BHM - Exam 3 (Questions from Book)

15.1 A 48-year-old woman reports to her family physician that she has been drinking a bottle of wine two to three times per week for the past 3 years. She has not been successful in her attempts to cut back her drinking, and her drinking has led to conflicts with her family. She has not had any problems at work as the result of her drinking, and she has never had symptoms of alcohol withdrawal. What is the best diagnosis? 1. Alcohol use disorder. 2. Alcohol dependence. 3. Alcohol abuse. 4. Alcoholism. 5. Alcohol abuse disorder.

1. Alcohol use disorder. Alcohol use disorder is the new DSM-5 disorder that merges the DSM-IV-TR disorders of alcohol dependence and alcohol abuse (options B, C). Neither alcoholism nor alcohol abuse disorder (options D, E) is a DSM-IV-TR or DSM-5 diagnosis. Alcohol use disorder (option A) is further specified as mild, moderate or severe, depending on # of symptoms.

17.6 Which personality disorder is more common in men than in women? 1. Antisocial personality disorder. 2. Borderline personality disorder. 3. Histrionic personality disorder. 4. Dependent personality disorder. 5. Schizotypal personality disorder.

1. Antisocial personality disorder.

17.7 Which is the only personality disorder with an age requirement and a requirement that certain childhood behaviors have continuity with adult traits? 1. Antisocial personality disorder. 2. Borderline personality disorder. 3. Avoidant personality disorder. 4. Dependent personality disorder. 5. Schizotypal personality disorder.

1. Antisocial personality disorder. Antisocial personality disorder cannot be diagnosed before age 18 years, and the diagnosis requires evidence of a childhood conduct disorder (option A). DSM-5 requires that the maladaptive personality features be present for at least 1 year if a personality disorder is diagnosed at an age less than 18 years.

17.11 Which personality disorder is associated with low resting pulse, low skin conductance, and increased amplitude on event-related potentials? 1. Antisocial personality disorder. 2. Borderline personality disorder. 3. Schizotypal personality disorder. 4. Schizoid personality disorder. 5. Avoidant personality disorder.

1. Antisocial personality disorder. Antisocial personality disorder is associated with low resting pulse, low skin conductance, and increased amplitude on event-related potentials. These findings suggest to some that antisocial persons are chronically underaroused and seek out potentially risky situations to raise their arousal to more optimal levels.

3.3 Which part of the brain is dedicated to speech production? 1. Broca's area. 2. Nucleus basalis. 3. Angular gyrus. 4. Wernicke's area. 5. Amygdala.

1. Broca's area. Within the left hemisphere, there are two major language regions as well as some subsidiary ones. Broca's area is the region dedicated to the production of speech. It contains information about the syntactical structure of language, provides the "little words" such as prepositions that tie the fabric of language together, and is the generator for fluent speech. Lesions to Broca's area, which occur in stroke victims, lead to halting, stammering, and ungrammatical speech.

15.19 What form of therapy for substance use disorders rewards patients for appropriate behavior (e.g., giving patients who submit clean urine samples vouchers that can be exchanged for retail goods and services)? 1. Contingency management. 2. Motivational interviewing. 3. Cognitive-behavioral therapy. 4. Behavioral activation. 5. Twelve-step program

1. Contingency management. Contingency management rewards appropriate behavior with material goods.

17.1 Which was the first DSM to include disturbances of personality? 1. DSM-I. 2. DSM-II. 3. DSM-III. 4. DSM-IV. 5. DSM-5.

1. DSM-I.

15.10 Which of the following are the last symptoms to develop during the course of severe alcohol withdrawal? 1. Delirium, fever, autonomic hyperarousal. 2. Auditory, visual, tactile hallucinations in the presence of a clear sensorium. 3. Seizures. 4. Anxiety, tremor, nausea. 5. Increased heart rate and blood pressure.

1. Delirium, fever, autonomic hyperarousal. Alcohol withdrawal delirium, which includes fever and autonomic hyperarousal, develops 2-3 days after cessation or major reduction in drinking behavior (option A). The first symptoms to develop are anxiety, tremor, nausea, and increased heart rate and blood pressure (options D, E). These symptoms develop 6-24 hours after cessation or reduction in drinking. Seizures (option C) occur from 7 hours up to 2 days after cessation or reduction in drinking. Hallucinations (B) can occur within 48 hours and can last for up to a week.

3.5 What is the primary neurotransmitter in the brain reward system, which is also associated with adventuresome and exploratory behaviors? 1. Dopamine. 2. Norepinephrine. 3. γ-Aminobutyric acid (GABA). 4. Serotonin. 5. Glutamate.

1. Dopamine. Dopamine is the primary neurotransmitter in the brain reward system and is associated with adventuresome and exploratory behavior.

13.4 A 28-year-old man reports to his family physician that he has had persistent difficulty achieving orgasm both with his partner and while masturbating. He has no trouble attaining an erection. His problem has been ongoing since the relationship began about a year ago. He reports that otherwise his relationship is going well. He does not take any medications except for fluoxetine. What is the most likely diagnosis? 1. Medication-induced sexual dysfunction. 2. Other specified sexual dysfunction. 3. Delayed ejaculation. 4. Male hypoactive sexual desire disorder. 5. Erectile disorder.

1. Medication-induced sexual dysfunction. Fluoxetine, along with the other selective serotonin reuptake inhibitors (SSRIs), can induce sexual dysfunction.

3.7 Which of the following nuclei in the brain contains the cell bodies of an important group of acetylcholine neurons? 1. Nucleus basalis. 2. Locus coeruleus. 3. Raphe nuclei. 4. Substantia nigra. 5. Caudate nucleus.

1. Nucleus basalis. The nucleus basalis contains the cell bodies of an important group of cholinergic neurons.

15.6 How many positive responses on a CAGE test are needed to indicate that a person may have an alcohol use disorder? 1. One. 2. Two. 3. Three. 4. Four. 5. The CAGE test is not a good screening test for alcohol use disorders.

1. One. Even one positive response or overly defensive answer on the CAGE test, a simple screen that can be used to assess the presence of an alcohol use disorder, can indicate problematic use. A positive screen should be followed up with more detailed discussion.

19.12 A patient reveals to his psychiatrist that he plans to harm a neighbor. The psychiatrist is obligated to break confidentiality in order to protect the potential victim. How shall the psychiatrist proceed? 1. Phone the neighbor to report the threat. 2. Phone the local police. 3. Ask the patient to phone the neighbor. 4. Report the threat to the local newspaper. 5. None of the above.

1. Phone the neighbor to report the threat. The Tarasoff rule refers to the duty to protect third parties from the actions of patients in their care. On rare occasions, in the course of treating a patient, the patient may threaten to harm an identifiable third party. The psychiatrist has a legal responsibility to protect that third party and may break confidentiality by notifying the threatened person and/or the police. Although the approach to warning a third party has been debated, phoning the neighbor directly.

17.19 Avoidant personality disorder can be very difficult to distinguish from which of the following disorders? 1. Social anxiety disorder. 2. Generalized anxiety disorder. 3. Panic disorder. 4. Persistent depressive disorder. 5. Autism spectrum disorder.

1. Social anxiety disorder. Avoidant personality disorder symptoms overlap significantly with social anxiety disorder.

15.18 A 23-year-old man with no previous psychiatric history is brought to the emergency room by the police for agitated and disorganized behavior. He is paranoid and believes that the government is sending him messages through a microchip that was implanted in one of his teeth. He has not slept for 3 days. He is distractible in interview but otherwise oriented. A urine drug screen is positive for amphetamine. He is otherwise medically stable and is admitted to the psychiatry unit. What is the best course of treatment for this patient's psychotic symptoms? 1. Supportive care and possibly short-term use of antipsychotic. 2. Antipsychotic therapy for 6 months. 3. Cognitive-behavioral psychotherapy. 4. Imipramine. 5. Lithium.

1. Supportive care and possibly short-term use of antipsychotic. Stimulant-induced psychoses generally resolve with sobriety; therefore, supportive care and a short-term antipsychotic is the best course of treatment.

19.11 Which of the following forms the basis of the insanity defense? 1. The M'Naghten standard. 2. The Drummond standard. 3. Dusky v. United States. 4. The Tarasoff rule. 5. The Peel Law.

1. The M'Naghten standard. The M'Naghten standard established standards for determining criminal responsibility.

17.2 Which of the following is not true of the general criteria of a personality disorder? 1. The behavior is consistent with the individual's cultural expectations. 2. It is stable over time, with onset in adolescence or early adulthood. 3. The disorder leads to distress or impairment. 4. The disorder is not limited to episodes of illness. 5. All of the above are part of the general criteria of a personality disorder.

1. The behavior is consistent with the individual's cultural expectations.

13.9 Which of the following medications is a standard treatment for erectile disorder? 1. Vardenafil. 2. Paroxetine. 3. Dibucaine. 4. Testosterone. 5. Topical estrogen.

1. Vardenafil. Vardenafil is one of the phosphoesterase-5 inhibitors, which are the first-line treatment for erectile disorder.

17.17 Which of the following does not represent a recommended treatment for borderline personality disorder? 1. Dialectical behavior therapy. 2. Benzodiazepine tranquilizers for accompanying anxiety. 3. Systems Training for Emotional Predictability and Problem Solving (STEPPS). 4. Antipsychotic medications for accompanying perceptual distortions and anger dyscontrol. 5. Selective serotonin reuptake inhibitors (SSRIs) for depression.

2. Benzodiazepine tranquilizers for accompanying anxiety. Benzodiazepines (option B) should be avoided in these patients because of their abuse potential and tendency to cause behavioral disinhibition.

17.3 A patient has long-standing discrete episodes of mania and depression dating to late adolescence. During manic episodes, he displays elevated mood, decreased sleep, pressured speech, and flight of ideas. The episodes typically result in psychiatric hospitalization. During the manic episodes, he engages in antisocial behavior, including committing assaults and writing bad checks. He is a quiet, law-abiding citizen between episodes of mania. What is the best diagnosis? 1. Antisocial personality disorder. 2. Bipolar I disorder. 3. Personality disorder due to bipolar disorder. 4. Bipolar I disorder plus antisocial personality disorder. 5. None of the above.

2. Bipolar I disorder.

3.2 Which of the following areas of the brain have a high concentration of dopamine D2 receptors and may be important sites for antipsychotic drug action? 1. Locus coeruleus. 2. Caudate and putamen. 3. Raphe nuclei. 4. Nucleus basalis. 5. None of the above.

2. Caudate and putamen. The basal ganglia are relevant to psychiatry because of their chemical anatomy. The caudate and putamen contain a very high concentration of dopamine receptors, particularly D2 receptors.

19.3 What level of evidence is generally required in cases of civil commitment? 1. Beyond a reasonable doubt. 2. Clear and convincing evidence. 3. Preponderance of the evidence. 4. Substantial evidence. 5. Some credible evidence.

2. Clear and convincing evidence. The civil commitment process generally requires clear and convincing evidence (option B), a standard generally thought of as the level of proof needed for three of four reasonable people to agree.

19.1 Which of the following is a criminal and not a civil issue? 1. Determining whether to hospitalize a patient for acute homicidal ideation against his or her will. 2. Determining whether a patient with schizophrenia is capable of understanding court processes and assisting the court-appointed attorney. 3. Potential Health Insurance Portability and Accountability Act (HIPAA) violations. 4. Providing information about proposed treatments and alternatives and ensuring that the patient is capable of understanding these issues. 5. Determining whether a psychiatrist was negligent in his professional duties after abruptly terminating a doctor-patient relationship because the patient did not promptly pay a bill.

2. Determining whether a patient with schizophrenia is capable of understanding court processes and assisting the court-appointed attorney. In the forensic world, the distinction between civil and criminal issues is fundamental. Whether a patient with schizophrenia is able to understand court processes and aid his or her attorney is an example of competence to stand trial, which is a criminal issue.

15.12 Which medication used to treat alcohol dependence works by inhibiting alcohol dehydrogenase? 1. Naltrexone. 2. Disulfiram. 3. Acamprosate. 4. Chlordiazepoxide. 5. Lorazepam.

2. Disulfiram. Disulfiram inhibits alcohol dehydrogenase, leading to the accumulation of acetaldehyde if the patient consumes alcohol, causing symptoms such as flushing, nausea, and vomiting to occur (option B). Naltrexone (option A) is a μ-opioid antagonist and reduces cravings. Acamprosate (option C) is a glutamate receptor modulator that reduces cravings. Chlordiazepoxide and lorazepam (options D, E) are benzodiazepines that can be used to treat acute alcohol withdrawal.

15.15 A 19-year-old man presents to the emergency room complaining of acute-onset severe anxiety, confusion, time expansion, and vivid visual hallucinations. He took LSD for the first time 3 hours ago and is very uncomfortable, but he is cooperative in interview. His pupils are dilated, and he has mild tachycardia. Reassurance does not succeed in calming him down. What is the next best step in managing this case? 1. Give an antipsychotic. 2. Give a benzodiazepine. 3. Give clonidine. 4. Give naltrexone. 5. Refer the man to a substance use treatment program.

2. Give a benzodiazepine. The man is experiencing a "bad trip" from LSD. Benzodiazepines can be used to calm patients who develop severe anxiety secondary to hallucinogen intoxication (option B).

19.10 According to current laws, a crime occurs when: 1. Illegal behavior occurs, regardless of the perpetrator's state of mind. 2. Illegal behavior occurs and the perpetrator has a blameworthy state of mind. 3. A perpetrator has a blameworthy state of mind regardless of whether illegal behavior occurs. 4. Illegal behavior occurs and the person does not have demonstrable mental illness. 5. A person with mental illness has a blameworthy state of mind.

2. Illegal behavior occurs and the perpetrator has a blameworthy state of mind. For a crime to occur, both bad behavior (actus rea) and a blameworthy state of mind (mens rea) must be present. A person may be so mentally ill as to lack this blameworthy state of mind by virtue of his or her disorder. In such a case, a person is said to lack criminal responsibility and is adjudicated as not guilty by reason of insanity.

19.2 Which of the following is not a key criterion considered in civil commitment proceedings? 1. Mental illness. 2. Outpatient supports. 3. Dangerousness. 4. Disability. 5. Grave disability.

2. Outpatient supports. The major criteria in determination of cases of civil commitment are mental illness, dangerousness, and disability (sometimes referred to as grave disability).

13.12 What is the DSM-5 term for an anomalous sexual activity preference? 1. Paraphilic disorder. 2. Paraphilia. 3. Infantilism. 4. Infantilism disorder. 5. None of the above.

2. Paraphilia. Paraphilia is the term used to describe anomalous sexual activity preference (option B). Paraphilic disorder (option A) refers to the distress experienced because of an anomalous sexual activity preference. Infantilism (option C) is a paraphilia in which the person obtains sexual arousal and gratification by behaving like an infant. Infantilism disorder (option D) is not a DSM-5 disorder. Infantilism should be coded as other specified paraphilic disorder.

19.6 What is the most common reason psychiatrists are sued for malpractice? 1. Failure to obtain informed consent. 2. Patient suicide. 3. Alleged injuries from psychotropic medications. 4. Patient abandonment. 5. Alleged electroconvulsive therapy-related injury.

2. Patient suicide. It is important to know that psychiatrists are sued less frequently than other medical specialists. Nonetheless, patient suicide is the most common reason for a psychiatrist to be sued (option B). Options A and C-E are less common reasons for which a psychiatrist may be sued.

17.13 You see a 33-year-old unemployed man in the outpatient clinic. He reports that he would like your assistance in getting disability for "anxiety." He says that for as long as he recalls, he has felt uncomfortable in social situations because he fears that other people will not understand him. He has never married and has no children. He has trouble maintaining employment due to anxiety. He sometimes thinks that magazine articles have special messages for him and may see shadows that look like people or animals. He has been trying to learn how to communicate telepathically by studying a "new age" book purchased on the Internet but has not been successful. He denies any history of auditory hallucinations and does not appear to have delusions. What is the best diagnosis? 1. Schizophrenia. 2. Schizotypal personality disorder. 3. Avoidant personality disorder. 4. Schizoid personality disorder. 5. Schizoaffective disorder.

2. Schizotypal personality disorder. The man in the vignette best meets the spirit of schizotypal personality disorder. Such patients are odd and eccentric and typically have unusual thinking and speech. Patients with paranoid personality disorder are distrustful of others but otherwise are not especially odd.

13.5 A 40-year-old man with type 2 diabetes mellitus reports to his family physician that he has progressive difficulty achieving an erection prior to intercourse with his wife. He continues to experience spontaneous erections at times when he is not planning to have intercourse. What is the most likely etiology of the patient's problem? 1. Secondary to type 2 diabetes mellitus. 2. Secondary to psychological factors. 3. Secondary to marital discord. 4. Secondary to a medical condition other than type 2 diabetes. 5. Unable to determine without more information.

2. Secondary to psychological factors. The presence of spontaneous erections would suggest a psychological origin of erectile dysfunction despite the presence of type 2 diabetes mellitus. In determining the cause, it is important to determine whether spontaneous erections occur at times when the man does not plan to have intercourse.

13.10 Which of the following is not typical of gender dysphoria? 1. Onset occurs in childhood. 2. The child prefers to play with children of the same gender. 3. The child expresses a strong desire to be rid of one's primary and secondary sexual characteristics because of incongruence between one's expressed and experienced gender. 4. The child expresses strong preference for cross-sex roles in make-believe play. 5. The child shows a strong preference for games, toys, and activities stereotypically associated with the opposite gender.

2. The child prefers to play with children of the same gender. In childhood, patients with gender dysphoria generally prefer to play with children of the opposite gender.

13.11 A 40-year-old man reports to his psychiatrist that he enjoys dressing in women's clothing prior to intercourse, but this has caused conflict with his wife. He identifies himself as heterosexual, and he reports he is comfortable being male. What is the best diagnosis? 1. Gender dysphoria. 2. Transvestic disorder. 3. Voyeuristic disorder. 4. Exhibitionistic disorder. 5. Frotteuristic disorder.

2. Transvestic disorder. Transvestic disorder is a paraphilia in which one becomes sexually aroused by dressing in the clothes of the opposite gender (option B).

15.4 Which neurotransmitter plays a role specifically in the development of opioid use disorders? 1. Dopamine. 2. β-Endorphin. 3. Acetylcholine. 4. Serotonin. 5. Norepinephrine.

2. β-Endorphin. Opioids activate μ receptors that release β-endorphins (option B), the chemical that is released when human beings engage in naturally rewarding activities (e.g., eating, sex).

17.15 A 26-year-old woman comes to your clinic to establish care for her mood swings that other psychiatrists have diagnosed as "bipolar disorder." She has persistent depression and severe mood swings, but she has never had a period of decreased sleep, pressured speech, or disinhibition that lasted for several days. She uses a razor blade to make small cuts on her forearms when anxious or upset but denies that she does this to kill herself. She has had several psychiatric hospitalizations for suicidal ideation, and she has overdosed multiple times. She endorses a deep fear that her loved ones will abandon her, and she has chronic feelings of emptiness. After your interview, she says that she thinks you are the best doctor she has ever had and that she has great confidence in your abilities. She speaks very poorly of her previous psychiatrist. What is the most likely diagnosis? 1. Bipolar II disorder. 2. Histrionic personality disorder. 3. Borderline personality disorder. 4. Dependent personality disorder. 5. Schizotypal personality disorder.

3. Borderline personality disorder. Patients with borderline personality disorder suffer from mood and interpersonal instability and often have fears of abandonment.

19.4 Most states have provisions for: 1. Involuntary inpatient treatment only. 2. Involuntary outpatient treatment only. 3. Both involuntary inpatient and outpatient treatment. 4. Neither involuntary nor voluntary outpatient treatment. 5. Voluntary outpatient treatment only.

3. Both involuntary inpatient and outpatient treatment. Besides inpatient treatment, most states (44 of 50) have provisions for involuntary outpatient treatment. Such treatment may be used when the patient is not quite ill enough to merit inpatient care, but he/she presents some risk of harm to self or others because of mental illness and will not voluntarily comply with outpatient treatment.

15.13 A 20-year-old student sees his internist for anxiety symptoms. He reports that he has started worrying about everything since he started college about 2 years ago. He has trouble falling asleep and staying asleep nearly every night. His mood is mildly irritable, and he appears restless. He does not smoke, use alcohol, or use illicit drugs. He reports that he drinks eight or more cups of coffee daily to help him stay motivated when studying, with his last cup around 8-10 P.M. What is the most likely diagnosis? 1. Generalized anxiety disorder. 2. Bipolar I disorder. 3. Caffeine-induced anxiety disorder. 4. Panic disorder. 5. Insomnia disorder.

3. Caffeine-induced anxiety disorder. Caffeine can cause or exacerbate anxiety disorders. Given this patient's excessive caffeine intake, caffeine-induced anxiety disorder is the best diagnosis (option C). Should he still complain of continued anxiety after significantly reducing his caffeine intake, generalized anxiety disorder (option A) would be a reasonable consideration.

13.3 A 22-year-old man reports to his family physician that he has had persistent difficulty achieving orgasm during intercourse with his partner. He has no trouble attaining an erection. The problem has been ongoing since the relationship began about a year ago. He does not have any difficulty achieving orgasm during masturbation and reports that otherwise his relationship is going well. He does not take any medications. What is the most likely diagnosis? 1. No diagnosis. 2. Other specified sexual dysfunction. 3. Delayed ejaculation. 4. Male hypoactive sexual desire disorder. 5. Erectile disorder.

3. Delayed ejaculation. The fact that the problem only occurs during intercourse with a partner does not preclude a diagnosis of delayed ejaculation.

3.1 Which of the following is not a primary function of the prefrontal system? 1. High-order abstract thought. 2. Creative problem solving. 3. Fear processing. 4. Temporal sequencing of behavior. 5. Moral judgment.

3. Fear processing. Fear processing is associated with the limbic system, especially the amygdala.

15.5 A 17-year-old girl is referred for treatment of substance misuse. She smokes cannabis nearly every day and has started to use cocaine a few times a week in the past 2 months. Her father drinks excessively, and the family receives government assistance. One reason she gives for using illegal drugs is that her friends use these substances, and it is hard for her not to go along with them. Which of the following factors associated with this patient is not associated with risk of developing a substance use disorder? 1. Low socioeconomic status. 2. Susceptibility to peer influence. 3. Female sex. 4. Age. 5. Parental alcoholism.

3. Female sex. The girl in the vignette unfortunately has many risk factors for substance misuse, which does not bode well for her future. That said, female sex is less likely to predispose to a substance use disorder than male sex (option C). Options A, B, D, and E are all factors are associated with risk of developing a substance use disorder.

13.6 A 30-year-old woman reports to her family physician of ongoing sexual difficulties with her partner for the last several years. She experiences vaginal and pelvic pain during intercourse. She denies that there is difficulty achieving vaginal penetration, and she is not sure about tightening of her pelvic muscles during penetration. What is the most likely diagnosis? 1. Dyspareunia. 2. Vaginismus. 3. Genito-pelvic pain disorder. 4. Female sexual interest/arousal disorder. 5. None of the above.

3. Genito-pelvic pain disorder. Genito-pelvic pain disorder is diagnosed when a person has pain or discomfort, muscular tightening, or fear about pain when having sexual intercourse.

3.10 Which type of study applies statistical analyses to large databases containing DNA from thousands of individuals affected by specific disorders? 1. Linkage study. 2. Candidate gene study. 3. Genome-wide association study. 4. Copy number variant survey. 5. Microarray analysis

3. Genome-wide association study. Genome-wide association studies apply statistical analyses to large databases containing DNA from thousands of individuals affected by specific disorders.

19.9 In order to be competent to stand trial, a defendant must meet all of the following criteria except: 1. Being able to understand the nature of the charges against him or her. 2. Being able to understand the possible penalty. 3. Having been shown to have both bad behavior and blameworthy state of mind at the time of the offense. 4. Being able to understand the legal issues and procedures. 5. Being capable of working with an attorney in preparing the defense.

3. Having been shown to have both bad behavior and blameworthy state of mind at the time of the offense. Bad behavior and blameworthy state of mind at the time of the offense (option C) are components of criminal responsibility rather than competence to stand trial.

17.18 Which of the following personality disorders is not a cluster C personality disorder? 1. Avoidant personality disorder. 2. Obsessive-compulsive personality disorder. 3. Histrionic personality disorder. 4. Dependent personality disorder. 5. All of the above are cluster C personality disorders.

3. Histrionic personality disorder. Histrionic personality disorder (option C) is a cluster B personality disorder.

17.16 A 40-year-old business executive seeks treatment for depression. She reports being upset since a colleague was given a promotion that she feels was rightfully hers. Her long-term goal is to become the CEO of a major global corporation. During the session, she questions the therapist's credentials, and at one point she accuses the therapist of being envious of her superior social status. She does not return after the first session and later tells an acquaintance that it was because the therapist didn't give her the admiration that she deserves. What is the most likely diagnosis? 1. Antisocial personality disorder. 2. Borderline personality disorder. 3. Narcissistic personality disorder. 4. Dependent personality disorder. 5. Histrionic personality disorder.

3. Narcissistic personality disorder. Narcissistic personality disorder is characterized by exaggerated sense of self-importance and lack of empathy.

17.20 Ebenezer Scrooge comes to your practice seeking therapy for life dissatisfaction. He spends all of his time working even though he is very wealthy, and he is very reluctant to spend his money on basic amenities such as heating during the cold winter months. He engages in very little recreation and has very little social interaction, and he rejects his nephew's dinner invitations. He expresses rigid, controversial opinions, such as that donating to charity is wasteful given that his hard-earned tax dollars finance workhouses and debtors' prisons. He micromanages his sole employee, but he reserves several tasks for himself for fear that his employee is not competent to handle these necessities to his satisfaction. What is the best diagnosis for this patient? 1. Schizoid personality disorder. 2. Narcissistic personality disorder. 3. Obsessive-compulsive personality disorder. 4. Avoidant personality disorder. 5. Antisocial personality disorder.

3. Obsessive-compulsive personality disorder.

15.16 A 30-year-old man requests help for an opioid abuse disorder. He has used large quantities of prescription narcotics obtained on the streets and will also inject heroin when it is available. He has tried to quit these drugs on his own several times without success. Which of the following is the best option to treat his opioid use disorder and reduce his risk of relapse and criminal activity? 1. Referral to Narcotics Anonymous. 2. Detoxification with clonidine followed by outpatient counseling. 3. Referral to a methadone maintenance program. 4. Prescribing naltrexone. 5. Detoxification with clonidine followed by referral to an intensive outpatient program.

3. Referral to a methadone maintenance program. Methadone maintenance programs have been shown to reduce risk of relapse, depression, criminal activity and to improve the functional status of patients with opioid use disorders. These programs typically provide counseling services in addition to the medication. Methadone maintenance programs have been shown to be better than abstinence in reducing relapse rates. The other response options (A, B, E) could each be useful, but option C is the most appropriate choice for this patient. Naltrexone (option D) has no role in the treatment of opioid use disorders.

17.12 A 27-year-old software engineer seeks psychiatric treatment for anxiety. He has lived alone all of his adult life. Outside of work, he has no social contacts apart from a weekly phone call to his mother. He spends most of his free time playing video games, and he expresses little interest in developing more social relationships or having a romantic relationship. He does not endorse any symptoms of major depression or psychosis. He is very stiff and formal in interview and displays little emotion. What is the best diagnosis? 1. Avoidant personality disorder. 2. Schizotypal personality disorder. 3. Schizoid personality disorder. 4. Autism spectrum disorder. 5. Antisocial personality disorder.

3. Schizoid personality disorder. Patients with schizoid personality disorder have a profound defect in the ability to form personal relationships and to respond to others in a meaningful way.

17.10 Which personality disorder is associated with impaired smooth pursuit eye movement, impaired performance on tests of executive function, and increased ventricular-brain ratio on computed tomography? 1. Antisocial personality disorder. 2. Borderline personality disorder. 3. Schizotypal personality disorder. 4. Schizoid personality disorder. 5. Avoidant personality disorder.

3. Schizotypal personality disorder. Schizotypal personality disorder, long considered to fall within the spectrum of disorders related to schizophrenia, is associated with impaired smooth pursuit eye movement, impaired performance on tests of executive function, and increased ventricular-brain ratio on computed tomography.

19.13 A woman with a psychosis is charged with murder. During her pretrial screening, her speech is disorganized such that she cannot engage in coherent dialogue with her attorneys. Which of the following best describes her legal situation with regard to the charges against her? 1. She is competent to stand trial but not guilty by reason of insanity. 2. She is not competent to stand trial and also not guilty by reason of insanity. 3. She is not competent to stand trial, and whether she is not guilty by reason of insanity has yet to be demonstrated. 4. She is guilty but mentally ill. 5. She has diminished capacity.

3. She is not competent to stand trial, and whether she is not guilty by reason of insanity has yet to be demonstrated. The ability to communicate with an attorney in order to prepare a defense is a component of competency to stand trial. Whether the patient has criminal responsibility has yet to be determined. Guilty but mentally ill and diminished capacity refer to degrees of criminal responsibility implemented by some states.

15.8 A 45-year-old man reports a 10-year history of heavy alcohol consumption to his family physician. He tells his physician that he is not as "sharp" as he used to be before he started drinking and that he has some mild difficulties with everyday memory tasks. He asks his doctor if these memory problems will be permanent. What is the best response? 1. "Even if you stop drinking, these memory problems are likely to be irreversible but not progressive." 2. "Even if you stop drinking, these memory problems are likely to be irreversible and progressive." 3. "If you stop drinking now, these memory problems may partially reverse." 4. "If you stop drinking now, your memory will likely fully completely reverse." 5. None of the above.

4. "If you stop drinking now, your memory will likely fully completely reverse." The physician can feel comfortable in sharing the good news: Neuropsychological testing of alcoholic persons generally reveals mild to moderate cognitive deficits that partially reverse with sobriety. Chronic alcohol misuse also has been associated with enlarged cerebral ventricles and widened cortical sulci-effects that also may be partially reversible if the individual stops drinking.

15.2 How long can cannabis be detected by urine drug screen after last use? 1. 24 hours. 2. 3 days. 3. 1 week. 4. 3 weeks. 5. 6 weeks.

4. 3 weeks. Cannabis is fat soluble and can be detected on urine drug screen up to 3 weeks after last use.

19.7 What percentage of physicians will face at least one malpractice suit at some point in their careers? 1. 10%. 2. 35%. 3. 50%. 4. 65%. 5. 80%.

4. 65%. Malpractice is negligence in the conduct of one's professional duties. The number of malpractice suits filed in the United States seems to climb each year. About two-thirds of physicians will experience at least one malpractice lawsuit during their professional career. The reaction among many physicians is to practice "defensive medicine," for example, ordering extra tests or refusing to treat certain patients.

13.1 How long should a disorder of sexual function be present prior to diagnosis? 1. At least 18 months. 2. At least 4 months. 3. At least 1 month. 4. At least 6 months. 5. At least 1 year.

4. At least 6 months.

17.4 A patient has long-standing discrete episodes of mania and depression dating back to late adolescence. During the manic episodes, he has elevated mood, decreased sleep, pressured speech, and flight of ideas that typically result in psychiatric hospitalization. He gets into more legal trouble than usual during these periods, but even during periods of euthymia, he tends to engage in illegal activities such as shoplifting and burglary. He has done so since early adolescence, and he does not show any remorse for these actions. How would you best diagnose this patient? 1. Antisocial personality disorder. 2. Bipolar I disorder. 3. Personality disorder due to bipolar disorder. 4. Bipolar affective disorder type 1 plus antisocial personality disorder. 5. None of the above.

4. Bipolar affective disorder type 1 plus antisocial personality disorder. In contrast to the patient in question 17.3, this patient has a long-standing pattern of antisocial behavior that is not limited to episodes of his illness. Therefore, it is most appropriate to diagnose him with both antisocial personality disorder and bipolar affective disorder.

13.13 What is the standard treatment for paraphilic disorders? 1. SSRI. 2. Leuprolide. 3. Naltrexone. 4. Cognitive-behavioral therapy. 5. Medroxyprogesterone.

4. Cognitive-behavioral therapy. Cognitive-behavioral therapy is the treatment mainstay for paraphilic disorders.

15.11 A psychiatrist is called to evaluate a 38-year-old man for admission to a psychiatric unit for alcohol detoxification and treatment of depression. He has been drinking large quantities of vodka daily for several months. He previously drank 3-4 beers nearly daily for almost 5 years. His last drink was 6 hours ago. He is currently pleasant and cooperative. His is fully oriented and in no distress. The psychiatrist asks the man if he has ever had the delirium tremens. He responds, "Oh yeah, I've got the shakes right now," and he holds out his hands to show the psychiatrist his mild tremor. How shall the psychiatrist proceed? 1. Recommend admission to intensive care because delirium tremens (DTs) can be fatal. 2. Admit the patient to psychiatry for alcohol rehabilitation. 3. Administer chlordiazepoxide now. 4. Collect additional information such as if the man has ever had confusion and fever during withdrawal or had become agitated. 5. None of the above.

4. Collect additional information such as if the man has ever had confusion and fever during withdrawal or had become agitated. Many patients (and physicians) do not know what constitutes alcohol withdrawal delirium and will confuse tremors that develop during the earliest part of withdrawal with DTs. In these cases, the psychiatrist should collect additional information to determine if the patient has ever had an alcohol withdrawal delirium episode (option D).

19.5 In which of the following situations is it the least clear cut whether patient confidentiality may be broken according to our laws? 1. Reporting infectious diseases such as tuberculosis or sexually transmitted infections. 2. Warning potential victims about threats made by patients. 3. Allowing access to medical charts for billing purposes. 4. Communicating with the family of a nonviolent psychiatric patient. 5. All of the above are clear cut cases in which confidentiality may be breached.

4. Communicating with the family of a nonviolent psychiatric patient. In many instances, a psychiatrist may have good reason to want to have open communication with a patient's family because this may be in the best interest of the patient's care. However, it is not always legally clear cut whether the psychiatrist may break confidentiality in these cases

15.14 Which of the following is not associated with cannabis use? 1. Increased risk of developing schizophrenia. 2. Increased risk of smoking cigarettes and abusing other drugs. 3. Tachycardia, dry mouth, and conjunctivitis during intoxication. 4. Flashbacks between periods of use. 5. Feeling that time has slowed and increased appetite during intoxication.

4. Flashbacks between periods of use. Flashbacks between periods of use are associated with hallucinogens such as lysergic acid diethylamide (LSD) (option D). Options A-C and E are associated with cannabis use.

17.5 Which of the following does not represent a major personality trait according to personality theorists who favor a dimensional perspective? 1. Extraversion. 2. Agreeableness. 3. Openness to experience. 4. Genuineness. 5. Neuroticism.

4. Genuineness. The best-known dimensional personality model was developed by psychologists Paul Costa and Robert McCrae and is known as the five-factor model. The traits outlined by the model include extraversion, agreeableness, conscientiousness, openness to experience, and neuroticism. OCEAN: Openness Concscientiousness Extraversion Agreeableness Neuroticism

3.6 Where does the brain's norepinephrine system originate? 1. Raphe nuclei. 2. Hypothalamus. 3. Ventral tegmental area. 4. Locus coeruleus. 5. Nucleus accumbens.

4. Locus coeruleus.

13.7 A 50-year-old man reports to his family physician that in the past few months he has had a new onset of premature ejaculation during intercourse. He is baffled about why it is happening at his age. He has been feeling more jittery than usual over the past few months, and he reports occasional palpitations and diaphoresis on review of systems. What is the next best step in management of this patient? 1. Refer to a psychiatrist. 2. Start a selective serotonin reuptake inhibitor (SSRI). 3. Refer to a psychotherapist. 4. Order thyroid-stimulating hormone. 5. None of the above.

4. Order thyroid-stimulating hormone. Hyperthyroidism can cause late-onset premature ejaculation, and the patient's other symptoms suggest hyperthyroidism as well.

13.8 What medication can be used to treat premature ejaculation? 1. Sildenafil. 2. Alprostadil. 3. Vardenafil. 4. Paroxetine. 5. Tadalafil.

4. Paroxetine. Medication has assumed an increasing role in the treatment of the sexual dysfunctions. Paroxetine (option D) and other SSRIs can be used to treat premature (early) ejaculation because a common side effect is ejaculatory delay. Men can also benefit from 1% dibucaine (Nupercaine) ointment applied to the coronal ridge and frenulum of the penis to reduce stimulation. Options A-C and E are used to treat erectile disorder.

17.8 Does the diagnosis of a personality disorder tend to be stable over time? 1. Most personality disorders are diagnostically stable throughout life, but the severity may diminish with age. 2. Most personality disorders are diagnostically stable, and symptoms severity is stable. 3. Severity of personality disorders diminishes, and many people will make a full psychosocial recovery. 4. Severity of the personality disorder diminishes, but many people will still have some degree of interpersonal dysfunction. 5. None of the above.

4. Severity of the personality disorder diminishes, but many people will still have some degree of interpersonal dysfunction. The severity of personality disorders tends to decrease as patients age, and many patients diagnosed with a personality disorder will no longer meet full criteria for a given disorder with time. Most will continue to have some degree of impairment in important life domains.

17.14 Which of the following is not a trait of histrionic personality disorder? 1. Unease in situations in which one is not the center of attention. 2. Inappropriate sexually seductive or provocative behavior. 3. Rapidly shifting and shallow expression of emotions. 4. Transient, stress-related paranoid ideation or severe dissociative symptoms. 5. Self-dramatization, theatricality, and exaggerated expression of emotion.

4. Transient, stress-related paranoid ideation or severe dissociative symptoms. Transient, stress-related paranoid ideation or severe dissociative symptoms is a trait of borderline personality disorder. Options A-C and E represent traits of histrionic personality disorder.

15.9 What percentage of motor vehicle deaths are related to alcohol? 1. 10%. 2. 20%. 3. 30%. 4. 40%. 5. >50%.

5. >50%.

15.20 Which of the following treatments has a role in treating gambling disorder? 1. Gamblers Anonymous (GA). 2. Naltrexone. 3. Motivational interviewing. 4. Cognitive-behavioral therapy (CBT). 5. All of the above.

5. All of the above. While there are no standard treatments for gambling disorder, each of the treatments listed has a role. GA is a self-help group patterned after Alcoholics Anonymous and provides support and encouragement to persons in recovery from gambling disorder. Naltrexone has been shown in clinical trials to reduce gambling urges. Motivational interviewing and CBT are often combined during the psychotherapeutic treatment of gambling disorder.

13.2 Which of the following would preclude a diagnosis of a sexual dysfunction? 1. Severe relationship stress. 2. A nonsexual mental disorder that would account for symptoms. 3. Disturbance caused by substance use or medication. 4. Disturbance caused by medical condition such as diabetes. 5. Any of the above would preclude diagnosis.

5. Any of the above would preclude diagnosis.

17.9 Which of the following has not been shown to contribute to the risk of developing a personality disorder? 1. Being a victim of child abuse. 2. Witnessing domestic violence in the home. 3. Parental divorce or separation. 4. Parental absence. 5. Arrested psychosexual development.

5. Arrested psychosexual development. Psychoanalysts have postulated that maladaptive personality traits arise from arrested psychosexual development, but there is no evidence to support this view.

15.3 Which neurotransmitter plays a key role in the development of all substance use disorders? 1. Serotonin. 2. Acetylcholine. 3. β-Endorphin. 4. Norepinephrine. 5. Dopamine.

5. Dopamine. Research has begun to identify the neurobiological substrates of addiction. Dopamine pathways that form part of the central nervous system "reward system" have been identified in the ventral tegmental region of the forebrain and in the nucleus accumbens. All drugs of abuse appear to target the brain's reward system by flooding the circuit with dopamine.

3.8 Which neurotransmitter provides inhibitory modulation to the globus pallidus, which if lost, will result in the choreiform movements of Huntington's disease? 1. Dopamine. 2. Serotonin. 3. Acetylcholine. 4. Glutamate. 5. GABA.

5. GABA. GABA provides inhibitory modulation of the globus pallidus, which if lost, will result in the choreiform movements of Huntington's disease.

15.7 Which of the following develops as a late-stage consequence of an alcohol use disorder? 1. Decreased work productivity. 2. Moodiness or irritability. 3. Palmar erythema. 4. Rosacea. 5. Jaundice.

5. Jaundice. Jaundice develops in the later stages of alcohol use disorder and indicates advanced liver disease.

15.17 A 26-year-old woman comes to your office seeking help for anxiety and panic attacks. She was last seen by your colleague a week ago, but she reports that she has lost her prescription for alprazolam. She asks you to write a new prescription for alprazolam 3 mg four times daily. She reports that nothing else works and that she has allergies to the selective serotonin reuptake inhibitors. Which of the following is not a valid reason to have serious concerns about prescribing alprazolam to this patient? 1. Concern about doctor-shopping behavior. 2. Report that "nothing else works." 3. Report of severe allergies to other medications commonly used to treat anxiety. 4. Report of a lost prescription. 5. Lethality of benzodiazepines in overdose.

5. Lethality of benzodiazepines in overdose. Benzodiazepines have a very high therapeutic window and are not often lethal in overdose.

19.8 According to the American Psychiatric Association, at what point does it become acceptable for a psychiatrist to have an intimate relationship with a former patient? 1. 6 months after termination of the doctor-patient relationship. 2. 1 year after termination of the doctor-patient relationship. 3. 3 years after termination of the doctor-patient relationship. 4. 10 years after termination of the doctor-patient relationship. 5. Never.

5. Never.

3.4 The nucleus accumbens is a key part of which functional system in the brain? 1. Executive system. 2. Limbic system. 3. Memory system. 4. Attention system. 5. Reward system.

5. Reward system. The nucleus accumbens is a key part of the reward system of the brain. Other areas involved in reward processing are the ventral tegmental area, the prefrontal cortex, the amygdala, and the hippocampus. The reward system is relevant to many types of psychiatric disorders. It is often said that substance abuse develops when exposure to a drug such as cocaine "highjacks the brain reward system" by inducing an intense experience of pleasure that stimulates craving and repeated drug-seeking behavior. This system has been implicated in all types of dependence on both illegal (e.g., amphetamines, opiates) and legal (e.g., nicotine, alcohol) substances. It is also thought to provide the basis for other types of pleasure-seeking or addictive behaviors and their consequences, such as gambling disorder or compulsive overeating.

3.9 Family studies of mental illness have shown that most major mental illnesses "run in families." Which of the following is not an essential element of a family study? 1. Identifying people with the disorder of interest (e.g., schizophrenia). 2. Identifying people who can serve as control subjects. 3. Interviewing first-degree relatives of ill persons and control subjects. 4. Comparing rates of the disorder of interest in relatives of those with the mental illness in question and relatives of control subjects. 5. Showing that the illness in question is inherited.

5. Showing that the illness in question is inherited.