psych exam review--questions and answers from the pretest book

28. A 24-year-old man returns from Iraq after a 13-month tour of duty. During that tour he was involved in battle situations and saw one of his friends injured by a car bomb. What percentage of American soldiers returning home from Iraq have posttraumatic stress disorder (PTSD)?

a. <1% b. 1% to 5% c. 15% to 20% d. 50% to 55% e. 85% to 90% 28. The answer is c. (Kaplan, pp 617.) It is estimated that 17% of soldiers returning from Iraq and Afghanistan have PTSD. The rate is higher among female soldiers, and they are more likely to seek help.

328. A 28-year-old taxi driver is chronically consumed by fears of having accidentally run over a pedestrian. Although he tries to convince himself that his worries are silly, his anxiety continues to mount until he drives back to the scene of the "accident" and proves to himself that nobody lies hurt in the street. This behavior best exemplifies which of the following?

a. A compulsion secondary to an obsession b. An obsession triggered by a compulsion c. A delusional ideation d. A typical manifestation of obsessive-compulsive personality disorder e. A phobia 328. The answer is a. (Jacobson, pp 85-91.) Recurrent obsessions and compulsions are essential features of obsessive-compulsive disorder (OCD). Obsessions are persistent thoughts or mental images that are sub- jectively experienced as intrusive and alien and characteristically provoke various levels of anxiety. Compulsions are repetitive acts, behaviors, or thoughts designed to counteract the anxiety elicited by the obsessions. Thus obsessions (which cause anxiety) are paired with their related compulsions (which help manage the anxiety produced). The diagnosis of obsessive-compulsive personality disorder is reserved for those patients with significant impairments in their occupational or social effectiveness. These patients are preoccupied with rules, regulations, orderliness, neat- ness, details, and the achievement of perfection.

321. A 23-year-old woman arrives at the emergency room complaining that, out of the blue, she had been seized by an overwhelming fear, associated with shortness of breath and a pounding heart. These symptoms lasted for approximately 20 minutes, and while she was experiencing them, she feared that she was dying or going crazy. The patient has had four similar episodes during the past month, and she has been worrying that they will continue to recur. Which of the following is the most likely diagnosis?

a. Acute psychotic episode b. Hypochondriasis c. Panic disorder d. Generalized anxiety disorder e. Posttraumatic stress disorder 321. The answer is c. (Jacobson, p 5.) This patient displays typical symptoms of recurrent panic attacks. Panic attacks can occur under a wide variety of psychiatric and medical conditions. The patient is diagnosed with panic disorder when there are recurrent episodes of panic and there is at least 1 month of persistent concern, worry, or behavioral change associated with the attacks. The attacks are not because of the direct effect of medical illness, medications, or substance abuse and are not better accounted for by another psychiatric disorder. While anxiety can be intense in generalized anxiety disorder, major depression, acute psychosis, and hypochondriasis, it does not have the typical presentation (ie, a discrete episode or panic attack) described in this question.

335. A 45-year-old policeman who has demonstrated great courage on more than one occasion while on duty is terrified of needles.

a. Agoraphobia b. Panic disorder c. Obsessive-compulsive disorder d. Social phobia e. Adjustment disorder f. Specific phobia g. Acute stress disorder 335 to 337. The answers are 335-f, 336-a, 337-d. (Moore and Jefferson, pp 163-167.) Phobic disorders include agoraphobia, specific phobias, and social phobia. They are all characterized by overwhelming,persistent, and irrational fears that result in the overpowering need to avoid the object or situation that is generating the anxiety. Agoraphobia is the marked fear and avoidance of being alone in public places where rapid exit would be difficult or help would not be available. Social phobia is characterized by avoidance of situations in which one is exposed to scrutiny by others and by fears of being humiliated or embarrassed by one's actions. Specific phobias are triggered by objects (often animals), heights, or closed spaces. A large variety of objects are associated with simple phobias.

336. For several months, a 32-year-old housewife has been unable to leave her house unaccompanied. When she tries to go out alone, she is overwhelmed by anxiety and fears that something terrible will happen to her and nobody will be there to help.

a. Agoraphobia b. Panic disorder c. Obsessive-compulsive disorder d. Social phobia e. Adjustment disorder f. Specific phobia g. Acute stress disorder 335 to 337. The answers are 335-f, 336-a, 337-d. (Moore and Jefferson, pp 163-167.) Phobic disorders include agoraphobia, specific phobias, and social phobia. They are all characterized by overwhelming,persistent, and irrational fears that result in the overpowering need to avoid the object or situation that is generating the anxiety. Agoraphobia is the marked fear and avoidance of being alone in public places where rapid exit would be difficult or help would not be available. Social phobia is characterized by avoidance of situations in which one is exposed to scrutiny by others and by fears of being humiliated or embarrassed by one's actions. Specific phobias are triggered by objects (often animals), heights, or closed spaces. A large variety of objects are associated with simple phobias.

337. A 17-year-old girl blushes, stammers, and feels completely foolish when one of her classmates or a teacher asks her a question. She sits at the back of the class hoping not to be noticed because she is convinced that the other students think she is unattractive and stupid.

a. Agoraphobia b. Panic disorder c. Obsessive-compulsive disorder d. Social phobia e. Adjustment disorder f. Specific phobia g. Acute stress disorder 335 to 337. The answers are 335-f, 336-a, 337-d. (Moore and Jefferson, pp 163-167.) Phobic disorders include agoraphobia, specific phobias, and social phobia. They are all characterized by overwhelming,persistent, and irrational fears that result in the overpowering need to avoid the object or situation that is generating the anxiety. Agoraphobia is the marked fear and avoidance of being alone in public places where rapid exit would be difficult or help would not be available. Social phobia is characterized by avoidance of situations in which one is exposed to scrutiny by others and by fears of being humiliated or embarrassed by one's actions. Specific phobias are triggered by objects (often animals), heights, or closed spaces. A large variety of objects are associated with simple phobias.

10. A 23-year-old woman comes to the psychiatrist because she "cannot get out of the shower." She tells the psychiatrist that she has been unable to go to her job as a secretary for the past 3 weeks because it takes her at least 4 hours to shower. She describes an elaborate ritual in which she must make sure that each part of her body has been scrubbed three times, in exactly the same order each time. She notes that her hands are raw and bloody from all the scrubbing. She states that she hates what she is doing to herself but becomes unbearably anxious each time she tries to stop. She notes that she has always taken long showers, but the problem has been worsening steadily for the past 5 months. She denies problems with friends or at work, other than the problems that currently are keeping her from going to work. Which of the following is the most likely diagnosis?

a. Attention-deficit hyperactivity disorder b. Obsessive-compulsive disorder c. Obsessive-compulsive personality disorder d. Separation anxiety disorder e. Brief psychotic disorder 10. The answer is b. (Jacobson, pp 85-91.) The essential features of obsessive-compulsive disorder are obsessions (recurrent and persistent thoughts that are experienced as intrusive and inappropriate and that cause anxiety) and compulsions (repetitive behaviors that the person feels driven to perform). In this disorder, the patient's symptoms are ego-dystonic to him or her, unlike the person with an obsessive-compulsive personality disorder. Patients with attention-deficit hyperactivity disorder have prob- lems with inattention, hyperactivity, and/or impulsivity. Patients with separation anxiety disorder worry about losing or harming major attachment figures and become anxious when separation from home or those major figures is anticipated. Patients with brief psychotic disorder show evidence of either delusions or hallucinations for a short period of time, usually after exposure to some external stressor.

350. A 65-year-old woman lives alone in a dilapidated house, although her family members have tried in vain to move her to a better dwelling. She wears odd and out-of-fashion clothes and rummages in the garbage cans of her neighbors to look for redeemable cans and bottles. She is very suspicious of her neighbors. She was convinced that her neighbors were plotting against her life for a brief time after she was mugged and thrown onto the pavement by a teenager, but now thinks that this is not the case. She believes in the "power of crystals to protect me" and has them strewn haphazardly throughout her house. Which of the following is the most likely diagnosis?

a. Autism b. Schizophrenia, paranoid type c. Schizotypal personality disorder d. Avoidant personality disorder e. Schizoid personality disorder 350. The answer is c. (Jacobson, pp 61, 187.) Schizotypal personality disorder, a cluster A disorder, is characterized by acute discomfort in close relationships, cognitive and perceptual distortions, and eccentric behavior beginning in early adulthood and present in a variety of contexts. Individuals with schizoid personality disorder do not present with the magical thinking, oddity, unusual perceptions, and odd appearance typical of schizotypal individuals. In schizophrenia, psychotic symptoms are much more prolonged and severe. Avoidant individuals avoid social interaction out of shyness and fear of rejection and not out of disinterest or suspiciousness. In autism, social interactions are more severely impaired and stereotyped behaviors are usually present.

36. A 32-year-old patient is being interviewed in his physician's office. He eventually answers each question, but he gives long answers with a great deal of tedious and unnecessary detail before doing so. Which of the following symptoms best describes this patient's presentation?

a. Blocking b. Tangentiality c. Circumstantiality d. Looseness of associations e. Flight of ideas 36. The answer is c. (Moore and Jefferson, p 9.) Tangentiality, circumstantiality, flight of ideas, and looseness of associations are forms of thought disorder. Circumstantiality is a disturbance in which the patient digresses into unnecessary details before communicating the central idea. Tangentiality is present when the patient wanders and digresses to unnecessary details and the substance of the idea is never communicated. In flight of ideas,there are rapid, continuous verbalizations or plays on words that produce constant shifting from one idea to another. Ideas tend to be connected. In looseness of associations, the flow of thought is disconnected--ideas shift from one subject to another in a completely unrelated way.

391. A 50-year-old man is brought to the emergency department by ambulance. His respirations are shallow and infrequent, his pupils are constricted, and he is stuporous. He was noted to have suffered a grand mal seizure in the ambulance. Which of the following drugs is this man most likely to have overdosed on?

a. Cocaine b. LSD c. Meperidine d. PCP e. MDMA (Ecstasy) 391. The answer is c. (Jacobson, pp 105-106.) Severe opiate intoxication is associated with respiratory depression, stupor or coma, and sometimes pulmonary edema. Less severe intoxication is associated with slurred speech, drowsiness, and impaired memory or attention. Early on, the pupils are constricted, but they dilate if the patient becomes anoxic because of the respiratory depression. Blood pressure is typically reduced. Meperidine intoxication in a chronic user is often complicated by delirium or seizures caused by the accumulation of normeperidine, a toxic metabolite with cerebral irritant properties.

403. A 64-year-old man is admitted to the emergency room after he was witnessed having a seizure on the sidewalk. Postictally, the patient was noted to be agitated and disoriented. Vital signs include: blood pressure 165/105 mm Hg, pulse 120 beat/min. From the following list, which is the most likely diagnosis?

a. Cocaine intoxication b. Alcohol withdrawal c. PCP withdrawal d. Cocaine withdrawal e. Alcohol intoxication 403 and 404. The answers are 403-b and 404-e. (Kaplan, p 399.) Alcohol withdrawal delirium is a medical emergency, since untreated, as many as 20% of patients will die, usually as a result of a concurrent medical illness such as pneumonia, hepatic disease, or heart failure. Symptoms of this delirium include: autonomic hyperactivity, hallucinations, and fluctuating activity levels, ranging from acute agitation to lethargy. The best treatment for this delirium is, of course, prevention. However, once it appears, chlordiazepoxide should be given orally, or if this is not possible (as in this case), lorazepam should be given IV or IM. Antipsychotic medications should be avoided, since they may further lower the seizure threshold.

292. A 32-year-old woman is brought to the emergency room by the police after she was found standing in the middle of a busy highway, naked,commanding the traffic to stop. In the emergency room she is agitated and restless, with pressured speech and an affect that alternates betweeneuphoric and irritable. Her father is contacted and states that this kind of behavior runs in the family. Which of the following is the most likely diagnosis?

a. Delirium b. Bipolar disorder, manic c. Bipolar disorder, mixed state d. Cyclothymia e. Schizophrenia 292. The answer is b. (Kaplan, pp 528, 547.) Mood elevation, mood lability, irritability, expansive behavior, increased energy, decreased need for sleep, lack of insight, poor judgment, disinhibition, impulsivity, and pressured speech are characteristic symptoms of elated acute mania. In more severe cases, mood-congruent delusional ideations and hallucinations are present.

228. A 26-year-old woman is brought to the emergency room by her husband after she begins screaming that her children are calling to her and becomes hysterical. The husband states that 2 weeks previously, the cou- ple's two children were killed in a car accident, and since that time the patient has been agitated, disorganized, and incoherent. He states that she will not eat because she believes he has been poisoning her food, and she has not slept for the past 2 days. The patient believes that the nurses in the emergency room are going to cause her harm as well. The patient is sedated and later sent home. One week later, all her symptoms remit spontaneously. Which of the following is the most likely diagnosis for this patient?

a. Delirium b. Schizophreniform disorder c. Major depression with psychotic features d. Brief psychotic disorder e. Posttraumatic stress disorder 228. The answer is d. (Kaplan, pp 501-504, Moore and Jefferson, pp125-126.) Brief psychotic disorder is characterized by the sudden appearance of delusions, hallucinations, and disorganized speech or behavior, usually following a severe stressor. The episode lasts at least 1 day and less than 1 month and is followed by full spontaneous remission. For the woman in the question, the psychotic episode was clearly precipitated by the death of her children. Schizophreniform disorder is differentiated from brief psychotic disorder by temporal factors (in schizophreniform disorder, symptoms are required to last more than 1 month) and lack of association with a stressor. Posttraumatic stress disorder has a more chronic course and is characterized by affective, dissociative, and behavioral symptoms.

219. A 40-year-old woman is arrested by the police after she is found crawling through the window of a movie star's home. She states that the movie star invited her into his home because the two are secretly married and "it just wouldn't be good for his career if everyone knew." The movie star denies the two have ever met, but notes that the woman has sent him hundreds of letters over the past 2 years. The woman has never been in trouble before and lives an otherwise isolated and unremarkable life. Which of the following is the most likely diagnosis?

a. Delusional disorder b. Schizoaffective disorder c. Bipolar I disorder d. Cyclothymia e. Schizophreniform disorder 219. The answer is a. (Kaplan, p 509.) This patient is suffering from an erotomanic delusion--the delusion of having a special relationship with another person, often someone famous.

218. A 47-year-old woman is brought to the emergency room after she jumped off an overpass in a suicide attempt. In the emergency room she states that she wanted to kill herself because the devil had been tormenting her for many years. After stabilization of her fractures, she is admitted to the psychiatric unit, where she is treated with risperidone and sertraline. After 2 weeks she is no longer suicidal and her mood is euthymic. However, she still believes that the devil is recruiting people to try to persecute her. In the past 10 years, the patient has had three similar episodes prior to this one. Throughout this time, she has never stopped believing that the devil is persecuting her. Which of the following is the most appropriate diagnosis for this patient?

a. Delusional disorder b. Schizoaffective disorder c. Schizophrenia, paranoid type d. Schizophreniform disorder e. Major depression with psychotic features 218. The answer is b. (Kaplan, pp 501-504.) Schizoaffective disorder is diagnosed when the required criteria for schizophrenia are met (delusions, hallucination, disorganized speech or behavior, and/or negative symptoms; duration of the disturbance, including prodromal and residual period, of at least 6 months with at least 1 month of active symptoms) and the patient experiences at some point in the course of the illness a major depressive episode or a manic episode. The woman in this question meets all these criteria. She has continuing psychotic symptomatology, interspersed with episodes of a major mood disorder. Notably, she has never had the mood symptoms without the psychotic symptoms, ruling out major depression with psychosis as the diagnosis. Delusional disorder is not accompanied by decline in functions or significant affective symptoms. Individuals with schizoid personality disorder do not experience psychotic symptoms.Bipolar disorder is differentiated from schizoaffective disorder by the absence of periods of psychosis accompanied by prominent affective symptoms.

212. A 24-year-old woman comes to the emergency room with the chief complaint that "my stomach is rotting out from the inside." She states that for the last 6 months she has been crying on a daily basis and that she has decreased concentration, energy, and interest in her usual hobbies. She has lost 25 lb during that time. She cannot get to sleep, and when she does, she wakes up early in the morning. For the past 3 weeks, she has become convinced that she is dying of cancer and is rotting on the inside of her body.Also, in the past 2 weeks she has been hearing a voice calling her name when no one is around. Which of the following is the most likely diagnosis?

a. Delusional disorder b. Schizoaffective disorder c. Schizophreniform disorder d. Schizophrenia e. Major depression with psychotic features 212. The answer is e. (Kaplan, pp 537-538.) This patient is presenting with a major depression with psychotic features. For over 2 weeks (the minimum for the diagnosis), the patient has been complaining of anhedo nia, crying, anergia, decreased concentration, 25-lb weight loss, and insomnia with early morning awakening. She also has somatic delusions that are mood congruent and an auditory hallucination. The presence of psychotic phenomena that follow a clear mood disorder picture makes the diagnosis of major depression with psychotic features the most likely.

213. A 19-year-old man is brought to the physician by his parents after he called them from college, terrified that the Mafia was after him. He reports that he has eaten nothing for the past 6 weeks other than canned beans because "they are into everything--I can't be too careful." He is convinced that the Mafia has put cameras in his dormitory room and that they are watching his every move. He occasionally hears the voices of two men talking about him when no one is around. His roommate states that for the past 2 months the patient has been increasingly withdrawn and suspicious. Which of the following is the most likely diagnosis?

a. Delusional disorder b. Schizoaffective disorder c. Schizophreniform disorder d. Schizophrenia e. Phencyclidine (PCP) intoxication 213. The answer is c. (Jacobson, pp 53-55) Schizophreniform disorder and chronic schizophrenia differ only in the duration of the symptoms and the fact that the impaired social or occupational functioning associated with chronic schizophrenia is not required to diagnose schizophreniform disorder. As with schizophrenia, schizophreniform disorder is characterized by the presence of delusions, hallucinations, disorganized thoughts and speech, and negative symptoms. The total duration of the illness, including prodromal and residual phases, is at least 1 month and less than 6 months. Approximately one-third of patients diagnosed with schizophreniform disorder experience a full recovery, while the rest progress to schizophrenia and schizoaffective disorder. Depending on the predominance of particular symptoms, four subtypes of schizophrenia are recognized: paranoid, disorganized, catatonic, and residual. The man in the question presents with the classic symptoms of paranoid schizophrenia. This subtype of schizophrenia is characterized by prominent hallucinations and delusional ideations with a relative preservation of affect and cognitive functions. delusions are usually grandiose or persecutory or both, organized around a central coherent theme. Hallucinations, usually auditory, are frequent and related to the delusional theme. Anxiety, anger, argumentativeness, and aloofness are often present. Paranoid schizophrenia tends to develop later in life and is associated with a better prognosis.

214. A 36-year-old woman is brought to the psychiatrist by her husband because for the past 8 months she has refused to go out of the house, believing that the neighbors are trying to harm her. She is afraid that if they see her they will hurt her, and she finds many small bits of evidence to support this. This evidence includes the neighbors' leaving their garbage cans out on the street to try to trip her, parking their cars in their driveways so they can hide behind them and spy on her, and walking by her house to try to get a look into where she is hiding. She states that her mood is fine and would be "better if they would leave me alone." She denies hearing the neighbors or anyone else talk to her, but is sure that they are out to "cause her death and mayhem." Which of the following is the most likely diagnosis?

a. Delusional disorder b. Schizophreniform disorder c. Schizoaffective disorder d. Schizophrenia e. Major depression with psychotic features 214. The answer is a. (Jacobson, pp 55-56.) The main feature of delusional disorder is the presence of one or more nonbizarre delusions without deterioration of psychosocial functioning and in the absence of bizarre or odd behavior. Auditory and visual hallucinations, if present, are not prominent and are related to the delusional theme. Tactile and olfactory hallucinations may also be present if they are incorporated in the delusional system (such as feeling insects crawling over the skin in delusions of infestation). Subtypes of delusional disorder include erotomanic, grandiose, jealous, persecutory, and somatic (delusions of being infested with parasites, of emitting a bad odor, of having AIDS). Delusional disorder usually manifests in middle or late adult life and has a fluctuating course with periods of remissions and relapses. The patient in the vignette clearly demonstrates persecutory delusions, but no hallucinations or other bizarre or odd behavior, which makes her diagnosis delusional disorder.

358. A demanding 25-year-old woman begins psychotherapy stating that she is both desperate and bored. She reports that for the past 5 or 6 years she has experienced periodic anxiety and depression and has made several suicidal gestures. She also reports a variety of impulsive and self-defeating behaviors and sexual promiscuity. She wonders if she might be a lesbian, though most of her sexual experiences have been with men. She has abruptly terminated two previous attempts at psychotherapy. In both cases she was enraged at the therapist because he was unwilling to prescribe anxiolytic medications. Which of the following is the most likely diagnosis?

a. Dysthymia b. Histrionic personality disorder c. Antisocial personality disorder d. Borderline personality disorder e. Impulse control disorder not otherwise specified 358. The answer is d. (Ebert, pp 523-526.) The patient's history and presenting symptoms are classic for the diagnosis of borderline personality disorder. Patients with borderline personalities present with a history of a pervasive instability of mood, relationships, and self-image beginning by early adulthood. Their behavior is often impulsive and self-damaging, their sexuality is chaotic, sexual orientation may be uncertain, and anger is intense and often acted out. Recurrent suicidal gestures are common. The shifts of mood usually last from a few hours to a few days. Patients often describe chronic feelings of boredom and emptiness.

30. A 19-year-old woman presents to the emergency room with the chief complaint of a depressed mood for 2 weeks. She notes that since her therapist went on vacation she has experienced suicidal ideation, crying spells, and an increased appetite. She states that she has left 40 messages on the therapist's answering machine telling him that she is going to kill herself and that it would serve him right for leaving her. Physical examination reveals multiple well-healed scars and cigarette burns on the anterior aspect of both forearms. Which of the following diagnoses best fits this patient's clinical presentation?

a. Dysthymic disorder b. Bipolar disorder c. Panic disorder d. Borderline personality disorder e. Schizoaffective disorder 30. The answer is d. (Moore and Jefferson, pp 253-255.) Individuals with borderline personality disorder characteristically form intense but very unstable relationships. Since they tend to perceive themselves and others as either totally bad or perfectly good, borderline individuals either idealize or devalue any person who occupies a significant place in their lives. Usually these perceptions do not last, and the person idealized one day can be seen as completely negative the next day. This inability to see people as inte- grated wholes of both good and bad aspects, but rather to put them in the "all" or "none" category, is called splitting.

223. A 39-year-old woman is arrested for breaking into the compound of a famous television star. She said she knew the star loved her and was giving her special messages to contact him from his weekly show.

a. Erotomanic 220 to 226. The answers are 220-d, 221-b, 222-c, 223-a, 224-e,225-g, 226-f. (Kaplan, pp 507-508, 510, 1076.) Persecutory and jealous delusions are probably the most frequently seen by psychiatrists. Patients with the persecutory subtype of delusion are convinced they are being harassed or harmed by others. Those with the jealous type are often verbally and physically abusive to those involved in the delusion (the wife in this case). These delusions are very difficult to treat. The erotomanic delusion consists of the patient believing that someone (usually someone of perceived higher status, like a TV star) is in love with them. Somatic type delusions cause the sufferer to believe that they are afflicted with some physical disorder, and this belief is fixed (unlike hypochondriasis, in which the sufferer can be relieved of the belief that something is wrong, if only temporarily). Grandiose delusions have the patient believing that there is something special about him/her, such as God giving special messages. Mixed delusions combine several types of delusions in one presentation. Unspecified delusions are those reserved for presentations which cannot be characterized by the previous types. One example is Capgras syndrome, which is a delusion in which the patient believes that familiar people havebeen replaced by imposters.

207. A 58-year-old woman with a chronic mental disorder comes to the physician with irregular choreoathetoid movements of her hands and trunk. She states that the movements get worse under stressful conditions. Which of the following medications is most likely to have caused this disorder?

a. Fluoxetine b. Clozapine c. Perphenazine d. Diazepam e. Phenobarbitol 206 and 207. The answers are 206-c, 207-c. (Kaplan, p 490.) Tardive dyskinesia (TD) is characterized by involuntary choreoathetoid movements of the face, trunk, and extremities. Tardive dyskinesia is associated with prolonged use of medications that block dopamine receptors, most commonly antipsychotic medications. Typical antipsychotic medications (such as perphenazine) and, in particular, high-potency drugs carry the highest risk of TD. Atypical antipsychotics are thought to be less likely to cause this disorder.

205. A 24-year-old man with chronic schizophrenia is brought to the emergency room after his parents found him in his bed and were unable to communicate with him. On examination, the man is confused and disori- ented. He has severe muscle rigidity and a temperature of 39.4°C (103°F). His blood pressure is elevated, and he has a leucocytosis. Which of the following is the best first step in the pharmacologic treatment of this man?

a. Haloperidol b. Lorazepam c. Bromocriptine d. Benztropine e. Lithium 205. The answer is c. (Kaplan, pp 1046-1047.) The patient has neuroleptic malignant syndrome (NMS), a life-threatening complication of antipsychotic treatment. The symptoms include muscular rigidity and dystonia, akinesia, mutism, obtundation, and agitation. The autonomic symptoms include high fever, sweating, and increased blood pressure and heartrate. Mortality rates are reported to be 10% to 20%. In addition to sup- portive medical treatment, the most commonly used medications for the condition are dantrolene (Dantrium) followed by bromocriptine (Par- lodel), although amantadine is sometimes used. Bromocriptine and amantadine possess direct dopamine receptor agonist effects and may serve to overcome the antipsychotic-induced dopamine receptor blockade. Dantrolene is a direct muscle relaxant.

197. Neuroleptic malignant syndrome

a. Hematocrit b. Prolactin c. Vitamin B12 d. CPK e. ECG f. Urine copper g. Urine vanillylmandelic acid (VMA) h. Venereal Disease Research Laboratory (VDRL) i. Serum ammonia d. CPK 196 to 200. The answers are 196-b, 197-d, 198-i, 199-h, 200-g. (Kaplan, pp 262-266.) Grand mal seizures are followed by a sharp rise in serum prolactin level that lasts approximately 20 minutes. Since in nonepileptic seizures prolactin levels do not change, this test may be helpful in the differential diagnosis. In neuroleptic malignant syndrome, the severe muscle contraction causes rhabdomyolysis and an increase of the serum CPK level. CPK levels also increase with dystonic reactions and following intramuscular injections. Serum ammonia is increased in delirium secondary to hepatic encephalopathy. Gastrointestinal hemorrhages and severe cardiac failure may also cause an increase in serum ammonia. A VDRL is helpful in the diagnosis of tertiary syphilis, which can present with irresponsible behavior, irritability, and confusion. A pheochromocytoma,diagnosed with a urine VMA, may present with a variety of psychiatric symptoms, including anxiety, apprehension, panic, diaphoresis, and tremor.

25. A patient is able to appreciate subtle nuances in thinking and can use metaphors and understand them. This patient's thinking can be best defined by which of the following terms?

a. Intellectualization b. Abstract c. Rationalization d. Concrete e. Isolation of affect 25. The answer is b. (Kaplan, p 273.) The capacity to generalize and to formulate concepts is called abstract thinking. The inability to abstract is called concreteness and is seen in organic disorders and sometimes in schizophrenia. Abstract thinking is commonly assessed by testing similarities, differences, and the meaning of proverbs. Intellectualization, rationalization, and isolation of affect are all unconscious defenses.

392. After ensuring adequate ventilation for the patient in the previous vignette, which of the following interventions should be next?

a. Intravenous naloxone b. Intravenous phenobarbitol c. Intravenous diazepam d. Forced diuresis e. Intramuscular haloperidol 392. The answer is a. (Kaplan, pp 448-449.) Naloxone, an opiate antagonist, is used to reverse the effects of opiates. The first treatment intervention, however, is to ensure that the patient is adequately ventilated. Tracheopharyngeal secretions should be aspirated, and the patient should be mechanically ventilated until naloxone is administered and a positive effect on respiratory rate is noticed. The usual initial dose of naloxone is 0.8 mg slowly administered intravenously. If there is no response, the dose can be repeated every few minutes. In most cases of opiate intoxication, 4 to 5 mg of naloxone (total dose) is sufficient to reverse the CNS depression. Buprenorphine may require higher doses. Diazepam is used to treat alcohol withdrawal symptoms. Forced diuresis is used in the treatment of salicylates and acetaminophen overdoses, not opiate intoxication. Haloperidol, an antipsychotic medication, is not used for the acute treatment of opiate intoxication.

404. In the vignette above, which of the following medications is most likely to be helpful to this patient postictally?

a. Librium IM b. Haloperidol po c. Clonidine po d. Haloperidol IM e. Lorazepam IM 403 and 404. The answers are 403-b and 404-e. (Kaplan, p 399.) Alcohol withdrawal delirium is a medical emergency, since untreated, as many as 20% of patients will die, usually as a result of a concurrent medical illness such as pneumonia, hepatic disease, or heart failure. Symptoms of this delirium include: autonomic hyperactivity, hallucinations, and fluc- tuating activity levels, ranging from acute agitation to lethargy. The best treatment for this delirium is, of course, prevention. However, once it appears, chlordiazepoxide should be given orally, or if this is not possible (as in this case), lorazepam should be given IV or IM. Antipsychotic medications should be avoided, since they may further lower the seizure threshold.

306. A 54-year-old man sees a physician complaining of a depressed mood and inability to sleep for the past 3 weeks. He tells the physician that in the past when he has had similar episodes, he was placed on a monoamine oxidase inhibitor, which proved effective. The physician diagnoses the patient with major depression and agrees to use an MAOI. Which of the following foods must be completely avoided by this patient while on this medication?

a. Licorice b. Coffee c. Chocolate d. Cheddar cheese e. Soy sauce 306. The answer is d. (Jacobson, pp 121-122.) There is a long list of foods that should be avoided while a patient is taking a monoamine oxidase inhibitor, but only a few that must be completely avoided--these include aged cheese, red wine, and cured meats. Others, including anchovies, beets, caviar, chocolate, coffee, colas, curry powder, figs, licorice, mushrooms, rhubarb, snails, soy sauce, and Worcestershire sauce, can be consumed in small quantities because although they contain small amounts of tyramine,they have only rarely been associated with hypertensive episodes.

291. A 25-year-old man comes to the psychiatrist with a chief complaint of depressed mood for 1 month. His mother, to whom he was very close,died 1 month ago, and since that time he has felt sad and been very tearful.He has difficulty concentrating, has lost 3 lb, and is not sleeping soundly through the night. Which of the following is the most likely diagnosis?

a. Major depression b. Dysthymia c. Posttraumatic stress disorder d. Adjustment disorder e. Uncomplicated bereavement 291. The answer is e. (Kaplan, pp 64-68.) The loss of a loved one is often accompanied by symptoms reminiscent of major depression, such as sad- ness, weepiness, insomnia, reduced appetite, and weight loss. When these symptoms do not persist beyond 2 months after the loss, they are consid- ered a normal manifestation of bereavement. A diagnosis of major depression in these circumstances requires the presence of marked functional impairment, morbid preoccupations with unrealistic guilt or worthlessness, suicidal ideation, marked psychomotor retardation, and psychotic symptoms, on top of the symptoms listed in the first sentence above. A diagnosis of adjustment disorder with depressed mood would not normally be given to someone when the "adjustment" is to the recent death of a loved one--instead, bereavement is the diagnosis given (complicated or uncomplicated).

308. A 14-year-old boy is brought to the psychiatrist because for the past 15 months he has been irritable and depressed almost constantly. The boy notes that he has difficulty concentrating, and he has lost 5 lb during that time period without trying. He states that he feels as if he has always been depressed, and he feels hopeless about ever feeling better. He denies suicidal ideation or hallucinations. He is sleeping well and doing well in school, though his teachers have noticed that he does not seem to be able to con- centrate as well as he had previously. Which of the following is the most likely diagnosis?

a. Major depression b. Dysthymic disorder c. Mood disorder secondary to a general medical condition d. Normal adolescence e. Cyclothymia 308. The answer is b. (Moore and Jefferson, pp 142-143.) This patient is suffering from a dysthymic disorder, characterized by an irritable or depressed mood for at least 1 year. (This patient is an adolescent--if he were an adult, the time requirement for the diagnosis of dysthymic would be 2 years.) The patient complains of difficulty concentrating and has had some weight loss. He also feels hopeless about ever not feeling depressed. However, he has no suicidal ideation or psychotic symptoms and no other vegetative symptoms. He is still doing well in school, a clue that the depression is probably not severe enough to rate a diagnosis of major depression,especially when combined with the length of time that this patient has been depressed and irritable.

169. A 53-year-old man is admitted to the cardiac intensive care unit after a myocardial infarction. The day after he is admitted, when the physician enters the room, the patient loudly declares that he "feels fine" and proceeds to get down on the floor to demonstrate this assertion by doing push-ups. Once persuaded to get back into bed, the patient becomes angry about the poor food quality and feels that only the "most qualified" specialist in the hospital should be treating him because he is, after all, the CEO of his own company. The patient's wife notes that this demanding behavior and haughty attitude are not unusual for him. Which of the following psychiatric diagnoses is most likely for this patient?

a. Mania b. Acute psychotic disorder c. Narcissistic personality disorder d. Delusional disorder e. Schizoaffective disorder 169. The answer is c. (Moore and Jefferson, pp 257-258.) This patient is demonstrating some very characteristic signs and symptoms of a person with a narcissistic personality disorder. His wife states that this kind of behavior is not new for this patient, making any of the more acute disorders unlikely. Patients with narcissistic personality disorder, in the face of some narcissistic insult (in this case, the myocardial infarction, reminding the patient that he is, indeed just human), often react with an exaggerated denial of the problem. In this case, the patient jumps down and does push-ups, to "prove" he has not been affected by the myocardial infarction. Approaches to this patient that do not involve direct confrontation but,rather, work with the patient's need to be admired are more likely to be successful.

161. A 24-year-old woman is hospitalized after a suicide gesture during which she superficially slashed both her wrists. At the team meeting 3 days later, the male resident argues that the patient has been doing quite well, seems to be responding to therapy, and should be allowed to leave on a pass. The nursing staff angrily argues that the resident is showing favoritism to the patient, and because of her poor compliance with the unit rules, she should not be allowed out. The resident insists the nurses are being punitive. The defense mechanism being used by the patient in this scenario is a feature of which of the following personality disorders?

a. Narcissistic b. Histrionic c. Borderline d. Antisocial e. Dependent 161. The answer is c. (Kaplan, pp 792-794.) Patients with borderline personalities see others (and themselves) as wholly good or totally bad, a psychological defense called splitting. They alternatively idealize or devalue important figures in their lives, depending on their perceptions of the others' intentions, interest, and level of caring. These dynamics often elicit similar responses in the environment, with the individuals being idealized having a considerably better opinion of the patient than those who are being devalued.

149. A 5-year-old boy shows no interest in other children and ignores adults other than his parents. He spends hours lining up his toy cars or spinning their wheels but does not use them for "make-believe" play. He rarely uses speech to communicate, and his parents state that he has never done so. Physical examination indicates that his head is of normal circumference and his gait is normal. Which of the following is the most likely diagnosis for this boy?

a. Obsessive-compulsive disorder b. Asperger syndrome c. Childhood disintegrative disorder d. Autism e. Rett disorder 149. The answer is d. (Jacobson, pp 295-302.) Autistic disorder is characterized by lack of interest in social interactions, severely impaired verbal and nonverbal communication, stereotyped behaviors, and a very restricted range of interests. Children with autism do not involve themselves in imaginative and imitative play and can spend hours lining and spinning things or dismantling toys and putting them together. Patients with obsessive-compulsive disorder may spend hours on repetitive tasks (such as lining up toys) but do not show the difficulties with language and social interaction that this patient displays. Patients with Asperger syndrome show no clinically significant delay in spoken or receptive language development, making this diagnosis unlikely. Patients with childhood dis- integrative disorder have approximately a 2-year period of normal development (including speech and interpersonal skills) before this regresses; this patient has never apparently had such a period. Patients with Rett disorder by the age of 5 would be expected to have microcephaly and a disordered gait (unsteady and stiff).

9. A 52-year-old man is sent to see a psychiatrist after he is disciplined at his job because he consistently turns in his assignments late. He insists that he is not about to turn in anything until it is "perfect, unlike all of my colleagues." He has few friends because he annoys them with his demands for "precise timeliness" and because of his lack of emotional warmth. This has been a lifelong pattern for the patient, though he refuses to believe the problems have anything to do with his personal behavior. Which of the fol- lowing is the most likely diagnosis for this patient?

a. Obsessive-compulsive disorder b. Obsessive-compulsive personality disorder c. Borderline personality disorder d. Bipolar disorder, mixed state e. Anxiety disorder not otherwise specified 9. The answer is b. (Kaplan, p 806.) The essential feature of obsessive-compulsive personality disorder is a preoccupation with perfection, orderliness, and control. Individuals with this disorder lose the main point of an activity and miss deadlines because they pay too much attention to rules and details and are not satisfied with anything less than "perfection." As in other personality disorders, symptoms are ego-syntonic and create inter- personal, social, and occupational difficulties. obsessive-compulsive disorder is differentiated from obsessive-compulsive personality disorder by the presence of obsessions and compulsions. In addition, patients with symptoms of obsessive-compulsive disorder view them as ego-dystonic. Patients with borderline personality disorder present with a history of pervasive instability of mood, relationships, and self-image beginning by early adulthood. Their behavior is often impulsive and self-damaging. Patients with bipolar disorder present with problems of mood stability; mood may be depressed for several weeks at a time, then euphoric. Patients with an anxiety disorder not otherwise specified present with anxiety as a main symptom, though they do not specifically fit any other, more specific anxiety disorder as per DSM-IV-TR (Diagnostic and Statistical Manual 4th ed,text revision).

150. A 15-year-old boy is arrested for shooting the owner of the convenience store he tried to rob. He has been in department of youth services custody several times for a variety of crimes against property, possession of illegal substances, and assault and battery. He is cheerful and unconcerned during the arrest, more worried about losing his leather jacket than about the fate of the man he has injured. Which of the following is the most likely diagnosis in this case?

a. Oppositional defiant disorder b. Antisocial personality disorder c. Narcissistic personality disorder d. Conduct disorder e. Substance abuse 150. The answer is d. (Moore and Jefferson, pp 46-47.) Children with conduct disorder display a persistent disregard for rules and other people's rights that lasts at least 1 year. Aggression toward people and animals, destruction of property, deceit and illegal activities, and frequent truancy from school are the main characteristics of the disorder. Approximately one-third of children diagnosed with conduct disorder proceed to become delinquent adolescents, and many are diagnosed with antisocial personality disorder in adulthood. Patients with antisocial personality disorder display a pervasive pattern of disregard for and violation of the rights of others since the age of 15 years, with evidence of a conduct disorder before age 15. Substance abuse is just one facet of conduct disorder. Children with oppositional defiant disorder are problematic and rebellious but do not routinely engage in aggressive, destructive, or illegal activities. Also, they do not present with the lack of empathy for others and the disregard for other people's rights that are typical of conduct disorder.

133. A 5-year-old boy is brought to the psychiatrist because he has difficulty paying attention in school. He fidgets and squirms and will not stay seated in class. It is noted that at home he talks excessively and has diffi- culty waiting for his turn. His language and motor skills are appropriate for his age. Which of the following is the most likely diagnosis?

a. Oppositional defiant disorder (ODD) b. Attention-deficit hyperactivity disorder (ADHD) c. Pervasive developmental disorder d. Separation anxiety disorder e. Mild mental retardation 133. The answer is b. (Kaplan, pp 1214-1215.) Excessive motor activity,usually with intrusive and annoying qualities, poor sustained attention,difficulties inhibiting impulsive behaviors in social situations and on cog- nitive tasks, and difficulties with peers are the main characteristics ofADHD, combined type. Symptoms must be present in two or more settings(in this case, home and school) and must cause significant impairment.

208. A 19-year-old woman is brought to the emergency room by her roommate after the patient told her that "the voices are telling me to kill the teacher." The roommate states the patient has always been isolative and "odd" but for the past 2 weeks she has been hoarding food, talking to herself, and appearing very paranoid. Which of the following tests are likely to be abnormal in this patient?

a. PET scan of dopamine receptors. b. EEG (will show a decreased alpha activity). c. Test of eye movements (patient will be unable to follow a moving visual target accurately). d. CT (lateral and third ventricle enlargement will be seen). e. All of these tests may be abnormal. 208. The answer is e. (Kaplan, p 473.) All of these abnormal findings may be present in a schizophrenic patient. EEG studies may also show increased theta and delta activity, in addition to decreased alpha activity. On PET scan, there is found an increase in D2 receptors in the caudate nucleus of drug-free schizophrenics. Eye movement dysfunction may be a trait marker for schizophrenia. CT scans have consistently shown enlarged lateral and third ventricles, as well as reductions in cortical volume.

32. A 28-year-old business executive sees her physician because she is having difficulty in her new position, as it requires her to do frequent public speaking. She states that she is terrified she will do or say something that will cause her extreme embarrassment. The patient says that when she must speak in public, she becomes extremely anxious and her heart beats uncontrollably. Based on this clinical picture, which of the following is the most likely diagnosis?

a. Panic disorder b. Avoidant personality disorder c. Specific phobia d. Agoraphobia e. Social phobia 32. The answer is e. (Moore and Jefferson, pp 11, 165-167.) A social phobia is a persistent and overwhelming fear of humiliation or embarrassment in social or performance situations. This leads to high levels of distress and avoidance of those situations. Often, physical symptoms of anxiety such as blushing, trembling, sweating, or tachycardia are triggered when the patient feels under evaluation or scrutiny.

14. An 18-year-old man is brought to the emergency room by his college roommate, after the roommate discovered that the patient had not left his room for the past 3 days, neither to eat nor to go to the bathroom. The roommate noted that the patient was kind of "weird." Mental status examination reveals that the patient has auditory hallucinations of two voices commenting upon his behavior. The patient's parents note that their son has always been somewhat of a loner and unpopular, but otherwise did fairly well in school.

a. Panic disorder b. Generalized anxiety disorder c. Schizoid personality disorder d. Schizotypal personality disorder e. Anxiety secondary to a general medical condition f. Factitious disorder g. Malingering h. Schizophreniform disorder i. Schizophrenia The answers are 12-c, 13-f, 14-h, 15-b. (Kaplan, pp. 591, 795, 659, 500, 624.) Patients with panic disorder experience anxiety attacks in a more or less random pattern, with no precipitating factors of which the patient is aware. Patients are often quite afraid of another attack and will constrict their daily activities to avoid recreating the environment in which the attack first occurred. It is quite common for them to fear that they are dying or losing their minds during these attacks as well. Patients with schizoid personality disorder are notable in that their symptoms (social isolation, inability to connect emotionally with others, tendency to daydream) are ego-syntonic--that is, they do not cause a problem for the patient and are not seen as such. These patients may have veryfew social connections, and unlike patients with avoidant personality disorder, they do not seem to miss the contact. Patients with factitious disorder are trying to achieve the role of a person with an illness (usually physical) so that they may be cared for by the health-care system. This constitutes primary gain, in that there is usually nothing they are trying to avoid by adopting the sick role (as opposed to the secondary gain of malingering, whereby a patient might enter the hospital, eg, to avoid being arrested by the police). Patients often will have undergone a series of medical procedures, and it is not unusual to find a history of a family member (or the patient himself/herself) being involved in a medical field as a line of work. Schizophreniform disorder is best thought of as a schizophrenia-like illness that simply has not been manifested for long enough to be called schizophrenia (6 months is the cutoff point between the two). Psychotic symptoms such as auditory or visual hallucinations are common, as is a premorbid history of being "weird" or a "loner." Generalized anxiety disor- der is identified by the fact that the patient has multiple worries, not just one or two. For example, the patient in question 15 is not worried just about having an anxiety attack or about the health of her daughter or about the war in Iraq. She is worried about a number of different scenarios, and they are not all related.

15. A 32-year-old woman comes to the psychiatrist with a chief complaint of anxiety. She notes that she worries about paying the mortgage on time, whether or not she will get stuck in traffic and be late for appointments, her husband's and daughter's health, and the war in Iraq. She notes that she has always been anxious, but since the birth of her daughter 2 years ago, the anxiety has worsened to the point that she feels she cannot function as well as she did previously.

a. Panic disorder b. Generalized anxiety disorder c. Schizoid personality disorder d. Schizotypal personality disorder e. Anxiety secondary to a general medical condition f. Factitious disorder g. Malingering h. Schizophreniform disorder i. Schizophrenia The answers are 12-c, 13-f, 14-h, 15-b. (Kaplan, pp. 591, 795, 659, 500, 624.) Patients with panic disorder experience anxiety attacks in a more or less random pattern, with no precipitating factors of which the patient is aware. Patients are often quite afraid of another attack and will constrict their daily activities to avoid recreating the environment in which the attack first occurred. It is quite common for them to fear that they are dying or losing their minds during these attacks as well. Patients with schizoid personality disorder are notable in that their symptoms (social isolation, inability to connect emotionally with others, tendency to daydream) are ego-syntonic--that is, they do not cause a problem for the patient and are not seen as such. These patients may have veryfew social connections, and unlike patients with avoidant personality disorder, they do not seem to miss the contact. Patients with factitious disorder are trying to achieve the role of a person with an illness (usually physical) so that they may be cared for by the health-care system. This constitutes primary gain, in that there is usually nothing they are trying to avoid by adopting the sick role (as opposed to the secondary gain of malingering, whereby a patient might enter the hospital, eg, to avoid being arrested by the police). Patients often will have undergone a series of medical procedures, and it is not unusual to find a history of a family member (or the patient himself/herself) being involved in a medical field as a line of work. Schizophreniform disorder is best thought of as a schizophrenia-like illness that simply has not been manifested for long enough to be called schizophrenia (6 months is the cutoff point between the two). Psychotic symptoms such as auditory or visual hallucinations are common, as is a premorbid history of being "weird" or a "loner." Generalized anxiety disor- der is identified by the fact that the patient has multiple worries, not just one or two. For example, the patient in question 15 is not worried just about having an anxiety attack or about the health of her daughter or about the war in Iraq. She is worried about a number of different scenarios, and they are not all related.

12. A 28-year-old man comes to the psychiatrist because his employer required it. The patient says that he does not know why the employer required it--that his job is good and that he likes it because it requires him to sit in front of a computer screen all day. He notes he has one friend whom he has had for more than 20 years and "doesn't need anyone else." The friend lives in another state and the patient has not seen him for at least a year. The patient denies any psychotic symptoms. His eye contact is poor and his affect is almost flat.

a. Panic disorder b. Generalized anxiety disorder c. Schizoid personality disorder d. Schizotypal personality disorder e. Anxiety secondary to a general medical condition f. Factitious disorder g. Malingering h. Schizophreniform disorder i. Schizophrenia12 to 15. The answers are 12-c, 13-f, 14-h, 15-b. (Kaplan, pp. 591, 795, 659, 500, 624.) Patients with panic disorder experience anxiety attacks in a more or less random pattern, with no precipitating factors of which the patient is aware. Patients are often quite afraid of another attack and will constrict their daily activities to avoid recreating the environment in which the attack first occurred. It is quite common for them to fear that they are dying or losing their minds during these attacks as well. Patients with schizoid personality disorder are notable in that their symptoms (social isolation, inability to connect emotionally with others, tendency to daydream) are ego-syntonic--that is, they do not cause a problem for the patient and are not seen as such. These patients may have veryfew social connections, and unlike patients with avoidant personality disorder, they do not seem to miss the contact. Patients with factitious disorder are trying to achieve the role of a person with an illness (usually physical) so that they may be cared for by the health-care system. This constitutes primary gain, in that there is usually nothing they are trying to avoid by adopting the sick role (as opposed to the secondary gain of malingering, whereby a patient might enter the hospital, eg, to avoid being arrested by the police). Patients often will have undergone a series of medical procedures, and it is not unusual to find a history of a family member (or the patient himself/herself) being involved in a medical field as a line of work. Schizophreniform disorder is best thought of as a schizophrenia-like illness that simply has not been manifested for long enough to be called schizophrenia (6 months is the cutoff point between the two). Psychotic symptoms such as auditory or visual hallucinations are common, as is a premorbid history of being "weird" or a "loner." Generalized anxiety disor- der is identified by the fact that the patient has multiple worries, not just one or two. For example, the patient in question 15 is not worried just about having an anxiety attack or about the health of her daughter or about the war in Iraq. She is worried about a number of different scenarios, and they are not all related.

13. A 42-year-old woman is admitted to the hospital for complaints of abdominal pain. Her history notes that her mother was a nurse and she herself is trained as a phlebotomist. On physical examination, she presents with multiple abdominal scars and marked abdominal tenderness. The patient is evasive when asked where she had the surgeries, but she can describe in great detail what was done in each.

a. Panic disorder b. Generalized anxiety disorder c. Schizoid personality disorder d. Schizotypal personality disorder e. Anxiety secondary to a general medical condition f. Factitious disorder g. Malingering h. Schizophreniform disorder i. Schizophrenia12 to 15. The answers are 12-c, 13-f, 14-h, 15-b. (Kaplan, pp. 591, 795, 659, 500, 624.) Patients with panic disorder experience anxiety attacks in a more or less random pattern, with no precipitating factors of which the patient is aware. Patients are often quite afraid of another attack and will constrict their daily activities to avoid recreating the environment in which the attack first occurred. It is quite common for them to fear that they are dying or losing their minds during these attacks as well. Patients with schizoid personality disorder are notable in that their symptoms (social isolation, inability to connect emotionally with others, tendency to daydream) are ego-syntonic--that is, they do not cause a problem for the patient and are not seen as such. These patients may have veryfew social connections, and unlike patients with avoidant personality disorder, they do not seem to miss the contact. Patients with factitious disorder are trying to achieve the role of a person with an illness (usually physical) so that they may be cared for by the health-care system. This constitutes primary gain, in that there is usually nothing they are trying to avoid by adopting the sick role (as opposed to the secondary gain of malingering, whereby a patient might enter the hospital, eg, to avoid being arrested by the police). Patients often will have undergone a series of medical procedures, and it is not unusual to find a history of a family member (or the patient himself/herself) being involved in a medical field as a line of work. Schizophreniform disorder is best thought of as a schizophrenia-like illness that simply has not been manifested for long enough to be called schizophrenia (6 months is the cutoff point between the two). Psychotic symptoms such as auditory or visual hallucinations are common, as is a premorbid history of being "weird" or a "loner." Generalized anxiety disor- der is identified by the fact that the patient has multiple worries, not just one or two. For example, the patient in question 15 is not worried just about having an anxiety attack or about the health of her daughter or about the war in Iraq. She is worried about a number of different scenarios, and they are not all related.

109. A 65-year-old woman with a history of chronic alcohol abuse cheerfully greets the resident doctor of her nursing home, whom she has met many times before, and calls him, "My dear friend Jack." The physician explains who he is and tells the patient his name. Two minutes later, when he asks the patient if she knows who he is, she answers with a smile, "Of course, you are my cousin Anthony from New Jersey." What vitamin deficiency can cause this form of amnestic disorder?

a. Pantothenic acid b. Folate c. Thiamine d. Riboflavin e. Niacin 109. The answer is c. (Kaplan, p 833.) Severe anterograde memory deficits with an inability to form new memories are the main feature of Korsakoff syndrome, or alcohol-induced persisting amnestic disorder.Retrograde amnesia is also present, with the most severe loss of memory occurring for events that were closer to the beginning of the disorder.Remote memories are relatively preserved. The disorder is because of dietary thiamine deficiency and subsequent damage of the thiamine-dependent structures of the brain (mammillary bodies and the regions sur- rounding the third and fourth ventricles). Korsakoff syndrome cansometimes (though rarely) be attributed to other causes of thiamine deficiency, such as diseases that cause severe malabsorption.

384. A 24-year-old woman drops out of college after 2 weeks. When asked why, she states that although she would desperately like to have friends, she is afraid to approach anyone because "they would think I'm just a nerd." Furthermore, in the middle of a class, one of the professors asked her a question and she became extremely uncomfortable. She has never had a significant relationship with anyone other than her parents and sister.

a. Paranoid b. Schizotypal c. Schizoid d. Narcissistic e. Borderline f. Histrionic g. Antisocial h. Obsessive-compulsive i. Dependent j. Avoidant k. No personality disorder apparent 384 to 387. The answers are 384-j, 385-c, 386-k, 387-k. (Ebert,pp 280, 513-516, 689.) Avoidant personality disorder is characterized by an intense need for connection and social interaction with others, coupled with an intense fear of rejection. This fear causes patients to avoid any new or social situations that might be potentially embarrassing, and to feel extremely inadequate about the ability to start and maintain any kind of relationship. Conversely, patients with schizoid personality disorder, while every bit as isolated as those with avoidant personality disorder, like it that way. They rarely come to psychiatric attention because their social isolation is ego-syntonic. They do not like social relationships and usually prefer isolated activities. They have few, if any, friends. Question 386 refers to a patient with obsessive-compulsive disorder (not obsessive-compulsive personality disorder). Patients with OCD are characterized by obsessions (in this case, that there is something wrong with the stove, furnace, and water heater) and compulsions (the checking activity). These rituals can very much disturb a patient's life and are almost always ego-dystonic. Prevent- ing the compulsions from occurring, however, causes a great deal of anxiety, as in this patient's case. Question 387 refers to a delusional patient (in this case, the patient has paranoid delusions). Delusions are fixed false beliefs that by their very definition cannot be changed. The magnitude of this patient's delusions is such that she acts on her paranoia by trying to steal her baby and scratch a nurse. Both obsessive-compulsive disorder and paranoid delusional disorder are often confused with obsessive-compulsive personality disorder and paranoid personality disorder, respectively.

385. A 32-year-old man comes to the psychiatrist because he is anxious about his new job. He notes that he previously held a job shelving books in the back of a library, but because of budget cuts he has been forced to interact with customers. He states he doesn't like being around people and prefers being by himself. He appears emotionally cold and detached during the interview.

a. Paranoid b. Schizotypal c. Schizoid d. Narcissistic e. Borderline f. Histrionic g. Antisocial h. Obsessive-compulsive i. Dependent j. Avoidant k. No personality disorder apparent 384 to 387. The answers are 384-j, 385-c, 386-k, 387-k. (Ebert,pp 280, 513-516, 689.) Avoidant personality disorder is characterized by an intense need for connection and social interaction with others, coupled with an intense fear of rejection. This fear causes patients to avoid any new or social situations that might be potentially embarrassing, and to feel extremely inadequate about the ability to start and maintain any kind of relationship. Conversely, patients with schizoid personality disorder, while every bit as isolated as those with avoidant personality disorder, like it that way. They rarely come to psychiatric attention because their social isolation is ego-syntonic. They do not like social relationships and usually prefer isolated activities. They have few, if any, friends. Question 386 refers to a patient with obsessive-compulsive disorder (not obsessive-compulsive personality disorder). Patients with OCD are characterized by obsessions (in this case, that there is something wrong with the stove, furnace, and water heater) and compulsions (the checking activity). These rituals can very much disturb a patient's life and are almost always ego-dystonic. Prevent- ing the compulsions from occurring, however, causes a great deal of anxiety, as in this patient's case. Question 387 refers to a delusional patient (in this case, the patient has paranoid delusions). Delusions are fixed false beliefs that by their very definition cannot be changed. The magnitude of this patient's delusions is such that she acts on her paranoia by trying to steal her baby and scratch a nurse. Both obsessive-compulsive disorder and paranoid delusional disorder are often confused with obsessive-compulsive personality disorder and paranoid personality disorder, respectively.

386. A 19-year-old man comes to the psychiatrist because he can't leave the house without checking the stove, furnace, and water heater 25 times in a specific order. He notes that while he hates to perform this behavior, if he does not, he feels overwhelmingly anxious. It sometimes takes him 3 hours to leave the house in the morning because of this behavior.

a. Paranoid b. Schizotypal c. Schizoid d. Narcissistic e. Borderline f. Histrionic g. Antisocial h. Obsessive-compulsive i. Dependent j. Avoidant k. No personality disorder apparent 384 to 387. The answers are 384-j, 385-c, 386-k, 387-k. (Ebert,pp 280, 513-516, 689.) Avoidant personality disorder is characterized by an intense need for connection and social interaction with others, coupled with an intense fear of rejection. This fear causes patients to avoid any new or social situations that might be potentially embarrassing, and to feel extremely inadequate about the ability to start and maintain any kind of relationship. Conversely, patients with schizoid personality disorder, while every bit as isolated as those with avoidant personality disorder, like it that way. They rarely come to psychiatric attention because their social isolation is ego-syntonic. They do not like social relationships and usually prefer isolated activities. They have few, if any, friends. Question 386 refers to a patient with obsessive-compulsive disorder (not obsessive-compulsive personality disorder). Patients with OCD are characterized by obsessions (in this case, that there is something wrong with the stove, furnace, and water heater) and compulsions (the checking activity). These rituals can very much disturb a patient's life and are almost always ego-dystonic. Prevent- ing the compulsions from occurring, however, causes a great deal of anxiety, as in this patient's case. Question 387 refers to a delusional patient (in this case, the patient has paranoid delusions). Delusions are fixed false beliefs that by their very definition cannot be changed. The magnitude of this patient's delusions is such that she acts on her paranoia by trying to steal her baby and scratch a nurse. Both obsessive-compulsive disorder and paranoid delusional disorder are often confused with obsessive-compulsive personality disorder and paranoid personality disorder, respectively.

216. A 20-year-old woman is brought to the emergency room by her family because they have been unable to get her to eat or drink anything for the past 2 days. The patient, although awake, is completely unresponsive both vocally and nonverbally. She actively resists any attempt to be moved. Her family reports that during the previous 7 months she became increasingly withdrawn, socially isolated, and bizarre; often speaking to people no one else could see. Which of the following is the most likely diagnosis?

a. Schizoaffective disorder b. Delusional disorder c. Schizophreniform disorder d. Catatonia e. PCP intoxication 216. The answer is d. (Kaplan, p 477.) Catatonic schizophrenia is characterized by marked psychomotor disturbances including prolonged immobility, posturing, extreme negativism (the patient actively resists any attempts made to change his or her position) or waxy flexibility (the patient maintains the position in which he or she is placed), mutism, echolalia (repetition of words said by another person), and echopraxia (repetition of movements made by another person). Periods of immobility and mutism can alternate with periods of extreme agitation (catatonic excitement).

215. A 35-year-old woman has lived in a state psychiatric hospital for the past 10 years. She spends most of her day rocking, muttering softly to her- self, or looking at her reflection in a small mirror. She needs help with dressing and showering, and she often giggles and laughs for no apparent reason. Which of the following is the most likely diagnosis?

a. Schizophrenia b. Delusional disorder c. Bipolar disorder, manic phase d. Schizoaffective disorder e. Schizophreniform disorder 215. The answer is a. (Kaplan, p 477.) The essential characteristics of the disorganized type of schizophrenia are disorganized speech and behav- ior, flat or inappropriate affect, great functional impairment, and inability to perform basic activities such as showering or preparing meals. Grimacing, along with silly and odd behavior and mannerisms, is common.Hallucinations and delusions, if present, are fragmented and not organized according to a coherent theme. This subtype is associated with poor pre- morbid functions, early insidious onset, and a progressive course without remissions. The patient has obviously had the disorder too long for the diagnosis to be schizophreniform, and the absence of mood symptoms makes a diagnosis of bipolar disorder or schizoaffective disorder unlikely. Patients with a delusional disorder do not generally have such a marked impairment in affect or function.

370. A young librarian has been exceedingly shy and fearful of people since childhood. She longs to make friends, but even casual social interactions cause her a great deal of shame and anxiety. She has never been at a party, and she has requested to work in the least active section of her library, even though this means lower pay. She cannot look at her rare customers without blushing, and she is convinced that they see her as incompetent and clumsy. Which of the following personality disorders is most likely?

a. Schizotypal b. Avoidant c. Dependent d. Schizoid e. Paranoid 370. The answer is b. (Jacobson, p 187.) Avoidant personality disorder is characterized by pervasive and excessive hypersensitivity to negative evaluation, social inhibition, and feelings of inadequacy. Impairment can be severe because of social and occupational difficulties. Males and females are equally affected. The prevalence ranges from 0.5% to 1.5% in the general population. Among psychiatric outpatients, the prevalence is as high as 10%. Patients with avoidant personality disorder would like friends, but are so afraid that they will be rejected that they do not try to make them. Patients with schizoid personality disorders, by contrast, are socially isolated and prefer it that way.

154. An emaciated and lethargic 16-year-old girl arrives at the emergency room. Her blood pressure is 75/50, her heart rate is 52 beats per minute, her potassium is 2.8 meq/L, and her bicarbonate is 40 meq/L. The girl's parents report that she has lost 35 lb in 3 months but is still convinced that she is overweight. She eats only very small amounts of low-calorie food, and she runs 2 to 3 hours every day. What other activities is this patient most likely to have engaged in?

a. Sexual promiscuity b. Ethanol abuse c. Purging d. Wearing tight clothes e. Shoplifting 154. The answer is c. (Kaplan, pp 728-729.) Anorexia nervosa is characterized by the refusal to maintain a minimal normal weight for height and age, intense fear of gaining weight, distorted body image, and amenorrhea. Body weight is controlled by drastic reduction of caloric intake, but most anorectic patients also use diuretics and laxatives. Purging, which causes hypokalemic alkalosis, can also be present but is not as frequent as in bulimia. The other listed behaviors are not characteristic of patients with anorexia.

323. A 20-year-old woman comes to her primary care doctor with multiple symptoms which are present across several organ systems. She has seen five doctors in the past 3 months, and has had six surgeries since the age of 18.

a. Somatization disorder b. Conversion disorder c. Hypochondriasis d. Body dysmorphic disorder e. Pain disorder 323 to 327. The answers are 323-a, 324-b, 325-c, 326-d, 327-e.(Kaplan, p 635.) Somatization disorder is characterized by a polysymptomatic presentation, with the patient presenting as someone who has been chronically sick. Females present with this disorder about 20 times more frequently than do males, and there is a 5% to 10% incidence in the primary care population. Patients have often had multiple surgeries. Patients with conversion disorder are generally young females with poor education; they typically are from rural areas and low socioeconomic class. They present acutely, usually with one symptom, but that symptom may be incompatible with known pathophysiologic mechanisms. Patients with hypochondriasis tend to be older, and men and women present with equal frequency. Patients are over-concerned with a disease, which amplifies their symptoms as a result. They are usually temporarily reassured with negative test findings, but soon find another illness to obsess about. Patients with a body dysmorphic disorder tend to be adolescent or young adult women, who have subjective feelings that they are ugly or have some body part that is deformed. Those with pain disorders are usually in their fourth or fifth decade of life, with women represented in the population twice as often as men. These patients have often had some precipitating event to their pain, but it continues with an intensity incompatible with known physiologic mechanisms.

338. Two years after she was saved from her burning house, a 32-year-old woman continues to be distressed by recurrent dreams and intrusive thoughts about the event.

a. Somatization disorder b. Specific phobia c. Dissociative identity disorder d. Obsessive-compulsive disorder e. Dissociative fugue f. Posttraumatic stress disorder g. Body dysmorphic disorder h. Dysthymia 338 to 342. The answers are 338-f, 339-g, 340-e, 341-d, 342-a.(Moore and Jefferson, pp 158-175.) One of the most characteristic features of posttraumatic stress disorder (PTSD) is the occurrence of repeated dreams, flashbacks, and intrusive thoughts of the traumatic event. Hyperarousal, irritability, difficulties concentrating, exaggerated startle response, emotional numbing, avoidance of places and situations associated with the traumatic experience, dissociative amnesia, and a sense of foreshortened future are other symptoms displayed by patients with PTSD. In body dysmorphic disorder, a person of normal appearance is preoccupied with some imaginary physical defect. The belief is tenacious and sometimes of delusional intensity. This diagnosis should not be made when the distorted ideations are limited to the belief of being fat in anorexia nervosa or to uneasiness with one's gender characteristics in gender identity disorder. Patients with obsessive-compulsive disorder (OCD) experience persistentthoughts, impulses, or repetitive behaviors that they are unable to stop voluntarily. Obsessions and compulsions are experienced as alien and ego-dystonic and are the source of much distress. Somatization disorder is characterized by a history of multiple physical complaints not explained by organic factors. The diagnosis requires the presence of four pain symp- toms, two gastrointestinal symptoms, one sexual symptom, and one pseudoneurological symptom over the course of the disorder. The essential feature of dissociative fugue is sudden travel away from home accompanied by temporary loss of autobiographic memory. Patients are confused about their identity and at times form new identities. Dissociative fugue may last from hours to months. During the fugue, individuals do not appear to have any psychopathology; usually they come to attention when their identity is questioned.

27. A 59-year-old man goes to a psychiatrist for a 3-month history of panic attacks. He notes for the past 3 months he has experienced "out of the blue," extreme episodes of fearfulness that last about 20 minutes. Dur- ing that time he experiences palpitations, sweating, shortness of breath, and trembling. He denies any substance abuse, and has never had symptoms like this before these past 3 months. Which of the following signs or symptoms would likely lead the physicians to expect a diagnosis of anxiety secondary to a general medical condition in this case?

a. The patient's age b. History of palpitations c. History of sweating d. History of shortness of breath e. History of trembling 27. The answer is a. (Kaplan, pp 591, 593.) It is unlikely that a 59-year-old man would suddenly begin to suffer from panic attacks. Much more likely is that these attacks are stemming from some as yet undiagnosed medical condition. The other options in the question are all part of the criteria to diagnose panic disorder itself.

206. A 54-year-old man with a chronic mental illness seems to be constantly chewing. He does not wear dentures. His tongue darts in and out of his mouth, and he occasionally smacks his lips. He also grimaces, frowns,and blinks excessively. Which of the following disorders is most likely in this patient?

a. Tourette syndrome b. Akathisia c. Tardive dyskinesia d. Parkinson disease e. Huntington disease 206 and 207. The answers are 206-c, 207-c. (Kaplan, p 490.) Tardive dyskinesia (TD) is characterized by involuntary choreoathetoid movements of the face, trunk, and extremities. Tardive dyskinesia is associated with prolonged use of medications that block dopamine receptors, most commonly antipsychotic medications. Typical antipsychotic medications (such as perphenazine) and, in particular, high-potency drugs carry the highest risk of TD. Atypical antipsychotics are thought to be less likely to cause this disorder.

209. In the patient in the above vignette, which of the following features would be indicative of a good prognosis with this disease?

a. Young onset b. Withdrawn behavior c. Poor support system d. Family history of mood disorders e. Neurologic signs and symptoms present 209. The answer is d. (Kaplan, p 476.) Factors weighting toward a good prognosis in schizophrenia include: late onset of the disease, obvious precipitating factors/stressors, an acute onset, good premorbid functioning, the presence of mood disorder symptoms, the patient being married, a family history of mood disorders, good support systems, and the presence of positive symptoms (as opposed to negative symptoms).