exam 1 ?s

A 37-year-old man comes in for follow-up of chronic neck and back pain following a motor vehicle accident 3 months earlier. He has severely limited range of motion of his neck and he is constantly in pain. He was a passenger in a car with his friend when they were rear-ended by a car going full speed on the freeway causing them to hit another car in front of them. The patient was trapped in the car and initially had difficulty getting out and remembers feeling panicked. He currently avoids riding in cars on the freeway because he is constantly looking around him and feels very anxious. He frequently has flashbacks of the accident especially when he tries to turn too quickly and has severe neck pain. He feels frustrated and angry about being physically limited and needing to take time off from work. 1. What are some of the symptom clusters of PTSD did this patient experience? A. Avoidance and reexperiencing B. Avoidance and numbing C. Avoidance and dissociation D. Numbing and hyperarousal E. Avoidance and delayed expression

A

Mr. Green is a 56-year-old patient with type 2 diabetes and hypertension who was recently transferred to your care by a primary physician who recently retired. He has been scheduled to see you for a routine follow-up. Earlier in the afternoon, you encountered and dealt with an emergent situation with one of your patients and are subsequently running behind schedule. Mr. Green arrived to his appointment on time and has been waiting for over an hour to see you. The clinic receptionist rushes back to see you between patients and expresses concern about his behavior. She tells you, "At first he seemed all right with having to wait, but he just started yelling at me and demanding to be seen immediately. I keep on telling him that you'll see him soon and ask him to sit down but that just seems to make him angrier. Now he's pacing around the room and staring at me. What should I do?" 1. Which of the following is likely the underlying cause of this patient's behavioral escalation? A. Unmet personal needs and dissatisfaction with his treatment B. An undiagnosed psychotic disorder C. Suboptimal treatment for major depressive disorder D. Traumatic brain injury E. Substance intoxication

A

A 38-year-old man presents to your office reporting he was placed on probation by his work for drinking alcohol on the job. He reports that he was feeling increased stress and pressure from his job starting one year ago owing to multiple ongoing projects. Around that time, he also began noticing episodes of suddenly feeling shaky, sweaty, and that he was going to lose control. This happened multiple times out of the blue while he was at home or working in the office. He says he couldn't take it anymore and started drinking beer to calm his nerves before going into work. The drinking increased and soon he was drinking 6 to 8 beers every day. After getting in trouble for drinking, he quit drinking 6 weeks ago but says he still feels "on edge" and is having trouble concentrating. "Beer is the only thing that works, doctor. I don't know what else to do!" 1. This patient most likely has _______________________ A. posttraumatic stress disorder B. borderline personality disorder C. panic disorder D. pheochromocytoma E. malingering

C

You are working a weekend shift in an urgent care clinic. A nurse approaches you and hands you a patient's chart. She tells you, "This patient, Mr. Johnson, is a big-timeP.321drug seeker. He is always coming in here with these bogus pain complaints and demanding OxyContin and other narcotics. You aren't gonna give him any, are you?" The first thing Mr. Johnson tells you is, "Hey, doctor, I got the worst migraine headache ever. The only thing that will take care of it is a shot of Demerol. Just give me that shot and I'll be out of here." You begin to question Mr. Johnson in detail about the onset, duration, and location of his pain. His answers are vague, nondescript, and contradictory. As the interview progresses, he gets increasingly hostile and eventually blurts out, "What's with all the stupid questions? I already told you what I need! Do your ******* job and give me the shot or I'll sue you!" You exit the room and review Mr. Johnson's medical records. They chronicle numerous urgent care visits for various pain complaints, which are unsubstantiated by objective findings. He demands opiates at each visit and often receives a prescription for a small supply of opiates with instructions to follow up with his primary care physician. He has a history of heroin dependence and has been arrested in the past for assault. After consulting with a colleague, you determine that he is likely seeking abusable medication and prepare to speak with him about the issue. 1. Which of the following precautions should be taken when going into the examination room to speak with this patient? A. Going in alone to maintain patient privacy B. Confronting him with documented proof of his past heroin use C. Leaving the door of the room open and standing near it D. Dictating the course of care in an authoritative fashion E. Ensuring the room is well-stocked with sharp objects or potential projectiles

C

2. What feature of the case is most consistent with active mania/hypomania or at least mixed features? A. Irritability B. Failure of multiple medications C. We still need to ask about elevated mood D. The fact that he is a writer (artistic) E. Active depression

Correct answer: A. Irritability. Although elevated mood is a hallmark of bipolar disorder, when a patient describes "irritable mood," that can be considered a manic-equivalent symptom. In fact, irritability has a much higher correlation with bipolar disorder than major depressive episodes (MDE) with 77% of patients with bipolar disorder reporting irritable mood compared with only 46% of patients with MDE

2. What is the best treatment approach? A. Change citalopram to bupropion B. Change citalopram to venlafaxine C. Add CBT D. Add supportive psychotherapy E. Any of the above

Correct answer: A. Although recurrent or severe depression is best managed in consultation with a psychiatrist, there are approaches that can be employed in primary care settings. This patient is reporting erectile dysfunction related to treatment with SSRI. He is also mildly obese. Given that his depression has recurred, this may be a good time to reevaluate choice of antidepressant. Bupropion may be a good choice given its low propensity to cause weight gain and sexual dysfunction. Although his mother responded to venlafaxine in the past, there's high likelihood the venlafaxine may also cause sexual side effects. Considering this patient's overall situation, bupropion may still be a better choice. Adding psychotherapy will be helpful for this patient because combination medication and psychotherapy tend to be more effective than either alone; the sexual side effects should still be addressed first. Another option would be to add bupropion as combination therapy to citalopram for depression treatment and to reduce sexual side effect. However, the patient must be agreeable to taking two medications rather than one.

3. Which of the following factors in this case might make ECT a particularly appropriate next treatment? A. Severe suicidality B. Comorbid psychosis C. Comorbid anxiety D. Failure to respond to an SSRI

Correct answer: A. ECT is indicated in urgent situations when rapid improvement is needed, such as malnutrition due to catatonia, agitated psychosis, or severe suicide risk.

Ms. B is a 36-year-old thin, married woman who has been on sertraline in the past. She reports that her mood has been low recently and presents to your primary care office requesting to restart sertraline. She is a rock musician who has purple hair and a rather flamboyant style. You restart the sertraline, but she calls you after a few days stating she has not been sleeping, is feeling "revved," and is contemplating having an affair with a casual acquaintance. You recognize the signs of mania and have her stop the sertraline. Having read this chapter, you are inclined to call in a prescription for lithium but need a little encouragement because you have not prescribed it before. 1. Which of the following statements about lithium therapy is true? A. Lithium monotherapy is equally effective compared with the combination of lithium + valproate. B. Lithium monotherapy is equally effective compared with valproate. C. Lithium monotherapy is less effective compared with the combination of lithium + valproate. D. Lithium monotherapy is less effective than valproate. E. Lithium monotherapy is less effective than lamotrigine.

Correct answer: A. In the United States, prescription of lithium for outpatients nearly halved between 1992 and 1996, and 1996 and 1999, whereas the rate of prescription of valproate almost tripled.44 Yet according to the BALANCE trial, lithium monotherapy was more effective in relapse prevention of bipolar I disorder than valproate and equally effective to the combination of lithium and valproate.45 Lithium offers an average 83% probability against an affective relapse after 1 year, 52% after 3 years, and 37% after 5 years.

3. What should you do at this point, in terms of medications? A. Switch from sertraline to a different SSRI. B. Switch from sertraline to a different class of antidepressant. C. Add an augmenting agent. D. Add a second antidepressant.

Correct answer: A. Several strategies are available for patients who do not respond to the first trial of antidepressant pharmacotherapy. Switching from one SSRI to another can be effective given that significant chemical and pharmacologic differences between SSRIs. The STAR*D study showed that among patients switched to a second SSRI versus a non-SSRI antidepressant (venlafaxine or bupropion), remission rates were similar across all three groups. However, a meta-analysis examining the effectiveness of within-class versus between-class antidepressant switches found a slight advantage of switching from an SSRI to a non-SSRI in terms of the likelihood of achieving remission.

. If SSRIs do not work, what is the next step? A. Propranolol B. Venlafaxine C. Risperidone D. Quetiapine E. Amitriptyline

Correct answer: B. After sertraline and paroxetine, SNRIs such as venlafaxine have shown benefits to patients with PTSD. Beta-blockers, antipsychotics, and tricyclic antidepressants lack evidence for efficacy.

Mr. C is a 29-year-old man with a long history of substance-related disorders (intravenous heroin, methamphetamine, and marijuana) who presents to the outpatient clinic following a recent emergency room visit for chest pain. He has a long history of emotional and physical trauma as a child, has been in and out of jail, and although he is concerned about the recent episode of chest pain, he is frustrated by his up and down mood and even a detached feeling that causes him to self-medicate with drugs and even cut himself at times to "feel real." He has felt like this "as long as I can remember." On physical examination he has many piercings, tattoos, a leopard-print suit, and long hair shaved on one side. 1. Which of the following psychiatric diagnoses is NOT high the differential diagnosis? A. Borderline PD B. Narcissistic PD C. Bipolar disorder D. ADHD E. Generalized anxiety disorder

Correct answer: B. Besides the stated substance-related disorder, one must remember that a patient with bipolar disorder (or other mood disorders) often self-medicates to target the symptoms. In this case, the history of trauma and self-injury puts borderline PD firmly in the differential as well. Many experts consider borderline PD part of the bipolar spectrum. ADHD must also be considered and questions about childhood and development will help in the evaluation. Additionally, anxiety disorders and somatic symptom disorders enter the differential of most presentations like this; however, there was nothing in the case that suggested narcissistic PD.

3. Which of the following is an U.S. FDA-approved treatment for PTSD? A. Nefazodone B. Sertraline C. Venlafaxine D. Olanzapine E. Duloxetine

Correct answer: B. The two SSRI antidepressants sertraline and paroxetine are the only FDA-approved medications for PTSD. Antipsychotics, such as olanzapine, have limited efficacy in PTSD and have no FDA indication for treatment of PTSD.

2. After further assessment and workup, you find no evidence of other psychiatric or medical pathology, and no adherence issues. What should you tell Jane? A. It is very unusual to not respond to a trial of SSRI at a therapeutic dose. B. This is not unusual; about one-third of patients do not respond to their first antidepressant trial. C. This is not unusual; about two-thirds of patients do not respond to their first antidepressant trial. D. Because sertraline hasn't been effective, she will likely need ECT.

Correct answer: B. When a patient has not responded to a first trial of an antidepressant, it is useful to inform him or her that only about one-third of patients remit with the initial antidepressant trial. The STAR*D study showed 37% of patients responded to initial treatment with the SSRI. Furthermore, of those who received a second line of treatment (switch to another SSRI or an SNRI), only 31% reached remission (or 19% of the original sample). This means that only 56% of patients remitted after two adequate antidepressant trials.

3. What aspect of the physical examination in this case best supports a diagnosis of bipolar disorder? A. Piercings B. Tattoos C. Leopard-print suit D. Hairstyle E. All of the above

Correct answer: C. All of the answers might be considered because many physical appearance and style characteristics have been studied and found to have some associations with bipolar disorder. However, of these, extravagant dressing style was one of the behavioral markers found to be significantly different in a bipolar cohort compared with a group with depression.46

Mr. A is a 32-year-old recently divorced, professional writer with metabolic syndrome and periods of "low mood" who presents to establish care in the primary care clinic. He has completed his previsit paperwork including the Patient Health Questionnaire-9 (PHQ-9) screening instrument for depression, scoring in the moderate range (14 out of 27). He reports that he has been prescribed two or three different antidepressants in the past, including fluoxetine, which left him "irritable," another medication that begins with the letter "C" that didn't really do anything for him, and he perhaps one other medication back in college when he felt low after a breakup with a girlfriend. During a review of systems, he discloses that he has trouble falling asleep. He wonders if there is anything that could help him with his mood and initial insomnia. 1. What is a good screening question if you, the busy PCP, is short on time but need to screen for mania? A. Have you had severe insomnia recently? B. Do you have a family history of bipolar disorder? C. Have you had friends tell you that you are going too fast or talking too fast? D. Have you been spending too much money? E. Do you use any substances like alcohol or marijuana?

Correct answer: C. Although all of these questions can be helpful, the following screening question is of greatest value: "Have you had periods of feeling so happy or energetic that your friends told you were talking too fast or that you were too 'hyper'?"P.127If this initial screen is positive, the "DIGFAST" mnemonic (Box 10-1) can be used to recall the cardinal symptoms of mania to assess more fully.

. Treatment for this patient might include _______________________ A. Suboxone B. low-dose risperidone C. sertraline D. alprazolam E. valproic acid

Correct answer: C. Patient education regarding symptoms of anxiety and symptoms of alcohol withdrawal is also important. In this case, treatment of substance use disorder is important given the patient's escalation in use. However, management of his probable panic disorder with an SSRI or CBT may help him to cope with his anxiety without using alcohol. Benzodiazepines, such as alprazolam, would be unwise given their abuse liability.

his patient presents with somatic concerns in addition to worry. Somatic concerns _______________________ A. are unusual for an anxiety disorder B. suggest co-occurrence of bipolar disorder C. are typical for an anxiety disorder D. suggest co-occurrence of obsessive-compulsive disorder E. suggest posttraumatic stress disorder

Correct answer: C. Patients with anxiety disorders often present to their primary care provider with somatic complaints, such as insomnia, so anxiety must be considered in each assessment. Her symptoms of insomnia likely would improve with treatment of GAD. Assuming she agrees to initiate treatment, we can see from her propensity to worry that it will be important to provide clear information about expectations and potential side effects of treatment options. Initiation of an SSRI or CBT would be equally reasonable at this point.

1. A 48-year-old Hispanic woman presents to your office complaining of low energy. She also reports 4 weeks of sleeping more than usual, overeating, and difficulty concentrating at work and at home. She notes less interest in socializing and hobbies such as knitting. Of note, 1 month ago her son moved away to college, and she was transitioned into a lower-paying, higher-demanding position at work. She denies feeling consistently down—"I don't have time to be depressed"—but admits to crying spells "on occasion." She has never been on medications for mood or sleep and has no family history of mental illness. She adamantly denies any suicidal ideation and denies access to firearms. Physical examination is normal, although the patient seems somewhat tearful and constricted in affect. In addition to possible somatic symptoms disorder, what the most likely diagnosis in this patient? A. Illness anxiety disorder B. Generalized anxiety disorder C. Adjustment disorder D. Major depressive disorder D. Bipolar disorder

Correct answer: D. Despite initial somatic complaints, the clinician should broaden theP.102initial differential and screen this patient for major depressive disorder, utilizing a screening tool such as the PHQ-9. The patient should also be screened for past or current manic, psychotic, or anxious symptoms. Despite the presence of recent identifiable stressors, which may prompt a diagnosis of adjustment disorder, the patient meets criteria for a major depressive episode.

3. If the patient decides to start medication treatment, how long should the treatment course last? A. 3 to 4 months B. 4 to 6 months C. 6 to 9 months D. 9 to 12 months E. 12 to 36 months

Correct answer: D. If she tolerates the initial dose well and with minimal side effects, the clinician should repeat her PHQ-9 within 4 to 8 weeks of initiation to test for treatment response. She should be treated for at least 9 to 12 months after symptom remission, and her clinician should continue to assess for recurrent depression and suicidal thoughts during subsequent routine primary care visits.

2. This patient is most likely to have comorbid _______________________ A. bipolar II disorder B. fibromyalgia C. restless leg syndrome D. generalized anxiety disorder E. borderline personality disorder

Correct answer: D. Initial management should begin with recognition that the patient has really struggled with symptoms over at least 6 months. While medications and psychotherapy are again equally effective for social anxiety disorder, many patients are hesitant about seeing a therapist because, by definition, they find new social interactions very uncomfortable. If a reasonably strong therapeutic relationship has developed, the patient may be more open to psychotherapy if a trial of a medication was not effective or was only partially effective.

2. What kind of psychotherapy would be best in this situation? A. Psychodynamic psychotherapy B. Interpersonal therapy C. Virtual reality therapy D. CPT E. Dignity therapy

Correct answer: D. Of the therapies listed, CPT is the only trauma-focused, evidence-based type. Virtual reality therapy is being investigated as a way to simulate triggers in a safe environment for individuals who have difficulty visualizing or emotionally engaging with their traumatic memories. However, it is still considered investigational and cognitive processing would be the preferred modality.

Jane is a 38-year-old single accountant with hypothyroidism, who after being laid off from her job begins to feel like she is a failure and to avoid her friends as she no longer finds social outings enjoyable. She has trouble concentrating on job applications because of negative ruminations about the state of her life; she has minimal appetite, stays in bed most of the day, and feels as if her situation will never improve. You diagnose her with major depression and start her on sertraline at 50 mg daily, increasing it over the next 4 weeks to a dose of 200 mg daily, and maintain her on this dose for 6 weeks. At this point she is able to get out of bed more and does socialize occasionally, but still has trouble completing job applications, continues to feel ashamed and worthless, and her appetite and energy level, while a bit improved, are still lower than before. 1. At this point you should: A. Check her TSH. B. Screen for bipolar disorder, eating disorder, and substance use disorders. C. Assess for medication adherence. D. All of the above.

Correct answer: D. Patients who do not respond to initial antidepressant therapy should be evaluated for comorbid psychiatric and medication conditions, P.115 as they can hinder the treatment of depression. One should consider undiagnosed psychosis, eating disorders, substance use disorders, obsessive-compulsive disorder, posttraumatic stress disorder, or neurocognitive disorders (such as dementia), which can resemble depression. Additionally, medical conditions that can mimic depression include hypothyroidism, anemia, sleep apnea, vitamin deficiencies, certain malignancy (pancreatic cancer), and autoimmune disorders. For patients not responding to an optimized dose of antidepressant, it would be beneficial to conduct thorough medical evaluation and obtain basic laboratory workup, which include a focused physical examination, vitamin D levels, thyroid function tests, CBC, liver and renal function, cortisol level, and workup for anemia or chronic inflammatory conditions.

2. What would be your first choice to help this patient's insomnia and nightmares? A. Zolpidem B. Hydroxyzine C. Paroxetine D. Prazosin E. Sertraline

Correct answer: D. Prazosin has been proven to help insomnia and nightmares due to PTSD. Paroxetine and sertraline help attenuate other symptoms of PTSD but would not be the first choice specifically for insomnia or nightmares. Zolpidem and hydroxyzine have no proven benefit for PTSD or nightmares.

3. Clinical predictors of TRD include all of the following except: A. Having first degree relative with psychiatric illness B. Presence of comorbid anxiety disorder C. Low social support D. Low birth weight

Correct answer: D. Risks for development of TRD include psychiatric comorbidity (anxiety disorders, panic disorder, substance use disorder), early age of onset of depression, low social support, negative social interaction, and weak social integration.

2. What needs to be done before confirming this case as "treatment resistant"? A. Initiate a trial of mirtazapine to confirm treatment resistance. B. Refer patient for psychotherapy. C. Confirm that each trial was of adequate duration at a therapeutic antidepressant dose. D. Refer to psychiatry for further evaluation.

Correct answer: D. The definition of TRD varies from provider; however, the term most frequently refers to a patient who has failed to respond to two adequate trials of an antidepressant. Therefore, it would be beneficial to have a psychiatrist assess whether the patient truly had trials of adequate dose and duration.

A 20-year-old college student presents for a well-woman visit. When asked about school, she says, "It depends on the course." In courses with traditional lectures and tests she does well. However, she feels she "totally botched" a speech in Spanish class earlier in the year where she "turned red," started sweating, and felt like she was unable to give coherent response to a question. She reports spending most of her classes worrying about whether she will be called on and sitting in the furthest seats from the professor. She has missed classes saying she had a headache and had to make up several tests. She notes that she has struggled since middle school with studying with classmates for fear she may say something stupid or embarrassing. 1. This case describes someone who presents with _______________________ A. acute stress disorder B. panic disorder C. schizoid personality D. social anxiety disorder E. health anxiety

Correct answer: D. This case highlights the distress many patients have in asking for help due to a sense of shame or embarrassment. Being on the lookout for physical symptoms, patterns of avoidance, and level of impairment in functionality is important. If the triggers are circumscribed around social interactions exclusively, social anxiety disorder would be the diagnosis.

2. What is the first-line treatment for this patient? A. Propranolol B. Transcranial magnetic stimulation (TMS) C. Psychodynamic psychotherapy D. Combination of sertraline and trauma-focused CBT E. Prazosin

Correct answer: D. Trauma-focused psychotherapy has the best evidence for treatment of PTSD and would be preferred over other psychotherapeutic modalities. Of the choices listed, the combination of sertraline, an SSRI that is U.S. FDA-approved for PTSD, and trauma-focused CBT would be best, although either treatment in monotherapy may alsoP.85be appropriate. Propranolol has limited evidence in treating symptoms of PTSD, and this patient is not endorsing nightmares and thus prazosin would not be a first-line treatment. TMS does not have an indication for PTSD.

A. 300 mg three times daily is the standard acute mania dose B. 300 mg twice daily is better tolerated in acute mania C. 15 mg/kg per day D. 25 mg/kg per day E. 450 mg at bedtime

Correct answer: E. 450 mg qhs. The starting dose of lithium is typically 15 mg/kg per day, but we would recommend starting more conservatively. It can be divided into twice-daily dosing at the start, but we advocate quickly moving to once-daily dosing of the long-acting formulation in the evening to minimize adverse effects and improve adherence. Of note, 25 mg/kg per day is typically the dose calculation for valproate. P.128

A 45-year-old woman with a history of fibromyalgia and chronic back pain complains of headaches and difficulty with sleep. She says she cannot sleep and requests medications to help her. Although initially not forthcoming about the details, she admits to having very vivid nightmares multiple times a week, waking up sweating and her heart racing. She recently started a new job working at a home for abused children, and hearing the children's stories have brought up old memories of her own abuse as a child. She goes on to report that she frequently has intrusive thoughts about the abuse throughout the day. She has also recently felt more depressed and irritable. She has had symptoms like this in the past, but they are more severe now and she has been missing work. 1. Which of the following is a likely diagnosis? A. Major depressive disorder B. Sleep disorder C. Depression due to general medical condition (fibromyalgia) D. PTSD E. Complex PTSD

Correct answer: E. Although the patient may also have comorbid major depressive disorder and depression due to a general medical condition should be on the differential, the symptoms described are more specific to PTSD. The patient's nightmares, when combined with her other symptoms, are better attributed to PTSD than to a parasomnia. She meets criteria for a DSM-5 diagnosis of PTSD, but PTSD due to prolonged and repeated exposure to trauma is better described as complex PTSD.

Mr. H is a 26-year-old man coming to you reporting that his depression is getting worse. He no longer enjoys playing the guitar and his energy is low. His girlfriend has complained to him that he is no longer interested in sex. He responds that getting erections is more difficult. Passive suicidal ideation is present, but there is no plan and he has no access to firearms. His mother has struggled with depression for many years and did well on venlafaxine. The patient has had two previous depressive episodes. He is currently prescribed citalopram 40 mg, which he has taken for the last 2 years until the current symptoms recurred about 8 weeks ago. Headache and dizziness are also among his complaints. He is not suicidal at this time and does not have access to firearms or prescription medications at home. You diagnose him with recurrent major depression and discuss the possibility of either increasing citalopram or changing to a different antidepressant. He attributes erectile dysfunction to the citalopram and admits to intermittently missing doses as a result. BMI is 31. 1. What is this patient's diagnosis? A. Bipolar I, most recent episode, depression B. Bipolar I, most recent episode, manic C. Bipolar II D. Major depressive disorder, single episode E. Major depressive disorder, recurrent

Correct answer: E. Despite previous response to citalopram, this patient is now experiencing a recurrence of depression.

How long should this patient be on antidepressant treatment? A. 3 to 6 months B. 6 to 9 months C. 9 to 12 months D. 12 to 36 months E. Lifelong

Correct answer: E. Given his history of two previous depressive episodes, he should be on lifelong antidepressant therapy. Mr. H should be followed closely and monitored for changes in depressive symptoms, medication side effects, and suicidal ideation

2. For the treatment of major depressive disorder, which of the following is the best intervention? A. Bupropion B. SSRI C. CBT D. Supportive psychotherapy E. Any of the above

Correct answer: E. Once the diagnosis of major depressive disorder has been established and discussed with the patient, she should be asked about her preference for psychotherapy or medications. Should she prefer psychotherapy, the primary care physician should assist with a referral to a local therapist and briefly introduce her to CBT. Should she prefer medication, an SSRI is a reasonable choice to start and the primary care provider should clearly discuss potential side effects. Bupropion is also a reasonable alternative to SSRI in individual concerned about sexual side effects with no history of seizure disorder.

A 31-year-old woman presents for follow-up of for difficulty sleeping. She reports lying in bed at night for hours ruminating about the day but has noticed that she worries all day as well. She reports feeling like she "can't relax" and always anticipates that "something will go wrong." She reports feeling this way since she was a teenager. She worries about her children's futures, her job as an accountant, her husband's high cholesterol, her mother who is in assisted living, finances, politics, and the weather. She recently had a well-woman visit with normal laboratory findings, Pap smear, breast examination, and thyroid screening, all of which were normal, but worries that "maybe they missed something." She has started feeling hot and tremulous and asks if laboratory tests can be done to see if she is starting menopause or if she should get workup for a seizure disorder. 1. What screening tool might be useful in evaluating this patient's complaints? A. Patient Health Questionnaire (PHQ-9) B. Alcohol Use Identification Test (AUDIT-C) C. Mood Disorders Questionnaire (MDQ) D. Adverse Childhood Experiences (ACES) E. None of the above

Correct answer: E. The presence of multiple, pervasive, and long-term worries without a unifying trigger suggests a diagnosis of GAD, and screening with GAD-7 can help uncover additional symptoms and assess severity.

3. Which of the following statements is true in the management of this patient? A. He should start divalproex for his irritability and anger. B. He should be forced to ride in the car along the freeway immediately. C. He should be given IV morphine for his pain. D. He should be referred to physical therapy (PT). E. He should be given haloperidol for his flashbacks.

D

A 25-year-old woman presents with palpitations that were concerning to her. She appeared very anxious and did not want the male medical assistant to touch her. She has no history of medical problems. She reports that she is a military veteran who was discharged 1 month ago. Since her discharge, she has been staying home most of the time and does not want to be in crowded places such as supermarkets and malls. She tells the female medical assistant that she is afraid of men and when she is around men, she gets palpitations. Eventually, she reports that she was raped 1 month before discharge by a group of men in her battalion, one of which was the supervisor. She never reported this as she was afraid of retaliation. However, since she has been discharged she has been having terrible nightmares that often cause her to wake up suddenly in the middle of the night. As a result, she has not been sleeping. She has been isolating herself and has become increasingly anxious and depressed. 1. What is the diagnosis in this case? A. Adjustment disorder B. Acute stress reaction C. Specific phobia D. Panic disorder E. PTSD

E

2. Regarding neuromodulatory approaches, all of the following are true except: A. TMS requires anesthesia. B. ECT leads to remission rates as high as 90%. C. DBS is not FDA approved for major depression. D. VNS is approved for failure to respond to four antidepressant medication trial.

Hide AnswerCorrect answer: A. Neuromodulation approaches utilize different techniques to directly stimulate the areas of the brain thought to be responsible for depression. TMS is a noninvasive approach and involves utilizing pulsed magnetic fields to the left dorsolateral prefrontal cortex via application of a magnetic coil to the scalp. Treatment can be administered in the outpatient setting while the patient is awake without the need for anesthesia. ECT utilizes electrical current applied to the brain to induce a seizure. ECT is administered in a hospital setting and requires anesthesia. DBS is the most invasive neuromodulatory approach. It involves the implantation of stimulating electrode wires directly into the brain regions responsible for depression. DBS is not FDA approved. VNS involves implantation of a programmable neurostimulator under the skin in the anterior chest wall. This procedure is approved for failure of at least four antidepressant treatments.

Mr. L is a 34-year-old man with a history of poor response to antidepressant treatment. He has comorbid diabetes and often forgets to take his insulin. His PCP has tried sertraline, bupropion, and venlafaxine. None of these medications have been helpful. He thought sertraline worked a bit initially but then seemed to lose its effect. 1. What is the percentage of patients who respond to an initial trail of antidepressant medication? A. Less than 2% B. 30% to 40% C. About 50% D. Two-thirds

Hide AnswerCorrect answer: B. The overall goal of the STAR*D trial was to assess the effectiveness of depression treatments in patients diagnosed with MDD, in both primary and specialty care settings. It is the largest and longest study ever conducted to evaluate depression treatment. The STAR*D study showed 37% of patients responded to initial treatment with the SSRI citalopram.

2. What does the patient's age suggest about the possibility of bipolar disorder? A. Bipolar disorder is mostly diagnosed in the fifth decade of life. B. Bipolar disorder is mostly diagnosed in the fourth decade of life. C. Bipolar disorder is mostly diagnosed in the third decade of life. D. Bipolar disorder is mostly diagnosed in the second decade of life. E. Bipolar disorder is mostly diagnosed in the first decade of life.

Hide AnswerCorrect answer: C. Whenever patients in their third decade of life talk about how they have had symptoms for "as long as they can remember," bipolar disorder must be firmly in the differential diagnosis because symptoms typically appear earlier than age 25.

Mrs. H is a 62-year-old African-American woman with history of osteoarthritis, hypertension, and major depression. Her symptoms include anhedonia, hopelessness, and anxiety. She has undergone trials of fluoxetine 60 mg daily for 3 months, mirtazapine 30 mg daily for 2 months, duloxetine 60 mg daily for 1 year, and nortriptyline 150 mg, which has been taken for the last 9 months. She has been hospitalized multiple times in the past for suicidal ideation including two suicide attempts when she overdosed on her medications and spent a week in the intensive care unit. She is currently feeling suicidal again with some transient thoughts of overdosing on her pills. 1. Does this patient have TRD? A. No, because she has not tried a combination of antidepressants. B. Yes, because she has failed to get better with nortriptyline. C. No, because she has not failed augmentation with an antipsychotic. D. Yes, because she has failed to respond to two adequate antidepressant trials.

Hide AnswerCorrect answer: D. The definition of TRD refers to a patient who has failed to respond to two adequate trials of an antidepressant. However, providers should assess whether the patient truly had trials of adequate dose and duration before determining the medications are ineffective. Medication should be prescribed at their maximum approved or tolerable doses before being declared ineffective. For instance, they should generally be increased to their highest tolerable doses, their maximum approved doses, or at a minimum to an above starting dose, and that medication should be maintained at that dose for 6 to 12 weeks to assess for efficacy.

2. What are the main concerns in prescribing lithium in this case? A. Lithium would not help because this is likely sertraline-induced mania B. Lithium is a perfect choice for this patient with no major concerns C. Potential to worsen insomnia D. Potential for weight gain and patient's age E. Child-bearing age and lab-monitoring requirements

Hide AnswerCorrect answer: E. Child-bearing age and labs. The potential for weight gain is a concern. But in this case, this woman is of child-bearing age and thus, any pharmacotherapy recommendation must be made with great care. It is highly recommended that pregnancy be a planned event. Lithium also requires periodic laboratory monitoring including serum lithium level, renal function, and annual TSH as it can lead to renal impairment, hypothyroidism, and even nephrogenic diabetes insipidus if prescribed long term.

2. Co-occurring substance use that may present with a similar presentation includes _______________________ A. opiate use B. tobacco use C. phencyclidine use D. amphetamine use E. none of the above

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