BM EM

What is the lifetime completed suicide risk for persons diagnosed with schizophrenia?

10%

You are evaluating a 19-year-old man for a possible psychotic disorder. During the assessment interview, he tells you that he believes that someone is following him but is not sure who it is. Every time he walks down the street he hears someone whisper his name, but when he turns around nobody is there. Also, he says, the other night the lights went out in his apartment. He said that this was a signal from his follower that he was watching him. He says he is scared to go out of the house because the person is always there, but he is also afraid in his apartment because he knows the person is watching. Question According to the DSM-5, for how long does this patient have to experience these symptoms to receive a diagnosis of schizophrenia?

6 months

A 22-year-old woman believes a nearby electrical plant is sending out energy waves to control her. She also believes that the "junk mail" sent to her contains secret coded messages. She states she has been able to decipher the codes and they reveal a plot to poison the local water supply. She says this has been confirmed by the voices of her dead parents. She states she has "known" these things for about 6 months. She also complains of having trouble sleeping, having very little appetite, having no desire to participate in activities, and states she has recently quit her job. Question Which of the following would indicate a better prognosis in this patient?

A history of normal baseline functioning between psychotic episodes A better prognosis is indicated in cases where a mood disorder with a history of normal baseline functioning between psychotic episodes is present (indicating the possibility of an atypical psychotic mood disorder).

A 25-year-old man is diagnosed with schizophrenia with predominantly negative symptoms. The patient has shown reduced performance in working memory tasks such as the Wisconsin Card Sorting Test. Question While viewing a magnetic resonance imaging (MRI) scan of the patient's brain, what would you expect to be the most significant finding with respect to his negative symptoms?

Abnormalities of the prefrontal cortex

A 74-year-old man is brought by his family for his annual examination. While conducting the examination, the physician notices that he is less social than usual. The patient's wife passed away 6 weeks ago, and he has been unhappy most of the time. His daughter reports he does not garden anymore and frequently cries around the house. Question What is the most likely diagnosis?

Acute grief

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

Adjustment disorder

An 8-year-old girl recently moved to another city. She started school soon after she moved; however, she hesitates to associate with anybody at school, and she seems to have a hard time paying attention in class. Question What is the most likely diagnosis?

Adjustment disorder

A 78-year-old woman has been referred to you by the primary physician in an assisted living facility. She is extremely fearful, nervous, worries excessively, has a depressed mood, poor sleep, poor appetite, and even has been developing rashes on her arms and hands. There is no underlying medical problem or previous mental health history. She scores perfectly on the mental status exam and has no serious medical problems. She was recently admitted to the assisted living facility from home. She has only been in the facility for 2 weeks. Question What is your provisional diagnosis?

Adjustment disorder with depressed mood and anxiety

A patient is smiling or laughing while talking of being tortured by electrical shock. This is a case of what kind of impaired functioning in individuals with schizophrenia?

Affect

It is 3 a.m. and you have been asked to take a call on the hospital ER's hotline. The adult female on the other end is telling you that she knows she is bleeding to death and she's afraid. You are concerned that she may have tried to commit suicide and try to get her address in order to send help, but she persists in describing her symptoms to you. She has a feeling of fluid running down her legs and it won't stop. The feeling has been present for much of the past 2 years and she knows she is going to die. Try as you might, you can't reassure the woman that she couldn't be bleeding to death for 2 years, but she insists, asking question after question about her symptoms in an effort to prove she is right and you are wrong. You question her and she tells you that she has had a drinking problem in the past, has been drinking that night, has been hospitalized, and has been a patient in a partial hospitalization program. Question What is the most likely diagnosis?

Alcohol-Induced Psychotic Disorder With Delusions and Hallucinations

A 45-year-old man is a chronic alcoholic; his family is concerned because he cannot remember anything anymore. The man denies having any problems, and he suggests that the family is just out to get his head examined, but the family members all agree that the man is often disoriented whether he is drinking or not, and they also say that he seems very apathetic. An interview reveals that while the man's immediate memory does indeed seem to be intact, he quickly forgets new information and he tends to try and cover the loss by filling in the details he cannot remember with fabrications. Question What is the most likely diagnosis?

Amnestic disorder Amnestic disorders are also characterized by an impairment of memory, but in contrast to delirium and dementia, amnestic disorders are not characterized by global deficits in intellectual and cognitive functioning. Short-term memory and recent memory are affected, and the individual usually lacks insight into these memory deficits and will try to minimize, deny, or rationalize them. Like delirium (and in contrast to dementia), the onset of amnestic disorders is usually sudden. If symptoms are of a global nature, therefore, and/or of gradual onset, underlying dementia or possibly a brain tumor should be suspected. Amnestic disorders are not well known; however, they are commonly seen among individuals who abuse alcohol. Occasionally, amnestic disorders will follow trauma, such as a head injury or electroconvulsive therapy. Delirium is characterized by a sudden onset of symptoms. Patients often have multiple cognitive deficits, such as an inability to maintain attention to external stimuli and/or perseveration, disorganized thinking (e.g., rambling, irrelevant, or incoherent speech), and reduced levels of consciousness (e.g., perhaps having difficulty staying awake during the examination); they may have disturbed sleep patterns, psychomotor agitation or retardation, disorientation, and/or memory impairment. Symptoms usually develop over a short period of time (spontaneously in many cases), and they fluctuate throughout the course of the day. There is either evidence of a specific organic factor (e.g., intracranial trauma, the effects of drugs, non-endocrine organ disease, endocrine dysfunction, a deficiency disease such as a thiamin deficiency, systemic infection, electrolyte imbalance, or a postoperative state) or in the absence of a known organic factor, one or more can normally be presumed. In contrast to delirium, dementia occurs most often in old age, and in most cases, it is caused by a primary, permanent, degenerative process affecting an individual's orientation, memory, perception, intellectual function, reasoning, and judgment. Frequently, individuals with dementia have poor impulse control and lability of mood that is not characteristic of the individual's premorbid personality. Early signs of dementia include difficulties in mental performance (e.g., memory), fatigue, and an inability to perform new or complex tasks. As the disorder progresses, everyday and familiar tasks become difficult to perform successfully and taking care of basic needs eventually becomes impossible. Language may or may not be affected, and affected individuals often will attempt to compensate for deficits by joking, changing the subject, or by diverting the interviewer's attention. Several medical conditions can cause psychiatric symptoms, but for a diagnosis of mental disorder due to a general medical condition to be made, the symptoms must be assumed to be the result of the direct physiological effects of a general medical condition. Examples of disorders falling into this category include mood disorder due to a general medical condition (e.g., HIV or AIDS), anxiety disorder due to a general medical condition (e.g., cancer), catatonic disorder due to a general medical condition (e.g., head trauma, encephalitis, cerebrovascular disease, metabolic conditions), psychotic disorder due to a medical condition (e.g., an electrolyte imbalance), and personality change due to a general medical condition (e.g., head trauma). It is important to note that when choosing this type of diagnosis there must be evidence from the individual's history, physical examination, or laboratory tests that the mental disturbance is a direct physiological consequence of a general medical condition, that the mental disturbance cannot be better explained by another mental disorder, and that the mental symptoms cannot occur solely in the course of delirium—unless a diagnosis of delirium due to a general medical condition is appropriate. It is important to consider whether the onset of the medical condition and mental symptoms occur closely in time (they usually do, but not always), whether the signs of the mental disorder are typical or atypical (they will often be atypical), and whether the known medical condition usually produces symptoms similar to those that the individual is experiencing. HIV is often accompanied by psychological changes that will vary with the stage of illness. Whereas depression and anxiety may occur early on, more pervasive changes such as personality changes and dementia may occur later. A diagnosis of an HIV-related psychiatric disorder is made when an individual qualifies for a psychiatric diagnosis and it is believed that the disorder is a direct result of having HIV illness. In some cases, it can be shown that the disorder is the direct physiological consequence of HIV infection, such as in the case of HIV-related dementia. The correct diagnosis, in this case, would be dementia due to a general medical condition, and HIV disease or similar would be noted as the cause. In other cases, mental symptoms may be due to a reaction to having HIV disease, such as depression or anxiety, but they would not be directly due to any HIV-related physiological changes. The correct diagnosis, in this case, would be the appropriate psychiatric disorder for which the diagnostic criteria are met, and HIV disease would be noted as a stressor or otherwise contributing factor.

A 32-year-old woman presents with a 2-month history of persistent sadness, frequent crying, impaired sleep, and anorexia. She has stopped going to work, and she dislikes speaking with her husband because she thinks that he does not understand her. According to the patient, her worst problem is that she does not enjoy anything. Reading the newspaper, attending movies, and going out with friends have all lost any interest for her. The patient reports being distraught about this lack of enjoyment, and worries that it will continue for the rest of her life. Question What is the most likely diagnosis?

Anhedonia Anhedonia is the inability to enjoy anything; it is often a profoundly disturbing feeling for depressed patients. Dysphoria is a state of generalized unhappiness, restlessness, dissatisfaction, or frustration Hyperphagia is one of the 'reverse vegetative signs' sometimes seen in depression, in which the patient eats more than necessary, usually without enjoyment. Regression is a defense mechanism in which the patient uses infantile or childlike dependency to ward off uncomfortable thoughts or feelings. Somatization is the conversion of psychic pain into physical pain, which allows the patient to concern himself with finding physical relief, rather than confronting the thoughts and feelings at the base of his unhappiness.

A 30-year-old male presents for routine follow-up. He has a history of intermittent headaches, low back pain, knee pain, and dysuria over the last year. Additionally, he notes nausea, diarrhea, poor libido, and extremity numbness. He states he feels worthless. He admits to daily alcohol use in an attempt to feel better. Lab studies, urine testing, plain radiographs, CT scans, and MRIs are all unremarkable and show no explanation for his symptoms, but he is consumed by worry about his illness. Question What is correct regarding this patient's condition?

Associated personality disorders and depression are common. (Somatic symptom disorder) This patient's most likely diagnosis is somatic symptom disorder. Patients with somatic symptom disorder have maladaptive thoughts, feelings, and behaviors that define the disorder, in addition to their somatic symptoms (e.g., depression, anxiety, suicidal gestures, substance abuse). They may be addicted to prescribed medications; at times they may exhibit drug-seeking behaviors. Symptomatic presentation, which can be quite dramatic, is frequently associated with concurrent psychosocial stressors. There is no specific psychopharmacologic treatment for somatic symptom disorder. These patients frequently suffer from comorbid psychiatric disorders (e.g., panic disorder or depression), however, which should be appropriately treated. Patients with somatic symptom disorder are at risk for iatrogenic complications of invasive or therapeutic procedures. Habituation to prescribed analgesics or anxiolytics also occurs frequently. Clinicians must exercise caution when prescribing any potentially lethal medication for these patients because they are prone to impulsive acting-out behaviors, including suicide attempts. Individuals who meet the full criteria for somatic symptom disorder tend to be female, unmarried, non-Caucasian, poorly educated, and from rural areas. There are no specific laboratory findings for somatic symptom disorder; the diagnosis is based on a lack of objective evidence to substantiate physical disease.

A 40-year-old man wants you to help him become more comfortable around people. He tells you that every time he is around groups of people he becomes anxious, has difficulty breathing, and begins to sweat. You see him once a week for three weeks and teach him various relaxation techniques to use when he begins to feel anxious. Question What type of therapy did you use with this client?

Behavioral therapy

A 21-year-old woman is markedly thin, and she describes being worried she is going to fail her college finals and not graduate. She presents because she cannot eat or sleep; she feels like she would be better off dead. She was doing well in classes until after a spring break trip to Europe. When queried about previous psychiatric treatment, she tells you that she went "a little nuts" when she was a freshman; it was her first semester and the first time she had lived so far from home. She stayed up for a week trying to write a novel, and during that time she bought two computers and a whole new wardrobe with her father's credit card. Question What is the most likely diagnosis?

Bipolar I Disorder Bipolar I disorder is a mood disorder characterized by the occurrence of one or more manic or mixed episodes alternating with one or more major depressive episodes. The patient above describes depressive symptoms with feeling "better off dead" as well as a history of manic behavior (stayed up for a week trying to write a novel, excessive spending habits). Major depressive episode symptoms develop over a period of days or weeks. For the majority of the time, there must be at least five symptoms present over at least a 2-week period; the symptoms include depressed/irritable mood, anhedonia, increased/decreased appetite, insomnia/hypersomnia, observable psychomotor retardation/agitation, anergia, predominant feelings of guilt or worthlessness, poor concentration and memory, recurrent thoughts of death, suicidal ideation, or a suicide attempt. A manic episode is a period of mood disturbance lasting a minimum of 1 week. The mood may be elevated and expansive or irritable. 3-4 symptoms must be present, including grandiosity, decreased need for sleep, pressured or excessive speech, distractibility, increased drives, and unrestrained involvement in pleasurable activities (e.g., spending sprees, sexual indiscretions, monetary investments). There is an accompanying significant impairment in social and occupational functioning. Psychotic symptoms may also be present. A mixed episode is a period of mood disturbance that lasts a minimum of 1 week; symptom criteria for both a major depressive episode and a manic episode must be met. There must also be marked impairment in social and occupational functioning. Cyclothymic disorder describes a condition involving numerous periods of hypomanic symptoms and numerous periods of depressed symptoms over a 2-year period; these symptoms cause significant impairment in social and occupational functioning. In addition, there is never a period longer than 2 months that there is an absence of symptoms.

What type of mood disorder has 3 categories?

Bipolar disorder The correct answer is bipolar disorder. There are 3 categories of bipolar disorder: 1) mixed, in which the most recent episode of the disorder exhibits both full depressive and full manic behavior in alternating patterns; 2) manic, in which the current or most recent episode is manic with a past history of depression; and 3) depressed, in which the most recent behavior is depressive but with a history of manic phases.

A 26-year-old man is brought to the emergency room by police after he was found shouting at staff at a busy hotel, where he claimed, "I am owner of the hotel." He had checked into the hotel 10 days ago with the intention of "buying all hotels in the area". Since checking in, he has been noticed to be up all night working on paperwork. Additionally, when approached by the staff concerning his stay, he replies by going on tangents without answering the question and always seems to be in a hurry because he speaks quickly. Question What disorder does the patient have?

Bipolar disorder The decreased need for sleep, pressured speech, and outrageous behavior are consistent with an acute manic event and consistent with bipolar disorder.Generalized anxiety disorder is characterized by excessive, poorly controlled anxiety about life circumstances that continues for more than 6 months.Panic attacks are characterized by brief attacks of intense anxiety with autonomic symptoms (e.g. tachycardia, hyperventilation, dizziness, and sweating). Episodes occur regularly, without an obvious precipitant.Major depression is characterized by depressed mood or anhedonia and depressive symptoms lasting at least 2 weeks.Bereavement is the collection of symptoms of depression that occur following death of a loved one. If the symptoms become prolonged or involve suicidal thoughts or psychoses, a diagnosis of depression may be made.

For many years, a middle-aged man has had "these swings" from being mildly elated to severely depressed. He is concerned that the swings may impact his ability to enjoy his "golden years" now that retirement is approaching. He has a past history of depression with suicidal ideation requiring hospitalization. The interview finds nothing unusual, but it is clear that he has been alternatingly depressed and hypomanic for decades despite his daily functioning never being significantly affected. Question What is the most likely diagnosis?

Bipolar disorder type II Bipolar disorder type II is the milder form of manic depression characterized by periods of major depression with alternating episodes of hypomania, a milder form of mania. Bipolar type II often features severe depression in comparison to hypomania, so hypomania is often overlooked, leading to misdiagnosis of major depressive disorder. Hypomania is an elevated, expansive, or irritable mood for at least 4 consecutive days without hospitalization or significant impairment in occupational or social function. People who experience a manic state often do not notice or understand that something is wrong with their behavior, but hypomanic states often leave that ability intact. Major depressive disorder—single-episode or recurrent—is one or more major depressive episodes without history of manic episodes. Function is significantly impaired in most areas, and individuals with major depression experience at least five related symptoms: depressed mood, loss of interest or pleasure, eating disturbance, sleep disturbances, and suicidal ideation. Persistent depressive disorder is less severe depression than in major depression, and it has a chronic course. A generally depressed mood must be present for at least 2 years to qualify, and there will likely be sleep or eating disturbances, low self-image, low energy, difficulty concentrating, and hopelessness. Daily functioning is usually not seriously impaired, but persistent depressive disorder may develop into major depression. Cyclothymia, like persistent depressive disorder, is a depressed mood that lasts at least 2 years (1 year in children). This patient's depressive episodes are not severe enough to be considered major depression, and the hypomanic episodes are not severe enough to be considered manic episodes. Daily functioning is not usually significantly impaired. Mood disorders not otherwise specified (NOS) include depressive disorders that may be superimposed on other disorders, such as major depressive episode superimposed on schizophrenia, residual type.

A 19-year-old woman presents with recurrent nightmares that interfere with her sleep. She has developed a fear of being alone. These symptoms started shortly after she witnessed the death of her sister in an automobile accident. Question What type of therapy is most likely to provide the quickest improvement in the patient?

Brief psychotherapy Brief psychotherapy is most likely to provide the best and most timely outcome in this patient. The primary goal of brief psychotherapy is the removal of the patient's symptoms. Placing the person first, it attempts to prevent the development of more serious symptoms and restore the patient to an adequate level of functioning so they can cope with day-to-day living. As the name implies, it is time-limited. Its roots are in psychoanalysis, with transference, insight, and "working through" being its key elements; these elements are accelerated.

A 23-year-old woman lost her son in a motor vehicle accident 2 days ago. She insists that the television be turned on because the morning news will implant important information about the accident in her brain. She tells you that she has been getting broadcasts daily for the past 2 days. 2 weeks later and with counseling, she is functioning normally and is not hearing voices. Question What is the most likely diagnosis?

Brief psychotic disorder Characterized by the sudden onset of at least one psychotic symptom, which lasts for up to 1 month. When the symptoms subside, the individual returns to their full premorbid level of functioning. The onset of brief psychotic disorder frequently occurs after a severe stressor; the stressor should be noted. The stressor for this woman, for example, was the death of her son. In cases related to childbirth, symptoms must occur within 4 weeks postpartum. The absence of the recent or heavy use of alcohol (or other drugs) distinguishes brief psychotic disorder from a substance-induced psychotic disorder.

You have been facilitating therapy with a 50-year-old man who came to see you because he felt depressed. During therapy you have been doing exercises such as identifying negative automatic thoughts, challenging negative automatic thoughts, and identifying unpleasant emotions. The therapy is based off of the assumption that the client had an early experience that led to the formulation of dysfunctional assumptions. With these assumptions in place the client experiences a stressful event that leads to the activation of negative automatic thoughts. The negative thoughts lead to depressive symptoms, which further escalate the automatic thoughts. This cycle continues until the negative automatic thoughts can be identified and challenged. Once these thoughts have been challenged the client can further employ problem-solving skills to deal with the stressful event. Question What type of psychotherapy are you using with this client?

CBT

A 28-year-old woman comes to see you. She complains of feeling sluggish and having very little energy. She states that she occasionally begins crying for no reason, and prefers to stay at home than be with her friends. She has continued to keep up with her job and has forced herself to keep her house clean and to stay on top of her weekly chores. Upon questioning she denies suicidal ideation or homicidal ideation. She states she just doesn't feel like doing anything. Question What is the best treatment for this patient?

CBT The depression has not caused significant impairments in her overall functioning; therefore, it falls into the mild-to-moderate range. Research has shown that the most effective way to treat mild to moderate depression is cognitive-behavioral therapy. Anti-depressants along with cognitive-behavioral therapy are extremely effective for major depression, but cognitive-behavioral therapy has been shown to have more long-term effects than pharmacotherapy, and it can prevent relapses of depression.

A 17-year-old boy presents for treatment of eczema on the back of his hands. You suspect it may be due to an anxiety disorder, though the patient denies this and says it is due to harsh hand soap. Upon questioning, he says he has not changed soap brands but that the label design changed and he thinks maybe something new was added. He is not sure how many times a day he washes his hands, but does so when eating, going to the bathroom, getting up, going to sleep, and sometimes in the middle of the night or whenever he "feels dirty." He does not think he takes a long time, but cannot say how long. He is in high school and admits to a recent drop in some of his grades; he thinks this is due to some difficulty focusing on schoolwork. He has also missed or been late to classes due to making sure that he locked his door, turned off appliances, and washed his hands. He has friends but has been spending less time with them, as he would rather be alone and has had trouble sleeping. He says that sometimes he gets sad and just feels hopeless, but he denies suicidal ideation. Appetite and weight have not changed. On exam, his vitals are stable; height and weight are at the 50th percentile. He is quiet but alert and cooperative. Skin reveals roughened dry erythematous broad areas to the dorsum of both hands and wrists extending to his lower forearms. The rest of the exam is normal. You refer him to child psychiatry. QuestionHighlights What is the most appropriate treatment for this patient?

CBT (OCD)

What medication necessitates a standing weekly blood draw? 1. Haloperidol (Haldol) 2. Chlorpromazine (Thorazine) 3. Valproic acid (Depakote) 4. Clozapine (Clozaril) 5. Carbamazepine (Tegretol)

Clozapine (Clozaril)

A 15-year-old boy presents to the emergency room complaining of several hours of shaking, chills, fatigue, and a sore throat. His medical history is remarkable for early onset schizophrenia, for which he is treated psychiatrically. He reports taking medication for his schizophrenia but does not remember the name of the drug. He has tried a number of different medications and is finally doing well on his current medication. He has no recent history of travel, has not been camping and denies any recent skin lesions.Physical examination reveals an adolescent male who is shivering despite a heavy sweatshirt and blanket. Vitals are: BP 140/85 mm Hg, pulse 120/minute, RR 20/minute, temp 101.5°F. HEENT exam is unremarkable except for pharyngeal erythema. The neck is supple without adenopathy. The remainder of the physical examination is normal.Laboratory results:UA: normalCBC: Hb 14.2 g/dlWBC 360 cells/mm3Hct 42.6%Neutrophils 204MCV 83Basophils 4MCH 30Eosinophils 2MCHC 34%Lymphocytes 132Platelet count 236,000Monocytes 18 Question What medication is most likely to have caused this patient's symptoms and abnormal CBC?

Clozapine (Clozaril) Clozapine is an atypical antipsychotic which is very effective in treating schizophrenia. The drug has a number of black box warnings so it is only indicated for treating refractory schizophrenia and is not a first-line treatment option. It has also been approved for use in reducing the risk of recurrent suicidal behavior in patients with schizophrenia. It has been shown to be effective in the treatment of refractory early-onset schizophrenia.

A 40-year-old man who works as a lawyer in Manhattan, consults you about his recent onset of depression. He generally feels well, but sometimes feels "very high and out of control". This is followed by significant depression, which usually remits after a long weekend of sleep at his lake cabin. He also apparently had visual hallucinations while driving back from a social function in the city. He has a negative psychiatry history. His physical exam is noncontributory except for nasal congestion, tachycardia with a grade 2/6 systolic flow murmur across the aortic valve, and mild tremulousness. He is orientated to time, place, and person and is generally alert. Question What is the most likely diagnosis?

Cocaine abuse A chronic user of cocaine, like the chronic user of alcohol, should always be considered in any patient with episodic depression and peculiar mood swings. Organic symptoms are like those of amphetamine use, mainly hyperpyrexia, tachycardia, and even cardiac arrhythmias. Routine continued cocaine 'snorting' often leads to nasal mucosal congestion and occasional septal perforation. Occasionally, there is a positive cardiac finding consistent with mitral or aortic valve abnormalities. The other syndromes listed have symptoms in common with cocaine use, but are not associated with all the findings associated.

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

Cocaine intoxication

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

Cocaine intoxication

A 32-year-old woman with a history of a schizoaffective disorder presents with an increase in auditory hallucinations and suicidal ideation. A psychiatrist is consulted. The psychiatrist assesses the patient and makes a recommendation for a 72-hour admission. After reviewing the patient's current medications and past therapeutic trials, the patient is started on clozapine (Clozaril). Question Due to the risk of toxicity with this medication, what lab test must be monitored in this patient?

Complete blood count (CBC) with absolute neutrophil count (ANC)

A man has a tendency to repeatedly check the stove making sure that it is turned off before he goes out. His reaction is a sign of what symptom?

Compulsions

A 17-year-old boy is rushed to the Emergency Department after an outbreak of gang violence. The incident resulted in 3 people dying, and 4 others are in critical condition. He was a witness to the violence, and his older brother is one of the deceased; however, he was not visibly injured by the incident. On examination, he is a healthy appearing 17-year-old in obvious emotional distress. During the assessment, he continually repeats, "I can't see!" He has never had a history of blindness or loss of sight, and his neurologic evaluation is normal. Question What is the most likely diagnosis?

Conversion disorder

An 80-year-old woman is referred to you for an expert opinion by her primary physician for sudden blindness that occurred last month. She was having no problems up until last month when all of a sudden she could not see. After completing a comprehensive exam, nothing medical could be found. You decide to contact her daughter to see if anything unusual could explain the situation. To your surprise, the daughter says that her mother came home one day and found her husband in their bed with the next-door neighbor and then suddenly passed out. Question Excluding any physiological explanation, what could be a provisional diagnosis?

Conversion disorder

A 45-year-old woman visits a clinic complaining of recurrent periods in which she feels separated from her body. She often feels as though "it's not me doing the moving or the thinking. I'm just a spectator while somebody or something else is making me do things." These episodes cause her considerable worry because she knows that these feelings cannot actually be trusted, that there is no possible way for something outside her to be controlling her behavior. Question In the absence of any general medical condition or any evidence of substance use, which psychiatric diagnosis might be suggested in this case?

Depersonalization disorder

A patient known to be a victim of childhood sexual abuse is currently in a volatile relationship. She reports that when she and her boyfriend argue, she feels as though she is standing outside herself watching the scene. Question What might be the secondary diagnosis?

Depersonalization/Derealization Disorder or DDD

A 32-year-old woman presents to the outpatient clinic due to weight loss. She has lost 10 pounds in the past month. The patient feels empty, and she lacks interest in her life. She has also been feeling guilty and experienced low self-esteem since the death of her husband 1 year ago. The patient doesn't enjoy anything that she used to in the past. Her appetite is decreased, but she is otherwise healthy. Question What is the most likely diagnosis?

Depression

A 35-year-old woman with no significant past medical history presents with a feeling of constant worry for the past year. She states she is anxious about constant deadlines at work, family obligations, financial constraints, car repairs, the health of her two young children. She denies tobacco, alcohol, or recreational drug use. She reports fatigue, restlessness, and muscle tightness, especially around her neck. She denies any chest pain, shortness of breath, palpitations, cough, edema, diaphoresis, or changes in weight, diet, or caffeine intake. Her physical exam reveals cervical myospasms but is otherwise unremarkable. Question What medication is expected to induce the most rapid clinical response?

Diazepam This patient's history is most consistent with generalized anxiety disorder (GAD). A combination of pharmacologic and psychotherapeutic interventions is most effective in treating GAD. Diazepam is a rapidly absorbed lipid-soluble benzodiazepine that improves symptoms in minutes to hours. The risk of tolerance and dependence, however, makes this class of drugs a poor long-term option. SSRIs like escitalopram are effective, but typically only after being taken for at least a few weeks. Unlike diazepam, oxazepam is a benzodiazepine that has a slower onset of action compared to diazepam. Instead of symptoms improving in minutes to hours, onset of action is a few hours after the first dose of oxazepam. Buspirone is also effective, but it can take at least 2 weeks before it begins to help. Lithium is the mainstay of treatment in bipolar disorder and as prophylaxis in recurrent mania and depression. Lithium is not indicated for GAD. The therapeutic effects of lithium may not appear until 7-10 days of treatment.

Hyperventilation in precipitating panic attacks has been offered as one hypothesis for the patient's active role in this phenomenon. Tests of transcutaneous arterial CO2 pressure (PCO2 ) were used to test this directly and provided evidence for:

Dismissing this purported mechanism of symptom production

A 45-year-old man is known to be an alcoholic. One day he leaves work and travels to another town, where he applies for a job using a different name (although he does not realize he is presenting himself as someone else). He returns home the following day and wonders why his family is concerned, as he claims to have no memory of his adventure. Question What has the patient likely experienced?

Dissociative Fugue

During therapy, your client begins to reveal what might be distinct personalities. You know she is an incest survivor. Although you have tentatively diagnosed her with a Post-Traumatic Stress Disorder, you wonder whether a correct diagnosis might be something else. Question What is another possible diagnosis?

Dissociative Identity Disorder

An individual is found wandering and claims that he cannot remember how he got where he is. He appears very confused and states that he's never had anything like this happen to him before. The individual is aware of his personal identity. Question Barring any physiological explanation for his condition, this individual is most likely suffering from what?

Dissociative amnesia Dissociative disorders, such as Dissociative Amnesia, Dissociative Fugue, Dissociative Identity Disorder, and Depersonalization Disorder, are characterized by sudden or gradual change in consciousness, identity, memory, or perception. These changes may be chronic or transient and they are not associated with physiological problems. Dissociative amnesia is diagnosed when an individual is unable to remember important information. Often the information will be stressful or traumatic in nature, the amnesia is temporary, and unless it occurs suddenly in response to a specific, extremely stressful event such as a natural disaster, Dissociative Amnesia normally takes the form of a retrospective forgetting of a stressful event (i.e., an event of the past is forgotten). A Dissociate Fugue is a rare condition that is most commonly seen after an individual experiences war or a natural disaster. Usually the individual travels during the fugue state, experiences confusion, and may take on a new identity. It normally lasts only a short time, and typically the individual is unable to remember things that happened during the fugue state. An example of a Dissociate Fugue that is not stress-related is a blackout experienced by an alcoholic. Dissociative Identity Disorder is a severe condition in which an individual has at least two distinct identities that can take over his or her behavior. Stress is thought to bring on the personality changes, and the disorder is believed to have its origins in severe childhood trauma. Dissociative Identity Disorder is controversial as a diagnosis, and often incorrectly diagnosed. Depersonalization Disorder is characterized by feeling unconnected to oneself, such as in feeling "unreal," having unusual body sensations, and in having an inability to recall personality information. While perceptions of time, other people, or of objects may be impaired, reality testing is essentially intact among individuals with Depersonalization Disorder. Like other Dissociative Disorders, acute stress is thought to be responsible for Depersonalization Disorder. When an individual experiences symptoms of Dissociative Disorders that are not sufficient to make a particular diagnosis, the diagnosis of Dissociate Disorder Not Otherwise Specified may be made.

A 70-year-old woman presents to be evaluated for bizarre behavior. Her daughter arrives with her and speaks with you alone; she describes her mother's behavior as consisting of mood swings, lavish trips, spending foolishly, staying up at night, and being hyper. According to her daughter, her mother has been diagnosed with bipolar disorder in the past. Past medical history is significant for chronic kidney disease stage III, obesity, diabetes mellitus, and hypertension. Question What drug might you consider?

Divalproex (Depakote) Divalproex (Depakote) is a preferred or suggested drug as a mood stabilizer; it has also been used to treat aggressive behavior in patients with Alzheimer's disease. It has been shown to be more favorable than using lithium, especially in nursing homes, because lithium can cause excessive weight gain. Lithium should not be used in patients with kidney disease. Divalproex (Depakote) should not be used in elderly patients who already have poor liver functioning.

Which of the following is thought to be the major neurotransmitter involved in schizophrenia?

Dopamine Explanation The major neurotransmitter involved in the etiology of schizophrenia is dopamine. The dopamine hypothesis of schizophrenia states that neurons in the schizophrenic's brain have become oversensitive to dopamine. Clinical evidence for this hyperdopaminergic state comes from the finding that phenothiazines (antipsychotic drugs) such as chlorpromazine, which block dopamine at the synapse, have a therapeutic effect. It has been found that the stronger the blockade, the more therapeutic the drug. Furthermore, it has been found in autopsy studies that the brains of schizophrenic patients have an increased number of dopamine receptors. Note that this is also true of patients who have never been treated with any kind of medication. On the other hand, it has been found that amphetamines which enhance dopamine activity, when taken in overdose, can result in amphetamine psychosis, a temporary condition similar to paranoid schizophrenia. Also, L-Dopa that is administered as treatment for Parkinson's Disease has been found to cause psychosis in some patients. Both of these findings may be taken as further evidence for the dopamine hypothesis of schizophrenia. Two other neurotransmitters are also involved in the etiology of schizophrenia, to some extent. Hyperdopaminergic activity can be caused by decreased levels of gamma-aminobutyric acid (GABA), and in paranoid schizophrenics, there may be an increased level of norepinephrine activity.

A 19-year-old man with a family history of schizophrenia is receiving medical attention for his first presentation of psychosis. After ruling out organic causes and substance abuse as etiologies of his symptomatology, antipsychotic therapy with haloperidol is initiated. Within 48 hours, the patient begins to experience involuntary spasmodic contractions of the muscles in his face and neck. Question Inhibition of what neurotransmitter/receptor is causing the patient's symptoms?

Dopamine (D2) (first gen antipsychotic, works on pos sx's caused by increase in dopamine)

A 34-year-old woman who works as a technician for a major company visits your outpatient clinic. She is complaining of fatigue, low energy, and a depressed mood. She states, "I have felt this way for most of my life." She is feeling depressed most of the time and denies any recent stressors or significant losses in her life. She has no interests outside of her job, she has no happy thoughts, and her self-esteem is very low. She denies suicidal thoughts but states that she does not care if she dies. She states that although she often feels tired, she has a hard time sleeping at night. She is taking no medications and denies substance abuse. Her physical exam is unremarkable. Her electrocardiogram is normal. Her blood work is as follows: Hemoglobin12.6 g/dLHematocrit34.5%Platelet354x109Sodium136 mmol/LPotassium4.0 mmol/LChloride102 mmol/LBicarbonate18 mmol/LGlucose100 mmol/LUrea12 mmol/LCreatinine0.6 mmol/LThyroid stimulating hormone level0.31 mU/L Most likely diagnosis?

Dysthymic disorder

A woman calls you to begin therapy. During the initial phone call, you ask her why she is seeking therapy. You learn that while the woman has never been depressed to the point of significantly impaired functioning, over the past 2.5 years she has felt as though she cannot sleep and complains of being tired all the time. She further describes that she feels like she is in a "slump" and is unable to do some of the things she would like to do. She is not suicidal and has never felt like she was even slightly manic. Question What is the most likely diagnosis?

Dysthymic disorder

The patient is a 36-year-old man who presents to your office suffering uncontrollable shaking, which manifests in social situations. He confides in you that it has ended 3 jobs and 3 relationships in the previous 6 years. Question What should you recommend?

Escitalopram (Lexapro) (Social Phobia)

A 31-year-old woman presents because she spends hours in her home due to intrusive thoughts followed by repetitive actions. She constantly has thoughts of checking locks, and she states that it takes her an hour to leave the house because she constantly has to check to make sure every door and window is locked shut. She is very disturbed by these thoughts and actions, and she wishes them to disappear. Question Which of the following treatment options should be initiated first in this patient?

Exposure and response prevention (OCD)

After multiple clinic visits, it becomes clear that a 34-year-old man is reporting symptoms of depression which do not exist, as confirmed by family members. The patient has a reasonably stable, ongoing relationship with his wife, and has no apparent problems or complaints about his job as a supermarket manager. The evaluating psychiatrist says that he believes that the patient enjoys the sympathy and attention paid to him by the psychiatrist and clinic personnel. Question What is the most likely diagnosis?

Factitious Disorder

You have a 38-year-old female nurse as an inpatient. She was admitted with a fever of 103 degrees Fahrenheit and elevated white count. Serum cultures were positive in two of three samples for Escherichia coli. She improves on I.V. antibiotics until the 4th day, when her temperature spikes to 104 degrees Fahrenheit. A new set of serum cultures are positive for Candida albicans. When you discuss the results with her, she seems somewhat detached and suggests consulting the nurse in charge of infection control. She also requests a bone marrow biopsy as part of her evaluation. She tells you she has a weak immune system and it is hard for her to work with sick people. Question You began to suspect a psychiatric consult might be needed to evaluate the possibility of what condition?

Factitious Disorder

A 37-year-old nurse presents with acute bouts of intractable diarrhea and abdominal pain. She has had multiple studies, including CT scan, barium enema, and colonoscopy, all of which have been negative. Stool exam is negative for ova and parasites. Chemistries are normal. Ultimately, a urine toxicology analysis returns positive for bisacodyl, a laxative. When the patient is confronted with a self-induced illness, she vigorously denies the allegation. Question What is the most likely diagnosis?

Factitious disorder

A 20-year-old man is being treated after an apparent suicide attempt. He is a junior at a nearby college and has been doing well in school. Peers recently noticed mood swings which have resulted in his being very unlike himself. He is experiencing periods of agitation and sleeplessness that alternate with episodes of lethargy, depression, and withdrawal from his family and friends. Today, he was found in his dorm room after taking an unknown quantity of pills. He left no note, but according to his friends, he has been extremely depressed lately. After his medical condition is stabilized, he is admitted to the psychiatric department for further observation and treated. His condition improves, and he is discharged. Question What is this patient's prognosis, appropriate diagnosis, and treatment?

Fair with a high chance of symptom recurrence The prognosis of this patient is fair with a high chance of symptom recurrence. The prognosis of bipolar disorder is worse than that of depression alone. Approximately 40% of patients experience another manic attack within the 1st 2 years after the initial episode. Only 50 - 60% of patients with bipolar disorder who are on medication are able to gain full control of their symptoms, which may even worsen with age. Patients are most likely to have a poor prognosis if they are boys/men, have a poor job history (including not being able to stay with a particular job for any reasonable length of time), abuse alcohol, have psychotic episodes, experience depressive periods between mania and depression, and have symptoms that begin earlier in life. Better prognosis is seen in patients with a late onset of symptoms, fewer suicidal thoughts and episodes of psychosis, few medical problems, and shorter duration manic phases.

A 32-year-old woman presents for follow-up after being seen in the emergency department 2 days prior. Her mother brought her in after witnessing the patient having a seizure. While in the ED, the patient was observed having another seizure. She appeared to be shaking with asynchronous movement of her right and left arms. She remained conscious throughout the episode. EEG monitoring was negative for any seizure-like activity. The patient was also seen in the ED 3 months ago following a sexual assault. The patient notes poor sleep and difficulty motivating herself to complete her daily activities. On examination, the patient appears tearful. Neurological examination is normal. Question What is the most appropriate medication for this patient?

Fluoxetine (Conversion disorder)

A 32-year-old woman presents to the outpatient clinic due to weight loss. She has lost 10 pounds in the past month. The patient feels empty, and she lacks interest in her life. She has also been feeling guilty and experienced low self-esteem since the death of her husband 1 year ago. The patient doesn't enjoy anything that she used to in the past. Her appetite is decreased, but she is otherwise healthy. Question What is the most suitable treatment?

Fluoxetine (Depression)

A 22-year-old college student is brought to the office by his roommate because he feels there is "something wrong" with him. He states that he spends hours cleaning himself several times a day and takes a shower for 2 hours in the morning. The patient states, "I just want to be clean!" Question What should this patient be treated with?

Fluoxetine (OCD)

A 36-year-old married woman presents with a 10-year history of fear of making mistakes and forgetting things, resulting in her spending time checking and mentally reviewing her activities; she also has a fear of becoming contaminated with unspecified germs and passing this contamination to others who might become ill and die, and she would be held responsible for their deaths. These fears developed when she was working as a surgical nurse. She became concerned that she would contaminate the surgical field and that this would result in serious consequences for the patient. She is no longer able to work and spends a substantial amount of her day washing and cleaning objects in her home. Her marriage is in trouble because of her fears. Question In addition to behavioral therapy, what drug should be used to treat this patient?

Fluoxetine (OCD)

A 35-year-old man tells you that, for the past 6 months, he has been "on pins and needles". He is not sleeping properly, he suffers vascular headaches, and he has difficulty concentrating. He claims that he feels this way most of the time and although he does not understand why he is far more nervous and stressed than usual. The man's psychosocial and medical histories are unremarkable. Question What is the most likely diagnosis?

GAD

A 60-year-old woman with a background of hypothyroidism that is adequately controlled with levothyroxine visits her family physician for follow up. The duration of her patient visits is generally over-extended due to manifestations of chronic anxiety and worry. In the past the symptoms have been difficult to control. There are no obvious stressors in her life. In addition, she is restless, fatigues easily, has difficulty concentrating, is irritable, and has muscle tension and sleep disturbance. She had worked as a secretary in a local medical office. She had to leave this job because, currently, the symptoms are causing significant distress and impairment in her day to day functioning. Question What is the most likely diagnosis?

GAD

A 23-year-old woman states that she has been feeling irritable and worries constantly about her children, who have recently started school. She also worries about her father, who was recently diagnosed with high blood pressure. She is concerned that her husband might leave her because they have been fighting more often than usual. The patient appears restless and fidgets frequently, wringing her hands while speaking. She adds that she has been on edge for at least the past 8 months and that she is having problems doing her job at work. Question What is the most likely diagnosis?

Generalized anxiety

Bipolar II disorder is characterized by a history of which of the following?

Hypomania and major depression

A 25-year-old man is brought to the urgent care center by his friend. He says that his friend has not been acting like himself for the past 10 days. He says he has been playing music extremely loudly and dancing to it all night. During the day, he goes shopping, and he has maxed out on all his credit cards. He has also been picking up a different woman every day in the past few days and taking them home, even though he has a steady girlfriend. He has hardly slept in the last few days. When his friend tried speaking to him, he just got annoyed and told him that the friend is jealous that he is having such a good time; the patient added that he is going to kill everyone who comes in his way, including the President. However, for the past 2 days, his mood has suddenly gone down, and he has mostly been in bed sleeping, refusing to eat, and crying most of the time; the evening of presentation, he tried to slit his wrists, and his friend stopped him and brought him to the hospital. The patient is diagnosed with a psychiatric illness and is put on maintenance therapy of the drug of choice for this illness. Question What is a possible side effect of the drug of choice for this disorder?

Hypothyroidism The patient has bipolar disorder, and the drug of choice for this disorder is lithium carbonate. One of the major adverse effects of this drug is hypothyroidism. Bipolar disorder is characterized by periods of deep, prolonged, and profound depression that alternate with periods of an excessively elevated and/or irritable mood known as mania. Manic episodes are characterized by profound mood disturbance, elation, irritability, grandiosity, diminished need for sleep, excessive talking, flight of ideas, increased distractibility, and excessive pleasurable activities (often with painful consequences). The mood disturbance is sufficient to cause impairment at work or danger to the patient or others.

A patient presents with severe, schizophrenic-like, cognitive dysfunction. His parents report that he has a history of "huffing" gasoline; he began doing so when he was quite young. You rule out schizophrenia as a diagnosis based on other findings. Question What is the most likely diagnosis?

Inhalant-related disorder

A 60-year-old woman is diagnosed with major depression. History, physical, and lab testing are completed, and it is recommended that she would benefit from talking to someone about some of the stressful events in her life that have occurred in the past. Question What therapy would be considered?

Interpersonal therapy Interpersonal therapy uses a non-authoritative approach that allows clients to take more of a lead in discussions so that, in the process, they will discover their own solutions. The therapist acts as a compassionate facilitator, listening without judgment and acknowledging the client's experience without moving the conversation in another direction. it focuses on interpersonal problems such as relationships, social roadblocks, and works to help overcome mood disorders. Cognitive therapy is a part of cognitive-behavioral therapy that focuses on unhealthy thoughts and works to replace these thoughts with more positive ways of thinking. Behavioral therapy is a part of cognitive-behavioral therapy that only focuses on the behavior rather than the preceding negative thoughts. It works to change self-destructive and negative behaviors into more positive outcomes. Group therapy encompasses any type of therapy but in a group setting. Family therapy is used to allow family members to interact with the therapist and to better understand the family dynamic and how it is associated with the mental health disorder, at hand.

The most effective treatment for bipolar I depression is a natural mineral salt called

Lithium

A 70-year-old woman presents after collapsing at work. She has a medical history significant for a mood disorder that causes her to have wild mood swings and reckless behavior. She was diagnosed with this disorder 1 year ago and has been taking her prescribed medication. She was recently hospitalized for acute gastroenteritis that was complicated for acute renal failure. Shortly after this, she reports experiencing nausea, vomiting, fatigue, tremor, and hyperreflexia. Lab results show an elevation in BUN and creatinine and elevated serum drug levels, but the results are otherwise normal. Question What drug is most likely responsible for her symptoms?

Lithium (for Bipolar disorder)

A 37-year-old war veteran comes to the clinic after returning from his last tour in Iraq. During his final days, he witnessed a car bombing that killed 4 of his friends. He feels that he may be experiencing a bout of depression due to the loss of his friends. When probed about the attack, he cannot recall the events that followed the bomb explosion. His memory of that day returns when he "wakes up" in a hospital tent several hours later. He received no injuries from the attacks. After a full work up, including an EEG and other lab work, prove to be negative, a diagnosis of dissociated amnesia is made. What type of amnestic pattern did this man present with?

Localized Several patterns can be found in amnestic events. In dissociative amnesia, localized and selective are the 2 most prevalent. Dissociative amnesia occurs after a traumatic or stressful event that cannot be attributed to forgetfulness. A full work-up includes excluding any organic cause that can explain the patient's inability to recall the events. Localized amnesia is the inability to recall any events after a traumatic event; the loss of memory can last for several hours to a couple of days. The selective pattern presents with the inability to recall all events, but certain memories stay intact. The generalized pattern is an extremely rare disturbance in which the individual cannot recall any events from his/her life. In the continuous pattern, there is a failure to recall any event after the date of the traumatic event. The systematized pattern of amnesia shows a disturbance in memory of topics pertaining to a certain person, place, or event.

A 60-year-old woman presents with a 6-week history of depressed mood, crying episodes, feelings of guilt, and an inability to sleep. She states that she has had these episodes before and was treated with antidepressant therapy. She reports that she has recently gained a significant amount of weight. Her daughter notes that there is a family history of this behavior; the patient has no significant medical problems. Question Of what condition is this suggestive?

Major depression, recurrent

A 37-year-old woman was diagnosed as HIV-positive 3 years ago; she is unable to work and is physically debilitated, so she asks you to provide her with medications with which to take her own life. Question What is the most common emotional disorder associated with such a request?

Major depressive disorder

A 60-year-old woman is referred to you for an expert evaluation by the adult protective services department for repeated problem behavior of filing lawsuits which seem frivolous and it is suspected that she is doing this to get settlements for financial gain. After interviewing the client, she has no other mental health history and says that she is suing her doctors for malpractice but does not give sufficient grounds. Client seems to have a repeated history and after obtaining court records, she has filed over 100 suits, of which none have settled. Question What is your provisional diagnosis?

Malingering

A 25-year-old man is referred to you for evaluation. He has no history of psychiatric disturbance, and there is no family history of psychiatric illness. During the evaluation, he states that he has seen people following him and he has been having difficulty concentrating. He believes that he is in danger and that the people following him are FBI agents. When asked about the onset of the symptoms, he states that they began about 1 month ago and they have persisted ever since. The patient is not currently taking any psychiatric drugs, but he has been taking antihistamines to treat allergies for about 1 month. Question What is the mostly likely diagnosis?

Medication-induced psychotic disorder The most likely cause of the patient's symptoms is substance/medication-induced psychotic disorder. The patient's symptoms had a sudden onset approximately 1 month ago, which is when the patient began taking antihistamines. Visual hallucinations with an absence of auditory hallucinations are commonly associated with substance-induced psychotic disorders, but they are rare in other psychotic disorders. For a diagnosis of schizophrenia, the symptoms need to have persisted for at least 6 months. Schizophrenia also has a gradual onset of symptoms that lead up to the first psychotic episode. Schizoaffective disorder can also be ruled out due to the absence of mood symptoms and because the onset and presentation of psychotic symptoms are similar to those seen in schizophrenia. Schizophreniform disorder is diagnosed when symptoms of schizophrenia are present for at least 1 month but less than 6 months; as with schizophrenia, sudden onset and visual hallucinations in the absence of auditory hallucinations are not common in schizophreniform disorder. Brief psychotic disorder can be ruled out because the symptoms have persisted for at least 1 month.

Temporal lobe damage results in

Memory loss/auditory deficits

An 87-year-old man who resides in an assisted living facility has been on a regimen of sertraline 50 mg daily for the treatment of depression. Recently, the staff has noted a change in his behavior. The change is marked by agitation and irritability. Friends have observed him to be withdrawn; he refuses to participate in recreational activities and rarely appears for meals. There are concerns about his symptoms, and the medical director at the facility requests a psychiatry consultation. Question What test would you most likely want to use in the evaluation of this patient?

Montgomery Asberg Depression Rating Scale (MADRS) The psychiatric evaluation of this patient would most likely include a measure of the severity of this patient's depressive symptoms as well as an assessment of current antidepressant drug therapy. The most appropriate tool for these purposes is the Montgomery Asberg Depression Rating Scale (MADRS). The MADRS is designed to be used in patients with major depressive disorder to measure the change in symptom severity during the treatment of depression. It is also a sensitive measure of the degree of severity of depressive symptoms. The Abnormal Involuntary Movement Scale (AIMS) is used to assess the occurrence of dyskinesias in patients receiving neuroleptic treatment. The Weinberg Screening Affective Scale (WSAS) is a self-reported questionnaire used to evaluate the presence of depressive symptoms in children and adolescents. The Disruptive Behavior Disorders Rating Scale (DBDRS) is a tool used to screen for attention deficit hyperactivity and conduct disorders. The Brief Psychiatric Rating Scale (BPRS) is designed to assess psychopathology, which includes positive, negative, and affective symptoms in patients with diagnosed or suspected schizophrenia or other psychotic illnesses.

A prolonged emotional state that affects almost all of a person's thoughts and behaviors is called a _____________ disorder

Mood

An 80-year-old man is referred to you for an assessment of pain all over his body. He has no significant medical history but after asking him to take a depression inventory, he appears very depressed and has low energy, fatigue, and insomnia. He also has crying spells. He has no other major mental health problem and is in good medical condition. Question What is your provisional diagnosis?

Mood disorder with pain Factitious disorder is a somatization disorder in which the patient intentionally develops physical or mental symptoms in order to play the sick role and get attention from health care professionals. Clients with malingering develop the signs and symptoms in order to have material gain such as drugs or money. Clients with a mood disorder such as depression sometimes complain of undifferentiated pain, and this is especially common in the elderly. Some clients with a history of substance abuse complain of mental or physical symptoms but the substance abuse is sometimes hidden and you must obtain a very comprehensive history. Pain due to a medical condition must always be ruled out, and pain is common in peptic or gastric ulcers, gallstones, diabetes, infections, and other physical disorders.

A 29-year-old computer technician is arrested after breaking into the office of his former employer. He had been a reliable and well-liked employee who had never had any problems on the job, but he was dismissed from his position due to corporate downsizing. Shortly after his departure, he learned that a female colleague had received a promotion. Without specific evidence, he nevertheless became convinced that this colleague had orchestrated his dismissal by writing negative memos about him to senior leadership. In the coming weeks, he rarely left his home. When he was seen, neighbors described his appearance as unkempt and observed him seeming to mumble under his breath. Convinced that he would find copies of the incriminating memos in his colleague's desk, he broke into the office to prove his suspicion. After a brief detainment by the police, he was released to psychiatric care. Within a few weeks of appropriate treatment, his symptoms had resolved and he had successfully started a new job. Question What is the recommended treatment for this condition?

Neuroleptic medication until symptoms stabilize, followed by gradual medication withdrawal unless symptoms recur Most patients with schizophreniform disorder respond quickly to neuroleptic medication. After clinical stabilization, medication therapy can usually be withdrawn gradually without increased risk of symptom recurrence. Occasionally, however, maintenance treatment is required.

A 49-year-old woman presents for a consultation 1 month after her 22-year-old son was killed in a fall at a construction site near her home. The patient is upset, restless, and reports feeling lonely. She lies awake at night. She does not feel like eating. She cries easily when she looks at their family pictures around the house. She wishes she could talk to him again, and she reports she sometimes thinks she sees him walking just outside their home. She says she wishes she would have died instead of him, but she denies any thoughts or plan of harming herself. Question What is the most likely diagnosis?

Normal grief reaction Grief or bereavement follows a loss or trauma. Restlessness, loneliness, disbelief, distractibility, numbness, reduced appetite, sadness, apathy, and a need to talk of the dead are all part of the normal grieving process. Hallucinations or inconsistent memories of the deceased can occur. Fleeting thoughts of wishing they had died with or instead of their love one can also occur. Though this is not a linear process and can vary greatly among individuals, it is not uncommon for a normal grief response to last 6-12 months.

A 35-year-old woman presents with severely chapped and calloused hands. You can find no evidence of infection or another explanation for her condition. You learn that she feels compelled to wash her hands at least every 30 minutes during the day. She is distressed by this behavior. Question What is the most likely diagnosis?

OCD

A woman loves to clean, and she spends much of her time looking around her home for things to straighten or dust. Unable to relax, she has been accused of being a perfectionist; in fact, she finds it hard to enjoy golf with her husband because she does not think he takes it seriously enough. While her home is extremely neat and clean, her attic contains boxes filled with old buttons, magazines, food coupons, and bits of string and broken lamps because she thinks she might need them someday. Extremely careful with her money, she is overly concerned with going broke; even if it means denying her family little things they would like, such as an occasional movie, she thinks that it is important to save as much money as possible. Question What is the most likely diagnosis?

OCD Obsessive-compulsive personality disorder (OCPD) is a personality disorder where the individual desires to main in full control of every situation. It is characterized by orderliness, perfectionism and excessive devotion to work to the point they exclude hobbies and friendships. The individual is often detail oriented and when things do not work out in their favor they can quickly become angry. They may be so obsessed with orderliness, rules, organization, lists and schedule that they often become so pre-occupied that cannot complete the task at hand. Additionally, they often practice hoarding behaviors, unable to spend money they earn or give away used items and clothing. The individual prefers this lifestyle and usually does not see this as a disorder but rather as a productive way to live. The compulsions or actions seen in this personality disorder are driven out of fear of being negatively judged or evaluated by others. This differs from the compulsions in OCD that are carried out in order to alleviate the anxiety from the individual's repetitive thoughts. Since OCPD is a personality disorder, it is usually diagnosed in adulthood and is known to affect twice as many males as females. Additionally, this disorder is ego-syntonic meaning that these characteristics of mental and interpersonal control are satisfying to the individual and align with their core beliefs, as opposed to the ego-dystonic thoughts and compulsions seen in OCD. Borderline personality disorder (BPD) is a complex severe mental illness that is characterized by poor interpersonal relationships, mood instability and unstable self-image and behavior. Personality disorders represent "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture" per the Diagnostic and Statistical Manual on Mental Disorders, Fifth Edition (DSM-5). Dependent personality disorder is a psychiatric condition marked by an overreliance on other people to meet one's emotional and physical needs. Anxiety disorder NOS is a rule out disorder that has characteristics of anxiety but does not meet any of the DSM criteria for the specific anxiety disorders

A 45-year-old man comes to see you because he is feeling extremely stressed out. He is a middle manager in a large corporation, and he states that he has too many things to do and he cannot organize all of his tasks. He states that even his lists are no longer working for him. He has so many tasks to do that he spends half of his day writing and re-writing his lists until they are perfect. He has not taken a vacation for almost 5 years. His family complains that they never see him because he is always at work. During the interview, he keeps muttering to himself that he cannot take time off because there is too much work to do. His boss came in to talk to him the other day, and he blew up at him. The man says that he cannot handle the pressure anymore; he claims that he would delegate tasks to his staff, but they do not pay attention to the details the way he does and do not seem to put a high priority on the tasks. When his boss hands him a task to do, he does not leave the office until that task is perfectly completed. The client is stiff as he sits in your office, and he adjusts his tie several times to make sure it is perfectly centered. Question What is the most likely diagnosis?

Obsessive-compulsive personality disorder

A 19-year-old woman presents with recurrent nightmares that interfere with her sleep. She has developed a fear of being alone. These symptoms started shortly after she witnessed the death of her sister in an automobile accident. Question Without further evaluation, what would be a tentative diagnosis?

PTSD

A 22-year-old woman has a history of being involved in a bank robbery 8 months ago. Since then she noticed she has been having loss of memory, flashbacks, disruptive sleep and nightmares recalling the event, irritable moods, and difficulty concentrating. She denies any palpitations, tachycardia, or any chest pain. She denies any repetitive behaviors or feeling uncomfortable in social settings. She also denies any need for order or symmetry, unwanted intrusive thoughts, or scrupulosity. The patient does not mention any concerns about excessive worrying. Upon physical exam, the patient appears disheveled, with poor hygiene and flattened affect. She does not present with any hair loss or baldness. Upon lab results, everything is within normal limits. Question What is the most likely diagnosis?

PTSD

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

PTSD

A 19-year-old male college student presents with pounding heart, sweating, coldness, and difficulty in breathing. He said that he was studying for an important exam and drinking lots of caffeine, then started to feel like he was going to die of an attack. Examination, ECG, and tests do not demonstrate any pathology. Question What is the most likely diagnosis?

Panic attack

A 15-year-old boy describes himself as an athletic sophomore on the track team. He has been having episodes that concern him because he has no control over them. Sometimes when he is in crowded spaces such as elevators, he feels his heart begin to pound and experiences dizziness and numbness in his hands and feet. The episodes have been affecting him for the past 7 months. He is concerned that he may have an attack at school or during a track meet. These symptoms do not occur in other social settings. The patient has no history of substance abuse, head trauma, diabetes, or exposure to toxins. There is no family history of this particular type of disorder, but his mother has anxiety and depression. Question What is the most likely diagnosis?

Panic disorder

A 23-year-old woman presents due to palpitations, numbness, shortness of breath, and sweating. She reports that these episodes have been occurring once or twice a week for the past several months and that she cannot discern any consistent pattern or trigger. Although the symptoms occur seemingly at random and independent of social situations, she reports that she has begun to limit her social activities for fear of having an episode while she is away from home. Physical exam and laboratory findings are within normal limits. Question What is the most likely diagnosis?

Panic disorder

A 33-year-old woman comes to your office and complains of recurrent "spells," during which, she feels intensely fearful and experiences shortness of breath and palpitations. After each episode, she says, she worries for weeks about having another spell. There is no medical explanation for her condition. Question What is the most likely diagnosis?

Panic disorder

A man presents complaining of dizziness and a pounding heart while he is at work. He also complains of numbness in his hands and feet. He cannot figure out what is causing his symptoms, and they do not seem to be related to anything, in particular. Symptoms are always the same, and they have been going on for 6 months now. He often worries that he'll be struck by one of these episodes during a business conference or on a business trip. He thinks he might be going crazy; occasionally, he takes a drink to try to steady himself. Sometimes, he gets dizziness with nausea; when he is overcome with the symptoms, he experiences a fear of losing control, dying, or going crazy. Neither his primary physician nor a gastroenterologist can find anything wrong with him. He is referred to a neurologist, and he cannot find anything either. He has no history of substance abuse; there is no history of head trauma or diabetes. He has not been exposed to any toxins. There is no family history of this type of disorder; however, his mother does suffer from anxiety and depression. Question What is the most likely diagnosis?

Panic disorder without agoraphobia

A 39-year-old woman presents with a history of repeated short episodes of intensely anxious and fearful moments with physiologic manifestations, such as trembling, tachycardia, dizziness, sweating, and a smothering sensation. She has these episodes almost daily and feels they greatly impact her life when they occur. She denies symptoms of agitation, insomnia, and depression, and she states she does not have a history of recreational drug use. After an extensive workup, a diagnosis is made. Question What is the best drug for treatment of her most likely condition?

Paroxetine This patient has panic disorder. The best drug for this condition is paroxetine, a selective serotonin reuptake inhibitor (SSRI). These drugs are the first-line pharmacological treatment of panic disorder because they are effective and dependence is not a concern as with benzodiazepines. Alprazolam and diazepam are also effective for panic disorder, but they are typically reserved for short-term use because the development of tolerance and dependence may occur over time. They are typically used to alleviate distress or impairment in the weeks before SSRIs take effect. Propranolol is a beta blocker that has been used for performance social anxiety disorder, though it is not approved for treatment of anxiety disorders. Hydroxyzine is used for the treatment of sleep disorders (e.g., insomnia associated with generalized anxiety) due to its sedative properties. This patient does not exhibit symptoms of agitation or insomnia.

A 31-year-old non-breastfeeding woman presents with recurrent episodes of severe palpitations, tachycardia, dyspnea, and impending dread that began shortly after the birth of her first child, which occurred about 4 weeks ago. Although the patient admits to very sporadic episodes of similiar symptoms previously, she was able to use meditation methods to resolve them. She has been attempting to use her techniques and unfortunately this has given her no relief from her symptoms. Question Based on her most likely diagnosis, what is best for the sustained treatment of her condition?

Paroxetine (Panic disorder)

A 25-year-old woman has a 2-month history of "episodes" that occur more than 3 times a week. She describes the episodes as a pounding heartbeat, breaking out in a sweat, and difficulty catching her breath. Occasionally, she will feel dizzy and faint with a "tingling" sensation throughout her body. Question Based on the suspected diagnosis, what is the first-line drug used in management of this disorder?

Paroxetine (panic disorder)

A 36-year-old woman presents because she has been feeling very tired and unhappy for the past 3 years; she thinks that she has no hope of better days in the future. She states that it is amazing her boss has not fired her yet because she is one of the company's worst employees. She cannot recall the last time she was excited about anything. She denies other symptoms. Her vital signs are stable. Her height and weight are within normal limits. Question What is the most likely diagnosis?

Persistent depressive disorder (AKA Dysthymic disorder)

A 42-year-old woman presents for a routine appointment. She is a relatively new patient; she was seen for the first time for her annual gynecologic examination 2 months ago. At that time, she was noted to be tearful and appeared sad. Although she is a professional chef, the patient describes little interest in eating. She has difficulty concentrating, and she has long been described as "irritable" by her co-workers and her husband. She feels tired during the day and is having difficulty sleeping at night. Despite the success of her restaurant, the patient reports feeling sad and hopeless most days for the past several years, and cannot recall any significant period of time when she was symptom-free. However, she remains active in her monthly book club and denies feelings of worthlessness or any thoughts of self-harm. She initially thought that she was menopausal, but her menses are regular. She now feels that she is depressed, and she would like to discuss her treatment options. She denies any current or past symptoms of mania. Physical examination is unremarkable, without obvious psychomotor symptoms.Labs (drawn during first week of menstrual cycle/follicular phase): FSH 10 mU/mL (menopausal range: 30-100) LH 8 mU/mL (menopausal range: 16-166) Chemistry panel and CBC values all within normal limits. Question What is the most likely diagnosis?

Persistent depressive disorder (Dysthymia)

Which of the following describes schizo-affective disorder?

Psychiatric illness with symptoms that meet criterion A for schizophrenia, along with a major affective illness

A 28-year-old woman comes to see you. Her family begged her to see a psychiatrist because she just lies in bed all day long. The woman states that she just can't seem to get herself out of bed and that she doesn't want others to see her crying. She states that she doesn't understand why she feels so sad all the time, but life just seems worthless all of a sudden. When asked about suicidal ideation, the woman states that she thinks about dying on a daily basis but she is not sure what the best way to kill herself would be. Question What is the best treatment for this patient?

Psycho-pharmacotherapy

A 40-year-old woman tells you that she is having marital problems. She tells you that her husband is always criticizing her and she feels like a slave in her own home. You tell her to free associate about everything that comes to mind regarding her marriage. During the free association, she tells you that she is frustrated, her sex life is horrible, she doesn't feel appreciated, and she feels inadequate. You ask the patient to tell you about her childhood relationship her father. The patient says that her father was always getting on her to do chores around the house. She always felt like nothing she did was ever good enough for her father. You tell the patient that she is transferring her feelings about her father onto her husband. It isn't her husband that she is really mad at, but her father. Question What type of therapy was used with the client in this case?

Psychoanalytical psychotherapy Psychoanalytical psychotherapy explores the unconscious thoughts and feelings, understanding aspects of the relationship between therapist and patient, which may relate to underlying emotional conflicts, interpretation of defensive processes that obstruct emotional awareness, and consideration of issues related to sense of self and self-esteem. Gestalt therapy is an existential/experiential form of psychotherapy that emphasizes personal responsibility, focusing on the individual's experience in the present moment. Person-centered therapy uses a non-authoritative approach that allows clients to take more of a lead in discussions so that they will discover their own solutions in the process. The therapist acts as a compassionate facilitator, listening without judgment and acknowledging the client's experience without moving the conversation in another direction. Behavioral therapy is a part of cognitive-behavioral therapy that only focuses on the behavior rather than the preceding negative thoughts. It works to change self-destructive and negative behaviors into more positive outcomes. Cognitive therapy is a subtype of cognitive behavioral therapy that solely focuses on the negative thought patterns of an individual and works to reframe these thoughts into positive thoughts.

A client comes to you, complaining of "lots of stress in my life." She says that she was recently divorced and that she lost her mother a few months ago. During the interview, you become aware that, although the client is well-related, there are certain inconsistencies in her presentation. The exceptions suggest deficiencies, or pathology, on which you cannot get a good grasp. Question You agree to work with her, and as the first part of treatment, you recommend she undergo what type of therapy?

Psychological testing Psychological testing is useful for gathering information about a client that may not be readily accessible through standard interviewing techniques. Tests include those that measure intelligence, tests designed to identify pathology, those that are useful in assessing the severity of a known disorder, and tests that can give a personality profile. Hypnosis is a controversial but widely used technique. In its most common form, an individual is helped to achieve an altered state, within which it is believed there will be access to information that is not readily available in the normal waking state. Biofeedback is useful for empowering individuals to take control of stress, or their reaction to situations, such as illness. For example, individuals with high blood pressure can be trained, using biofeedback, to lower their blood pressure at will, and similarly, individuals with cancer can use biofeedback to prevent the psychological stress of their illness from having severe physiological effects. Brief psychotherapy is useful when a specific problem needs to be addressed in a short time, without looking at the greater context of the problem, or the reasons the problem developed. Although it is similar to Crisis Intervention, Brief psychotherapy goes beyond merely restoring an individual to his or her previous level of functioning, but is not as extensive as longer-term therapy would be. Marital therapy can be approached from almost any theoretical framework. The focus is normally on problems, as they affect a specific significant relationship, not on the purely individual aspects of those problems.

A 16-year-old boy is brought in. His mother says he accidentally cut his wrist with a kitchen knife; he has been a good student until recently, has never taken drugs, and does not drink alcohol. He has never been under psychiatric care or counseling. You examine the patient alone; he presents with two superficial left wrist lacerations. He is right-handed. No suturing is necessary, so you clean the wounds and update his tetanus status. In conversation, you learn that his schoolwork has dropped two grade levels; he tells you that he is not sleeping or eating well. He has been drinking alcohol he stole from his parents, and last week he started thinking he "wanted it all to end." An on-call psychiatrist will arrive 1 hour. You tell the mother you are concerned about the patient's mental status and you want him to see the psychiatrist. She wants to take her son home, and she appears anxious. Question What action should you take?

Refuse to release the patient until he is evaluated by the psychiatrist.

A 27-year-old woman presents with excruciating back pain. She states that the pain started earlier that morning and caused her to miss work. She has had similar pain like this before, but no doctor has ever found anything wrong. She is currently on fluoxetine for depression and periodic ibuprofen for pain. On physical exam, tissue texture changes are noted at L1 to L3, with no additional findings. The woman seems to be in an immense amount of pain, however, and she continues to insist that something is horribly wrong with her. Diagnostic results are negative, and a pain medication is prescribed. She returns later in the week with the same issue but no new findings. History shows episodes similar to this involving joint pain, abdominal pain, headaches, bloating, diarrhea, a "lump in the throat" feeling, and menstrual cramps. Question What is the best way to manage this patient?

Schedule frequent visits and involve her in the decision-making process (Somatic Symptom Disorder)

A 28-year-old man presents for a checkup. Medical records indicate a 3-year history of hospitalizations for mania and depression. The last admission occurred 7 months ago and was due to a suicide attempt after a major depression. The patient has been taking lithium since the last hospitalization; there have been no further mood disturbances, but his mother relates that the patient remains convinced that the "city officers" poisoned the water system over the last 2 months. He refuses to drink tap water. His mother heard him talking alone in his room, and she found several bottles of water under his bed. She reports he has not been very social with his friends over the last 6 months and is showing signs of depression. On examination, the patient appears disheveled; he experiences auditory hallucinations and persecutory delusions throughout the interview. His speech is disorganized. Question What is the most likely diagnosis?

Schizoaffective disorder Schizoaffective disorder is diagnosed when patients with a clinical picture of a mood disorder also have psychotic symptoms that resemble schizophrenia. The requirement for diagnosis is that the psychotic symptoms have to persist more than 2 weeks after the mood disturbances resolve or in the presence of a mood disorder. This patient has been taking lithium, which resolved the mood problems, but he also manifests persistent positive symptoms for schizophrenia for more than 2 weeks. Treatment involves antipsychotics associated with a mood stabilizer, antidepressants, and electroconvulsive therapy.

A 42-year-old man is an outpatient at a psychiatric hospital. He has a history of mood disturbances and psychotic symptoms. You ask some questions of the man's family because the man is hallucinating too severely to cooperate. You learn that although the man is almost always depressed, and that the psychotic symptoms come and go, he has not been depressed at all for about 3 weeks. Question What is the most likely diagnosis?

Schizoaffective disorder Characterized by a combination of the symptoms of a mood disorder (e.g., depression) and schizophrenia in individuals who do not meet the full diagnostic criteria for either disorder. Individuals who are suspected to be suffering from a form of schizophrenia on first glance, but who have significant symptoms related to mood, might be more accurately diagnosed as having schizoaffective disorder. The psychotic features of schizoaffective disorder are generally more prominent than would be seen in an individual diagnosed with a mood disorder with psychotic features. Additionally, the diagnosis requires that the psychotic symptoms be present for at least 2 weeks, during which time there are no mood symptoms. Mood symptoms are, however, required to be present for most of the duration of the illness.

A 22-year-old woman believes a nearby electrical plant is sending out energy waves to control her. She also believes that the "junk mail" sent to her contains secret coded messages. She states she has been able to decipher the codes and they reveal a plot to poison the local water supply. She says this has been confirmed by the voices of her dead parents. She states she has "known" these things for 4 months. She also complains of having trouble sleeping, having very little appetite, having no desire to participate in activities, and states she has recently quit her job. Question What is the most likely diagnosis?

Schizoaffective disorder It is a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression. Symptoms are present for less than 6 months in duration. If symptoms are present for longer than six months, then the disorder becomes schizophrenia.

A 23-year-old man is brought to therapy by a relative, who says the patient has been acting strangely for the past 6 or 7 months; according to the relative, for the past month, the patient has been obsessed with watching television news because he says the newscasters are transmitting private information to him. Question What is the most likely diagnosis?

Schizophrenia

A 70-year-old woman has been refusing to leave her room at the nursing home facility where she resides. She says that people are following her, and she even refuses to go out with her daughter. She has a long history of mental illness; her ex-husband had her committed to a state hospital, where she had resided for over 30 years. On interview, it is difficult to obtain a history; her thinking is disordered and her speech is erratic. When asked why he committed her, she says that she believes her husband was trying to kill her. Question What is the most likely diagnosis?

Schizophrenia

Over the past several months, a 15-year-old boy has been withdrawing from his friends. He has lost interest in his schoolwork, walks around without showering for weeks on end, and refuses to change his clothing. Frequent fits of anger have resulted in his punching holes in the wall in his home and making threatening gestures toward his parents. The oldest of 3 children, the boy is seen by his parents as going through a phase, and they do not take it seriously; however, his schoolmates have noticed that he is quick to take offense and thinks people are talking about him. He has begun carrying a prayer book and expressing himself in an odd fashion; his friends say it is like he is speaking in riddles. The boy also believes that he has a spirit that watches over him and protects him. He admits to hearing voices and he believes that his friends are going to kidnap him. Question What is the most likely diagnosis?

Schizophrenia

Your patient is a 15-year-old boy who historically has been socially withdrawn and maladjusted. In the past year, he has become more withdrawn and frequently appears confused about his surroundings. His older brother, who found him wandering aimlessly down the street, apparently responding to a visual and/or auditory hallucination brings him to your office. You prescribe clozapine as the appropriate medication for his apparent disorder. Question To what childhood psychiatric disorder do these symptoms allude?

Schizophrenia

A 19-year-old woman presents for a psychiatric evaluation. She has never been to a psychiatrist before, and she has no reported history of psychiatric illness. During the evaluation, she states that she keeps hearing frightening voices that tell her to hurt people she loves; she is very disturbed by this. She also states that she becomes confused; sometimes when people are talking to her, the words do not make sense. She says she can only hear 1 word at a time, and when a person is finished with a sentence she forgets the 1st words of that sentence. She notes that 'the world no longer feels real'. The patient denies drug and alcohol use, and she is not currently under the care of a physician. She is not taking any medications at this time. She tells you that the symptoms have persisted for approximately 2 months. What is the most likely DSM-V diagnosis for this patient?

Schizophreniform disorder

A 25-year-old man presents with beliefs that the government reads his mail and has satellites spy on him. He is wearing dirty clothes and broken glasses. He claims that for the past 45 days he has been hearing his mother's voice; she is warning him to be careful, especially of those around him, because he is being followed. His mother died 5 years ago. The man does not appear depressed or euphoric. Past history of medications or drug abuse could not be elicited. He admits that he consumed alcohol every day for 5 years until about 6 years ago. He claims he broke the habit and has not consumed alcohol since. He refuses to cooperate with further examination. He was treated with haloperidol and sent home on risperidone. When the patient presents for a follow-up visit after 3 months, he appears to be in remission. He denies hearing voices and being spied on. Question What is the most likely diagnosis?

Schizophreniform disorder

A 29-year-old computer technician is arrested after breaking into the office of his former employer. He had been a reliable and well-liked employee who had never had any problems on the job, but he was dismissed from his position due to corporate downsizing. Shortly after his departure, he learned that a female colleague had received a promotion. Without specific evidence, he nevertheless became convinced that this colleague had orchestrated his dismissal by writing negative memos about him to senior leadership. In the coming weeks, he rarely left his home. When he was seen, neighbors described his appearance as unkempt and observed him seeming to mumble under his breath. Convinced that he would find copies of the incriminating memos in his colleague's desk, he broke into the office to prove his suspicion. After a brief detainment by the police, he was released to psychiatric care. Within a few weeks of appropriate treatment, his symptoms had resolved and he had successfully started a new job. QuestionHighlights

Schizophreniform disorder

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

Sedative abuse

A 15-year-old boy presents for follow-up of previously diagnosed Asperger syndrome, now autism spectrum disorder. The patient is accompanied by his mother. He is considered high functioning. He attends public school, goes to daily cognitive/behavioral sessions, and attends weekly counseling sessions. The mother states she has noted a significant increase in the patient's anxiety symptoms that have become detrimentally disruptive to daily activities. Question What would be your initial choice of pharmacologic treatment to help decrease the effects of this patient's anxiety?

Sertraline

A woman continues to complain of significant pain several months after undergoing abdominal surgery, there is no physiological basis for her symptoms; all lab tests and imaging are negative. She is frustrated because she is trying to maintain a full-time job but is constantly in pain. Question What is the most likely diagnosis?

Somatic symptom disorder

A 28-year-old woman presents to a psychiatric clinic hearing voices in her head that keep arguing; she believes that one of the voices might be trying to kill her. She is very soft spoken, polite, and well-groomed. She explains that she often becomes confused and finds herself in unfamiliar places. She has a history of alcohol abuse, but no drug abuse. Her medical files show an extensive medical history for unexplained injuries, stomach problems, and unusual bruising beginning in early childhood. The women denies being physically or sexually abused as a child, but states that she has weird nightmares about a strange dark figure standing over the bed of a small child; she does not recognize the child or the man. The following week the woman comes back to the clinic and her behavior appears to be very different from the previous week. She speaks loudly and acts as if she has never seen the psychiatrist before. She is very uncooperative and refuses to answer most questions. Question What is the most common etiological factor in this patient's condition?

Severe child abuse (Dissociative identity disorder)

A 23-year-old woman has problems in performance situations in which she is unfamiliar with the other people present. She is concerned that she will be humiliated or embarrassed, and she worries that people will be able to see her anxiety. She knows that her fears are out of proportion to the situation, but she nonetheless avoids situations that she perceives will provoke her anxiety. This has resulted in occupational dysfunction. There is no history of medical illness, substance use, or other mental disorder. Question What is the most likely diagnosis?

Social phobia

A 20-year-old woman presents with abdominal pain. In the past, she has sought treatment for head, back, joint, and chest pain; she has also complained of nausea and vomiting. She has a history of irregular menses, and she has complained of localized weakness to her right leg. Her symptoms have never been fully explained, and you rule out such diagnoses such a factitious disorder and malingering. Question What is the most likely diagnosis?

Somatic Symptom Disorder According to the DSM-5, Somatic Symptom Disorder refers to one or more persistent bodily symptoms, such as aches or pains, that either distress or cause significant disruption to one's daily life. An individual is often given this label after they have seen their physician who then realizes that the patient is excessively preoccupied with their symptoms. Individuals given this label are also likely to be disproportionately anxious about their symptoms.

A 35-year-old Caucasian woman with a history of headaches presents to your outpatient clinic in December with complaints of joint pains. When pursuing her history you note that she also has intolerance to lots of different food types, stomach bloating, rectal pain with defecation, dysmenorrhea, chronic irregular periods, and difficulty swallowing. She denies feelings of depression or sleep disturbances over the past year and when asked about hobbies she happily talks about her active interest in jazz music. She also denies substance abuse. She takes several vitamins and acetaminophen. Her physical exam is normal. Her complete blood count, erythrocyte sedimentation rate, renal, and liver panels are all normal. Question What is the most likely diagnosis?

Somatic symptom disorder

A 47-year-old man is supposed to go on an extended business trip to Europe, but he cannot seem to get the fear of crossing the Atlantic Ocean out of his mind. As a child, he refused to go boating on the lake with his family, and he generally avoided going to rivers or on ocean fishing trips. He is delaying his trip because his anxiety is becoming worse, and it has reached a point where he is seriously thinking of looking for someone else in his company to go. This would be his first trip abroad, and he has never had to cross an ocean before. Flying has never been something the man enjoys, but it is not the flying so much as the ocean that is concerning him. Question What is the most likely diagnosis?

Specific phobia

John, a 38-year-old single male, has always been a hard-working man who gets up in the morning at 5 a.m. and goes to his job at the local cake factory where he is in charge of the icing machine. The men on the line where John has been working for 15 years, enjoy his sense of humor and each day they have more than a few beers with their lunch. When he returns home in the evening John likes to sit down on the porch and drink a six-pack with his hunting buddies and this has been a daily routine for much of his adult life. Living in the home left to him by his parents upon their deaths, John has been having some problems lately with his memory and an uneasy feeling that there's someone in the house with him. He has begun locking the doors to unused rooms and now confines himself to the three downstairs rooms where he keeps his dogs with him. His diet has been mostly prepared foods and pizza and he hasn't had a physical exam in years. Question Upon reviewing this case, you would most probably want to rule out:

Substance-Induced Psychotic Disorder With Delusions

A 42-year-old man presents to the emergency department with bruises sustained in a bar fight. He had several alcoholic drinks before the episode. He has been having a strange feeling that people are staring at him because they do not like him. He does not always feel this way, but it regularly happens when he has been out drinking. He has gotten into several fights and has almost run other cars off the road because he did not like the way another driver looked at him. He has previously been steadily employed, but in recent months, he has had increasing conflicts at work that led to his being terminated. He reports no other symptoms and has no other relevant medical history. He drinks alcohol 3-4 times a week, often in excess. He denies suicidal or homicidal ideation. Question What is your initial diagnosis?

Substance-induced psychotic disorder The most important details for diagnosis of substance-induced psychotic disorder are that he only has these delusions during periods of intoxication. Patients with schizophrenia frequently exhibit paranoia and have psychotic episodes that cause them to behave erratically. Their symptoms are not episodic. Mood disorders include depression and bipolar disorder. Patients with mood disorders may exhibit psychotic symptoms, such as paranoia. However, this patient does not report any other symptoms consistent with depression or mania. Patients with posttraumatic stress disorder (PTSD) may exhibit paranoid behavior and may become argumentative without no apparent instigation, but they usually report a history of trauma, making the diagnosis less likely. Intermittent explosive disorder, which can be diagnosed in children as young as 6, is characterized by a wide variety of aggressive outbursts.

A 45-year-old man suffers from chronic insomnia. When he lost his job 3 years ago, he was prescribed triazolam 0.25 mg HS, which he continues to take. He has found another job, but he has not been successful in gaining the same type of managerial position for which he was once paid a six-figure salary. Initially, the insomnia was the only problem he had, in addition to having 2 or 3 drinks with dinner. Recently, he has developed further behavioral problems. Although he continues to take 0.25mg HS triazolam, he is still suffering from sleep problems. He does not have a significant past medical history. The family physician has refused to refill the prescription, so he has found a series of physicians who have given him prescriptions for triazolam (Halcion) and alprazolam (Xanax). His mood has deteriorated to the point that he finds himself becoming verbally aggressive toward coworkers, which is causing serious problems on the job. The patient's boss is concerned that his work has fallen off, and he seems to have problems remembering customers' orders; he is also missing deadlines. He is frequently bumping into furniture and appears to be poorly coordinated. He is now becoming disturbed because he cannot seem to remember things that he did during the day and is having more fights with his wife. Question What is the most likely diagnosis?

Substance/medication-induced mood disorder

A 78-year-old man presents to your office for follow up of his depression. He has been on antidepressant medication for about 1 year. Although he initially had some improvement in his mood, the past few months he has complained of more problems with tearfulness and sleep disturbances. While he describes himself as always being kind of a "blue" person, the death of his wife last year initiated this most recent bout of major depression. On questioning, he reveals that he has been drinking more alcohol than usual. He is feeling very sad about the impending anniversary of his wife's death next month. He also describes that he has been keeping a loaded shotgun in the house, "just in case," without elaborating for what. He expresses sadness at his isolation, saying that he does not matter much to anyone these days. Labs from his previous visit last month reveal a TSH of 2.5mIU/L and a non-reactive VDRL. Question What should you do next?

Talk to him about hospitalization, and commit him involuntarily if he refuses

A 69-year-old homeless man with a history of schizoaffective disorder has developed rhythmic movements of the tongue, jaw, trunk, and upper extremities. He appears unable to control the movements. His mental condition is otherwise stable. He denies illicit substance abuse. Question What is the most likely diagnosis?

Tardive dyskinesia

Psychoanalytic psychotherapy views maladaptive behavior as

Unconscious, unresolved conflicts of childhood

A 25-year-old woman is brought in by her sister. The woman has had increasingly frequent incidences of bizarre behavior, and her family is concerned. The most notable episodes occurred within the past week. She seemed sad and distant for a couple of days, then she left abruptly and returned home after being gone for 2 days. During that time, the woman told her sister that she had driven for 3 hours for no particular reason and spent much of her time partying and spending money. The normally intelligent woman was unable to remember where she had gone, and she could not explain why she left in the first place. After running out of money and sleeping in her car for 2 nights, she called her sister, who came and got her. Her sister found her dirty and speaking quickly about nothing in particular. She was brought home, and she now looks quite calm and seems a bit solemn. On examination, the woman's vital signs are within normal limits. Lab work reveals nothing abnormal. The patient did not display any unusual behavior. She was quite pleasant and cooperative. Her score on the mini-mental state exam was 29, but she does not seem to recall much about what happened a few days ago. Question What is the most likely diagnosis?

bipolar disorder

A 25-year-old woman learns of the death of her father; within hours, her speech becomes disorganized, and she is found walking outside her house without any clothes on. She claims that her father is inside the house and telling her to do these things "in his honor". The symptoms remit after 3 days. The woman returns to her full premorbid level of functioning, but she is obviously confused over the events of the past few days. Question What is the most likely diagnosis?

brief psychotic disorder

A 30-year-old woman presents for advice. Her husband's older brother has been under psychiatrist treatment for more than a month; he started voicing bizarre ideas, hearing stressful commands, and became paranoid because of flashbacks of fictional events from his past. He believes that many people from his local community are involved in a conspiracy against him, and that he is being followed and watched. He is 38 years old and his mother committed suicide 10 years ago. The patient is worried that her husband and their children could be at risk for developing a similar condition. Question What will be the most useful biological marker of early onset of a similar disease in her husband and children?

common endophenotype This patient's brother-in-law most likely has schizophrenia. The prodromal phase of schizophrenia has received a great deal of attention, and multiple biological markers have been identified that may allow earlier diagnosis and treatment of patients. Biological markers are defined as objective, measurable phenomena that may identify subjects at increased risk for development of disease; they are often found not only in the patients but also in first-degree relatives. They may target etiology of the disease, risk factors, pathophysiology, or manifestations of the illness. Endophenotypes, a subset of biological markers, are measurable components unseen by the unaided eye. They parse behavioral symptoms into more stable phenotypes with a clear genetic connection, defining illness-related characteristics observable through other tests (neurophysiologic, biochemical, endocrinologic, neuroanatomic, cognitive, or neuropsychological). A valid endophenotype should be closely related to more pathophysiologic genes for the nosologic category. Endophenotype must be associated with illness in the general population, must be stable over time and observable (despite the fact that the patient is in partial or complete remission), should be heritable, and should segregate with illness within families. In this family, in which the proband has the endophenotype, several markers must be looked at: neurological (e.g., lack of sensory gating, prepulse inhibition, or decline in working memory), genetic (e.g., RELN gene, FABP 7 gene, CHRNA 7 gene, DAOA, NRG1, dysbindin, DISC1, RGS4, COMT genes), electrophysiological (e.g., abnormality of the P50 auditory evoked potential, eye tracking dysfunction), and neurodevelopmental (e.g., minor physical anomalies, signs of poor neurologic maturation, high-steepled palate, hypertelorism, large head circumference, small nasal volumes, positive glabellar tap). Those who are shown to have a propensity for schizophrenia must not be marginalized or discriminated against.

A 23-year-old woman presents for evaluation of mood swings. She has a 5-year history of depressive episodes; they alternate with "high energy" states. She becomes demoralized, nearly anhedonic, and insomniac for days at a time. However, her symptoms do not meet criteria for major depression. Similarly, her "high energy" states, while noticeable and different from her baseline, do not meet criteria for mania. Examination and laboratory evaluation rules out psychotic disorder, medical illness, or drug use. Question What is the most likely diagnosis?

cyclothymic disorder

What is the differential diagnosis between schizophreniform disorder and schizophrenia?

duration of symptoms

A healthy 24-year-old man has an intense fear of snakes. His behavioral therapist has him imagine a large room full of all kinds of snakes. Question This technique is an example of what?

implosion Implosion, the confrontation of an anxiety-provoking object or event in the imagination, is used for phobias. Flooding involves setting up a situation in which the patient cannot escape from the feared stimulus; the idea is that escape and relief from anxiety merely strengthens the phobic position. Systematic desensitization occurs with gradually increasing the strength of the stimulus. Relaxation training uses various methods to decrease somatic anxiety reactions. None of these behavioral methods involve interpretation of behavior.

A 30-year-old woman is brought to the hospital by her husband, who states that his wife has not been normal for the last few months. He says that she has become extremely withdrawn in the last month. She is in a constantly sad mood, and he has found her crying alone many times when he has come home from work. On questioning the patient, she admits that she feels tired all the time and that she has lost all interest in life. She has decreased appetite and has lost 8 pounds in 1 month. She says that she feels worthless and that she doesn't deserve to live and has thought about killing herself many times in the past few days. She has even thought of a few ways to kill herself. When her husband tries to comfort her, she just shouts at him and shuts herself in her room. Question What is the most likely diagnosis?

major depressive disorder

A patient complains of fatigue and recent weight loss. She has called in sick to work every day for 2 weeks and reports not wanting to get out of bed. She states she feels as though her life is worthless and that she constantly thinks of "gloom and doom". Question What is the most likely diagnosis?

major depressive disorder

A patient presents with deteriorating work and feelings of worthlessness and hopelessness; symptoms have been worsening over the past month. The patient also gives history of excessive fatigue and loss of interest in pleasurable activities. They also have trouble eating and sleeping, and they are increasingly withdrawing from family and friends. These symptoms have been present for more than 2 months. Question What is the most likely diagnosis?

major depressive disorder

A 35-year-old man presents for follow-up treatment. He states that he takes his medicine exactly every 8 hours and keeps a record of how many pills he takes at what time; he wakes up in the middle of the night worrying if he missed a dose. He is worried that maybe the medicine is not going to take effect because he took 1 of the pills 15 minutes late. Question What kind of disorder does this man most likely have?

obsessive-compulsive

A mid-level manager complains that he is having problems at work because his employees just will not take the care he does in doing their jobs. Consequently, he says, he fears that their lack of interest in their work will prevent him from getting ahead because his attention to detail and devotion are not seen by his boss when overall production is low. Probing reveals that there are actually more problems here than just the attitudes of this man's employees. His attention to detail often gets in the way, and it prevents work from being accomplished in a timely manner. You formulate further questions to determine if this man might have what personality disorder?

obsessive-compulsive

A 24.year-old woman presents after a recent trauma (a car accident that killed her husband) with hallucinations, incoherent speech, and intermittent catatonia. The symptoms have persisted for 1 week (following the accident). Question Given that the patient is neither suicidal nor assaultive, what would be the next step in treatment?

prescribe antipsychotics

A diagnosis of Schizoid Personality Disorder instead of Schizophrenia would be made in the absence of:

psychosis Even severe Schizoid Personality Disorders (those who exhibit schizophrenic-like social withdrawal) rarely become psychotic. Schizoid Personality Disorder is characterized by a detachment/withdrawal from social relationships. For a diagnosis of Schizophrenia, one must have only an active case of bizarre delusions or hallucinations. Social withdrawal is an essential feature of Schizoid Personality Disorder. Flattened affect is a criterion for both disorders. Drug use would need to be eliminated for either diagnosis. Active symptoms is a vague answer. What active symptoms?

The essential feature of Panic Disorder is the presence of which of the following?

recurrent yet unexpected panic attacks

A 56-year-old woman, stable on lithium for 5 years, is hospitalized after having collapsed on a walk during a heat wave in the month of August. She has a sudden onset of a gait disorder, associated with a hematocrit of 50%, serum sodium 150mmol/L, and a lithium level of 4.5mg/dL. She had recently been provided with a diuretic for blood pressure control. Question In order to prevent permanent neurological residuals, which of the following do you recommend?

renal dialysis

Police officers found a 27-year-old man walking aimlessly and shouting the names of former presidents. Urine toxicology is negative, and the man appears to be oriented with respect to person, place, and time. He has had 5 similar admissions over the past year. Attempts to interview the patient are fruitless; he is easily derailed from his train of thought. A phone call to a friend listed in the chart provides the additional information that the man is homeless and unable to care for himself. Question This patient's signs and symptoms are characteristic of what pathology?

schizophrenia

Along the front edge of the parietal lobe is a continuous strip that receives sensations from the body and is called the

somatosensory cortex

A 25-year-old primigravida woman gave birth to a healthy male infant at 40 weeks gestation by normal spontaneous vaginal delivery (NSVD). She breastfeeds on demand and was doing well until day 4 postpartum. At that time, she developed insomnia, fatigue, and feelings of sadness and depression, which have been present for the last 3 weeks. She cries easily and feels guilty that she does not enjoy her baby as much as she had expected. She has not yet resumed any predelivery social activities and is often ready for bed when her spouse returns from work to assume care for the baby. Because she feels so tired, she wishes she had never begun breastfeeding. Question What is the best initial choice of treatment for this patient?

supportive psychotherapy (drugs are second line in PPD)