriend after he noticed a change in her personality over the preceding 6 months. He states that she frequently becomes excessively preoccupied with a sin- gle theme, often religious in nature. She was not previously a religious per- son. He also notes that she often perseverates on a theme while she is speaking, and that she is overinclusive in her descriptions. Finally, he notes that while previously the two had a satisfying sexual life, now the patient appears to have no sex drive whatsoever. The physician finds the patient to be very emotionally intense as well. Physical examination was normal. Which of the following is the most likely diagnosis? a. Wernicke-Korsakoff syndrome b. Temporal lobe epilepsy c. Pick disease d. Multiple sclerosis e. HIV-related dementia

179. A 26-year-old man comes to the emergency room with the chief complaint of suicidal ideation. He is admitted to the psychiatric ward, where he is noncompliant with all treatment regimens and does not show any psychiatric symptoms other than his insistence that he is suicidal. It is subsequently discovered that he is wanted by the police, who have a war- rant for his arrest. Which of the following best describes this behaviour? a. Primary gain b. Secondary gain c. Displacement d. Rationalization e. Marginal intellectual function

2.A 32-year-old woman is seen in an outpatient psychiatric clinic for the chief complaint of a depressed mood for 4 months. During the interview, she gives very long, complicated explanations and many unnecessary details before finally answering the original questions. Which of the fol- lowing psychiatric findings best describes this style of train of thought? a. Loose association b. Circumstantiality c. Neologism d. Perseveration e. Flight of ideas

202. Which of the following is the most common cause of dementia? a. Major depression b. Alzheimer disease c. Normal-pressure hydrocephalus d. Vitamin B12 deficiency e. Multiple small infarcts

21. A 30-year-old man is brought to the emergency room after threatening to kill his 19-year-old girlfriend after she told him she was breaking up with him. The patient smells strongly of alcohol. The patient is from a high socioeconomic status and reports many social supports. Which of the fol- lowing pairs of factors make this patient's risk of violent behavior higher? a. His age and his alcohol use b. His alcohol use and the impending breakup with the girlfriend c. The impending breakup with the girlfriend and his high socioeconomic status d. His high socioeconomic status and the presence of many social supports in his life e. The age difference of the couple and a verbal threat of violence by the patient

218. A 47-year-old woman is brought to the emergency room after she jumped off an overpass in a suicide attempt. In the emergency room she states that she wanted to kill herself because the devil had been tormenting her for many years. After stabilization of her fractures, she is admitted to the psychiatric unit, where she is treated with risperidone and sertraline. After 2 weeks she is no longer suicidal and her mood is euthymic. How- ever, she still believes that the devil is recruiting people to try to persecute her. In the past 10 years, the patient has had three similar episodes prior to this one. Throughout this time, she has never stopped believing that the devil is persecuting her. Which of the following is the most appropriate diagnosis for this patient? a. Delusional disorder b. Schizoaffective disorder c. Schizophrenia, paranoid type d. Schizophreniform disorder e. Major depression with psychotic features

227. A 30-year-old man is brought to the emergency room after he was found wandering on the streets with no shoes on in the middle of winter. He is admitted to the inpatient psychiatric unit and stabilized on antipsy- chotic medication. Looking at past records, his psychiatrist notes that he is repeatedly noncompliant with his medication postdischarge, and each time he relapses within 6 months. Which of the following medications is the best one for this patient to be maintained on? a. Clozapine b. Haloperidol decanoate c. Chlorpromazine d. Thioridazine e. Quetiapine

241. A 45-year-old man is diagnosed as having diabetes and will require insulin. His physician explains the use of the medication and tells the patient that he will need to be seen at frequent intervals until his glucose levels come under good control. The patient has always been somewhat hostile with the physician, but upon hearing this news, he says angrily, "You doctors are always the same! You always want control--of my time, of my money, and now of my every action!" As far as the physician knows, this patient has never had an unpleasant encounter with a physician before. Which of the following is the most likely explanation for the patient's reac- tion to his doctor? a. The patient is becoming delusional. b. The patient is experiencing transference to this authority figure. c. The patient is splitting. d. The patient is becoming manic. e. The patient is anticipating being rejected by his physician.

243. In the above patient, which of the following signs or symptoms should push the physician to recommend insight-oriented psychodynamic psychotherapy once the patient's life had returned to a less-stressful state? a. Poor reality testing b. High tolerance for frustration c. Organically based cognitive dysfunction d. Low intelligence e. Poor impulse control

244. A 32-year-old woman presented to the psychiatric emergency room after a suicide attempt in which she swallowed a bottle of aspirin. On the inpatient unit it was noted that she was stealing needles and injecting feces under her skin to cause infections. She has a long history of multiple sur- gical procedures for unclear reasons. Which of the following guidelines is most useful for therapy with patients with this disorder? a. Appoint a psychiatrist as the primary gatekeeper for all medical and psychiatric treatments. b. Consider using face-saving behavioral strategies to promote healing. c. Aggressively and directly confront this patient's behavior and her illness. d. Discharge the patient from the hospital as soon as possible. e. Use invasive diagnostic procedures early to get a quick diagnosis of any pre- senting physical signs or symptoms.

25. A patient is able to appreciate subtle nuances in thinking and can use metaphors and understand them. This patient's thinking can be best defined by which of the following terms? a. Intellectualization b. Abstract c. Rationalization d. Concrete e. Isolation of affect

3.A 23-year-old man comes to the psychiatrist with a chief complaint of a depressed mood. He is very anxious and obviously uncomfortable in the physician's office. Which of the following actions should be used to help develop rapport with this patient? a. Inform the patient that his problem is simple and easily fixed. b. Express compassion with the difficult position the patient is in. c. Tell the patient that you too are nervous when you see new patients. d. Ask the patient why he is so unusually anxious about seeing a psychiatrist. e. Get right to the patient's complaint so that the patient can leave as soon as possible.

31. A 29-year-old man is brought to the emergency room by his wife after he woke up with paralysis of his right arm. The patient reports that the day before, he had gotten into a verbal altercation with his mother over her intrusiveness in his life. The patient notes that he has always had mixed feelings about his mother, but that people should always respect their mothers above all else. Which of the following diagnoses best fits this patient's clinical picture? a. Major depression b. Conversion disorder c. Histrionic personality disorder d. Fugue state e. Adjustment disorder

39. A patient with a chronic psychotic disorder is convinced that she has caused a recent earthquake because she was bored and wishing for some- thing exciting to occur. Which of the following symptoms most closely describes this patient's thoughts? a. Thought broadcasting b. Magical thinking c. Echolalia d. Nihilism e. Obsession

9.A 52-year-old man is sent to see a psychiatrist after he is disciplined at his job because he consistently turns in his assignments late. He insists that he is not about to turn in anything until it is "perfect, unlike all of my col- leagues." He has few friends because he annoys them with his demands for "precise timeliness" and because of his lack of emotional warmth. This has been a lifelong pattern for the patient, though he refuses to believe the problems have anything to do with his personal behavior. Which of the fol- lowing is the most likely diagnosis for this patient? a. Obsessive-compulsive disorder b. Obsessive-compulsive personality disorder c. Borderline personality disorder d. Bipolar disorder, mixed state e. Anxiety disorder not otherwise specified

97. The observation that levodopa (a drug used to treat Parkinson disease) can cause mania and psychosis in some patients supports which neuro- chemical theory of psychiatric behavior? a. Norepinephrine b. Dopamine c. Glycine d. Serotonin e. Glutamine

106. A 52-year-old housewife has gained weight, although she has no increased appetite. She feels tired all the time and does not seem to care about anything anymore. She complains of being cold all the time. On examination, she appears depressed, and her hair is dry and brittle. Which of the following laboratory findings is she likely to display? a. Elevated adrenocorticotropic hormone (ACTH) b. Low cortisol level c. Elevated thyroid-stimulating hormone (TSH) d. Low calcium level e. Elevated follicle-stimulating hormone (FSH)

109. A 65-year-old woman with a history of chronic alcohol abuse cheer- fully greets the resident doctor of her nursing home, whom she has met many times before, and calls him, "My dear friend Jack." The physician explains who he is and tells the patient his name. Two minutes later, when he asks the patient if she knows who he is, she answers with a smile, "Of course, you are my cousin Anthony from New Jersey." What vitamin defi- ciency can cause this form of amnestic disorder? a. Pantothenic acid b. Folate c. Thiamine d. Riboflavin e. Niacin

11.A 37 year-old man with chronic schizophrenia is brought to see a new psychiatrist for treatment. While taking the history, the psychiatrist finds that the patient functions with a flat affect and circumstantial speech all the time. He has few friends. He is able to hold a menial job at the halfway house where he lives, and his behavior is not influenced by delusions or hallucinations currently. What should the psychiatrist rate the patient on Axis V (global assessment of functioning)? a. >95 b. 70 c. 55 d. 30 e. 15

110. A 24-year-old woman comes to the emergency room because she "can't stand the addiction to cocaine anymore." She tells the physician that she has been using cocaine in increasing amounts for the past 2 years, and now her use is totally out of control. Which of the following systems is involved in this drug's capacity for such a high addiction potential in human beings? a. Serotonergic b. GABA-ergic c. Dopaminergic d. Noradrenergic e. Biogenic amine system

116. A 71-year-old man has been treated by a neurologist for Parkinson disease for the past 2 years. One week after his last visit, he called his neu- rologist, reporting that he suddenly began seeing little people walking all over his furniture. Which of the following is the most likely cause of this hallucination? a. L-dopa was decreased at the last visit. b. The patient is delirious. c. L-dopa was increased at the last visit. d. The patient has developed a psychotic depression. e. The Parkinson disease is worsening.

139. A 7-year-old boy avoids sleepovers because he wets his bed one to two times per week and is afraid his friends would tease him. He has never achieved a year-long period of dryness throughout the night. A physiologic work-up shows no evidence of an organic cause for this problem, and there is no evidence of a psychiatric disorder in any other category. Which of the following treatments is likely to be effective and should be tried first? a. Pharmacotherapy with imipramine b. Bladder training (reward for delaying micturition during daylight hours) c. Classic conditioning with a bell-and-pad apparatus d. Pharmacotherapy with desmopressin e. Psychotherapy

143. A 1-year-old girl has been hospitalized on numerous occasions for periods of apnea. Each time, her mother called an ambulance after her daughter had stopped breathing suddenly. All work-ups in the hospital have been negative, and the patient has never had an episode in front of anyone but her mother. The patient's mother seems very involved with the child and the staff on the unit, and she does not seem hesitant about con- senting to lab tests on her daughter, even if the tests are invasive. Which of the following statements is true about the disorder described in this case? a. It is usually self-limited. b. The father is usually the perpetrator. c. It constitutes a form of child abuse. d. Usually only one child in a family is victimized. e. The caregiver's motivation is watching the child suffer.

144. A social worker makes a routine visit to a 3-year-old boy who has just been returned to his biological mother after spending 3 months in foster care as a result of severe neglect. The child initially appears very shy and clings fearfully to his mother. Later on, he starts playing in a very destruc- tive and disorganized way. When the mother tries to stop him from throw- ing blocks at her, he starts kicking and biting. The mother becomes enraged and starts shouting. Which of the following is the most likely diag- nosis for this child? a. Oppositional defiant disorder b. ADHD c. Reactive attachment disorder d. Posttraumatic stress disorder (PTSD) e. Major depression

154. An emaciated and lethargic 16-year-old girl arrives at the emergency room. Her blood pressure is 75/50, her heart rate is 52 beats per minute, her potassium is 2.8 meq/L, and her bicarbonate is 40 meq/L. The girl's parents report that she has lost 35 lb in 3 months but is still convinced that she is overweight. She eats only very small amounts of low-calorie food, and she runs 2 to 3 hours every day. What other activities is this patient most likely to have engaged in? a. Sexual promiscuity b. Ethanol abuse c. Purging d. Wearing tight clothes e. Shoplifting

161. A 24-year-old woman is hospitalized after a suicide gesture during which she superficially slashed both her wrists. At the team meeting 3 days later, the male resident argues that the patient has been doing quite well, seems to be responding to therapy, and should be allowed to leave on a pass. The nursing staff angrily argues that the resident is showing favoritism to the patient, and because of her poor compliance with the unit rules, she should not be allowed out. The resident insists the nurses are being punitive. The defense mechanism being used by the patient in this scenario is a feature of which of the following personality disorders? a. Narcissistic b. Histrionic c. Borderline d. Antisocial e. Dependent

162. A 45-year-old woman, who has been on chronic steroid treatment for her asthma, has thin arms and legs but has a large amount of fat deposited on her abdomen, chest, and shoulders. Her skin is thin and atrophic, and she bruises easily. She has purple striae on her abdomen. Physical exami- nation shows elevated blood pressure and laboratory tests show decreased glucose tolerance. Which of the following psychiatric conditions is the most likely diagnosis? a. Major depression b. Bipolar-mania c. Substance-induced mood disorder d. Delirium e. Schizoaffective disorder

165. A 40-year-old woman's cognitive functions have progressively deteri- orated for several years, to the point where she needs nursing home-level care. She is depressed, easily irritated, and prone to aggressive outbursts, a dramatic change from her premorbid personality. She also presents with irregular, purposeless, and asymmetrical movements of her face, limbs, and trunk, which worsen when she is upset and disappear in sleep. Her MRI shows atrophy of the caudal nucleus and the putamen. Which of the fol- lowing is the most likely diagnosis of this patient? a. Creutzfeldt-Jakob disease b. Wilson disease c. Huntington disease d. Alzheimer disease e. Multi-infarct dementia

166. A 37-year-old mildly retarded man with trisomy 21 syndrome has been increasingly forgetful. He makes frequent mistakes when counting change at the grocery store where he has worked for several years. In the past, he used to perform this task without difficulty. He often cannot recall the names of common objects, and he has started annoying customers with his intrusive questions. Which of the following is the most likely diagnosis of this patient? a. Pseudodementia b. Hypothalamic tumor c. Alzheimer disease d. Wilson disease e. Thiamine deficiency

169. A 53-year-old man is admitted to the cardiac intensive care unit after a myocardial infarction. The day after he is admitted, when the physician enters the room, the patient loudly declares that he "feels fine" and pro- ceeds to get down on the floor to demonstrate this assertion by doing push- ups. Once persuaded to get back into bed, the patient becomes angry about the poor food quality and feels that only the "most qualified" specialist in the hospital should be treating him because he is, after all, the CEO of his own company. The patient's wife notes that this demanding behavior and haughty attitude are not unusual for him. Which of the following psychi- atric diagnoses is most likely for this patient? a. Mania b. Acute psychotic disorder c. Narcissistic personality disorder d. Delusional disorder e. Schizoaffective disorder

170. A 22-year-old college student comes to the physician with the com- plaint of shortness of breath during anxiety-provoking situations, such as examinations. She also notes perioral tingling, carpopedal spasms, and feelings of derealization at the same time. All of the symptoms pass after the anxiety over the situation has faded. The episodes have never occurred "out of the blue." Which of the following is the most likely diagnosis? a. Panic disorder b. Generalized anxiety disorder c. Hyperventilation d. Anxiety disorder not otherwise specified e. Anxiety disorder secondary to a general medical condition

171. Which of the following treatments should the physician suggest first for the patient in the vignette above? a. Alprazolam prn b. Fluoxetine daily c. Rebreathe into a paper bag during the episode d. Biofeedback e. Hypnosis

173. A 23-year-old man comes to the physician with the complaint that his memory has worsened over the past 2 months and that he has difficulty concentrating. He has lost interest in his friends and his work. He has dif- ficulty with abstract thoughts and problem solving. He has also felt depressed. MRI scan shows parenchymal abnormalities. Which of the fol- lowing is the most likely diagnosis? a. Alzheimer disease b. Vascular dementia c. HIV-related dementia d. Lewy body disease e. Binswanger disease

182. A 3-year-old child is brought to the emergency room by his parents after they found him having a generalized seizure at home. The child's breath smells of garlic, and he has bloody diarrhea, vomiting, and muscle twitching. Which of the following poisons is it likely that this child has encountered? a. Thallium b. Lead c. Arsenic d. Carbon monoxide e. Aluminum

184. Which of the following courses of action is most likely to be helpful in the case of the woman in the vignette above? a. Refer the patient to psychotherapy b. Start the patient on an antidepressant c. Have the patient see a primary care physician at regular intervals d. Begin a diagnostic work-up for ovarian cancer e. Start the patient on an antipsychotic for her delusional belief

191. A 52-year-old man undergoes a successful mitral valve replacement. He is sent to the intensive care unit to recover. The day after the surgery, he appears irritable and restless. Hours later he is agitated, disoriented, hyper- vigilant, and uncooperative. This agitation alternates with periods of som- nolence. Which of the following is most likely to be helpful? a. Intramuscular Thorazine b. Oral alprazolam c. Modification of environment d. Oral lithium e. Supportive psychotherapy

193. A 34-year-old man comes to the physician with the chief complaint of new-onset visual hallucinations for 1 month. He states that he sees flash- ing lights and movement when he knows that there is no one in the room with him. He also complains of a headache that occurs several times per week and is dull and achy in nature. Physical examination reveals papilledema and a homonymous hemianopsia. A brain tumor is found on MRI. In which of the following areas of the brain is this tumor most likely found? a. Frontal lobe b. Parietal lobe c. Occipital lobe d. Temporal lobe e. Cerebellum

20.A 6-year-old girl is brought to the physician by her mother, who says the child has been falling behind at school. She notes that the girl did not speak until the age of 4. She is friendly at school, but is unable to complete most tasks, even when aided. She is noted to have a very short attention span and occasional temper tantrums at school and at home. Which of the following tests would be most helpful in establishing the diagnosis? a. Electroencephalogram (EEG) b. Hearing test c. IQ testing d. Complete blood count (CBC) e. Lumbar puncture

205. A 24-year-old man with chronic schizophrenia is brought to the emergency room after his parents found him in his bed and were unable to communicate with him. On examination, the man is confused and disori- ented. He has severe muscle rigidity and a temperature of 39.4°C (103°F). His blood pressure is elevated, and he has a leucocytosis. Which of the fol- lowing is the best first step in the pharmacologic treatment of this man? a. Haloperidol b. Lorazepam c. Bromocriptine d. Benztropine e. Lithium

206. A 54-year-old man with a chronic mental illness seems to be con- stantly chewing. He does not wear dentures. His tongue darts in and out of his mouth, and he occasionally smacks his lips. He also grimaces, frowns, and blinks excessively. Which of the following disorders is most likely in this patient? a. Tourette syndrome b. Akathisia c. Tardive dyskinesia d. Parkinson disease e. Huntington disease

207. A 58-year-old woman with a chronic mental disorder comes to the physician with irregular choreoathetoid movements of her hands and trunk. She states that the movements get worse under stressful conditions. Which of the following medications is most likely to have caused this disorder? a. Fluoxetine b. Clozapine c. Perphenazine d. Diazepam e. Phenobarbital

213. A 19-year-old man is brought to the physician by his parents after he called them from college, terrified that the Mafia was after him. He reports that he has eaten nothing for the past 6 weeks other than canned beans because "they are into everything--I can't be too careful." He is convinced that the Mafia has put cameras in his dormitory room and that they are watching his every move. He occasionally hears the voices of two men talk- ing about him when no one is around. His roommate states that for the past 2 months the patient has been increasingly withdrawn and suspicious. Which of the following is the most likely diagnosis? a. Delusional disorder b. Schizoaffective disorder c. Schizophreniform disorder d. Schizophrenia e. Phencyclidine (PCP) intoxication

24. A psychiatrist is seeing a patient in his outpatient practice. The patient treats the psychiatrist as if he were unreliable and punitive, though he had not been either. The patient's father was an alcoholic who often did not show up to pick her up from school and frequently hit her. The psychiatrist begins to feel as if he must overprotect the patient and treat her gingerly. Which of the fol- lowing psychological mechanisms best describes the psychiatrist's behavior? a. Reaction formation b. Projection c. Countertransference d. Identification with the aggressor e. Illusion

28. A 24-year-old man returns from Iraq after a 13-month tour of duty. During that tour he was involved in battle situations and saw one of his friends injured by a car bomb. What percentage of American soldiers returning home from Iraq have posttraumatic stress disorder (PTSD)? a. <1% b. 1%to5% c. 15% to 20% d. 50% to 55% e. 85% to 90%

36. A 32-year-old patient is being interviewed in his physician's office. He eventually answers each question, but he gives long answers with a great deal of tedious and unnecessary detail before doing so. Which of the fol- lowing symptoms best describes this patient's presentation? a. Blocking b. Tangentiality c. Circumstantiality d. Looseness of associations e. Flight of ideas

38. A 26-year-old woman with panic disorder notes that during the mid- dle of one of her attacks she feels as if she is disconnected from the world, as though it were unreal or distant. Which of the following terms best describes this symptom? a. Mental status change b. Illusion c. Retardation of thought d. Depersonalization e. Derealization

5.A 56-year-old man has been hospitalized for a myocardial infarction. Two days after admission, he awakens in the middle of the night and screams that there is a man standing by the window in his room. When the nurse enters the room and turns on a light, the patient is relieved to learn that the "man" was actually a drape by the window. This misperception of reality is best described by which of the following psychiatric terms? a. Delusion b. Hallucination c. Illusion d. Projection e. Dementia

1.A 42-year-old man comes to the emergency room with the chief com- plaint that "the men are following me." He also complains of hearing a voice telling him to hurt others. He tells the examiner that the news anchorman gives him special messages about the state of the world every night through the TV. Which of the following psychiatric findings best describes this last belief of the patient? a. Grandiose delusion b. Illusion c. Loose association d. Idea of reference e. Clouding of consciousness

102. A 36-year-old moderately retarded man with a long head, large ears, and hyperextensible joints is very shy and starts rocking and flapping his hands when he is upset. His disorder, the second most common single cause of mental retardation, is which of the following? a. Down syndrome b. Hurler syndrome c. Williams syndrome d. Fragile X syndrome e. Rett disorder

118. A 76-year-old man is diagnosed with dementia of the Alzheimer type. Which of the following chemicals has been most commonly associ- ated with this disease? a. Peptide neurotransmitter b. Epinephrine c. Dopamine d. Acetylcholine e. Serotonin

126. Which of the following sites is thought to be significant for formation and storage of immediate and recent memories? a. Hypothalamus b. Nucleus basalis of Meynert c. Mesolimbic circuit d. Hippocampus e. Amygdala

136. For the past 3 months, a 15-year-old girl has had to turn her light on and off 23 times at exactly 10:30 PM before she can go to bed. She can spend from 1 to 2 hours on this ritual because she has to start again if she is interrupted or loses count. She is upset if the position or the order of the objects she has on her desk is changed even slightly and cannot stop wor- rying about her family's safety. The girl knows that this behavior is not "normal" and is concerned and unhappy about it. In conjunction with pharmacologic treatment, which of the following therapies has been proven effective for this disorder? a. Play therapy b. Psychodynamic psychotherapy c. Group therapy d. Cognitive-behavioral therapy e. Family therapy

138. A 5-year-old is being evaluated for ADHD. He has a past history of failure to thrive and he is still at the 15th percentile for weight and height. The evaluator notices that he has unusually small eyes with short palpebral fissures, as well as a thin upper lip with a smooth philtrum. Which sub- stance did his mother most likely abuse during pregnancy? a. Heroin b. Nicotine c. Cannabis d. Alcohol e. Cocaine

140. A 13-year-old girl grunts and clears her throat several times in an hour, and her conversation is often interrupted by random shouting. She also performs idiosyncratic, complex motor activities such as turning her head to the right while she shuts her eyes and opens her mouth. She can prevent these movements for brief periods of time, with effort. Which of the following is the most appropriate treatment for this disorder? a. Individual psychodynamic psychotherapy b. Lorazepam c. Methylphenidate d. Haloperidol e. Imipramine

147. A 14-year-old boy is brought to the physician because he told his mother he wished he were dead. He has been irritable for the past several weeks, and has been isolating himself in his room, avoiding his friends. He has been complaining of general aches and pains as well. Which of the fol- lowing statements is true about this disorder? a. It is rare in children. b. Its presentation in children is similar to that in adults. c. Medications are not the treatment of choice. d. Psychotic symptoms are common. e. Questions about suicide will increase the likelihood of self-destructive behavior.

149. A 5-year-old boy shows no interest in other children and ignores adults other than his parents. He spends hours lining up his toy cars or spinning their wheels but does not use them for "make-believe" play. He rarely uses speech to communicate, and his parents state that he has never done so. Physical examination indicates that his head is of normal circum- ference and his gait is normal. Which of the following is the most likely diagnosis for this boy? a. Obsessive-compulsive disorder b. Asperger syndrome c. Childhood disintegrative disorder d. Autism e. Rett disorder

150. A 15-year-old boy is arrested for shooting the owner of the conve- nience store he tried to rob. He has been in department of youth services custody several times for a variety of crimes against property, possession of illegal substances, and assault and battery. He is cheerful and unconcerned during the arrest, more worried about losing his leather jacket than about the fate of the man he has injured. Which of the following is the most likely diagnosis in this case? a. Oppositional defiant disorder b. Antisocial personality disorder c. Narcissistic personality disorder d. Conduct disorder e. Substance abuse

151. For the past 10 years, the memory of a 74-year-old woman has pro- gressively declined. Lately, she has caused several small kitchen fires by for- getting to turn off the stove, she cannot remember how to cook her favorite recipes, and she becomes disoriented and confused at night. She identifies an increasing number of objects as "that thing" because she cannot recall the correct name. Her muscle strength and balance are intact. Which of the following is the most likely diagnosis? a. Huntington disease b. Multi-infarct dementia c. Creutzfeldt-Jakob disease d. Alzheimer disease e. Wilson disease

164. A 34-year-old man recurrently perceives the smell of rotten eggs. This kind of hallucination is most commonly seen in patients with which of the following diagnoses? a. Parietal tumors b. Narcolepsy c. Grand mal epilepsy d. Partial complex seizures e. Wilson disease

174. A 37-year-old alcoholic is brought to the emergency room after he was found unconscious in the street. He is hospitalized for dehydration and pneumonia. While being treated, he becomes acutely confused and agitated. He cannot move his eyes upward or to the right, and he is ataxic. Which of the following is the most likely diagnosis? a. Alcohol intoxication b. Korsakoff syndrome c. Alcohol delirium d. Wernicke encephalopathy e. Alcohol seizures

177. A 43-year-old woman comes to the emergency room with a temper- ature of 38.3°C (101°F) and a large suppurating ulcer on her left shoulder. This is the third such episode for this woman. Her physical examination is otherwise normal, except for the presence of multiple scars on her abdomen. Which of the following is the most likely diagnosis? a. Malingering b. Somatoform disorder c. Borderline personality disorder d. Factitious disorder e. Body dysmorphic disorder

181. Which of the following endogenous substances is likely to have caused this phenomenon from the vignette above? a. Estrogen b. Thyroid hormone c. Progesterone d. Prolactin e. Alcohol dehydrogenase

183. A 34-year-old woman comes to the physician with the chief com- plaint of abdominal pain. She states that she has been reading on the inter- net and is convinced that she has ovarian cancer. She says that she is particularly concerned because the other physicians she has seen for this pain have all told her that she does not have cancer, and she has been hav- ing the pain for over 8 months. She reports that she has undergone pelvic examinations, ultrasounds, and other diagnostic work-ups, all of which have been negative. She tells the physician that she is initially reassured by the negative tests, but then the pain returns and she becomes convinced that she has cancer again. She notes that she has taken so much time off from work in the past 8 months that she has been reprimanded by her boss. Which of the following is the most likely diagnosis? a. Pain disorder b. Malingering c. Factitious disorder d. Hypochondriasis e. Conversion disorder

185. A man given a sugar pill for mild pain reports that 15 minutes later the pain has completely resolved. Which of the following conclusions is most appropriate about this occurrence? a. The man is drug seeking. b. The man is malingering. c. The man has a factitious disorder. d. The man is demonstrating a placebo response. e. The man had no real pain to begin with.

189. Which of the following is the most common cause of delirium in the elderly? a. Substance abuse b. Accidental poisoning c. Hypoxia d. Use of multiple medications e. Alcohol withdrawal

19.An 18-year-old man is brought to the emergency room by police after he is found wandering in the street, screaming loudly at passersby. In the emergency room he is placed in an examination room, and paces the floor and pounds his fist against the door repeatedly. Which of the following actions should be taken by the psychiatrist first? a. Rule out an organic mental disorder b. Rule out psychosis c. Give the patient 5 mg of haloperidol IM d. Make sure the physical environment is safe for the interviewer e. Put the patient into soft restraints

192. A 23-year-old woman comes to the physician with the chief com- plaint of a depressed mood for 6 months. She states that she has felt lethar- gic, does not sleep well, and has decreased energy and difficulty concentrating. She notes that she has gained over 15 lb without attempting to do so, and seems to bruise much more easily than previously. On phys- ical examination, she is noted to have numerous purple striae on her abdomen, proximal muscle weakness, and a loss of peripheral vision. A brain tumor is found on MRI. In which of the following areas of the brain was this tumor most likely found? a. Frontal lobe b. Cerebellum c. Thalamus d. Pituitary e. Brainstem

194. A 26-year-old man comes to the physician with the chief complaint that he has been uncharacteristically moody and irritable. On several occa- sions his wife has noted that he has had angry outbursts directed at the children and that they were so severe that she had to step in between him and them. He states that he has "spells" in which he smells the odors of rot- ten eggs and burning rubber. During this time he feels disconnected from his surroundings, as if he were in a dream. A brain tumor is found on MRI. In which of the following areas of the brain is this tumor most likely found? a. Frontal lobe b. Parietal lobe c. Occipital lobe d. Temporal lobe e. Cerebellum

209. In the patient in the above vignette, which of the following features would be indicative of a good prognosis with this disease? a. Young onset b. Withdrawn behavior c. Poor support system d. Family history of mood disorders e. Neurologic signs and symptoms present

216. A 20-year-old woman is brought to the emergency room by her fam- ily because they have been unable to get her to eat or drink anything for the past 2 days. The patient, although awake, is completely unresponsive both vocally and nonverbally. She actively resists any attempt to be moved. Her family reports that during the previous 7 months she became increasingly withdrawn, socially isolated, and bizarre; often speaking to people no one else could see. Which of the following is the most likely diagnosis? a. Schizoaffective disorder b. Delusional disorder c. Schizophreniform disorder d. Catatonia e. PCP intoxication

228. A 26-year-old woman is brought to the emergency room by her hus- band after she begins screaming that her children are calling to her and becomes hysterical. The husband states that 2 weeks previously, the cou- ple's two children were killed in a car accident, and since that time the patient has been agitated, disorganized, and incoherent. He states that she will not eat because she believes he has been poisoning her food, and she has not slept for the past 2 days. The patient believes that the nurses in the emergency room are going to cause her harm as well. The patient is sedated and later sent home. One week later, all her symptoms remit sponta- neously. Which of the following is the most likely diagnosis for this patient? a. Delirium b. Schizophreniform disorder c. Major depression with psychotic features d. Brief psychotic disorder e. Posttraumatic stress disorder

230. A 25-year-old woman is diagnosed with schizophrenia when, after the sudden death of her mother, she begins complaining about hearing the voice of the devil and is suddenly afraid that other people are out to hurt her. Her history indicates that she has also experienced a 3-year period of slowly worsening social withdrawal, apathy, and bizarre behavior. Her fam- ily history includes major depression in her father. Which of the following details of her history leads the physician to suspect that her outcome may be poor? a. She is female. b. She was age 25 at diagnosis. c. She had an acute precipitating factor before she began hearing voices. d. She had an insidious onset of her illness. e. There is a history of affective disorder in her family.

231. A 22-year-old man is brought to the emergency room after he became exceedingly anxious in his college dormitory room, stating that he was sure the college administration was sending a "hit squad" to kill him. He also notes that he can see "visions" of men dressed in black who are car- rying guns and stalking him. His thought process is relatively intact, with- out thought blocking or loose associations. His urine toxicology screen is positive for one of the following drugs. Which drug is the most likely cause of these symptoms? a. Barbiturates b. Heroin c. Benzodiazepines d. Amphetamines e. MDMA (Ecstasy)

232. A 72-year-old woman is brought to the emergency room by her daughter after she found her mother rummaging in the garbage cans out- side her home. The daughter states that the patient has never had any behavior like this previously. On interview, the patient states she sees "mar- tians hiding around her home, and on occasion, hears them too." She also demonstrates a constructional apraxia, with difficulty drawing a clock and intersecting pentagons. All of these symptoms point to a medical cause for this patient's behavior except one. Which symptom is common in patients with a psychiatric cause for their behavior (ie, not a medical cause)? a. Patient's age b. No previous history of this behavior c. Visual hallucinations d. Auditory hallucinations e. Constructional apraxia

234. A 62-year-old man with chronic schizophrenia is brought to the emergency room after he is found wandering around his halfway house, confused and disoriented. His serum sodium concentration is 123 meq/L and urine sodium concentration is 5 meq/L. The patient has been treated with risperidone 4 mg/day for the past 3 years with good symptom control. His roommate reports that the patient often complains of feeling thirsty. Which of the following is the most likely cause of this patient's symptoms? a. Renal failure b. Inappropriate antidiuretic hormone (ADH) secretion c. Addison disease d. Psychogenic polydipsia e. Nephrotic syndrome

238. A 25-year-old man is brought to the physician after complaining about a visual hallucination of a transparent phantom of his own body. Which of the following specific syndromes is this patient most likely to be displaying? a. Capgras syndrome b. Lycanthropy c. Cotard syndrome d. Autoscopic psychosis e. Folie á deux

245. What is the most common reason that psychotherapy for personality disorders is so difficult to carry out successfully? a. The traits are often ego-dystonic. b. The patients are usually too sick to use psychotherapy. c. These disorders respond better to medication than to psychotherapy. d. The patients often see the source of their problems in others, not themselves. e. The patients do not have the ego strength for weekly meetings.

249. A 22-year-old student is in therapy because he has a long history of chaotic interpersonal relationships, episodes of psychosis, and multiple hospitalizations. He has attempted suicide three times, mostly precipitated by his feeling overwhelmed in some social setting. One session, he comes to his therapist greatly upset and anxious because he forgot to study some material that will be on an upcoming examination. The therapist reminds the patient that he has done well on previous examinations and suggests that they spend the session devising a study plan for the time the patient has left before the test. Such an intervention is commonly used in which of the following therapies? a. Psychoanalysis b. Object relation psychotherapy c. Cognitive-behavioral therapy d. Supportive psychotherapy e. Interpersonal psychotherapy

26. A 65-year-old man, who had been hospitalized for an acute pneumo- nia 3 days previously, begins screaming for his nurse, stating that "there are people in the room out to get me." He then gets out of bed and begins pulling out his IV line. On examination, he alternates between agitation and somnolence. He is not oriented to time or place. His vital signs are as follows: pulse, 126 beats per minute; respiration, 32 breaths per minute; blood pressure (BP), 80/58; temperature, 39.2°C (102.5°F). Which of the following diagnoses best fits this patient's clinical picture? a. Dementia b. Schizophreniform disorder c. Fugue state d. Delirium e. Brief psychotic episode

30. A 19-year-old woman presents to the emergency room with the chief complaint of a depressed mood for 2 weeks. She notes that since her ther- apist went on vacation she has experienced suicidal ideation, crying spells, and an increased appetite. She states that she has left 40 messages on the therapist's answering machine telling him that she is going to kill herself and that it would serve him right for leaving her. Physical examination reveals multiple well-healed scars and cigarette burns on the anterior aspect of both forearms. Which of the following diagnoses best fits this patient's clinical presentation? a. Dysthymic disorder b. Bipolar disorder c. Panic disorder d. Borderline personality disorder e. Schizoaffective disorder

6.A 22-year-old woman is seen by a psychiatrist in the emergency room after she is found walking in the middle of a busy street with no shoes on. During her interview she is asked to count backwards from 100 by 7's. Which of the following best describes the cognitive functions being tested by this request? a. Orientation b. Immediate memory c. Fund of knowledge d. Concentration e. Abstract reasoning

7.A 72-year-old woman is admitted to the burn unit with second- and third-degree burns covering 35% of her body, which she received in a house fire. At 8 pm on the fourth day of her hospital stay, she pulls out her IV and begins screaming that people are trying to hurt her. Several hours later she is found to be difficult to arouse and disoriented. Which of the fol- lowing is the most likely diagnosis? a. Emergence of an underlying dementia b. Brief reactive psychosis c. Acute manic episode d. Delirium e. Acute stress disorder

8.A psychiatric resident is called to consult on the case of a 75-year-old woman who had undergone a hip replacement 2 days before. On examina- tion, the resident notes that the patient states the date as 1956, and she thinks she is at her son's house. These impairments best illustrate which aspect of the mental status examination? a. Concentration b. Memory c. Thought process d. Orientation e. Level of consciousness

98. A 24-year-old man with Tourette disorder comes to his psychiatrist because he has just gotten engaged. He states that his father also has Tourette's and he is worried that when he becomes a father he will pass the disorder on to his children. No one on his mother's side of the family has Tourette's that he is aware of. What is the best response for the psychiatrist to give this patient? a. Do not worry, there is no evidence for the genetic transmission of Tourette's. Your children have no higher risk of having it than the general population. b. Because Tourette's is a genetically linked disorder passed on by the Y-chromo- some, 100% of your sons will have it, but none of your daughters. c. Tourette's is an X-linked recessive disorder, none of your sons or daughters will have the disorder (although your daughters will be carriers of the disease). d. There is a definite genetic component to Tourette's, but this is multigenic and so difficult to characterize the chances of your children having it. Only 10% of Tourette's patients do not have a relative with it, so you are likely to pass this disorder on. e. This disorder is inherited through an autosomal dominant mechanism. All of your sons and daughters will have Tourette's.

100. After being struck on the head by a four-by-four piece of wood, a previously serious and dependable construction worker starts making inappropriate sexual remarks to his coworkers, is easily distracted, and loses his temper over minor provocations. What part of his brain has most likely been damaged? a. Occipital lobe b. Temporal lobe c. Limbic system d. Basal ganglion e. Frontal lobe

101. A young girl who was underweight and hypotonic in infancy is obsessed with food, eats compulsively, and at age 4, is already grossly over- weight. She is argumentative, oppositional, and rigid. She has a narrow face, almond-shaped eyes, and a small mouth. Which of the following is the most likely diagnosis? a. Down syndrome b. Fragile X syndrome c. Fetal alcohol syndrome d. Hypothyroidism e. Prader-Willi syndrome

105. A 17-year-old boy is brought to the emergency room by his friends after he "took a few pills" at a party and developed physical symptoms, including his neck twisting to one side, his eyes rolling upward, and his tongue hanging out of his mouth. The patient responds immediately to 50 mg of diphenhydramine intramuscularly with the resolution of all phys- ical symptoms. Which of the following substances is most likely to have caused the symptoms? a. Methamphetamine b. Meperidine c. Alprazolam d. Methylphenidate e. Haloperidol

113. Which of the following findings is associated with non-REM (NREM) sleep? a. Penile tumescence b. Apnea c. Narcolepsy d. Dreaming e. Night terrors

115. A 34-year-old man comes to see a psychiatrist because he has been fired for constantly being late to his job. The man states that he feels as if he is in danger of contamination from germs and as a result, he must take showers continuously, often for as many as 8 h/day. Which of the following transmitters is thought to be involved in this disorder? a. Dopamine b. Norepinephrine c. Acetylcholine d. Histamine e. Serotonin

132. A 48-year-old man with Huntington disease experiences irregular, involuntary spasmodic movements of his limbs and facial muscles, as well as psychosis. In a postmortem autopsy, which structure in his brain will likely be markedly shrunken? a. Cerebellum b. Striatum c. Putamen d. Substantia nigra e. Caudate nucleus

145. A first-grade teacher is concerned about a 6-year-old girl in her class who has not spoken a single word since school started. The little girl par- ticipates appropriately in the class activities and uses gestures and drawings and nods and shakes her head to communicate. The parents report that the little girl talks only in the home and only in the presence of her closest rel- atives. Which of the following is the most likely diagnosis? a. Autism b. Expressive language disorder c. Oppositional defiant disorder d. School phobia e. Selective mutism

153. A 24-year-old previously healthy man is brought to the emergency room after he began yelling that people on the bus were out to hurt him. In the emergency room, he is agitated, hypervigilant, and anxious. He is unable to give much history other than to say that he is a graduate student and nothing like this has ever happened before. Which of the following is the most likely cause of this behavior? a. Delirium b. Pick disease c. Dissociative disorder d. Vitamin B12 deficiency e. Cocaine intoxication

158. A 24-year-old man smells burnt rubber, then turns his head and upper body to the right, makes chewing movements, and fumbles with his clothes. During the episode, which lasts 1 minute, he appears dazed. Which of the following is the most likely diagnosis? a. Frontal lobe tumor b. Derealization disorder c. Conversion disorder d. Absence seizure e. Partial complex seizure

17.A 22-year-old woman is seen in the emergency room after a suicide attempt. She swallowed 10 aspirin in the presence of her mother, with whom she had just had an argument. The patient has a long history of cut- ting herself superficially with razor blades, which her psychiatrist of the last 5 years confirms by telephone. The patient currently lives in a stable environment (a halfway house) where she has been for 3 years. Which of the following option is the best course of action for the physician in the emergency room? a. Admit the patient involuntarily b. Admit the patient voluntarily c. Admit the patient to a medical floor d. Discharge the patient to outpatient therapy after meeting with the patient's mother e. Discharge the patient back to outpatient therapy and the halfway house

175. Which of the following is the most appropriate treatment for the patient in the vignette above? a. Dilantin b. Valium c. Haloperidol d. Amobarbitol e. Thiamine

176. A 65-year-old woman is brought to the physician because she has become easily distractible, apathetic, and unconcerned about her appear- ance. She has trouble remembering familiar words and locations, and she experiences urinary incontinence. On physical examination, her gait is seen to be ataxic. When copying a complex picture, she makes many mistakes. The patient most likely has which of the following disorders? a. Parkinson disease b. Thiamine deficiency c. Vitamin B12 deficiency d. Wilson disease e. Normal-pressure hydrocephalus

190. A 61-year-old woman comes to the physician with a 6-month history of mild memory loss. She also has had mild-moderate difficulty with cal- culations which she had previously been able to perform without difficulty. Physical examination and laboratory tests were all within normal limits. Which medication is indicated and should be a first choice for therapy in this case? a. Tacrine b. Rivastigmine c. Galantamine d. Ondansetron e. Donepezil

208. A 19-year-old woman is brought to the emergency room by her roommate after the patient told her that "the voices are telling me to kill the teacher." The roommate states the patient has always been isolative and "odd" but for the past 2 weeks she has been hoarding food, talking to herself, and appearing very paranoid. Which of the following tests are likely to be abnormal in this patient? a. PET scan of dopamine receptors. b. EEG (will show a decreased alpha activity). c. Test of eye movements (patient will be unable to follow a moving visual target accurately). d. CT (lateral and third ventricle enlargement will be seen). e. All of these tests may be abnormal.

211. The patient in the above vignette was admitted and started on a daily dose of fluphenazine. After discharge from the hospital, she was kept on a low dose of the medication for 6 weeks. She showed only a minimal response to the drug, even after it was raised to a moderate dosage level. Which of the following is the next therapeutic step? a. Give a high dose of fluphenazine b. Give a low dose of clozaril c. Give a low dose of haloperidol d. Give fluphenazine decanoate IM e. Give a low dose of olanzapine

212. A 24-year-old woman comes to the emergency room with the chief complaint that "my stomach is rotting out from the inside." She states that for the last 6 months she has been crying on a daily basis and that she has decreased concentration, energy, and interest in her usual hobbies. She has lost 25 lb during that time. She cannot get to sleep, and when she does, she wakes up early in the morning. For the past 3 weeks, she has become con- vinced that she is dying of cancer and is rotting on the inside of her body. Also, in the past 2 weeks she has been hearing a voice calling her name when no one is around. Which of the following is the most likely diagnosis? a. Delusional disorder b. Schizoaffective disorder c. Schizophreniform disorder d. Schizophrenia e. Major depression with psychotic features

237. A 52-year-old man is seen by a psychiatrist in the emergency room because he is complaining about hearing and seeing miniature people who tell him to kill everyone in sight. He states that these symptoms developed suddenly during the past 48 hours, but that he has had them "on and off" for years. He states that he has never previously sought treatment for the symptoms, but that this episode is particularly bad. He denies the use of any illicit substances. The patient is alert and oriented to person, place, and time. His mental status examination is normal except for his auditory and visual hallucinations. His thought process is normal. His drug toxicology screen is positive for marijuana. He is quite insistent that he needs to be "put away" in the hospital for the symptoms he is experiencing. Which of the following is the most likely diagnosis? a. Substance-induced psychosis b. Schizophrenia c. Schizoaffective disorder d. Schizophreniform disorder e. Malingering

239. A 40-year-old woman with a history of chaotic interpersonal rela- tionships enters psychoanalytic psychotherapy. She alternates between periods in which she idealizes the therapist and the progress of the therapy and periods of unrelenting anger when she is convinced that the therapist is unhelpful and that the therapeutic work is worthless. Which of the fol- lowing defense mechanisms is being used by the patient in this scenario? a. Reaction formation b. Denial c. Projection d. Projective identification e. Splitting

240. A patient comes to the psychiatrist for treatment of his posttraumatic stress disorder (PTSD), which he developed from his experiences escaping the World Trade center collapse. He is adamantly opposed to taking med- ications. He chooses EMDR (eye movement desensitization and reprocess- ing) as his treatment of choice. Which of the following describes this treatment regiment? a. The patient is taught stress management techniques with EEG monitoring. b. The patient is asked to relive the stressful events while scanning relaxation materials. c. The patient concentrates on slowing his blink rate while processing the stress- ful event. d. The patient follows a small light projected on the ceiling to achieve a deeply relaxed state. e. The patient focuses on the lateral movement of the therapist's finger while maintaining a mental image of the stressful event.

242. A 45-year-old woman comes to the psychiatrist requesting help in coping with her life. The patient states both of her parents have recently been diagnosed with cancer and her husband has just instituted divorce proceedings. She states she feels overwhelmed and anxious, with bouts of crying and panic attacks. Which one of the following therapies should be offered to this patient? a. Medication management b. Psychoanalytic psychotherapy c. Psychodynamic psychotherapy d. Family therapy e. Supportive psychotherapy

246. Under hypnosis, a woman who was sexually abused by her father throughout most of her childhood sobbingly pleads, "Daddy, please don't hurt me." At the end of the session, she states that she understands better why she always had a strong sense of revulsion when any man touched her. This experience is an example of which of the following? a. Conversion disorder b. Histrionic personality traits c. Visual hallucination d. Reaction formation e. Abreaction

247. A patient in psychodynamic therapy has been coming late to the last few sessions and complaining in the sessions that he has nothing to talk about. His therapist points out that up until several weeks ago they were making very rapid progress into uncovering some of the difficult thoughts and feelings the patient had about his parents. What therapeutic principle best exemplifies the recent changes in the patient's behavior? a. Countertransference b. Ego strength c. Abreaction d. Projective identification e. Resistance

32. A 28-year-old business executive sees her physician because she is having difficulty in her new position, as it requires her to do frequent pub- lic speaking. She states that she is terrified she will do or say something that will cause her extreme embarrassment. The patient says that when she must speak in public, she becomes extremely anxious and her heart beats uncontrollably. Based on this clinical picture, which of the following is the most likely diagnosis? a. Panic disorder b. Avoidant personality disorder c. Specific phobia d. Agoraphobia e. Social phobia

4.An 18-year-old man is seen by a psychiatrist in the emergency room. During the history, the patient is asked to describe his mood. He answers the following, "My mood is flextitating, I am up and down." The patient is exhibiting which of the following thought disorders? a. Clang association b. Thought blocking c. No thought disorder is apparent d. Tangentiality e. Neologism

95. An 18-year-old man is admitted to the psychiatric unit after his par- ents find him in his room muttering to himself and convinced that people are going to hurt him. During his stay in the hospital, the patient is fre- quently found standing in the center of his room with both arms over his head, immobile. The patient can maintain this position for hours at a time. Which of the following best describes this patient's posturing? a. Negativism b. Automatism c. Stereotypy d. Waxy flexibility e. Catalepsy

96. Benzodiazepines, barbiturates, and many anticonvulsants exert their influence through which of the following types of receptors? a. Muscarinic b. Dopaminergic c. Glutamic d. Adrenergic e. γ-Aminobutyric acid (GABA)-ergic

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