Psych/behavioral RR

Social or legal problems that result from substance use are defined by which of the following terms?

Abuse

What disorder is characterized by emotional or behavioral responses that develop within 3 months of a stressful event, in excess of what would be expected given the nature of the event, and not including the loss of a loved one?

Adjustment disorder Adjustment disorders comprise a category of emotional or behavioral responses to a stressful event that develop within 3 months after the onset of a stressor, and the patient's reaction must be in excess of what would be expected given the nature of the event. The pathophysiology of adjustment disorders is unknown, but investigators have observed neurochemical changes in patients with these disorders. Adjustment disorders are subtyped according to whether the predominant symptoms are depressed mood, anxiety, or a disturbance of conduct. The symptoms are described as acute if they persist for less than 6 months, and as chronic if they last longer than 6 months. By definition, however, the symptoms cannot persist for more than 6 months after the termination of the stressor. Therefore, the designation of chronic adjustment disorder is given when the stressor itself (e.g., living in a dangerous neighborhood) is ongoing. Though the course of an adjustment disorder is usually brief, the symptoms can be severe and may include suicidal ideation.

A 14-year-old boy has been described by others as the "school bully." For the past 16 months he stole money from his parents, got into fights at school almost daily, failed to turn in most of his homework, and destroyed multiple items both at home and school. During parent-principal meetings the young boy denies having remorse for his actions and considers himself just a "normal" 14-year-old. Which of the following disorders is this individual suffering from?

Conduct disorder Conduct disorder criteria involves symptoms from 3 of 4 categories that include aggression to people and animals, destruction of property, deceitfulness or theft, serious violation of the rules. Symptoms must persist for over 12 months with at least 1 criterion for the past 6 months. They must also be under the age of 18.

A 56-year-old widow comes to the physician at the request of her daughter. The patient's husband passed away unexpectedly 14 months ago from a heart attack. She tells you that she has been having a very difficult time since her husband's death. She hasn't been sleeping well because she can't get used to sleeping alone. She no longer enjoys going over to her daughter's house and finds interacting with her grandchildren too tiresome. She says she keeps thinking about the day her husband died and feels guilty about not being able to get him to the hospital sooner. She denies any plans to hurt herself, but does say she wonders if she'd be better off if she could join her husband. Which of the following diagnoses is most appropriate?

Persistent complex bereavement disorder Intense symptoms of depression and guilt that persist beyond 12 months following the death of a loved one is indicative of persistent complex bereavement disorder. Not only do symptoms persist beyond 12 months, but they are generally severe in nature and interfere with daily functioning. According to the DSM V, persistent complex bereavement disorder, also called complicated grief disorder, has overlapping symptoms with major depressive disorder and posttraumatic stress disorder (PTSD), but is currently considered an independent condition.

A 21-year-old man runs a successful business as a methamphetamine cook. He frequently uses his own product. Recently, he has not been able to fill his typical orders due to being "high" all the time. Which of the following would best describe his substance use?

Abuse The substance use disorders include substance tolerance, dependence and abuse. Substance abuse is defined as a maladaptive pattern of recurrent substance use leading to clinically significant impairment or distress. This can manifest as failure to fulfill work (as in the above patient), school or home obligations, increased incidence of physically hazardous situations (driving while intoxicated), recurrent substance-related legal problems or recurrent social or interpersonal problems (fights, arguments).

A 55-year-old man presents with a chief complaint of "feeling low". He has been tearful and depressed since he lost his job four months ago. He has been unable to find a new job. The patient is frustrated and admits to driving recklessly. What is the most likely diagnosis?

Adjustment disorder Adjustment disorder consists of maladaptive behavioral or emotional symptoms. These follow a stressful life event and occur within three months and end within six months. The stress is not due to bereavement. In adults, divorce, loss of employment, and new parenthood are common stressors. In children, school problems, moving homes, and parental divorce may be precipitators. Emotional symptoms may include depressed mood and anxiety. Behavioral symptoms may include truancy, vandalism, reckless driving or fighting. In all cases, the reaction is out of proportion to the event and causes the patient impairment of normal functioning. Treatment is usually supportive, including psychotherapy or group therapy. Pharmaceutical treatment is not first-line treatment, but may be initiated for excessive insomnia, anxiety or depression.

A 17-year-old boy is brought to the emergency department by his friends. They were at a house party and found their friend unconscious after he ingested an unknown substance. On physical exam, vital signs are temp 96°F, heart rate 50, respiratory rate of 4, and oxygen saturation 92% on room air. The boy's pupils are miotic. On lung auscultation, there are crackles bilaterally. You administer supplemental oxygen. Which of the following is the most appropriate clinical intervention?

Administer intravenous naloxone Intravenous naloxone is an appropriate first step in managing a patient with acute heroin (opiate) overdose. Heroin is an addictive opiate that can be injected intravenously or subcutaneously, or can be snorted. It has a rapid onset of action, and easily crosses the blood brain barrier, producing euphoria. Other effects of the drug include decreased pain sensation, diminished level of consciousness, flushed skin, constipation, and pinpoint pupils. In an overdose, patients will exhibit hypothermia and respiratory depression, which can lead to coma and death. The withdrawal symptoms are reversed, including dilated pupils, restlessness, lacrimation, rhinorrhea, diarrhea, and sweating, as well as tachycardia and hypertension. Diagnosis of heroin intoxication is clinical and typically follows the opiate toxidrome of miosis, CNS depression, and hypoventilation. Naloxone is an opiate antagonist that will reverse respiratory depression and other effects caused by opiates. Other medications such as methadone and buprenorphine can assist with detoxification.

A 49-year-old man presents to the Emergency Department complaining of sweating and tremors. The patient drinks a bottle of liquor per day and stopped suddenly because of a pending court case. His last alcoholic drink was 3 days ago. On physical examination, his blood pressure is 168/105 mm Hg, pulse rate is 106/minute, respirations are 22/minute, and temperature is 99.3°F. The patient appears agitated and restless with a visible tremor of bilateral hands. The triage team ordered folic acid, thiamine, and a multivitamin. Which of the following is the most appropriate disposition?

Admit the patient and start diazepam Admit the patient and start diazepam is the correct disposition because this patient is suffering from alcohol withdrawal, which potentially can be fatal. Withdrawal symptoms occur when a patient has alcohol use disorder and has developed a tolerance to alcohol, where an increased amount of alcohol is needed to achieve the desired effect. When tolerance has developed, cessation leads to withdrawal. Early symptoms of alcohol withdrawal include anxiety, irritability, headache, tremor, tachycardia, hypertension, hyperthermia, and hyperactive reflexes. Seizures (usually grand mal) can develop between 12-24 hours after withdrawal starts. After 24-72 hours, life-threatening delirium tremens may occur, which manifests with signs of altered mental status, hallucinations and marked autonomic instability. Treatment of alcohol withdrawal involves giving a benzodiazepine (e.g. diazepam) until symptoms lessen and then tapering the dosage over days to weeks. Thiamine, folic acid, and vitamin B12 are also administered and any electrolyte abnormalities are corrected (typically low potassium and magnesium). Following withdrawal, the patient should be referred to support groups. Long term medication used to deter use of alcohol include naltrexone, disulfiram, and acamprosate.

You finish taking a history of a patient at risk for suicide. Which of the following would suggest the highest likelihood of committing suicide?

Age over 85 yo Suicide is the tenth most common cause of death in the US, and is in the top 3 most common causes of death in adolescents and young adults. It is more common in non-Hispanic White and American Indian men between the ages of 45-59 years. The greatest suicide rate is in elderly white males over 85 years old (A). Frequently, the primary care provider needs to assess the risk of suicide. Activities associated with committing suicide include buying a rope or firearm, filling out a will, contacting old friends and writing a suicide note. Common characteristics of those who commit suicide include a sense of violation, a preoccupation with death, a lack of humor, distractibility, few friends or family members, hopelessness and an inability to help themselves or a sense that there is nothing to help their condition. When evaluating for suicide risk, identify any of the above characteristics. Also, determine if suicidal ideation (thoughts of hurting oneself) is present, and if so, determine if a suicide plan is in place. The more detailed the plan, the higher likelihood of suicide. Also, determining the purpose of suicide can help to gauge the seriousness of the action. Any question of suicide must be coupled to an inquiry into the possibility of homicide, as both situations represent aggression. If there is a tendency toward aggression towards others (homicide), the likelihood of aggression toward oneself (suicide) is high. Furthermore, the presence of any of the following supports an actual committal of suicide: definite plan, activities one does before dying (saying goodbye to friends), family history of suicide, possession of a firearm, current substance use, depression of any type, anxiety of any type, command hallucinations, recent discharge from a psychiatric hospital, severe immediate loss such as an unexpected divorce, or isolation (patient is alone).

A 29-year-old woman presents to your office with a complaint of worsening anxiety. Which additional finding would suggest a diagnosis of generalized anxiety disorder rather than panic disorder?

Anxiety occurring more days than not for at least 6 mo Generalized anxiety disorder (GAD) is a common psychiatric disorder often seen in the primary care setting. It is characterized by excessive and persistent worrying that occurs more days than not for six or more months. Other clinical manifestations include insomnia, headaches, difficulty relaxing, and fatigue. The anxiety symptoms experienced with GAD are difficult to control and cause significant distress and impairment in activities of daily living. GAD is two times more common in women than in men and is the most common psychiatric disorder seen in the elderly. Diagnosis is determined using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Recommended treatment is with a combination of pharmacotherapy and psychotherapy.

A 3-year-old boy from South America presents to your office with his father for a well-child exam. While listening to his lungs you notice that his back is covered with circular lesions approximately 3-4 cm in diameter with central ecchymosis and petechiae. Which of the following is the next best step?

Ask about traditional medical practices being used A number of cultural practices can mimic signs of child abuse. Cupping is a technique used in Latin America, Asia, the Middle East and Eastern Europe. An open-mouthed vessel is heated and applied to the skin. Practitioners believe this will pull out the ailments and the result is lesions that appear like circular burns. Familiarity with cultural practices and medical conditions that can mimic child abuse can help to determine the correct diagnosis, start appropriate treatment and avoid unnecessary reports to child protective services.

A 74-year-old woman is brought to her primary care provider by her adult son. The son says she has been very difficult at home and is "losing it." He seems very frustrated about her diminishing ability to take care of herself the way she used to and no longer thinks he can trust her watching his children. At her last visit you noted mild cognitive impairment. Today, she appears withdrawn and hesitates to make eye contact with you. She lets her son do most of the talking. Which of the following is the most appropriate next step?

Ask son to step out so you can speak with the patient alone All patients, regardless of age, ought to be given a chance to speak with their physician alone. Elderly patients often visit the physician with a spouse, child, or other care-giver. It is important to preserve the relationship with both the patient and their loved one, while ensuring that the patient is the provider's priority. To strengthen the physician-patient relationship and to explore issues that may be sensitive, the physician should spend time with a patient in private. Recognizing mistreatment can often be difficult as older adults may be unable to provide information because of cognitive impairment. Abuse and neglect are most often discovered during routine visits at the physician's office and therefore the patient should be interviewed without the caregiver present.

What is true regarding anorexia nervosa?

Associated with a body image disturbance Eating disorders are the third leading chronic illness, after obesity and asthma in adolescent girls. An individual with anorexia nervosa refuses to maintain a minimally normal body weight, is fearful of gaining weight, and exhibits a distorted body self-image. The patient's body image is the predominant measure of self-worth, along with denial of the seriousness of the illness. The long-term mortality rate for anorexia nervosa is 6% to 20%, the highest rate for any psychiatric disorder. Anorexia is associated with amenorrhea, depression, fatigue, weakness, hair loss, bone pain, constipation, and abdominal pain. Signs include brittle hair and nails, dry, scaly skin, loss of subcutaneous fat, fine facial and body hair (lanugo), and breast and vaginal atrophy. A prime objective in assessment is to distinguish "normal dieters" from individuals with eating disorders. Another important aspect to evaluation is to exclude certain medical conditions such as inflammatory bowel disease, hyperthyroidism, chronic infection, diabetes mellitus, and Addison's disease. Indications for inpatient management include extremely low weight (<75% of expected body weight) or rapid weight loss; severe electrolyte imbalances, cardiac disturbances, or other acute medical disorders; severe or intractable purging; psychosis or a high risk of suicide; and symptoms refractory to outpatient treatment. A multidisciplinary team that includes a primary physician, mental health professional, and nutritionist should manage patients with eating disorders. Refeeding should occur in a monitored setting due to the risk of dysrhythmia.

Which of the following statements is true regarding teenage suicide?

Attempts are more common in girls than boys Suicide attempts are more common in girls than boys (approximately 3:1), whereas boys complete suicide at a rate 4 times that of girls and represent 79.4% of all suicides. Youth suicide is a major and preventable public health problem. It ranks as the 3rd and 4th leading causes of death among young people ages 15-24 year and 10-14 year, respectively. Suicide is very rare before puberty. Rates of completed suicide increase steadily across the teen years and into young adulthood, peaking in the early 20s. The male:female ratio for completed suicide rises with age from 3:1 in young children to approximately 4:1 in 15-24 year olds, and to greater than 6:1 among 20-24 yr olds. It is estimated that for every completed youth suicide, as many as 200 suicide attempts are made. Ingestion of medication is the most common method of attempted suicide.

A four-year-old boy is seen in your office for routine physical. His mother is concerned that he is not speaking like a normal four year old. On further evaluation, you notice he has poor eye contact and rapid hand movements, and he is preoccupied by repeatedly spinning the wheels on the toy cars he brought with him. What is the most likely diagnosis?

Autism spectrum disorder Autistic disorder is a clinical diagnosis. The core features include impaired social interactions, communication, and behavior. Early social skills deficits include poor eye contact, lack of interactive play, and lack of interest in other children. Children can range from being nonverbal to having impaired speech. Their speech may have odd intonation and be characterized by echolalia. Language delay becomes a concern when there is lack of babbling or gestures by 12 months, lack of single words by 16 months, absent two-word phrases by 24 months, and any loss of language skills at any time. Children with autism often have abnormal play skills. They have a preoccupation with parts of objects like the child in this vignette. These children are withdrawn and can spend hours playing alone. Intellectual skills can vary, and some children may show normal or even accelerated development in certain areas.

A 29-year-old woman presents to the psychiatric clinic for a "lifetime" of intense anxiety not relieved by 12-weeks on fluoxetine. She reports low self-esteem, feeling "very uneasy" in social situations, and says she wishes she could make friends but worries that she'll say something "dumb" to people. Which of the following personality disorders does she most likely have?

Avoidant personality disorder Avoidant personality disorder is characterized by this patient's symptoms of low self-esteem and desire for relationships which remains fruitless due to persistent fear of rejection. Other symptoms of avoidant personality disorder include a hypersensitivity to criticism and failure, often making patients unable to hold jobs and maintain relationships. Personality disorders in general are present in patients from the time of their childhood, and may have resulted in development of recurrent maladaptive behaviors to cope with impaired personality traits. When maladaptive coping skills eventually prove unable to allow the patient to navigate their responsibilities and relationships successfully, anxiety and depression often present. Without proper management, psychosis may even develop. The cornerstone of treatment for personality disorders includes regular behavior therapy to extinguish inappropriate behaviors, and allow patients to recognize appropriate behaviors. Group psychological counseling is often helpful. Medical therapy is targeted at symptoms and can include antipsychotics, anxiolytics, and selective serotonin reuptake inhibitors.

You suspect bipolar I disorder or major depression in a 17-year-old student. Which of the following tools is most appropriate in confirming one of these diagnoses?

Beck depression inventory for primary care When staff-assisted depression care is available, screening for depression and bipolar disorders is recommended for patients 12 to 18 years of age. Appropriate screening tools include the age-appropriate Patient Health Questionnaire or the primary care version of the Beck Depression Inventory. The Beck Depression Inventory for Primary Care is adapted from the Beck Depression Inventory, a 21-question multiple-choice self-report inventory and one of the most widely used instruments for measuring the severity of depression. The questionnaire is designed for individuals aged 13 and over, and is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex.

A seven-year-old girl presents with a caregiver for concerns about having episodes of seizures and low blood sugar. The child has no documented medical problems and reportedly takes no medications. The child does not speak, appears frail, and is held closely by the caregiver throughout the visit. The caregiver presses you to admit the child to the hospital for an extensive workup. Which of the following is the most common caregiver population in which this disorder is diagnosed?

Biological mothers This caregiver is exhibiting behavior consistent with factitious disorder imposed on another. Factitious disorder imposed on another is characterized by the production or feigning of physical or psychological symptoms in another person, usually a child but may also be an adult under the care of the person with the disorder. Common presentations of this disorder include bleeding, seizures, poisoning, apnea, altered mental status, diarrhea, vomiting, fever, rash, hypoglycemia, hematuria, or recurrent infections often with unusual organisms. Warning signs that raise the possibility of this disorder include unexplained, persistent, or recurrent illnesses, discrepancies among the history, clinical findings, and patient's general health, symptoms and signs that occur only in the caregiver's presence, a caregiver who is extremely attentive and always in the hospital, or a caregiver who appears less worried about the patient's illness than about the medical staff. Ninety-eight percent of perpetrators are biological mothers from all socioeconomic groups. Many have a background in health professions or social work. Depression, anxiety, and somatization are common in the perpetrator population and many have a history of an abusive experience in the past. During clinical assessment of the victim in a case of factitious disorder imposed on another, clinicians should have a high index of suspicion. The provider should document inconsistencies of the caregiver's story with the patient's condition, lack of objective diagnostic evidence, lack of witnessing any symptoms, caregiver's response to negative testing, and whether treatment is provided for objective reasons or to meet the caregiver's demands. Treatment of factitious disorder imposed on another involves treating the victim, the perpetrator, and the family. These patients should universally be admitted to the hospital when the diagnosis of factitious disorder imposed on another is suspected in order to observe the caregiver-patient interaction, closely observe the suspected perpetrator, and determine the temporal relation between the symptoms and the perpetrator's presence.

A patient with major depression spends $100,000 at a casino over the past week. He presents with his wife, who states they now are in severe debt and cannot make any more mortgage payments. She also reports that over the past week her husband talked all the time and never slept more than 3 hours at a time. Which of the following is the most likely diagnosis?

Bipolar I Bipolar disorder is characterized by manic or hypomanic behaviors that are sometimes accompanied by a depressive disorder. Onset is usually in late childhood and early adolescence, and there is no sex or race predilection. Bipolar type I is defined as at least 1 manic episode with or without major depression. Bipolar type II is defined as at least 1 hypomanic episode with a major depressive episode. A manic episode is defined as at least 1 week of at least 3 of the following findings that cause a marked occupational or social disturbance or an unequivocal uncharacteristic change in functioning or necessitates hospitalization: inflated self-esteem/grandiosity, decreased need for sleep, more talkative, flight of ideas/racing thoughts, distractibility, increased goal-directed activity or psychomotor agitation, excessive involvement in pleasurable activities that likely having poor repercussions. Patients with bipolar disorders have higher rates of general medical conditions and other mental health disorders. First-line treatment involves mood stabilizers with lithium, valproic acid, carbamazepine, lamotrigine, or atypical antipsychotics. Mood stabilizers treat at least one phase of bipolar disorder (mania or depression) without worsening the other phase. Antidepressants are not mood stabilizers and can precipitate mania. Behavioral therapy is also useful in the treatment of bipolar disorder. The symptoms of a manic episode of bipolar disorder are expressed in the mnemonic DIG FAST.

A 19-year-old man presents with his parents who state that their son has shown signs of impulsivity, pressured speech, racing thoughts, and a decreased need for sleep over the last three to four weeks that has caused him to miss school. What is the most likely diagnosis?

Bipolar disorder Bipolar disorder is a chronic mood disorder characterized by the presence of mania (bipolar I disorder) or hypomania and depression (bipolar II disorder). Manic episodes are distinct periods of abnormally and persistent moods that can be euphoric, expansive, or irritable. Manic patients often have greatly inflated self-esteem, confidence, decreased need for sleep, pressured speech, racing or crowded thoughts, distractibility, increased involvement in goal-directed activities (e.g., starting many projects but being unable to finish any), hypersexuality, and excessive involvement in pleasurable activities with a high potential for painful consequences. Despite mania being the defining characteristic of the disease, depressed moods tend to predominate, with bipolar I patients experiencing a 3:1 ratio of depression to mania over the course of the illness. Hypomania consists of manic episodes that do not lead to social or occupational dysfunction. Pharmacologic treatment for bipolar consists of mood stabilizers such as lithium, valproic acid, and carbamazepine. Bipolar is associated with a high rate of suicide (up to 15%) and several comorbidities such as substance abuse and anxiety disorders.

A 23-year-old man presents with leg pain for three months and requests hydromorphone for pain. The nurse approaches you because she believes the patient is "drug seeking" as he became extremely upset when she told him that he would have to wait for the doctor to evaluate him before pain medications could be given. Upon entering the room, the patient speaks pleasantly with you and compliments you on your kindness. He tells you that he only comes to this hospital because "it's the best in the world," and "none of the other doctors understand me." Upon informing the patient that you will not be prescribing hydromorphone, he becomes extremely upset and starts yelling. This patient is exhibiting traits that are consistent with which of the following personality disorders?

Borderline This patient exhibits a number of features typically seen in borderline personality disorder. Borderline personality disorder is characterized by unstable relationships, self image and affect. This instability is often marked with impulsiveness. In the emergency department, these patients will often "split" providers: they will act with affection and respect to some providers and anger and disregard to others. Substance abuse and drug seeking behavior are often seen in borderline patients as well.

A patient with chronic spinal pain begins to obtain off-the-street opioids in an attempt to enhance his prescribed opioid analgesics. In addition to psychotherapy for substance dependence, you prescribe which of the following substitution adjuvant medications?

Buprenorphine and naloxone Dependence can be defined as the state at which a person who uses substances develops tolerance or withdrawal symptoms (physical or psychological or both). Physical dependence can occur from recreational, illicit, or prescription drug. Once a patient develops withdrawal symptoms after stopping use of an illegal or prescribed drug, substance dependence can be diagnosed. Some consider drug addiction to be dependence in the setting of significant impairment of a person's social, vocational and avocational responsibilities or in the setting of continued physical harm. Several symptoms may arise, some of the more common ones are diaphoresis, hypertension, tachycardia, tremors, confusion, hallucinations and seizures. Treatment of dependence is usually accomplished by a slow taper over weeks to months.. The use of substitute drugs that are partial agonists or less harmful are frequently used to assist dependence management. Buprenorphine/naloxone combination is used in the treatment of opioid dependence. The goal of this is to provide a clinically supervised, stable dose of a partial opioid agonist (buprenorphine) and opioid-antagonist (naloxone) to provide pain and craving control, which allows the addict to function while reducing the negative aspects of addiction.

A 34-year-old woman presents to her primary care provider desiring information on smoking cessation. She has a 15-year-pack history and currently smokes 1 pack per day. She has a past medical history of asthma, anorexia nervosa, hypothyroidism, and migraine headaches. Which of the following smoking cessation medications is contraindicated in this patient?

Bupropion Bupropion should be avoided in patients with a history of anorexia nervosa. Cigarette use is the most common preventable cause of mortality in the United States. Almost 70% of patients who smoke say that they want to quit. There are two different types of pharmaceutical methods for helping patients quit smoking: nicotine replacement therapy (NRT) and the centrally-acting medications, varenicline and bupropion. First-line treatment for tobacco abuse is combination of NRT and either varenicline or bupropion. In the United States, NRT options include nicotine patches, lozenges, gums, nasal sprays, and inhalers. The most common side effects associated with NRT are local irritation, headache, and gastrointestinal symptoms (e.g. nausea, vomiting, diarrhea, and abdominal pain). NRT is safe to use in patients with stable cardiovascular disease. Varenicline is a partial nicotinic receptor agonist, thereby reducing nicotine withdrawal symptoms. Varenicline should be started one week prior to the anticipated start date. Varenicline is almost entirely excreted by the kidney and requires dose reduction in patients with moderate renal dysfunction. Neuropsychiatric side effects are a potential side effect of varenicline, although evidence regarding this side effect are mixed. Varenicline is not recommended in patients with a history of unstable psychiatric status or recent suicidal ideation. All patient started on varenicline should be monitored for anxiety, depression, agitation, irritability, or suicidal ideation. Bupropion is an atypical antidepressant that enhances central nervous system noradrenergic and dopaminergic release. Bupropion also has the potential side effect of neuropsychiatric symptoms and patients should be monitored closely when treatment is initiated. Bupropion is contraindicated in patients with a seizure disorder or a history of anorexia nervosa. Bupropion is often used in patients who are concerned about gaining weight after quitting. Insomnia, agitation, and dry mouth are the most common side effects of bupropion.

Which of the following historical findings will most likely lead to a diagnosis of panic disorder?

Chest pain Chest pain is a symptom that is highly characteristic for panic disorder. A panic attack is an episode of intense fear along with cardiorespiratory, gastrointestinal, or neurologic changes that can persist up to several hours. When these episodes recur and fear of future attacks develops or behaviors are changed for at least one month in an attempt to avoid a panic attack, a diagnosis of panic disorder is made. Patients with panic disorder present with symptoms of chest pain, shortness of breath, nausea, vomiting, headache, dizziness, or fear of dying when the episodes of panic attacks occur. These symptoms are reasons for presentation to a medical professional and diagnosis is made clinically when the physiological changes are not better explained by another psychiatric or medical disorder. Treatment includes supportive measures followed by psychotherapy and pharmaceutical therapeutics to treat anxiety.

Which of the following diagnostic criteria differentiate Tourette syndrome from other neurological disorders?

Childhood onset Tourette syndrome (TS) is a neurological disorder characterized by the presence of vocal or motor tics. Vocal tics are involuntary utterances that may range from noises to words or sentences. Motor tics are sudden, brief intermittent movements such as facial grimacing, shoulder shrugging, eye blinking or head jerking. One diagnostic criterion for TS defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is onset before age 18 years. Other criteria for diagnosis include the presence of multiple motor and one or more vocal tics, persistence of tics for more than one year, and the symptoms not being related to a medical condition or physiologic effects of a substance. TS is found more commonly in boys than girls. Treatment includes patient education, dopamine agonists or antagonists, and botulinum toxin injections. Most tics in patients with TS resolve by age 18 years.

A 52-year-old business executive presents to the ED with diaphoresis, tachycardia, visual hallucinations, and recent seizure. The patient states that he drinks alcohol daily but he is trying to quit. His last drink was one day ago. Which of the following is the most appropriate medication at this time?

Chlordiazepoxide Abrupt cessation of alcohol intake in a chronic alcoholic can lead to alcohol withdrawal syndrome. A history and physical is usually all that is necessary to make a diagnosis. Ethanol withdrawal is characterized by a autonomic hyperactivity (diaphoresis, tachycardia), hand tremor, insomnia, nausea, vomiting, hallucinations (visual), anxiety psychomotor agitation and seizures. Treatment includes monitoring, serial Clinical Institute Withdrawal Assessment for Alcohol (revised) (CIWA-Ar) testing and long acting benzodiazepines like chlordiazepoxide or diazepam.

A 28-year-old previously healthy woman presents to your office with a complaint of feeling depressed. In the past 6 months she feels very tired despite sleeping 10-12 hours per night, has no desire to exercise like she did previously, has lost 10 pounds and complains of not having an appetite. She admits to having thoughts of wishing she weren't alive anymore, although denies being suicidal. Which of the following is considered first-line therapy for this patient?

Citalopram Depression is a very common mental health complaint seen in primary care. Diagnosis of depression is made when patients have at least one episode of major depression and no history of mania or hypomania. An episode of major depression lasts at least two weeks and includes having five or more symptoms of depression including anhedonia, depressed mood, change in appetite or weight, insomnia or hypersomnia, low energy, inability to concentrate, feeling guilty or worthless, and thoughts of death or suicide. Selective serotonin reuptake inhibitors (SSRIs), such as citalopram, are considered first-line pharmacologic treatment for adults with depression. Initial treatment for patients with depression should include both psychotherapy and pharmacotherapy with SSRIs.

A 24-year-old woman presents to your office with a complaint of severe anxiety. Approximately three times per week she has episodes of sweating, chest pain, heart palpitations, shaking and fear of losing control or dying. The episodes seem to occur and resolve spontaneously. Which of the following is the most appropriate therapy?

Citalopram Panic disorder is a psychiatric illness characterized by recurrent episodes of panic attacks. Panic attacks are periods of intense fear with specific symptoms that develop quickly and peak less than 10 minutes from the onset of the attack. Symptoms include sweating, chest pain, heart palpitations, shaking, fear of losing control, fear of dying, perceived shortness of breath, nausea, dizziness, chills or hot flashes. Panic disorder often occurs co-morbidly with other psychiatric disorders, such as major depressive disorder, schizophrenia, obsessive-compulsive disorder, agoraphobia, and social phobia. Women experience panic disorder two to three times more frequently than men. Development of panic disorder generally occurs between ages 18-45 years, with the average age being 24 years. Diagnosis is determined using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Initial treatment for panic disorder is with an antidepressant, cognitive behavioral therapy, or a combination of the two. When a decision is made to treat with medication, first-line treatment is with a selective serotonin reuptake inhibitor (SSRI), such as citalopram.

An 18-year-old man presents to the ED in police custody after using an unknown drug. Vital signs are BP 170/85, HR 120, T 37.8°C, RR 18, and pulse ox 99% on room air. On exam, he is agitated and diaphoretic. His pupils are 7 mm and reactive. Which of the following substances did this patient most likely use?

Cocaine The sympathomimetic toxidrome is seen with the acute abuse of cocaine, amphetamines, or decongestants. Cocaine causes release of dopamine, epinephrine, norepinephrine, and serotonin. The greatest impact comes from the adrenergic stimulation by norepinephrine and epinephrine. Norepinephrine causes vasoconstriction by stimulating alpha-adrenergic receptors on vascular smooth muscle. Epinephrine increases myocardial contractility and heart rate through stimulation of beta-1-adrenergic receptors. In addition to causing catecholamine release, the reuptake of these neurotransmitters is inhibited. Clinically, patients are usually hypertensive and tachycardic and exhibit mydriatic pupils. In massive overdoses, cardiovascular collapse can result in shock and wide-complex dysrhythmias. CNS effects include seizures. Sympathomimetic toxidrome is sometimes difficult to distinguish from anticholinergic toxidrome. The difference is that patients usually present with dry mucous membranes with an anticholinergic overdose, whereas patients are diaphoretic with sympathomimetics. Treatment is usually supportive. Benzodiazepines should be administered for agitation, hypertension, and hyperthermia.

Which of the following psychotherapy techniques is most effective for panic disorder?

Cognitive behavioral therapy Cognitive behavioral therapy is a psychotherapeutic technique that focuses on a person's thoughts and beliefs and how it influences their actions, and ways to change their thinking to become more positive and healthy. Panic disorder is characterized by an intense fear along with physiological symptoms of chest pain, shortness of breath, nausea, vomiting, and headache. This is accompanied by fear of future attacks and behavioral changes in order to prevent the onset of a panic attack. Theorists believe that panic disorder is an acquired fear of those aroused bodily sensations. Cognitive behavioral therapy allows a patient to expose those fears, analyze why they are present, and teaches them ways to cope in anxiety-provoking situations. By educating a patient, teaching self-monitoring of emotions, exposing a patient to their fear, and re-learning behavioral techniques, cognitive behavioral therapy is effectively able to decrease the symptoms of panic disorder.

What is considered the first-line therapy for bulimia?

Cognitive behavioral therapy Cognitive-behavioral therapy (CBT) is the best-evidenced approach for treatment of bulimia nervosa. Bulimia nervosa is characterized by binge eating episodes, followed by inappropriate compensatory behaviors, such as self-induced vomiting, laxative or diuretic misuse, fasting, and excessive exercise. A sense of loss of control about overeating accompanies these episodes of binge eating. These behaviors are associated with overvaluation of shape and weight. The episodes must occur at a frequency of two times per week for 3 months to meet diagnostic thresholds. Bulimic behaviors usually have their onset during middle adolescence (14-16 years old). Full-syndrome bulimia nervosa is most common during late adolescence and young adulthood (17-24 years old). Onset of bulimia nervosa is rare in younger children, although not unknown. It is common for other psychiatric disorders to coexist with bulimia nervosa, particularly depression, anxiety disorders, and substance use. Individuals with bulimia have normal or near-normal body weight.

A mother presents to clinic with her 15-year-old son. She is concerned because over the past 2 years he has been having significant behavioral problems. At home he is bullying his younger siblings, staying out past curfew, and she recently caught him setting fires in the backyard. At school he is consistently truant and failing all of his classes. Last weekend police picked him up for spray-painting graffiti on a local church. When asked to explain his behavior, the patient says, "I don't have to explain anything, I can do what I want." This patient meets criteria for which of the following disorders?

Conduct Disorder According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), conduct disorder is characterized by behavior which violates the basic rights of others, societal norms, or age-appropriate rules in a repetitive and persistent manner. At least 3 criteria need to be present for the past 12 months, including bullying or threatening others, deliberate fire setting or destruction of property, staying out past curfew, and truancy from school. These behaviors cause significant impairment in academic, social and occupational functioning and may be specified as occurring with limited pro-social emotions, such as lack of remorse or empathy.

Which of the following conditions, in which laws and social norms are repetitively violated, is the most common precursor to antisocial personality disorder?

Conduct disorder Conduct disorder is a disorder of children and adolescents. It is characterized by a persistent and repetitive pattern in which the subject violates the basic rights of others. Usually the subject repetitively violates laws and social norms. As with other behavior or conduct disorders, it is important first to rule out an underlying substance abuse disorder as the cause of changing behaviors and actions. The childhood-onset subtype, before the age of 10 years, results in longer lasting and more pervasive behaviors than the adolescent-onset (after the age of 10 years) subtype. Children in the childhood-onset subtype have a greater incidence of ADHD, academic problems, family dysfunction, violence and aggression. Conduct disorder is the best predictor of antisocial personality disorder, which cannot be diagnosed until the subject is 18 years old.

A 2-year-old boy presents with a burn to his right hand as seen above. The patient's mother states that he mistakenly got burned by hot water when she tipped a hot tea kettle over. What management is indicated? (four circular burns)

Consultation with child services for suspected abuse This patient presents with a partial thickness second degree burn with a mechanism of injury that does not fit the injury pattern raising suspicion for child abuse. The most likely etiology of these burns is from a cigarette. Cigarette burns are typically round and sharply-demarcated. They are sometimes confused with healing impetigo. Child physical abuse refers to infliction of injury to any part of the child. This may present as bruising, fractures, brain injury, burns or internal hemorrhage. Often patients will present with multiple injuries in various stages of healing or patterned injuries (resembling objects). Burns may occur from contact with a hot object or with immersion in hot water. Although accidental hot water burns are common, those sustained from abuse will have characteristic patterns as well. Immersion injuries to extremities will present with glove-stocking distribution involvement. Additionally, intentional immersion injuries may present with burns to the anogenital area. Children with burn injuries with these patterns should always be investigated for possible abuse.

Which of the following is consistent with a diagnosis of bulimia?

Contraction alkalosis Bulimia is associated with a number of signs and symptoms as well as laboratory abnormalities. Bulimia is often a more difficult diagnosis to make than anorexia as patients with anorexia have significant weight change while those with bulimia often maintain a normal weight. Patients with eating disorders have high rates of other psychiatric comorbidities. Major depression is seen in up to 80% of patients with anorexia. Substance abuse is more common in bulimia (30-70%) than in anorexia (12-18%). Patients with eating disorders present with vague symptoms including fatigue, dizziness, nausea and generalized weakness. Vomiting in bulimia can cause dysphagia, sore throat and hematemesis. Gastric acid can cause tooth decay from enamel erosion. Additionally, vomiting can cause contraction alkalosis.

A 32-year-old woman presents to your office for her annual exam. She reveals that one month ago her 6-year-old daughter was killed in a motor vehicle accident. Since the accident she has been crying uncontrollably, can't sleep through the night, and sometimes sees her daughter walking in the upstairs hall. Which of the following is a risk factor for the development of poor bereavement outcomes?

Death of a child Prolonged or complicated grief is characterized by persistent, disruptive emotional responses for at least six months after the death of a loved one. Risk factors include death of a child, past history of mental health issues, dependent relationship with the deceased, and poor social supports. Symptoms include difficulty with moving on and accepting the death, bitterness, numbness or detachment, agitation or being on edge, lack of trust, feelings of emptiness, and a sense that the future holds no meaning. Prolonged or complicated grief can lead to bereavement-related depression or medical sequelae such as exacerbation of chronic disease and substance abuse. Complicated grief can be difficult to differentiate from depression, therefore patients meeting criteria for complicated grief should be referred to a psychiatrist for evaluation. Providers should also encourage individuals with complicated grief to practice self-care, develop new routines and relationships, and provide referrals to support groups.

What is most consistent with alcohol withdrawal?

Delirium, hallucinations, tremor Major alcohol withdrawal, also known as delirium tremens, occurs in less than 5% of alcoholics in withdrawal. Delirium tremens is usually preceded by minor withdrawal symptoms, but may occur at any time in the course of withdrawal. The delirium often begins 3 to 4 days after the last drink and is characterized by a marked change in sensorium with agitation, visual hallucinations, and severe disorientation. Most alcoholics who withdraw from alcohol experience minimal symptoms, such as sleep disturbance or anxiety. A small number may have tremulousness, agitation, diaphoresis, and cognitive impairment. The tremors or shakes typically begin 12 to 14 hours after a period of heavy drinking and are usually noted in the early morning. Other symptoms of withdrawal include nausea, vomiting, poor oral intake, sweats, and anxiety. Seizures during alcohol withdrawal tend to occur as one isolated seizure or a brief cluster of seizures. Treatment is supportive (eg. intravenous hydration, nutritional supplementation, close monitoring) as well as benzodiazepines for control of psychomotor agitation and seizures.

A 45-year-old man who lives alone and is a highly functional working individual, tells you that the police are coming into his home each night and stealing food from his refrigerator and unlocking all the doors. Which of the following is the most likely diagnosis?

Delusional disorder The term delusional disorder refers to a condition whose core feature is persistent, nonbizarre delusions not explained by other psychotic disorders. It is a fixed false belief that has a certain level of plausibility. The delusion may emerge gradually and become chronic, and sometimes is associated with a precipitating event. Behavioral, emotional, and cognitive responses generally are appropriate, and neither mood disorders nor schizophrenic illness is present. There are several types of delusions, and the predominant type is identified to make the diagnosis. Minimal deterioration in personality or function and the relative absence of other psychopathologic symptoms have been considered important evidence for distinguishing this disorder from schizophrenia and other psychotic condition.

A 67-year-old man is brought to the Emergency Department by his son and 70-year-old wife, who are concerned with his behavior. For the last six months, he has held a false belief that his wife is having sexual relationships with multiple men. His wife states she has not been sexually active for over ten years and denies the allegations. The son confirms he has been present with his mother when some of the alleged indiscretions have taken place and can confirm no other relationships are occurring. The patient has installed security cameras around the house in an attempt to "catch her in the act" and has not uncovered anything unusual. The patient is a recently retired detective, who explains that he is gathering evidence of his wife's infidelity. He denies alcohol and illicit drug use. He takes a statin to control his cholesterol, but is otherwise healthy. He has no prior mental health history and denies any manic or depressive symptoms. He denies hallucinations. His mood and affect are euthymic. His speech is organized and his behavior is polite. Which of the following is the most likely diagnosis?

Delusional disorder Delusional disorder is the presence of one or more delusions for a month or longer in a person who, except for the delusions and their behavioral ramifications, does not appear odd and is not functionally impaired. Prominent hallucinations and other psychotic or marked mood symptoms are absent. People with delusional disorder typically reject the characterization of their beliefs as false. They generally have no insight into their illness. Comorbidities are common, especially depression and anxiety. The onset of delusional disorder can be acute. Subtypes of delusional disorder include erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified types. First-line treatment of delusional disorder is usually with antipsychotic medication. Because many patients reject medication, psychotherapy is also appropriate

Which of the following is adequate for a new diagnosis of schizophrenia?

Delusions and disorganized speech for 6 mo The diagnosis of schizophrenia rests on the presence of a combination of features outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Delusions and disorganized speech for at least 6 months is required to make the diagnosis. It is critical to make sure that a patient without a history of psychiatric illness has a full evaluation and meets these specific criteria because there are organic causes of psychosis that can mimic schizophrenia including meningitis, encephalitis, thyroid disorder, and drug ingestion. Duration of symptoms is one of the vital pieces of the history in making this determination.

A wife is upset about how her husband has behaved after receiving a new diagnosis of terminal lung cancer. He has spent the last few days on the internet feverishly looking up his old girlfriends in an attempt to find phone numbers and call them. He has only slept a few hours in this time period, and has eaten only pretzels and soda. When the wife is finally able to get his attention, she asked him what he was doing, to which he responded "I feel great, so I thought I'd catch up with some old friends." He does not meet diagnostic criteria for a manic episode, and has no history of bipolar disorder. You suspect he may be in which stage of the Kubler-Ross grief reaction?

Denial The grief reaction has been described to occur in five stages by Elisabeth Kubler-Ross. This popular theory has not been tested though. It describes the emotions people experience when they are dealing with the death of a loved-one, catastrophic loss, tragedy or a new diagnosis of terminal illness. This staging system helps practitioners identify people who are grieving. Passage through the stages may not be linear, and some patients do not experience each stage. Denial is the first stage and acceptance is the fifth and final stage. Denial is a temporary attempt at personal defense, experienced consciously or subconsciously, in which a person downplays their symptoms ("I feel fine") or minimizes the situation ("This can't happen to me"). Usually people in the denial stage become ever more aware of their possessions and those who will survive their death. This can lead to a "reaching-out" to long lost relationships.

What has been shown to render some improvement in individuals with borderline personality disorder?

Dialectic behavior therapy There are no proven therapies to reduce the severity of borderline personality disorder (BPD). The most promising psychological therapy is dialectic behavioral therapy (DBT). DBT is a multi-faceted program specifically designed to treat BPD. This approach works towards helping people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings and behaviors that lead to the undesired behavior. The few, small studies of DBT found improvement in many symptoms of BPD, but long-term data is lacking. Another promising therapy is psychoanalytic-oriented day hospital therapy.

A 54-year-old man with chronic alcohol abuse presents with confusion and visual hallucinations. Vital signs are HR 113, BP 164/95, finger stick blood glucose 113 mg/dL, and T 100.5°F. Physical examination reveals a disheveled man with tremors, tongue fasciculations, and agitation. What management should be pursued?

Diazepam This patient presents with alcohol withdrawal syndrome complicated by delirium tremens and requires treatment with benzodiazepines (diazepam). Alcohol withdrawal syndrome is a complicated disease that is not fully understood. Chronic alcohol consumption causes depression of the central nervous system (CNS). Removal of the sedative leads to uncontrolled CNS excitation represented by autonomic hyperactivity and altered mental status. Patients may exhibit tachycardia, hypertension, hyperthermia, anxiety, tremors, tongue fasciculations, hyper-reflexia, sleep disturbance, auditory and visual hallucinations and seizures. In delerium tremens, patients will have gross tremors, marked visual hallucinations, profound confusion and agitation. Withdrawal symptoms can begin within 6 hours of cessation of alcohol intake and typically peaks after 24-36 hours of abstinence. It is vital to investigate the cause of alcohol cessation as it may be due to another severe medical illness (pneumonia, meningitis, sepsis, myocardial infarction, cerebrovascular accident etc.). Treatment focuses on supportive care and sedation with benzodiazepines. Some patients may be resistant to benzodiazepines either due to cross-tolerance or concomitant benzodiazepines abuse. Patients refractory to these medications can be treated with barbiturates (typically phenobarbital) and in severe cases, propofol.

Which of the following is associated with an organic cause of psychosis?

Disorientation Psychosis can be caused by both organic (medical) and functional (psychiatric) etiologies. It is critical for the clinician to exclude organic causes of psychosis before transferring the patient to psychiatric services. The delay in diagnosis and therefore treatment is potentially harmful to the patient. Unfortunately, it can be difficult to differentiate the etiologies. Patients with organic causes of psychosis tend to have recent memory deficits, psychomotor retardation, visual hallucinations, emotional lability, disorientation and occasional periods of lucidity. Additionally, those with organic psychosis are more likely to have a sudden onset of symptoms, abnormal vital signs or physical examination findings and social immodesty. In patients over 40 years of age without a prior psychiatric history, an organic cause of psychosis should always be assumed.

Which of the following is correct with regards to autism?

Early intervention with a multidisciplinary approach improves outcomes Early intervention with a multidisciplinary approach improves autism outcomes. The term autism refers to a spectrum of pervasive developmental disorders characterized by various degrees of impaired social interaction and communication and repetitive, stereotyped patterns of behavior. These patients like aloneness, are hypersensitive to touch, desire sameness in every day activity, often have a lack of understanding, and can have good rote memory skills. Patients may have relatively good skills in one area and very poor skills in others. The incidence of autistic disorder is 5 to 20 per 10,000 persons, with a much higher occurrence among siblings of affected patients. Evidence is mounting that both genetic and environmental factors influence the etiology of autism.

A 46-year-old man with a history of depression presents with a self inflicted laceration to the left arm. The wound is superficial and the patient states that he didn't want to hurt himself. He reports that he is recently divorced, lives alone, and has increased stress at work. These stressors have worsened his depression. Which of the following is the next best step in management of this patient?

Emergency psychiatric evaluation This patient presents with a possible suicide attempt and a number of high risk factors for suicidality warranting an emergency evaluation from psychiatry. Patients often present to the emergency department after an attempt that may appear minor. Many of these patients have a normal mental status making it vital to obtain details about the occurrence as well as the context. Additionally, patients may experience shame about the event and attempt to explain it as an accident. It is central in management for the physician to treat all possible suicide attempts as the serious events they are. All of these patients have the potential to attempt again and may be successful. For this reason, any patient presenting with a possible suicide attempt should have an emergent psychiatric evaluation.

An 18-year-old woman with a history of frequent visits to the ED presents with multiple superficial lacerations to her left wrist. She is agitated and states she is suicidal. She is yelling at the nurses and demands to be seen only by the psychiatrist. Which of the following is the most appropriate next step in management?

Engage in conversation and discuss her symptoms and validate her distress Borderline personality disorder (BPD) is a common emergency psychiatric presentation. BPD is characterized by unstable personal relationships, unstable self-image, and inappropriate behaviors. The disorder may include chronic feelings of emptiness, which may be misdiagnosed as depression, or lability of mood, which may be mistaken for mania or hypomania. Borderline patients typically live lives of crisis and constant conflict. Patients with BPD usually present to the ED after deliberate self-injury or suicidal attempts. Recurrent suicidal threats or acts and self-injury with a combination of strong preoccupation with expected rejection and abandonment are the strongest indicators. These patients feel they need to be connected to someone who they believe really cares. Therefore, the first step is to engage the patient in conversation and discuss his or her symptoms and validate his or her distress.

Which of the following best defines delusions?

Erroneous beliefs that usually involve a misinterpretation of perception or experiences Delusions are erroneous beliefs that usually involve a misinterpretation of perceptions or experiences. Their content may include a variety of themes (persecutory, referential, somatic, religious, or grandiose). In persecutory delusions the person believes he or she is being tormented, followed, tricked, spied on, or ridiculed. In referential delusions the person believes that certain gestures, comments, passages from books, newspapers, song lyrics, or other environmental cues are specifically directed at him or her.

A 31-year-old woman presents to your office with a complaint of feeling depressed. In the past two months she has lost 10 pounds, is experiencing insomnia, has low energy, difficulty concentrating, and feels worthless. She denies thoughts of suicide. Which of the following is the most appropriate therapy?

Escitalopram Depression is the most common psychiatric disorder and is frequently seen in the primary care setting. Adults should be screened for depression by their primary care providers when staff-assisted care supports are in place which allow for accurate diagnosis, treatment and follow up. Diagnosis of clinical depression relies on the history and physical examination. Diagnostic criteria for a major depressive episode includes five or more symptoms present during a two week period which represents a change from previous functioning. At least one of the symptoms must be depressed mood or loss of interest or pleasure. Other symptoms include weight loss or gain, increase or decrease of appetite, insomnia or hypersomnia, fatigue or low energy, difficulty concentrating, feelings of worthlessness or guilt, and thoughts of death or suicide. First-line treatment for depression is pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) such as escitalopram, psychotherapy, or a combination of both

A previously healthy 52-year-old woman presents to your office with a complaint of diffuse pruritus. She is concerned about insects under her skin. She brought a sample of her skin mixed with debris that she believes are the insects. She is requesting that you send it to the lab. Physical exam reveals scattered ulcers and erosions in varying stages of healing with excoriations all over her body. Which of the following is the most effective management?

Establish a strong therapeutic alliance Delusions of parasitosis (DoP) is a delusional disorder involving the firm belief by the patient that the pruritus is caused by an infestation of insects or parasites. Patients present with self-inflicted skin manifestations from scratching or digging and may bring a sample of debris, lint, or pieces of skin that they say contain the insects or parasites. Diagnosis involves excluding any true skin infestations, such as scabies, as well as ruling out systemic disease that may cause pruritus. Once a physical etiology has been excluded, diagnosis is through meeting criteria established by the Diagnostic and Statistical Manual of Mental Disorders (DSM). Initial management is by establishing a strong therapeutic alliance with the patient and respecting the patient's autonomy in all encounters. First-line pharmacologic treatment is with antipsychotic medications.

A 45-year-old man presents from home with a complaint of abdominal pain. A review of his previous visits shows two prior evaluations for similar abdominal pain during which he revealed that he had swallowed writing utensils. Endoscopic removal of the writing utensils was required in both cases. An X-ray today confirms the presence of a pen in the esophagus. What is his most likely diagnosis?

Factitious disorder Factitious disorder imposed on self, previously known as Munchausen syndrome, is a disorder in which patients feign illness in order to obtain attention, sympathy or to play the sick role rather than for external rewards such as medications or financial gain. ​Factitious disorders are different from somatic disorders and malingering because of intention. Patients will often have objective physical findings as a result of their self-harm. In some cases, they may induce a serious illness in order to have prolonged hospitalization in the patient role. They are willing to undergo procedures in order to maintain their sick role.

A 26-year-old woman is brought in by her husband for evaluation. He states that over the last week, she has exhibited a number of concerning symptoms including tremors and seizures. On entering the room, the patient is noted to be resting comfortably. When asked about the tremor, the patient begins to exhibit coarse diffuse tremors. During the evaluation the patient has generalized shaking but is able to respond to questions. Further discussion with the patient's husband reveals that they are currently going through a separation and there has been a lot of stress at home. Which of the following disorders accounts for the patient's symptoms?

Factitious disorder This patient exhibits signs and symptoms of factitious disorder. Factitious disorder is characterized by falsified general medical or psychiatric symptoms. Patients deceptively misrepresent, simulate, or cause symptoms of an illness or injury in themselves, even in the absence of obvious external rewards such as financial gain, housing, or medications. Symptoms may develop after an identifiable psychosocial stress or as part of a pattern of general life (i.e. this is the way the patient deals with life events). Symptoms can be both psychological and physical. If the patient admits to producing the symptoms, they would not be included in the factitious category. This patient presents with volitional tremors and pseudoseizures that are characterized by general shaking but preserved cognitive function.

Which of the following clinical scenarios in a patient with chronic ethanol use should prompt admission to the hospital?

Fever, tachycardia, hypertension The spectrum of illnesses related to chronic alcohol use is quite broad and frequently encountered in the ED. Acutely intoxicated patients are common in urban settings and require monitoring for clinical sobriety and safety prior to discharge. Patients may request admission for detoxification in the setting of cessation of alcohol use. When alcohol use is abruptly stopped or markedly decreased, patients may develop alcohol withdrawal with mild symptoms, alcohol related seizures or in the most serious and life-threatening form of withdrawal, delirium tremens. The patient described here has several abnormal vital signs (fever, tachycardia, hypertension). These abnormalities are concerning for major alcohol withdrawal which is a constellation of symptoms which may include anxiety, irritability, tremors, tachycardia, fever, hypertension, decreased seizure threshold and both auditory and visual hallucinations. In its most severe form, patients develop delirium tremens, which is a severe hyper-adrenergic state with confusion, hallucinations and hemodynamic instability. This condition is life-threatening and requires aggressive treatment with benzodiazepines and possibly antipsychotics.

A 21-year-old woman presents to your office for her annual exam. While taking the patient's history, she reveals that she has been eating excessive amounts of food and then vomiting almost daily for the past six months. She has started working with a nutritionist and is seeing a cognitive behavioral therapist but would like to know if there are any medications that might help her treatment. Which of the following is the most appropriate medication for this patient?

Fluoxetine Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating and inappropriate compensatory behavior such as self-induced vomiting or laxative abuse. For diagnosis, the behaviors must occur at least once per week for 3 months. Individuals feel out of control with their behaviors and are overly concerned with their physical appearance and weight. Treatment for bulimia nervosa includes psychotherapy, nutritional rehabilitation, pharmacotherapy and management of medical complications. The selective serotonin reuptake inhibitor (SSRI) fluoxetine is the only SSRI approved for use in treating bulimia nervosa.

A 27-year-old woman presents to your office with complaints of depression and thoughts of suicide. She is interested in starting both counseling and medication to address her symptoms. Which of the following is the safest medication to consider prescribing?

Fluoxetine Depression and suicidal ideation are common complaints seen in the primary care setting. Any patient who reveals having thoughts of suicide should be assessed further to determine more details about the thoughts of suicide, as well as intent and plan. Risk factors for suicide include psychiatric illness, history of previous suicide attempts, individuals who have never been married, previous or active military service, childhood abuse, family history of suicide, and access to weapons. Women attempt suicide twice as often as men, but men are three times more likely to be successful. Management of a patient who is suicidal includes risk factor reduction, managing the underlying cause, close monitoring, and follow up. Determination of the lethality of the patient's current medication regimen is part of the risk reduction process. Selective serotonin reuptake inhibitors (SSRIs) seem to be safer in the case of an overdose than other agents. SSRIs, such as fluoxetine, are therefore the agents of choice in the treatment of depression for patients who are potentially suicidal.

Which of the following medications is most likely to cause side effects such as tardive dyskinesia and have limited efficacy in treating the negative symptoms of schizophrenia?

Haloperidol Typical antipsychotics such as haloperidol have a relatively high risk of adverse effects such as tardive dyskinesia and parkinsonism, especially in older patients. They are mainly effective against the positive symptoms. Antipsychotics are never to be given as an isolated measure; other forms of treatment, such as individual or family therapy and psychosocial measures, should continue. Special education and support measures (compliance therapy) are useful where there are compliance problems. Schizophrenia is a chronic psychiatric disorder with no single feature that is pathognomic. Without treatment many patients may experience a downward drift in socioeconomic class.

A 51-year-old woman presents for follow-up after being started on fluoxetine 20 mg daily 4 weeks ago for depressive symptoms. She has a history of major depression and was successfully treated with fluoxetine for several months after her last episode three years ago. The patient reports that the worst of the depressive symptoms have improved, but she still continues to experience mild sadness and tearfulness on occasion. She does not have any suicidal or homicidal ideation. She reports no side effects from the use of fluoxetine. No manic symptoms are present. Which of the following is the best approach to continuing pharmaceutical treatment?

Increase the dose of fluoxetine to 40 mg daily Increase the dose of fluoxetine to 40 mg daily is the best approach. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used as first-line treatment for major depression. This patient has shown improvement with the initial dose of fluoxetine without any side effects. Increasing the dose is most appropriate change, since the most common mistake in a trial of an antidepressant is the use of too low a dosage for too short a time. Major depressive disorder (MDD) has a chronic course with relapses. Diagnosis of MDD is made based on five or more of the following symptoms having been present for more than 2 weeks and resulting in altered functioning. At least one symptom must be depressed mood or anhedonia. Symptoms include depressed mood, anhedonia, weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings or worthlessness or guilt, reduced ability to concentrate, and thoughts, plans, or attempts of suicide. No manic symptoms should be present, now or in the past.

A 34-year-old woman has been seen multiple times in the past several months for various pain-related complaints. On each occasion, no physical or laboratory findings were found to explain the symptoms. The patient is involved in a worker's compensation case and could make a significant amount of money if it is demonstrated that her physical complaints are related to work conditions. Which one of the following diagnoses characterizes her unexplained physical symptoms?

Malingering This patient most likely is malingering, which is to purposefully feign physical symptoms for external gain. The most common goals of people who malinger in the emergency department are obtaining drugs and shelter. In the clinic or office, the most common goal is financial compensation. According to the DSM-5, malingering should be suspected in the presence of any combination of the following: medicolegal presentation, marked discrepancy between the claimed distress and the objective findings, lack of cooperation during evaluation and in complying with prescribed treatment or presence of an antisocial personality disorder.

A 15-year-old girl presents to clinic for a well child check. During her Home and Environment, Education and Employment, Activities, Drugs, Sexuality, Suicide and Depression (HEADSS) exam, she reports using marijuana on a weekly basis for the past six months. She also drinks alcohol to excess once every few weeks. She denies smoking tobacco or using any other illicit substances. Which of the following is the most accurate information to give this patient?

Marijuana can cause dependence and withdrawal Marijuana is the most commonly abused illicit drug, and is used by over 1/3 of US high school students. The active component, tetrahydrocannabinol (THC), leads to the effects of euphoria, elation, and hallucination. Side effects of the drug include impaired short-term memory, poor attention, loss of judgment, distorted time perception, and occasionally visual hallucinations and distorted body image. In the acute setting, serious adverse effects might include anxiety, panic, psychotic symptoms at high doses, and motor vehicle accidents. Marijuana is used in many medical conditions due to its antiemetic properties and appetite stimulation. Dependence occurs in about 10% of users. Withdrawal usually occurs within 24 to 48 hours of stopping the drug, and symptoms include malaise, irritability, insomnia, diaphoresis, night sweats, GI disturbance, and drug craving. The withdrawal symptoms usually peak by day 4 and are resolved by day 10-14.

What is true regarding attention deficit hyperactivity disorder?

Most frequently diagnosed disorder in children Attention-deficit/hyperactivity disorder (ADHD) is the most frequently diagnosed behavioral disorder of childhood, with a prevalence of 4% to 12%. At least 10% of behavior problems seen in a general pediatric practice are caused by ADHD. ADHD is characterized by a triad of symptoms including inattention, impulsivity, and hyperactivity. Symptoms must be present in 2 areas of social interaction (home and school); must have been present prior to age 12 years; must have persisted for longer than 6 months; and must be maladaptive or inappropriate for the child's developmental stage. Research suggests that ADHD has a central nervous system (CNS) basis; however, no specific etiology has been discovered. Various brain imaging studies of ADHD patients have demonstrated abnormalities of brain metabolism, supporting the validity of ADHD as a disorder. However, the strongest evidence of validity has been course prediction and treatment response to medication. There is no independent valid test to determine that a child has ADHD. The diagnosis can only be obtained reliably by using well-established diagnostic assessment methods. This involves using the standardized diagnostic criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (or DSM).

The DSM-V groups personality disorders into three clusters: odd/eccentric, dramatic/erratic and anxious/fearful. Which of the following is the correct personality disorder and cluster?

Narcissistic personality disorder-- dramatic/erratic (cluster B) Cluster B is the dramatic, overly emotional, or erratic group, including antisocial, borderline, histrionic, and narcissistic personality disorders. Personality disorders are distinguished by persistently inadequate adaptive capacities affecting several realms of functioning, such as social relationships or occupational performance. People with personality disorders have chronic problems dealing with responsibilities, roles, and stressors; they also have difficulty understanding the causes of their problems or changing their behavior patterns. Cluster B individuals often are characterized as labile, unpredictable, unlikable, and impulsive. The initial presentation typically is crisis-related and chaotic, often involving severe symptoms (that may decrease after the crisis has passed), substance abuse, and conflicts with family members, employers, or the healthcare system. Persons with cluster B disorders have difficulty establishing and maintaining interpersonal relationships (e.g., with medical providers) and often have a history of discharge against medical advice, doctor shopping, or failure to follow recommended treatment.

What is the most common form of child abuse in the United States?

Neglect Most states recognize four major types of maltreatment: neglect, physical abuse, psychological maltreatment, and sexual abuse. In the United States, medical providers are mandated reporters of child abuse. Neglect is the most common type of child maltreatment in the United States (78.5%) and is caregiver failure to meet basic nutritional, medical, educational, and emotional needs of a child. Neglect is legally reportable. Nutritional neglect is likely the most common form of neglect that is recognized, typically in the form of failure to thrive (FTT). Risk factors for neglect include poverty, poor support systems, parental mental health issues or mental disability, parental substance abuse, poor parenting skills, or complex child needs. The history and physical exam are extremely important when child abuse is suspected. A thorough history from everyone involved using open-ended questions, is the recommended approach. A full physical exam, including a genital exam is warranted. Signs such as bruising in non-mobile children, ligature marks, or burn marks are red flags for child abuse. Imaging should include a full skeletal survey in any child younger than 2 years with suspected physical abuse as well as a non-contrast computed tomography scan of the head in all children aged 6 months or younger with suspicion of abuse or children younger than 24 months with any suspected intracranial trauma. In cases of neglect, particularly when failure to thrive (FTT) is in question, a workup for organic problems may be undertaken. A provider who can follow up the laboratory results, monitor weight gain closely, and work with the family should be involved. Failure to thrive may require admission or close follow up with a specialist.

On a Sunday afternoon, a surgical oncologist and his family attend a football game in the city where he practices. While at the game, he runs into a physician colleague that works at the same institution. After some casual small talk, his colleague inquires, "Are you taking care of Mr. Clarke, my personal trainer? I heard through the grapevine that he has melanoma, and I didn't know if you had started him on any chemotherapy or performed any surgical intervention yet. Hopefully you'll be able to take very good care of him." In this situation, the surgical oncologist may confirm which of the following?

No information at all In order to be in compliance with patient confidentiality, a physician must not discuss any information regarding a patient's care with a physician who is not actively involved in that patient's care. This not only includes the diagnosis, treatment and prognosis of a patient's care, but also the confirmation or denial of whether or not a person is, in fact, a patient of the physician in question. A physician has an ethical responsibility to his or her patients to respect and protect their confidentiality in every situation, including non-physician interactions as well as with physician colleagues who are not involved in the active care of the patient. The most appropriate course of action in a situation as described above would be to withhold information concerning the patient's condition and medical course. Physicians should not be dishonest or lie in order to protect patient confidentiality. Federal and state laws designed to safeguard patient confidentiality are inadequate against the rapid and innovative use of electronic health websites. Health professionals must be aware that this information is not always secure and that they are accountable for maintaining privacy for the patient.

A 35-year-old man with a history of alcohol abuse presents to your office with complaints of a 3-day history of abdominal pain and vomiting after a night of binge drinking. He has not eaten in days. Laboratory values show an elevated anion gap, ketonemia and normal glucose levels. In addition to thiamine, what other treatment should be provided for this patient?

Normal saline and glucose This patient is suffering from alcoholic ketoacidosis, which is defined by the clinical triad of ketones in the blood or urine, an elevated anion gap and a normal glucose level. Classically, these patients are chronic alcoholics and in a state of starvation. Blood alcohol may be undetectable and the patient may be hypoglycemic. Patients typically have high osmol and anion gaps. Treatment of alcoholic ketoacidosis includes vigorous volume repletion with normal saline, along with administration of thiamine and glucose. Alcohol appears to significantly increase the amount of thiamine required to treat the patient successfully compared with other individuals in whom thiamine deficiency has been due to starvation. Thiamine is administered initially before giving glucose and normal saline to the patient. Administering dextrose to an individual in a thiamine-deficient state exacerbates the process of cell death and can worsen the patient.

An 82-year-old woman presents for evaluation of pain on her sacrum. The patient is alert and oriented to person, place, and time. Physical examination is notable for a stage II pressure ulcer. Multiple bruises are noted on her legs as well. She acknowledges that she remains in bed most of the day and sometimes her son who is her caretaker forgets to give her meals or change her diaper. She also states that the son causes her pain by pinching her arms and legs when she does not move quickly enough. You are concerned about elder neglect and abuse. She does not wish to report her son or speak with social work. Which is your most appropriate action?

Notify adult protective services Up to two million elderly people are abused or neglected each year in the US. There are several categories of elder abuse including: physical abuse, sexual abuse, neglect, emotional or psychological abuse, abandonment, and financial or material exploitation. Unlike child abuse, interventions cannot be made against the abused persons wishes. Adults have the right to refuse intervention even if that means returning to a dangerous situation. However, in most states, emergency physicians are mandatory reporters of suspected elderly abuse or neglect and adult protective services should be informed.

A 25-year-old woman presents to the emergency department requesting help with detoxification from her substance use. She reports severe restlessness, anxiety, insomnia, and generalized myalgias in the past 24 hours since her last substance intake. Physical examination shows excessive lacrimation, diaphoresis, and piloerection. Withdrawal from which of the following substance is the most likely cause of this patient's condition?

Opioids Sufferers of opioid use disorder often begin by being prescribed opioid medication. Tolerance develops rapidly with long-term use of opioids and addiction can lead to drug-seeking behavior and experimentation with heroin. Opioid intoxication induces symptoms of euphoria followed by apathy, pinpoint pupils, constipation, drowsiness, slurred speech, and memory impairment. Overdose can lead to respiratory depression and coma and is treated with naloxone, an opioid antagonist. Opioid withdrawal is diagnosed when three or more of the following occur: dysphoric mood, nausea or vomiting, myalgias, lacrimation, rhinorrhea, pupillary dilation, piloerection, sweating, diarrhea, yawning, fever, and insomnia. Rapid detoxification from opioids is not life-threatening, but is extremely uncomfortable. Withdrawal is treated with supportive measures. Slower, tapered detoxification and withdrawal can be achieved using methadone (a mu agonist that is gradually titrated down) or buprenorphine (a partial mu agonist and antagonist that has a ceiling effect and long duration).

The parents of a 7-year-old boy ask you to evaluate him because of increasing concerns about his temper tantrums over the past 9 months. He becomes angry and hostile, argues constantly, and refuses to follow rules or directions. The boy often becomes aggressive and destructive, breaking his toys and sweeping his dinner plate and glass of milk onto the floor. The parents believe that their son is deliberately behaving this way to annoy them. This history is most consistent with which one of the following?

Oppositional defiant disorder This child meets the DSM-V criteria for oppositional defiant disorder, defined as a pattern of negative, hostile, and defiant behavior lasting at least 6 months. The child will often lose his or her temper, argue with adults, actively defy or refuse to comply with adults' requests or rules, deliberately annoy people, blame others for their mistakes or misbehavior, be easily annoyed by others, appear angry and resentful, or be spiteful or vindictive. The disturbance in behavior must also cause clinically significant impairment in social, academic, or occupational functioning, and the behaviors must not occur exclusively during the course of a psychotic or mood disorder. Coexisting conditions are common in children with oppositional defiant disorder, particularly ADHD and mood disorders. Research supports outpatient psychological interventions for children with oppositional defiant disorder. Studies have demonstrated that parent training is an effective means of reducing disruptive behavior.

An 18-year-old woman complains of heart palpitations, diaphoresis, nausea, shaking of her whole body along with a choking sensation. These symptoms have occurred 3-4 times per week for the last 2 weeks. She states that the symptoms are most common shortly before going to bed and begin suddenly peaking in 10 minutes and eventually spontaneously resolving. These symptoms are accompanied with the intense fear that she is going to die. Which of the following is the most likely diagnosis?

Panic attack Panic attacks are a collection of distressing physical, cognitive, and emotional symptoms that may occur in a variety of anxiety disorders, such as specific phobias, social phobias, post-traumatic stress disorder (PTSD), and acute stress disorder. Panic attacks are discrete periods of intense fear in the absence of real danger, accompanied by at least 4 of 13 cognitive and physical symptoms. The attacks have a sudden onset, build to a peak quickly, and are often accompanied by feelings of doom, imminent danger, and a need to escape. Symptoms of panic attacks can include somatic complaints (e.g., sweating, chills), cardiovascular symptoms (pounding heart, accelerated heart rate, chest pain), neurologic symptoms (trembling, unsteadiness, lightheadedness, paresthesias), GI symptoms (choking sensations, nausea), and pulmonary symptoms (shortness of breath). In addition, patients with panic attacks may worry they are dying, "going crazy," or have the sensation of being detached from reality. Patients with panic disorder experience recurrent, unexpected panic attacks, followed by at least 1 month of persistent worry that they will suffer another panic attack. Panic disorder patients may begin to avoid places where a prior attack occurred or where help may not be available

A 45-year-old woman presents to the office with a complaint of chest tightness and shortness of breath when entering an elevator. For the past year she has taken the stairs in fear that the elevator will break down, leaving her stuck in the enclosed space. Which of the following is the most likely diagnosis?

Panic disorder Panic disorder is characterized as recurrent attacks of intense fear that begin abruptly and may last up to several hours along with worrying about the onset of future attacks. It is a type of anxiety disorder that includes panic attacks, defined as episodes of spontaneous intense fear accompanied by cardiorespiratory distress, gastrointestinal changes, or neurologic symptoms. Patients endorse heart palpitations, chest pain, sweating, nausea, vomiting, headache, dizziness, or even a fear of dying. These symptoms can last from a few minutes to a few hours and attacks commonly warrant emergency room visits. A panic disorder is defined as recurrent panic attacks and one month or more of worrying about future attacks or changing a behavior in order to avoid an attack. Diagnosis is made clinically and treatment includes psychotherapy and pharmaceutical interventions.

A 60-year-old woman presents to your office accompanied by her adult daughter with a complaint of anxiety. She says that she's always been a "worrier," but since the birth of her grandchild last year her anxiety has gotten worse. Further discussion reveals that she sleeps only 2-3 hours per night, has daily headaches, and her daughter complains that she calls their house at least 15 times every day asking about her grandchild's safety. Which of the following is the most appropriate therapy?

Paroxetine Generalized anxiety disorder (GAD) is defined by having uncontrollable anxiety and worry that interfere with daily activities for at least 6 months. Symptoms occur on more days than not during this time period. First-line medications for GAD include SSRI's or SNRI's, including paroxetine. Psychotherapy is also recommended in the treatment of GAD. If one SSRI does not have the desired effect, then a trial of a different SSRI is used prior to initiating a second-line medication.

Which of the following is included in the criteria of substance abuse?

Persistent or recurrent social or interpersonal problems caused or exacerbated by substance Substance abuse is the compulsion to use substances despite adverse consequences. One or more of the following must be seen in a 12-month period: continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by substance, recurrent substance related legal problems, recurrent use in physically hazardous situations, recurrent use resulting in failure to fulfill major role obligation at work, home, or school. These symptoms must never have met dependence criteria for the same class.

A 19-year-old woman refuses to go to any park or playground because of an excessive fear and anxiety that she may see a dog. She has never been bitten or had a previous bad experience with a dog. Which of the following conditions is she most likely suffering from?

Phobia A phobia is an excessive and unreasonable degree of fear triggered either by exposure to or anticipation of a specific object or circumstance. People with specific phobias realize that their level of fear is excessive, but they still try to avoid any exposure to the feared object or circumstance. These avoidance attempts and the anxiety that results when avoidance is unsuccessful cause a significant disruption in normal functioning. This can be distinguished from fear, which is a normal psychological and physiological reaction to an actual threat or danger, or to the anticipation of an actual threat or danger. Many phobias begin in childhood—particularly those of the animal and nature type. Very often there has never been an exposure to the feared object or situation. Cognitive behavioral therapy is probably the most effective treatment for a specific phobia. Through a process of graded exposure called systematic desensitization, individuals with a phobia are able to extinguish or control their response.

Which of the following distinguishes conduct disorder from oppositional defiant disorder?

Physical aggression towards others Conduct disorder can be distinguished from oppositional defiant disorder by the presence of physical aggression and other severe forms of antisocial behavior. Conduct disorder is characterized by a persistent pattern of serious rule-violating behavior, including behaviors that harm (or have the potential to harm) others. The patient with conduct disorder typically shows little concern for the rights or needs of others. The symptoms of conduct disorder are divided into 4 major categories: (1) Physical aggression to people and animals including bullying, fighting, weapon carrying, cruelty to animals, and sexual aggression; (2) Destruction of property, including fire setting and breaking and entering; (3) Deceitfulness and theft; and (4) Serious rule violations, including running away from home, staying out late at night without permission, and truancy. To meet the diagnosis, >3 of these symptoms must be present at least 1 year (1 or more in the past 6 months) and must impair the youth's function at home, at school, or with peers. The onset of conduct disorder may occur in early childhood but usually occurs in late childhood or adolescence. In a majority of patients, the disorder remits by adulthood. A substantial fraction of patients develop antisocial personality disorder as adults. Early onset of conduct disorder, along with high frequency of diverse antisocial acts across multiple settings, predicts a worse prognosis and increased risk for antisocial personality disorder. Patients with conduct disorder also are at risk for the development of mood, anxiety, somatoform, and substance-use disorders in adulthood.

A 14-year-old boy exhibits chronic conflict with his parents and siblings and has been suspended from school on a number of occasions. Which of the following additional findings would suggest a diagnosis of conduct disorder rather than oppositional defiant disorder?

Physical cruelty to animals Conduct disorder (CD) is one of the most difficult and challenging mental health conditions seen in children and adolescents. Individuals with conduct disorder exhibit a number of problematic behaviors, including antisocial and defiant activities, such as physical and sexual violence, stealing, lying, and running away. CD behaviors fall into four categories: aggression and cruelty toward both people and animals, destruction of property, serious violations of rules and deceit, lying, and theft. Onset of CD occurs in early to middle childhood and the presence of CD is a risk factor for the development of antisocial personality disorder in adulthood. Diagnosis is determined using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Individuals with CD are highly resistant to treatment. Treatment is more successful when initiated early. Oppositional defiant disorder (ODD) and CD may have similar presentations; however, the behaviors of CD include more deliberate destruction, deceit, aggression, and serious rule violations.

A previously healthy 10-year-old girl presents to your office with a complaint of repetitive, intermittent shoulder shrugging that began one year ago. She says that she can sense when the movement is going to occur, then feels relief after doing it. Her mother says that her daughter is becoming more socially withdrawn because she is embarrassed about these movements. She denies any other complaints. Which of the following is the most appropriate therapy?

Pimozide Tourette syndrome (TS) is a neurologic disorder that presents during childhood, generally before age 11. Clinical manifestations of TS include motor or vocal tics. Motor tics are sudden, brief intermittent movements such as facial grimacing, shoulder shrugging, eye blinking or head jerking. Vocal tics are involuntary utterances that may range from noises to words or sentences. TS is known to be a genetic disorder, although non-genetic cases have been documented and are believed to be related to brain trauma or streptococcal infection. Diagnosis is based on clinical criteria. The first step in management of TS is education for the patient, family, and those who interact with the patient. When symptoms interfere with school, work or social interactions, pharmacologic intervention is recommended. Tics may be treated with antidopaminergic medications such as pimozide. Botulinum toxin injections are also used in the treatment of TS.

A 24-year-old man presents to clinic with a complaint of difficulty sleeping due to frequent nightmares. He has visual flashbacks and avoids large crowds due to the inability to escape easily. He is nervous, sweating, and startles easily on examination. Which of the following is the most likely diagnosis?

Posttraumatic stress disorder Posttraumatic stress disorder is a cognitive and behavioral psychiatric disorder that is brought on by trauma and is characterized by intrusive thoughts, nightmares, flashbacks, difficulty sleeping, hypervigilance, and avoidance of situations or people who remind the patient of the trauma. Trauma of all types, including sexual, combat, interpersonal relationships, or motor vehicle accidents, can lead to posttraumatic stress disorder. Patients typically complain of flashbacks, severe anxiety, increased startle response and hyperarousal; which ultimately results in loss of interest in activities and detachment from others. Complications of the disease include depression, anxiety, and suicidal and homicidal ideations. Treatment includes psychotherapy and pharmacotherapy with a selective serotonin reuptake inhibitor.

A 16-year-old girl presents to the ED via ambulance for general pain. She is a refugee from a conflict area who is known to have frequent nighttime visits to the ED over the past year for the same chief complaint. She's undergone multiple medical workups that have all been negative. In the ED she appears angry, irritable, and demonstrates hypervigilance. After a brief conversation with the patient her pain resolves and she feels much better. Which of the following is the most likely diagnosis?

Posttraumatic stress disorder Posttraumatic stress disorder (PTSD) is a long-lasting anxiety response following a traumatic or catastrophic event. Although most people encounter trauma over a lifetime, about 20-30% develop PTSD but over half of these people will recover without treatment. Prediction models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD. Other risk factors include military experiences, war-zone exposure, domestic violence, and foster care. PTSD often leads to patients having difficulty falling or staying asleep, problems with concentration, hypervigilance, irritability, angry outbursts, and increased startle response. The patient in the above clinical scenario is a refugee from a conflict region and exhibits symptoms consistent with PTSD (anger, irritability, and hypervigilance). An important management principle when caring for a patient with PTSD is to ensure his or her safety and to validate his or her symptoms. Detailed questioning should be avoided as it may trigger severe symptoms.

Which of the following risk factors is the strongest predictor of suicide?

Prior history of suicide attempts In the United States there are approximately 10-40 suicide attempts for every completed suicide. Evaluation of risk factors is critical when determining if a patient is at high risk for suicide. Patients with a previous suicide attempt are 5-6 times more likely to attempt suicide again and 50% of individuals who complete suicide have a prior history of at least one suicide attempt. Providers who suspect that a patient may be suicidal should evaluate for suicidal ideation, plan and intent. There is no data to suggest that asking a patient about suicide will initiate a suicidal plan or attempt. Patients deemed high risk for suicide due to risk factors, suicidal ideation, plan or intent should be connected with emergency psychiatric services immediately and monitored for safety.

A 30-year-old woman presents to your office requesting medication to help her quit smoking. Which of the following is a contraindication to prescribing bupropion?

Seizure disorder Bupropion is one of two pharmacologic agents used for smoking cessation, the other being varenicline. Bupropion is an antidepressant that is believed to enhance central nervous system noradrenergic and dopaminergic release. Patients start the medication one week prior to their quit date then continue the medication for eleven more weeks. Side effects of bupropion include headache, insomnia, agitation and dry mouth. Bupropion decreases the seizure threshold and is therefore contraindicated in patients with seizure disorder or any predisposition to seizures.

A 21-year old woman sees you because of a depressed mood since the birth of her son 2 months ago. She is breastfeeding, and her baby is doing well. She denies any suicidal or homicidal ideation and has never had thoughts about hurting the baby. She has a history of depression 2 years ago that was associated with starting college. She began taking sertraline, changed her schedule, and spent more time exercising. Within 6 months her depression resolved and she stopped the medication. She reports this current depression feels worse than her previous depression. Which one of the following would be the most appropriate medication for this patient?

Sertraline Selective serotonin reuptake inhibitors such as sertraline are the most commonly used medications for postpartum depression. They have fewer side effects and are considered safer than tricyclic antidepressants, especially in depressed women who may be at increased risk for medication overdose. In one study, infant serum levels of sertraline and paroxetine were undetectable. It is also recommended that a woman with postpartum depression be started on a medication that she had taken previously with a good response, unless there is evidence of potential harm to her infant.

You are seeing an 11-year-old girl for follow up of excessive handwashing and frequent worrying. You referred her for psychotherapy and she has been receiving cognitive behavioral therapy for 3 months with a child psychologist. However, her mother reports minimal improvement of her symptoms. The patient remains preoccupied with the thought of germs multiplying in her hands that may cause her to get sick. Her compulsion with handwashing is evident both at home and in school, causing impairment in school functioning as well as skin peeling and erythema of her hands. You decide that pharmacotherapy, in addition to cognitive behavioral therapy is the next best course of action. Which of the following is the most appropriate medication therapy to start?

Sertraline The patient has symptoms of anxiety and obsessive-compulsive disorder which are impairing her overall functioning. In obsessive-compulsive disorder, the obsessions are dysfunctional and compulsions are out of the ordinary, and while associated with relief of distress reaction, these are not pleasurable to the individual. People with obsessive-compulsive disorder have insight about their condition. One way to differentiate fears and worries in anxiety disorders from obsessions is that they often pertain to real life situations, while obsessions typically involve some degree of irrationality. Although the first-line of treatment for anxiety and obsessive-compulsive disorder is cognitive behavioral therapy, use of medication with a selective serotonin reuptake inhibitor (SSRI) such as citalopram, fluoxetine or sertraline, in conjunction with cognitive behavioral therapy has been associated with a superior response to either treatment alone.

Which one of the following cardiac rhythm abnormalities is most common in patients with anorexia nervosa?

Sinus bradycardia Anorexia nervosa is characterized by restriction of food intake resulting in low body weight, intense fear of gaining weight or becoming fat, and disturbance of body image. It occurs most often in adolescent females and is often accompanied by depression and other comorbid psychiatric disorders. For low-weight patients with anorexia nervosa, virtually all physiologic systems are affected, ranging from hypotension and osteopenia to life-threatening dysrhythmias, often requiring emergent assessment and hospitalization for metabolic stabilization. Sinus bradycardia is almost universally present in patients with anorexia nervosa. It is hypothesized that this is due to vagal hyperactivity resulting from an attempt to decrease the amount of cardiac work by reducing cardiac output. As cachexia progresses, patients with anorexia nervosa lose strength and endurance, move more slowly, and demonstrate decreased performance in sports. Overuse injuries and stress fractures can occur. Bradycardia, orthostatic hypotension, and palpitations may progress to potentially fatal dysrhythmias. The focus of initial treatment for patients who have anorexia nervosa with cachexia is restoring nutritional health, with weight gain as a surrogate marker. Feeding tubes may be needed in severe cases when the patient has a high resistance to eating. Refeeding syndrome can occur in a malnourished individual when a rapid increase in food intake results in dramatic fluid and electrolyte shifts, and is potentially fatal.

A 27-year-old woman presents to your office with complaints of pain and discomfort. She tells you that she has seen numerous doctors and none of them have been able to help her. Her symptoms today include nausea, gluten sensitivity, irregular menses, weakness in her legs, headache, dysuria, dyspareunia, and back pain. She would like you to do a CT scan to determine the cause of her complaints. Which of the following is the most likely diagnosis?

Somatization disorder Somatization disorder is characterized by physical complaints from various organ systems. Diagnostic criteria include a history of multiple physical complaints starting prior to age 30 years resulting in the patient seeking treatment from many different medical providers. The physical complaints cause significant impairment in the patient's life, including occupational and social functioning. Symptoms must consist of four pain symptoms, two gastrointestinal symptoms, one sexual symptom and one pseudoneurologic symptom not fully explained by a confirmed medical condition. Impulsive and demanding behavior, such as requesting specific diagnostic testing, may occur with patients who meet criteria for this disorder, however there is no evidence that the patient is being deceptive. Treatment focuses on behavior modification including regularly scheduled, brief visits to the medical provider without a diagnostic focus.

Which of the following factors predicts the highest risk of suicide completion?

Substance abuse Suicidal ideation is very common with up to one-third of the population experiencing it in their lifetime. Suicide rates vary with multiple factors including age, gender, race, and marital status. Females attempt suicide three to four times more often than men, but men are more successful in suicide completion. Up to one-quarter of suicides by men are successful as opposed to 5% in women because men tend to use more violent methods. Patients with active substance abuse, including alcohol, are among the highest risk for suicide completion. Other very high risk groups include those with underlying psychiatric disorders, adolescents, elders, and patients with some chronic illnesses. A history of prior suicide attempt raises the risk significantly although 60-70% of successful suicides occur in individuals without any previous attempt. Additionally, the presence of a firearm in the household is an independent risk factor.

A 28-year-old man presents to the emergency department by ambulance. His family called for help after finding him unresponsive at home with a syringe on the floor beside him. His blood pressure is 120/78 mm Hg, pulse 95/min, and respirations are 6/min and shallow. On physical exam he is non-responsive to questions, his skin is cool with cyanosis, and his pupils are minimally reactive to light and constricted. Which of the following is the most appropriate next step in management?

Support airway and breathing Opioid abuse and overdose is a problem in the United States and worldwide. Deaths due to overdose are common and increasing in number. Clinical features of opioid intoxication include altered mental status, hypoventilation, decreased bowel sounds, low to normal blood pressure and heart rate, and miotic pupils. Medical providers should attempt to obtain as much historical information as possible, however an accurate history is not essential in initial management of these patients. Hypoventilation is the most common vital sign abnormality. The first step in management of an overdose is supporting the patient's airway by providing assisted ventilation with supplemental oxygen through the use of a bag-valve-mask.

A 23-year-old man with a history of opiate abuse presents with tachycardia, hypertension and mydriasis. Which of the following is true regarding management?

Symptom control may be achieved with clonidine This patient presents with opiate withdrawal and management should focus on the relief of symptoms. The onset of withdrawal symptoms depends on the opiate agent used. Heroin withdrawal typically occurs within 4-6 hours of discontinuation whereas methadone has a longer half-life and withdrawal may be delayed 24-48 hours. Withdrawal leads to sympathetic discharge and adrenergic hyperactivity. Symptoms include CNS excitation, tachypnea and mydriasis. Tachycardia and hypertension are common. Additionally, patients will often complain of nausea, vomiting and diarrhea. Physical examination may also reveal piloerection, yawning, rhinorrhea and lacrimation. Opiate withdrawal is not life-threatening. Supportive and symptomatic care can decrease the patient's discomfort. Clonidine has been used to mitigate symptoms as have antiemetics.

During an intake history, a patient describes her husband as a violent, angry man. You suspect domestic violence of a physical nature. You counsel the woman that serious injury or death most commonly occurs during which of the following situations?

When she tried to leave the husband Domestic abuse, also known as domestic violence, spousal abuse or intimate partner violence, is a behavior pattern in which the abuser displays any of the following against a partner: aggression, assault, control, intimidation, stalking, sexual abuse, mental or psychological abuse or economic deprivation. Three phases of abuse have been described. The tension building phase is characterized by poor communication, tension and fear. This is followed by a violent phase or episode. The honeymoon phase then follows, and is characterized by the abuser offering apology, sympathy, affection and remorse. In those abused, especially if they continue to live with the abuser, a high incidence of psychological disorders exists, and includes, stress, fear, generalized anxiety disorder, panic disorder, depression, suicide and post-traumatic stress disorder. One study shows 60% of victims meet the diagnostic criteria for depression, either during or after termination of the relationship. Physical abuse can occur during a relationship. However, assaults occur more commonly near the end of relationships. Up to 75% of domestic assaults occur during an attempt to report abuse or leave an abusive relationship.

A patient with schizophrenia is starting treatment with clozapine. Which of the following needs to be monitored weekly?

White blood cell and absolute neutrophil count Clozapine is a second-generation antipsychotic used in the treatment of schizophrenia that is found resistant to other antipsychotics. It may also be helpful in treating individuals with schizophrenia who exhibit self-injurious or suicidal-type behaviors. Clozapine has a unique side effect profile and patients prescribed this medication are entered into a computer-based registry that requires specific monitoring parameters during the course of treatment. Use of clozapine involves a risk of life-threatening agranulocytosis, therefore regular monitoring of white blood cell and absolute neutrophil count (ANC) is required. A baseline complete blood count and ANC is performed prior to initiation of therapy, then done weekly for the first six months of therapy. Other adverse effects of clozapine may include myocarditis, pulmonary embolism, weight gain, insulin resistance, seizures, and sedation. Because of the potential risks, patients determined to be candidates for treatment with clozapine should be referred to a psychiatric provider with experience in treating patients with this agent.

A 53-year-old woman with a history of poorly controlled schizophrenia presented to the Emergency Department two weeks ago with altered mental status, auditory hallucinations, and agitation. During her inpatient psychiatry admission, she stabilized on clozapine. Which of the following laboratory tests should be performed at baseline and then weekly during treatment with clozapine?

White blood cell count White blood cell count is required due to the risk of life-threatening agranulocytosis. Clozapine is an antipsychotic medication used in patients with schizophrenia or schizoaffective disorder, who are resistant to other antipsychotic treatments. Patients being treated with clozapine must have a baseline white blood cell (WBC) count before initiating treatment and weekly throughout treatment. The US Food and Drug Administration requires patients in the United States to have a minimum absolute neutrophil count (ANC) level > 1500/microL to initiate treatment with clozapine.

Which of the following represents the classic order of the stages of grief?

denial, anger, bargaining, depression, acceptance The stages of mourning and grief represent a universal experience across cultures and backgrounds. The five stages of normal grief were first proposed by Elisabeth Kubler-Ross in 1969. People spend different amounts of time in each stage of grief. The first reaction to bad news is denial of the reality of the situation. Denial is a defense mechanism that buffers the immediate pain of shock. This is followed by anger that may be aimed at people or inanimate objects. It can often be directed at the doctor who delivered the news. Bargaining is the next stage and is a response to feelings of helplessness and vulnerability. Depression typically follows bargaining. There is often depression over the practical implications of the news as well as a deeper emotional depression. Finally, acceptance is reached.

What are the components of the "female athlete triad"?

low bone density, menstrual dysfunction, low energy availability The female athlete triad is defined by the presence of low bone density (can be normal), menstrual dysfunction (ranges from normal ovulatory cycles to luteal phase defects and anovulatory eumenorrhea to amenorrhea), and low energy availability (ranges in athletes from inadvertent undereating to disordered eating to a frank eating disorder). It is important to recognize the precursors to the development of the female athlete triad when they may be more amenable to treatment, resulting in less severe long-term sequelae. Caloric deficiency is the primary cause of amenorrhea in athletic women, and treatment should focus on the restoration of normal calorie intake. Athletic amenorrhea is caused by hypothalamic-pituitary axis suppression and is a diagnosis of exclusion. Bone mineral density is adversely affected by menstrual dysfunction and, although treatment with hormone replacement (e.g., oral contraceptives) should be considered, this does not fully address the mechanisms of bone loss. It is never normal or desirable for a female athlete to cease menstrual function, and this should not be seen as a marker of adequate training. Exercise alone should not be blamed for menstrual dysfunction. Many women engage in exercise to control body weight and improve exercise capacity. Amenorrhea only occurs when there is a relative caloric deficiency due to inadequate nutritional intake relative to the amount of energy expended.

You provide care to a middle-aged man with hypertension and diabetes. He recently lost his job, and you are concerned that he may be exhibiting mild symptoms of depression. According to the US Preventive Services Task Force, screening for depression is recommended if which of the following exists?

there is a cognitive-behavior therapist that works in your clinic The US Preventive Services Task Force recommends that adults should only be screened for depression when there is staff-assisted care and support available to make an accurate diagnosis, offer effective treatment and provide follow-up care. There is evidence that this model improves clinical outcomes. Staff-assisted care support refers to ancillary staff that can assist the primary care physician in many areas, such as behavior treatment, medication adherence and follow-up care. This can include trained nursing staff, cognitive behavior therapists and psychiatrist/psychologists. The USPSTF recommends against routine screening of adults for depression if there is no staff-assisted care support currently established. It is suggested to screen adults for depression when personnel or systems are in place to ensure appropriate follow-up and management of patients who screen positive. There is limited evidence to guide the optimal frequency of screening for depression. To facilitate ease of implementation, screening at the time of a routine health visit is suggested.