final exam

A 5-year-old boy has difficulty making friends, and problems with initiating and sustaining back and forth conversation, reading social cues, and sharing his feelings with others. He makes good eye contact, has normal speech intonation, displays facial gestures, and has a range of affect that generally seems appropriate to the situation. He demonstrates an interest in trains that seems abnormal in intensity and focus, and engages in little imaginative or symbolic play. Which of the following diagnostic criteria for autism spectrum disorder is not met in this case? Select one: a. Deficits in emotional reciprocity b. Deficits in non-verbal communication behaviors used for social interaction c. Deficits in developing and maintaining relationships d. Restricted, repetitive patterns of behaviors, interests, or activities e. Symptoms with onset early in childhood that cause significant impairments

B. Deficits in non-verbal communication behaviors used for social interaction -The criteria for deficits in non-verbal communication behaviors is not met. DSM-5 Criterion A for autism spectrum disorder specifies that all three symptom clusters must be met. This boy's nonverbal communication is reported to be unimpaired (although this should be confirmed with a standard instrument such as Autism Diagnostic Observation Schuyler). Based on current history he could not be diagnosed with autism spectrum disorder. In order to meet Criterion B, at least two symptoms clusters must be met. Although this boy has a highly restricted and focused interest that seems abnormal in intensity and focus, he would need to have at least one other symptom in Criterion B (which includes stereotyped or repetitive motor movements, use of objects, or speech, insistence on sameness, inflexible adherence to routines or ritualized patterns of verbal or nonverbal behavior; or hyper or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment.

What is the prevalence of ADHD in adults? Select one: a. 8% b. 10% c. 2.5% d. 0.5% e. 5%

C. 2.5%

A 5-year-old hyperactive, impulsive, and inattentive boy presents with hypertelorism, highly arched palate, and low- set ears. He is uncoordinated and clumsy; he has no sense of time, and his toys and clothes are constantly strewn all over the house. He has recently developed what appears to be a motor tic involving blinking. He enjoys playing with peers, who tend to like him, although he seems to willfully defy all requests from his parents and kindergarten teacher, which does not seem to be due simply to inattention. He is delayed in beginning to learn how to read. What is the least likely diagnosis? Select one: a. Autism spectrum disorder b. Developmental coordination disorder c. Oppositional defiant disorder (ODD) d. Specific learning disorder e. ADHD

a. Autism spectrum disorder The least likely diagnosis is autism spectrum disorder. There is no evidence that this boy has a disorder of relatedness, especially since he enjoys playing with peers who like hi. He has signs and symptoms of ADHD, along with some soft neurological signs and minor physical anomalies that can be associated with ADHD, although genetic and neurological evaluations seem warranted. He may have an associated specific learning disorder in reading, which should also be evaluated through testing by a psychologist. Finally, it may be warranted to assign a diagnosis of ODD since his oppositional behavior is not due simply to inattention.

Ruth, a 71-year-old woman with dementia, who is taking a cholinesterase inhibitor, has been exhibiting psychiatric symptoms, including extreme agitation and aggression toward her two daughters who help care for her. Which of the following medications might be tried first to alleviate these presenting symptoms? Select one: a. Citalopram 20mg / once a day b. Galantamine 8mg, / twice a day c. Risperidone 0.5mg/ once a day d. Selegiline 8mg / once a day

a. Citalopram 20mg / once a day First-line treatment of agitation and aggression in dementia is generally SSRI/SNRI, which is now replacing the use of atypical antipsychotics due to increased concern of cardiovascular events and mortality in the elderly.

Major or mild neurocognitive disorder (NCD) due to prion disease encompasses NCDs associated with a group of subacute spongiform encephalopathies caused by transmissible agents known as prions. What is the most common prion disease? Select one: a. Creutzfeldt-Jakob disease b. Wernicke-Korsakoff syndrome c. Bovine spongiform encephalopathy (Mad Cow Disease) d. Huntington's disease e. Neurosyphilis

a. Creutzfeldt-Jakob disease Prion diseases include among others, the most common, which is Creutzfeld-Jakob disease (CJD). Typically, individuals with CJD present with neurocognitive deficits, ataxia, and abnormal movements such as myoclonus, chorea or dystonia. A startle reflex is also common. The history usually reveals rapid progression to major NCD over as little was 6 months and thus the disorder is usually seen only at the major level (advanced stages). The disease can be confirmed, at this point, only by biopsy or autopsy. The other options in this question are not prion caused disorders.

A 15-year-old with inattentive type ADHD has a hard time staying focused on the task at hand, has trouble organizing her work, and relies heavily on her mother to follow through with her homework. Problem solving is one of the hardest tasks for her. Her difficulty with sustained attention could be related to aberrant activation in the Select one: a. Dorsolateral prefrontal cortex b. Prefrontal cortex c. Orbitofrontal cortex d. Supplementary motor cortex

a. Dorsolateral prefrontal cortex ~ Sustained attention and problem solving are hypothetically modulated by the cortico-striatal-thalamic-cortico loop involving the dorsolateral prefrontal cortex. Inefficient activation of the DLPFC can lead to problems following through, finishing tasks, organizing, etc.

Both major and mild neurocognitive disorders can increase the risk of delirium and complicate its course. Traditionally delirium is distinguished from dementia on the basis of the key features of acute onset, impairment in attention, and which of the following? Select one: a. Fluctuating course b. Steady course c. Presence of mania d. Presence of depression e. Cog wheeling movements

a. Fluctuating course According to Criterion B for delirium, the disturbance develops over a short period of time, usually hours to a few days, and tends to fluctuate during the course of the day, often worsening in the evening and night when external orienting stimuli decrease.

The diagnostic criteria for major or mild neurocognitive disorder with Lewy (NCDLB) bodies include fulfillment of criteria for major or mild neurocognitive disorder and presence of a 'combination of core diagnostic features and suggested diagnostic features for either probable or possible neurocognitive disorder with Lewy bodies.' Another feature necessary for the diagnosis is that 'the disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental neurological, or systemic disorder.' Which of the following completes the list of features necessary for the diagnosis of Lewy body Dementia? Select one: a. An acute onset and rapid progression b. An insidious onset and gradual progression c. An insidious onset and a rapid progression d. A waxing and waning presentation e. A characteristic finding on ultrasound of the neck.

b. An insidious onset and gradual progression The onset of dementia is insidious and gradual This is true of NCDLB, which includes not only progressive cognitive impairment with early changes in complex attention and executive function rather than learning and memory, but also recurrent complex visual hallucinations with concurrent symptoms of rapid eye movement sleep behavior disorder, as well as hallucinations in other sensory modalities, depression, and delusions.

The parents of a 15-year-old tenth grade girl believe that she should be doing better in high school given how bright she seems and the fact that she received mostly A's through eighth grade. Her papers are now handed in late, and she makes careless mistakes on examinations. They have her tested and the WAIS-IV results are as following: Verbal IQ 125; Perceptional Reasoning Index 122; Full-Scale IQ 123; Working Memory Index 55th percentile; Processing Speed Index 50th percentile. Weaknesses in executive function are noted. During a psychiatric evaluation she reports a long history of failing to finish chores and tasks, difficulty sustaining attention while in class or doing homework, failing to finish chores and tasks, significant difficulties with time management, planning, and organization. She has no history of restlessness or impulsivity. She is well liked by her peers. There is no evidence of substance abuse or medical problems. Select one: a. Adjustment disorder with anxiety b. Specific learning disorder c. ADHD d. Developmental coordination disorder e. Major depressive disorder

c. ADHD The girl has six symptoms in the inattention cluster of ADHD and meets criteria for this disorder. She has common associated features of ADHD, including weakness in working memory and processing speed, and problems handing in her work on time. There is no evidence from the testing or the history that her writing difficult is secondary to a primary disorder involving writing, or that she has any other specific learning disorder. Given that she is active with peers, has no sleep or mood problems noted, depressive disorder is not an appropriate diagnosis

A 37-year-old Wall Street trader schedules a visit after his 8-year-old son was diagnosed with ADHD. Although he does not currently note motor restlessness like his son, he recalls being that way when he was a boy, along with being quite inattentive, being impulsive, talking excessively, interrupting, and having problems waiting his turn. He was an underachiever in high school and college, when he inconsistently did his work and had difficulty following the rules. Nevertheless, he never failed any classes. He was never evaluated by a psychologist or psychiatrist. He works about 60-80 hours a week and often gets insufficient sleep. He tends to make impulsive business decisions, can be impatient and short-tempered, and notes that his mind tends to wander in one-on-one interactions with associates, with his wife, and during business meetings. He is often late for things. He is forgetful and disorganized. Nevertheless, he tends to perform fairly well and is quite successful, although he can occasionally feel overwhelmed and demoralized. What is the most likely diagnosis? Select one: a. Major depressive disorder b. Generalized anxiety disorder c. ADHD in partial remission d. Oppositional defiant disorder

c. ADHD in partial remission This is not an uncommon story of a parent who presents to treatment after a child is diagnosed with ADHD, and the parent recognizes similarities for his/her own childhood. This man does present with a possibly history of ADHD during childhood, and possibly a prior history of oppositional defiant disorder. Currently there is no evidence that he has difficulty with rules, and the fact that he is no longer restless is common for the developmental course of ADHD. Currently his ADHD symptoms include three symptoms of the inattention cluster (difficulty sustaining attention, difficulty organizing tasks and activities, and forgetfulness. He hs only one clear symptom of impulsivity: the impatience. Since he retained only some of the symptoms, a diagnosis of ADHD in partial remission is appropriate. It is unclear to what degree his work schedule and insufficient sleep may be contributing to his distress.

A 44-year-old man with newly diagnosed ADHD has severe liver damage caused by many years of heavy drinking. You know that while most medications used for ADHD should be used with caution, or not at all, in clients with cardiac impairments, only one drug requires special care when prescribing it to a person with liver impairment. Which drug is it? Select one: a. Lisdexamfetamine b. d,l-methylphenidate c. Atomoxetine d. d,l-amphetamine

c. Atomoxetine Atomoxetine needs to be adjusted in persons with hepatic impairment. For clients with moderate impairment, the dose should be reduced to 50% of normal dose. For clients with severe liver damage, the drug should be reduced to 25% of normal dose because it is metabolized in the liver and could be insufficiently metabolized. Atomoxetine itself can rarely cause liver damage.

What is the prevalence of ADHD in children? Select one: a. 8% b. 10% c. 2% d. 0.5% e. 5%

e. 5% Population surveys suggest that ADHD occurs in most cultures in about 5% of children. Differences in ADHD prevalence across regions appear attributable mainly to different diagnostic and methodological practices. However, there may be a cultural variation in attitudes toward the interpretations of children's behavior. Clinical identification in the United States for African American and Latino populations tends to be lower than that for the Caucasian population. Informant symptoms ratings may be influenced by the cultural group of the child and the informant, suggesting that culturally appropriate practices are relevant for assessing ADHD

Which of the following is a core feature of major or mild neurocognitive disorder with Lewy bodies? Select one: a. Spontaneous features of parkinsonism, with onset at least 1 year prior to development of cognitive decline b. Fulfillment of criteria for rapid eye movement (REM) sleep behavior disorder c. Evidence of low striatal dopamine transporter uptake in basal ganglia as demonstrated by a single photon emission computed tomography (SPECT) or positron emission tomography (PET) imaging d. Recurrent auditory hallucinations e. Fluctuating cognition with pronounced variations in attention and alertness

e. Fluctuating cognition with pronounced variations in attention and alertness The core feature here is fluctuating cognition in attention and alertness. Lewy body is also characterized by visual, not auditory hallucinations, and onset of parkinsonism arising after not earlier than cognitive impairment. Low striatal dopamine transporter is a diagnostic marker but not a diagnostic criteria.

A previously healthy 67-year-old man, who is experiencing an acute change in mental status, is brought to the emergency department by his family. There is no evidence in the initial history, physical examination, and laboratory studies to indicate substance intoxication or withdrawal, or to suggest another medical problem as the cause of his altered mental state. Over the course of 1 hour of observation, his level of alertness varies from alert but distractible, with apparent auditory and visual hallucinations, to somnolent; he has difficulty sustaining attention to an examiner, and he cannot perform simple tasks such as serial subtractions or spelling words backwards. What is the most appropriate diagnosis? Select one: a. Delirium b. Delirium due to another medical condition c. Delirium due to substance intoxication d. Delirium due to multiple etiologies e. Unspecified delirium

e. Unspecified delirium This man meets criteria for some sort of delirium, but at this point in the course of his illness it cannot be determined what the cause is. The 'unspecified delirium' category can be used when the clinician chooses not to specify a specific cause, when the diagnostic criteria for delirium are not entirely fulfilled, or when the specific diagnostic subtype of delirium cannot be ascertained

An 11-year-old girl with autism spectrum disorder displays no spoken language and is minimally responsive to overtures from others. She can be somewhat inflexible, which interferes with her ability to travel, do schoolwork, and be managed in the home. She has some difficulty transitioning, and she has trouble organizing and planning activities. These problems can usually be managed with incentives and reinforcers. What severity levels should be specified in the DSM-5 diagnosis? Select one: a. Level 3 (requiring very substantial support) for social communication, and level 1(requiring support) for restricted and repetitive behaviors b. Level 1 (requiring support) for social communication, and Level 3 (requiring very substantial support) for restricted and repetitive behaviors c. Level 1 (requiring support) for social communication, and Level 2 (requiring substantial support) for restricted and repetitive behaviors d. Level 2 (requiring substantial support) for social communication, and Level 1 (requiring support) for restricted and repetitive behaviors

a. Level 3 (requiring very substantial support) for social communication, and level 1(requiring support) for restricted and repetitive behaviors In DSM-5 severity is noted separately for social communication impairments and for restricted, repetitive patterns of behavior. In this case, the social communication deficits are quite severe, warranting a classification of level 3, but the restricted, repetitive behaviors are milder, reflecting the lowest classification of level 1. Level 2 is an intermediate category reflecting the need for substantial support. Although these decisions can be subjective and vary, in this case the Level 2 doesn't seem appropriate for either social communication or repetitive behavior domains.

A 24-year-old woman has just been diagnosed with ADHD and is going to begin taking medication. She is adamant about not being put on a medication that is "known to make you and addict and will lead to heroin abuse." Her PMHNP chooses to prescribe lisdexamfetamine, because it is approved for adults and because it is the only amphetamine to date that may theoretically lack abuse potential. Why is this? Select one: a. Lisdexamfetamine must be enzymatically converted to amphetamine in the gut to become effective and thus is only absorbed slowly b. Lisdexamfetamine must be enzymatically converted to amphetamine in the bloodstream to become effective, and thus enters the brain slowly c. Lisdexamfetamine is packaged with slow-release technology that become ineffective with tampering d. Lisdexamfetamine is packaged with slow-release technology that prevents the 'kick' experienced with immediate-release amphetamine

a. Lisdexamfetamine must be enzymatically converted to amphetamine in the gut to become effective and thus is only absorbed slowly -Lisdexamfetamine the pro-drug of d-amphetamine. It is only metabolically activated once it has been absorbed by the intestinal wall and converted into the active compound d-amphetamine and l-lysine

A 69-year-old semiretired radiologist with responsibility for chest x-ray interpretation at his academic medical center has been referred by the hospital's Employee Assistance Program for clinical evaluation because of concerns expressed by other clinicians that he has been making many mistakes in his x-ray interpretations over the past several months. Evaluation discloses a remote history of alcohol dependence with sobriety for the past 20 years, and a depressive episode following the death of his wife 9 years before the current problem, treated with cognitive-behavioral therapy with full resolution of symptoms after 6 months and no recurrence. He acknowledges some problems concentrating but no other symptoms, and he minimizes the alleged x-ray interpretation problems. He cannot state the correct day of the week and cannot recall the previous day's news events, but he can describe the highlights of his long career in medicine in great detail. Collateral history from his children reveals that on several occasions in the past year neighbors in his apartment building complained that he forgot to turn off his stove after cooking, resulting in a smoke-filled apartment. He scores 21/30 on the Mini-Mental Status Exam. Which diagnosis best fits this clinical picture? Select one: a. Major neurocognitive disorder (NCD) b. Mild NCD c. Adjustment disorder d. Major depressive disorder e. Anxiety disorder

a. Major neurocognitive disorder (NCD) This man meets criteria for major neurocognitive disorder because of significant changes in cognition and impairment in activities of daily living. Neither his remote history of alcohol dependence nor his remote history of depression accounts for his cognitive problems and there is no evidence of another mental disorder.

A 7-year-old boy has just been diagnosed with ADHD, combined type, and his care provider feels that the best therapeutic choice is a stimulant. Family history is significant for depression and diabetes. The child's medical history is significant for asthma. Physical exam reveals no abnormalities. According to current recommendations, what should be the care provider's next step? Select one: a. Prescribe a stimulant, as no additional tests are indicated for this child b. Obtain an electrocardiogram (ECG), as this child's family and physical exam warrant it. c. Obtain an electrocardiogram (ECG), as this is mandatory prior to prescribing a stimulant to any child d. Prescribe a non-stimulant, as a stimulant would not be appropriate for this child

a. Prescribe a stimulant, as no additional tests are indicated for this child Current recommendations from the American Heart Association are that it is reasonable but not mandatory to obtain and electrocardiogram prior to prescribing a stimulant to a child. The American Academy of Pediatrics does NOT recommend an ECG prior to starting a stimulant for most children.

A 10-year-old boy demonstrates hand-flapping, finger-licking, and he repetitively flips coins and lines up his trucks. He tends to 'echo' the last several words of questions posed to him before answering. He mixes up his pronouns (refers to himself in the second person), tends to repeat phrases in a perseverative fashion, and is quite fixated on routines related to dress, eating, travel, and play. He spends hours in his garage playing with his father's tools. What do these behaviors represent? Select one: a. Restricted, repetitive patterns of behaviors, interests, or activities characteristic of ASD b. Symptoms of obsessive compulsive disorder c. Prototypical manifestations of obsessive-compulsive disorder d. Symptoms of pediatric acute-onset neuropsychiatric syndrome (PANS) e. Complex tics

a. Restricted, repetitive patterns of behaviors, interests, or activities characteristic of ASD -These are manifestations of repetitive, restricted patterns of behaviors, interests, or activities. It is necessary to have only two out of the four symptoms in this ASD category (along with meeting criterion A) to qualify for the autism spectrum disorder diagnosis.

A 7-year-old girl presents with a history of normal language skills (vocabulary and grammar intact) but is unable to use language in a socially pragmatic manner to share ideas and feelings. She has never made good eye contact and she has difficulty reading social cues. Consequently, she has difficulty making friends, which is further complicated by her being somewhat obsessed with cartoon characters, which she repetitively scripts. She tends to excessively smell objects. Because she insists on wearing the same shirt and shorts every day, regardless of the season, getting dressed is a difficult activity. These symptoms date from early childhood and cause significant impairment in her functioning. What diagnosis best fits this child's presentation? Select one: a. Asperger's disorder b. Autism spectrum disorder c. Pervasive developmental disorder not otherwise specified d. Social (pragmatic) communication disorder e. Rett syndrome

b. Autism spectrum disorder -Autism spectrum disorder (ASD) best fits this presentation. Asperger's disorder is now considered part of the Autism Disorder Spectrum as is pervasive developmental disorder not otherwise specified. Although the girl has intact formal language skills, it is the use of language for social communication that is particularly affected in ASD. A specific language delay is not required. The girl meets all three components of criterion A (deficits in social-emotional reciprocity, deficits in nonverbal communicative behaviors used for social interaction, and deficits in developing, maintaining, and understanding relationships), and two components of Criterion B (highly restricted, fixated interests that are abnormal in intensity or focus, and hyper/hypo reactivity to sensory input or unusual interest in sensory aspects of the environment.

A young man who is pre-med and has a family history of Alzheimer's disease is interested in learning more about the brain regions involved in memory and the development of Alzheimer's disease. You describe the pathways of acetylcholine, an important neurotransmitter involved in dementia. As part of your explanation, you tell him that the major cholinergic projections stem from the ____ to the ____ which are believed to be involved in memory. Select one: a. Basal forebrain; nucleus accumbens b. Basal forebrain; prefrontal cortex c. Striatum; hypothalamus d. Striatum; prefrontal cortex

b. Basal forebrain; prefrontal cortex Acetylcholine is an important neurotransmitter, and is thought to be involved in memory. Major acetylcholine neurotransmitter projections, originating in the basal forebrain project to the prefrontal cortex, hippocampus, and amygdala

The most frequent complaint of parents about their child with autism is. Select one: a. Their lack of usual play skills b. Delays in the acquisition of language c. Stereotyped movements d. Their lack of interest in social interaction e. Their difficulty tolerating change and variations in routines

b. Delays in the acquisition of language As many as 50% of all individuals with autism never develop speech. Delays in the acquisition of language are the most frequent presenting complaints of parents whose children are later diagnosed with autism. The usual pattern of language acquisition, babbling, practicing sounds, are often absent. Infants and young children with autism may take a parent's hand to obtain a desired object without initiating eye contact. When children with autism do use speech, their language is different. They often echo words and sounds they have heard (echolalia). They struggle with the flexibility of language, for example they do not recognize that changes in perspective of the speaker require pronoun changes, leading to pronoun reversal. 'You want juice,' rather than 'I want juice. Speech is often non-reciprocal, a term that indicates speech is not intended to produce communication with another.

The ApoE2 gene variant increases the risk of getting Alzheimer disease Select one: a. True b. False

b. False The ApoE2 gene may actually be a protective factor against the disease. It is the ApoE4 variant that increases the risk for Alzheimer disease

Medications for Alzheimer disease can reverse the course of the disease Select one: a. True b. False

b. False The correct answer is: False

Scarlet, a 25-year-old bartender, was diagnosed with ADHD at age 10. She has been on and off medication since then; first on immediate release methylphenidate, then on the methylphenidate patch. She has experimented with illicit drugs during her late adolescence and is still a heavy drinker. After a few years of self-medication with alcohol and cigarettes, she is seeking medical attention again. You decide to put her on 80mg / day of atomoxetine (Strattera), one of the nonstimulant medications effective in ADHD. Why does atomoxetine lack abuse potential? Select one: a. It decreases norepinephrine levels in the nucleus accumbens, but not in the prefrontal cortex b. It increases dopamine levels in the prefrontal cortex but not in the nucleus accumbens c. It modulates serotonin levels in the raphe nucleus d. It increases dopamine in the striatum and anterior cingulate cortex

b. It increases dopamine levels in the prefrontal cortex but not in the nucleus accumbens The prefrontal cortex lacks high concentrations of dopamine transporters, so DA relies on norepinephrine transporters in this region. Atomoxetine is a selective NE reuptake inhibitor. By blocking NE uptake transport in the PFC, atomoxetine thereby blocks DA reuptake, making more DA available in the PFC.

Which of the following neurocognitive disorders (NCDs) is especially characterized by deficits in domains such as speech production, word-finding, object naming, or word comprehension, whereas episodic memory, perceptual motor-abilities, and executive functions are relatively preserved? Select one: a. Behavioral-variant major or mild frontotemporal NCD b. Language-variant major or mild frontotemporal NCD c. Major or mild vascular NCD d. Major or mild NCD due to Alzheimer's disease e. Major or mild NCD with Lewy bodies

b. Language-variant major or mild frontotemporal NCD This is an example of the Language-variant major or mild frontotemporal NCD. Frontotemporal NCD comprises a number of syndromic variants characterized by the progressive developments of behavioral and personality change and/or language impairment. In the language variant form, with primary progressive aphasia of graduate onset, the classifiers used are: semantic variant, agrammatic / non-fluent variant, and logopenic variant, and each variant has distinctive features and corresponding neuropathy.

Which of the following statements about Rett syndrome is true? Select one: a. Occurs only in boys b. Occurs only in girls c. Does not involve motor abnormalities d. Shows no loss of social skills e. Is associated with normal intelligence

b. Occurs only in girls Rett syndrome occurs only in girls. It is a progressive condition that develops after 6 months of apparently normal development after birth. Head circumference at birth is normal and early developmental milestones, including social interactions, are unremarkable. Between 6 and 48 months, most commonly between 6 and 12 months, a progressive encephalopathy develops. Head growth begins to decelerate, with resultant microcephaly. Motor abnormalities occur: purposeful hand movements are lost. Gait and truncal apraxia, ataxia, and poor coordination develop in preschool years. Expressive and receptive language skills deteriorate and are associated with marked mental retardation. A loss of social interactional skills is observed during preschool years. The etiology of the disease is not known. A genetic basis for the disease is most likely.

Tammy, age 27, whose inattention and hyperactivity responded well to a daily dose of 0.2mg of clonidine, comes to see you because she has been put in charge of a huge project at work and is afraid of failing to manage it properly. You agree to increase her clonidine to 0.3mg / day for the time of this project only. A few weeks later she comes back saying that, after successfully completing her project, she went on vacation to relax with her friends and experienced extreme dizziness and drowsiness when they went to the hotel sauna. Additionally, she had forgotten to pack enough clonidine so she had not been taking any for the last couple of days. At her yearly physical yesterday her PCP said that her blood pressure was extremely high. What could have happened? Select one: a. The session in the sauna led to her high blood pressure b. The rapid discontinuation of the medication led to the high blood pressure c. The rapid increase in the medication dose led to the high blood pressure d. High blood pressure can be experienced on vacation as a rebound effect following a high stress period.

b. The rapid discontinuation of the medication led to the high blood pressure When clonidine is stopped, it should be tapered to avoid rebound effects including nervousness and increased blood pressure.

A 35-year-old man brings his 60-year-old father for evaluation of cognitive and functional decline, stating that he thinks his father has dementia. The son is also worried about the possibility of a hereditary illness. the physician notes to herself that the father has substantial cognitive impairment and features suggestive of the diagnosis of major cognitive disorder due to Huntington's disease, but she is not sure about the cause of the neurocognitive disorder. She also notes that the son appears extremely anxious. She has a tight schedule and cannot provide a counseling for the patient's son until the next day. What is the most appropriate diagnosis to record on the insurance claim that the patient's son will submit on his father's behalf? Select one: a. Unspecified central nervous system (CNS) disorder b. Unspecified neurocognitive disorder c. Unspecified mild neurocognitive disorder d. Huntington's disease e. Problem related to living alone (V code category reflecting other problems related to the social environment

b. Unspecified neurocognitive disorder

A 79-year-old woman with a history of depression is being evaluated at a nursing home for a suspected urinary tract infection. She is easily distracted, perseverates on answers to questions, asks the same question repeatedly, is unable to focus, and cannot answer questions regarding orientation. The mental status changes evolved over a single day. Her family reports that they thought she 'wasn't herself' when they saw her the previous evening, but the nursing report this morning indicates that she was cordial and appropriate. What is the most likely diagnosis? Select one: a. Major depressive disorder, recurrent episode b. Depressive disorder due to another medical condition c. Delirium d. Major depressive disorder, with anxious distress e. Obsessive-compulsive disorder

c. Delirium The woman's symptoms are closely connected to the onset of the urinary tract infection Her mental status changes have a temporal, fluctuating course with disturbance in attention and cognition. These are the diagnostic features of delirium.

A 7-year-old boy in second grade displays significant delays in his ability to reason, solve problems, and learn from experiences. He has been slow to develop reading, writing, and mathematical skills in school. All through development these skills lagged behind peers, although he is making slow progress. These deficits significantly impair his ability to play in an age-appropriate manner with peers and to begin to acquire independent skills at home. He requires ongoing assistance with basic skills (dressing, feeding, and bathing himself, doing any type of schoolwork) on a daily basis. Which of the following diagnoses best fits this scenario Select one: a. Childhood onset major neurocognitive disorder b. Specific learning disorder c. Intellectual disability d. Communication disorder e. Autism spectrum disorder

c. Intellectual disability -Intellectual disability best fits the scenario because it is characterized by deficits in general mental abilities, which result in impairments of intellectual and adaptive functioning. In specific learning disorder and communication disorders there is no general intellectual impairment. Autism spectrum disorder must include history suggesting persistent deficits in social communication and social interaction across multiple contexts (Criterion A), or 'restricted' repetitive patterns of behavior, interests or activities (Criterion B). Intellectual disability is categorized as a neurodevelopmental disorder and is distinct from the neurocognitive disorders which are characterized by a loss of cognitive functioning. There is no evidence for a neurocognitive disorder in this case, although major neurocognitive disorder may co-occur with intellectual disability (e.g. an individual with Down syndrome who develops Alzheimer disease, or an individual with intellectual disability who loses further cognitive capacity following a brain injury. In such cases the diagnoses of intellectual disability and neurocognitive disorder may both be given).

A 72-year-old man with no history of alcohol or other substance use disorders and no psychiatric history is bought to the emergency department (ED) because of transient episodes of unexplained loss of consciousness. His wife reports that he has experienced repeated falls and syncope over the past year, as well as auditory and visual hallucinations. A thorough workup for cardiac disease has found no evidence of structural heart disease or arrhythmias. In the ED, he is found to have severe autonomic dysfunction, including orthostatic hypotension and urinary incontinence. What is the best provisional diagnosis for this man? Select one: a. New-onset schizophrenia b. New-onset schizoaffective disorder c. Possible major or mild neurocognitive disorder with Lewy bodies d. Possible major or mild neurocognitive disorder due to Alzheimer's disease e. New-onset seizure disorder

c. Possible major or mild neurocognitive disorder with Lewy bodies With the limited information available, the best working diagnosis is neurocognitive disorder with Lewy bodies. (NCDLB). Individuals with NCDLB frequently experience repeated falls and syncope with transient episodes of unexplained loss of consciousness. Severe autonomic dysfunction such as orthostatic hypotension and urinary incontinence may also be observed. Auditory and other non-visual hallucinations are common, as are systematized delusions, delusional mis-identification and depression.

Gary is a 72-year-old man with severe memory loss and cognitive deficits. He was diagnosed with Alzheimer's disease at age 67. Imaging of Gary's brain when he was 63-years-old and asymptomatic would likely have revealed: Select one: a. Increased glucose uptake on PET scans but no beta amyloid accumulation b. No beta amyloid accumulation c. Some beta amyloid accumulation d. Abundant beta amyloid accumulation

c. Some beta amyloid accumulation Research indicates that some beta amyloid pathology may be present during the long pre-clinical phase of Alzheimer's disease, during which individuals are either asymptomatic or exhibit signs of mild cognitive impairment.

The essential feature of the DSM-5 diagnosis of delirium is a disturbance in attention/awareness and in cognition that develops over a short period of time, represents a change from baseline, and tends to fluctuate in severity during the course of a day. Which of the following additional conditions must apply? Select one: a. There must be laboratory evidence of an evolving dementia b. The disturbance must be associated with a disruption of the sleep-wake cycle. c. The disturbance must not occur in the context of a severely reduced level of arousal, such as coma d. The disturbance must be a direct physiological consequence of a substance abuse disorder e. The disturbance must not be superimposed on a preexisting neurocognitive disorder

c. The disturbance must not occur in the context of a severely reduced level of arousal, such as coma the ability to evaluate a disturbance in attention and cognition of delirium requires a level of arousal sufficient for response to verbal stimulation. Therefore, delirium should not be diagnosed in the context of coma. Both major and mild neurocognitive disorders (NCDs) can increase the risk for delirium and complicate the course. The most common differential diagnostic issue when evaluating confusion in older adults is disentangling the symptoms of delirium and dementia. It is possible to have a delirium superimposed on a pre-existing NCD such as that due to Alzheimer's disease

Major and mild neurocognitive disorders (NCDs) exist on a spectrum of cognitive and functional impairments. Which of the following constitutes an important threshold differentiating major from mild? Select one: a. Whether or not the individual is concerned about the decline in cognitive function b. Whether or not there is impairment in cognitive performance as measured by standardized testing or clinical assessment c. Whether or not the cognitive impairment is sufficient to interfere with independent completion of activities of daily living d. Whether or not the cognitive deficits occur exclusively in the context of a delirium e. Whether or not the cognitive deficits are better explained by another mental disorder

c. Whether or not the cognitive impairment is sufficient to interfere with independent completion of activities of daily living The key differentiating factor between major and mild neurocognitive disorders is the amount of impairment in the activities of daily living. For both mild and major NCD Criterion A requires evidence of a decline based on 1) concern on the part of the client, a knowledgeable informant, or a clinician that there has been such a decline; and 2) impairment in cognitive performance as document by standardized testing or other objective assessment. For major NCD a significant decline and substantial impairment are specified. For mild NCD, the words modest and mild are used.

A 70-year-old retired biology teacher has shown signs of mild cognitive impairment. As you discuss treatment options with him he asks you to explain the progression of this Alzheimer dementia from a neurobiological perspective. You lay out the course of the amyloid cascade hypothesis that follows this progression Select one: a. synaptic malfunction, amyloid plaques, apoptosis, microtubular tangles, amyloid buildup b. amyloid buildup, microtubular tangles, apoptosis, synaptic malfunction, amyloid plaques, inflammatory cytokines c. amyloid buildup, synaptic malfunction, amyloid plaques, microtubular tangles, inflammatory cytokines, apoptosis d. microtubular malfunction, amyloid buildup, synaptic malfunction, apoptosis, inflammatory cytokines,

c. amyloid buildup, synaptic malfunction, amyloid plaques, microtubular tangles, inflammatory cytokines, apoptosis The hypothesized sequence is amyloid buildup, synaptic malfunction, amyloid plaques, microtubular tangles, inflammatory cytokines, apoptosis

A 15-year-old boy has developed concentration problems in school that have been associated with a significant decline in grades. When interviewed he explains that his mind is occupied with worrying about his mother, who has a serious autoimmune disease. As his grades falter he becomes increasingly demoralized and sad, and he notices that his energy level drops, further compromising his ability to pay attention in school.At the same time he complains of feeling restless and unable to sleep. What is the most likely diagnosis? Select one: a. Bipolar disorder b. Specific learning disorder c. ADHD d. Adjustment disorder with mixed anxiety and depressed mood e. Separation anxiety disorder

d. Adjustment disorder with mixed anxiety and depressed mood The inattention seen in this boy relates to anxiety and depressive symptoms that are in reaction to his mother's illness and his subsequent decline in grades. Inattention related to ADHD is not associated with worry and rumination, as would be the case in anxiety disorders. To diagnosis adjustment disorders, attention must also be paid the to the presence of a stressor and the time-frame.

A 79-year-old man presents to your office with his wife. He currently appears dull and blunted. She lists significant medical history such as chronic renal failure, mild cirrhosis, arrhythmias, and a recent diagnosis of moderately severe Alzheimer's disease by their family physician. Which of the following medications for Alzheimer's disease would it be most important to discontinue if you learned the man was taking it? Select one: a. Donepezil b. Rivastigmine c. Memantine d. Galantamine

d. Galantamine Galatamine is contraindicated in cases with any renal, hepatic, or cardiac problems. Furthermore, it is a cholinesterase inhibitor prescribed more as first-line for mild, early-stage Alzheimer, rather than moderately severe cases.

A three-and-a-half-year-old girl with a history of lead exposure and seizure disorder demonstrates substantial delays across multiple domains of functioning, including communication, learning, attention, and motor development, which limit her ability to interact with same age peers and require substantial support in all activities of daily living at home. Unfortunately, her mother is an extremely poor historian and the child has received no formal psychological or learning evaluation to date. She is about to be evaluated for readiness to attend preschool. What is the most appropriate diagnosis? Select one: a. Major neurocognitive disorder b. Developmental coordination disorder c. Autism spectrum disorder d. Global developmental delay e. Specific learning disorder

d. Global developmental delay The child warrants the diagnosis global developmental delay. Although the girl's deficits may be suggestive of intellectual disability, that diagnosis cannot be made in this case because information is lacking (e.g. about age at onset of her symptoms), and she is too young to participate in standardized testing. At this point there is no information to suggest that this child has dementia (major neurocognitive disorder), an autism spectrum disorder (no evidence of symptoms in the core autism spectrum disorder categories), a specific disorder relating to coordination or specific areas of learning weakness (which generally would not be able to be diagnosed until the elemental school years).

In major or mild frontotemporal neurocognitive disorder, which of the following is a diagnostic feature of the language variant? Select one: a. Severe semantic memory impairment b. Severe deficits in perceptual-motor function c. Receptive aphasia d. Grammar, word-finding, or word-generation difficulty e. Hyperorality

d. Grammar, word-finding, or word-generation difficulty The language variant diagnosis specifically requires worsening in language function -- grammar, word-finding, or word-generation difficulties. Hyperorality is a diagnostic feature of the behavior deficit variant.

The DSM-5 diagnosis of intellectual disability includes severity specifiers: mild, moderate, severe, and profound, with which to indicate the level of support required in various domains of adaptive functioning. Which of the following features would not be characteristic of an individual with a 'Severe' level of impairment? Select one: a. The individual generally has little understanding of written language or concepts involving numbers, quantity, time, and money b. The individual's spoken language is quite limited in terms of vocabulary and grammar c. The individual requires support for all activities of daily living, including meals, dressing, bathing, and toileting d. In adulthood the individual may be able to sustain competitive employment in a job that does not emphasize conceptual skills e. The individual cannot make responsible decisions regarding the well-being of self or others

d. In adulthood the individual may be able to sustain competitive employment in a job that does not emphasize conceptual skills Competitive employment may be attainable by individuals with a 'Mild' level of impairment but would not be characteristic of those with a 'Severe' level of impairment. Intellectual disability is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains. The conceptual (academic) domain involves competence in memory, language, reading, writing, math reasoning, the acquisition of practical knowledge, problem solving, and judgment in novel situations, among others. The social domain involves awareness of others' thoughts, feelings, and experiences; empathy; interpersonal communication skills; friendship abilities, and social judgment, among others. The practical domain involves learning and self-management across life settings, including personal care, job responsibilities, money management, recreation, self-management of behavior, and school and work organization, among others.

A 68-year-old semi-retired cardiologist with responsibility for electrocardiogram interpretation at his community hospital is referred by the hospital's Employee Assistance Program for clinical evaluation because of concerns expressed by other clinicians that he has been making many mistakes in his ECG interpretations over the past few months. The client discloses symptoms of a persistent sadness since the death of his wife six months prior to the evaluation, with frequent thoughts of death, trouble sleeping, and escalating usage of sedative-hypnotics and alcohol. He has some trouble concentrating, but he has been able to maintain his household, pay his bills, shop, and prepare meals by himself without difficulty. He scores 28/30 on the Mini-Mental State Examination (MMSE). Which of the following would be the primary consideration in the differential diagnosis? Select one: a. Major neurocognitive disorder b. Mild neurocognitive disorder c. Adjustment disorder d. Major depressive disorder e. Bereavement disorder

d. Major depressive disorder The primary consideration would be major depressive disorder. Not enough information has been provided to know for certain whether the man meets criteria for a specific mood disorder diagnosis -- or a substance use disorder -- and a NCD cannot be ruled out. Although his score on the MMSE is within the normal range, he does meet Criterion A for NCD in that concerns about a decline in cognitive function have been raised due to his increased error rate in interpreting ECGs. However, he has not demonstrated loss of ability to perform activities of daily living and to live independently, so he does not qualify for a diagnosis of major NCD.

John, a 73-year-old mid-stage Alzheimer's patient, has been on donepezil 10mg/day for approximately eight months to aid in improving his cognitive functioning. His wife has begun to notice a loss of effectiveness over the past month, and they present today to determine a new course of action. You decide to augment the donepezil with 5mg/ day of Memantine. Which of the following properties of Memantine may be useful in treating Alzheimer's disease? Select one: a. Serotonin 3 (5HT3) antagonism b. Sigma 2 antagonism c. N-methyl-D-aspartate (NMDA) agonism at the PCP site d. N-methyl-D-aspartate (NMDA) antagonism at the magnesium site

d. N-methyl-D-aspartate (NMDA) antagonism at the magnesium site Memantine is an NMDA antagonist that binds to the magnesium site. It works as an uncompetitive open channel MNDA receptor antagonist. Memantine is quickly reversible if phasic bursts of glutamate occur, but it is able to block tonic glutamate release from having negative downstream effects. This hypothetically stops the excessive glutamate from interfering with the resting glutamate neuron's physiological activities, thus improving memory

A 28-year-old man with generalized anxiety disorder has been treated successfully with paroxetine for three years. He also has a history of childhood AHD but is not currently being treated for it. In addition, he has a history of stimulant abuse, but has been clean for several years. He presents now stating that he is having significant work impairment due to inattention and disorganization and is in danger of losing his job. Full evaluation reveals that he does meet criteria for current ADHD. Because of his history of substance abuse, atomoxetine is chosen as a treatment. What pharmacokinetic interaction, if any, would you expect between atomoxetine and paroxetine? Select one: a. Atomoxetine is an inducer of CYP 450 2D6 and paroxetine is metabolized by CYP 450 2D6, so the dose of paroxetine should be increased b. Paroxetine is an inducer of CYP 450 2D6 and atomoxetine is metabolized by CYP 450 2D6, so the dose of atomoxetine should be increased c. Atomoxetine is an inhibitor of CYP 450 2D6 and paroxetine is metabolized by CYP 450 2D6, so the dose of paroxetine should be decreased. d. Paroxetine is an inhibitor of CYP 450 2D6 and atomoxetine is metabolized by CYP 450 2D6, so the dose of atomoxetine should be decreased.

d. Paroxetine is an inhibitor of CYP 450 2D6 and atomoxetine is metabolized by CYP 450 2D6, so the dose of atomoxetine should be decreased. In the presence of paroxetine, an inhibitor of CYP 450 2D6 the dose of atomoxetine should be decreased

A mother brings her 17-year-old daughter, Clarice, to see you. She has been successfully treated with 40mg/day of sustained release, d,l-methylphenidate (Ritalin SR) for three years. However, she has recently become irritable and secretive, and comes home late with no explanation. Her mother has noticed that she has been stealing money from her purse. Clarice's performance in school is sliding and the teacher has brought up her lack of attention. What do you do next? Select one: a. Raise the dose of methylphenidate to 60 mg/day to deal with the breakthrough symptoms b. Switch her to 40mg / day of immediate release d/l-methylphenidate (Ritalin) and suggest psychoeducation c. Switch Clarice to 60mg / day of atomoxetine (Strattera) and screen for substance abuse disorder d. Stop pharmacotherapy and do not switch immediately; monitor progression of symptoms for a time off medication

d. Stop pharmacotherapy and do not switch immediately; monitor progression of symptoms for a time off medication While switching to atomoxetine, a medication with lesser abuse potential, and screening for a substance abuse disorder would be wise, the best thing might be to stop the medication altogether, establish a new baseline, and make sure she is both compliant and not abusing drugs. Then, a stimulant can be reinstituted with more confidence.