Human Behavior Exam 3: Practice Questions

1 Stereotypic Movement Disorder With SIB Intellectual disability (intellectual developmental disorder) frequently may involve self-injurious behavior (SIB) and Stereotypic Movement Disorder, where the individual engages in repetitive nonfunctional motor behavior, self-picking, self-biting, head banging, waving, body rocking, mouthing objects, or hitting one's own body. The SIB, in order to be diagnosed, must be of sufficient magnitude to require medical attention because of the harm involved. There is no specific age of onset and the more self-injurious patients frequently are blind or deaf and may be suffering from lack of stimulation. The behaviors may change and a patient will not necessarily limit themselves to head banging only. The description gave no indication of psychotic processes; therefore, any disorder involving psychosis is not warranted. A simple diagnosis of Trichotillomania would not be adequate in the face of the intellectual disability (intellectual developmental disorder), movement disorder, and SIB, which is not limited to hair pulling. The behavior must also last for at least 4 weeks or longer.

A 12-year-old girl engages in excessive body rocking, head banging, picking at her arms until they become sore, and pulling her hair out. Frequently, the staff in her school have to tie mitts on her hands to keep her from continuing to harm herself. She also hits herself in the head, and has caused noticeable swelling; in at least one instance, several sutures were required to close a gash on her cheek. A prior instance of head banging 1 year ago resulted in a detached retina, and she now has impaired eyesight. The girl has been given an FSIQ=63. What is the most likely diagnosis? 1 Stereotypic Movement Disorder With SIB 2 Obsessive-Compulsive Disorder 3 Trichotillomania 4 Disorder of Infancy, Childhood or Adolescence NOS 5 Psychotic Disorder NOS

3 Bulimia nervosa Bulimia nervosa is characterized by binge eating and purging. Patients are often at a normal weight. Physical examination findings that should heighten a clinician's suspicion of bulimia nervosa includes the following: calluses on backs of multiple fingers of bilateral hands, discolored teeth, and loss of dental enamel, exposing the dentin. These consistently show a longstanding behavior pattern that is consistent of bulimia nervosa.

A 25-year-old woman presents for an annual physical examination that is required by her new employer. As you progress through the history and review of systems, you come across very few positive responses. However, when completing the physical examination you note following: 25 year old female appearing her stated age of normal size and weight; large calluses on many fingers of both hands; and severe discoloration of teeth with some having exposed dentin. What is the most likely diagnosis? 1 Pica 2 Body Dysmorphic Disorder 3 Bulimia nervosa 4 Anorexia nervosa 5 Rumination

4 Inhalant use Inhalants are typically not part of a routine toxicology screening, and given the limited and nonspecific availability of symptomology for inhalant use, this diagnosis might only be made through the process of elimination. A long-term inhalant user might suffer from both CNS and PNS damage, in addition to suffering damage to muscles, the liver, and other organs. Alcohol intoxication is marked by an unsteady gait and slurred speech. It takes several hours for alcohol to begin to be excreted by the body. Caffeine intoxication can create nervousness, excitement, and diuresis. Cocaine intoxication can typically be characterized by a "high" followed by a "crash." The high can be characterized by increased activity such as agitation, talkativeness, and anxiety. The crash is frequently characterized by a slowing of activity and usually, the user sleeps for several hours. Cocaine withdrawal is similar to amphetamine withdrawal and usually results in great fatigue, increased appetite, and the development of a dysphoric mood.

A 16-year-old boy presents with trouble breathing, excessive coughing, headache, abdominal pain, and vomiting. A toxicology screening returns negative. The patient is not suffering from pneumonia or bronchitis; he has no history of asthma. Based on these findings and patient history, what is the most likely diagnosis? 1 Alcohol intoxication 2 Caffeine intoxication 3 Cocaine use 4 Inhalant use 5 Cocaine withdrawal

3 Anorexia nervosa The probable diagnosis in this patient is anorexia nervosa. It is a psychiatric disorder characterized by refusal to maintain a minimally normal weight with serious physiological consequences. It is primarily a phenomenon of puberty and adolescence. Bulimia nervosa is also an eating disorder characterized by binges of eating usually followed by purging (self-induced vomiting, laxative, and/or diuretic abuse). Patients may be of normal weight or overweight.

A 16-year-old girl is brought to the clinic by her mother. Her mother says that her daughter has not been eating well in the last few months. She has been skipping at least 1 meal per day and has constantly been losing weight; however, she continues to exercise rigorously everyday. She has amenorrhea for the past 4 months. On physical examination, patient has dry skin, lanugo, parotid gland enlargement, and dental enamel erosion. The patient's BMI is 16. What is the most likely diagnosis? 1 Bulimia nervosa 2 Body dysmorphic disorder 3 Anorexia nervosa 4 Anxiety disorder 5 Adjustment disorder

5 Phencyclidine intoxication Phencyclidine (PCP) intoxication typically involves violent or combative behaviors. Normal or small pupils are present (hallucinogens typically produce large pupils) and the patient may have ataxia, nystagmus, or muscle rigidity. Treatment should NOT include phenothiazines, as they may compound the PCP's anticholinergic and hypotensive effects. Marijuana intoxication is characterized by increased appetite, tachycardia, dry mouth, and behavioral or psychological changes (e.g., poor motor coordination, euphoria, and impaired judgment). Caffeine intoxication (more than 250 mg.) involves nervousness, insomnia, diuresis, tachycardia, and/or psychomotor agitation. Amphetamine withdrawal occurs after prolonged use and typically involves fatigue, increased appetite, and insomnia. LSD flashbacks are a result of prior hallucinogen usage. The perceptual distortions present during intoxication are reexperienced (e.g., flashes of color, trails of images, hallucinations).

A 19-year old male is brought to the ER. He displays violent behavior and is combative. His pupils appear normal, but there is some muscle rigidity. What might the preliminary diagnosis be? 1 Marijuana intoxication 2 Caffeine intoxication 3 Amphetamine withdrawal 4 An LSD flashback 5 Phencyclidine intoxication

2 Phencyclidine intoxication Phencyclidine intoxication is characterized by disinhibition, aggressive behavior, anxiety, panic, rage and impaired judgment. Physiological changes can include hyperthermia, elevated blood pressure, tachycardia, hyperacusis, nystagmus, diminished pain responsiveness, dysarthria, and seizures. Opioid intoxication is characterized by behavioral changes that include euphoria followed by apathy, shortened attention span and memory dysfunction, psychomotor agitation or retardation and poor judgment. Physiological changes that may present include slurred speech, drowsiness, and pupillary constriction. Benzodiazepine intoxication is characterized by disinhibition, mood lability and impaired judgment. Physiological symptoms may include slurred speech, poor coordination, nystagmus, impaired memory, and coma. Cocaine intoxication is characterized by behavioral changes that include euphoria, hypervigilance and paranoia, interpersonal sensitivity, anxiety and poor judgment. There are also possible physiological changes that include pupillary dilation, tachycardia or bradycardia, elevated or lowered blood pressure, psychomotor agitation, cardiac arrhythmias, seizures, and diaphoresis. Inhalant intoxication is characterized by behavioral changes that include apathy, assaultiveness and impaired judgment. Physiological changes include nystagmus, slurred speech, psychomotor retardation, as well as movement abnormalities, such as incoordination, depressed reflexes, ataxic gait, and tremor. Mood presentation can range from euphoria to stupor.

A 19-year-old college student is brought to the emergency room by the campus police. He was found naked outside a sorority house screaming obscenities and beating his fists on the ground. He is cooperative in the examination room but appears flushed and anxious, and he is holding his hands over his ears. Vital signs are as follows: Temp 99.8, HR 140, and BP 170/110 mmHg. His neurological exam is notable for horizontal nystagmus and minimal pain response to pressing his nailbed. What is the most likely diagnosis? 1 Opioid intoxication 2 Phencyclidine intoxication 3 Benzodiazepine intoxication 4 Cocaine intoxication 5 Inhalant intoxication

4 Post-traumatic stress disorder The young woman's symptoms meet at least 4 of the criteria for a diagnosis of post-traumatic stress disorder (re-experience the event, avoidance of stimuli associated with the trauma, sleep problems, outbursts of anger, functional impairment). Recurrent nightmares and distressing dreams are ways in which a traumatized person re-experiences the traumatic event. Her screaming, verbal fights with her boyfriend coupled with her feelings of depersonalization during the fights may be subconscious defensive maneuvers to both vent her (displaced) rage and remove herself from reminders of the traumatic event. Her disabling fear of being alone or going to work may demonstrate that she is fearful of being a victim again and may be experiencing some depression also.

A 19-year-old woman presents with recurrent nightmares that interfere with her sleep. She has developed a fear of being alone. These symptoms started shortly after she witnessed the death of her sister in an automobile accident. Without further evaluation, what would be a tentative diagnosis? 1 Panic disorder with agoraphobia 2 Brief psychotic disorder 3 Bipolar I disorder, most recent episode depressed 4 Post-traumatic stress disorder 5 Conversion disorder

2 Restoration of normal electrolyte levels Based on the symptomatic description, the young girl most probably suffers anorexia, a complex disorder that requires long case-specific treatments that involve both medical care and psychotherapy. Treatment of anorexia is usually started if patients are in stable medical condition, so controlling and stabilizing her electrolytes would be the first step for her treatment. Cognitive-behavioral therapy, a healthy eating plan, and encouragement to join an eating disorder support group can all be part of a treatment plan for someone suffering from eating disorders, but they are not usually administered as a first treatment step to patients that show signs of other medical conditions.

A 20-year-old female college student aspiring to become a professional ballet dancer reports to her primary care physician concern about her ability to have children since her menarche has not started yet. She is 5'8" tall and weighs 100 lb. She is overly concerned about being overweight and diets almost every day of the week. She says that she has been recently vomiting frequently. She is fatigued and looks pale. Blood tests reveal a slight hypokalemia. What is the best initial step in management of this patient? 1 Cognitive-behavioral therapy 2 Restoration of normal electrolyte levels 3 A healthy eating plan 4 Encouragement to join an eating disorder support group 5 Treatment with antidepressants

3 Opiate This patient is experiencing classic withdrawal symptoms of an opiate; these include flu-like symptoms, nausea and/or vomiting, runny nose, yawning, diarrhea, piloerection, fever, insomnia, goose bumps, sweating, and pupillary dilation (a clear, late withdrawal symptom). Supportive care and medications are the treatments for opiate withdrawal; this includes relief from physical symptoms. The most commonly used medication is clonidine.

A 20-year-old man presents because he is feeling nervous, cannot sleep at night, has a loss of appetite, a low-grade fever, a runny nose, and stomach cramps. On physical exam, the hair on his arms is standing on end, he is sweating, and his pupils are dilated. He states that he is accustomed to taking a certain drug, but he has not been able to obtain it for the last 72 hours. From what type of drug is this patient most likely withdrawing? 1 Barbiturate 2 Benzodiazepine 3 Opiate 4 Nicotine 5 LSD

2 Bulimia nervosa Bulimia nervosa is characterized by binge eating followed by inappropriate compensatory behavior, such as purging. Purging usually consists of self-induced vomiting and abuse of laxatives; less commonly, purging involves the use of diuretics or enemas. Anorexia nervosa is characterized by a fear of gaining weight, plus a disturbance in how a person identifies with their weight or body shape. They also have amenorrhea. They also sometimes binge and purge, but their weight is always below normal.

A 23-year-old woman came to the dentist presenting with multiple dental caries. This is her third visit in a 6-month period with the same problem. On questioning the patient, she admitted her concern about gaining weight, and that she has multiple binge eating sessions every day followed by purging. The patient looks average weight for her age with pale skin and normal development. What is the patient's condition due to? 1 Anorexia nervosa 2 Bulimia nervosa 3 Depression 4 Anxiety 5 Vitamin D deficiency

3 Fluoxetine Bulimia nervosa is 1 of the most common eating disorders and can be life-threatening if not treated appropriately. The first-line agent of choice to treat bulimia nervosa is fluoxetine at an initial dose of 20 mg/d, with an increase in dosage over 1 - 2 weeks to 60 mg/d in the morning (as tolerated). Bupropion is contraindicated in the treatment of bulimia nervosa and is known to causes seizures. It is prescribed for smoking cessation therapy in patients without disorders. Citalopram has shown benefit in the treatment of bulimia but is not FDA approved, nor is it a first-line medication; dosages cannot exceed 40 mg/d, which may be suboptimal for many patients. Valproic acid is a mood stabilizer that has been shown to cause weight gain and therefore is usually inappropriate to some patients who are weight preoccupied. It can be used if other therapies such as SSRIs are ineffective.

A 23-year-old woman presents for a routine check-up. She has no current complaints but admits to using laxatives and diuretics on an average of once a week after she consumes an enormous amount of food. She denies self-induced vomiting and does not have physical signs that would raise concern. She also denies alcohol and drug use. Her physical examination is within normal limits, including her weight and vital signs. In addition to psychotherapy, what pharmacologic therapy should be prescribed as a first-line agent in order to treat her disorder? 1 Bupropion 2 Citalopram 3 Fluoxetine 4 Lithium 5 Valproic acid

1 Cocaine intoxication Cocaine intoxication can typically be characterized by a "high" followed by a "crash." The high can be characterized by increased activity such as agitation, talkativeness, and anxiety. The crash is frequently characterized by a slowing of activity and usually, the user sleeps for several hours. Amphetamine withdrawal usually results in great fatigue, increased appetite, and the development of a dysphoric mood. Marijuana use will typically create increased appetite and a state of lethargy.

A 24-year-old male is brought to the emergency room. He is highly agitated and will not sit still. His speech is rambling and is dotted with paranoid delusions. About 1 hour later, the patient's excited speech slows and he quietly mutters to himself before falling asleep. The patient is most likely suffering from: 1 Cocaine intoxication 2 Alcohol intoxication 3 Amphetamine withdrawal 4 Marijuana use 5 Caffeine intoxication

A) Amphetamine-related disorder The patient's intoxication is an amphetamine-related disorder. Methylphenidate is a prescription amphetamine drug used to treat attention deficit hyperactivity disorder. It is also a commonly abused drug, owing to its ability to enhance mental and physical capacity. Common signs of amphetamine abuse include sympathetic stimulation, such as tachycardia, elevated blood pressure, and mydriasis.

A 25-year-old man presents with euphoria and has clinical symptoms that include tachycardia and nausea. He admits to having used methylphenidate earlier in the day. He also smokes marijuana occasionally. How would you categorize his intoxication? A) Amphetamine-related disorder B) Cocaine-related disorder C) Hallucinogen-related disorder D) Inhalant-related disorder E) Opioid-related disorder

4 Adjustment disorder Of the diagnoses given, adjustment disorder is the best answer. A diagnosis of adjustment disorder requires that symptoms develop within 3 months of onset of identifiable psychosocial stressors. This patient has experienced 2 specific stressors that could cause his symptoms. Conversion disorder involves deficits in voluntary motor or sensory functioning. For a diagnosis of post-traumatic stress disorder, symptoms must follow exposure to a traumatic event. Personality disorder is indicated when there is a presence of enduring personality traits that deviate remarkably from what might be expected, and that leads to significant distress or impairment. An essential feature of avoidant personality disorder is a pattern of avoidant behavior to social and occupational activities, in addition to feelings of inadequacy with a preoccupation with being criticized.

A 28-year-old homosexual man recently came out to his parents. His parents have since refused to talk with him. Additionally, the man's lover recently announced he is moving out. The patient reports feeling depressed; he is not sleeping well. He states his performance at work is declining, and he is afraid of losing his job. He is not socializing with friends and tends to stay home. What is the most likely diagnosis? 1 Conversion Disorder 2 Post-Traumatic Stress Disorder 3 Personality Disorder 4 Adjustment disorder 5 Avoidant Personality Disorder

1 Bulimia nervosa The correct answer is bulimia nervosa. Bulimia is an eating disorder in which patients gorge on food (binge eating) and then purge, either by self-induced vomiting or with the use of laxatives. Some of the health problems associated with Bulimia include laceration of the gastrointestinal tract, discoloration of the teeth, hernias in the esophagus, kidney damage, and hormonal imbalances. Treatment for bulimia focuses on getting patients to monitor their eating habits and then helping them to extinguish the urge to vomit.

A 28-year-old woman presents with obsessive concerns about gaining weight. Physical exam reveals a slightly overweight woman with poor dentition, enlarged parotid glands, and scars on the dorsal side of her hands. Upon further questioning, she admits to binge eating and then self-induced vomiting to prevent weight gain. What is the most likely diagnosis? 1 Bulimia nervosa 2 Anorexia nervosa 3 Obesity 4 Hyperphagia 5 Pica

4 Naloxone The patient's apnea and pinpoint pupils are consistent with an acute opioid overdose; therefore, treatment with naloxone is indicated. Naloxone is an opioid receptor antagonist with a high affinity for opioid receptors. Naloxone displaces receptor-bound opioids, which leads to a reversal of opioid-induced respiratory depression and coma. Opioid receptors of various subtypes are present throughout the central and peripheral nervous systems. In addition to their analgesic properties, opioids cause respiratory depression via receptors in the medullary respiratory center. Pupillary constriction occurs as a result of opioid receptor activation in the Edinger-Westphal nucleus of the oculomotor nerve. Other side effects of opioids are constipation caused by gastrointestinal smooth muscle relaxation and nausea caused by receptor stimulation in the chemoreceptor trigger center of the 4th ventricle.

A 29-year-old man is found unconscious by his roommate. He has a history of manic-depression and substance abuse. His roommate states that he recently broke up with his girlfriend and was laid off from his job. When the paramedics arrive, the patient is nonresponsive and nearly apneic. His pulse is palpable and regular at a rate of approximately 80 beats per minutes. His pupils are pinpoint but equal. In addition to immediate cardiopulmonary resuscitation, treatment with what drug therapy is most likely to be lifesaving? 1 Atropine 2 Epinephrine 3 Flumazenil 4 Naloxone 5 Phenobarbital

4 Cocaine Intoxication Cocaine intoxication presents with impaired judgment, agitation, high energy, high blood pressure, diaphoresis, and dilated pupils. Bipolar disorder is characterized by episodes of depression mixed with episodes of mania Adjustment disorder occurs within 3 months of an identified stressor and can present with a drastic change in mood and personality. Schizophrenia is characterized by hallucinations, paranoia, and ideas of false belief. Intermittent explosive disorder is a behavioral disorder characterized by explosive outbursts of anger and violence, often to the point of rage, that are disproportionate to the situation at hand.

A 30-year-old man presents in a state of euphoria, but he is also demonstrating an obvious impairment in judgment. He was walking on the railing of a local bridge; his friends managed to get him down and forced him to seek medical attention. Lately, he has been neglecting his work, going in late, and feeling unappreciated. His pupils are dilated. He has elevated blood pressure and is diaphoretic. His clothes are too loose to be stylish, and he is perspiring heavily. The manner in which he relates to you is somewhat condescending, and he is grandiose in his thinking. There is no history of psychiatric illness, and there is no medical illness that you can detect. What is the most likely diagnosis? 1 Bipolar Disorder NOS 2 Adjustment disorder with mixed disturbance of emotions and conduct 3 Schizophrenia 4 Cocaine Intoxication 5 Intermittent Explosive Disorder

5 Caffeine intoxication The presenting signs and symptoms characterize caffeine intoxication. While most of the symptoms that this patient is experiencing may be found after consuming as little as 2 cups of coffee, agitation and tirelessness usually occur only when caffeine intake is substantially greater—perhaps as much as a gram or more per day. Symptoms of caffeine intoxication are sometimes confused with other Axis I disorders, so it is important to consider caffeine intoxication, especially when the patient who has such symptoms is in generally excellent mental and physical health. Generalized anxiety disorder, panic disorder, a manic or hypomanic episode, and various sleep disorders have symptoms similar to those seen in caffeine intoxication; each can be ruled out with a careful interview.

A 34-year-old man presents for the first time in your office complaining of episodic restlessness, nervousness, sleeplessness, tirelessness, increased urination, and gastrointestinal upset. A quick physical reveals an irregular heartbeat and he appears to have psychomotor agitation. You observe that his face is quite red and his speech is rapid. The patient complains that he is unable to function well at school when these "attacks" occur, and they are increasing in frequency, now that he is studying for exams. Interview and history reveal that the patient has no personal or known family history of mental illness, and physical examination is unremarkable except for the current symptoms. The patient says that he has been under a lot of pressure lately because he is working long shifts in a local café, and he studies most of the rest of the time for upcoming doctoral comprehensive exams. He drinks coffee for most of his shift, and he eats chocolate covered espresso beans to stay alert while he studies. What is the most likely diagnosis? 1 Alcohol abuse 2 Sedative abuse 3 Hypnotic abuse 4 Anxiolytic abuse 5 Caffeine intoxication

2 Rumination After eliminating gastrointestinal or other medical conditions, the best tentative diagnosis is rumination: repeated regurgitation of food that persists for at least 1 month. It is believed that a lack of stimulation, neglect, or a poor parent-child relationship may be responsible for an infant developing this disorder. It is usually associated with another mental disorder when its onset is in older children or adults.

A 9-month-old female infant is presented by the mother. The patient is the mother's first child, and the pregnancy was unplanned. The mother states that the patient eats well, but she seems to purposely spit up the meals within minutes of eating. The infant arches her back and strains while holding her head back. She tightens her abdominal muscles and makes sucking movements with her tongue. The mother says this has been going on for about 3 months. Visual exam reveals that the infant's weight is lower than average, and she appears to have minor symptoms of malnutrition. A complete GI workup is unremarkable, including stool specimen and imaging. What is the most likely diagnosis? 1 Avoidant/restrictive food intake disorder 2 Rumination 3 Pica 4 Intellectual disability 5 Elimination disorder

2 Decrease or stop caffeine intake This patient is demonstrating symptoms of caffeine intoxication caused by the consumption of large amounts of caffeine. Symptoms of caffeine intoxication can include insomnia, nervousness, restlessness, tachycardia, diuresis, and agitation. Caffeine is not considered a drug by many people, so they do not consider excessive consumption to be a problem. Many foods and drinks contain caffeine that consumers may not be aware of, so it becomes easy to ingest large quantities without realizing it. When caffeine is ingested, it enters the bloodstream and can lead to an increase in the secretion of norepinephrine in the brain, causing an increase in neuron activity. It binds to adenosine receptors and can block the sedative effect that adenosine can produce. As a result, people become more alert and feel less tired.

A 36-year-old man with a history of diabetes and obesity presents with weakness and flu-like symptoms. His girlfriend reports that he had taken several caffeine pills the day before, but he denies a suicide attempt. During evaluation at the hospital, he experiences vomiting and seizures. A laboratory workup is within normal limits. He is admitted to the hospital and improves over the course of his 3-day admission. He is subsequently released with no lingering effects. What is the most common treatment for this patient after hospital discharge? 1 As needed anxiety medication 2 Decrease or stop caffeine intake 3 Oral steroid taper 4 Oral daily levothyroxine 5 Antidepressant medication

3 Attention deficit hyperactivity disorder The most appropriate diagnosis for this patient is attention deficit hyperactivity disorder (ADHD). The American Academy of Pediatrics (AAP) has concluded that primary care providers should evaluate any pediatric patients ages 4-18 who have academic or behavioral problems or if they display signs of inattention, hyperactivity, or impulsivity. These signs should be observed in more than one setting and should be reported by a mixture of parents, guardians, teachers, or other school and mental health clinicians.

A 5-year-old boy presents because of concerns about his behavior. His mother notes he gets extremely distracted and can only focus for 1-2 minutes at a time. He cannot seem to sit still, and he displays extremely impulsive behavior at inappropriate times. She describes impulsive behavior recently at a funeral and at an older sibling's music recital. Because the mother works full time, the patient attends daycare after kindergarten. His kindergarten teacher and the daycare staff have expressed similar concerns. What is the most likely diagnosis? 1 Oppositional defiant disorder 2 Autism spectrum disorder 3 Attention deficit hyperactivity disorder 4 Post-traumatic stress disorder 5 Depression

4 Cocaine use The signs and symptoms of cocaine use are often very similar to that of amphetamine use. Of the signs and symptoms noted above, all would be consistent with amphetamine use except perforation of the nasal septum, which suggests that the patient used his drug intranasally.

A 55-year-old man is agitated and anxious and disoriented; he appears to be responding to visual hallucinations. According to his partner, the patient has been very moody lately and he has had a lot of difficulty sleeping. When he does sleep, according to the partner, the patient has frightening dreams. Examination reveals a man in significant distress: tremor, sweating, tachycardia, hyperventilation, and slow response to questions. The patient's nasal septum is perforated. You perform a urine toxicology screen, and proceed to treat the patient for which condition while you await the results? 1 Hypnotic use 2 Sedative use 3 Polysubstance use 4 Cocaine use 5 Alcohol use

2 Night Terrors The clinical picture is typical of night terrors, a condition seen most commonly in preadolescent boys. It is characterized by an abrupt arousal from asleep with sweating, tachycardia, and confusion for a few minutes, and subsequent amnesia of the event. Nightmares also occur commonly in this age group, but are not associated with as terrifying an arousal as night terrors; furthermore, the child goes back to sleep with difficulty and remembers the dream the next day.

A 6-year-old boy is brought to the pediatrician by his parents with the complaint of recurrent nightmares. The parents report that for the past week the child has been waking up about 2 hours after being put to bed, screaming and unresponsive to all efforts by the parents to calm the child. Within a few minutes, the child falls back asleep and the next morning does not recall any scary dreams or even waking up the previous night. What is the most likely diagnosis? 1 Nightmares 2 Night Terrors 3 Child abuse 4 Munchausen syndrome 5 Insomnia

2 Sedative abuse Sedative abuse is characterized by either episodic or chronic use of sedating drugs to reduce excitement and induce quiet without the drowsiness of other central nervous system depressants. Examples of the abusive use of sedatives include using the drug despite adverse effects, in situations where it is physically hazardous to do so or to experience its side effects rather than its therapeutic effects. In this case, the patient admits to using propranolol, a sedative, as a means of tempering the effects of a drug-induced high. This meets the criteria for using the drug to exploit its side effect profile. Sedatives are commonly abused in this way.

A 65-year-old man is seen in your office for the first time. He is a Vietnam veteran, and since returning from the war, he has experienced persistent anger, vigilance, and startled responses, which have effectively immobilized him for the better part of the past 10 years. He saw a psychiatrist once, who prescribed propranolol 160mg/day for these symptoms of post-traumatic stress disorder. He saw the psychiatrist for a while and, feeling that he was not getting relief, he stopped attending sessions. He refilled his prescriptions and then continued getting renewals from another doctor. The patient does not take the pills as they were prescribed: his usual way of using the propranolol is to come down from a drug-induced high. In addition to your concern about this patient's use of drugs to get high, what other problem is most worthy of further exploration? 1 Hypnotic abuse 2 Sedative abuse 3 Polysubstance abuse 4 Alcohol intoxication 5 Alcohol abuse

4 Attention deficit hyperactivity disorder Those with oppositional defiant disorder, conduct disorder, unspecified attention-deficit/ hyperactive disorder, and antisocial personality disorder act out behaviorally. They refuse to comply with rules and they refuse to do their school work due to an unwillingness to conform to others' demands and a disregard for social norms. Children with ADHD, on the other hand, often exhibit these behaviors due to poor attention skills and lack of impulse control.

A 9-year-old boy is referred for an assessment at the request of his school. His teacher's report states that he often speaks out of turn during class, fidgets in his seat, and gets up out of his chair during class and begins walking around the classroom. He has become so disruptive that he often spends most of his day in the principal's office. The principal states that he is often very helpful to him during the day and volunteers to help him file papers or clean up around the office. On the playground, he frequently argues with his classmates, and he refuses to wait his turn when playing games. The child's mother states that when they have guests over or when she is talking to others, the boy will try to climb in her lap and have a conversation with her. She worries about his behavior because he will climb up on the bookshelves or on top of the house, and she worries that he will hurt himself. He frequently argues with his siblings, and he will often walk into their rooms and take their stuff without asking. During the assessment, the boy is very cooperative. He answers all of your questions. He appears to work hard on the assessment tests, but he frequently gets up during the tests and walks around your office. What is the most likely diagnosis? 1 Oppositional defiant disorder 2 Conduct disorder 3 Unspecified attention-deficit/ hyperactive disorder 4 Attention deficit hyperactivity disorder 5 Antisocial personality disorder

2 Separation anxiety disorder Separation anxiety disorder is usually found in infancy, childhood, or adolescence and has an essential feature of excessive anxiety related to separation from the home or someone who the child is attached to. The disturbance is more than what is normally expected for the child's age, and itis present for at least 4 weeks, begins before age 18, and causes significant impairment in social, academic, occupational, or other important areas. Somatic problems may accompany the disorder and frequent nightmares involving danger to the family.

A bright young 6-year-old boy is often found sleeping outside his parents' bedroom door in the morning. The parents state that on several occasions over the past few months, he has refused to go to school, citing vague abdominal problems. His medical evaluations have failed to reveal any abnormalities, and he is growing and developing normally. The parents feel they provide their child a loving and close-knit family environment. They are distraught, do not understand what is wrong, and come to you for a consult. What is the most likely diagnosis? 1 Pervasive developmental disorder not otherwise specified 2 Separation anxiety disorder 3 Panic disorder 4 General anxiety disorder 5 Reactive attachment disorder

1 Mescaline This patient's presentation is most consistent with intoxication from a hallucinogen, such as LSD or mescaline. The psychological symptoms of marked perceptual distortions, illusions and hallucinations, derealization and depersonalization are all consistent with these agents. She describes a synesthesia, (when the sounds became colors), the phenomenon of a stimulus in one sense producing sensations in another. Patients intoxicated with these substances usually have insight that their symptoms are due to the drugs they have taken. This is in contrast to patients experiencing amphetamine psychosis. Physical exam signs of LSD or mescaline intoxication include tachycardia, palpitations, sweating, tremor, hyperreflexia, and dilation of the pupils. Patients experience the above psychological symptoms but usually maintain a clear sensorium. Although these substances usually induce a feeling of euphoria, occasionally, LSD or mescaline intoxication can cause symptoms of severe depression or anxiety, a "bad trip." Additionally these substances can cause "flashback" symptoms, brief hallucinations, weeks to years after the drug use. These flashbacks can occur despite cessation of the drug, and occur more commonly in patients who use marijuana.

A parent brings her 16-year-old daughter to the emergency room, after coming home from work early and discovering her daughter "on drugs." While her mother is in the examination room, the patient denies taking any drugs, but admits that she did take "something my friend gave me," when examined alone. She reports that she has taken this substance every few weeks for at least the past year, saying she just does it for "fun" with her friends. She says that today she took the substance by mouth approximately 2 hours prior to presentation. She describes seeing hallucinations of geometric shapes and the appearance of objects changing shapes before her eyes. She also describes "seeing" music becoming the colors red and blue shortly after taking the illicit substance. Physical exam reveals dilated pupils and tachycardia. What is the most likely drug involved in this patient's intoxication? 1 Mescaline 2 Alcohol 3 Opium 4 Diazepam 5 Methaqualone

B. Heroin

A patient has piloerection, abdominal pain, nausea, yawning. What drug withdrawal is this consistent with? A. Cannabis B. Heroin C. Alcohol D. MDMA

2 Cocaine-related disorder Substance-related disorders can be caused by drugs of abuse (e.g., alcohol, cocaine, inhalants), environmental toxins (e.g., heavy metals, pesticides, "huffing" gasoline fumes), or by the side effects of prescribed medications used legally or illicitly (e.g., amphetamines). Exposure to these substances may cause dependence and/or intoxication. Benzoylecgonine is a major metabolite of cocaine.

A patient undergoes tests that conclude that she has benzoylecgonine in her urine. An examination suggests she is in a substance-induced state. From what type of disorder is she most likely suffering? 1 Amphetamine-related disorder 2 Cocaine-related disorder 3 Hallucinogen-related disorder 4 Inhalant-related disorder 5 Opioid-related disorder

A.Complex sleep behaviors

A patient uses zolpidem for sleep. His wife has observed him getting up to eat and tries to initiate sex with her, but he seems strange and then goes back to sleep. This would be classified as which of the following? A.Complex sleep behaviors B.Non-REM Sleep Arousal Disorder C.Nightmare disorder D.REM Sleep Behavior Disorder

2 Using laxatives to lose calories This patient's two most likely diagnoses are binge-eating disorder and bulimia nervosa. The core features of bulimia are binge eating, inappropriate behavior to avoid weight gain, and excessive worry about body image. Using laxatives to lose calories is an example of inappropriate behavior to lose weight (along with vomiting, diuretic use, and excess exercise). Eating to soothe mental anguish, eating to the point of discomfort, feeling that she cannot control her eating behavior, and eating fast during binge episodes are common to bulimia nervosa and binge-eating disorder.

A slightly overweight 15-year-old girl presents for evaluation because of concerns about an eating disorder. Her family recently moved, and she feels overwhelmed and stressed adapting to a new school environment. She misses her old friends and feels she has difficulty making new friends because she is overweight. According to her parents, she continues to consume large amounts of food even though her weight is not changing. What additional finding would best distinguish between this patient's two most likely diagnoses? 1 Eating to soothe mental anguish 2 Using laxatives to lose calories 3 Eating to the point of discomfort 4 Feeling unable to control her eating behavior 5 Eating fast during binge episodes

2 Sedative abuse Sedative abuse is characterized by either episodic or chronic use of drugs such as diazepam, which reduce excitement and induce quiet without the drowsiness of other central nervous system depressants. Examples of the abusive use of sedatives include using the drug despite adverse effects in situations where it is physically hazardous to do so or to experience its side effects rather than its therapeutic effects. In this case, the patient admits to using diazepam as a means of tempering the effects of amphetamines. This meets the criteria for using the drug to exploit its side effect profile. It is also possible that using amphetamines and diazepam regularly could put her baby in danger, which would also be consistent with sedative abuse. It is common to abuse sedatives in combination with other drugs.

A woman in her early 30's is seen in your office for the first time. She gave birth to a healthy male infant 8 months ago, and since that time she has experienced excessive anxiety that she relates to being a new mother. More recently, her mood has been quite low and her husband has expressed concern that she is depressed. The patient says that her son is very active and, as a means of keeping up, she started using diet pills. They boost her energy as she had hoped they would, but she also finds that once she is energized she often has to bring herself down so that she may relax in preparation for a good night's sleep. To do this, the patient says that she routinely takes diazepam, 20 mg. The patient admits that she abuses amphetamines and that she needs to find other ways to cope with the demands of being a mother. The history and physical reveals no other remarkable information. In addition to the likelihood of amphetamine abuse, what is the patient exhibiting signs of? 1 Opioid abuse 2 Sedative abuse 3 Polysubstance abuse 4 Alcohol intoxication 5 Alcohol abuse

2 Amphetamine abuse Amphetamine abuse, particularly abuse that leads to a psychotic episode, is often indistinguishable from other disorders, such as paranoid schizophrenia. The difference here, however, is this patient's depression. Often after using a significant amount of amphetamines, a patient will "crash" into a depression that can last some weeks, if untreated. The depression is characterized by excessive sleeping, fatigue, apathy, and flattening of affect that is far more than in the usual depression.

A woman in her mid 30's is seen in your office for the first time. She was court-ordered into treatment due to a recent arrest. The patient says that about a month ago she was out getting high one night and "things got out of control". According to the police report, the patient was found high in a tree, naked. She was disoriented, hyperalert, hostile, and aggressive towards the police officers. She was extremely talkative and she complained of severe abdominal pain. The medical examination that followed revealed malnutrition, hypertension, pupillary dilation, tremulousness, tachycardia, repetitious compulsive behavior, and hepatitis C. The patient tells you that she remembers visual and auditory hallucinations, particularly voices that criticized her behavior, and that following the episode she slept for 18-20 hours per day for about 3 days. Significant depression has ensued since. The patient admits that she used an illicit drug and that it led to this episode; however, out of shame, she is initially unwilling to tell you what drug she used. What is the most likely diagnosis? 1 Hypnotic abuse 2 Amphetamine abuse 3 Polysubstance abuse 4 Cocaine abuse 5 Alcohol abuse

6 Body mass index 15kg/m2 The indications for hospitalizations of children and adolescents with anorexia nervosa include heart rate of <30 bpm or <40 bpm with hypotension, orthostatic blood pressure resulting in increase in heart rate of >20 bpm or resulting in drop in systolic blood pressure of > 20 mm Hg or diastolic pressure of >10 mm Hg, hypothermia <35°C, cardiac dysrhythmia, BMI <16 kg/m2, marked dehydration or lack of improvement or worsening despite outpatient treatment.

An 18-year-old girl is brought to your office by her mother with a 2-week history of epigastric discomfort. She tells you that her stomach hurts whenever she eats something, describing it as a burning sensation associated with nausea. Her mother is very concerned because her daughter has lost almost 12kg during the past 3 months. Her weight is 45kg; height is 1.7m and her current body mass index is 15.5. On detailed questioning, she tells you that she is trying to control her weight and she is conscious about her body image. In the morning she runs almost 5 miles and she joined the gym 4 months ago where she exercises almost 2 hours daily. Her diet is very restricted and she drinks 3 cups of coffee and 2 cans of diet cola per day. She has 3-4 bowel movements daily, using laxatives to control her body weight and diuretics to increase her performance in college sports. Her last menstrual period was 4 months ago. She feels cold most of the time. Her past medical history is unremarkable except for acne, for which she is using benzoyl peroxide. She denies any suicidal ideation. She occasionally drinks alcohol but denies smoking. Physical examination reveals a thin girl lying comfortably and in no distress. Temperature - 37.0°C, heart rate 55, blood pressure 90/50, respiratory rate 16. Orthostatic blood pressure results in an increase in heart rate of 15 bpm and in a drop in blood pressure of 5 mm Hg. Body mass index 15 kg/m2. HEENT exam reveals PERRLA with normal oral mucosa; neck is supple without masses or adenopathy. Skin is dry and there are scars on the dorsum of the hands. Cardiac examination reveals mid-systolic click with late diastolic murmur. The S1 and S2 are normal. Chest is clear to auscultation bilaterally. Abdomen is soft and nontender and gut sounds are normal. The patient's cranial nerves II through XII are intact and muscle strength and cutaneous sensation are normal. Deep tendon reflexes are normal. What is an indication for hospitalization of this patient? 1 Heart rate of 55 2 Potassium level of 3.6mmol/dl 3 Blood pressure of 90/50mm Hg 4 Orthostatic blood pressure resulting in increase in heart rate of 15bpm 5 Orthostatic blood pressure resulting in drop in blood pressure of 5 mm Hg 6 Body mass index 15kg/m2

3 Initiate stimulant medication. This patient presents with attention deficit hyperactivity disorder (ADHD). Patients with ADHD have inattentive, hyperactive, and impulsive behaviors. To meet the criteria for ADHD, some symptoms must have been present by age 7. The first-line treatment for ADHD is to initiate stimulant medication. These medications come in short- and long-acting formulations, and they have shown the best efficacy for ADHD.

An 8-year-old boy presents for evaluation of problems at school and at home. His parents report that he does not pay attention in class, he is frequently in trouble for being disruptive, and he often forgets to do his schoolwork. He has had similar problems since starting school (in kindergarten), but they are worsening. The teacher reports the patient often seems distracted. He rarely sits still at his desk, fidgets often, and blurts out comments without waiting his turn. Physical examination is remarkable for increased motor activity but is otherwise normal. What is the best intervention for this patient's condition? 1 Eliminate refined sugars from diet. 2 Initiate short-acting benzodiazepines. 3 Initiate stimulant medication. 4 Order electroencephalogram. 5 Refer for biofeedback.

2 Conduct disorder Conduct disorder may develop as early as age 5-6 and is seen more frequently in physically strong males. Symptoms frequently include aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules. Diagnosis requires the presence of at least 3 of 15 specific criteria in the past 12 months, with at least one criterion present in the past 6 months. The disorder may continue to increase in seriousness until the adult years, which is when crimes of burglary and sexual misconduct start to be seen. The diagnosis may then become antisocial personality disorder.

An active 10-year-old boy stays out late at night and has a history of running away from home and skipping school. When he attends school, he bullies other children and seems to enjoy getting into fights. He previously attacked another student with a brick and destroyed library books for fun. He is imaginative and often has a good cover story for where he has been when something has been stolen or is broken. A favorite weekend activity for the past 6 months has been shoplifting. What is the most likely diagnosis? 1 Oppositional defiant disorder 2 Conduct disorder 3 Antisocial personality disorder 4 Unspecified disruptive, impulse control, and conduct disorder 5 Unspecified ADHD

D. Overt behavior; unconscious conflicts

Behavior therapy is to ___________ as psychoanalysis is to ___________? A. Unconscious thoughts; current thoughts and feelings B. Current thoughts and feelings; overt behavior C. Unconscious conflicts; overt behavior D. Overt behavior; unconscious conflicts

4 Aggression to animals Aggression to animals (and/or people) is one criterion necessary to give a diagnosis of conduct disorder over a diagnosis of oppositional defiant disorder. Destruction of property, theft, and deceit are other criteria.

Conduct disorder would be a better diagnosis than oppositional defiant disorder when what trait is present? 1 Hostile behavior towards adults 2 Drug use 3 Onset before age 15 4 Aggression to animals 5 Intrusion on others

C.1 AM

For the last 2 weeks, a patient goes to bed at 10 PM. S/he regularly wakes up at 12:30 AM and does not get back to sleep until 4:00 AM. S/he then sleeps until 6 AM, when s/he has to wake up to go to work. What time should they go to bed for the next week as part of sleep restriction therapy? A.11 PM B.12:30 AM C.1 AM D.2:30 AM

3 4 As measured by a polysomnograph, normal sleep can be divided into four stages of NREM (non-REM) and REM (rapid eye movement) sleep. REM sleep is where dreams occur. Stage 1 sleep is where a person transitions from wakefulness to sleep. Stage 2 is where sleep spindles and K complexes (EEG waveforms) occur. Stages 3 and 4 are the deepest levels of sleep, with stage 4 including REM sleep.

Normal sleep is characterized by how many distinct sleep stages? 1 2 2 3 3 4 4 5

1 Posttraumatic Stress Disorder For a diagnosis of Posttraumatic Stress Disorder (PTSD) to be made, a person must have experienced, witnessed, or been confronted with an event involving actual or potential death or serious injury; the person must have also experienced feelings of intense fear, helplessness, or horror. Additionally, the person must have experienced at least 1 of the following criteria: recurrent and intrusive recollections of the event, dreams, a sense of reliving the event, psychological distress when exposed to cues related to the event, and/or a physiological response to these cues. There must be a persistent avoidance of stimuli and numbing of responses, duration of more than 1 month, and a clinically significant impairment in social, occupational, or other areas of the person's life. Acute stress disorder presents with the same signs and symptoms as PTSD, however the duration of these signs and symptoms is the only differing factor between these two related disorders. Symptoms for acute stress disorder must last for at least three days in duration up to one month but resolve after one month. If symptoms persist beyond this timeframe then a diagnoses of PTSD can be made.

Numerous psychological problems are caused by persistent, recurring experiences of intrusive thoughts related to a traumatic event in which a patient is involved or witnesses serious injury, death, or physical threat(s) to themselves or others. The problems include intense fear, helplessness or horror, physiological reaction to cues that symbolize the event, avoidance, diminished interest in significant activities, a feeling of detachment, restricted range of affect, and a feeling of a foreshortened future. These problems last for at least one month in duration. These are features of what condition? 1 Posttraumatic Stress Disorder 2 Generalized Anxiety Disorder 3 Acute Stress Disorder 4 Substance-Induced Anxiety Disorder 5 Anxiety Disorder NOS

4 Delta waves Stage 1- lightest sleep, a transition stage; low voltage, desynchronized theta waves. Stage 2- sleep spindles, (13-15 cps) and high spikes (K complexes). Stage 3- some delta waves (high voltage at 0.5-2.5 cps). Stage 4- deepest sleep, mostly in first half of night; mostly delta waves.

The deepest of the sleep stages is Stage 4 and is characterized by which EEG wave pattern? 1 Alpha waves 2 K complexes 3 Sleep spindles 4 Delta waves 5 Desynchronized waves

D.Marked distress over minor changes in environment or schedule

The mother of a 6-year-old boy consults you regarding a recommendation from her son's teacher that he be evaluated for attention deficit hyperactivity disorder (ADHD). Which of the following characteristics is NOT included in the criteria for diagnosing ADHD in children? A.Inability to remain seated in the classroom B.Difficulty following instructions or completing tasks C.Intrusiveness and frequent interruptions into conversations or activities of others D.Marked distress over minor changes in environment or schedule E.Impulsively engaging in physically dangerous activities

2 THC

The psychoactive substance found in cannabis is 1 d-lysergic acid diethylamide 2 THC 3 Opium 4 XTC 5 Methadone

4 Cocaine intoxication The clinical picture is suggestive of cocaine intoxication. Presenting symptoms of cocaine intoxication can include hypertension, tachycardia, diaphoresis, anxiety, dilated pupils, agitation, nasal congestion, and psychosis. A narcotic overdose may present with symptoms of miotic pupils and decreased pulse and blood pressure. Acute anxiety, a schizophrenia, and bipolar disorder are all psychiatric disorders. They would not cause changes such as pupillary dilatations or nasal congestion.

The sister of a 20-year-old man is concerned because her brother has not been himself lately; his mood has been alternating from happy and euphoric to irritable and depressed. The man states that he is adjusting to his new life at college, which has so far been stressful. He states that he does not smoke, does not do recreational drugs, and only drinks socially at parties. Physical examination reveals marked nasal congestion, dilated pupils, heart rate of 120 beats/min, and a blood pressure of 155/92 mm Hg. What is the best diagnosis? 1 Narcotic overdose 2 Acute anxiety 3 Schizophrenia 4 Cocaine intoxication 5 Bipolar disorder

C. Methamphetamine

What drug use is this consistent with? A. Cocaine B. Caffeine C. Methamphetamine D. Heroin

3 90 minutes A normal REM latency is 90 minutes after initiation of NREM sleep. Shortened REM latency periods occur with major depression and narcolepsy.

What is a normal Rapid Eye Movement (REM) latency? 1 2 minutes 2 20 minutes 3 90 minutes 4 3 hours 5 6 hours

3 5 years old Enuresis, the repeated voiding of urine into the bed or clothes, must occur at least twice a week for at least 3 consecutive months, in a child at least 5 years old (or of an equivalent developmental level).

What is the age cutoff for the diagnosis of Enuresis? 1 3 years old 2 4 years old 3 5 years old 4 6 years old 5 7 years old

C.Hallucinogens - Lysergic acid diethylamide (LSD) Psilocybin (found in hallucinogenic mushrooms) Peyote Marijuana MDMA (Ecstasy) Diphenhydramine (Benadryl) Dextromethorphan (DM in cough syrup)

Which of the following drugs can cause hallucinogen persisting perception disorder? A.Alcohol B.Benzodiazepines C.Hallucinogens D.Opioids

C.Hypnotics - also alcohol, opioids, sedatives, anxiolytics

Which of the following drugs can have the most severe withdrawal symptoms? A.Inhalants B.Hallucinogens C.Hypnotics D.Stimulants

2 Anorexia Nervosa

Which of the following is an eating disorder in which the patient is on a self-starvation diet? 1 Bulimia Nervosa 2 Anorexia Nervosa 3 Obesity 4 Hyperphagia 5 Pica

A.Alcohol

Which of the following is most associated with poor sleep? A.Alcohol B.Antibiotics C.Benzodiazepines D.Antihistamines

B. Disulfiram (Antabuse)

Which of the following medications will produce uncomfortable symptoms if a patient drinks alcohol? A.Acamprosate (Campral) B.Disulfiram (Antabuse) C.Naltrexone (Vivitrol) D.Pregabalin (Lyrica)

A. Bruxism Euphoria, bruxism, altered sense of time, heightened senses, affectionate, impaired judgement, persisting perception disorder, rhabdomyolysis, and serotonin syndrome

Which of the following symptoms is a cardinal sign of MDMA use? A.Bruxism B.Hypothermia C.Increased appetite D.Rapid Speech

B.CBT for insomnia Z medications work faster

Which of the following treatments has been found to be most effective for insomnia? A.Aerobic exercise before sleep B.CBT for insomnia C.SSRIs D."Z" medications

A.Amphetamines

While home for Christmas vacation, a 20-year-old college student sees you for his annual physical exam. Since arriving home, he reports noticing depression, fatigue, irritability, anxiety, trouble concentrating and increased appetite. He is most likely withdrawing from: A.Amphetamines B.Benzodiazepines C.Cocaine D.Marijuana

1 Oppositional defiant disorder Oppositional defiant disorder can be differentiated from conduct disorder and antisocial personality disorder by the severity of the symptoms. Those with oppositional defiant disorder do not display the assaultive and criminal behavior, or violation of age-appropriate societal norms. Further, in order to be diagnosed with antisocial personality disorder, a person has to be at least 18 years of age.

You have been working with a 13-year-old girl. Her school referred her to you. The referral paperwork stated that she refuses to follow the rules at school and frequently talks back to her teachers. In conversations with her mother, the mother states that she refuses to help out with chores around the house and comes and goes as she pleases. Her mother states the child often starts yelling at her when asked to do simple chores around the house. When asked how long this behavior has been occurring, the mother stated she has been like this for at least one year. She has no reported history of arrests, drug use, or violent behavior. She currently denies any depression or suicidal behavior. During the interview, she is uncooperative and often sarcastic. What is the most likely DSM-5 diagnosis for this client? 1 Oppositional defiant disorder 2 Conduct disorder 3 Antisocial personality disorder 4 Other specified and unspecified disruptive disorder 5 Attention deficit hyperactivity disorder