Psych Q&A PANCE

Question: What type of fracture of the elbow is a child most likely to sustain by falling from a jungle gym?

Answer: Supracondylar fractures are the most common pediatric elbow fracture and occur after a fall from a jungle gym or a tree.

Question: What are some symptoms seen in early ethanol withdrawal?

Answer: Sweating, flushing, sleep disturbances, hallucinations, seizures, mild mental status changes.

Question: What is methadone maintenance therapy?

Answer: This is also a substitute maintenance medication for those dependent on opiates

Question: Which of the personality disorders are associated with an increased risk of suicide attempts?

Answer: Borderline and histrionic personality disorders.

Question: An overdose of which antihypertensive mimics opiate intoxication?

Answer: Clonidine.

Question: What is the most common type of delusion?

Answer: Persecutory.

Question: What electrolytes are depleted in re-feeding syndrome?

Answer: Phosphate and magnesium.

Question: What is the strongest risk factor for post partum depression?

Answer: Postpartum depression in a previous pregnancy.

Question: What is the main difference between posttraumatic stress disorder and adjustment disorder?

Answer: Posttraumatic stress disorder is associated with re-experiencing and avoidance of the stressful event and increased arousal.

Question: Which type of symptoms (e.g., positive, negative, cognitive) in a patient with schizophrenia respond best to antipsychotic treatment?

Answer: The positive symptoms (e.g., hallucinations, delusions) respond better than the other symptom domains to antipsychotic medications

Question: What is the significance of the Tarasoff vs. Regents case?

Answer: This case establishes the physicians duty to breach patient confidentiality if the patient poses a significant threat to a 3rd party.

Question: True or False: Antisocial personality disorder is strongly associated with drug and alcohol abuse?

Answer: True.

Question: Compared to antidepressant medications, how effective is cognitive behavioral therapy in the treatment of panic disorder?

Answer: Equally effective.

Question: True or false: Preschoolers may be diagnosed with conduct disorder?

Answer: True.

Question: In what population is conversion disorder most common?

Answer: Young women with low socioeconomic status and a low level of education.

Question: What is the disorder called which patients deliberately impose harm on self for the principal purpose of assuming the sick role?

Answer: Factitious disorder (previously referred to as Munchausen syndrome).

Question: What is the DSM-5 term for the formerly described "Munchausen syndrome by proxy"?

Answer: Factitious disorder imposed on another.

Question: What are the clinical signs of subcutaneous heroin injection?

Answer: Fat necrosis, lipodystrophy, atrophy over the extremities, and skin abscesses.

Question: What mechanism is most common for completed suicides?

Answer: Firearms.

Question: What are some common negative symptoms seen in schizophrenia?

Answer: Flat affect, lack of energy, inexpressive facial expressions, poverty of speech, and monotone speech.

Question: Opioid use via contaminated needles warrants testing for which viral infections?

Answer: HIV and hepatitis

Question: What is the name to describe the sample of debris, lint, or pieces of skin sometimes presented by patients with delusions of parasitosis?

Answer: Matchbox sign.

Question: What is the treatment for persistent complex bereavement disorder?

Answer: Psychotherapy.

Question: What is the most common type of psychiatric disorder?

Answer: Specific phobia is now known to be one of the most common psychiatric disorders in the general population with a 7-9% lifetime prevalence.

Question: What screening tool or questionnaire is most often used to screen for bipolar disorder?

Answer: The Mood Disorder Questionnaire (MDQ) is a tool that combines DSM-IV criteria and clinical experience to screen for bipolar disorder.

Question: What is the treatment of conduct disorder?

Answer: Multisystemic Treatment, an intensive integrative program that emphasizes correct behavior within the individual or the individual's family, instead of within society as a whole.

Question: What is the syndrome called when parents create illness in their children?

Answer: Munchausen by proxy.

Question: Flat affect and lack of energy are considered what types of symptoms in a patient with schizophrenia?

Answer: Negative symptoms

Question: Can psychotropic drugs be the mainstay of treatment for personality disorders?

Answer: No, a treatment plan that focuses largely or exclusively on medications probably will not meet the needs of a patient with a personality disorder.

Question: Should you directly challenge a delusional patient about his or her false beliefs?

Answer: No, avoid directly challenging the patient but do not pretend to be in full acceptance.

Question: What is the first-line treatment for anorexia nervosa?

Answer: Nutritional rehabilitation and psychotherapy.

Question: What is the most common personality disorder?

Answer: Obsessive-compulsive personality disorder.

Question: What are two absolute contraindications to treatment with clozapine?

Answer: Prior history of clozapine-induced agranulocytosis or myocarditis.

Question: What is the best treatment for adjustment disorders?

Answer: Psychotherapy is the treatment that is most frequently recommended.

Question: What other non-pharmaceutical treatment should be offered to this patient?

Answer: Psychotherapy, especially cognitive behavioral therapy.

Question: What is the most common side effect of olanzapine?

Answer: Weight gain.

Question: Is adjustment disorder more prevalent in men or women?

Answer: Women are diagnosed with adjustment disorder twice as often as men.

Question: Can clozapine cause significant weight gain?

Answer: Yes.

Question: What is the clinical diagnostic triad for Wernicke encephalopathy?

Answer: Memory impairment, gait disorders and oculomotor dysfuction.

Question: Are individuals with bulimia typically underweight or overweight?

Answer: Most patients with bulemia maintain normal or near-normal body weight.

Question: What are the most common methods of successfully completed suicides and suicide attempts?

Answer: Most successfully completed suicides involve firearms, and most suicide attempts involve ingestion.

Question: What disorder is characterized by anxiety occurring within three months of an identifiable stressor?

Answer: Adjustment disorder

=Question: What substance use disorder is most commonly associated with panic disorder?

Answer: Alcohol use disorder

Question: What are the 4 Cluster B personality disorders?

Answer: Antisocial, borderline, histrionic, and narcissistic

Question: Which autistic disorder includes impaired social interaction and autistic behaviors but excludes language delay?

Answer: Asperger syndrome.

Question: Antisocial personality disorder is part of which cluster group?

Answer: Cluster B.

Question: How much calcium and vitamin D should the female athlete add to their diets?

Answer: 1200-1500 mg of calcium and 400 IU of vitamin D.

Question: What percentage of children diagnosed with ADHD have more than one psychiatric diagnosis?

Answer: 65%.

Question: How long must a patient experience symptoms of post-traumatic stress to be diagnosed with PTSD?

Answer: >1 month.

Question: What is agoraphobia?

Answer: A fear of being in situations where the sufferer perceives certain environments as dangerous or uncomfortable, often due to the environment's vast openness or crowdedness.

Question: Which behavioral interventions are effective in treating marijuana dependence?

Answer: Cognitive-behavioral therapy and motivational incentives.

Question: Which two common medical conditions need to be evaluated in a patient with a new diagnosis of depression?

Answer: Diabetes and lipid disorders.

Question: What is the treatment of mild to moderate cases of serotonin syndrome?

Answer: Cessation of the offending agents, benzodiazepines, IV hydration and observation.

Question: Which are the 2 neurologic receptors affected by long-term alcohol use?

Answer: Chronic alcohol use results in down-regulation of GABA receptors and up-regulation of NMDA receptors

Question: What type of therapy should be used as adjunctive treatment for those with PTSD?

Answer: Cognitive behavioral therapy.

Question: What physical health problems are associated with bulimia?

Answer: Electrolyte disturbances, loss of dental enamel, and esophageal tears.

Question: True or False: Factitious disorder is more common in males than females.

Answer: False.

Question: True or false: Borderline personality disorder is a Cluster A personality disorder?

Answer: False. Cluster B personality disorder

Question: What is the reason for amenorrhea when using first generation anti-psychotics?

Answer: Hyperprolactinemia.

Question: What is the clinical presentation of serotonin syndrome?

Answer: Hyperthermia, hypertension, hallucinations, dizziness, ataxia, tremors, sweating, diarrhea and dilated pupils.

Question: What is necessary if a patient's screening form is positive for depression?

Answer: A full diagnostic interview to determine the presence or absence and severity of mood and other comorbid psychiatric disorders.

Question: What is Munchausen syndrome?Question: What is Munchausen syndrome?

Answer: A syndrome in which the patient deceptively exaggerates or feigns illness. This is an extreme form of factitious disorder.

Question: A patient with conduct disorder diagnosed at 15 years of age may go on to develop which personality disorder as an adult?

Answer: Antisocial personality disorder.

Question: How long should treatment with an SSRI continue in patients with generalized anxiety disorder?

Answer: At least 12 months.

Question: What is the first-line therapy for those who can't take stimulant medication due to a personal or family history of drug abuse?

Answer: Atomoxetine.

Question: What group has the highest suicide rate in the United States?

Answer: Caucasian men, aged 85 years and older.

An 18-year-old woman with a history of frequent visits to the ED presents with multiple superficial lacerations to her left wrist. She is agitated and states she is suicidal. She is yelling at the nurses and demands to be seen only by the psychiatrist. Which of the following is the most appropriate next step in management? A) Administer 5 mg of intramuscular haloperidol B) Consult the psychiatry service C) Engage in conversation and discuss her symptoms and validate her distress D) Place her alone in a private room and wait for her to calm down

C) Engage in conversation and discuss her symptoms and validate her distress Explanation: Borderline personality disorder (BPD) is a common emergency psychiatric presentation. BPD is characterized by unstable personal relationships, unstable self-image, and inappropriate behaviors. The disorder may include chronic feelings of emptiness, which may be misdiagnosed as depression, or lability of mood, which may be mistaken for mania or hypomania. Borderline patients typically live lives of crisis and constant conflict. Patients with BPD usually present to the ED after deliberate self-injury or suicidal attempts. Recurrent suicidal threats or acts and self-injury with a combination of strong preoccupation with expected rejection and abandonment are the strongest indicators. These patients feel they need to be connected to someone who they believe really cares. Therefore, the first step is to engage the patient in conversation and discuss his or her symptoms and validate his or her distress. Chemical sedation (A) is an option if the patient becomes physically threatening to herself or others. However, the patient should first be engaged in behavior modification. The psychiatrist (B) should ultimately be consulted, but after the patient has been stabilized and a complete medical exam is performed. The patient should not be left alone in a room (D) as she is at risk for harming herself. Patients with borderline personality disorder are seeking validation from others and therefore will continue to be disruptive until they can be engaged in conversation.

What disorder is characterized by emotional or behavioral responses that develop within 3 months of a stressful event, in excess of what would be expected given the nature of the event, and not including the loss of a loved one? A) Adjustment disorder B) Bereavement C) Grief reaction D) Personality disorder

Correct Answer A) Adjustment disorder Explanation: Adjustment disorders comprise a category of emotional or behavioral responses to a stressful event that develop within 3 months after the onset of a stressor, and the patient's reaction must be in excess of what would be expected given the nature of the event. The pathophysiology of adjustment disorders is unknown, but investigators have observed neurochemical changes in patients with these disorders. Adjustment disorders are subtyped according to whether the predominant symptoms are depressed mood, anxiety, or a disturbance of conduct. The symptoms are described as acute if they persist for less than 6 months, and as chronic if they last longer than 6 months. By definition, however, the symptoms cannot persist for more than 6 months after the termination of the stressor. Therefore, the designation of chronic adjustment disorder is given when the stressor itself (e.g., living in a dangerous neighborhood) is ongoing. Though the course of an adjustment disorder is usually brief, the symptoms can be severe and may include suicidal ideation. If the stressful event involves the loss of a significant figure in the patient's life, bereavement (B) is diagnosed rather than an adjustment disorder. Grief reaction (C) may be defined as the physical and emotional pain precipitated by a significant loss. The loss may be of a person or pet, but it can also be of a meaningful place, job, or object. This behavior is not out of proportion to the stressor. Personality disorders (D) involve persistently inadequate adaptive capacities and patterns of behaviors leading to significant impairments in social relationships and occupational performance that does not involve a specific stressor.

A 17-year-old boy is brought to the emergency department by his friends. They were at a house party and found their friend unconscious after he ingested an unknown substance. On physical exam, vital signs are temp 96F, heart rate 50, respiratory rate of 4, and oxygen saturation 92% on room air. The boys pupils are miotic. On lung auscultation, there are crackles bilaterally. You administer supplemental oxygen. Which of the following is the most appropriate clinical intervention? A) Administer intravenous naloxone B) Begin intravenous fluids with sodium bicarbonate C) Initiate therapy with benzodiazepines D) Perform gastric lavage

Correct Answer A) Administer intravenous naloxone Explanation: Intravenous naloxone is an appropriate first step in managing a patient with acute heroin (opiate) overdose. Heroin is an addictive opiate that can be injected intravenously or subcutaneously, or can be snorted. It has a rapid onset of action, and easily crosses the blood brain barrier, producing euphoria. Other effects of the drug include decreased pain sensation, diminished level of consciousness, flushed skin, constipation, and pinpoint pupils. In an overdose, patients will exhibit hypothermia and respiratory depression, which can lead to coma and death. The withdrawal symptoms are reversed, including dilated pupils, restlessness, lacrimation, rhinorrhea, diarrhea, and sweating, as well as tachycardia and hypertension. Diagnosis of heroin intoxication is clinical and typically follows the opiate toxidrome of miosis, CNS depression, and hypoventilation. Naloxone is an opiate antagonist that will reverse respiratory depression and other effects caused by opiates. Other medications such as methadone and buprenorphine can assist with detoxification. Salicylate overdose (B) may cause respiratory depression, but should not affect the pupil size. Bicarbonate-containing fluids in salicylate toxicity can alkalinize the urine, which assists in renal excretion of the drug. Benzodiazepines (C) are used in alcohol withdrawal to prevent delirium tremens. Alcohol intoxication can result in altered mental status and respiratory depression, but should not cause miotic pupils. In a heroin overdose, benzodiazepines might worsen the respiratory depression, leading to intubation. In phencyclidine (PCP) overdose (D), the patient may exhibit altered mental status and aggressive behavior. The respiratory depression and miotic pupils would not be expected. Gastric lavage may be useful in treatment of PCP overdose, since PCP has poor gastric absorption. Gastric lavage would not be expected to improve symptoms in heroin overdose, especially if the heroin was administered intravenously or inhaled.

You finish taking a history of a patient at risk for suicide. Which of the following would suggest the highest likelihood of committing suicide? A) Age over 85 years B) Cohabitation with parents C) Married with children D) Tactile hallucinations

Correct Answer A) Age over 85 years

Which of the following conditions, in which laws and social norms are repetitively violated, is the most common precursor to antisocial personality disorder? A) Conduct disorder B) Malicious compliance behavior disorder C) Oppositional defiant disorder D) Passive-aggressive personality disorder

Correct Answer A) Conduct disorder Explanation: Conduct disorder is a disorder of children and adolescents. It is characterized by a persistent and repetitivepattern in which the subject violates the basic rights of others. Usually the subject repetitively violates laws and social norms. As with other behavior or conduct disorders, it is important first to rule out an underlying substance abuse disorder as the cause of changing behaviors and actions. The childhood-onset subtype, before the age of 10 years, results in longer lasting and more pervasive behaviors than the adolescent-onset (after the age of 10 years) subtype. Children in the childhood-onset subtype have a greater incidence of ADHD, academic problems, family dysfunction, violence and aggression. Conduct disorder is the best predictor of antisocial personality disorder, which cannot be diagnosed until the subject is 18 years old. Malicious compliance behavior (B) describes a person who strictly follows orders from management authorities in an intentional act of harming said management, business or employees. This industrial behavior can be thought of as sabotage. Passive-aggressive personality disorder (D) is a pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance of work or social obligations. Characteristics include procrastination or a deliberate task avoidance, hostile joking and resentment. Oppositional defiant disorder (C) is characterized by a pervasive pattern of disobedience, anger, stubbornness, hostility and defiant behavior toward authority figures. Law violation is not a common trait. It cannot be diagnosed if a child matches criteria for conduct disorder.

A 2-year-old boy presents with a burn to his right hand as seen above. The patient's mother states that he mistakenly got burned by hot water when she tipped a hot tea kettle over. What management is indicated? A) Consultation with child services for suspected abuse B) Consultation with plastic surgery for skin grafting C) Discharge home with silvadene and follow up D) Transfer to a burn center

Correct Answer A) Consultation with child services for suspected abuse Explanation: This patient presents with a partial thickness second degree burn with a mechanism of injury that does not fit the injury pattern raising suspicion for child abuse. The most likely etiology of these burns is from a cigarette. Cigarette burns are typically round and sharply-demarcated. They are sometimes confused with healing impetigo. Child physical abuse refers to infliction of injury to any part of the child. This may present as bruising, fractures, brain injury, burns or internal hemorrhage. Often patients will present with multiple injuries in various stages of healing or patterned injuries (resembling objects). Burns may occur from contact with a hot object or with immersion in hot water. Although accidental hot water burns are common, those sustained from abuse will have characteristic patterns as well. Immersion injuries to extremities will present with glove-stocking distribution involvement. Additionally, intentional immersion injuries may present with burns to the anogenital area. Children with burn injuries with these patterns should always be investigated for possible abuse. Small, isolated burns rarely need intervention from a plastic surgeon for skin grafting (B) or transfer to a burn center (D). The patient should not be discharged home (C) until a full evaluation has been made into the possibility of child abuse.

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

Correct Answer D) Panic attack Explanation: Panic attacks are a collection of distressing physical, cognitive, and emotional symptoms that may occur in a variety of anxiety disorders, such as specific phobias, social phobias, post-traumatic stress disorder (PTSD), and acute stress disorder. Panic attacks are discrete periods of intense fear in the absence of real danger, accompanied by at least 4 of 13 cognitive and physical symptoms. The attacks have a sudden onset, build to a peak quickly, and are often accompanied by feelings of doom, imminent danger, and a need to escape. Symptoms of panic attacks can include somatic complaints (e.g., sweating, chills), cardiovascular symptoms (pounding heart, accelerated heart rate, chest pain), neurologic symptoms (trembling, unsteadiness, lightheadedness, paresthesias), GI symptoms (choking sensations, nausea), and pulmonary symptoms (shortness of breath). In addition, patients with panic attacks may worry they are dying, "going crazy," or have the sensation of being detached from reality. Patients with panic disorder experience recurrent, unexpected panic attacks, followed by at least 1 month of persistent worry that they will suffer another panic attack. Panic disorder patients may begin to avoid places where a prior attack occurred or where help may not be available. Angina (A) shares many of the symptoms of a panic attack. However, given the patient's age and frequency of symptoms, coronary ischemia is much less likely to be the cause of her symptoms. Bipolar disorder (B) is a chronic mood disorder characterized by the presence of mania (bipolar I disorder) or hypomania and depression (bipolar II disorder). Manic episodes are distinct periods of abnormally and persistent moods that can be euphoric, expansive, or irritable. Although manic patients are often thought to be always euphoric, only about 20% of patients experience pure euphoria; most describe a mix of severe irritability, severe emotional lability, and volatility. Generalized anxiety disorder (C) is excessive anxiety and worry about a number of events or activities, occurring most days over 6 months. Patients have difficulty controlling the worry, report subjective distress, and may experience difficulties in social or occupational functioning. The intensity, duration, or frequency of the worry is out of proportion to the actual likelihood or impact of the feared event. Patients must have at least three associated physical symptoms, including restlessness, irritability, muscle tension, disturbed sleep, fatigability, and difficulty concentrating.

Which one of the following has been shown to render some improvement in individuals with borderline personality disorder? A) Dialectic behavioral therapy B) Omega-3 fatty acids C) Second-generation antipsychotics D) Selective serotonin reuptake inhibitors

Correct Answer A) Dialectic behavioral therapy Explanation: There are no proven therapies to reduce the severity of borderline personality disorder (BPD). The most promising psychological therapy is dialectic behavioral therapy (DBT). DBT is a multi-faceted program specifically designed to treat BPD. This approach works towards helping people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings and behaviors that lead to the undesired behavior. The few, small studies of DBT found improvement in many symptoms of BPD, but long-term data is lacking. Another promising therapy is psychoanalytic-oriented day hospital therapy. Omega-3 fatty acids (B), second-generation antipsychotics (C) have been shown to be helpful for some symptoms of borderline personality disorder but not for overall severity. Their benefits are based on single-study results and side effects were not addressed in the studies. Selective serotonin reuptake inhibitors (SSRIs) (D) are not recommended for borderline personality disorder unless there is a concomitant mood disorder.

A 46-year-old man with a history of depression presents with a self inflicted laceration to the left arm. The wound is superficial and the patient states that he didn't want to hurt himself. He reports that he is recently divorced, lives alone, and has increased stress at work. These stressors have worsened his depression. Which of the following is the next best step in management of this patient? A) Emergency psychiatric evaluation B) Outpatient referral to psychiatry C) Prescribe antidepressant and discharge with follow up D) Prescribe anxiolytic and discharge

Correct Answer A) Emergency psychiatric evaluation Explanation: This patient presents with a possible suicide attempt and a number of high risk factors for suicidality warranting an emergency evaluation from psychiatry. Patients often present to the emergency department after an attempt that may appear minor. Many of these patients have a normal mental status making it vital to obtain details about the occurrence as well as the context. Additionally, patients may experience shame about the event and attempt to explain it as an accident. It is central in management for the physician to treat all possible suicide attempts as the serious events they are. All of these patients have the potential to attempt again and may be successful. For this reason, any patient presenting with a possible suicide attempt should have an emergent psychiatric evaluation. Although anxiolysis (D) may be necessary in the ED to keep the patient calm, discharging them on an anxiolytic without a psychiatric evaluation is dangerous. Likewise, prescribing an antidepressant (C) without further evaluation can be harmful. Both of these medications may be used in a future attempt. After psychiatric evaluation, the patient may be deemed to be safe for follow up as an outpatient (B) but this determination should not be made until a full psychiatric assessment is performed.

Which of the following best defines delusions? A) Erroneous beliefs that usually involve a misinterpretation of perceptions or experiences B) Hallucinations occurring in the absence of insight into their pathological nature C) Marked disorientation, confusion, and fluctuating consciousness D) Sensory perceptions without external stimulation

Correct Answer A) Erroneous beliefs that usually involve a misinterpretation of perceptions or experiences Explanation: Delusions are erroneous beliefs that usually involve a misinterpretation of perceptions or experiences. Their content may include a variety of themes (persecutory, referential, somatic, religious, or grandiose). In persecutory delusions the person believes he or she is being tormented, followed, tricked, spied on, or ridiculed. In referential delusions the person believes that certain gestures, comments, passages from books, newspapers, song lyrics, or other environmental cues are specifically directed at him or her. Psychosis (B) is restricted to delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature. Hallucinations (D) are sensory perceptions without external stimulation. Hallucinations may occur in any sensory modality (auditory, visual, olfactory, gustatory, and tactile). Auditory hallucinations are the most common. Delirium (C) is characterized by marked disorientation, confusion, and fluctuating consciousness.

A 36-year-old man presents to the ED after having a seizure. He has a folder full of medical records dating back 15 years. Several of the records are from other cities and states. It is now 11:00 pm on a Friday night. His primary care physician, neurologist, and psychiatrist are "out of town" and he believes that he needs to be admitted for the duration of the weekend. He has another episode of shaking in the ED and immediately following this he returns to his baseline. He is now awake and alert. You immediately draw a serum lactate and it is normal. Which of the following diagnoses should be strongly considered in this patient? A) Factitious disorder B) Functional neurological symptom disorder C) Illness anxiety disorder D) Somatic symptom disorder

Correct Answer A) Factitious disorder Explanation: The patient likely has factitious disorder imposed on self. This is a psychiatric disorder in which the individual feigns disease in an attempt to gain attention, sympathy, or reassurance. There is often a longstanding history of doctor and hospital shopping, frequent hospitalizations, and extensive medical records. They are generally well spoken, intelligent and able to communicate in medical jargon. They often present on the weekend and after regular office hours in an attempt to limit access to medical records and personal physicians. Individuals often want to be admitted to the hospital and once admitted are difficult to discharge home. The normal serum lactate and lack of a post-ictal state essentially rule out true seizure activity and support the fact the patient is faking his seizure episodes. Functional neurological symptom disorder (B) is characterized by an unexplained symptom (i.e. blindness, paralysis, mutism) that is triggered by a psychological stressor. The medical work-up will be normal in these individuals. Illness anxiety disorder (C) is the preoccupation or fear of having a medical condition. Somatic symptoms, if present, are mild in intensity. Somatic symptom disorder (D) is diagnosed when there are unexplained physical (pain, GI, sexual, or neurologic) symptoms that lead to significant social and occupational impairment.

Which of the following is the most common type of child abuse? A) Neglect B) Physical C) Psychological D) Sexual

Correct Answer A) Neglect Explanation: Child abuse can be defined as physical, sexual or emotional maltreatment, either via commission or omission, that results in actual, potential or threatened harm to a child. The most common form of child abuse is neglect. Neglect is defined as the failure of a parent or responsible adult to provide food, clothing, shelter medical care and supervision. A history of childhood abuse can lead to several chronic conditions, especially psychiatric issues such as anxiety, depression, acting-out, post-traumatic stress disorder, chronic pain, neurocognitive disorders, personality disorders and disorganized attachment. Up to 80% of abused children have one psychiatric disorder by age 21 years. Less common forms of child abuse include physical (B), then sexual (D) and finally, psychological (C). Common physical signs of physical child abuse include bruising, minor cuts (multiple "mishaps"), fractures (especially rib fractures) and intracerebral hemorrhage. Early diagnosis and treatment are paramount in preventing chronic sequelae.

A 55-year-old man presents with a chief complaint of "feeling low". He has been tearful and depressed since he lost his job four months ago. He has been unable to find a new job. The patient is frustrated and admits to driving recklessly. What is the most likely diagnosis? A) Acute stress disorder B) Adjustment disorder C) Normal grief reaction D) Post traumatic stress disorder

Correct Answer B) Adjustment disorder Explanation: Adjustment disorder consists of maladaptive behavioral or emotional symptoms. These follow a stressful life event and occur within three months and end within six months. The stress is not due to bereavement. In adults, divorce, loss of employment, and new parenthood are common stressors. In children, school problems, moving homes, and parental divorce may be precipitators. Emotional symptoms may include depressed mood and anxiety. Behavioral symptoms may include truancy, vandalism, reckless driving or fighting. In all cases, the reaction is out of proportion to the event and causes the patient impairment of normal functioning. Treatment is usually supportive, including psychotherapy or group therapy. Pharmaceutical treatment is not first-line treatment, but may be initiated for excessive insomnia, anxiety or depression. Acute stress disorder (A) occurs within a month of a stressful or traumatic event. Patients are often anxious, hypervigilant, and have a reduced sense of their surroundings. Normal grief reaction (C) begins immediately or soon after the loss of a loved one. Culturally, grief may last different lengths of time, but a diagnosis of depression is not usually considered until at least 2 months after the loss. Post traumatic stress disorder (D) occurs after exposure to a traumatic event and is characterized by anxiety, flashbacks, and impaired functioning. Symptoms can occur from one week to many years after the event.

A 19-year-old man presents with his parents who state that their son has shown signs of impulsivity, pressured speech, racing thoughts, and a decreased need for sleep over the last three to four weeks that has caused him to miss school. What is the most likely diagnosis? A) Attention-deficit/hyperactivity disorder B) Bipolar disorder C) Major depressive disorder D) Schizophrenia

Correct Answer B) Bipolar disorder Explanation: Bipolar disorder is a chronic mood disorder characterized by the presence of mania (bipolar I disorder) or hypomania and depression (bipolar II disorder). Manic episodes are distinct periods of abnormally and persistent moods that can be euphoric, expansive, or irritable. Manic patients often have greatly inflated self-esteem, confidence, decreased need for sleep, pressured speech, racing or crowded thoughts, distractibility, increased involvement in goal-directed activities (e.g., starting many projects but being unable to finish any), hypersexuality, and excessive involvement in pleasurable activities with a high potential for painful consequences. Despite mania being the defining characteristic of the disease, depressed moods tend to predominate, with bipolar I patients experiencing a 3:1 ratio of depression to mania over the course of the illness. Hypomania consists of manic episodes that do not lead to social or occupational dysfunction. Pharmacologic treatment for bipolar consists of mood stabilizers such as lithium, valproic acid, and carbamazepine. Bipolar is associated with a high rate of suicide (up to 15%) and several comorbidities such as substance abuse and anxiety disorders. Attention-Deficit/Hyperactivity Disorder (A) is associated with difficulty focusing and distractibility but not manic behavior. Patients with major depressive disorder (C) do not have manic or hypomanic episodes. The essential feature of a major depressive episode is a period lasting at least two weeks during which the patient experiences depressed mood or loss of interest or pleasure in almost all activities, a distinct change in usual self and clinically significant distress or changes in functioning. Schizophrenia (D) is not associated with mania and is characterized by hallucinations, delusions, behavioral disturbances, disrupted social functioning, and associated symptoms in what is usually an otherwise clear sensorium.

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

Correct Answer B) Borderline Explanation: This patient exhibits a number of features typically seen in borderline personality disorder. Borderline personality disorder is characterized by unstable relationships, self image and affect. This instability is often marked with impulsiveness. In the emergency department, these patients will often "split" providers: they will act with affection and respect to some providers and anger and disregard to others. Substance abuse and drug seeking behavior are often seen in borderline patients as well. Antisocial personality disorder (A) is typified by a disregard and violation of the rights of others. Histrionic personality disorder (C) involves excessive emotionality and attention seeking. Narcissistic personality disorder (D) involves patterns of grandiosity and lack of empathy to others.

A patient with chronic spinal pain begins to obtain off-the-street opioids in an attempt to enhance his prescribed opioid analgesics. In addition to psychotherapy, which of the following medications can be used in the treatment of opioid use disorder? A) Bromocriptine B) Buprenorphine and naloxone C) Disulfiram D) Modafinil

Correct Answer B) Buprenorphine and naloxone Explanation: Patients with opioid use disorder can develop withdrawal symptoms after stopping use of the opioid. Common symptoms include diaphoresis, rhinorrhea, nausea, vomiting, diarrhea, mild hypertension and tachycardia, piloerection, and yawning. The use of substitute drugs that are partial agonists or less harmful (e.g., buprenorphine and naloxone) are frequently used to assist management of opioid use disorder. The goal is to provide a clinically supervised, stable dose of a partial opioid agonist (buprenorphine) and opioid-antagonist (naloxone) to provide pain and craving control, which allows the patient to function while reducing the negative aspects of addiction. Bromocriptine (A) is a dopamine agonist that was previously used in the treatment of Parksinon disease. Disulfiram (C) is used in alcohol, not opioid, use disorder. Modafinil (D) shows some promise in the treatment of stimulant, not opioid, use disorder.

Which of the following psychotherapy techniques is most effective for panic disorder? A) Acceptance and commitment therapy B) Cognitive behavioral therapy C) Dialectical behavior therapy D) Interpersonal therapy

Correct Answer B) Cognitive behavioral therapy Explanation: Cognitive behavioral therapy is a psychotherapeutic technique that focuses on a person's thoughts and beliefs and how it influences their actions, and ways to change their thinking to become more positive and healthy. Panic disorder is characterized by an intense fear along with physiological symptoms of chest pain, shortness of breath, nausea, vomiting, and headache. This is accompanied by fear of future attacks and behavioral changes in order to prevent the onset of a panic attack. Theorists believe that panic disorder is an acquired fear of those aroused bodily sensations. Cognitive behavioral therapy allows a patient to expose those fears, analyze why they are present, and teaches them ways to cope in anxiety-provoking situations. By educating a patient, teaching self-monitoring of emotions, exposing a patient to their fear, and re-learning behavioral techniques, cognitive behavioral therapy is effectively able to decrease the symptoms of panic disorder. Acceptance and commitment therapy (A) is a form of mindfulness therapy that focus on acceptance of a problem and ways to develop strategies to cope with them. While it can be used as a psychotherapy for panic disorder, it has not yet been proven to be as effective as cognitive behavioral therapy. Dialectical behavior therapy (C) is when two opposing views are discussed until a balance of the two extremes is reached. This allows the patient to feel validated in their belief while also concluding the need to change. This form of therapy is typically used in patients suffering from borderline personality disorder or suicidal ideation. Interpersonal therapy (D) identifies how a person interacts with others and works to improve communication. This form of psychotherapy is often used to treat major depression disorder and has not been shown to be more effective than cognitive behavioral therapy in those suffering from panic disorder.

A 45-year-old man who lives alone and is a highly functional working individual, tells you that each night there are people around his house who are constantly watching him throughout the night. Which of the following is the most likely diagnosis? A) Delirium B) Delusional disorder C) Depression D) Schizophrenia

Correct Answer B) Delusional disorder Explanation: The term delusional disorder refers to a condition whose core feature is persistent, nonbizarre delusions not explained by other psychotic disorders. It is a fixed false belief that has a certain level of plausibility. The delusion may emerge gradually and become chronic, and sometimes is associated with a precipitating event. Behavioral, emotional, and cognitive responses generally are appropriate, and neither mood disorders nor schizophrenic illness is present. There are several types of delusions, and the predominant type is identified to make the diagnosis. Minimal deterioration in personality or function and the relative absence of other psychopathologic symptoms have been considered important evidence for distinguishing this disorder from schizophrenia and other psychotic condition. Delirium (A) has a fluctuating course, with confusion, memory impairment, and transient delusions that contrast with the persistent delusions in most idiopathic delusional disorders. Profound changes in mood suggest depression (C). In delusional disorders, mood may be depressed, but the change usually is not as overwhelming and pervasive as in depression. Depression refers to a group of signs and symptoms, such as changes in appetite, sleep, libido, concentration, decisiveness, interest, and energy. Schizophrenia (D) should be considered when the delusions are bizarre; affect is blunted or incongruent with thinking; thought disorder, if present, is pervasive; and role functioning is impaired.

Which of the following is associated with an organic cause of psychosis? A) Auditory hallucinations B) Disorientation C) Normal vital signs D) Slow onset of symptoms

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

A 22-year-old war veteran returns from Afghanistan. Shortly after returning home, he is found wandering in a city far from his home and does not recall his name or how he got there. Which of the following is the most likely diagnosis? A) Depersonalization disorder B) Dissociative fugue C) Dissociative identity disorder D) Post-traumatic stress disorder

Correct Answer B) Dissociative fugue Explanation: Dissociative fugue is a subtype of dissociative amnesia in DSM-5 and is characterized by sudden unexpected travel or wandering in a dissociated state. Dissociative amnesia is a potentially reversible memory impairment that primarily affects autobiographical memory. Patients with the disorder cannot recall important personal information and it usually occurs after traumatic or stressful event such as physical injury, sexual abuse or combat. A subset of patients with generalized dissociative amnesia present with dissociative fugue, involving apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information. The essential feature of depersonalization disorder (A) is the persistent or recurrent feeling of detachment or estrangement from one's own self. The patient generally has intact memory for life history, but experiences repeated states of depersonalization and derealization. With dissociative identity disorder (C), the patient has two or more distinct personality states with at least two of these identities recurrently taking control of the person's behavior. Post-traumatic stress disorder (D) is characterized by amnesia for a traumatic event and symptoms of hyperarousal, avoidance and dissociation. Depersonalization disorder, dissociative identity disorder and post-traumatic stress disorder all share elements of dissociative fugue but are not characterized by wandering and loss of autobiographical memory.

A 19-year-old woman is brought in by her husband for evaluation. He states that over the last week, she has exhibited a number of concerning symptoms including tremors and seizures. On entering the room, the patient is noted to be resting comfortably. When asked about the tremor, the patient begins to exhibit coarse diffuse tremors. During the evaluation the patient has generalized shaking but is able to respond to questions. Further discussion with the patient's husband reveals that they are currently going through a separation and there has been a lot of stress at home. Which of the following disorders accounts for the patient's symptoms? A) Conversion disorder B) Factitious disorder C) Hypochondriasis D) Somatization

Correct Answer B) Factitious disorder Explanation: This patient exhibits signs and symptoms of factitious disorder. Factitious disorder is characterized by falsified general medical or psychiatric symptoms. Patients deceptively misrepresent, simulate, or cause symptoms of an illness or injury in themselves, even in the absence of obvious external rewards such as financial gain, housing, or medications. Symptoms may develop after an identifiable psychosocial stress or as part of a pattern of general life (i.e. this is the way the patient deals with life events). Symptoms can be both psychological and physical. If the patient admits to producing the symptoms, they would not be included in the factitious category. This patient presents with volitional tremors and pseudoseizures that are characterized by general shaking but preserved cognitive function. Conversion disorder (A) describes the presence of a single unexplained symptom affecting voluntary or sensory function suggestive of a neurologic or medical condition. Patients are typically oblivious to or express no concern about the symptom. Hypochondriasis (C) is a preoccupation with having a serious medical condition. Somatization (D) is the unexplained presence of physical symptoms (multiple) that result in seeking treatment and significant social impairment.

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

Correct Answer B) Fluoxetine (Prozac) Explanation: Depression and suicidal ideation are common complaints seen in the primary care setting. Any patient who reveals having thoughts of suicide should be assessed further to determine more details about the thoughts of suicide, as well as intent and plan. Risk factors for suicide include psychiatric illness, history of previous suicide attempts, individuals who have never been married, previous or active military service, childhood abuse, family history of suicide, and access to weapons. Women attempt suicide twice as often as men, but men are three times more likely to complete the act. Management of a patient who is suicidal includes risk factor reduction, managing the underlying cause, close monitoring, and follow up. Determination of the lethality of the patient's current medication regimen is part of the risk reduction process. Selective serotonin reuptake inhibitors (SSRIs) seem to be safer in the case of an overdose than other agents. SSRIs, such as fluoxetine, are therefore the agents of choice in the treatment of depression for patients who are potentially suicidal. Tricyclic antidepressants, such as amitriptyline (A) and nortriptyline (C), are lethal if taken in high doses and their use should be avoided in patients who are suicidal. Venlafaxine (D) is a serotonin norepinephrine reuptake inhibitor that is dangerous in overdose and should also be avoided in patients deemed a high risk for suicide.

You suspect bipolar I disorder in a 17-year-old student. Which of the following tools is most appropriate for screening for this diagnosis? A) Beck Depression Inventory for Primary Care B) Mood disorder questionnaire C) My Mood Monitor D) Myers-Briggs Type Indicator

Correct Answer B) Mood disorder questionnaire Explanation: When staff-assisted mental health care is available, screening for depression and bipolar disorders is recommended for patients 12 to 18 years of age. The mood disorder questionnaire, a 15-question self-reporting questionnaire, is used to screen for bipolar disorder but is not considered diagnostic. Rather, patients with a positive screening test should be further interviewed to establish the diagnosis. This questionnaire has a greater specificity than sensitivity. Appropriate screening tools for depression include the age-appropriate patient health questionnaire or the primary care version of the Beck Depression Inventory. The Beck Depression Inventory for Primary Care (A) is adapted from the Beck Depression Inventory, a 21-question multiple-choice self-report inventory and one of the most widely used instruments for measuring the severity of depression. The questionnaire is designed for individuals aged 13 and over, and is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex. The My Mood Monitor (C) is used to screen for depression and anxiety symptoms. The Myers-Briggs Type Indicator (D) is a personality assessment tool. It measures patient preferences in how decisions are made.

Which of the following is true regarding anorexia nervosa? A) Affects men more than women B) Anti-depressants are an effective treatment C) Associated with a body image disturbance D) Menorrhagia is an early symptom

Correct Answer C) Associated with a body image disturbance Explanation: Eating disorders are the third leading chronic illness, after obesity and asthma in adolescent girls. An individual with anorexia nervosa refuses to maintain a minimally normal body weight, is fearful of gaining weight, and exhibits a distorted body self-image. The patient's body image is the predominant measure of self-worth, along with denial of the seriousness of the illness. The long-term mortality rate for anorexia nervosa is 6% to 20%, the highest rate for any psychiatric disorder. Anorexia is associated with amenorrhea, depression, fatigue, weakness, hair loss, bone pain, constipation, and abdominal pain. Signs include brittle hair and nails, dry, scaly skin, loss of subcutaneous fat, fine facial and body hair (lanugo), and breast and vaginal atrophy. A prime objective in assessment is to distinguish "normal dieters" from individuals with eating disorders. Another important aspect to evaluation is to exclude certain medical conditions such as inflammatory bowel disease, hyperthyroidism, chronic infection, diabetes mellitus, and Addison's disease. Indications for inpatient management include extremely low weight (<75% of expected body weight) or rapid weight loss; severe electrolyte imbalances, cardiac disturbances, or other acute medical disorders; severe or intractable purging; psychosis or a high risk of suicide; and symptoms refractory to outpatient treatment. A multidisciplinary team that includes a primary physician, mental health professional, and nutritionist should manage patients with eating disorders. Refeeding should occur in a monitored setting due to the risk of dysrhythmia. Various antidepressants (B) are effective for treatment of bulimia nervosa but have not shown definite benefit for anorexia nervosa. Cognitive-behavioral therapy has been shown to be the most effective psychological approach to anorexia nervosa. Girls who are postmenarchal are typically amenorrheic (D) and do not experience menorrhagia. Almost 95% of those with anorexia are women (A).

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

Correct Answer C) Conduct disorder Explanation: Conduct disorder criteria involves symptoms from 3 of 4 categories that include aggression to people and animals, destruction of property, deceitfulness or theft, serious violation of the rules. Symptoms must persist for over 12 months with at least 1 criterion for the past 6 months. They must also be under the age of 18. Attention deficit hyperactivity disorder (ADHD) (B) requires patterns of either inattention or hyperactivity or both that interfere with daily life. In either category they must meet six or more symptoms as listed by the DSM-5 manual. Antisocial personality disorder (A) as defined by the DSM-5 requires the individual to be at least 18 years old and three or more criterion: failure to conform to social norms, deceitfulness, impulsivity, recklessness, disregard for others, or lack of remorse for their actions. Obsessive compulsive personality disorder (D) is characterized by a preoccupation with orderliness, perfectionism, and control. The individual lacks flexibility, and openness for change. They also are unaware of the fact that their actions may cause distress to others. They must meet four or more of the criteria as laid out by the DSM-5 manual.

Which of the following is correct with regards to autism? A) Caused by thimerosal-containing vaccines B) Developmental screening tests have good sensitivity for autism C) Early intervention with a multidisciplinary approach improves outcomes D) Onset typically occurs after the age of 5

Correct Answer C) Early intervention with a multidisciplinary approach improves outcomes Explanation: Early intervention with a multidisciplinary approach improves autism outcomes. The term autism refers to a spectrum of pervasive developmental disorders characterized by various degrees of impaired social interactionand communication and repetitive, stereotyped patterns of behavior. These patients like aloneness, are hypersensitive to touch, desire sameness in every day activity, often have a lack of understanding, and can have good rote memory skills. Patients may have relatively good skills in one area and very poor skills in others. The incidence of autistic disorder is 5 to 20 per 10,000 persons, with a much higher occurrence among siblings of affected patients. Evidence is mounting that both genetic and environmental factors influence the etiology of autism. Assertions that autism is caused by thimerosal-containing vaccines (A) have been discounted by a comprehensive meta-analysis. Standard developmental screening tests (B) have poor sensitivity for autism. A variety of screening tools aimed specifically at autism are available but also lack sensitivity. Therefore, physicians should take parental concerns about delayed speech and language development seriously, especially beyond 18 months of age, even in the context of normal screening. Autistic disorder has onset before age 3 years not after 5 years of age (D).

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

Correct Answer C) Factitious disorder Explanation: Factitious disorder imposed on self, previously known as Munchausen syndrome, is a disorder in which patients feign illness in order to obtain attention, sympathy or to play the sick role rather than for external rewards such as medications or financial gain. ​Factitious disorders are different from somatic disorders and malingering because ofintention. Patients will often have objective physical findings as a result of their self-harm. In some cases, they may induce a serious illness in order to have prolonged hospitalization in the patient role. They are willing to undergo procedures in order to maintain their sick role. Borderline personality disorder (A) is characterized by a pattern of instability in interpersonal relationships and self-image. Patients have extremely labile moods and are at risk for suicide, eating disorders, post-traumatic stress disorder and substance abuse. Patients classically split providers identifying some as good and some as bad subsequently pinning them against each other in the course of their care. Drug-seeking behavior (B) is a challenging diagnosis in which a patient feigns illness as a type of malingering in order to obtain drugs. Typically the patient has active issues with substance abuse. Malingering (D) is separate from somatization disorders and factitious disorders because the patient simulates a disease for some secondary gain. Factitious patients will do things creating actual objective findings.

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

Correct Answer C) Malingering Explanation: This patient most likely is malingering, which is to purposefully feign physical symptoms for external gain. The most common goals of people who malinger in the emergency department are obtaining drugs and shelter. In the clinic or office, the most common goal is financial compensation. According to the DSM-5, malingering should be suspected in the presence of any combination of the following: medicolegal presentation, marked discrepancy between the claimed distress and the objective findings, lack of cooperation during evaluation and in complying with prescribed treatment or presence of an antisocial personality disorder. Conversion disorder (A) involves a single voluntary motor or sensory dysfunction suggestive of a neurologic condition, but not conforming to any known anatomic pathways or physiologic mechanisms. Factitious disorder (B) involves adopting physical symptoms for unconscious internal gain, such as deriving comfort from taking on the role of being sick. Somatization disorder (D) is related to numerous unexplained physical symptoms that last for several years and typically begin before 30 years of age.

A 15-year-old girl presents to clinic for a well child check. During her Home and Environment, Education and Employment, Activities, Drugs, Sexuality, Suicide and Depression (HEADSS) exam, she reports using marijuana on a weekly basis for the past six months. She also drinks alcohol to excess once every few weeks. She denies smoking tobacco or using any other illicit substances. Which of the following is the most accurate information to give this patient? A) Chronic marijuana use improves focus and performance B) In human studies, marijuana has shown teratogenicity C) Marijuana can cause dependence and withdrawal D) Tetrahydrocannabinol concentrations are lower in today's marijuana compared to prior decades

Correct Answer C) Marijuana can cause dependence and withdrawal Explanation: Marijuana is the most commonly abused illicit drug, and is used by over 1/3 of US high school students. The active component, tetrahydrocannabinol (THC), leads to the effects of euphoria, elation, and hallucination. Side effects of the drug include impaired short-term memory, poor attention, loss of judgment, distorted time perception, and occasionally visual hallucinations and distorted body image. In the acute setting, serious adverse effects might include anxiety, panic, psychotic symptoms at high doses, and motor vehicle accidents. Marijuana is used in many medical conditions due to its antiemetic properties and appetite stimulation. Dependence occurs in about 10% of users. Withdrawal usually occurs within 24 to 48 hours of stopping the drug, and symptoms include malaise, irritability, insomnia, diaphoresis, night sweats, GI disturbance, and drug craving. The withdrawal symptoms usually peak by day 4 and are resolved by day 10-14. Chronic marijuana use (A) is associated with anxiety and depression, as well as learning difficulties, poor job performance, and respiratory complications such as sinusitis, bronchitis, and asthma. Animal studies have shown possible teratogenicity (B), but no human studies have ever shown this adverse effect. THC concentrations (D) are 5 to 15-fold higher in today's marijuana compared to the marijuana used in the 1970s.

Martin is a 10-year-old boy recently diagnosed with attention deficit hyperactivity disorder, and his parents are interested in starting a medication. Which of the following medications is most appropriate for this patient? A) Clonidine B) Guanfacine C) Methylphenidate D) Sertraline

Correct Answer C) Methylphenidate Explanation: Methylphenidate is a stimulant and is the first-line medication for a patient newly diagnosed with ADHD. ADHD is a childhood disorder that is characterized by hyperactivity, inattention, and impulsivity. Stimulants help to reduce hyperactivity and increase a patient's attention. They are used as first-line therapy because of their safety, efficacy, and rapid onset. Clonidine (A) is an alpha-2 adrenergic agonist that has been found to be an effective treatment for ADHD but should be used as an adjunct or second-line therapy. Patients who fail the initial stimulant medication can be tried on a second stimulant or an alpha-2 adrenergic agonist such as clonidine. Guanfacine (B) is also an alpha-2 adrenergic agonist that should only be prescribed after a stimulant has initially been tried and found to be ineffective. Sertraline (D) is a selective serotonin reuptake inhibitor that is used to treat depression and anxiety. This class of medications has not been shown to treat the symptoms of ADHD and therefore should not be prescribed unless other co-morbidities exist.

Which of the following is true regarding attention deficit hyperactivity disorder? A) Characterized by speech delay, poor eye contact, and lack of stranger anxiety B) More prevalent in girls than boys C) Most frequently diagnosed behavioral disorder in children D) Symptoms most commonly begin in adolescence

Correct Answer C) Most frequently diagnosed behavioral disorder in children Explanation: Attention-deficit/hyperactivity disorder (ADHD) is the most frequently diagnosed behavioral disorder of childhood, with a prevalence of 4% to 12%. At least 10% of behavior problems seen in a general pediatric practice are caused by ADHD. ADHD is characterized by a triad of symptoms including inattention, impulsivity, and hyperactivity. Symptoms must be present in 2 areas of social interaction (home and school); must have been present prior to age 12 years; must have persisted for longer than 6 months; and must be maladaptive or inappropriate for the child's developmental stage. Research suggests that ADHD has a central nervous system (CNS) basis; however, no specific etiology has been discovered. Various brain imaging studies of ADHD patients have demonstrated abnormalities of brain metabolism, supporting the validity of ADHD as a disorder. However, the strongest evidence of validity has been course prediction and treatment response to medication. There is no independent valid test to determine that a child has ADHD. The diagnosis can only be obtained reliably by using well-established diagnostic assessment methods. This involves using the standardized diagnostic criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (or DSM). Speech delay, poor eye contact, and lack of stranger anxiety are characteristic of autism (A), not ADHD. ADHD is more prevalent in boys (B) than girls. Symptoms must have been present (D) before the age of 12.

The DSM-V groups personality disorders into three clusters: odd/eccentric, dramatic/erratic and anxious/fearful. Which of the following is the correct personality disorder and cluster? A) Avoidant personality disorder - odd/eccentric (cluster A) B) Borderline personality disorder - odd/eccentric (cluster A) C) Narcissistic personality disorder - dramatic/erratic (cluster B) D) Schizoid personality disorder - anxious/fearful (cluster C)

Correct Answer C) Narcissistic personality disorder - dramatic/erratic (cluster B) Explanation: Cluster B is the dramatic, overly emotional, or erratic group, including antisocial, borderline, histrionic, and narcissistic personality disorders. Personality disorders are distinguished by persistently inadequate adaptive capacities affecting several realms of functioning, such as social relationships or occupational performance. People with personality disorders have chronic problems dealing with responsibilities, roles, and stressors; they also have difficulty understanding the causes of their problems or changing their behavior patterns. Cluster B individuals often are characterized as labile, unpredictable, unlikable, and impulsive. The initial presentation typically is crisis-related and chaotic, often involving severe symptoms (that may decrease after the crisis has passed), substance abuse, and conflicts with family members, employers, or the healthcare system. Persons with cluster B disorders have difficulty establishing and maintaining interpersonal relationships (e.g., with medical providers) and often have a history of discharge against medical advice, doctor shopping, or failure to follow recommended treatment. Avoidant personality disorder (A) is the anxious/fearful patient these patients often are anxious, timid, perfectionistic, and conflict-avoidant; presentation frequently is triggered by depression or somatic complaints. The borderline personality disorder (B) is the dramatic/erratic patient with characteristics as above. The schizoid personality disorder (D) is the odd/eccentric patient. These patients are characterized by the absence of close relationships, indifference to the praise or criticism of others and emotional coldness or detachment.

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

Correct Answer C) Normal saline and glucose Explanation: This patient is suffering from alcoholic ketoacidosis, which is defined by the clinical triad of ketones in the blood or urine, an elevated anion gap and a normal glucose level. Classically, these patients are chronic alcoholics and in a state of starvation. Blood alcohol may be undetectable and the patient may be hypoglycemic. Patients typically have high osmol and anion gaps. Treatment of alcoholic ketoacidosis includes vigorous volume repletion with normal saline, along with administration of thiamine and glucose. Alcohol appears to significantly increase the amount of thiamine required to treat the patient successfully compared with other individuals in whom thiamine deficiency has been due to starvation. Thiamine is administered initially before giving glucose and normal saline to the patient. Administering dextrose to an individual in a thiamine-deficient state exacerbates the process of cell death and can worsen the patient. Bicarbonate and insulin (A) is administered to patients in severe diabetic ketoacidosis with a pH less than 7. Levels of glucagon and hydrocortisone (B) are typically elevated in patients with alcoholic ketoacidosis. The body is in a state of starvation, which results in hypoglycemia triggering the release of glucagon. The body is undergoing a stressful state causing the release of hydrocortisone. Pyridoxine (D), also known as vitamin B6, is not used for the treatment of alcoholic ketoacidosis. Common uses of this vitamin include anti-emetic in pregnancy and as an isoniazid adjunct in the treatment of tuberculosis.

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

Correct Answer C) Opioids Explanation: Sufferers of opioid use disorder often begin by being prescribed opioid medication. Tolerance develops rapidly with long-term use of opioids and addiction can lead to drug-seeking behavior and experimentation with heroin. Opioid intoxication induces symptoms of euphoria followed by apathy, pinpoint pupils, constipation, drowsiness, slurred speech, and memory impairment. Overdose can lead to respiratory depression and coma and is treated with naloxone, an opioid antagonist. Opioid withdrawal is diagnosed when three or more of the following occur: dysphoric mood, nausea or vomiting, myalgias, lacrimation, rhinorrhea, pupillary dilation, piloerection, sweating, diarrhea, yawning, fever, and insomnia. Rapid detoxification from opioids is not life-threatening, but is extremely uncomfortable. Withdrawal is treated with supportive measures. Slower, tapered detoxification and withdrawal can be achieved using methadone (a mu agonist that is gradually titrated down) or buprenorphine (a partial mu agonist and antagonist that has a ceiling effect and long duration). Amphetamines (A) cause withdrawal if they are abruptly discontinued after long-term use. Symptoms include fatigue, insomnia or hypersomnia, anxiety, increased appetite, and drug cravings. Cocaine (B) withdrawal presents with exhaustion ("crash") and dysphoria. Phencyclidine (D) does not have tolerance or withdrawal associated with it.

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

Correct Answer C) Paroxetine Explanation: Generalized anxiety disorder (GAD) is defined by having uncontrollable anxiety and worry that interfere with daily activities for at least 6 months. Symptoms occur on more days than not during this time period. First-line medications for GAD include SSRI's or SNRI's, including paroxetine. Psychotherapy is also recommended in the treatment of GAD. If one SSRI does not have the desired effect, then a trial of a different SSRI is used prior to initiating a second-line medication. Imipramine (A) is a tricyclic antidepressant that is considered second-line in the treatment of GAD. Lorazepam (B) is a benzodiazepine that can be used to augment SSRI therapy, especially in cases of agitation. Use of benzodiazepines is declining due to concerns about dependence and tolerance. Quetiapine (D) is an atypical antipsychotic that has been used in the treatment of GAD, however its use is off-label and it is not currently approved by the FDA.

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

Correct Answer C) Phobia Explanation: A phobia is an excessive and unreasonable degree of fear triggered either by exposure to or anticipation of a specific object or circumstance. People with specific phobias realize that their level of fear is excessive, but they still try to avoid any exposure to the feared object or circumstance. These avoidance attempts and the anxiety that results when avoidance is unsuccessful cause a significant disruption in normal functioning. This can be distinguished from fear, which is a normal psychological and physiological reaction to an actual threat or danger, or to the anticipation of an actual threat or danger. Many phobias begin in childhood—particularly those of the animal and nature type. Very often there has never been an exposure to the feared object or situation. Cognitive behavioral therapy is probably the most effective treatment for a specific phobia. Through a process of graded exposure called systematic desensitization, individuals with a phobia are able to extinguish or control their response. Generalized anxiety disorder (A) is generalized and not related to a specific situation or object. Panic disorder (B)and attacks are not related to a fear of a specific object. Post-traumatic stress disorder (D) occurs when panic symptoms are triggered by severe trauma.

Which of the following class of medications is used as first-line therapy for post-traumatic stress disorder? A) Atypical antipsychotics B) Benzodiazepines C) Selective serotonin reuptake inhibitors D) Tricyclic antidepressants

Correct Answer C) Selective serotonin reuptake inhibitors Explanation: Selective serotonin reuptake inhibitors are used as first-line therapy for post-traumatic stress disorder (PTSD) in combination with cognitive and behavioral therapies. PTSD is a severe disorder characterized by intrusive thoughts, sleep disturbance, nightmares, and hypervigilance as a result of a traumatic experience or event. Pharmacologic treatment is used to decrease the severity of the symptoms. Selective serotonin reuptake inhibitors (SSRIs) are used as first-line therapy because they have been proven to most effectively decrease the symptoms of PTSD. Atypical antipsychotics (A) are antipsychotic medications that can be used as adjunctive therapy to an SSRI medication but should not be used as first-line therapy. In clinical trials, atypical antipsychotics have been shown to have some benefit only when used in conjunction with an SSRI and therefore should not be used as monotherapy. Benzodiazepines (B) are psychoactive drugs most commonly used to treat anxiety and hyperarousal. This class of medications can be used in an acute hyperarousal state of PTSD but should not be used as first-line therapy. Additionally, because of the high prevalence of drug use in patients with PTSD, benzodiazepines should be avoided since this class of medications has historically been commonly abused. Tricyclic antidepressants (D) are a type of antidepressant that have not been shown to reduce the severity of symptoms associated with PTSD.

You provide care to a middle-aged man with hypertension and diabetes. He recently lost his job, and you are concerned that he may be exhibiting mild symptoms of depression. According to the US Preventive Services Task Force, screening for depression is recommended if which of the following exists? A) A local suicide prevention hotline routinely handles calls from your surrounding area B) The patient has a strong social support of friends, family and coworkers C) There is a cognitive-behavior therapist that is available to your clinic D) You have developed a detailed depression screening form

Correct Answer C) There is a cognitive-behavior therapist that is available to your clinic Explanation: The US Preventive Services Task Force recommends that adults should only be screened for depression when there is staff-assisted care and support available to make an accurate diagnosis, offer effective treatment and provide follow-up care. There is evidence that this model improves clinical outcomes. Staff-assisted care support refers to ancillary staff that can assist the primary care physician in many areas, such as behavior treatment, medication adherence and follow-up care. This can include trained nursing staff, cognitive behavior therapists and psychiatrist/psychologists. The USPSTF recommends against routine screening of adults for depression if there is no staff-assisted care support currently established. It is suggested to screen adults for depression when personnel or systems are in place to ensure appropriate follow-up and management of patients who screen positive. There is limited evidence to guide the optimal frequency of screening for depression. To facilitate ease of implementation, screening at the time of a routine health visit is suggested. A suicide prevention hotline (A) may not be beneficial in the treatment of adult depression. Family and non-family support alone (B) does not warrant routine screening of depression. Screening (D) and feedback alone does not improve clinical outcomes.

A 28-year-old woman presents to your office with a complaint of mood swings. She tells you that she constantly fights with her boyfriend and gets angry easily. She often uses cocaine and binge eats when under stress. Last month, she held a knife to her wrist during an argument with her boyfriend but did not follow through with the suicide attempt. Which of the following is the most appropriate next step in management? A) Admission to an inpatient psychiatric unit B) Begin course of amitriptyline C) Begin course of lorazepam D) Cognitive behavior therapy

Correct Answer D) Cognitive behavior therapy Explanation: The hallmark features of borderline personality disorder (BPD) are instability of relationships, affect, and self-image, along with impulsive behaviors, including suicide attempts. BPD affects women more frequently than men, and patients often have co-morbid psychiatric disorders. The etiology of BPD is unknown but is believed to be a combination of psychosocial, biologic, and genetic factors. Diagnosis is made using the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and BPD must be differentiated from other psychiatric disorders with similar characteristics. The manic behaviors of bipolar disorder may mimic the impulsivity seen in patients with BPD. First-line treatment for patients with BPD is psychotherapy, with different types of cognitive behavior therapy being most effective. Suicidal ideation and attempts are common in patients with BPD, therefore these patients should be monitored closely. Gestures, such as holding a knife to a wrist, need to be taken seriously; however, it may also be part of a BPD patient's effort to avoid abandonment in a primary relationship. Admission to an inpatient psychiatric unit (A) is reserved for individuals who are actively suicidal with a specific plan and means to harm themselves. Pharmacotherapy is sometimes used as an adjunct to psychotherapy with first-line choices being mood stabilizers and antipsychotics. Caution should be used in prescribing tricyclic antidepressants, such as amitriptyline (B) due to the potential for lethality in overdose. The use of benzodiazepines, such as lorazepam (C) is not recommended in patients with BPD.

A 45-year-old woman presents to the office with a complaint of chest tightness and shortness of breath. It has happened at the grocery store and when entering an elevator. For the past year she has taken the stairs in fear that the elevator will break down, leaving her stuck in the enclosed space. Which of the following is the most likely diagnosis? A) Generalized anxiety disorder B) Obsessive compulsive disorder C) Panic attack D) Panic disorder

Correct Answer D) Panic disorder Explanation: Panic disorder is characterized as recurrent attacks of intense fear that begin abruptly and may last up to several hours along with worrying about the onset of future attacks. It is a type of anxiety disorder that includes panic attacks, defined as episodes of spontaneous intense fear accompanied by cardiorespiratory distress, gastrointestinal changes, or neurologic symptoms. Patients endorse heart palpitations, chest pain, sweating, nausea, vomiting, headache, dizziness, or even a fear of dying. These symptoms can last from a few minutes to a few hours and attacks commonly warrant emergency room visits. A panic disorder is defined as recurrent panic attacks and one month or more of worrying about future attacks or changing a behavior in order to avoid an attack. Diagnosis is made clinically and treatment includes psychotherapy and pharmaceutical interventions. Generalized anxiety disorder (A) is a psychiatric disorder characterized by uncontrollable, excessive worrying that is hard to control, causes significant impairment, and occurs on most days for at least six months. Most patients with generalized anxiety disorder present with symptoms of hyperarousal, hyperactivity, and muscle tension. They typically do not present with cardiorespiratory or gastrointestinal distress. Obsessive compulsive disorder (B) is characterized by recurrent intrusive thoughts or urges that cause anxiety along with repetitive behaviors that the patient feels must be done. The obsessions typically do not prompt cardiorespiratory or gastrointestinal changes. Panic attack (C) occurs when there is an intense, spontaneous fear along with cardiorespiratory, gastrointestinal, or neurologic changes of chest pain, shortness of breath, nausea, vomiting, dizziness, or headache. When an isolated episode of these changes occurs it is considered a panic attack. When there is fear of future attacks or if there is a change in behavior in an attempt to try to prevent future attacks, it is then considered panic disorder.

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

Correct Answer D) Persistent complex bereavement disorder Explanation: Intense symptoms of depression and guilt that persist beyond 12 months following the death of a loved one is indicative of persistent complex bereavement disorder. Not only do symptoms persist beyond 12 months, but they are generally severe in nature and interfere with daily functioning. According to the DSM V, persistent complex bereavement disorder, also called complicated grief disorder, has overlapping symptoms with major depressive disorder and posttraumatic stress disorder (PTSD), but is currently considered an independent condition. Normal grief (B) is limited to 12 months following the loss of a loved one. Feelings of pervasive hopelessness, helplessness, worthlessness, guilt, lack of pleasure, and suicidal ideation are present in patients with depression or complicated grief, but are not components of normal grief. Major depressive disorder (C) can overlap with persistent complex bereavement, but the latter is considered an independent condition. Acute stress disorder (A) is similar in symptomatology to post traumatic stress disorder, but is restricted to within 1 months following exposure to a traumatic event.

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

Correct Answer D) Sertraline Explanation: The patient has symptoms of anxiety and obsessive-compulsive disorder which are impairing her overall functioning. In obsessive-compulsive disorder, the obsessions are dysfunctional and compulsions are out of the ordinary, and while associated with relief of distress reaction, these are not pleasurable to the individual. People with obsessive-compulsive disorder have insight about their condition. One way to differentiate fears and worries in anxiety disorders from obsessions is that they often pertain to real life situations, while obsessions typically involve some degree of irrationality. Although the first-line of treatment for anxiety and obsessive-compulsive disorder is cognitive behavioral therapy, use of medication with a selective serotonin reuptake inhibitor (SSRI) such as citalopram, fluoxetine or sertraline, in conjunction with cognitive behavioral therapy has been associated with a superior response to either treatment alone. Benzodiazepines such as alprazolam (A) are not effective in the treatment of pediatric obsessive-compulsive disorder, but may have value in the treatment of panic disorder. Paroxetine (B) is not approved in pediatric population and has many associated side effects. Risperidone (C) is an atypical antipsychotic that may be used as an adjunct to SSRI for those who are refractory to attempts at treatment, but they have significant adverse effects and requires laboratory monitoring.

A 17-year-old woman presents to your clinic with a chief complaint of sadness, loss of appetite, and the inability to sleep. She is having a hard time focusing at work and she is tired all of the time. She tells you that for the past month she has been hearing voices telling her to harm herself. She is interested in treatment. What is the most appropriate first-line therapy for this condition? A) Lithium B) Psychotherapy C) Sertraline D) Sertraline and olanzapine

Correct Answer D) Sertraline and olanzapine Explanation: Major depressive disorder is defined as an episode of major depression lasting at least two weeks with the following symptoms: (SIGECAPS) sleep changes, interest (lack thereof), guilt, energy (lack thereof), cognition/concentration (lack thereof), appetite (increased or decreased), psychomotor (agitation or retardation), and suicide (thoughts of or attempts). Major depressive disorder with psychotic features is defined by the above mentioned symptoms plus psychotic features of delusions or hallucinations, either auditory or visual. The first-line treatment for major depressive disorder with psychotic features is an antidepressant plus an antipsychotic medication. Studies show that sertraline, an antidepressant, in combination with olanzapine, an antipsychotic, works more effectively than just sertraline or just olanzapine alone. Lithium (A), a mood stabilizer, can be added to the medication regimen if after four to eight weeks, there is no improvement of symptoms while on an antidepressant plus antipsychotic. While psychotherapy (B) should be a part of the treatment course for major depressive disorder with psychotic features, it is not first-line therapy. Psychotherapy can be initiated after starting an antidepressant plus antipsychotic medication, especially if the patient is resistant to these medications. Sertraline (C) is an antidepressant that if used alone in cases of major depressive disorder with psychotic features would be an under-treatment.

A 28-year-old man presents to the clinic for his annual physical. The patient has a history of schizophrenia, which has been well managed with the medication olanzapine. Which of the following is the most appropriate screening test? A) Complete blood count with differentialYour Answer B) Electrocardiogram C) Fundoscopic exam D) Serum lipid panel

Correct Answer D) Serum lipid panel Explanation: Schizophrenia is one of the most disabling and economically catastrophic medical disorders which involves chronic or recurrent psychosis. Age of onset is typically during adolescence, with a slightly higher prevalence in males. Risk factors associated with the development of schizophrenia include living in an urban area, obstetrical complications, and late winter-early spring birth. Positive symptoms include hallucinations, delusions, bizarre behavior (e.g., catatonic behavior), and disorganized speech. Negative symptoms include a flat or blunted affect, anhedonia, apathy, and lack of interest in socialization. Cognitive symptoms include impairments in attention, executive function, processing speed, and memory. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria for diagnosis of schizophrenia requires the presence of characteristic symptoms of the disorder (e.g., positive symptoms, negative symptoms) coupled with social or occupational dysfunction for at least six months in the absence of another diagnosis that would better explain the presentation. Antipsychotic medications are first-line medication treatment. First-generation (i.e., typical) antipsychotic medications primarily antagonize the D2 receptors and have a greater risk of extrapyramidal symptoms. Second-generation (i.e., atypical) antipsychotics antagonize both the serotonin receptors and dopamine receptors, with D4 receptors blocked at a higher rate than D2 receptors. Olanzapine, an atypical antipsychotic, is associated with significant weight gain and adverse metabolic effects including weight gain, diabetes mellitus, and hypercholesterolemia. For this reason, monitoring via a serum lipid panel and with blood glucose measurements is warranted. A complete blood count with differential (A) would be an appropriate screening test in a patient taking the atypical antipsychotic clozapine. Clozapine has been associated with granulocytopenia and agranulocytosis which requires frequent monitoring. An electrocardiogram (B) would be an appropriate screening test to obtain prior to starting an antipsychotic that may prolong the QTc interval, such as clozapine, thioridazine, iloperidone, and ziprasidone. While olanzapine can prolong the QTc interval, this is less common than an increase in serum lipid levels. A fundoscopic exam (C) would be an appropriate exam to perform on a patient who was taking thioridazine at a dose of 600 mg per day or more, given the increased risk for developing retinitis pigmentosa.

A patient with schizophrenia is starting treatment with clozapine. Which of the following needs to be monitored weekly? A) Electrocardiogram B) Fasting plasma glucose C) Hemoglobin and hematocrit D) White blood cell and absolute neutrophil count

Correct Answer D) White blood cell and absolute neutrophil count Explanation: Clozapine is a second-generation antipsychotic used in the treatment of schizophrenia that is found resistant to other antipsychotics. It may also be helpful in treating individuals with schizophrenia who exhibit self-injurious or suicidal-type behaviors. Clozapine has a unique side effect profile and patients prescribed this medication are entered into a computer-based registry that requires specific monitoring parameters during the course of treatment. Use of clozapine involves a risk of life-threatening agranulocytosis, therefore regular monitoring of white blood cell and absolute neutrophil count (ANC) is required. A baseline complete blood count and ANC is performed prior to initiation of therapy, then done weekly for the first six months of therapy. Other adverse effects of clozapine may include myocarditis, pulmonary embolism, weight gain, insulin resistance, seizures, and sedation. Because of the potential risks, patients determined to be candidates for treatment with clozapine should be referred to a psychiatric provider with experience in treating patients with this agent. Due to the risk of clozapine-induced myocarditis, an electrocardiogram (A) should be obtained at baseline prior to initiating treatment, then weekly monitoring of eosinophil count, troponin, and sedimentation rate or C-reactive protein needs to occur for at least the first four weeks of treatment. Metabolic side effects including hyperglycemia, insulin resistance and diabetes mellitus can occur with clozapine. Fasting plasma glucose (B) is recommended monthly at the initiation of treatment. Screening with hemoglobin A1C may also be used. Monitoring of hemoglobin and hematocrit (C) does not play a role in the management of patients taking clozapine.

A 21-year-old man presents somnolent. There is no evidence of trauma and his pupils are 2 mm. His vital signs are: T 36.8°C; HR 58; RR 6; BP 96/52 and oxygen saturation 93% on room air. Fingerstick glucose is 85 g/dL. Which of the following is an appropriate treatment? A) Atropine B) Fomepizole C) Naloxone D) Naltrexone

Correct Answer C) Naloxone Explanation: The classic opioid toxidrome involves central nervous system depression, respiratory depression and miosis. In the central nervous system, opiate use leads to decreased respiratory effort which leads to hypoxia and hypercapnia. Profound hypoxia may lead to excitatory neurologic effects like seizures. One particular opiate, meperidine, may also lead to seizures in large quantities due to its metabolite normeperidine. Opiates stimulate the third nerve nucleus leading to miosis of the pupils. However, certain opiates do not cause miosis including meperidine, propoxyphene and diphenoxylate-atropine. The treatment of opiate intoxication is naloxone, a pure opioid competitive antagonist. Naloxone can be administered intravenously, intramuscularly or intranasally. Fomepizole (B) is the antidote used in toxic alcohol ingestions. By blocking alcohol dehydrogenase, fomepizole prevents the production of the toxic metabolites of ethylene glycol and methanol. Atropine (A) is a pure anticholinergic agent that is used as the antidote in cholinergicpoisoning (e.g. insecticide poisoning).Naltrexone (D) is an opioid antagonist that is primarily used for patients with alcohol dependence. Its mechanism of action is not fully understood. It can be used in patients with opioid addiction as well to help block receptors and prevent additional recreational use. It is not used acutely in the reversal of opiate intoxication.

A 14-year-old boy exhibits chronic conflict with his parents and siblings and has been suspended from school on a number of occasions. Which of the following additional findings would suggest a diagnosis of conduct disorder rather than oppositional defiant disorder? A) Being spiteful or vindictive B) Often losing temper C) Physical cruelty to animals D) Refusal to comply with requests from authority figures

Correct Answer C) Physical cruelty to animals Explanation: Conduct disorder (CD) is one of the most difficult and challenging mental health conditions seen in children and adolescents. Individuals with conduct disorder exhibit a number of problematic behaviors, including antisocial and defiant activities, such as physical and sexual violence, stealing, lying, and running away. CD behaviors fall into four categories: aggression and cruelty toward both people and animals, destruction of property, serious violations of rules and deceit, lying, and theft. Onset of CD occurs in early to middle childhood and the presence of CD is a risk factor for the development of antisocial personality disorder in adulthood. Diagnosis is determined using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Individuals with CD are highly resistant to treatment. Treatment is more successful when initiated early. Oppositional defiant disorder (ODD) and CD may have similar presentations; however, the behaviors of CD include more deliberate destruction, deceit, aggression, and serious rule violations. The behaviors of ODD are based more on defiance and arguments than the aggressive nature of CD. Diagnosis of ODD is also with the DSM-5 criteria, which include being spiteful or vindictive (A), often losing temper (B), and refusal to comply with requests from authority figures (D). Symptoms of ODD may resolve over time, especially if the child receives treatment for comorbid conditions such as attention deficit disorder. Without intervention, some individuals with ODD progress to CD.

A 53-year-old woman with a history of poorly controlled schizophrenia presented to the Emergency Department two weeks ago with altered mental status, auditory hallucinations, and agitation. During her inpatient psychiatry admission, she stabilized on clozapine. Which of the following laboratory tests should be performed at baseline and then weekly during treatment with clozapine? A) Fasting lipid panel B) Hemoglobin A1c C) Prolactin level D) White blood cell count

D) White blood cell count Explanation: White blood cell count is required due to the risk of life-threatening agranulocytosis. Clozapine is an antipsychotic medication used in patients with schizophrenia or schizoaffective disorder, who are resistant to other antipsychotic treatments. Patients being treated with clozapine must have a baseline white blood cell (WBC) count before initiating treatment and weekly throughout treatment. The US Food and Drug Administration requires patients in the United States to have a minimum absolute neutrophil count (ANC) level > 1500/microL to initiate treatment with clozapine. Fasting lipid panel (A) should be tested in patients using any antipsychotic medication, including clozapine, due to the long-term risk of increased hyperlipidemia. This does not need to be drawn weekly. Hemoglobin A1c (B) should be tested in patients using clozapine or any antipsychotic medication. The long-term risk of diabetes mellitus has been shown to be approximately 30% over a ten year period with usage of clozapine. Current recommendations are testing every six months. Prolactin level (C) testing is needed with all antipsychotic medications except clozapine. Hyperprolactinemia may occur due to the antipsychotic medication's effect on inhibition of dopamine.

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

Explanation: Somatic symptom disorder is characterized by physical complaints from various organ systems. Diagnostic criteria include a history of one or more somatic symptoms associated with excessive thoughts, feelings, and behaviors, such as devoting significant time and energy to the health concerns or persistent thoughts or anxiety about the symptoms or the patient's general health. The physical complaints cause significant impairment in the patient's life, including occupational and social functioning. While symptoms may change, the disorder is persistent, usually lasting more than six months. Symptom are not fully explained by a confirmed medical condition. Impulsive and demanding behavior, such as requesting specific diagnostic testing, may occur with patients who meet criteria for this disorder, however there is no evidence that the patient is being deceptive. Treatment focuses on behavior modification including regularly scheduled, brief visits to the medical provider without a diagnostic focus. Factitious disorder (A) involves purposefully feigning illnesses. Individuals with factitious disorder may exaggerate physical symptoms or mimic illness. The intention of the patient to be in the sick role and the use of deception to attain this goal is what differentiates factitious disorder from somatic symptom disorder. Functional neurological symptom disorder (B), formerly conversion disorder, is characterized by voluntary alterations in motor or sensory function without evidence of deceptive behavior. The symptoms are not consistent with known medical or neurological conditions. This patient has symptoms related to multiple different organ systems. Malingering (C) is characterized by purposefully feigning illness with the intent of gaining external rewards (e.g., narcotic prescriptions, time off work, etc).

Question: A body mass index of 25.0-29.9 kg/m2 is considered to be in which weight category?

Answer: Overweight. Obesity is >30

Question: What other mechanism can retinal hemorrhages occur in other than abusive head trauma?

Answer: Severe blunt force mechanism such as a motor vehicle collision or fall from a great height.

Question: What is a common side effect of SSRI treatment that patients often complain about?

Answer: Sexual dysfunction

Question: What is the primary evidence-based treatment for youths with conduct disorder?

Answer: Social competence training, parent and family skills training, medications, academic engagement and skills building, and school interventions.

Question: What is the most important complications of panic disorder?

Answer: Suicidal ideation and suicide attempts

Question: True or false: Benzodiazepines should be avoided in the treatment of panic disorder for patients with a history of substance abuse?

Answer: True.

Question: Name some common psychiatric comorbidities in perpetrators of domestic violence?

Answer: Borderline and antisocial personality disorders, bipolar disorder, schizophrenia and substance abuse

Question: Which type of personality disorder would be present in a patient who is shy, withdrawn, and strongly desires to avoid close relationships?

Answer: Desired avoidance of close relationships is typical of schizoid personality disorder.

Question: Shaken baby syndrome, a common form of infant abuse, typically leads to which pathologic findings?

Answer: Intracerebral hemorrhage, intracranial hypertension, and permanent neurological damage.

Question: How long after cessation of alcohol ingestion does delirium tremens occur?

Answer: It typically occurs at least 72 hours after cessation of alcohol ingestion.

Question: What tool is commonly used at 18 months of age to screen for an autism spectrum disorder?

Answer: M-CHAT questionnaire

Question: Which gender has a higher prevalence of conduct disorder?

Answer: Male.

Question: What medication is commonly used for maintenance therapy for opiate use disorder?

Answer: Methadone

Question: What is the duration of action for naloxone?

Answer: Naloxone will reverse opiate effects for 1-2 hours.

Question: What are some common side effects of venlafaxine?

Answer: Nausea, restlessness, insomnia, headache, sexual dysfunction, hypertension.

Question: Based on the 2007 Youth Risk Behavior Survey, what percentage of students in grades 9 through 12 reported that they had seriously considered attempting suicide in the 12 months preceding the survey?

Answer: 14.5%.

Question: What personality disorder is frequently found in association with malingering?

Answer: Antisocial personality disorder.

Question: What class of medications is used in the short term treatment for alcohol withdrawal?

Answer: Benzodiazepines.

Question: How many patients with depression meet criteria for a bipolar disorder?

Answer: Between 21 and 26%

Question: According to the DSM-5 criteria, what is the minimum age that a patient may be diagnosed with posttraumatic stress disorder?

Answer: Six years of age.

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

C) Notify adult protective services

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

Correct Answer A) Admit the patient and start diazepam Explanation: Admit the patient and start diazepam is the correct disposition because this patient is suffering from alcohol withdrawal, which potentially can be fatal. Withdrawal symptoms occur when a patient has alcohol use disorder and has developed a tolerance to alcohol, where an increased amount of alcohol is needed to achieve the desired effect. When tolerance has developed, cessation leads to withdrawal. Early symptoms of alcohol withdrawal include anxiety, irritability, headache, tremor, tachycardia, hypertension, hyperthermia, and hyperactive reflexes. Seizures (usually grand mal) can develop between 12-24 hours after withdrawal starts. After 24-72 hours, life-threatening delirium tremens may occur, which manifests with signs of altered mental status, hallucinations and marked autonomic instability. Treatment of alcohol withdrawal involves giving a benzodiazepine (e.g. diazepam) until symptoms lessen and then tapering the dosage over days to weeks. Thiamine, folic acid, and vitamin B12 are also administered and any electrolyte abnormalities are corrected (typically low potassium and magnesium). Following withdrawal, the patient should be referred to support groups. Long term medication used to deter use of alcohol include naltrexone, disulfiram, and acamprosate. Admit the patient and start disulfiram (B) is incorrect because the patient needs a benzodiazepine medication to prevent delirium tremens and potentially fatal consequences. Disulfiram is a medication used in some patients for long-term adherence to alcohol abstinence. Ingestion of alcohol while taking disulfiram causes copious vomiting and potentially more severe reactions. Discharge the patient with a prescription for diazepam (C) or disulfiram (D) is incorrect because alcohol withdrawal is potentially lethal and this patient should be admitted

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

Correct Answer A) Bipolar I Explanation: Bipolar disorder is characterized by manic or hypomanic behaviors that are sometimes accompanied by a depressive disorder. Onset is usually in late childhood and early adolescence, and there is no sex or race predilection. Bipolar type I is defined as at least 1 manic episode with or without major depression. Bipolar type II is defined as at least 1 hypomanic episode with a major depressive episode. A manic episode is defined as at least 1 week of at least 3 of the following findings that cause a marked occupational or social disturbance or an unequivocal uncharacteristic change in functioning or necessitates hospitalization: inflated self-esteem/grandiosity, decreased need for sleep, more talkative, flight of ideas/racing thoughts, distractibility, increased goal-directed activity or psychomotor agitation, excessive involvement in pleasurable activities that likely having poor repercussions. Patients with bipolar disorders have higher rates of general medical conditions and other mental health disorders. First-line treatment involves mood stabilizers with lithium, valproic acid, carbamazepine, lamotrigine, or atypical antipsychotics. Mood stabilizers treat at least one phase of bipolar disorder (mania or depression) without worsening the other phase. Antidepressants are not mood stabilizers and can precipitate mania. Behavioral therapy is also useful in the treatment of bipolar disorder. The symptoms of a manic episode of bipolar disorder are expressed in the mnemonic DIG FAST. Bipolar II (B) disorder is a hypomanic episode in a patient with depression without any history of any manic episodes. The above actions clearly indicate a manic, and not hypomanic, episode. A hypomanic episode (C) is defined as at least 3 of the manic episode symptoms that lasts at least 4 days and is not severe enough to cause marked social or occupational functioning or hospitalization. Not being able to pay a mortgage is a marked social disturbance. Majordepression (D) is defined as five or more of the following, with at least one of the five being either depressed mood or loss of interest/pleasure, present during the same 2-week period: depressed mood most of the day, marked decreased interest/pleasure in most daily activities, weight loss when not trying to lose weight, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue/loss of energy, feelings of worthlessness or excessive guilt, decreased concentration or indecisiveness and recurrent thoughts of death or recurrent suicidal ideation or suicide attempt or plan for suicide. This patient's actions do not match an acute flare of depression.

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

Correct Answer A) Bupropion Explanation: Bupropion should be avoided in patients with a history of anorexia nervosa. Cigarette use is the most common preventable cause of mortality in the United States. Almost 70% of patients who smoke say that they want to quit. There are two different types of pharmaceutical methods for helping patients quit smoking: nicotine replacement therapy (NRT) and the centrally-acting medications, varenicline and bupropion. First-line treatment for tobacco abuse is combination of NRT and either varenicline or bupropion. In the United States, NRT options include nicotine patches, lozenges, gums, nasal sprays, and inhalers. The most common side effects associated with NRT are local irritation, headache, and gastrointestinal symptoms (e.g. nausea, vomiting, diarrhea, and abdominal pain). NRT is safe to use in patients with stable cardiovascular disease. Varenicline is a partial nicotinic receptor agonist, thereby reducing nicotine withdrawal symptoms. Varenicline should be started one week prior to the anticipated start date. Varenicline is almost entirely excreted by the kidney and requires dose reduction in patients with moderate renal dysfunction. Neuropsychiatric side effects are a potential side effect of varenicline, although evidence regarding this side effect are mixed. Varenicline is not recommended in patients with a history of unstable psychiatric status or recent suicidal ideation. All patient started on varenicline should be monitored for anxiety, depression, agitation, irritability, or suicidal ideation. Bupropion is an atypical antidepressant that enhances central nervous system noradrenergic and dopaminergic release. Bupropion also has the potential side effect of neuropsychiatric symptoms and patients should be monitored closely when treatment is initiated. Bupropion is contraindicated in patients with a seizure disorder or a history of anorexia nervosa. Bupropion is often used in patients who are concerned about gaining weight after quitting. Insomnia, agitation, and dry mouth are the most common side effects of bupropion. Buspirone (B) approved for the treatment of anxiety and is used off-label as an atypical antidepressant. Buspirone use is contraindicated in patients who are on or have used monoamine oxidase inhibitors (MAOIs) within the previous 2 weeks. Dizziness and drowsiness are the most common side effects of buspirone. Buspirone is not used for smoking cessation. Varenicline (C) is used for smoking cessation, but can be used in patients with a history of anorexia nervosa. Venlafaxine (D) is a serotonin-norepinephrine reuptake inhibitor that is used to treat major depression, generalized anxiety disorder, social anxiety disorder, and panic disorder. Venlafaxine is contraindicated in patients who take or who have taken MAOIs within the past 2 weeks. Venlafaxine should also be avoided in patients who are taking linezolid. Some of the most common side effects of venlafaxine include headache, insomnia, drowsiness, dizziness, and nausea. Venlafaxine has a black box warning for increased risk of suicide in children, adolescents, and young adults. Venlafaxine is not used for smoking cessation.

Which of the following is consistent with a diagnosis of bulimia? A) Congestive heart failure B) Contraction alkalosis C) Hyperkalemia D) Hypothermia

Correct Answer ( B) Contraction alkalosis Explanation: Bulimia is associated with a number of signs and symptoms as well as laboratory abnormalities. Bulimia is often a more difficult diagnosis to make than anorexia as patients with anorexia have significant weight change while those with bulimia often maintain a normal weight. Patients with eating disorders have high rates of other psychiatric comorbidities. Major depression is seen in up to 80% of patients with anorexia. Substance abuse is more common in bulimia (30-70%) than in anorexia (12-18%). Patients with eating disorders present with vague symptoms including fatigue, dizziness, nausea and generalized weakness. Vomiting in bulimia can cause dysphagia, sore throat and hematemesis. Gastric acid can cause tooth decay from enamel erosion. Additionally, vomiting can cause contraction alkalosis. Hypokalemia, not hyperkalemia (C) is associated with bulimia. Congestive heart failure (A) and hypothermia (D) are seen in anorexia due to caloric restriction.

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

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

Question: Which antidepressant is contraindicated in patients with eating disorders?

Answer: Bupropion

Question: Which smoking cessation medication is recommended for patients who are concerned about post-cessation weight gain?

Answer: Bupropion

Question: What are the two sub types of illness anxiety disorder?

Answer: Care-seeking type and care-avoidant type.

Question: Before what day of abstinence is it rare for delirium tremens to develop?

Answer: Day three.

Question: Which of subtype of delusional disorder is most likely for this patient?

Answer: Jealous type.

Question: What is Russell's sign?

Answer: The presence of calluses on the knuckles that result from induced vomiting in bulimia.

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

Correct Answer C) Conduct disorder Explanation: According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), conduct disorder is characterized by behavior which violates the basic rights of others, societal norms, or age-appropriate rules in a repetitive and persistent manner. At least 3 criteria need to be present for the past 12 months, including bullying or threatening others, deliberate fire setting or destruction of property, staying out past curfew, and truancy from school. These behaviors cause significant impairment in academic, social and occupational functioning and may be specified as occurring with limited pro-social emotions, such as lack of remorse or empathy. Antisocial personality disorder (A) is a diagnosis given to individuals 18 years of age or older who have a history of at least some symptoms of conduct disorder before age 15. Individuals with attention deficit/hyperactivity disorder (B)exhibit behaviors that interfere with functioning, such as inability to pay attention in school or avoiding tasks that require sustained concentration, but do not act in a manner that violates other individual's rights. Conduct disorder and oppositional-defiant disorder (D) may present similarly, but individuals with oppositional-defiant disorder do not engage in destruction of property such as fire setting or graffiti. Symptoms of oppositional-defiant disorder are also less severe than those of conduct disorder.

You are working in the ED when the police bring in a 26-year old man who was involved in a bar fight. The patient is well known to staff as he frequently seeks treatment in the ED for injuries related to fights and alcohol abuse. He has been caught smoking cigarettes in the ED bathroom, has urinated on the floor, and been known to steal food trays and other patients' belongings. As you enter his examination room, you overhear him giving the registration clerk a false identity. Which of the following personality disorders best fits with this patient's behavior? A) Antisocial B) Borderline C) Paranoid D) Schizoid

Correct Answer A) Antisocial Explanation: Individuals with antisocial personality disorder have a blatant disregard for the rights of others (e.g. stealing food trays and other people's belongings) and violate social norms (e.g. urinating on the floor, smoking in a hospital bathroom) and have a lack of remorse for their actions. They often lie and manipulate situations (e.g. give a false identity). They are often aggressive (e.g. get into frequent altercations), irritable, and impulsive, which leads to frequent encounters with law enforcement. This personality can be difficult for emergency physicians, however it is best to set limits, avoid becoming angry, and focus on the chief complaint. Borderline personality disorder (B) is characterized by unstable interpersonal relationships, impulsivity, and a distorted self-image. Paranoid personality disorder (C) manifests as mistrust, hyper-vigilance, and hypersensitivity. Schizoid (D) individuals are socially withdrawn, isolated, and tend to be emotionally apathetic.

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

Correct Answer D) Oppositional defiant disorder Explanation: This child meets the DSM-V criteria for oppositional defiant disorder, defined as a pattern of negative, hostile, and defiant behavior lasting at least 6 months. The child will often lose his or her temper, argue with adults, actively defy or refuse to comply with adults' requests or rules, deliberately annoy people, blame others for their mistakes or misbehavior, be easily annoyed by others, appear angry and resentful, or be spiteful or vindictive. The disturbance in behavior must also cause clinically significant impairment in social, academic, or occupational functioning, and the behaviors must not occur exclusively during the course of a psychotic or mood disorder. Coexisting conditions are common in children with oppositional defiant disorder, particularly ADHD and mood disorders. Research supports outpatient psychological interventions for children with oppositional defiant disorder. Studies have demonstrated that parent training is an effective means of reducing disruptive behavior. Conduct disorder (C) involves more deliberate aggression, destruction, deceit, and serious rule violations, such as staying out all night, animal cruelty, bullying, burglary or chronic school truancy. Meeting the criteria for conduct disorder excludes the diagnosis of oppositional defiant disorder. When conduct disorder is carried into adulthood, it is known as antisocial personality disorder (A). Individuals with antisocial personality disorder display a pervasive pattern of disregard for and violation of the rights of others and the rules of society. The diagnosis of antisocial personality disorder is made only after one is aged at least 18 years, however the features must start to be exhibited by age 15 years or earlier. Bipolar disorder (B) is characterized by symptoms that include periods of mania, hypomania, psychosis, or depression interspersed with periods of relative wellness. Defiance and hostile behavior is not generally seen in bipolar disorder.

A 3-year-old boy from South America presents to your office with his father for a well-child exam. While listening to his lungs you notice that his back is covered with circular lesions approximately 3-4 cm in diameter with central ecchymosis and petechiae. Which of the following is the next best step? A) Ask about traditional medicinal practices being used B) Begin workup for bleeding disorders C) Call child protective services D) Obtain a urinalysis

Correct Answer A) Ask about traditional medicinal practices being used Explanation: A number of cultural practices can mimic signs of child abuse. Cupping is a technique used in Latin America, Asia, the Middle East and Eastern Europe. An open-mouthed vessel is heated and applied to the skin. Practitioners believe this will pull out the ailments and the result is lesions that appear like circular burns. Familiarity with cultural practices and medical conditions that can mimic child abuse can help to determine the correct diagnosis, start appropriate treatment and avoid unnecessary reports to child protective services. Bleeding disorders such as von Willebrand disease, factor VIII and IX deficiency or immune thrombocytopenia can present similarly to bruising caused by child abuse. Workup for bleeding disorder (B) may be appropriate after a complete history including questions about cultural practices is completed. Child protective services (C) should be called once the diagnosis of child abuse has been made and differential diagnoses have been ruled out. When in doubt, involve an interdisciplinary team to help determine the best course of action. Urinalysis (D) should be obtained when the history and physical point to abdominal trauma, dehydration or renal failure as the cause of the lesions.

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

Correct Answer A) Cocaine Explanation: The sympathomimetic toxidrome is seen with the acute abuse of cocaine, amphetamines, or decongestants. Cocainecauses release of dopamine, epinephrine, norepinephrine, and serotonin. The greatest impact comes from the adrenergic stimulation by norepinephrine and epinephrine. Norepinephrine causes vasoconstriction by stimulating alpha-adrenergic receptors on vascular smooth muscle. Epinephrine increases myocardial contractility and heart rate through stimulation of beta-1-adrenergic receptors. In addition to causing catecholamine release, the reuptake of these neurotransmitters is inhibited. Clinically, patients are usually hypertensive and tachycardic and exhibit mydriatic pupils. In massive overdoses, cardiovascular collapse can result in shock and wide-complex dysrhythmias. CNS effects include seizures. Sympathomimetic toxidrome is sometimes difficult to distinguish from anticholinergic toxidrome. The difference is that patients usually present with dry mucous membranes with an anticholinergic overdose, whereas patients are diaphoretic with sympathomimetics. Treatment is usually supportive. Benzodiazepines should be administered for agitation, hypertension, and hyperthermia. Dextromethorphan (B), a common ingredient in cold preparations, shares similar properties to phencyclidine (PCP) and other opioid compounds. It inhibits the uptake of serotonin and blocks the NMDA receptor at the PCP binding site. Clinically, overdose causes lethargy, agitation, dysarthria, ataxia, diaphoresis, hypertension, and nystagmus. At high doses, intoxication resembles that of LSD, with euphoria and hallucinations. Dystonic reactions have been reported in children after therapeutic administration. Because dextromethorphan inhibits the uptake of serotonin, when it is ingested with a serotonin reuptake inhibitor, it can induce serotonin syndrome. Fluoxetine (C) is a selective serotonin reuptake inhibitor (SSRI). In overdose, the increased serotonin has its greatest affect on the gastrointestinal (nausea, vomiting, abdominal pain); cardiovascular (tachycardia, bradycardia, QTc prolongation); and central nervous systems (dizziness, hyper-reflexia, agitation). Overdose of fluoxetine alone rarely produces serotonin syndrome. Phencyclidine (PCP) (D) is a dissociative agent that when smoked, leads to a wide variety of findings. Patients may exhibit bizarre behavior, agitation, and violence. A blank or catatonic stare is common. Vertical, horizontal, and rotary nystagmus is often present.

Which of the following is adequate for a new diagnosis of schizophrenia? A) Delusions and disorganized speech for six months B) Delusions and hallucinations for two weeks C) Flat affect and avolition for two weeks D) Hallucinations and chronic alcohol use

Correct Answer A) Delusions and disorganized speech for six months Explanation: The diagnosis of schizophrenia rests on the presence of a combination of features outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Delusions and disorganized speech for at least 6 months is required to make the diagnosis. It is critical to make sure that a patient without a history of psychiatric illness has a full evaluation and meets these specific criteria because there are organic causes of psychosis that can mimic schizophrenia including meningitis, encephalitis, thyroid disorder, and drug ingestion. Duration of symptoms is one of the vital pieces of the history in making this determination. Delusions and hallucinations are common symptoms seen in schizophrenia but should be present for at least six months, not two weeks (B). Flat affect and avolition (C) for two weeks are symptoms that can be seen schizophrenia but should be present for at least six months. The presence of active substance abuse (D) prohibits making the diagnosis of schizophrenia.

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

Correct Answer A) Escitalopram Explanation: Depression is the most common psychiatric disorder and is frequently seen in the primary care setting. Adults should be screened for depression by their primary care providers when staff-assisted care supports are in place which allow for accurate diagnosis, treatment and follow up. Diagnosis of clinical depression relies on the history and physical examination. Diagnostic criteria for a major depressive episode includes five or more symptoms present during a two week period which represents a change from previous functioning. At least one of the symptoms must be depressed mood or loss of interest or pleasure. Other symptoms include weight loss or gain, increase or decrease of appetite, insomnia or hypersomnia, fatigue or low energy, difficulty concentrating, feelings of worthlessness or guilt, and thoughts of death or suicide. First-line treatment for depression is pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) such as escitalopram, psychotherapy, or a combination of both. Imipramine (B) is a tricyclic antidepressant. Tricyclic antidepressants are generally not used as first-line treatment for depression because of side effect profile and concerns for safety related to overdose. Lithium (C) is used in the treatment of bipolar disorder. Risperidone (D) is a second generation antipsychotic used in the treatment of schizophrenia and bipolar disorder.

Which of the following clinical scenarios in a patient with chronic ethanol use should prompt admission to the hospital? A) Fever, tachycardia, hypertensionCorrect Answer B) Intoxication with vomiting C) Mild tachycardia, tongue fasciculations D) Normal vital signs, one seizure six hours ago

Correct Answer A) Fever, tachycardia, hypertensionCorrect Answer Explanation: The spectrum of illnesses related to chronic alcohol use is quite broad and frequently encountered in the ED. Acutely intoxicated patients are common in urban settings and require monitoring for clinical sobriety and safety prior to discharge. Patients may request admission for detoxification in the setting of cessation of alcohol use. When alcohol use is abruptly stopped or markedly decreased, patients may develop alcohol withdrawal with mild symptoms, alcohol related seizures or in the most serious and life-threatening form of withdrawal, delirium tremens. The patient described here has several abnormal vital signs (fever, tachycardia, hypertension). These abnormalities are concerning for major alcohol withdrawal which is a constellation of symptoms which may include anxiety, irritability, tremors, tachycardia, fever, hypertension, decreased seizure threshold and both auditory and visual hallucinations. In its most severe form, patients develop delirium tremens, which is a severe hyper-adrenergic state with confusion, hallucinations and hemodynamic instability. This condition is life-threatening and requires aggressive treatment with benzodiazepines and possibly antipsychotics. Intoxication with vomiting (B) is a common presentation in both chronic alcohol users and binge drinkers. It is important to recognize that alcohol intoxication is a diagnosis of exclusion as the cause of a patient's altered mental status. Routine investigations include fingerstick glucose, careful history and an assessment for trauma. In most cases of intoxication, patients are monitored for clinical sobriety or metabolization of the ethanol intoxication. Attention is paid to the ability of a patient to maintain an adequate airway, especially in the context of vomiting. A patient with mild tachycardia and tongue fasciculations (C) is consistent with mild alcohol withdrawal. Patients may also develop nausea, a coarse tremor, insomnia and some hypertension. With treatment and observation for 4 to 6 hours in the ED, patients may be eligible for discharge. A patient with normal vital signs and a seizure 6 hours ago (D) is unlikely to have seizures related to severe alcohol withdrawal. Alcohol-related seizures are common. First time seizures should have the usual seizure evaluation including measurement of electrolytes and neuroimaging. If a patient had an isolated seizure and is seizure-free for a period of 6 hours without signs of ongoing withdrawal, they are eligible for discharge from the ED.

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

Correct Answer A) Librium (chlordiazepoxide) Explanation: Abrupt cessation of alcohol intake in a chronic alcoholic can lead to alcohol withdrawal syndrome. A history and physical is usually all that is necessary to make a diagnosis. Ethanol withdrawal is characterized by a autonomic hyperactivity (diaphoresis, tachycardia), hand tremor, insomnia, nausea, vomiting, hallucinations (visual), anxiety psychomotor agitation and seizures. Treatment includes monitoring, serial Clinical Institute Withdrawal Assessment for Alcohol (revised) (CIWA-Ar) testing and long acting benzodiazepines like chlordiazepoxide or diazepam. Haloperidol (B) can be used to treat agitation and hallucinations of alcohol withdrawal syndrome, however, it can lower the seizure threshold. This would not be prudent in a patient with possible recent seizure activity. Phenytoin (C) does not treat alcohol withdrawal syndrome seizures, however, it may be considered as adjuvant therapy in a patient with a documented seizure disorder. The atypical antipsychotic quietiapine (D) is not used in the treatment of alcohol withdrawal hallucinations.

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

Correct Answer B) Avoidant personality disorder Explanation: Avoidant personality disorder is characterized by this patient's symptoms of low self-esteem and desire for relationships which remains fruitless due to persistent fear of rejection. Other symptoms of avoidant personality disorder include a hypersensitivity to criticism and failure, often making patients unable to hold jobs and maintain relationships. Personality disorders in general are present in patients from the time of their childhood, and may have resulted in development of recurrent maladaptive behaviors to cope with impaired personality traits. When maladaptive coping skills eventually prove unable to allow the patient to navigate their responsibilities and relationships successfully, anxiety and depression often present. Without proper management, psychosis may even develop. The cornerstone of treatment for personality disorders includes regular behavior therapy to extinguish inappropriate behaviors, and allow patients to recognize appropriate behaviors. Group psychological counseling is often helpful. Medical therapy is targeted at symptoms and can include antipsychotics, anxiolytics, and selective serotonin reuptake inhibitors. Antisocial personality disorder (A) typically manifests as pervasively selfish, callous, and impulsive actions. Patients may have frequent legal problems and demonstrate an inability to learn from negative experiences. Low self-esteem and fear of rejection are not prominent features. Dependent personality disorder (C) is characterized by low self-confidence. However this personality disorder centers more on extreme passivity in relationships and a need for others to make decisions for the patient. Paranoid personality disorder (D), while characterized by an overarching tendency to anxiety and hypersensitivity, usually causes patients to be abnormally suspicious, hyper-alert, and often defensive toward those around them.

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

Correct Answer B) Biological mothers Explanation: This caregiver is exhibiting behavior consistent with factitious disorder imposed on another. Factitious disorder imposed on another is characterized by the production or feigning of physical or psychological symptoms in another person, usually a child but may also be an adult under the care of the person with the disorder.Common presentations of this disorder include bleeding, seizures, poisoning, apnea, altered mental status, diarrhea, vomiting, fever, rash, hypoglycemia, hematuria, or recurrent infections often with unusual organisms. Warning signs that raise the possibility of this disorder include unexplained, persistent, or recurrent illnesses, discrepancies among the history, clinical findings, and patient's general health, symptoms and signs that occur only in the caregiver's presence, a caregiver who is extremely attentive and always in the hospital, or a caregiver who appears less worried about the patient's illness than about the medical staff. Ninety-eight percent of perpetrators are biological mothers from all socioeconomic groups. Many have a background in health professions or social work. Depression, anxiety, and somatization are common in the perpetrator population and many have a history of an abusive experience in the past. During clinical assessment of the victim in a case of factitious disorder imposed on another, clinicians should have a high index of suspicion. The provider should document inconsistencies of the caregiver's story with the patient's condition, lack of objective diagnostic evidence, lack of witnessing any symptoms, caregiver's response to negative testing, and whether treatment is provided for objective reasons or to meet the caregiver's demands. Treatment of factitious disorder imposed on another involves treating the victim, the perpetrator, and the family. These patients should universally be admitted to the hospital when the diagnosis of factitious disorder imposed on another is suspected in order to observe the caregiver-patient interaction, closely observe the suspected perpetrator, and determine the temporal relation between the symptoms and the perpetrator's presence. While adoptive fathers (A), foster parents (C), and older siblings (D) may all develop factitious disorder imposed on another, it is found primarily in biological mothers, accounting for 98% of cases.

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

Correct Answer B) Citalopram Explanation: Depression is a very common mental health complaint seen in primary care. Diagnosis of depression is made when patients have at least one episode of major depression and no history of mania or hypomania. An episode of major depression lasts at least two weeks and includes having five or more symptoms of depression including anhedonia, depressed mood, change in appetite or weight, insomnia or hypersomnia, low energy, inability to concentrate, feeling guilty or worthless, and thoughts of death or suicide. Selective serotonin reuptake inhibitors (SSRIs), such as citalopram, are considered first-line pharmacologic treatment for adults with depression. Initial treatment for patients with depression should include both psychotherapy and pharmacotherapy with SSRIs. Amitriptyline (A) is a tricyclic antidepressant. Tricyclic antidepressants were considered first-line before SSRIs were developed and are still used to treat depression as well as other mental health disorders and chronic pain. Olanzapine (C) is an atypical antipsychotic and is not used as first-line pharmacotherapy in the treatment of depression. Phenelzine (D) is a monoamine oxidase inhibitor and is not used as first-line treatment for depression due to having an extensive side effect profile, dietary restrictions and numerous drug-drug interactions. Monoamine oxidase inhibitors do play a role in treating atypical depression or depression that is resistant to treatment.

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

Correct Answer B) Death of a child Explanation: Prolonged or complicated grief is characterized by persistent, disruptive emotional responses for at least six months after the death of a loved one. Risk factors include death of a child, past history of mental health issues, dependent relationship with the deceased, and poor social supports. Symptoms include difficulty with moving on and accepting the death, bitterness, numbness or detachment, agitation or being on edge, lack of trust, feelings of emptiness, and a sense that the future holds no meaning. Prolonged or complicated grief can lead to bereavement-related depression or medical sequelae such as exacerbation of chronic disease and substance abuse. Complicated grief can be difficult to differentiate from depression, therefore patients meeting criteria for complicated grief should be referred to a psychiatrist for evaluation. Providers should also encourage individuals with complicated grief to practice self-care, develop new routines and relationships, and provide referrals to support groups. Crying uncontrollably (A), insomnia (C) and visual hallucinations (D) are all normal grief reactions. Reactions to grief come in waves, with individuals feeling good one day and extremely sad the next. The distressing emotions of normal grief slowly decrease in intensity, with the individual eventually coming to accept the loss. Impairments caused by grief reactions begin to resolve by six months, although important events such as birthdays and anniversaries may cause grief reactions to return for years after the death.

Which of the following is most consistent with alcohol withdrawal? A) Agitation and increased appetite B) Delirium, hallucinations, tremor C) Depressed mood with diarrhea D) Dilated pupils, runny nose and watery eyes

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

Which of the following is the most common manifestation of abusive head trauma in infants? A) Epidural hematoma B) Retinal hemorrhage C) Subarachnoid hemorrhage D) Subdural hematoma

Correct Answer B) Retinal hemorrhage Explanation: Abusive head trauma (previously referred to as shaken baby syndrome) is a form of inflicted head trauma and the leading cause of child abuse fatalities. It is a well-recognized clinical syndrome caused by violent shaking of infants, direct blows to the head, dropping or throwing a child, and asphyxia. It typical occurs in infants younger than 1 year, but may be seen in children up to 3 years old. The classic constellation of abusive head trauma includes subdural hematoma, traumatic brain injury, and retinal hemorrhages. Retinal hemorrhages are present in up to 75% of cases and are virtually pathognomonic. Absence of retinal hemorrhage does not rule out child abuse. The pathophysiology of retinal hemorrhages is uncertain. It is unclear whether bleeding is a result of increased intracranial pressure transmitted to the eye or occurs directly within the eye itself, perhaps through increased pressure along the retinal vein with subsequent disruption of the vessel. Retinal hemorrhages may involve the area in front of the retina (preretinal hemorrhages), the vitreous, and the subretinal space in addition to the retina. Hemorrhages may be described as "dot and blot" hemorrhages or flame or splinter hemorrhages. Epidural hematoma (A), subarachnoid hemorrhage (C), and subdural hematoma (D) all occur in abusive head trauma but less often than retinal hemorrhages do.

Which one of the following cardiac rhythm abnormalities is most common in patients with anorexia nervosa? A) Atrial fibrillation B) Sinus bradycardia C) Sinus tachycardia D) Ventricular fibrillation

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

A 27-year-old woman presents with symptoms of excessive eating followed by vomiting. Her BMI is 29 kg/m2 and her teeth are eroded. Which of the following is the most likely diagnosis? A) Anorexia nervosa B) Binge eating disorder C) Bulimia nervosa D) Purging disorder

Correct Answer C) Bulimia nervosa Explanation: Bulimia nervosa is a psychological disorder characterized by excessive eating followed by a compensatory behavior in an attempt to lose weight (e.g., vomiting or using laxatives). It is most commonly seen in womenapproximately 20 years of age and often accompanies other psychological disorders (e.g., anxiety, depression, and suicidality). Patients with bulimia nervosa have a range of body mass indexes from normal to obese, and they often restrict their caloric intake between their binge episodes in order to maintain or lose body weight. Patients present with tachycardia, hypotension, dry skin, and eroded tooth enamel. They are often anxious or suicidal. Assessment should include both a general examination as well as a psychiatric examination. Complications of bulimia nervosa include gastrointestinal disorders, dehydration, and type 2 diabetes mellitus. Treatment includes nutritional counseling, medical management, cognitive behavioral therapy, and pharmacologic therapy. Anorexia nervosa (A) is an eating disorder defined as low body mass index, fear of gaining weight, and a distorted perception of body weight. Patients with this disorder do not intake an adequate amount of calories and lose weight by purging or excessive exercise. Co-morbidities often include a history of other psychiatric disorders and suicidality, and patients are typically thin with dry skin and hair loss, and women have amenorrhea. Binge eating disorder (B) is the overly excessive intake of food due to patients feeling they do not have control over what they are eating. Patients typically eat until they are excessively full, they eat large amounts of food when not hungry, and they are embarrassed afterwards. In binge eating disorder, there is no act of purging after eating. Co-morbidities include psychiatric disorders and type 2 diabetes. Purging disorder (D) is characterized by compensatory actions to control weight, such as self-induced vomiting or laxatives in the absence of excessive binge eating. Patients typically present with a normal body mass index, swollen gums, and eroded teeth enamel.

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

Correct Answer C) Delusional disorder Explanation: Delusional disorder is the presence of one or more delusions for a month or longer in a person who, except for the delusions and their behavioral ramifications, does not appear odd and is not functionally impaired. Prominent hallucinations and other psychotic or marked mood symptoms are absent. People with delusional disorder typically reject the characterization of their beliefs as false. They generally have no insight into their illness. Comorbidities are common, especially depression and anxiety. The onset of delusional disorder can be acute. Subtypes of delusional disorder include erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified types. First-line treatment of delusional disorder is usually with antipsychotic medication. Because many patients reject medication, psychotherapy is also appropriate. Bipolar disorder (A) would require at least one episode of mania with possible episodes of major depression. Brief psychotic disorder (B) occurs when delusions or psychotic symptoms last less than one month. For schizophrenia (D) to be diagnosed, the patient would require at least one more psychotic behavior pattern in addition to delusions, such as hallucinations, disorganized speech or behavior, or negative symptoms, such as diminished emotional expression.

Which of the following represents the classic order of the stages of grief? A) Anger, denial, bargaining, depression, acceptance B) Bargaining, anger, denial, depression, acceptance C) Denial, anger, bargaining, depression, acceptance D) Depression, denial, anger, bargaining, acceptance

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

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

Correct Answer C) Fluoxetine Explanation: Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating and inappropriate compensatory behavior such as self-induced vomiting or laxative abuse. For diagnosis, the behaviors must occur at least once per week for 3 months. Individuals feel out of control with their behaviors and are overly concerned with their physical appearance and weight. Treatment for bulimia nervosa includes psychotherapy, nutritional rehabilitation, pharmacotherapy and management of medical complications. The selective serotonin reuptake inhibitor (SSRI) fluoxetine is the only SSRI approved for use in treating bulimia nervosa. The tricyclic antidepressant desipramine (A) is a third-line option for the treatment of bulimia nervosa. Diazepam (B)and lorazepam (D) are benzodiazepines, which have no role in the treatment of bulimia nervosa.

A 35-year old man believes he has colon cancer. He reports that his "peristalsis is louder than usual" and he has "excessive flatulence." He shows you a logbook that he has been keeping of his bowel habits for the last six months. He denies weight loss, fatigue, night sweats, blood in his stool, or family history of colon cancer. He is having difficulty sleeping. What is the most likely diagnosis? A) Body dysmorphic disorder B) Conversion disorder C) Illness anxiety disorder D) Somatization disorder

Correct Answer C) Illness anxiety disorder Explanation: The patient is suffering from illness anxiety disorder. This was a new diagnosis that was introduced with DSM-5 it replaced reactive hypochondriasis. Patients that were previously diagnosed with reactive hypochondriasis will now be classified as somatic symptom disorder or illness anxiety disorder. Most patients fall under the somatic symptom disorder diagnosis. If the patient complains predominantly of physical symptoms the patient has somatic symptom disorder. Patients that have minimal physical symptoms have illness anxiety disorder. The patient will have excessive worry about having or acquiring a serious undiagnosed general medical disease. If there are physical symptoms present it is typically due to an exaggeration of normal body functions. It is typically chronic in nature Body dysmorphic disorder (A) is the preoccupation with an imagined physical defect or a real, although minor defect that is exaggerated (such as a large nose). Conversion disorder (B) is characterized by abnormalities or deficits of motor or sensory function that are not medically explained, such as blindness, seizure, paresis, paralysis, tremors, aphonia or anesthesia. Classically symptoms occur suddenly following a psychosocial stressor and are non-painful. Somatization disorder (D) begins before 30 years of age and manifests as multiple, unexplained physical complaints (four pain symptoms, two gastrointestinal symptoms, one sexual symptom, and one neurologic symptom).

Which of the following medications can be prescribed to assist in weight gain for a patient with anorexia nervosa? A) Alprazolam B) Fluoxetine C) Olanzapine D) Risperidone

Correct Answer C) Olanzapine Explanation: Olanzapine is an atypical antipsychotic that is typically used to treat bipolar disorder or schizophrenia but has also been shown to cause weight gain in those with anorexia nervosa. Pharmacotherapy has not been shown to be an effective treatment for anorexia nervosa when used as monotherapy, but for those acutely ill who have not demonstrated a response to psychotherapy and nutritional rehabilitation, olanzapine can be added to the treatment regimen. Alprazolam (A) is a benzodiazepine used to treat anxiety and panic disorder and has been shown to have little effect on weight gain in patients with anorexia nervosa. While this medication can decrease the anxiety associated with eating, it should not be prescribed with the intent to gain weight. Fluoxetine (B) is a selective serotonin reuptake inhibitor that has not been shown to cause weight gain. Fluoxetine can be used as treatment for bulimia nervosa to help prevent binge eating but is not beneficial for anorexia nervosa. Risperidone (D) is an atypical antipsychotic used to treat bipolar disorder and schizophrenia. Unlike olanzapine, risperidone does not have a side effect of weight gain and therefore should not be used as treatment for anorexia nervosa.

Which of the following factors predicts the highest risk of suicide completion? A) Female gender B) Married relationship status C) Substance abuse D) Unemployment

Correct Answer C) Substance abuse Explanation: Suicidal ideation is very common with up to one-third of the population experiencing it in their lifetime. Suicide rates vary with multiple factors including age, gender, race, and marital status. Females attempt suicide three to four times more often than men, but men are more successful in suicide completion. Up to one-quarter of suicides by men are successful as opposed to 5% in women because men tend to use more violent methods. Patients with active substance abuse, including alcohol, are among the highest risk for suicide completion. Other very high risk groups include those with underlying psychiatric disorders, adolescents, elders, and patients with some chronic illnesses. A history of prior suicide attempt raises the risk significantly although 60-70% of successful suicides occur in individuals without any previous attempt. Additionally, the presence of a firearm in the household is an independent risk factor. Unemployment (D) appears to be a risk factor for suicide in 18 to 24 year old men as the highest risk. It does slightly increase the risk in other age groups. Females (A) attempt suicide more often than men but are less successful in completing the attempt. Pregnant women and mothers are at lower risk than others. Being married (B) is protective against suicide. Those at highest risk are single persons or those who are separated, widowed or divorced.

During an intake history, a patient describes her husband as a violent, angry man. You suspect domestic violence of a physical nature. You counsel the woman that serious injury or death most commonly occurs during which of the following situations? A) After an argument about financial issues B) After an argument about sex-life issues C) When she tries to leave the husband D) When the husband tries to apologize for his actions

Correct Answer C) When she tries to leave the husband Explanation: Domestic abuse, also known as domestic violence, spousal abuse or intimate partner violence, is a behavior pattern in which the abuser displays any of the following against a partner: aggression, assault, control, intimidation, stalking, sexual abuse, mental or psychological abuse or economic deprivation. Three phases of abuse have been described. The tension building phase is characterized by poor communication, tension and fear. This is followed by a violent phase or episode. The honeymoon phase then follows, and is characterized by the abuser offering apology, sympathy, affection and remorse. In those abused, especially if they continue to live with the abuser, a high incidence of psychological disorders exists, and includes, stress, fear, generalized anxiety disorder, panic disorder, depression, suicide and post-traumatic stress disorder. One study shows 60% of victims meet the diagnostic criteria for depression, either during or after termination of the relationship. Physical abuse can occur during a relationship. However, assaults occur more commonly near the end of relationships. Up to 75% of domestic assaults occur during an attempt to report abuse or leave an abusive relationship. Common occurrences in domestic violence marriages include arguments about financial issues (A), arguments about sex-life issues (B) and apologizes from the husband after his actions (D). They are, however, not the most common situations that lead to significant physical assault or death.

Which of the following distinguishes conduct disorder from oppositional defiant disorder? A) Angry and resentful B) Argues with adults C) Deliberately trying to annoy someone D) Physical aggression towards others

Correct Answer D) Physical aggression towards others Explanation: Conduct disorder can be distinguished from oppositional defiant disorder by the presence of physical aggression and other severe forms of antisocial behavior. Conduct disorder is characterized by a persistent pattern of serious rule-violating behavior, including behaviors that harm (or have the potential to harm) others. The patient with conduct disorder typically shows little concern for the rights or needs of others. The symptoms of conduct disorder are divided into 4 major categories: (1) Physical aggression to people and animals including bullying, fighting, weapon carrying, cruelty to animals, and sexual aggression; (2) Destruction of property, including fire setting and breaking and entering; (3) Deceitfulness and theft; and (4) Serious rule violations, including running away from home, staying out late at night without permission, and truancy. To meet the diagnosis, >3 of these symptoms must be present at least 1 year (1 or more in the past 6 months) and must impair the youth's function at home, at school, or with peers. The onset of conduct disorder may occur in early childhood but usually occurs in late childhood or adolescence. In a majority of patients, the disorder remits by adulthood. A substantial fraction of patients develop antisocial personality disorder as adults. Early onset of conduct disorder, along with high frequency of diverse antisocial acts across multiple settings, predicts a worse prognosis and increased risk for antisocial personality disorder. Patients with conduct disorder also are at risk for the development of mood, anxiety, somatoform, and substance-use disorders in adulthood. Being angry and resentful (A), arguing with adults (B), deliberately trying to annoy someone (C) are some of the criteria for oppositional defiant disorder. Oppositional defiant disorder is characterized by a persistent pattern of angry outbursts, arguing, vindictiveness, and disobedience, generally directed at authority figures (such as parents and teachers). To meet the diagnosis, >4 of these types of behavior must be more frequent and more severe than children of a given developmental stage normally exhibit (especially when tired, hungry, or under stress), must be present at least 6 months, and must impair the youth's function at home, at school, or with peers.

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

Correct Answer D) Posttraumatic stress disorder Explanation: Posttraumatic stress disorder (PTSD) is a long-lasting anxiety response following a traumatic or catastrophic event. Although most people encounter trauma over a lifetime, about 20-30% develop PTSD but over half of these people will recover without treatment. Prediction models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD. Other risk factors include military experiences, war-zone exposure, domestic violence, and foster care. PTSD often leads to patients having difficulty falling or staying asleep, problems with concentration, hypervigilance, irritability, angry outbursts, and increased startle response. The patient in the above clinical scenario is a refugee from a conflict region and exhibits symptoms consistent with PTSD (anger, irritability, and hypervigilance). An important management principle when caring for a patient with PTSD is to ensure his or her safety and to validate his or her symptoms. Detailed questioning should be avoided as it may trigger severe symptoms. Borderline personality disorder (B) is characterized by unstable personal relationships, unstable self-image, and inappropriate behaviors. Patients with BPD usually present to the ED after deliberate self-injury or suicidal attempts. Malingering (C) is fabricating or exaggerating the symptoms of mental or physical disorders for secondary gain. This may include financial compensation, avoiding school, work or military service, obtaining drugs, getting lighter criminal sentences or to attract attention or sympathy. An adjustment disorder (A) occurs when an individual is unable to adjust to or cope with a particular stressor, like a major life event. The condition is different from anxiety disorder, which lacks the presence of a stressor, or posttraumatic stress disorder that is associated with a more intense stressor.

A 24-year-old veteran presents to clinic with a complaint of difficulty sleeping due to frequent nightmares. He has visual flashbacks and avoids large crowds due to the inability to escape easily. He is nervous, sweating, and startles easily on examination. Which of the following is the most likely diagnosis? A) Agoraphobia B) Generalized anxiety disorder C) Panic disorder D) Posttraumatic stress disorder

Correct Answer D) Posttraumatic stress disorder Explanation: Posttraumatic stress disorder is a cognitive and behavioral psychiatric disorder that is brought on by trauma and is characterized by intrusive thoughts, nightmares, flashbacks, difficulty sleeping, hypervigilance, and avoidance of situations or people who remind the patient of the trauma. Trauma of all types, including sexual, combat, interpersonal relationships, or motor vehicle accidents, can lead to posttraumatic stress disorder. Patients typically complain of flashbacks, severe anxiety, increased startle response and hyperarousal; which ultimately results in loss of interest in activities and detachment from others. Complications of the disease include depression, anxiety, and suicidal and homicidal ideations. Treatment includes psychotherapy and pharmacotherapy with a selective serotonin reuptake inhibitor. Agoraphobia (A) is a type of anxiety disorder that is characterized by the fear and avoidance of places or situations that cause helplessness or embarrassment. While a patient with agoraphobia may avoid large crowds, they typically do not endorse nightmares or flashbacks that hinder their daily lives. Generalized anxiety disorder (B) is characterized by persistent worrying which causes distress and impairs daily activities. Patients may complain of difficulty sleeping, hyperarousal, and muscle tension, but they typically do not endorse flashbacks or nightmares. Panic disorder (C) is characterized by recurrent panic attacks and situational avoidance for fear of future attacks. A panic attack is an episode of intense fear accompanied by cardiorespiratory or gastrointestinal changes, such as shortness of breath, chest pain, nausea, or vomiting. Patients who suffer from recurrence of these attacks will develop a fear of future attacks and will change their behaviors in an attempt to avoid further panic attack episodes. They do not, however, typically complain of nightmares or an increase in the startle response.

Which of the following risk factors is the strongest predictor of suicide? A) Access to firearms B) History of depression C) Male sex D) Prior history of suicide attempts

Correct Answer D) Prior history of suicide attempts Explanation: In the United States there are approximately 10-40 suicide attempts for every completed suicide. Evaluation of risk factors is critical when determining if a patient is at high risk for suicide. Patients with a previous suicide attempt are 5-6 times more likely to attempt suicide again and 50% of individuals who complete suicide have a prior history of at least one suicide attempt. Providers who suspect that a patient may be suicidal should evaluate for suicidal ideation, plan and intent. There is no data to suggest that asking a patient about suicide will initiate a suicidal plan or attempt. Patients deemed high risk for suicide due to risk factors, suicidal ideation, plan or intent should be connected with emergency psychiatric services immediately and monitored for safety. Access to firearms (A) and male sex (C) are risk factors for suicide, but are not the strongest predictors. History of depression (B), schizophrenia and bipolar disorder are the second most common risk factors for suicide after a prior history of attempts. Other risk factors for suicide include substance abuse, hopelessness, impulsivity, single marital status, unskilled occupation, physical illness, family history of suicide, and identification as gay, lesbian, bisexual or transgender.

A 30-year-old woman presents to your office requesting medication to help her quit smoking. Which of the following is a contraindication to prescribing bupropion? A) Cardiovascular disease B) Chronic obstructive pulmonary disease C) Depression D) Seizure disorder

Correct Answer D) Seizure disorder Explanation: Bupropion is one of two pharmacologic agents used for smoking cessation, the other being varenicline. Bupropion is an antidepressant that is believed to enhance central nervous system noradrenergic and dopaminergic release. Patients start the medication one week prior to their quit date then continue the medication for eleven more weeks. Side effects of bupropion include headache, insomnia, agitation and dry mouth. Bupropion decreases the seizure threshold and is therefore contraindicated in patients with seizure disorder or any predisposition to seizures. Patients with stable cardiovascular disease (A) and chronic obstructive pulmonary disease (B) may safely use bupropion. Bupropion is an antidepressant used in patients with depression (C). Bupropion has been associated with an increased risk of suicidal behavior and depression, but less so than varenicline. Discussion with patients about the risks and benefits of this medication should occur and patients should be advised to seek medical attention for any unusual mood symptoms or behavior.

A 29-year-old woman presents to your office with a complaint of worsening anxiety. Which additional finding would suggest a diagnosis of generalized anxiety disorder rather than panic disorder? A) Anxiety occurring more days than not for at least six months B) Changes in personality C) Excessive concern about medically unexplained symptoms D) Frequent periods of intense fear

Correct Answer A) Anxiety occurring more days than not for at least six months Explanation: Generalized anxiety disorder (GAD) is a common psychiatric disorder often seen in the primary care setting. It is characterized by excessive and persistent worrying that occurs more days than not for six or more months. Other clinical manifestations include insomnia, headaches, difficulty relaxing, and fatigue. The anxiety symptoms experienced with GAD are difficult to control and cause significant distress and impairment in activities of daily living. GAD is two times more common in women than in men and is the most common psychiatric disorder seen in the elderly. Diagnosis is determined using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Recommended treatment is with a combination of pharmacotherapy and psychotherapy. Changes in personality (B) and frequent periods of intense fear (D) occur in patients with panic disorder. Excessive concern about medically unexplained symptoms (C) is seen with both GAD and illness anxiety disorder (hypochondriasis). Individuals with GAD generally worry about multiple concerns, whereas individuals with illness anxiety disorder (hypochondriasis) are focused on their perceived medical issues.

Which of the following historical findings will most likely lead to a diagnosis of panic disorder? A) Chest pain B) Flashbacks C) Hyperarousal D) Loss of interest

Correct Answer A) Chest pain Explanation: Chest pain is a symptom that is highly characteristic for panic disorder. A panic attack is an episode of intense fear along with cardiorespiratory, gastrointestinal, or neurologic changes that can persist up to several hours. When these episodes recur and fear of future attacks develops or behaviors are changed for at least one month in an attempt to avoid a panic attack, a diagnosis of panic disorder is made. Patients with panic disorder present with symptoms of chest pain, shortness of breath, nausea, vomiting, headache, dizziness, or fear of dying when the episodes of panic attacks occur. These symptoms are reasons for presentation to a medical professional and diagnosis is made clinically when the physiological changes are not better explained by another psychiatric or medical disorder. Treatment includes supportive measures followed by psychotherapy and pharmaceutical therapeutics to treat anxiety. Flashbacks (B) are symptoms typically of posttraumatic stress disorder. Patients suffering from posttraumatic stress disorder undergo a single or multiple episodes of extreme stress which leads to cognitive and psychological trauma. Symptoms include flashbacks, intrusive thoughts, nightmares, sleep disturbance, and hypervigilance. Patients who suffer from panic disorder typically do not present with complaint of flashbacks. Hyperarousal (C) is defined as psychological or physiological increased tension with symptoms of decreased sleep, decreased pain tolerance, and increased startle response. It is a characteristic of various psychological disorders including generalized anxiety disorder and posttraumatic stress disorder, however, is typically not a finding with panic disorder. Loss of interest (D) is a common finding of major depression disorder, a syndrome of sadness and despair. Patients with panic disorder typically change their behavior in an attempt to avoid a panic attack, but they usually do not complain of loss of interest.

A 19-year-old man presents to the clinic after losing his job a month ago. During your interview, the patient admits to drinking daily. You suspect the patient has alcohol use disorder. Which of the following is a criterion for diagnosis of alcohol use disorder? A) Craving or strong urge to use alcohol B) Drinking at least six alcoholic beverages per day C) Having legal problems related to alcohol use D) Symptoms lasting at least six months

Correct Answer A) Craving or strong urge to use alcohol Explanation: Alcohol abuse and dependence was replaced by alcohol use disorder with the DSM-5 update. Although the crosswalk between DSM-IV and DSM-5 disorders is imprecise, alcohol dependence is approximately comparable to substance use disorder, moderate to severe subtype, while alcohol abuse is similar to the mild subtype. Alcohol use disorder is classified based on severity, mild, moderate, or severe, which correlates to how many DSM-5 criteria are present. Mild severity includes two to three symptoms, moderate severity includes four to five symptoms, and severe includes six or more symptoms. DSM-5 criteria for alcohol use disorder include: recurrent drinking resulting in failure to fulfill major role obligations, recurrent drinking in hazardous situations, continued drinking despite alcohol-related social or interpersonal problems, evidence of tolerance, evidence of alcohol withdrawal or use of alcohol for relief or avoidance of withdrawal, drinking in larger amounts or over longer periods than intended, persistent desire or unsuccessful attempts to stop or reduce drinking, great deal of time spent obtaining, using or recovering from alcohol, important activities given up or reduced because of drinking, continued drinking despite knowledge of physical or psychological problems cause by alcohol, and craving or having a persistent urge to drink alcohol. There are higher rates of alcohol abuse associated with young people, males and Native Americans. Drinking at least six alcoholic beverages per day (A) is not required for a diagnosis of alcohol use disorder. There is no minimum amount of alcohol consumption needed for diagnosis. Having legal problems related to alcohol use (C) was previously part of the DSM-IV criteria for alcohol abuse but was removed from the DSM-5 criteria. Patients need to have symptoms of alcohol use disorder for at least 12 months, not six months (D), to meet criteria for diagnosis.

A previously healthy 52-year-old woman presents to your office with a complaint of diffuse pruritus. She is concerned about insects under her skin. She brought a sample of her skin mixed with debris that she believes are the insects. She is requesting that you send it to the lab. Physical exam reveals scattered ulcers and erosions in varying stages of healing with excoriations all over her body. Which of the following is the most effective management? A) Establish a strong therapeutic allianceCorrect Answer B) Permethrin cream as needed C) Referral to psychiatryYour Answer D) Referral to substance abuse treatment

Correct Answer A) Establish a strong therapeutic allianceCorrect Answer Explanation: Delusions of parasitosis (DoP) is a delusional disorder involving the firm belief by the patient that the pruritus is caused by an infestation of insects or parasites. Patients present with self-inflicted skin manifestations from scratching or digging and may bring a sample of debris, lint, or pieces of skin that they say contain the insects or parasites. Diagnosis involves excluding any true skin infestations, such as scabies, as well as ruling out systemic disease that may cause pruritus. Once a physical etiology has been excluded, diagnosis is through meeting criteria established by the Diagnostic and Statistical Manual of Mental Disorders (DSM). Initial management is by establishing a strong therapeutic alliance with the patient and respecting the patient's autonomy in all encounters. First-line pharmacologic treatment is with antipsychotic medications. In treating DoP, it is important that the medical provider does not offer treatment that will strengthen the patient's delusion, such as prescribing permethrin as needed (B). A referral to psychiatry (C) is an appropriate part of the management of DoP, but should only be done once a therapeutic alliance has been established since initially patients will not accept that their symptoms are due to a psychiatric etiology. Substance abuse should be ruled out as a possible cause of symptoms, but this may be done as part of the history in the outpatient setting and a referral to substance abuse treatment (D) is only necessary if the patient has a substance abuse disorder.

A four-year-old boy is seen in your office for routine physical. His mother is concerned that he is not speaking like a normal four year old. On further evaluation, you notice he has poor eye contact and rapid hand movements, and he is preoccupied by repeatedly spinning the wheels on the toy cars he brought with him. What is the most likely diagnosis? A) Attention deficit hyperactive disorder B) Autism spectrum disorder C) Expressive speech delay D) Obsessive compulsive disorder

Correct Answer B) Autism spectrum disorder Explanation: Autistic disorder is a clinical diagnosis. The core features include impaired social interactions, communication, and behavior. Early social skills deficits include poor eye contact, lack of interactive play, and lack of interest in other children. Children can range from being nonverbal to having impaired speech. Their speech may have odd intonation and be characterized by echolalia. Language delay becomes a concern when there is lack of babbling or gestures by 12 months, lack of single words by 16 months, absent two-word phrases by 24 months, and any loss of language skills at any time. Children with autism often have abnormal play skills. They have a preoccupation with parts of objects like the child in this vignette. These children are withdrawn and can spend hours playing alone. Intellectual skills can vary, and some children may show normal or even accelerated development in certain areas. Attention deficit hyperactivity disorder (A) is not associated with the behavior and language deficits described in this vignette. The child in this vignette may have expressive speech delay (C); however, his behavior characteristics are more consistent with an autism spectrum disorder. This child's behavior is not typical of an obsessive compulsive disorder (D).

A 23-year old woman presents to the ED after taking six multivitamin tablets after her "boyfriend" threatened to break up with her. She just started dating him last weekend and "knows he is the one." She has been treated for multiple sexually transmitted infections in the past and admits to multiple "one-night stands." She has multiple shallow, linear scars on her forearms consistent with self-inflicted cutting. When you enter her examination room, she is upset and crying into the phone saying, "my nurse hates me." When asked why she feels this way, she tells you "the nurse said she would get me a blanket, but never came back." Which of the following personality disorders does this patient most likely have? A) Antisocial B) Borderline C) Paranoid D) Schizoid

Correct Answer B) Borderline Explanation: Individuals that suffer from borderline personality disorder are emotionally unstable, develop unstable interpersonal relationships (e.g. labile relationship with new "boyfriend"), and tend to participate in impulsive behaviors (e.g. suicide gestures, frequent "one-night stands"). They often have an intense fear of abandonment (e.g. suicidal gesture when boyfriend threatens to leave, overreaction to nurse not returning with a blanket). They possess a distorted self-image, often feeling worthless and flawed (e.g. nurse must hate her when she didn't come back with the blanket) and tend to inflict self-harm (e.g. self-inflicted cutting). Individuals with antisocial personality disorder (A) have a blatant disregard for the rights of others, violate social norms, and have a lack of remorse for their actions. They often lie and manipulate situations. They are often aggressive, irritable, and impulsive, which leads to frequent encounters with law enforcement. Paranoid personality disorder (C)manifests more as mistrust in others, hyper-vigilance, and suspiciousness. They tend to bear grudges, be overly sensitive, and are easily slighted. People with schizoid personality disorder (D) are socially withdrawn, isolated, prefer to live alone and lead solitary lifestyles. They are classically described as "loners" as they have very few close interpersonal relationships. Because they do not openly display their emotions, they tend to be perceived as emotionally cold, aloof, and apathetic.

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

Correct Answer B) Citalopram Explanation: Panic disorder is a psychiatric illness characterized by recurrent episodes of panic attacks. Panic attacks are periods of intense fear with specific symptoms that develop quickly and peak less than 10 minutes from the onset of the attack. Symptoms include sweating, chest pain, heart palpitations, shaking, fear of losing control, fear of dying, perceived shortness of breath, nausea, dizziness, chills or hot flashes. Panic disorder often occurs co-morbidly with other psychiatric disorders, such as major depressive disorder, schizophrenia, obsessive-compulsive disorder, agoraphobia, and social phobia. Women experience panic disorder two to three times more frequently than men. Development of panic disorder generally occurs between ages 18-45 years, with the average age being 24 years. Diagnosis is determined using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Initial treatment for panic disorder is with an antidepressant, cognitive behavioral therapy, or a combination of the two. When a decision is made to treat with medication, first-line treatment is with a selective serotonin reuptake inhibitor (SSRI), such as citalopram. There is no evidence to support the use of anticonvulsants, such as carbamazepine (A) in the treatment of panic disorder. Tricyclic antidepressants, such as imipramine (C) are sometimes used, but because of their substantial side effect burden and poor tolerance they are not first-line agents. Second-generation antipsychotics, such as risperidone (D) are not recommended in the treatment of panic disorder due to concern about side effects.

A 24-year-old previously healthy woman presents to the ED complaining that she cannot move her legs. The symptoms occurred suddenly after she was told that her fiancé died in a motorcycle accident. She denies any associated symptoms, including pain. The sensation and deep tendon reflexes in her lower extremities are normal. She has normal muscle tone. What is the most likely diagnosis? A) Body dysmorphic disorder B) Conversion disorder C) Reactive hypochondriasis D) Somatization disorder

Correct Answer B) Conversion disorder Explanation: The patient is likely suffering from conversion disorder. Conversion disorder is characterized by abnormalities or deficits of motor or sensory function that are not medically explained, such as blindness, seizure, paresis, paralysis, tremors, aphonia, or anesthesia. Classically, symptoms occur suddenly following a psychosocial stressor and are non-painful. Body dysmorphic disorder (A) is the preoccupation with an imagined physical defect or a real, although minor defect that is exaggerated (such as a large nose). Hypochondriac patients will be preoccupied with health and disease, often convinced that they have a particular disease or illness despite reassurance. Reactive hypochondriasis (C), also called transient hypochondriasis, occurs following a psychosocial stressor, such as recent loss of a family member. The difference between this and conversion disorder is that with hypochondriasis, the patient will be convinced they have an illness and although they may have minor symptoms or physical findings, the patient misinterprets the symptoms they are experiencing. Somatization disorder (D) begins before 30 years of age and manifests as multiple, unexplained physical complaints (four pain symptoms, two gastrointestinal symptoms, one sexual symptom, and one neurologic symptom).

Which of the following medications is most likely to cause side effects such as tardive dyskinesia and have limited efficacy in treating the negative symptoms of schizophrenia? A) Aripiprazole B) Haloperidol C) Quetiapine D) Risperidone

Correct Answer B) Haloperidol Explanation: Typical antipsychotics such as haloperidolhave a relatively high risk of adverse effects such as tardive dyskinesiaand parkinsonism, especially in older patients. They are mainly effective against the positive symptoms. Antipsychotics are never to be given as an isolated measure; other forms of treatment, such as individual or family therapy and psychosocial measures, should continue. Special education and support measures (compliance therapy) are useful where there are compliance problems. Schizophrenia is a chronic psychiatric disorder with no single feature that is pathognomic. Without treatment many patients may experience a downward drift in socioeconomic class. Atypical antipsychotics are associated with fewer extrapyramidal side effects and also can treat the negative symptoms of schizophrenia. Aripiprazole(A), quetiapine(C), and risperidone(D), are all atypical antipsychotics.

What is the most common form of child abuse in the United States? A) Emotional B) Neglect C) Physical D) Sexual

Correct Answer B) Neglect Explanation: Most states recognize four major types of maltreatment: neglect, physical abuse, psychological maltreatment, and sexual abuse. In the United States, medical providers are mandated reporters of child abuse. Neglect is the most common type of child maltreatment in the United States (78.5%) and is caregiver failure to meet basic nutritional, medical, educational, and emotional needs of a child. Neglect is legally reportable. Nutritional neglect is likely the most common form of neglect that is recognized, typically in the form of failure to thrive (FTT). Risk factors for neglect include poverty, poor support systems, parental mental health issues or mental disability, parental substance abuse, poor parenting skills, or complex child needs. The history and physical exam are extremely important when child abuse is suspected. A thorough history from everyone involved using open-ended questions, is the recommended approach. A full physical exam, including a genital exam is warranted. Signs such as bruising in non-mobile children, ligature marks, or burn marks are red flags for child abuse. Imaging should include a full skeletal survey in any child younger than 2 years with suspected physical abuse as well as a non-contrast computed tomography scan of the head in all children aged 6 months or younger with suspicion of abuse or children younger than 24 months with any suspected intracranial trauma. In cases of neglect, particularly when failure to thrive (FTT) is in question, a workup for organic problems may be undertaken. A provider who can follow up the laboratory results, monitor weight gain closely, and work with the family should be involved. Failure to thrive may require admission or close follow up with a specialist. Physical abuse (C) is characterized by physical injury such as bruises, fractures, tissue disruption resulting from hitting, punching, pinching, kicking, biting, burning, shaking, or otherwise harming a child. Child sexual abuse (D) has been defined by the American Academy of Pediatrics as the engaging of a child in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give informed consent, and violate the social taboos of society. Emotional abuse (A) is ongoing emotional maltreatment. Emotional abuse can involve deliberately trying to scare or humiliate a child or isolating or ignoring them.

What is considered the first-line therapy for bulimia? A) Antidepressants B) Antipsychotics C) Cognitive behavioral therapy D) Weight management plan

Correct Answer C) Cognitive behavioral therapy Explanation: Cognitive-behavioral therapy (CBT) is the best-evidenced approach for treatment of bulimia nervosa. Bulimia nervosa is characterized by binge eating episodes, followed by inappropriate compensatory behaviors, such as self-induced vomiting, laxative or diuretic misuse, fasting, and excessive exercise. A sense of loss of control about overeating accompanies these episodes of binge eating. These behaviors are associated with overvaluation of shape and weight. The episodes must occur at a frequency of one time per week for 3 months to meet diagnostic thresholds. Bulimic behaviors usually have their onset during middle adolescence (14-16 years old). Full-syndrome bulimia nervosa is most common during late adolescence and young adulthood (17-24 years old). Onset of bulimia nervosa is rare in younger children, although not unknown. It is common for other psychiatric disorders to coexist with bulimia nervosa, particularly depression, anxiety disorders, and substance use. Individuals with bulimia have normal or near-normal body weight. Antidepressants (A) are useful but are not as effective as cognitive behavioral therapy and are a second-line treatment. However these medications may be used to augment psychological treatments or as an alternative when psychological treatments are not effective, are refused, or are not available. Antipsychotics (B) are not indicated in the treatment of bulimia. Dysfunctional attitudes toward body shape and weight are the maintaining factors for the bulimia nervosa not the need for a weight management plan (D). As a result of these distorted ideas, there is an overvaluing of appearance, particularly thinness.

A 36-year old woman presents complaining of 10/10 low back pain. She dramatically describes how she injured herself during sexual intercourse with a younger man. Despite her pain, she is resting comfortably on the stretcher and talking loudly on her cell phone. Her hair and makeup are well done and she is dressed in provocative clothing. She demands to be evaluated by a male doctor. She makes a point to undress in front of the physician and is wearing lingerie. Which of the following personality disorders does this patient most likely have? A) Antisocial B) Borderline C) Histrionic D) Narcissistic

Correct Answer C) Histrionic Explanation: Individuals with histrionic personality disorder tend to be excessively emotional and overall demonstrate attention-seeking behavior. They want to be the center of attention. They often exaggerate (e.g. complaining of 10/10 pain although resting comfortably and talking on the phone), can be very flirtatious, overly dramatic and may be sexually seductive (e.g. flirting with the doctor, wearing lingerie, and talking about her sexual escapades). They rely on this manipulative behavior to meet their needs. This disorder is more common in women and affects approximately 3% of the general population. Individuals with antisocial personality disorder (A) have a blatant disregard for the rights of others, frequently violate social norms and display a lack of remorse. Borderline personality disorder (B) is characterized by unstable interpersonal relationships, impulsivity and a distorted self-image. Narcissistic (D) individuals have a distorted sense of self-importance and believe they deserve special treatment.

What are the components of the "female athlete triad"? A) Anemia, iron deficiency, menorrhagia B) Delayed puberty, ligamentous injuries, weight loss C) Low bone density, menstrual dysfunction, low energy availability D) menstrual dysfunction, hirsutism, ovarian cysts

Correct Answer C) Low bone density, menstrual dysfunction, low energy availability Explanation: The female athlete triad is defined by the presence of low bone density (can be normal), menstrual dysfunction (ranges from normal ovulatory cycles to luteal phase defects and anovulatory eumenorrhea to amenorrhea), and low energy availability (ranges in athletes from inadvertent undereating to disordered eating to a frank eating disorder). It is important to recognize the precursors to the development of the female athlete triad when they may be more amenable to treatment, resulting in less severe long-term sequelae. Caloric deficiency is the primary cause of amenorrhea in athletic women, and treatment should focus on the restoration of normal calorie intake. Athletic amenorrhea is caused by hypothalamic-pituitary axis suppression and is a diagnosis of exclusion. Bone mineral density is adversely affected by menstrual dysfunction and, although treatment with hormone replacement (e.g., oral contraceptives) should be considered, this does not fully address the mechanisms of bone loss. It is never normal or desirable for a female athlete to cease menstrual function, and this should not be seen as a marker of adequate training. Exercise alone should not be blamed for menstrual dysfunction. Many women engage in exercise to control body weight and improve exercise capacity. Amenorrhea only occurs when there is a relative caloric deficiency due to inadequate nutritional intake relative to the amount of energy expended. Although anemia, iron deficiency and menorrhagia (C) can all be seen in any woman who has heavy menstrual cycles, it is not called the female athlete triad. Delayed puberty, ligamentous injuries and weight loss (D) can all be seen individually in the exercising woman, but these components are not called the female triad. Many of these women suffer from stress fractures as opposed to ligamentous injuries secondary to osteoporosis. Amenorrhea, hirsutism and ovarian cysts (B) are all components of polycystic ovarian syndrome.

Which one of the following is highly suspicious for non-accidental trauma in a pediatric patient? A) Clavicle fracture B) Distal radius fracture C) Posterior rib fracture D) Spiral fracture of the tibia

Correct Answer C) Posterior rib fracture Explanation: Posterior rib fractures, metaphyseal fractures, multiple and bilateral fractures, fractures in different stages of healing, vertebral body fractures, fractures of the digits, scapular fractures, sternal fractures, and complex skull fractures are usually seen in child maltreatment or abuse. A skeletal survey should be obtained if suspicion for any of the above fractures is present as well as a consult to child protective services. Due to the greater pliability of children's ribs, greater force is required to produce a fracture and is usually caused by a direct blow to the ribs. Clavicle fractures (A) are common fractures seen due to injury during labor and delivery in the case of shoulder dystocias. Distal radial fractures (B) are seen when a patient falls on an outstretched hand and also in patients with osteoporosis. Spiral fractures of the tibia (D) are commonly known as "toddler's fractures" and occur after a rotational fall.

Katie is a 35-year-old woman who presents to the emergency department after being found wandering the streets yelling incoherently at imaginary people. After further investigation, you discover that she has been found arguing with an imaginary person for the past eight months and believes that she is being followed by the CIA. What is the most likely diagnosis? A) Delusional disorder B) Schizoaffective disorder C) Schizophrenia D) Schizophreniform disorder

Correct Answer C) Schizophrenia Explanation: Schizophrenia is a psychiatric disorder characterized by psychoses. Characteristic symptoms include hallucinations, delusions, disorganized speech or behavior. Negative symptoms must be present for at least six months in order to make the diagnosis. These symptoms begin to interfere with social, occupational, or self-care of a person. Treatment of schizophrenia is lifelong and requires both pharmacotherapy and psychotherapy. Delusional disorder (A) is a disorder of non-bizarre delusional thinking without the presence of other schizophrenic symptoms. These thoughts do not appear odd, do not cause daily impairments, and are not accompanied by hallucinations or psychosis. Schizoaffective disorder (B) is similar to schizophrenia in that it is characterized by hallucinations, delusions, disorganized speech or behavior, and/or negative symptoms, but it also has a mood component involved. These patients experience manic episodes or episodes of depression. Schizophreniform disorder (D) is a disorder with the same characteristic symptoms as schizophrenia but the duration of symptoms is less than six months.

A 32-year-old woman is brought to the ED by her husband because she "has been acting strangely." She has a past medical history of depression that is well controlled with fluoxetine. He also reports she has been suffering from a cold and took over-the-counter cough medication a few hours prior to the onset of her symptoms. She is agitated and confused. Her blood pressure is 160/80 mm Hg, pulse is 140 beats per minute, and temperature is 39°C. She is flushed and her pupils are dilated. She has clonus and hyperreflexia in her lower extremities, as well as a tremor in her hands. What is the most likely diagnosis? A) Malignant hyperthermia B) Neuroleptic malignant syndrome C) Serotonin syndrome D) Tyramine reaction

Correct Answer C) Serotonin syndrome Explanation: The patient is suffering from serotonin syndrome likely due to an interaction between her antidepressant medication, fluoxetine and dextromethophan, a cough suppressant found in many over-the-counter cough and cold medications. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). Serotonin syndrome results from excessive serotonin accumulation in the synaptic cleft and manifests as a triad of altered mental status, autonomic instability, and neuromuscular abnormality. Serotonin syndrome often occurs as the result of a drug-drug interaction between medications that increase the amount of serotonin in the synaptic cleft, however can occur following an overdose with an SSRI. Malignant hyperthermia (A) occurs with the use of certain anesthetic agents (halothane and succinylcholine) and manifests as severe muscle rigidity and hyperthermia. Neuroleptic malignant syndrome (B) is a life-threatening condition characterized by muscle rigidity, autonomic instability, altered mental status, and hyperthermia that occurs soon after initiation or dose adjustment of a dopaminergic or antipsychotic drug. A tyramine reaction (D) is a drug-food interaction that occurs when a patient taking an MAOI inhibitor ingests a tyramine containing food. Symptoms start immediately following ingestion and include headache, hypertension, flushing, and diaphoresis.

A 51-year-old woman presents for follow-up after being started on fluoxetine 20 mg daily 4 weeks ago for depressive symptoms. She has a history of major depression and was successfully treated with fluoxetine for several months after her last episode three years ago. The patient reports that the worst of the depressive symptoms have improved, but she still continues to experience mild sadness and tearfulness on occasion. She does not have any suicidal or homicidal ideation. She reports no side effects from the use of fluoxetine. No manic symptoms are present. Which of the following is the best approach to continuing pharmaceutical treatment? A) Continue fluoxetine and also start bupropion B) Discontinue fluoxetine and switch to lithium C) Discontinue fluoxetine and switch to sertraline D) Increase the dose of fluoxetine to 40 mg daily

Correct Answer D) Increase the dose of fluoxetine to 40 mg daily Explanation: Increase the dose of fluoxetine to 40 mg daily is the best approach. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used as first-line treatment for major depression. This patient has shown improvement with the initial dose of fluoxetine without any side effects. Increasing the dose is most appropriate change, since the most common mistake in a trial of an antidepressant is the use of too low a dosage for too short a time. Major depressive disorder(MDD) has a chronic course with relapses. Diagnosis of MDD is made based on five or more of the following symptoms having been present for more than 2 weeks and resulting in altered functioning. At least one symptom must be depressed mood or anhedonia. Symptoms include depressed mood, anhedonia, weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings or worthlessness or guilt, reduced ability to concentrate, and thoughts, plans, or attempts of suicide. No manic symptoms should be present, now or in the past. Sertraline (C) is also an SSRI. Switching to a different SSRI would be appropriate if there were no response to the fluoxetine. Lithium (B) is a mood stabilizer, used primarily in patients with bipolar disorder. This patient has never had a manic episode. Bupropion (A) is often used as an adjunct to an SSRI when more than one full-dose SSRI has not achieved complete remission of depressive symptoms.

Which of the following is considered a risk factor for suicide? A) Female sex B) First trimester pregnancy C) First year of marriage D) Recent incarceration

Correct Answer D) Recent incarceration Explanation: Suicide is the fourth leading cause of death in the United States for individuals between the ages of 18 and 65. Therefore, it is important for emergency physicians to have an understanding of the risk factors associated with suicide. Individuals who were incarcerated and recently released are at high risk of committing suicide. During the first two weeks of release, the suicide risk is up to 12 times that of the general population and approaches that of individuals who have been recently released from an inpatient psychiatric facility. Other important risk factors include male sex, Caucasian and Native American race, history of psychiatric illness, history of previous suicide attempts, unemployment, drug and alcohol abuse, chronic illness and pain, recent sexual or physical abuse, homelessness, veterans, divorce or martial separation, firearms in the home, and lack of religious affiliation. As a whole, the female (A) sex is not a risk factor for suicide; male sex is at a higher risk. Marriage (C) is protective, although divorce and separation are risk factors. Pregnancy (B) is also protective, although women in the post-partum period are prone to depression and may carry a suicide risk.

A 23-year-old man with a history of opiate abuse presents to the emergency department with tachycardia, hypertension and mydriasis. Which of the following is true regarding management? A) Antiemetics should be witheld as they may cause serious side effects B) Consider ICU admission for the potential for symptoms to worsen C) Naloxone should be given D) Symptom control may be achieved with clonidine

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

A 42-year-old woman presents to the clinic stating that she has constant feelings of "being worried." She notes that she has felt this way for over a year and notes that she has always been a worrier, but the constant thoughts are making it difficult to sleep and concentrate on her work. She feels restless and irritable most days. Which of the following medications is the most appropriate for long-term management of her diagnosis? A) Bupropion B) Methylphenidate C) Risperidone D) Venlafaxine

Correct Answer D) Venlafaxine Explanation: Generalized anxiety disorder is diagnosed when a patient reports symptoms of excessive worry for a minimum of six months. Somatic symptoms may include fatigue, restlessness, insomnia, irritability, muscle tension, and edginess. Most patients realize their level of worry is inappropriate to their situation but feel as if they have no control. Venlafaxineis an antidepressant approved by the FDA for treatment of generalized anxiety disorder. It is a selective serotonin-norepinephrine reuptake inhibitor (SNRI) and is considered a first-line treatment for anxiety disorder. Risperidone (A) is an atypical antipsychotic that is not currently recommended for anxiety although may have some use in treatment of post-traumatic stress disorder. Methylphenidate (C) is a stimulant that is commonly used in attention deficit disorder. Bupropion (D) is an antidepressant but has some stimulating side effects that can worsen somatic symptoms in patients with anxiety.

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

Correct Answer ( D ) D) Support airway and breathing Explanation: Opioid abuse and overdose is a problem in the United States and worldwide. Deaths due to overdose are common and increasing in number. Clinical features of opioid intoxication include altered mental status, hypoventilation, decreased bowel sounds, low to normal blood pressure and heart rate, and miotic pupils. Medical providers should attempt to obtain as much historical information as possible, however an accurate history is not essential in initial management of these patients. Hypoventilation is the most common vital sign abnormality. The first step in management of an overdose is supporting the patient's airway by providing assisted ventilation with supplemental oxygen through the use of a bag-valve-mask. Naloxone (A) is an opioid antagonist and should be administered to all patients with opioid overdose, preferably by intravenous route. Naloxone may be given by subcutaneous or intramuscular route if obtaining intravenous access will cause a delay in administration. However, the treatment for opioid overdose is oxygen. Meaning, these patients first require management of airway and breathing. Sodium bicarbonate (B) is administered in various other overdoses such as salicylate (aspirin) and tricyclic antidepressants, but is not useful in opioid overdose. Use of activated charcoal (C)is contraindicated in this patient since he is obtunded. Moreover, the patient requires immediate attention to his airway and breathing and any delay can result in death.

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

D) Sertraline Explanation: Selective serotonin reuptake inhibitors such as sertraline are the most commonly used medications for postpartum depression. They have fewer side effects and are considered safer than tricyclic antidepressants, especially in depressed women who may be at increased risk for medication overdose. In one study, infant serum levels of sertraline and paroxetine were undetectable. It is also recommended that a woman with postpartum depression be started on a medication that she had taken previously with a good response, unless there is evidence of potential harm to her infant. Tricyclic antidepressants such as amitriptyline (A) are excreted into breast milk and there is some concern regarding potential toxicity to the newborn. Phenytoin (C) and diazepam (B) are not antidepressants. Phenytoin and diazepam are Category D for use in pregnant women. Diazepam is potentially toxic to infants and can accumulate in breastfed infants, and it is not recommended for lactating women.