EXAMMASTER PSYCH 1

A 36-year-old woman presents because she has been feeling very tired and unhappy for the past 3 years; she thinks that she has no hope of better days in the future. She states that it is amazing her boss has not fired her yet because she's one of the company's worst employees. She can't recall the last time she was excited about anything. She denies other symptoms. Her vital signs are stable. Her height and weight are within normal limits. Question What is the most likely diagnosis? Answer Choices 1 Major depressive disorder 2 Persistent depressive disorder (dysthymia) 3 Bipolar I disorder 4 Bipolar II disorder 5 Kindling

Correct Answer: Persistent depressive disorder (dysthymia) Show ExplanationExplanation Persistent depressive disorder (dysthymia) is diagnosed when a patient presents with chronic depression for at least 2 years in duration that has not been severe enough to be classified as major depressive disorder. The patient must present with 2 of the following symptoms: increased or decreased appetite, increased or decreased sleep, low energy, low self-esteem, poor concentration, poor decision-making ability, and hopelessness. The diagnosis is more common in women than men. Major depressive disorder is characterized by a more severe depression for at least 2 weeks; it presents with at least 5 of the following symptoms: 1. depressed mood most of the day, felt by the patient or observed by others 2. lack of interest in all activities (anhedonia, an inability to experience pleasure) 3. significant weight loss or gain or an increase or decrease in appetite 4. insomnia or hypersomnia every day 5. psychomotor agitation or retardation every day 6. fatigue or loss of energy every day 7. feelings of worthlessness or inappropriate guilt 8. diminished ability to think or concentrate 9. recurrent thoughts of death with a suicidal attempt or a specific plan for committing suicide A single pole in which the patient experiences manic, hypomanic, or depressive symptoms characterizes bipolar I disorder. If the 1st episode is not manic, sometimes the diagnosis is not made until a manic episode arises. If the symptoms arise due to the use of substances (e.g., antidepressive medicines), then it is not considered bipolar I disorder. Attempted and successful suicides are common in patients with bipolar I disorder. Sexually transmitted diseases are more frequent in this population when they are in the manic stage. There is also poor compliance in taking medicines due to impaired judgment. Bipolar I disorder is associated with eating disorders, anxiety disorders, and attention deficit hyperactivity disorder. The mean age at which it occurs is 21 years old. Bipolar II disorder is diagnosed when a patient has had at least 1 episode of major depression and 1 hypomanic episode without the presence of any manic or mixed episodes. Suicide is common during the depressive episodes. The disorder is seen in association with substance abuse or anxiety disorders, which is also the case in bipolar I disorder. The lifetime risk of getting the disease is .5%, and the risk is higher in women than in men. Unlike bipolar I disorder which presents with mania or mixed syndromes, the bipolar II disorder has no presence of mania or mixed syndromes. Kindling is a phenomenon characterized by repeated subthreshold stimulations of the brain that result in seizure activity; bipolar disorders follow the same scenario. For example, a person may experience a certain stress that sets off their 1st episode of mania; mania will appear with a lower grade of stress and then eventually it will appear all by itself. Anticonvulsants (e.g., valproic acid and carbamazepine) are useful in treating patients with seizures and patients with bipolar disorders.

Stephanie, an attractive, red-haired woman of 26, is an airline stewardess who has been having marital difficulties with her husband, who is a pilot for another airline. She dropped out of college in her senior year, occasionally smokes marijuana, and has had breast implants. Frequently, she and her husband get into violent fights over little things in the home; primarily the fights revolve around him not being attentive enough to her. At these times, she hates him and wants him to die. She often goes into a fetal position in the middle of the living room floor. The next morning, she awakens in an amorous mood and wants to make love, believing him to be the most wonderful man on this earth. More than once, she has made a suicidal gesture when she thought her husband would leave her. Stephanie enjoys flirting with men on the plane. During some days of the week when she's in a strange town, she actively engages in browsing through shopping malls and trying to attract men who are with their wives. It's a game she enjoys. When stressed, she becomes paranoid and has a feeling of being able to step outside her body and watch herself. There is also a terrible sense of emptiness. Question What is the most likely diagnosis? Answer Choices 1 Histrionic personality disorder 2 Dependent personality disorder 3 Borderline personality disorder 4 Brief reactive psychosis 5 Narcissistic personality disorder

Correct Answer: Borderline personality disorder Borderline personality disorder individuals show a persistent pattern of undermining their efforts to succeed and destroying good relationships. There may be multiple attention-seeking suicidal gestures, minor self-inflicted wounds, psychotic symptoms, feelings of depersonalization or derealization, sexual conflicts, mood disturbance, and a tendency to see people as either bad or good. With few, if any, close friends, they lead a life of isolation and are continuously looking for love and affection or for someone to show them they are attractive. Frequent co-occurring disorders may include mood disorders, substance-related disorders, eating disorders, and ADHD. Histrionic personality disorder is similar to borderline, but does not exhibit the chronic feelings of emptiness, shifting moods, or self-destructive behavior. Persons with histrionic personality disorder also do not exhibit paranoid ideation or dissociative symptoms, which are present in persons with borderline personality disorder. Narcissistic personality individuals do not fear abandonment, engage in self-destructive behavior, or have a problem with self-image. Persons with dependent personality disorder have difficulty making decisions and an unrealistic fear of being alone or taking care of him or herself. They are overly needy of support form others. Patients exhibiting a brief reactive psychosis experience an event that precipitates an episode of disorientation with reality, including hallucinations and delusions.

A 60-year-old woman presents with a 6-week history of depressed mood, crying episodes, feelings of guilt, and an inability to sleep. She states that she has had these episodes before and was treated with antidepressant therapy. She reports that she has recently gained a significant amount of weight. Her daughter notes that there is a family history of this behavior; the patient has no significant medical problems. Question Of what condition is this suggestive? Answer Choices 1 Bipolar disorder 2 Major depression, recurrent 3 Major depression 4 Depressed mood 5 Acute stress disorder

Correct Answer: Major depression, recurrent Show Explanation Explanation The correct response is major depression, recurrent. There are several indicators of a major depression in older adults. A major depressive disorder must consist of several symptoms for at least 2 weeks; these symptoms are depressed mood, decreased interest in normal activities, significant weight loss or gain, insomnia or hyper-sleeping, psychomotor agitation or retardation, feelings of worthlessness or guilt, and/or poor concentration, and possible passive or direct suicidal threats. Depressed mood is an indicator, but not a diagnosis. Major depression, recurrent is a term used to indicate that the older adult has had a previous episode and was treated. Treatment of major depression in older adults is most successful with a combination of antidepressant medications plus interpersonal supportive psychotherapy. Behavioral, cognitive, and family therapies have shown less promising results. Also, brief or short therapy has shown to be as effective or more effective as long-term psychotherapy. ECT (electroconvulsive therapy) is a treatment of choice in the elderly if they do not respond to antidepressants, or if they have a vegetative-type depression. In diagnosing major depression, it is very important to first do a complete medical examination and take a history; doing so will rule out possible physical causes before drugs are prescribed. In treating depression, older adults usually do not want to see a psychiatrist unless it is indicated, and most older adults see their primary physician; psychiatrists are usually brought in to consult or act as a liaison to the primary physician. Bipolar disorder is characterized by 1 or more manic episodes, or mixed manic and depressive episodes. There is usually grandiosity, a decreased need for sleep, psychomotor agitation, and excessive involvement with pleasurable activities (e.g., sex, spending, or traveling). Acute stress disorder is an acute phase stress reaction. This will occur in the first month after being exposed to a traumatic event. Persons experiencing acute stress disorder are at a high risk for PTSD. Persons will exhibit symptoms in these categories: intrusion, negative mood, dissociation, avoidance, and arousal.

A 35-year-old woman has a history of difficulty in social relationships. She is highly demanding and hyperfocused on her appearance. When she wants a haircut, she refuses to wait for an appointment; she demands immediate service regardless if others were waiting ahead of her. She frequently ignores her boyfriend at social functions, and even though he goes out of his way to try to please her, she flirts with other men. As a result of these behaviors, she has few close friends. Question What is the most likely diagnosis? Answer Choices 1 Obsessive-compulsive personality disorder 2 Bipolar disorder 3 Alcohol abuse 4 Narcissistic personality disorder 5 Schizotypal personality disorder

Correct Answer: Narcissistic personality disorder Show Explanation Explanation The patient's presentation is most consistent with narcissistic personality disorder. Narcissistic personality traits include an overblown sense of self-importance and self-centeredness with little concern for the needs of other people. As a result, people with narcissistic personality disorder often antagonize people who try to befriend them; therefore, they have trouble maintaining long-term relationships. Irresponsible or erratic behavior is uncommon in patients with this condition. Schizotypal personality disorder is a condition characterized odd behavior, paranoia, and social isolation. They have few friends and lack insight as to how their personality impairs their relationship with others. However, unlike patients with schizophrenia, they do not exhibit frank psychosis. Bipolar disorder is an affective disorder marked by extreme swings in moods. During manic episodes, patients exhibit increased energy, euphoric mood, and disinhibition. They may engage in risky behavior and exhibit poor judgment. These "highs" are punctuated by equally extreme periods of depression; the periods are characterized by feelings of hopelessness, lack of energy, apathy, and suicidal ideation or attempts. Obsessive-compulsive personality disorder is characterized by the restricted ability to be warm and tender, perfectionism with demands of perfectionism in others, and a dedication to work and accomplishment. Although driven, patients with this disorder also tend to express insecurities and a tendency toward indecisiveness. Alcohol abuse is usually marked by episodes of disinhibition and irresponsible behavior, which may in the long run compromise relationships and job security. Social relationships suffer due to the patient's unpredictable mood and actions. Patients may get into trouble with the law or engage in uncharacteristically dangerous or violent behavior while under the influence of alcohol, thereby placing themselves and others at risk. Substance abuse may also compromise school or work performance.

A 22-year-old postpartum woman presents with a loss of interest in eating, increased sleepiness, and fatigue at her 1st week checkup. It was her 1st pregnancy. She has been happily married for 2 years; she has a stable job and good family support. Out of his wife's hearing range, her husband reports that she seems more irritable, snapping at him for trivial things. She broke down sobbing when asked about her parents, who passed away in a car accident 1 year earlier. Question What is the most likely diagnosis? Answer Choices 1 Postpartum depression 2 Post partum psychosis 3 Normal peurperium 4 Dysthymia 5 Postpartum blues

Correct Answer: Postpartum blues Show Explanation Explanation Postpartum blues is the correct answer. Postpartum blues refer to a transient condition characterized by mild (and often rapid) mood swings from elation to sadness, irritability, anxiety, decreased concentration, insomnia, tearfulness, and crying spells. It usually peaks on the 5th postpartum day, with resolution within 2 weeks. Symptoms do not reach the DSM V criteria for major depression. Associations include race, socioeconomic status, family support systems, and education levels. Postpartum depression is incorrect. While the symptoms may be similar to postpartum blues, a major depressive episode is characterized by the presence of a severely depressed mood that persists for at least 2 weeks. Postpartum (puerperal) psychosis is incorrect. Postpartum psychosis usually begins in the same time-frame as depression, but it is characterized by frank psychotic symptoms, such as hallucinations, delusions, grossly disorganized behaviour, and cognitive impairment. At times, thoughts of self-harm or harming the baby may predominate. Some researchers believe it to be an overt manifestation of an underlying low grade bi-polar disease that is exacerbated by the sudden hormonal changes of pregnancy. Normal puerperium is incorrect. When emotions are not transient and influence day-to-day activities as they do in this vignette, they are not considered normal. Dysthymia is incorrect. By definition, dysthymia requires a persistently low mood for over 2 years. This patient has no such history.

A 15-year-old boy presents with a diagnosis within the autism spectrum disorder. He is considered high-functioning: he attends a public school, goes to daily cognitive/behavioral sessions, and he attends weekly counseling sessions with a provider who specializes in treating adolescent patients with a diagnosis within the autism spectrum disorder. His mother has noted a significant increase in episodes of what she can only describe as temper tantrums; severe irritability and quickly changing moods are also present. These occurrences have become so severe that they have begun to disrupt the patient's daily activities. Question Of the following, what medication is used to treat irritability in children and adolescents with autism spectrum disorder? Answer Choices 1 Sertraline 2 Paroxetine 3 Atomoxetine 4 Clonidine 5 Risperidone

Correct Answer: Risperidone Show Explanation Explanation The correct response is risperidone. Adolescents classified as having a diagnosis within the autism spectrum disorder (ASD) will have varying degrees of impairment in their social and behavioral function. Family education, behavioral and educational interventions, and counseling have a significant place in this treatment plan; pharmacotherapy may be considered, but it should be used as adjunctive therapy. In 2006, the United States Food and Drug Administration (FDA) approved risperidone, an atypical antipsychotic (in the oral disintegrating tablet form), for the symptomatic treatment of irritability in both children and adolescents with autism spectrum disorder. This is considered the 1st FDA-approved drug treatment for behaviors specifically associated with ASD, and it has been used off-label for many years for these symptoms. Other symptoms that risperidone could be considered to help treat in patients with ASD include aggression and deliberate self-injury. When beginning any pharmacotherapy for these patients, having a 'start low and go slow' regimen is strongly recommended, with consistent follow-up visits for evaluation of alleviation of the symptoms. Selective serotonin reuptake inhibitor (SSRI) pharmacologic agents (e.g., sertraline or fluoxetine) are generally introduced to help alleviate anxiety symptoms. The patient in the above scenario is currently not experiencing or expressing any excessive anxiety. Although paroxetine is a type of SSRI that is used to treat patients with depression, obsessive-compulsive disorder, anxiety disorder, post-traumatic stress disorder, or premenstrual dysphoric disorder, it is currently not a recommended first-line treatment option for symptomatic behavior in ASD patients. Patients who express symptoms consistent with hyperactivity and inattention should be treated with methylphenidate, atomoxetine, or clonidine; this is not consistent with the symptoms described in this patient.

A 32-year-old man presents with a 4-year history of worsening hypersomnolence. The symptoms began in his teens, and he would often fall asleep in class. He states that he sometimes becomes extremely sleepy while driving and has come close to being in accidents on several occasions. He sleeps 6 to 7 hours a night, but he still feels sleepy during the day. The patient also admits to occasional hypnagogic hallucinations. Question What regarding the patient's condition is true? Answer Choices 1 Symptoms are similar in adults and in children 2 An MRI of the brain is the main diagnostic test for this condition 3 Antidepressants may be used in treatment of this condition 4 The condition is indistinguishable from idiopathic hypersomnia 5 Men are affected more often than women

Correct Answer: Antidepressants may be used in treatment of this condition Show Explanation Explanation The diagnosis in this patient is narcolepsy. Narcolepsy is characterized by daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis. It is a chronic sleep disorder caused by the brain's inability to regulate sleep-wake cycles normally. Antidepressant drugs, such as tricyclics and selective serotonin reuptake inhibitors, have proven effective in controlling cataplexy in many patients. There is no cure for narcolepsy. Modafinil is used for the treatment of symptoms. CNS stimulants, such as methylphenidate, dextroamphetamine sulfate, methamphetamine, and amphetamine, may be used. Patients should avoid alcohol and caffeine-containing beverages before bedtime. Narcolepsy is thought to result from genetic predisposition, abnormal neurotransmitter functioning and sensitivity, and abnormal immune modulation. Human leukocyte antigen subtypes and abnormalities in monoamine synaptic transmission are thought to be involved. The cause of narcolepsy remains unknown. Men and women are affected equally, and children as young as 2 years old may also be affected. The age of onset distribution is biphasic; the highest peak occurs at the age of 15, and a smaller peak occurring at around age 36. Symptoms in children may be variable and subtler than they are in adults. This often makes the age of diagnosis later. In idiopathic hypersomnia, features of cataplexy or megaphagia are absent. Sleep-onset REM episodes, the characteristic polysomnographic feature of narcolepsy, are also absent. It should be noted that patients with narcolepsy do not always present with cataplexy or a history of cataplexy. They will still have the hallmark symptoms, such as excessive daytime sleepiness, sleep-onset REM episodes, hypnagogic hallucinations, etc.

A 9-year-old boy is referred for an assessment at the request of his school. His teacher's report states that he often speaks out of turn during class, constantly fidgets in his seat, and frequently gets up out of his chair during class and begins walking around the classroom. He has become so disruptive that he often spends most of his day in the principal's office. The principal states that he is often very helpful to him during the day and volunteers to help him file papers or clean up around the office. On the playground, he frequently argues with his classmates, and he refuses to wait his turn when playing games. The child's mother states that when they have guests over or when she is talking to others, the boy will try to climb in her lap and have a conversation with her. She worries about his behavior because he will climb up on the bookshelves or on top of the house, and she worries that he will hurt himself. He frequently argues with his siblings, and he will often walk into their rooms and take their stuff without asking. During the assessment, the boy is very cooperative. He answers all of your questions. He appears to work hard on the assessment tests, but he frequently gets up during the tests and walks around your office. Question What is the most likely diagnosis? Answer Choices 1 Oppositional defiant disorder 2 Conduct disorder 3 Unspecified attention-deficit/ hyperactive disorder 4 Attention deficit hyperactivity disorder 5 Antisocial personality disorder

Correct Answer: Attention deficit hyperactivity disorder According to the DSM 5, for individual younger than age 17 a diagnosis of attention deficit hyperactivity disorder (ADHD) requires at least 6 of the 9 inattentive symptoms and/or hyperactive-impulsive symptoms. In the case study above, the boy clearly demonstrates 6 hyperactive-impulsive symptoms. • Often fidgets with hands or feet or squirms in seat • Often leaves seat in classroom or in other situations in which remaining seated is expected • Often runs about or climbs excessively in situations in which it is inappropriate • Often talks excessively • Often has difficulty waiting turn • Often interrupts or intrudes on others Many children with ADHD may have a co-morbid diagnosis of conduct disorder or oppositional defiant disorder. ADHD can be differentiated from oppositional defiant disorder, conduct disorder, disruptive behavior disorder not otherwise specified, and antisocial personality disorder by the motivation behind the behavior. Those with oppositional defiant disorder, conduct disorder, unspecified attention-deficit/ hyperactive disorder, and antisocial personality disorder act out behaviorally. They refuse to comply with rules, and they refuse to do their school work due to an unwillingness to conform to others' demands and a disregard for social norms; however, children with ADHD often exhibit these behaviors due to poor attention skills and lack of impulse control.

A 70-year-old woman presents with a poor appetite and a history of depressive disorder with seasonal pattern. Every October or November, she has decreased appetite, decreased energy, and wants to sleep all of the time and hibernate. Question What drug is most likely to benefit this client? Answer Choices 1 Paroxetine 2 Fluoxetine 3 Sertraline 4 Bupropion 5 Amitriptyline

Correct Answer: Bupropion Show Explanation Explanation The FDA has approved bupropion (Wellbutrin) as the drug of choice for depressive disorder with seasonal pattern. The effectiveness of bupropion for the prevention of episodes was established in 3 double-blind, placebo-controlled trials in adults with a history of major depressive disorder in autumn and winter. Seasonal pattern is a specifier of depressive disorders, characterized by recurrent seasonal patterns of depressive episodes; its onset is most commonly in the fall or winter, and remission occurs in spring or summer. It usually begins in October or November and ends by February or March. Etiology of depressive disorder with seasonal pattern is unclear; it may be caused by an increase in the duration of secretion of melatonin (a hormone produced by the pineal gland) that normally occurs at night. Symptoms include lethargy, decreased interest in and withdrawal from usual activities, hypersomnia, and overeating (e.g., carbohydrate craving and weight gain). There is depression and anxiety along with fatigue, loss of libido, and decreased socialization Phototherapy is the most effective treatment for depressive disorder with seasonal pattern. Pharmacotherapy with antidepressants is also used for seasonal affective disorder. Bupropion is a noradrenaline and dopamine re-uptake inhibitor. It is beneficial in the prevention of recurrence of depressive disorder with seasonal pattern, in cases of decreased energy, pleasure, and interest, in major depression with concomitant anxiety, as well as in elderly depressed patients. The mechanism of action of bupropion (Wellbutrin) in SAD is not clear; it appears to be a dopamine re-uptake inhibitor and a weak serotonin and norepinephrine reuptake inhibitor. Dry mouth and insomnia are the common side effects. Because of its favorable side effect profile, bupropion is safe and effective in elderly depressed patients. Paroxetine hydrochloride is a selective serotonin reuptake inhibitor (SSRI). One of its side effects is sedation in elderly and it is the most sedating of the SSRIs. Because of its sedation, it is not preferred in SAD patients who are likely to have hypersomnia. Other side effects include low blood pressure, headaches, dizziness, insomnia, ear pain, or eye pain. Typical dosing in the elderly is 20-30 mg. Fluoxetine hydrochloride (Prozac) belongs to the class of SSRIs and causes fewer side effects than tricyclics, but it does have a long half-life. As in most antidepressant therapies, they take at least 2-4 weeks to reach a therapeutic level. Dosing is usually once daily and at a 10-20 mg level. Higher doses are not usually recommended in the elderly. Fluoxetine hydrochloride is known to cause agitation, nervousness, and insomnia in the elderly; it is not recommended in clients who have sleeping disturbances or are agitated. Sertraline is also an SSRI and is usually not a first choice of drug to use in treatment of depression in the older population. It usually has more side effects than Fluoxetine hydrochloride. Common side effects include nausea, anorexia, dry mouth, insomnia, and sexual dysfunction. This drug also begins with lower dosing and has a 4-week window period. Amitriptyline hydrochloride is a tricyclic antidepressant drug. Patients aged over 60 are highly susceptible to hazardous anticholinergic side effects of amitriptyline, such as dry mouth, blurred vision, constipation, urinary dysfunction, hypotension, tachycardia, and cognitive impairment. Therefore, it is not preferred in the elderly.

A 24-year-old man presents with rambling speech that is dotted with paranoid delusions. He is highly agitated and will not sit still. About 1 hour later, the patient's excited speech slows, and he quietly mutters to himself before falling asleep. On Examination: Temp- 37°C, PR- 108/min, BP- 140/70 mm Hg, and RR- 22/min. General examination reveals irregular skin flushing over the trunk. Other system examination is normal. Question What helps in differentiating amphetamine from cocaine intoxication? Answer Choices 1 Heightened sensitivity to noise 2 Increased appetite 3 Duration of the high 4 Elevated blood pressure 5 Signs of recent weight loss

Correct Answer: Duration of the high Show Explanation Explanation Typically, the effects of a single dose of amphetamines lasts 4 to 6 hours, and those from cocaine rarely last more than 2 hours. Amphetamine is absorbed completely in 4 to 6 hours following oral ingestion. The half-life of amphetamine is 11 - 13 hours. When cocaine is taken orally, the onset of action is 10 minutes; it peaks in 60 minutes, the duration of action is 60 minutes, and the half-life is 60 - 90 minutes. The other symptoms could be present in either cocaine or amphetamine use. The effects of amphetamine are due to increase in the release of biogenic amines (norepinephrine, dopamine, and serotonin) from the storage sites. It also slows down the catecholamine metabolism by inhibiting monoamine oxidase. Most of the symptoms are due to central nervous system stimulation. Patients with amphetamine intoxication exhibit features of CNS stimulation, which include change in mental status, agitation, euphoria, hallucinations, dyskinesias, formication, and symptoms of stroke. Chronic use can cause paranoia, delusions, and hallucinations, which are usually visual, tactile, or olfactory in nature. The other signs and symptoms include weight loss, chest pain, palpitations, decreased appetite, nausea, vomiting and diarrhea, difficulty in micturition, diaphoresis, skin flushing, hypertension, hyperthermia, tachycardia, myalgia, and signs of rhabdomyolysis and renal failure. Patients with no life threatening signs need only sedation and no laboratory workup. Patients with seizures and prolonged change in mental status require blood glucose and electrolyte analysis. In patients with hyperthermia, a hepatic and renal profile as well as blood count workup should be done. Toxicological screening for amphetamine in urine may be carried out. Imaging modalities such as CT brain, chest X-ray, and echocardiography may be required in patients with stroke, suspected abscess, or in patients with chest pain. General supportive measures include stabilizing the patient's airway, breathing, and circulation. In patients with acute oral ingestion, activated charcoal may be administered. The treatment for patients with no-life threatening symptoms is sedation and observation. Agitation and convulsion may be treated with diazepam or with chlorpromazine. Hyperthermia can be managed by tepid sponging and administration of diazepam or dantrolene. Patients with renal failure require dialysis.

An 86-year-old woman living in a long-term care facility tells you that she is taking 8 different medications. On examination, you note that her lips pucker, her tongue twists around in her mouth and exits her mouth constantly, and she grimaces spontaneously. Question What medication is most likely to cause these involuntary movements? Answer Choices 1 Haloperidol 2 Lorazepam 3 Nortriptyline 4 Fluoxetine 5 Hydrochlorothiazide

Correct Answer: Haloperidol Show Explanation Explanation The patient is demonstrating tardive dyskinesia, which is a side effect of neuroleptics such as haloperidol. Haloperidol is a neuroleptic medication that is typically used to treat psychoses, agitation, and occasionally hyperactivity. Tardive dyskinesia may or may not cease once medication has been withdrawn. The other medications listed are not neuroleptics and do not cause tardive dyskinesia as frequently as neuroleptics.

A 29-year-old man is found unconscious by his roommate. He has a history of manic-depression and substance abuse. His roommate states that he recently broke up with his girlfriend and was laid off from his job. When the paramedics arrive, the patient is nonresponsive and nearly apneic. His pulse is palpable and regular at a rate of approximately 80 beats per minutes. His pupils are pinpoint but equal. Question In addition to immediate cardiopulmonary resuscitation, treatment with what drug therapy is most likely to be lifesaving? Answer Choices 1 Atropine 2 Epinephrine 3 Flumazenil 4 Naloxone 5 Phenobarbital

Correct Answer: Naloxone Show Explanation Explanation The patient's apnea and pinpoint pupils are consistent with an acute opioid overdose; therefore, treatment with naloxone is indicated. Naloxone is an opioid receptor antagonist with a high affinity for opioid receptors. Naloxone displaces receptor-bound opioids, which leads to a reversal of opioid-induced respiratory depression and coma. Opioid receptors of various subtypes are present throughout the central and peripheral nervous systems. In addition to their analgesic properties, opioids cause respiratory depression via receptors in the medullary respiratory center. Pupillary constriction occurs as a result of opioid receptor activation in the Edinger-Westphal nucleus of the oculomotor nerve. Other side effects of opioids are constipation caused by gastrointestinal smooth muscle relaxation and nausea caused by receptor stimulation in the chemoreceptor trigger center of the 4th ventricle. Atropine is a muscarinic antagonist. It is used to treat overdoses due to organophosphate-type insecticides that inhibit the acetylcholinesterase enzyme, leading to acute increases in acetylcholine levels. Symptoms of muscarinic activation include salivation, lacrimation, miosis, and bradycardia. Muscarinic activation can also impair diaphragmatic motor function, leading to respiratory distress and ultimately seizure activity. The clinical scenario presented is not consistent with organophosphate exposure, and the heart rate of 80 beats per minute makes the diagnosis unlikely. Therefore, there is no immediate role for atropine administration. Epinephrine is a direct-acting adrenergic agonist that acts on both alpha and beta-receptors. The principal effect of epinephrine is increased cardiac inotropy and chronotropy, leading to increased cardiac output. Combined vasoconstrictive and vasodilator effects usually lead to a rise in systolic and no change or slight lowering of diastolic blood pressures. Epinephrine is also a powerful bronchodilator due to activation of respiratory beta-2 receptors. Epinephrine is indicated in cases of cardiac arrest as well as anaphylactic shock - neither of which is present in this case. Flumazenil is a competitive antagonist of the gamma-aminobutyric acid (GABA) receptor and is used in cases of benzodiazepine overdose. Benzodiazepines are used to treat anxiety and have sedative effects that may lead to coma at high doses. Although benzodiazepine overdose is possible in this scenario, it does not explain the pupillary constriction. Phenobarbital is a barbiturate with sedative-hypnotic and anticonvulsant properties that, like the benzodiazepines, acts by GABA receptor stimulation. Phenobarbital is used to treat status epilepticus. It is also used to minimize brain oxygen consumption under circumstances of compromised regional cerebral perfusion. Based on this case presentation, there is no indication for phenobarbital.

A 12-year-old girl is brought to your attention because she recently started refusing to go to school. When her mother tries to explain that she must go to school, the girl flies into a rage and tells her mother that she will not talk to her when she returns from school. In the evenings, she becomes anxious and refuses to go out because of the fear of darkness. Her relationships with her friends are the same as always, and her grades have not changed. However, she has problems with her teachers, who find her behavior disrespectful. Her parents have been separated for a period of several months. Before that, she had witnessed intense fighting between her parents; at times, police were called to intervene. Her physical and laboratory findings, including drug tests, are normal. Question What is the most likely diagnosis? Answer Choices 1 Separation anxiety disorder 2 Panic disorder 3 Agoraphobia 4 Social anxiety disorder 5 Post-traumatic stress disorder

Correct Answer: Separation anxiety disorder Show Explanation Explanation Separation anxiety disorder is the most prevalent of the anxiety disorders; it is frequent in children of divorce and marital separation. Patients have difficulties controlling their strong feelings of betrayal and anger. Their anger is regularly misdirected at the other parent or teachers. The excessive anxiety that separation causes should be beyond what is considered normal for the patient's developmental stage and should last for at least 4 weeks to satisfy the diagnostic criteria of this disorder. Panic disorder is characterized by the presence of recurrent and unpredictable panic attacks, which are episodes of intense fear and discomfort associated with a variety of physical symptoms and a fear of impending doom or death. Diagnostic criteria are at least 1 month of concern or worry about the attacks or a change in behavior related to them. A diagnosis has to be made after a medical etiology for the panic attacks has been ruled out. Specific fear, like fear of darkness, is not a panic disorder. Agoraphobia occurs commonly in patients with panic disorder; it is an acquired irrational fear of going outside and being in places where one might feel trapped or unable to escape. Usually the patient becomes housebound and dependent on the company of others to go out. Your patient refuses to go to school, but she goes out. Patients suffering from social anxiety disorder will present with difficulties in social situations, such as speaking in public, eating in a restaurant, and using public washrooms because of the fear of scrutiny by the others or a fear of being embarrassed or humiliated. Children feel the absence of a parent or the collapse of their parent's marriage as a traumatic emotional event. However, a traumatic event that leads to post-traumatic stress disorder is the exposure to threat of personal death or injury or the death of a loved one; the patient may feel depersonalized and unable to recall specific aspects of the trauma. Trauma is re-experienced through intrusions in thought, dreams, or flashbacks. Patients often actively avoid stimuli that precipitate recollections of the trauma. There is also increase in vigilance, arousal, and startle response. Your patient does not have these symptoms.

A 25-year-old primigravida woman gave birth to a healthy male infant at 40 weeks of gestation by normal spontaneous vaginal delivery (NSVD). She breastfeeds on demand and was doing well until day 4 postpartum. At that time, she developed insomnia, fatigue, and feelings of sadness and depression. She cries easily and feels guilty that she does not enjoy her baby as much as she had expected. She has not yet resumed any of her predelivery social activities and is often ready for bed when her husband returns from work to assume care for the baby. Because she feels so tired, she wishes she had never begun breastfeeding. Question What is the best initial choice of treatment for this patient? Answer Choices 1 A monoamine oxidase inhibitor (MAOI) 2 A selective serotonin reuptake inhibitor (SSRI) 3 A tricyclic antidepressant (TCA) 4 Lithium carbonate 5 Supportive psychotherapy alone

Correct Answer: Supportive psychotherapy alone Show Explanation Explanation This patient has postpartum depression (PPD). The treatment of choice for PPD includes supportive psychotherapy, family (especially spousal) support, understanding, and reassurance, and patient education (reassuring the patient that this is a common normal occurrence). Postpartum depression, commonly referred to as PPD and postpartum blues, is a puerperium condition characterized by mild depressive symptoms that occur during this period. PPD occurs in approximately 50% to 80% of puerperal women. The syndrome is usually transitory, resolving spontaneously within a few days to 2 weeks. Classically postpartum blues starts with a brief period of weeping on the third or fourth day after delivery and peaks between days 5 and 10 after delivery. In addition to depression, sadness, and fatigue, symptoms can also include anxiety, headaches, poor concentration, and confusion. Although the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM 5), describes PPD as occurring within 4 weeks postpartum and the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10), describes it as occurring within 6 weeks postpartum, a mounting body of evidence suggests that PPD can occur even 6 months after delivery. The cause of postpartum blues is unknown, but a hormonal basis is suspected. Of the hormones involved, the most likely candidate is progesterone, and the most likely alteration is progesterone deficiency. TCAs, SSRIs, and MAOIs are incorrect. These antidepressant mediations are all considered second line for PPD. They are reserved for severe cases of postpartum depression, where the patient is unable to care for herself or her baby. When indicated, they should accompany supportive psychotherapy as oppose to being a substitute for it. Lithium carbonate is incorrect. It is a mood-stabilizing agent used in the treatment for manic and bipolar disorders.

A 14-year-old boy presents to you while accompanied by his mother because of problems he causes in the family. He demonstrates boisterous and antagonistic behavior and is often in conflict with his father. She is worried because recently he started talking about suicide or running away, and he is spending his free time with an 18-year-old boy. She feels that this companionship is inappropriate. The patient does well in school. During the interview, your patient reports that since the age of 5 or 6 years old, he has wished to be a girl. He dresses in his mother's clothes, he liked to play with dolls, and he prefers the company of girls at school. Now he wants to dress like a girl all the time. His father either makes jokes at his clothing preferences or becomes angry about his son's preferences. Your patient tells you that he recently met a boy who seems to share the same interests. Question How would you characterize his sexual identity? Answer Choices 1 Transgender 2 Heterosexual 3 Homosexual 4 Asexual 5 Bisexual

Correct Answer: Transgender Show Explanation Explanation Transgender is by definition an individual that express tendencies to vary from culturally conventional gender roles; he/she may even consider conventional sexual orientation labels inapplicable to him/her. Your patient expresses a gender identity problem; he feels himself to be of a gender different from his biological sex. You should think about a gender identity disorder when self-identification as female, male, neither, or both does not match one's assigned sex. Assigned sex is the identification by others as female, male, or intersex based on physical or chromosomal sex. Sexual orientation is how a person is physically and emotionally aroused toward the other persons. Your patient does not give you information about his sexual orientation. Transgender does not imply any specific sexual orientation; you cannot label your patient as homosexual just because he is dressing up in female fashion and likes the company of a person with similar preferences. Asexuality is the lack of sexual attraction to others, the lack of interest in sex, or a lack of a sexual orientation. You do not yet know whether your patient has any kind of sexual interest or sexual orientation. Based on this interview alone, you cannot determine the sexual orientation of your patient. He could be a transvestite because his gender role does not match societal norms. Transvestites have a transgender identity that manifests as dressing up in the clothing of the opposite gender and obtaining pleasure from such actions. Both transgendered individuals and transvestites can be heterosexual, homosexual, or bisexual.

An infant is able to climb stairs alone and begins to use her right hand more than her left hand. Her mother notices that she always looks to see if her mother is there when she plays. She is able to scribble spontaneously. Her favorite word is "no," but she also uses 2-word phrases such as "go eat." She also will say "my nose" while pointing to her own nose. If she is taken from her mother and does not see her mother, she cries frantically. She is able to stack 3 cubes on top of each other when playing. Question Approximately what age is this infant? Answer Choices 1 Newborn infant 2 7 months 3 12 months 4 18 months 5 30 months

Correct Answer: 18 months Show Explanation Explanation This clinical scenario is typical of an 18-month-old child. During this stage, a child should be able to climb stairs alone and start developing a hand preference. The child will experience separation anxiety from 10-18 months of age. From 18-24 months of age, the child can use 2-word sentences. From 18-30 months, the child's vocabulary expands; this period is usually characterized by the "terrible twos," which is when the child starts to develop autonomy and their favorite word is "no." At 18 months, their motor development is such that they can stack blocks and scribble spontaneously. A newborn infant demonstrates reaching and grasping behavior, the Babinski reflex, the ability to imitate facial expressions, synchronization of their limb movements with the speech of others, and attachment behaviors (e.g., crying and clinging). A 7-month-old can sit without support, can stand with support, and demonstrates repetitive responding. Between 7-9 months, an infant may begin experiencing stranger anxiety. At 12 months, a child is able to hold their fingers in a way known as the pincer grasp. The 1ststeps happen between 12 and 13 months. Separation anxiety begins between 8 and 12 months, and it usually terminates around 24 months. Stranger anxiety disappears after 12 months. At 30 months, a child's vocabulary expands; they can also recognize themselves as a boy or girl, and toilet training can be achieved at this time. They can kick a ball and balance on 1 foot for 1 second; they can also stand on their tiptoes.

A 14-year-old girl presents 1 day after passing out at gymnastics practice. The patient sustained no head injury and regained consciousness immediately. She admits to some dizziness, but states that otherwise she feels fine and is eager to return to practice. She appears thin, despite wearing baggy clothes. On examination, her skin is dry and cool to touch. There is soft, downy hair covering her body. Heart rhythm is regular, but she is mildly tachycardic and slightly hypotensive. Neurological examination is normal. Question What is the likely diagnosis? Answer Choices 1 Cushing's syndrome 2 Addison's disease 3 Anorexia nervosa 4 Bulimia nervosa 5 Absence seizure

Correct Answer: Anorexia nervosa The patient is a thin-appearing girl who had an episode of syncope; paired with the presence of soft downy hair over her body (lanugo), this is highly suggestive of anorexia nervosa. Participation in sports where thin body image is idealized, such as gymnastics, puts an individual at increased risk for anorexia nervosa. This patient requires careful intervention in order to avoid the complications of anorexia nervosa, including death. Cushing's syndrome is associated with high levels of cortisol. It causes symptoms such as weight gain, striae, round face, fatigue, and poor wound healing. Addison's disease is due to insufficient production of cortisol by the adrenal glands. It is associated with symptoms such as fatigue, nausea, vomiting, and hyperpigmentation of the skin. Patients with bulimia nervosa do not typically experience extreme weight loss. Patients are more likely to present with dental erosion (due to frequent vomiting) and enlargement of the parotid salivary glands. Lanugo would not be present in a patient with bulimia nervosa. Absence seizure is incorrect. The patient did not suffer any seizure-like activity and has symptoms suggestive of anorexia nervosa.

An 18-year old high school dropout recently set a fire in his old school classroom because he was dared to do so by other students. He has been sent to you for evaluation. You interview him and find that he had a number of problems related to truancy and fighting in school; he has been found with liquor in his locker at school, and he always seems to feel that someone else is responsible for his having done something. When he was 10, the patient burned down a barn; last year, he and some friends threw rocks at passing cars on the expressway. What is the provisional diagnosis? Answer Choices 1 Conduct disorder 2 Antisocial personality disorder 3 Impulse control disorder 4 Oppositional defiant disorder 5 Substance abuse NOS

Correct Answer: Antisocial personality disorder The antisocial personality disorder patient is usually male, has had many problems with authority figures and the law prior to the age of 15; however, the diagnosis is never made in regards to anyone under the age of 18. The DSM5 diagnostic criterion include disregard for and violation of others rights since age 15, as indicated by 1 of the 7 sub features: 1. Failure to obey laws and norms by engaging in behavior which results in criminal arrest, or would warrant criminal arrest 2. Lying, deception, and manipulation, for profit or self-amusement, 3. Impulsive behavior 4. Irritability and aggression, manifested as frequently assaulting others, or engaging in fighting 5. Blatant disregard for the safety of self and others 6. A pattern of irresponsibility 7. Lack of remorse for actions (American Psychiatric Association, 2013) For the diagnosis to be made, the antisocial behavior must not occur in the context of schizophrenia or bipolar disorder.

A 22-year-old man presents to establish care. He states that he was 'beaten up' by his parents as a child, and he was sent to a series of foster homes because he ran away from his home several times. His schooling was rare; he was frequently in trouble for truancy, vandalism, starting fights, and stealing. He dropped out of school at age 15; during that year, he was arrested for car theft and driving while drunk. He has not worked at any job for more than 4 months and has had frequent changes of address because he did not pay rent and meet other financial obligations. He boasts about being the father of 2 children by 2 different women, but he has not provided any support or made any contact with either of them since their pregnancies. He has used several aliases. He has no history of a psychotic break. His IQ testing is normal. Question What is the most likely diagnosis? Answer Choices 1 Abused child reaction formation 2 Antisocial personality disorder 3 Borderline personality disorder 4 Schizotypal personality disorder with psychoactive substance abuse 5 Unipolar manic disorder

Correct Answer: Antisocial personality disorder Show Explanation Explanation The patient meets the criteria for antisocial personality disorder. Criteria include age of onset older than 18, evidence of conduct disorder in childhood, a pattern of irresponsible and antisocial behavior since age 15, and absence of schizophrenia or manic episodes. Abused child reaction formation is not a recognized diagnosis in the DSM. Although this patient has some features of borderline personality disorder (e.g., unstable relationships), the persistently aggressive nature and lack of remorse are much more typical of antisocial personality disorder. Schizotypal personality disorder is not usually associated with such pervasive antisocial behavior and violence. The patient's boasting quality might seem somewhat grandiose, but no other features suggest mania.

A 29-year-old man is currently incarcerated for manslaughter; he has been incarcerated most of his adult life. He also shows at least 3 arrests before the age of 18, beginning at the age of 14. His arrests include drug possession, spousal abuse, drunk and disorderly conduct, and theft. From his perspective, the manslaughter was self-defense because the man that he killed was checking out his wife, and he had to defend his property. He states that if he had it to do all over again, he would have killed the man again. He demonstrates no remorse for his crime. The man never graduated from high school; he started cutting classes in 8th grade, and by the time he began 10th grade he just stopped going to school. He has not held a job for more than a couple of months; he states that his bosses were all jerks and did not treat him right, so he quit. The man states that all of his other crimes were lies and that he was wrongly accused, but the police reports state that he was caught in the act for theft, drug possession, and drunk and disorderly conduct. The neighbors had called regarding the spousal abuse charge because they heard his wife screaming for help. What is the most likely DSM-V diagnosis for this patient? Answer Choices 1 Antisocial personality disorder 2 Conduct disorder 3 Oppositional defiant disorder 4 Unspecified disruptive, impulse-control, and conduct disorder 5 Attention-deficit hyperactivity disorder

Correct Answer: Antisocial personality disorder Show Explanation Explanation This patient demonstrates a failure to conform to social norms with respect to lawful behaviors, deceitfulness (as demonstrated by lying), aggressiveness, consistent irresponsibility (as demonstrated by failing to complete school and inability to sustain consistent employment), and a lack of remorse. All of the aforementioned traits and behaviors are consistent with a diagnosis of antisocial personality disorder. Furthermore, his symptoms of antisocial behavior have been apparent since the age of 13 or 14. Since the patient is over 18 years of age and the criteria for antisocial personality disorder have been met, conduct disorder, oppositional defiant disorder, and unspecified disruptive, impulse-control, and conduct disorder can be ruled out. Attention-deficit hyperactivity disorder can be ruled out by the severity of the patient's symptoms and lack of remorse for his behavior; in addition, people with attention-deficit hyperactivity disorder do not exhibit the level of criminal behavior that is seen in those with antisocial personality disorder.

Parents bring their 3-year-old son for evaluation of a recently diagnosed intellectual disability. The test for intellectual disability was performed primarily because of delayed speech. Mother states that her child started to babble at about 9 months of age and then learned a few words such as "Dada" and "Boo" at 18 months. Despite the efforts of his parents to stimulate his language (by reading to him, singing, exposing him to sounds, music, talks, TV, teaching him to mimic their speech, etc.), his speech has remained far behind the other children of the same age. He is not interested in playing with the other children, always looks serious, and behaves more independently than other children. His prenatal and past medical history is unremarkable; he was always healthy, and his immunizations are up to date, including MMR. While you are taking the anamnesis, he does not seem interested in the conversation. Instead, he started spinning himself, an activity that he enjoyed so much that he did not respond when parents tried to stop him. When asked, his parents left the room, but the child did not pay attention to them leaving. Then he saw fancy colored wooden sticks and started sorting them out by colors because nobody could interrupt him. Developmental screening today is impossible because he simply ignores you; therefore, you decide to schedule a follow up evaluation. Question What is your initial diagnosis Answer Choices 1 Autism spectrum disorder 2 MMR adverse effect 3 Transcortical mixed aphasia 4 Conduct disorder 5 Tourette's syndrome

Correct Answer: Autism spectrum disorder Show Explanation Explanation Your patient probably has autism spectrum disorder. He does not seem to be attached to his parents; his language is not developed; he does not interact with you; and he enjoys spinning himself and arranging things in a peculiar way. Autism spectrum disorders are characterized by disturbances in social interactions and communication together with the restricted or repetitive interests and/or activities that are present prior to 3 years of age. It may be is associated with intellectual disability and is most common in males. Social disturbance manifests as lack of eye contact, poor or absent attachments, and general lack of social interest. Communicative disturbance manifests as lack of communicative speech, as well as the inability to demonstrate the reciprocity in dialogue and/or to use language for communication. Behavioral disturbances may manifest as attachments to objects, stereotyped movements, and the enjoyment in spinning objects or themselves. It has never been proved that autistic disorder is an adverse effect of MMR immunization. Besides, the patient probably received that vaccine 2 years ago Mixed transcortical aphasia is a rare form of aphasia, usually a consequence of a vascular event (stroke), and is characterized by problems in producing and understanding speech with preserved repetition. Conduct disorder is a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months and at least one criterion present in the past 6 months: aggression to people and animals, destruction of property, deceitfulness or theft, serious violations of rules that causes clinically significant impairment in social, academic, or occupational functioning, prior to age of 10. Your patient clearly does not have a conduct disorder. Gilles de la Tourette syndrome is a part of a spectrum of tic disorders, characterized by multiple motor tics and at least one vocal tic. These tics characteristically wax and wane, can be suppressed temporarily, and are preceded by a premonitory urge. This inherited neuropsychiatric disorder starts in childhood. Your patient has no tics.

A 25-year-old man rarely goes out, and his mother is pressuring him to get a girlfriend. He reveals that he has never felt comfortable around other people because he feels too much pressure to "perform". He fears rejection. Question What type of personality disorder does he exhibit? Answer Choices 1 Obsessive-compulsive 2 Narcissistic 3 Borderline 4 Dependent 5 Avoidant

Correct Answer: Avoidant Show Explanation Explanation Avoidant personality disorder is characterized by social inhibition and feelings of inadequacy. Individuals who suffer from this disorder are extremely sensitive to negative feedback from others. They avoid social activities due to their fear of having to participate. Obsessive-compulsive personality disorder is characterized by a lifelong pattern of being preoccupied with perfectionism, orderliness, and control. Individuals with obsessive-compulsive disorder have difficulty being open with others, they are unable to be flexible because it means giving up control, and their perfectionism usually makes them very inefficient in their accomplishments. Other symptoms include excessive devotion to work or to other tasks, being overly conscientious about moral or ethical issues, and having restricted expression of affect. The major features of narcissistic personality disorder are grandiosity (an inflated sense of self-importance), a need for admiration, and a lack of empathy for others. If criticized, the narcissistic individual often reacts with rage and he/she often exploits others. Feelings of grandiosity usually preoccupy the individual, and there is often a profound sense of entitlement. Borderline personality disorder is most often associated with a pattern of unstable interpersonal relationships. Self-image is poor, affect is often labile or depressed, and these individuals are highly impulsive - especially with regard to self-destructive behaviors. Individuals with borderline personality disorder are chronically bored and empty feeling. They alternate between overly idealizing others and devaluing them. Their emotions are intense. Although individuals with borderline personality disorder are said to have a need to be taken care of, they have difficulty accepting the help of others because they mistrust their intentions. Individuals with dependent personality disorder, on the other hand, tend be clingy and submissive in their behaviors because their need to be taken care of is so pervasive. They have difficulty making everyday decisions without consulting others, and they agree with others even if they believe the person to be wrong due to their intense fear of rejection. They have difficulty doing things on their own, and their most pervasive fear is that of being abandoned.

A 27-year old accountant who lives with his mother and has an intense concern that he will be criticized or disapproved of. He steers clear of after-work activities with his fellow workers. He has never had sex, but he is not homosexual and finds women attractive. Needing some assurance that he will be liked, he has problems in social situations and finds it difficult to date because he views himself as inept or inferior to others. Never having had a chance to engage in sports activities as a youngster, he does not want to try his hand at tennis because he may be embarrassed by his poor showing. Question What is the most likely diagnosis? Answer Choices 1 Borderline personality disorder 2 Narcissistic personality disorder 3 Dependent personality disorder 4 Avoidant personality disorder 5 Schizoid personality disorder

Correct Answer: Avoidant personality disorder The avoidant personality disorder involves a pattern, beginning by early adulthood, of avoiding activities where criticism, disapproval, or rejection is possible. Patients with this disorder show an unwillingness to become involved with people without some assurance that they will be liked; they also show restraint in intimate relationships. There is inhibition in trying new situations or activities due to a fear of embarrassment or appearing inept or inferior, and criticism plays a major role in everything they do.

An 18-year-old woman is afraid of dogs. As a child, she was bitten, and she has been afraid ever since. You begin therapy by having the client do relaxation exercises while looking at the word "dog". Once the client is comfortable with this process, you have her do relaxation exercises while looking at a picture of a dog. The next step is to have the client do relaxation exercises while watching a dog from a distance. Finally, you have the client do deep breathing exercises while sitting in the same room as a small dog. The final step is to have the client sit in the same room as a big dog while performing deep breathing exercises. What type of therapy are you using with the client? Answer Choices 1 Cognitive therapy 2 Gestalt therapy 3 Behavioral therapy 4 Psychoanalytic therapy 5 Existential therapy

Correct Answer: Behavioral therapy Show Explanation Explanation The technique being used in this case study is called systematic desensitization. This is a common technique used for phobias or fears in behavioral therapy. Behaviorists are not concerned with the patient's cognitive or emotional processes. They assume that these processes cannot be measured; therefore, they should not be the focus of therapy. On the other hand, behavior can be measured and observed. The therapist can observe when a client can stay in the room with anxiety-provoking stimuli without trying to leave. In cognitive, gestalt, psychoanalytic, and existential therapies, the focus is more on what is going on internally. These therapists want to know what the client is thinking and feeling when in the presence of the anxiety provoking stimuli. The therapist will spend a lot of time talking with the client and assisting the client in changing how they feel about the stimuli or getting to the root of the fear.

A 25-year-old woman is brought in by her sister. The woman has had increasingly frequent incidences of bizarre behavior; they have caused her family concern. The most notable episodes occurred within the past week. She seemed sad and distant for a couple of days; then she left abruptly and returned home after being gone for 2 days. During that time, the woman told her sister that she had driven for 3 hours for no particular reason and spent much of her time partying and spending money. The normally intelligent woman was unable to remember where she had gone, and she could not explain why she left in the first place. After running out of money and sleeping in her car for 2 nights, she called her sister, who came and got her. Her sister found her dirty and speaking quickly about nothing in particular. She was brought home, and she now looks quite calm and seems a bit solemn. On examination, the woman's vital signs are within normal limits. Lab work reveals nothing abnormal. The patient did not display any unusual behavior. She was quite pleasant and cooperative. Her score on the mini mental status exam was 29; however, she does not seem to recall much about what happened a few days ago. Question What is the most likely diagnosis? Answer Choices 1 Bipolar disorder 2 Schizophrenia 3 Schizoaffective disorder 4 Schizophreniform disorder 5 Hyperthyroidism

Correct Answer: Bipolar disorder Show Explanation Explanation Bipolar disorder is characterized by mood swings, which can occur in both men and women. However, in women, bipolar disorder II and rapid cycle bipolar disorder are more common. Patients alternate between periods of mania and depression. During the manic periods, they may talk quickly, act erratically, have increased libido, and engage in reckless behavior. This behavior may be totally out of character in a person who is normally quite intelligent and productive. In severe cases, they may have periods of psychosis. During the depressive phase, the patient may sleep often and have decreased energy and periods of sadness. Bipolar disorder may be broken down into disorders known as bipolar I, bipolar II, cyclothymia (oscillating high and low moods), and major depression. Bipolar I, also known as manic-depression or classic bipolar disorder, is characterized by episodes of major depression contrasting with episodes of mania, which lead to severe impairment of function. Bipolar II is a milder disorder in which depression alternates with periods of hypomania. Hypomania is a less severe form of mania that does not have periods of psychoses or lead to disruption of function. In the majority of cases, symptoms begin between the ages of 15 - 20 years. The 2nd most frequent age of onset is 20 - 25 years. Some patients may have a family history of bipolar disorder, and it is thought to occur equally in men and women. The workup should include tests that will rule out other organic causes for the symptoms. For example, labs tests to check thyroid function and calcium levels should be standard. Other tests should include an EEG and a thorough psychiatric evaluation that takes into account the appearance and behavior of the patient. It is very important to determine if the patient has thoughts of suicide or homicide. Mood stabilizers, such as lithium carbonate and carbamazepine, are the mainstays of treatment in patients with bipolar disorder. Antipsychotic medications, such as risperidone or haloperidol, also may be used if psychotic features are seen. It is important to remember that many patients who are started on medical treatment may stop taking their medications when they begin to feel better. It is essential to stress the need to comply with medical treatment. It is also necessary to educate family members about the disorder and the need to stay with the prescribed treatment. Schizophrenia is a chronic psychotic disorder, with the onset of symptoms usually seen in teens or young adults. Schizophrenia results in fluctuating, gradually deteriorating disturbances in thinking, perception, and behavior. The symptoms must continue for at least 6 months, with at least 1 month of active symptoms; they must result in substantial impairment of functioning. It is not characterized by mood swings, as in bipolar disorder. Using the Diagnostic and Statistical Manual of Mental Disorders, schizoaffective disorder is defined as having features of both schizophrenia (including hallucinations, distorted thinking, delusions) and a mood component (such as depression or mania). The diagnosis is made when the patient has features of both illnesses but cannot be diagnosed as having either schizophrenia or a mood disorder alone. The diagnosis of schizoaffective disorder is made when the patient meets criteria for major depressive disorder or mania, while also meeting the criteria for schizophrenia; also, the patient must have experienced psychosis for at least 2 weeks without a mood disorder. Schizophreniform disorder is a condition in which patients exhibit at least 2 of the following symptoms, each for a 1-month period of time. The symptoms are: delusions or hallucinations; disorganized or catatonic behavior; and disorganized speech. Schizoaffective disorder and mood disorder with psychotic features must be excluded by determining that no major depressive, manic, or mixed episodes have occurred concurrently with the symptoms of psychosis. Hyperthyroidism may lead to anxiety, hyperactivity, and other mood changes. However, this patient has had normal blood work and vital signs. If the patient did have hyperthyroidism, the medical workup would most likely show tachycardia and a decrease in TSH levels.

A 19-year-old student is referred for psychiatric assessment after an attempted suicide 2 days ago. On questioning, the patient informs that the precipitant to her attempted suicide was a recent break-up with her boyfriend. Her history is significant for multiple suicide attempts since the age of 12. On further questioning, the patient informs that she has a chronic feeling of emptiness and sometimes feels disconnected from reality. She also gets into fights with her boyfriends as she has difficulty controlling her anger. The patient admits that she has had highly problematic relationships with men and that she falls quickly in and out of love. Examination reveals several cuts on the wrists and arms. Question What personality disorder does this patient have? Answer Choices 1 Narcissistic 2 Dependent 3 Borderline 4 Histrionic 5 Paranoid

Correct Answer: Borderline The patient has borderline personality disorder (BPD). This psychiatric condition is characterized by emotional turmoil, affective instability, chronic suicidal behavior (suicide ideation and attempts), and instability of interpersonal relationships. Histrionics tend to over dramatize all aspects of their lives and store these over dramatizations as impressions in their brains. They tend to be excessively emotional and attention-seeking. Narcissists have a sense of grandiosity, a constant need for admiration, and a general lack of empathy. Dependent types have submissive and clinging behavior and fears of separation, Paranoid types are characterized by their distrust and suspicion of others.

A 25-year-old man states that he feels sad all of the time, he feels lonely, and all of his relationships seem to fail. His last relationship ended just a few weeks ago and only lasted about 9 weeks. He says his relationships always start out great. He and his love interest will spend endless hours together discussing every detail of their lives. A few weeks into the relationship, things always change. His girlfriends always pull away from him, and they stop respecting his needs. He often tells his girlfriends that if they leave him, he will kill himself. These threats are frequently followed by intense displays of anger. He has been hospitalized 1 time for overdosing on medication and 2 times for superficial cuts to his arm. When asked about his parents, the man states that he rarely speaks with them. They do not seem to understand him or care about him as much as they do his siblings. Although the man went to college for a while, he never seemed able to settle on a major. He has a poor work history, and he frequently changes careers. He states that sometimes the jobs seem like more than he can handle, and he just wants something that does not require so much concentration. He further explains that he does not feel like getting up in the morning, and he has difficulty forcing himself to go to work. He frequently has difficulty sleeping and often spends hours tossing and turning in bed. He says he gets up in the morning feeling just as tired as he was when he went to bed. Question What is the most likely diagnosis? Answer Choices 1 Dysthymic disorder 2 Histrionic personality disorder 3 Dependent personality disorder 4 Major depressive disorder 5 Borderline personality disorder

Correct Answer: Borderline personality disorder Show Explanation Explanation The 4 core defining features of all Personality Disorders according to the DSM 5 include 1) distorted thinking patterns, 2) problematic emotional responses, 3) over- or under-regulated impulse control, and 4) Interpersonal difficulties. A patient must demonstrate "significant and enduring" problems across time in 2 of the 4 areas to receive a diagnosis. Each of the ten specific personality disorders has its own set of observable characteristics. A patient must meet the minimum number of criteria established for any disorder. The most appropriate diagnosis for this patient is borderline personality disorder which falls within Cluster B (dramatic, emotional, erratic Cluster). The patient is experiencing the following BPD criteria: IMPAIRMENTS IN PERSONALITY FUNCTIONING: Self Functioning - chronic feelings of emptiness (identity), instability in goals, aspirations, values, and career plans (self-direction) and Interpersonal Functioning - unstable, conflicted close relationships, marked real or imagined abandonment; alternating between over involvement and withdrawal (intimacy). He is also demonstrating PATHOLOGICAL PERSONALITY TRAITS: Negative Affectivity - Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances. (emotional liability), frequent feelings of being down; suicidal behavior (depressivity). Disinhibition - difficulty establishing or following plans (Impulsivity), engagement in self-damaging activities (Risk taking). Antagonism - persistent or frequent angry feelings (Hostility). Paranoid personality disorder and schizoid personality disorder fall within Cluster A (odd, eccentric cluster). Distorted thinking is the dominating characteristic of these disorders, and common features among this cluster include social withdrawal and social awkwardness. Patients with paranoid personality disorder believe others are out to take advantage of, humiliate, or otherwise harm them. Persons with schizoid personality disorder tend to be socially isolated and don't seek out close relationships as they have a pervasive pattern of social detachment and restricted range of expression, emotionally. Among Cluster C (anxious, fearful cluster) are avoidant personality disorder and dependant personality disorder. These disorders share the charactaristic of high anxiety levels. Avoidant personality disorder has an intense fear of ridicule leading to avoidance of social situations. This limits development of social skills. A strong need to be taken care of by others is at the core of the dependant personality disorder and this person may have difficulty standing up for themselves, avoids conflict and immediately seeks another source of support when a relationship ends.

A 35-year old woman is very concerned that she will be abandoned by her boyfriend. She has always been very intense in her relationships; she frequently alternates between idealization and devaluation, is often highly impulsive, and engages in reckless driving and casual sex. When left alone, her thoughts turn to suicide, and she has made several gestures in the past. Her mood ranges from intense dysphoria to anger, and she sometimes suffers from feelings of dissociation. Question What is the most likely diagnosis? Answer Choices 1 Paranoid personality disorder 2 Dependent personality disorder 3 Borderline personality disorder 4 Histrionic personality disorder 5 Schizoid personality disorder

Correct Answer: Borderline personality disorder Show Explanation Explanation The borderline personality disorder is characterized by intense feelings with marked fluctuations from idealization to devaluation, concerns of abandonment, impulsivity in at least 2 areas which are self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating), suicidal behavior, gestures, threats or self-mutilating behavior, chronic feelings of emptiness, and (occasionally) dissociative symptoms. The histrionic personality disorder appears similar, but its hallmark is a craving to be the center of attention. They use physical appearance as an attention-getting device, they are dramatic and theatrical, and they are easily influenced by others or circumstances.

A 9-year-old boy presents with burning during urination and a creamy white penile discharge. The grandmother is concerned about sexual abuse by a female caregiver. Question What is the most likely diagnosis? Answer Choices 1 Candidal urethritis 2 Chlamydia urethritis 3 Glans-Balanitis 4 Gonoccocal urethritis 5 Human papillomavirus

Correct Answer: Chlamydia urethritis Chlamydia is one of the most common sexually transmitted disease; it would be the most appropriate response in this case. Male patients may be asymptomatic or they may have a white penile discharge as seen in this patient. Gonococcus is also a sexually transmitted disease. It most often causes a yellowish-greenish discharge rather than a white discharge. Candida is a yeast infection. It is usually associated with vaginitis or bladder infection, although a urethritis may occur. Itching is a common symptoms, as well as a thick white discharge. Although it may be transmitted sexually, this is not the most common route of transmission. Glans-Balanitis is an acute or chronic inflammatory condition affecting the glans penis. It may occur as a complication of an infection. This diagnosis would not explain the patient's penile discharge. Human papillomavirus infection does not typically cause a white urethral discharge. It is most commonly associated with genital warts

A 32-year-old woman with a history of a schizoaffective disorder presents with an increase in auditory hallucinations and suicidal ideation. A psychiatrist is consulted; he assesses the patient and makes a recommendation for a 72-hour admission. After reviewing the patient's current medications and past therapeutic trials, the patient is started on clozapine. Question Due to the risk of toxicity with this medication, what lab test must be monitored in this patient? Answer Choices 1 Liver function tests (AST, ALT) 2 Renal function tests (BUN, creatinine) 3 Coagulation studies (PT/INR, aPTT) 4 Complete blood count (CBC) with absolute neutrophil count (ANC) 5 Fasting blood sugar

Correct Answer: Complete blood count (CBC) with absolute neutrophil count (ANC) Show Explanation Explanation Clozapine (Clozaril®) is a second-generation antipsychotic medication indicated for the management of treatment-resistant schizophrenia and for reducing the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder. Due to the risk of agranulocytosis (low white blood cell [WBC] count, specifically neutrophils), patients taking clozapine must have a baseline CBC and ANC before initiation of treatment and a WBC count and ANC every week for the first 6 months. If counts have been acceptable up to this point, the frequency of blood draws can be reduced.

A 14-year-old boy is expelled from school for repeated fighting; his school records show that he frequently cuts school. He has been arrested on 3 separate occasions and is currently on probation. His 1st arrest was for assaulting another boy, the 2nd arrest was for possession of cocaine, and the 3rd arrest was for breaking and entering. The patient has been using drugs for approximately 2 years, and he has been drinking since he was 11. The boy states that he hits other people because they have it coming to them. The boy's mother tells you that he is completely out of control at home; he comes and goes as he pleases, and he refuses to listen to her. In addition, he set a fire in the backyard a couple of months ago. What is the most appropriate DSM-V diagnosis for this patient? Answer Choices 1 Antisocial personality disorder 2 Conduct disorder 3 Oppositional defiant disorder 4 Unspecified disruptive, impulse-control, and conduct disorder 5 Attention-deficit hyperactivity disorder

Correct Answer: Conduct disorder Show Explanation Explanation This patient demonstrates aggressive behavior towards other people (as evidenced by assaultive behavior), destruction of property (as evidenced by setting fires), theft, and serious violations of rules (as evidenced by repeatedly cutting school, drug use, and noncompliance with rules at home); these are all consistent with a diagnosis of conduct disorder. Even though many of the patient's symptoms are consistent with antisocial personality disorder, since the patient is under the age of 18, a diagnosis of antisocial personality disorder cannot be applied. Since the symptoms for conduct disorder have been met, both oppositional defiant disorder and unspecified disruptive, impulse-control, and conduct disorder can be ruled out. Attention-deficit hyperactivity disorder can be ruled out by the severity of the symptoms and lack of remorse for his behavior. Furthermore, those with attention-deficit hyperactivity disorder do not exhibit the level of criminal behavior that is seen in those with conduct disorder.

An 18-month-old boy is brought in for a well-child visit. His mother states that he does not say any words, including 'mama' or 'dada'. He does have monosyllabic babble and points to objects that he wants. The remainder of the child's development is within normal limits, including gross and fine motor skills. He was born full-term via normal spontaneous vaginal delivery with no complications. He has always been healthy. He is currently not on any medications; he has no known drug allergies and all of his vaccinations are up-to-date. On observation, the child plays with the mother and makes good eye contact with her. The physical exam of the child is normal. The head circumference is normal. There is no cleft lip or palate, and the neurologic exam is within normal limits. Question What is the most appropriate next step in the management of this patient? Answer Choices 1 Chromosomal analysis for fragile X syndrome 2 Reassess the language in 3 months 3 Computerized tomography scan of the brain without contrast 4 Consult audiology for a hearing evaluation 5 Testing for pervasive developmental delay

Correct Answer: Consult audiology for a hearing evaluation Show Explanation Explanation The correct response is consult audiology for a hearing evaluation. Speech and language disorders are a serious medical problem that require prompt evaluation. The development of language follows a predictable sequence. Between 12 and 18 months, the child uses single words with an average vocabulary of 20 words. The 2-word sentence stage lasts from 18 to 24 months. Between 24 and 36 months the child begins to speak in 3 to 4-word sentences. A child who does not say any words by 18 months needs further workup. Language acquisition depends on the ability to hear spoken words, the cognitive ability to process language, and the opportunity to practice speech. The differential of speech and language disorders in children is lengthy: • Voice disorders • Sound and speech production disorders ◦ Secondary to oral-facial structural abnormalities ◦ Secondary to neural abnormalities • Speech and language disorders ◦ Secondary to cognitive impairment ◦ Secondary to hearing impairment ◦ Secondary to adverse environmental factors • Primary developmental language disorders ◦ Developmental dysphagias ▪ Mixed repetitive/expressive disorders ▪ Verbal auditory agnosia ▪ Phonologic/syntactic syndrome ▪ Expressive disorders ▪ Developmental verbal dyspraxia ▪ Speech programming deficit disorder ▪ Higher order processing disorder ▪ Lexical deficit disorder ▪ Semantic-pragmatic disorder ◦ Autism ◦ Reading disorders ◦ Language disorders • Acquired speech and language disorders • Mixed disorders Many of these are very specialized diagnoses. 1 of the most common etiologies of speech and language disorder in this patient's age group is hearing loss. Without the ability to hear the words, a child cannot develop language. The cause of hearing loss is also extensive; in an otherwise normal child with speech and language delay, referral to audiology to assess hearing is the 1st and most important step in the child's evaluation. Fragile X syndrome is 1 of the more common genetic etiologies of intellectual disabilities with an incidence of 1 in 1000 boys. Children with fragile X syndrome always have intellectual disabilities with a delay in developmental milestones, including gross motor and language. These children usually show macrocephaly (enlarged head circumference) and facial dysmorphology. The diagnosis is made by DNA testing. Although this diagnosis should be considered in any boy with a developmental delay, it is less likely than a hearing deficit; therefore, this answer is not correct. Without other signs of the disorder, a hearing test should be done before DNA tsting for fragile X syndrome. Since the child is out of the normal range for language development, it is inappropriate to wait and reassess; this would further delay the diagnosis and intervention. In a child with isolated speech and language delay with no other neurologic abnormality, a computerized tomography scan (CT) of the brain would not be warranted. If the child has an abnormal head circumference or another neurologic abnormality (e.g., a seizure disorder), a CT scan would be more appropriate. Autism spectrum disorder and other pervasive developmental disorders can present with language delay or regression. Based on the history given, this child is not likely to have autism spectrum disorder. Children with the disorder generally have qualitative impairment in social interactions. This patient child has normal play with his mother and makes good eye-to-eye contact; therefore, pervasive development disorder is further down on the differential.

A 6-year-old girl presents with hematuria. Review of the child's prior medical records reveals approximately 20 visits to 8 different emergency departments and clinics over the past year for the same complaint. Thorough urologic evaluations have been negative, except for the occasional and inconsistent finding of elevated red blood cells on urinalysis without casts. The child is admitted to the general pediatric ward. Physical examination is negative except for mild erythema of the urethral meatus. Initial laboratory evaluation, including a serum BUN of 8 mg/dl, serum creatinine of 1.0 mg/dl, serum total protein of 7.1 mg/dl, and serum albumin of 4.3 mg/dl, is normal. Urinalysis performed on a sample brought to hospital by the girl's mother is positive for blood. This sample is grossly bloody. However, samples subsequently obtained in hospital under nursing supervision are negative. Renal ultrasonography is normal. The child's mother appears quite cheerful and is rather conversant with medical terms concerning renal disease, such as glomerulonephritis and gross hematuria. She is happy to suggest additional diagnostic tests. Question What is the most appropriate next step in the evaluation of this child? Answer Choices 1 Consultation with child protective services 2 Hematology consultation to rule out coagulopathy 3 Intravenous pyelography 4 Surreptitious video monitoring of the child's room 5 Urology consultation

Correct Answer: Consultation with child protective services Show Explanation Explanation Multiple negative evaluations, inconsistent positive findings, the use of multiple health care facilities, and inappropriate maternal affect should suggest a condition fabricated by a caregiver. Once called "Munchhausen syndrome by proxy," this scenario can be taken to dangerous lengths, sometimes causing multiple invasive and unnecessary surgeries and diagnostic procedures. It is considered a form of child abuse; therefore, the situation warrants the involvement of child protective services. The absence of conclusive evidence of hematuria, as well as the lack of historical or physical findings of bleeding elsewhere, renders a coagulopathy unlikely. The lack of conclusive evidence of hematuria and evidence of normal renal function do not support performing intravenous pyelography. While video monitoring may gather evidence of the mother's manipulating urine specimens or of injuring the child, the physician should not be cast in the primary role of detective in this situation. Such efforts should be coordinated by child protective services. Again, the absence of any real evidence of renal or genitourinary pathology argues against a urology consultation as the next step.

A 17-year-old boy is rushed to the Emergency Department after an outbreak of gang violence. The incident resulted in 3 people dying, and 4 others are in critical condition. He was a witness to the violence, and his older brother is one of the deceased; however, he was not visibly injured by the incident. On examination, he is a healthy appearing 17-year-old in obvious emotional distress. During the assessment, he continually repeats, "I can't see!" He has never had a history of blindness or loss of sight, and his neurologic evaluation is normal. Question What is the most likely diagnosis? Answer Choices 1 Multiple sclerosis 2 Pituitary tumor 3 Occlusion of the middle cerebral artery 4 Malingering 5 Conversion disorder

Correct Answer: Conversion disorder Show Explanation Explanation This patient is suffering conversion disorder, which mimics symptomatology in either the motor or sensory systems. Symptoms can vary from blindness to paralysis and anesthesia. However, in conversion disorder, a physiologic cause must always be considered because an organic cause may be manifested by the conversion disorder. Multiple sclerosis can result in diplopia due to intranuclear ophthalmoplegia. A pituitary neoplasm that grows outside of the sella turcica can press on the optic chiasm, resulting in bitemporal hemianopia. Occlusion of the inferior division of the middle cerebral artery is uncommon, but it can result in contralateral homonymous hemianopia. Malingering is not considered a mental illness and receives a V-code in the DSM5 as a condition that may be a focus of clinical attention. When considering malingering in cases of conversion disorder, there is a conscious exaggeration of a genuine illness or a fraudulent allegation that the genuine symptoms, once present, are still present because this will result in gain for the patient

A 30-year-old man presents with a psychiatric treatment history, but he cannot remember his diagnosis. He describes a pattern of mood disturbances that have occurred since he was 18 years old. He says he is always going up or down, but he usually feels as if he is on top of the world. He is a very driven and successful business entrepreneur, and he speaks rapidly about his prior ventures. He is currently involved in marketing a software product; he has been divorced twice and is currently engaged. He describes his biggest challenge to be 'pacing himself' to prevent burn out, which he characterizes as acute physical exhaustion and about 7 days of 'hibernation' to catch up on sleep. Question What is the most likely diagnosis? Answer Choices 1 Major depressive episode 2 Manic episode 3 Mixed episode 4 Bipolar I disorder 5 Cyclothymic disorder

Correct Answer: Cyclothymic disorder Show Explanation Explanation Cyclothymic disorder describes a condition involving numerous periods of hypomanic symptoms and numerous periods of depressed symptoms over a 2-year period; these symptoms cause significant impairment in social and occupational functioning. In addition, there is never a period longer than 2 months in which symptoms are absent. Hypomanic symptoms include inflated self-esteem, decreased need for sleep, pressured or excessive speech, racing thoughts, distractibility, increased drives, psychomotor agitation, and unrestrained involvement in pleasurable activities. Major depressive episode symptoms develop over a period of days or weeks. For the majority of the time, there must be at least 5 symptoms present over at least a 2-week period; these symptoms include depressed or irritable mood, loss of interest/pleasure in activities, weight fluctuation of 5% or more corresponding to an increase or decrease in appetite, insomnia or hypersomnia, predominant feelings of guilt/worthlessness, poor concentration/memory, and suicidal ideation. A manic episode is a period of mood disturbance lasting a minimum of 1 week. The mood may be elevated and expansive or irritable. 3 - 4 symptoms must be present; they include grandiosity, decreased need for sleep (not insomnia), pressured or excessive speech, distractibility, increased drives, and unrestrained involvement in pleasurable activities. There is accompanying significant impairment in social and occupational functioning. Psychotic symptoms may also be present. A mixed episode is a period of mood disturbance that lasts a minimum of 1 week; symptom criteria for both a major depressive episode and a manic episode must be met. There must also be marked impairment in social and occupational functioning. Bipolar I disorder is a mood disorder characterized by the occurrence of 1 or more manic or mixed episodes alternating with 1 or more major depressive episodes.

A 40-year-old man presents with stage 4 liver cancer. The patient, despite the diagnosis, continues to make business transactions over the hospital telephone and tells everyone he is fine. He gets angry with the nurses for thinking he is sick and giving him medicine. Question What is this man experiencing? Answer Choices 1 Anger 2 Acceptance 3 Grieving 4 Denial 5 Impotence

Correct Answer: Denial Show Explanation Explanation Denial is the avoidance of awareness of some painful reality (e.g., feeling that one is not sick so as to not have to face the painful consequences of the illness). Denial, anger, bargaining, grieving, and acceptance are all Kubler-Ross dying stages; these stages do not have to occur in this order and more than 1 stage can be present at a time. Anger is when patients are angry that something bad is happening to them and ask, 'why me?'. Acceptance is when the patients accept that they are going to die and life must go on. Grieving is when patients enter into a depression where they show signs of decrease in sleep, appetite, and attention or concentration. During this time, they may even consider suicide. Impotence is not related to the stages of dying; it is one of the 4 factors involved in the development of hopelessness. The 4 factors are: a sense of powerlessness or impotence, guilt, anger, and a sense of loss leading to depression.

A 42-year-old man has just been informed that he has poorly differentiated small cell carcinoma of the lung. When asked if he understands the serious nature of his illness, the patient proceeds to tell his physician how excited he is about renovating his home. Question This patient is exhibiting what mechanism? Answer Choices 1 Denial 2 Displacement 3 Projection 4 Rationalization 5 Reaction formation 6 Sublimation

Correct Answer: Denial Show Explanation Explanation This patient is in denial about his serious illness, and by talking about something totally unrelated he is trying to avoid the bad news he has just received. Displacement involves the transferring of feelings to an inappropriate person, situation, or object (e.g., a man who has been yelled at by his boss takes out his anger on his wife). Projection is the attribution of one's own traits to someone else (e.g., a philandering husband accuses his wife of having an affair). Rationalization involves creating explanations for an action or thought, usually to avoid self-blame. Reaction formation is the unconscious changing of a feeling or idea to its opposite (e.g., a man acts very friendly toward a coworker when, in fact, he is unconsciously jealous). Sublimation involves turning an unacceptable impulse into an acceptable one (e.g., someone with very aggressive impulses becomes a professional boxer).

A 26-year-old man ran into a woman with whom he had a relationship in high school 10 years ago. He has always had strong feelings for her and was mildly shocked to find that she is now a happily married woman with a healthy 4-year-old son. Invited to the couple's house for dinner that night, he becomes extremely playful and affectionate with the son; he does so to the detriment of the adult conversation with the couple. Question What mechanism is this man displaying? Answer Choices 1 Denial 2 Detachment 3 Displacement 4 Dissocation 5 Fantasy

Correct Answer: Displacement Show Explanation Explanation Displacement is the process by which pent-up emotions are redirected away from the primary object of that emotion toward other persons, ideas, or objects. This is what is happening in this example. The man is displacing his feelings for his former love onto her son. Like displacement, the other choices are examples of defense mechanisms that are ways of dealing with anxiety or stress. Denial involves keeping thoughts out of one's consciousness in order to try not to deal with them. Dissociation involves separating an act from its emotion. In the extreme, this may express itself as a conversion disorder. Fantasizing involves daydreaming about events that have not occurred; although this occurs in creative processes, it may also be a sign of mental illness. Detachment is characterized by distant interpersonal relationships.

A 60-year-old woman presents to be evaluated for bizarre behavior. Her daughter arrives with her and speaks with you alone; she describes her mother's behavior as consisting of mood swings, lavish trips, spending foolishly, staying up at night, and being hyper. According to her daughter, her mother has been diagnosed with bipolar disorder in the past. She feels her mother needs a mood stabilizer; however, you would rather not try lithium because of excessive weight gain. Question What drug might you consider? Answer Choices 1 Risperidone (Risperdal) 2 Haloperidol (Haldol) 3 Divalproex (Depakote) 4 Trazodone (Desyrel) 5 Trifluoperazine (Stelazine)

Correct Answer: Divalproex (Depakote) Divalproex (Depakote) is a preferred or suggested drug as a mood stabilizer; it has also been used to treat aggressive behavior in patients with Alzheimer's disease. It has been shown to be more favorable than using lithium, especially in nursing homes, because lithium can cause excessive weight gain; however, it should not be used in the elderly who already have poor liver functioning. Risperidone (Risperdal) is actually a drug better used in treating non-psychotic dementia and managing psychotic episodes of schizophrenia and other disorders in the elderly. It often is used in nursing homes for patients with dementia, but it should be used with caution because it is a high potency drug with effects of agitation, fatal cardiac arrhythmia, low blood pressure, electrolyte imbalances, infections, and central nervous system effects. Trifluoperazine (Stelazine) is an acceptable form of treatment for a number of disorders (e.g., psychosis, depressive disorders, alcohol withdrawal, nausea, and dementia); it is sometimes used to treat Huntington's disease. It is usually not suggested as a mood stabilizer, and there is the potential for many side effects. Trazodone (Desyrel) is used as an antidepressant, but it has actually been shown to be a better drug for insomnia treatment in the elderly; it has been used to treat aggressive behaviors in the elderly who have Alzheimer's disease. It is usually very effective in nursing homes. Haloperidol (Haldol) is a suggested treatment for acute episodes of agitation and aggressive behavior in the elderly who have dementia. It is also used for paranoid episodes and psychotic episodes, but it does have a lot of potential side effects such as memory loss, agitation, cardiac arrhythmias, dangerously low blood pressure, and pseudo-Parkinson like symptoms.

An 8-year-old boy presents for evaluation of problems at school and at home. His parents report that he does not pay attention in class; he is frequently in trouble for disrupting the class, and he often forgets to do his schoolwork. He has had similar problems since starting school (in kindergarten), but they are becoming more problematic; his teacher suggested medical evaluation. The teacher reports the patient often seems distracted. He rarely sits still at his desk; he fidgets often, and when he does pay attention to the class discussions, he blurts out comments without waiting his turn. His parents report that the boy has always been 'on the go' and talks excessively; he does not seem to listen when spoken to. He seems capable of doing his schoolwork, but he appears to make careless mistakes. The parents feel the boy is generally well-adjusted; he enjoys sports, has friends, and sleeps well. The parents deny any known medical history, and his prenatal course and delivery were unremarkable. He has never had any surgeries; he takes no medications and does not have any allergies. He lives at home with his biological parents and a younger sister. On physical exam, the boy appears normally developed. Some increased motor activity is noted, but the physical exam is otherwise normal. Question What additional aspect of the history would best fit with this patient's likely condition? Answer Choices 1 Family describes persecutory or grandiose delusions from the patient 2 Father reports similar symptoms throughout his childhood and persisting into adulthood 3 Patient complains of frequent physical ailments for attention 4 Patient frequently eats candy and sugary foods 5 Patient witnessed a traumatic event

Correct Answer: Father reports similar symptoms throughout his childhood and persisting into adulthood Explanation This patient is presenting with attention deficit hyperactivity disorder (ADHD). Patients with ADHD may have inattentive, hyperactive, and/or impulsive behaviors. To meet criteria for ADHD, some symptoms must have been present by age 7 years. There are several suspected risk factors, but a genetic factor has shown to be 1 of the strongest associations for ADHD. The father reporting similar symptoms throughout his childhood and persisting into adulthood is the best fit with this patient who has ADHD. If the family describes persecutory or grandiose delusions from the patient, those delusions are associated with schizophrenia, a psychiatric condition of disordered thoughts, emotions, and behaviors; hallucinations are also possible. This child's presented history and physical do not support a diagnosis of schizophrenia (which is often diagnosed at a later age). If the patient complains of frequent physical ailments for attention, a suspected disorder may be a somatoform disorder (e.g., factitious disorder or malingering). Frequent physical complaints are not associated with ADHD. For years, the general public has associated hyperactivity with sugar consumption; true ADHD is not linked with any dietary factor. A history of the patient frequently eating candy and sugary foods does not fit with this disorder. If the patient witnessed a traumatic event, he may present with signs and symptoms of post-traumatic stress disorder (PTSD). Sometimes, when they are experiencing flashbacks, patients with PTSD can appear distracted. Often, there is hypervigilance, anxiety about the event, disrupted sleep, and hyperarousal. This patient's symptoms have been present for several years, and they fit a diagnosis of ADHD.

A 23-year-old woman presents to her psychiatrist's office for a follow up regarding her 2-year history of bulimia nervosa. Until this time, she has been undergoing cognitive behavioral therapy (CBT) several times per week. She has shown great improvement, but she would like to consider additional measures to control her disorder. Question What medication would be an appropriate adjunctive treatment for the patient's bulimia nervosa while she continues to undergo CBT? Answer Choices 1 Fluoxetine (Prozac) 60 mg daily 2 Diazepam (Valium) 2 mg twice daily 3 Carbamazepine (Tegretol) 200 mg twice daily 4 Donepezil (Aricept) 5 mg daily 5 Methylphenidate HCl (Concerta) 18 mg daily

Correct Answer: Fluoxetine (Prozac) 60 mg daily Show Explanation Explanation The correct answer is fluoxetine (Prozac) 60 mg daily. While CBT is considered to be the first-line treatment for bulimia nervosa, antidepressant medications have been shown to be helpful. The antidepressant medications can reduce binging and purging regardless of whether the patient also has a concurrent mood disorder. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that is commonly used to treat major depressive disorder, depressive episodes in patients with bipolar disorder, and bulimia nervosa. The initial dose is usually 20 mg daily, but the dose usually needs to be titrated up to 60-80 mg daily in order to effectively decrease binge eating. Other antidepressants used in the treatment of bulimia nervosa are effective at the same dosages that they are used to treat depressive disorders and do not require the increased titration that fluoxetine does. Diazepam (Valium) 2 mg twice daily is not the correct answer, as this medication is used to treat anxiety and not bulimia nervosa. Diazepam is a benzodiazepine that is typically given as 2-10mg 2-4 times daily in order to treat adults with anxiety disorders. Carbamazepine (Tegretol) 200 mg twice daily is not the correct answer. Carbamazepine is a dibenzazepine used in the treatment of generalized tonic-clonic, partial, or mixed seizures; it is not used for the treatment of bulimia nervosa. Donepezil (Aricept) 5 mg daily is not the correct answer. Donepezil is a reversible acetylcholinesterase inhibitor that is used to treat Alzheimer's dementia, and it is not used to treat bulimia nervosa. Methylphenidate HCl (Concerta) 18 mg daily is not the correct answer. Methylphenidate is a stimulant used in the treatment of adults and children with attention deficit hyperactivity disorder, and it is used not in the treatment of bulimia nervosa.

A 13-year-old boy presents with dysmorphic features (e.g., a long face, prominent jaw, and large ears), large testes, and intellectual disability (intellectual developmental disorder). History reveals that 2 other family members also have intellectual disability. Question What is the most likely clinical diagnosis in this child? Answer Choices 1 Klinefelter syndrome 2 Noonan syndrome 3 Patau syndrome 4 Fragile X syndrome 5 Prader-Willi syndrome

Correct Answer: Fragile X syndrome Show Explanation Explanation The most likely clinical diagnosis is fragile X syndrome; it accounts for 3% of cases of intellectual disability (intellectual developmental disorder). Macroorchidism and hereditary intellectual disability are 2 specific features of this syndrome. Fragile sites are regions of chromosomes that have a tendency for separation, breakage, or attenuation under particular growth conditions. 1 fragile site associated with fragile X syndrome is on the distal long arm of chromosome Xq27.3. In Klinefelter syndrome, most children (80%) have a male karyotype with an extra X,47,XXY. The remaining 20% have a higher grade of sex chromosome aneuploidy, (i.e., 48,XXXY; 49XXXXY; 48,XXYY). Klinefelter syndrome is the most common cause of hypogonadism and infertility in boys/men; puberty occurs at the normal time, but the testes and penis remain small. Noonan syndrome is an autosomal dominant disorder. Clinical features are similar to Turner syndrome, but Noonan syndrome affects both sexes, while Turner syndrome occurs only in girls/women. Clinical features include a short stature, a low posterior hairline, a shield-like chest, and a short webbed neck. Pulmonary stenosis due to valve dysplasia is the most common cardiac anomaly in Noonan syndrome. In Turner syndrome, the common cardiac defects are bicuspid aortic valve, coarctation of aorta, aortic stenosis, and mitral valve prolapse. Patau syndrome (trisomy 13) is characterized by intellectual disability (intellectual developmental disorder), cleft lip and palate, microcephaly, low-set ears, central nervous system malformations (e.g., holoprosencephaly), and microphthalmia. Prader-Willi syndrome manifests with hypotonia, intellectual disability (intellectual developmental disorder), hypogonadism, and hyperphagia (leading to obesity). Some children with Prader-Willi syndrome have a partial deletion of the paternally derived chromosome 15 and loss of paternally-expressed genes.

A 25-year-old woman presents with inability to achieve intercourse with her partner since their relationship began 6 months prior. She states that she cannot even insert a tampon due to the pain. Further history reveals that a year ago, her partner at that time forcefully made her have intercourse on several occasions. What is the next step in the workup of this patient to confirm the suspected diagnosis? Answer Choices 1 Referral to psychiatrist 2 Laboratory workup to expose the underlying medical condition 3 Transvaginal ultrasound 4 Gynecologic examination 5 Transabdominal ultrasound

Correct Answer: Gynecologic examination Show Explanation Explanation This patient is presenting with Genito-Pelvic Pain/Penetration Disorder, also known as vaginismus. The characteristics of Genito-Pelvic Pain/Penetration Disorder is continuing or repeated problems with any of the following: penetration vaginally during intercourse, significant pelvic or vulvovaginal pain during attempts at penetration or vaginal intercourse, anxiety or fear in anticipation of, during, or as a result of vaginal penetration that causes pelvic or vulvovaginal pain, or significant tensing of the muscles of the pelvic muscles when vaginal penetration is being attempted. To confirm diagnosis, a gynecologic exam must be performed to identify possible physical causative factors or any associated conditions. The exam is also useful to confirm the diagnosis; involuntary spasm of the muscles around the vagina will be palpable during the exam. Laboratory workup and ultrasound will show nothing definitive to confirm the diagnosis of Genito-Pelvic Pain/Penetration Disorder.

A 22-year-old college student presents because she does not eat properly and has missed several menstrual cycles. Her sorority sisters are certain she is not pregnant because she rarely, if ever, leaves their sorority house except to attend classes; she has not dated in more than 6 months. On examination, she is underweight. She walks unaided and her speech is clear and distinct. She has adequate vision, normal-appearing facial expressions, and adequate hearing. On her college entrance physical examination, her height was 5'7" and her weight was 130 pounds. Her weight 1 year later is now 103 pounds. Question What area of her nervous system is involved with her disorder? Answer Choices 1 Hypothalamus 2 Spinal cord 3 Peripheral nerves 4 Cerebellum 5 Cranial nerves

Correct Answer: Hypothalamus Most of the neurologic examination can be accomplished by direct observation of the patient, with a focused observation of the movement of the patient. The absence of menstrual cycles in the absence of sexual contact is the usual and expected pattern associated with the loss of 1/5th of her pre-illness body weight, resulting in hypothalamic dysfunction consistent with her diagnosis of anorexia nervosa. The absence of a gait disorder is reasonably strong evidence against any involvement of her spinal cord, cerebellum, and/or peripheral nerves. The history of leaving her sorority house to attend classes, coupled with the observation that her speech, vision, hearing, and facial expressions all appear to be essentially unremarkable, suggests that her cranial nerves are intact.

A 16-year-old girl is belligerent and has slurred speech; she had brandished a knife in her kitchen and threatened to go find her ex-boyfriend. A neurological examination reveals difficulty with hand coordination, decreased deep tendon reflexes, and an ataxic gait. There are also several beats of horizontal nystagmus and a tremor in both of her upper extremities. The girl's stepmother states that the patient was in a rehab center last year while living with her mother, but she does not know any details about the admission. Question Based on this information, what is the most likely diagnosis? Answer Choices 1 Opioid intoxication 2 Phencyclidine intoxication 3 Sedative, hypnotic, or anxiolytic intoxication 4 Cocaine intoxication 5 Inhalant intoxication

Correct Answer: Inhalant intoxication Show Explanation Explanation Inhalant intoxication is characterized by behavioral changes that include apathy, assaultiveness, and impaired judgment. Physiological changes include nystagmus, slurred speech, psychomotor retardation, and movement abnormalities (e.g., incoordination, depressed reflexes, ataxic gait, and tremor). Mood presentation can range from euphoria to stupor. Opioid intoxication is characterized by behavioral changes that include euphoria followed by apathy, shortened attention span and memory dysfunction, psychomotor agitation or retardation, and poor judgment. Physiological changes that may present include slurred speech, drowsiness, and pupillary constriction. Phencyclidine intoxication is characterized by disinhibition, aggressive behavior, anxiety, panic, rage, and impaired judgment. Physiological changes can include hyperthermia, elevated blood pressure, tachycardia, hyperacusis, nystagmus, diminished pain responsiveness, dysarthria, and seizures. Sedative, hypnotic, or anxiolytic intoxication is characterized by disinhibition, mood lability, and impaired judgment. Physiological symptoms may include slurred speech, poor coordination, nystagmus, impaired memory, and coma. Cocaine intoxication is characterized by behavioral changes that include euphoria, hypervigilance, paranoia, interpersonal sensitivity, anxiety, and poor judgment. There are also possible physiological changes that include pupillary dilation, tachycardia or bradycardia, elevated or lowered blood pressure, psychomotor agitation, cardiac arrhythmias, seizures, and diaphoresis.

A 25-year-old woman presents after collapsing at work. She has a medical history significant for a mood disorder that causes her to have wild mood swings and reckless behavior. She was diagnosed with this disorder 1 year ago; since then, she has been taking her prescribed medication. Her symptoms consist of nausea, vomiting, fatigue, tremor, and hyperreflexia. Lab results show an elevation in BUN and creatinine and elevated serum drug levels, but the results are otherwise normal. Question What drug is most likely responsible for her symptoms? Answer Choices 1 Carbamazepine 2 Lithium 3 Lorazepam 4 Valproic acid 5 Risperidone

Correct Answer: Lithium Show Explanation Explanation Lithium is usually the first-line treatment for mood stabilization; however, it does have side effects that can be quite serious (e.g., polyuria, tremors, seizures, and coma). Other less common side effects include rashes, drowsiness, blurred vision, diarrhea, polyuria, polydipsia, and a metallic taste. Lithium toxicity can result in movement disorders, seizures, and even coma. Lithium should not be used in patients with poor renal function, hypersensitivity to the drug, or cardiovascular disease. In this patient, her elevated BUN and creatinine point to an underlying renal disease that caused her lithium level to become elevated. Carbamazepine is known to cause aplastic anemia and agranulocytosis; therefore, patients must be monitored during treatment. Lorazepam may cause agitation, ataxia, slurred speech, nystagmus, and an altered mental status. Valproic acid may cause confusion, headache, cerebral edema, hallucinations, and irritability. Risperidone may cause an oculogyric crisis, neuroleptic malignant syndrome, and autonomic instability (often manifested as an elevation in core body temperature).

A 37-year-old war veteran comes to the clinic after returning from his last tour in Iraq. During his final days, he witnessed a car bombing that killed 4 of his friends. He feels that he may be experiencing a bout of depression due to the loss of his friends. When probed about the attack, he cannot recall the events that followed the bomb explosion. His memory of that day returns when he "wakes up" in a hospital tent several hours later. He received no injuries from the attacks. After a full work up, including an EEG and other lab work, prove to be negative, a diagnosis of dissociated amnesia is made. What type of amnestic pattern did this man present with? Answer Choices 1 Localized 2 Selective 3 Generalized 4 Continuous 5 Systematized

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

A 7-year-old boy presents with his parents for evaluation of behavior problems in school; the problems have been ongoing for over 6 months. The boy's teacher recommended he be evaluated. She reports that he tests at grade level, but he seems to make careless mistakes on schoolwork and has trouble maintaining attention to instruction; he does not finish his homework, and he often loses his homework, pencils, and books. The boy is seen often fidgeting at his desk; he blurts out answers and has difficulty waiting his turn. The parents agree that they have seen similar traits at home, such as forgetting to do daily activities and being easily distracted, for several years. They view him as a happy, bright boy who is very active. He has had normal vision and hearing screenings. The father reports that he was very similar as a child and still struggles with focus and concentration as an adult, but he never received any help. The parents deny any major changes in the family situation. They would like medical help to improve their son's performance in school. The boy has been seen regularly for his well-child exams and has always met milestones and had normal exams. Today, he is quickly moving about the exam room; he looks at a book for a few moments, and he then looks to the window for a short while before interrupting his parents. Question Assuming the parents agree to medication for their son, what medication is the most appropriate initial treatment? Answer Choices 1 Amitriptyline 2 Bupropion 3 Clonazepam 4 Methylphenidate 5 Sertraline

Correct Answer: Methylphenidate Show Explanation Explanation This child meets criteria for attention deficit hyperactivity disorder (ADHD), and it would be most appropriate to start methylphenidate, a central nervous system stimulant. This medication is considered a first-line therapy for ADHD; it works by regulating dopamine and norepinephrine levels. Amitriptyline is a tricyclic antidepressant (TCA). Sometimes, TCA's are used off-label for ADHD, but they are used after other first-line therapies have failed or if there are comorbidities. However, due to the side effect profile and lower efficacy for ADHD symptoms, amitriptyline is not recommended at this time for this patient. Bupropion is an antidepressant; it also regulates dopamine and norepinephrine levels. It is used off-label for adult ADHD, but it is not indicated for use in children under the age of 18. It would not be a first-line treatment for this child. Clonazepam is a benzodiazepine medication; it is approved for seizure disorders in children. It functions as a sedative and can be used for panic disorder and associated anxiety problems in adults. It may seem useful to 'calm down' this patient's hyperactivity, but the first-line stimulant (methylphenidate) will accomplish this. Clonazepam is inappropriate for a 7-year-old with ADHD. Sertraline is an antidepressant approved for use in children with obsessive-compulsive disorder. It has no role in treating ADHD. If the child's symptoms were thought to be anxiety-related with some obsessive traits, sertraline may be considered.

A 58-year-old woman presents for a follow-up; she is accompanied by her adult daughter. The patient had gone to the emergency department via ambulance after the daughter discovered her mother, confused and shaking, at home. The patient underwent several days of inpatient treatment for substance withdrawal. Her initial symptoms included hallucinations, tremor, nausea, anxiety, insomnia, and a seizure. The patient denies current symptoms. The patient and daughter both note the patient has increased tolerance to greater amounts of her substance and loss of control; the patient has a frequent need for the substance. Her work and home relationships suffer due to her condition. The patient has no other medical conditions, is menopausal, has had no surgeries, takes no medications, and has no allergies. The patient readily admits abuse and dependence on her substance of choice, with a desire to prevent relapse. She has not used any other substances, and has been abstinent of all substance use since hospital discharge. She is currently in individual and group programs to assist her in relapse prevention. She would like pharmacological help to maintain her sobriety. Question What medication is most appropriate in preventing this patient from returning to her likely substance of abuse? Answer Choices 1 Diazepam (Valium) 2 Methadone (Methadose/Dolophine) 3 Naloxone (Narcan) 4 Naltrexone (ReVia/Vivitrol) 5 Varenicline (Chantix)

Correct Answer: Naltrexone (ReVia/Vivitrol) Show Explanation Explanation The acute episode described by the patient and her daughter is consistent with delirium tremens, a serious and possibly fatal condition resulting from alcohol withdrawal. Symptoms include seizures, tremor, nausea, anxiety, visual and auditory hallucinations, confusion, and diminished orientation. Delirium tremens can progress to coma and death if not recognized and treated. Alcohol dependence is common, and many patients diminish and hide their alcohol consumption. Acute intervention includes supportive treatment of symptoms and benzodiazepines. In order to maintain abstinence, psychosocial support is vital. In addition, 2 medications, naltrexone (ReVia/Vivitrol) and acamprosate (Campral), are approved for maintenance treatment of alcohol dependency. Diazepam (Valium) is a benzodiazepine and is often indicated for acute alcohol withdrawal; it is not appropriate for use in preventing relapse in alcoholics. As a controlled substance with abuse potential, it would be risky to prescribe diazepam to this patient. Methadone (Methadose/Dolophine) is a long-acting opioid. It is used for pain treatment and acute detox and maintenance treatment of opioid addiction; this patient's history does not suggest opioid addiction. Acute intoxication symptoms may include sedation, euphoria, pinpoint pupils, unconsciousness, and withdrawal symptoms (e.g., nausea, vomiting, dilated pupils, abdominal cramps, and insomnia). Naloxone (Narcan) is an opioid antagonist used for opioid overdose and reversal. This patient's presentation does not suggest dependence or abuse of opiates. Varenicline (Chantix) affects nicotinic acetylcholine receptors and is approved for smoking cessation. This patient's presentation does not indicate tobacco dependence.

A woman talks incessantly about how important her work is. She is director of an advocacy program. It seems as if her world revolves around her work; she believes that, without her at the helm of the program, "the little people would just never be able to organize to fight their cause." Her words remind you of a famous tax fraud case, and you wonder if this woman is suffering from some type of personality disorder. What personality disorder does she likely have? Answer Choices 1 Obsessive-compulsive 2 Narcissistic 3 Borderline 4 Dependent 5 Avoidant

Correct Answer: Narcissistic Show Explanation Explanation The major features of narcissistic personality disorder are grandiosity (an inflated sense of self importance), a need for admiration, and a lack of empathy for others. If criticized, the narcissistic individual often reacts with rage, and he/she often exploits others. Feelings of grandiosity usually preoccupy the individual, and there is often a profound sense of entitlement. Obsessive-compulsive personality disorder is characterized by a lifelong pattern of being preoccupied with perfectionism, orderliness, and control. Individuals with obsessive-compulsive disorder have difficulty being open with others, they are unable to be flexible because it means giving up control, and their perfectionism usually makes them very inefficient in their accomplishments. Other symptoms include excessive devotion to work or to other tasks, being overly conscientious about moral or ethical issues, and having restricted expression of affect. Borderline personality disorder is most often associated with a pattern of unstable interpersonal relationships. Self-image is poor; their affect is often labile or depressed, and these individuals are highly impulsive, especially with regard to self-destructive behaviors. Individuals with borderline personality disorder are chronically bored and empty feeling. They alternate between overly idealizing others and devaluing them. Their emotions are intense. Although individuals with borderline personality disorder are said to have a need to be taken care of, they have difficulty accepting the help of others because they mistrust their intentions. Individuals with dependent personality disorder, on the other hand, tend be clingy and submissive in their behaviors because their need to be taken care of is so pervasive. They have difficulty making everyday decisions without consulting others, and they agree with others even if they believe the person to be wrong due to their intense fear of rejection. They have difficulty doing things on their own, and their most pervasive fear is that of being abandoned. Avoidant personality disorder is characterized by social inhibition and feelings of inadequacy. Individuals who suffer from this disorder are extremely sensitive to negative feedback from others. They avoid social activities due to their fear of having to participate.

A 40-year-old man comes to see you at the insistence of his wife. He states that there is nothing wrong with him, but if seeing a psychiatrist will satisfy his wife, then he is willing to do it. The client states that he is a very successful businessman, and tells you that his wife recommended he see a therapist. He states that, if he was going to receive counseling, then he wanted to see a psychiatrist because they have more education. The patient then states that his wife is frustrated because they have no friends and he is too picky about people. Upon further elaboration, the client says that he is not going to spend time with just anyone, and he adds that spending time with people less educated and less intelligent than himself is a waste of time. When asked about his job, the client states that it is okay, but he is underappreciated. He tells you that, without him, the company would never make any money; however, he feels that nobody ever recognizes how important he is to the company. Question What is the most likely diagnosis? Answer Choices 1 Borderline personality disorder 2 Histrionic personality disorder 3 Antisocial personality disorder 4 Narcissistic personality disorder 5 Obsessive-compulsive personality disorder

Correct Answer: Narcissistic personality disorder Show Explanation Explanation This client is experiencing an inflated sense of self, believes that he has special abilities, will only associate with those of "high status," and believes that he deserves special recognition. These symptoms are all characteristic of narcissistic personality disorder. Narcissistic personality disorder can be differentiated from borderline personality disorder and histrionic personality disorder by the extreme grandiosity of those with narcissistic personality disorder. Antisocial personality disorder can be distinguished from narcissistic personality disorder by the presence of impulsive and aggressive behaviors and a history of conduct disorder. This disorder can be differentiated from obsessive-compulsive personality disorder by the fact that many people with narcissistic personality disorder believe that they have achieved perfection, whereas those with obsessive-compulsive personality are overly self-critical.

An 82-year-old woman presents with her anxious daughter, who lives with her. The daughter has noticed recent 'lapses in memory' and feels that her mother has become forgetful of late. Her lapses in memory usually relate to people's names and recollection of past events and recent conversations. According to her, she is otherwise healthy, takes calcium and vitamin D for osteoporosis, asprin for her heart, and vitamin B complex. She has no history of trauma, strokes, or CNS infections. Her lapses in memory mostly affect short term memory. She is able to carry out activities of daily living and is well oriented to time, place, and person. Her husband passed away 18 months previously, and she sometimes finds it difficult to sleep when she remembers his death. She feels 'lonely' and 'desperate' at times. Her BP is 130/80 mm Hg, and other vitals are normal. Neurological, cardiac, respiratory, and abdominal exam are normal. Her MMSE score is 28/30. Question What is the most likely diagnosis? Answer Choices 1 Pseudodementia 2 Normal aging 3 Alzheimer's disease 4 Pick's disease 5 Parkinson's disease

Correct Answer: Normal aging Normal aging is the correct answer. Normal aging is associated with a decline in memory abilities in many cognitive tasks. This is known as age-related memory impairment. Episodic memory is especially impaired in normal aging. In contrast, procedural memory (performing tasks) shows no decline with age, and semantic memory (vocabulary, etc.) may actually improve. In this patient, there is no impairment of activities of daily living, and it is mostly episodic memory that is affected. Furthermore, the MMSE score is within normal limits. Pseudodementia is incorrect. Pseudodementia is a clinical syndrome seen in association with an underlying psychiatric illness, usually depression. Patients with pseudodementia may be identified by a few clinical pointers. They usually have a more gradual onset of dementia, have intact concentration and attention, and are overly concerned about their loss of memory. On the other hand, true dementia usually starts insidiously; patients may have impaired concentration and attention, and patients usually appear unconcerned with their loss of memory. Alzheimer's type dementia is the most common type of dementia. It is a form of true dementia and, as such, usually starts insidiously. As mentioned, patients may have impaired concentration and attention and usually appear unconcerned with their loss of memory. Activities of daily living are often severely impaired, and the MMSE score is decreased. Pick's disease is incorrect. Pick's disease, or fronto-temporal dementia, is characterized by dementia with symptoms of frontal lobe dysfuction, such as disinhibition. Parkinson's disease is incorrect. Parkinson's disease is characterized by the triad of rigidity, bradykinesia, and tremor, none of which this patient has.

You have just finished a health maintenance visit on a feisty 2-year-old; he was brought in by his mother. He seems to be growing well, his weight and height are following the 50th percentile, he is meeting major motor and language milestones on time, and his mother has no concerns. On first entering the room, he is observed sitting quietly in a corner of the room on the floor looking at some picture books while you take a full history from his mother. When you try to pick him up to put on the examining table, however, he begins to throw himself backwards on the floor repeatedly, cries and screams loudly, and hits you and his mother. With some difficulty, you complete a cursory exam and ask about his behavior at home and any family stressors while he moves away from his mother and goes back to his corner to look at books. Question What observed behavior would most likely indicate a disorder of affective development? Answer Choices 1 Prolonged loud crying 2 Throwing himself to the ground repeatedly 3 Hitting anyone within reach including his mother 4 Sitting quietly reading 5 Not seeking out his mother

Correct Answer: Not seeking out his mother Show Explanation Explanation Affective development during the toddler years, which occurs between the ages of about 18 to 36 months, includes an emerging temperament, the striving for autonomy and independence from caregivers, achievement of impulse control, and the continued importance of attachment to family. The attachment bond that forms between the infant and caregiver is important in both social and emotional development during infancy and the preschool years. The toddler relies on secure parental ties for the confidence to venture out and explore, being always cognizant of the caregiver's presence and intermittently returning for reassurance. Disorders of attachment may result from inconsistent care giving and may be more common if there are family stressors such as poverty, drug use, or emotional illness. These affected toddlers may show no interest in exploring their environment, may display separation problems, or distrust the primary caregiver, which is evidenced in this case by not seeking out the primary caregiver, his mother. With the acquisition of improved motor skills comes a new drive for autonomy and independence. The child finds he can now move easily away from the parent and manipulate utensils and other objects. With these new skills, he will begin to test boundaries and limits leading to daily struggles for autonomy in the form of temper tantrums. As he develops his own opinions and preferences about everyday activities, he may cry, hit, and throw himself on the ground if he does not get his way. A child's temperament, or behavioral style, determines how he approaches a given situation. Temperament has strong genetic elements and is often apparent in early infancy. By the toddler years, temperament is generally evident and predictable. Temperament will influence personal interactions and is composed of different attributes, including activity level, distractibility, adaptability, attention span and persistence, intensity of reaction, threshold of responsiveness, and quality of mood. Certain clusters of these attributes will define 3 different temperamental styles: easy, slow to warm, or difficult. The "easy" child tends to be cheerful, has regular eating and sleeping schedules, adapts well to new situations, and has positive moods. The "slow to warm" child has low activity levels with mild responses and tends to withdraw and take longer to adapt in new situations. The "difficult" child adapts poorly to new situations, has increased intense emotional reactions, and tends to be emotionally negative and unpredictable. Sitting quietly and looking at books may reflect this child's "slow to warm" temperament.

A mid-level manager complains that he is having problems at work because his employees just will not take the care he does in doing their jobs. Consequently, he says, he fears that their lack of interest in their work will prevent him from getting ahead because his attention to detail and devotion are not seen by his boss when overall production is low. Probing reveals that there are actually more problems here than just the attitudes of this man's employees. His attention to detail often gets in the way, and it prevents work from being accomplished in a timely manner. You formulate further questions to determine if this man might have what personality disorder? Answer Choices 1 Obsessive-compulsive 2 Narcissistic 3 Borderline 4 Dependent 5 Avoidant

Correct Answer: Obsessive-compulsive Show Explanation Explanation Obsessive-compulsive personality disorder is characterized by a lifelong pattern of being preoccupied with perfectionism, orderliness, and control. Individuals with obsessive-compulsive disorder have difficulty being open with others, they are unable to be flexible because it means giving up control, and their perfectionism usually makes them very inefficient in their accomplishments. Other symptoms include excessive devotion to work or to other tasks, being overly conscientious about moral or ethical issues, and having restricted expression of affect. The major features of narcissistic personality disorder are grandiosity (an inflated sense of self importance), a need for admiration, and a lack of empathy for others. If criticized, the narcissistic individual often reacts with rage, and he/she often exploits others. Feelings of grandiosity usually preoccupy the individual, and there is often a profound sense of entitlement. Borderline personality disorder is most often associated with a pattern of unstable interpersonal relationships. Self-image is poor, affect is often labile or depressed, and these individuals are highly impulsive - especially with regard to self-destructive behaviors. Individuals with borderline personality disorder are chronically bored and empty feeling. They alternate between overly idealizing others and devaluing them. Their emotions are intense. Although individuals with borderline personality disorder are said to have a need to be taken care of, they have difficulty accepting the help of others because they mistrust their intentions. Individuals with dependent personality disorder, on the other hand, tend be clingy and submissive in their behaviors because their need to be taken care of is so pervasive. They have difficulty making everyday decisions without consulting others, and they agree with others even if they believe the person to be wrong due to their intense fear of rejection. They have difficulty doing things on their own, and their most pervasive fear is that of being abandoned. Avoidant personality disorder is characterized by social inhibition and feelings of inadequacy. Individuals who suffer from this disorder are extremely sensitive to negative feedback from others. They avoid social activities due to their fear of having to participate.

A 3-month-old boy presents with a 12-hour history of lethargy. Physical exam reveals a child who cries and becomes irritable when examined. There is edema noted over the left side of the head. There is no papilledema, and his mother denies a history of the child vomiting. There is a single faint bruise on the upper lip. A CT of the head reveals a linear skull fracture of the left parietal bone; there is no evidence of intracranial injury. On further questioning, the mother states, "My baby rolled over the sofa onto a carpeted floor 2 days ago." Question What is the best management in this case? Answer Choices 1 Give 80cc of 0.9% normal saline (i.e 20mL/Kg) 2 Give intravenous mannitol to lower intracranial pressure 3 Discharge the child after a 4 hour observation period if the infant is asymptomatic 4 Discharge the child immediately with instructions about precautions following head injury 5 Obtain a skeletal survey to rule out child abuse

Correct Answer: Obtain a skeletal survey to rule out child abuse Show Explanation Explanation Child abuse frequently is unrecognized and unreported, and non-accidental injuries cause 1000's of childhood deaths per year. The possibility of abuse should be considered in any child who presents with a serious injury. Therefore, a skeletal survey should be obtained in this case. A detailed history is the crucial initial step in differentiating accidental from intentional injury. An incomplete or changing history, a history of injury not appropriate for the developmental age of a child, or a history that is incompatible with the type of severity of the injury also are suggestive of the abuse. Linear skull fractures may occur when a child falls onto a hard surface. Rolling off a sofa or a bed, as was reported for this child, is usually associated with only minor injuries, such as abrasions or soft tissue injuries. Also, when a parent seeks medical care for a child who has sustained an accidental head injury, he or she usually volunteers a clear history concerning recent trauma or injury immediately. Failure to give any history for a head injury until confronted with obvious evidence of trauma (e.g., hematoma, skull fracture) is highly suggestive of either neglect or non-accidental trauma. Signs and symptoms of head trauma and central nervous system injury in young children are non-specific and include vomiting, lethargy, seizure activity, and irritability. More serious signs are a rise in intracranial pressure present with a significantly altered level of consciousness, apnea or other respiratory abnormality, hemodynamic instability, or shock. The triad of vomiting, headache, and papilledema, called the Cushing triad, is considered classic of raised intracranial pressure. Findings on physical examination include soft-tissues swelling or lacerations of the scalp, bony step-offs, a bulging fontanelle, split sutures, or pupillary abnormalities. An infant who is the victim of suspected non-accidental trauma should never be discharged to the care providers without a full evaluation for other injuries and further investigations of all of the circumstances surrounding the injury. Bruises over the face in younger children and over the shin, elbow, or forearm in older children should raise suspicion. Skeletal surveys are indicated for all infants who are suspected victims of abuse to document the presence of recent or healed fractures. CT is the most appropriate investigation to evaluate whenever there are signs or symptoms of head trauma. In the absence of findings consistent with increased intracranial pressure, intravenous mannitol is not indicated. Intravenous fluids should be administered judiciously, and fluid boluses are contraindicated in the absence of shock.

A 19-year-old college student presents with pounding heart, sweating, coldness, and difficulty in breathing. He said that he was studying for an important exam and drinking lots of caffeine, and he then started to feel like he was going to die of an attack. Examination, ECG, and tests do not demonstrate any pathology. Question What is the most likely diagnosis? Answer Choices 1Panic attack 2 Panic disorder 3 Hyperthyroidism 4 Generalized anxiety disorders 5 Myocardial infarction

Correct Answer: Panic attack The correct answer is panic attack. Panic attack is diagnosed after excluding all physical causes (examination and tests were normal). DSM 5 panic attack criteria include: • Palpitations, pounding heart, or accelerated heart rate • Sweating • Trembling or shaking • Sense of shortness of breath or smothering • Feeling of choking • Chest pain or discomfort • Nausea or abdominal distress • Feeling dizzy, unsteady, lightheaded, or faint • Derealization or depersonalization (feeling detached from oneself) • Fear of losing control or going crazy • Fear of dying • Numbness or tingling sensations • Chills or hot flashes The patient is diagnosed with a panic disorder when the patient suffers repeated panic attacks or is worried about having more attacks. Panic attacks are aggravated by caffeine and/or smoking. The other differentials in this case are ruled out by examination and tests.

A 25-year-old woman presents with a 10-minute history of sharp pain localized to her anterior right chest wall. It began on her way to an audition and is associated with feeling lightheaded and tingling sensations running down her back. She also reports that she is afraid of "losing control." Question What is the most likely cause of this patient's chest pain? Answer Choices 1 Tietze's syndrome 2 Myocardial infarction 3 Panic disorder 4 Mallory-Weiss Syndrome 5 Tuberculous pleuritis

Correct Answer: Panic disorder Chest pain due to a panic disorder has a variable presentation. It can be retrosternal or localized; it can be brief or last for over 30 minutes. Numerous terms such as aching and sharp can be used to describe it. Other symptoms of a panic disorder such as feeling lightheaded, short of breath, or nauseated; paresthesias, palpitations, derealization, and the fear of losing control may also be present. The history helps elicit precipitating factors and prior panic attacks. Tuberculous pleuritis chest pain ispleuritic and aggravated by coughing. It is described as sharp. Other symptoms such as fever, dyspnea, and weight loss may also be present. On examination, there may be dullness on percussion and absent breath sounds on the affected side. In Tietze's syndrome, patients present with anterior chest pain that is aggravated by taking a deep breath, sneezing, and turning motions. On examination, the affected costochondral junctions are erythematous, warm, and tender on palpation. The most commonly affected are the 2nd or 3rd costochondral joints. Patients with myocardial infarction usually present with a left-sided or retrosternal pain that may radiate to the jaw, neck, and shoulder. They describe it as heaviness or a squeezing sensation. It is of variable duration and often lasts for more than 30 minutes. There is a gradual intensification of the pain. The onset of the pain may be during physical exertion or at rest. It is not relieved by nitroglycerine. On examination, they may be dyspneic and diaphoretic. In the Mallory-Weiss Syndrome, patients present with hematemesis, especially after repeated severe retching and vomiting, which results in a mucosal tear at the gastroesophageal junction. They may also have retrosternal chest pain.

A 23-year-old woman presents due to palpitations, numbness, shortness of breath, and sweating. She has noticed that this occurs about 1-2 times per week. These symptoms occur independent of being in social situations. Physical exams and laboratory findings are within normal limits. Question What is the most likely diagnosis? Answer Choices 1 Generalized anxiety disorder 2 Panic disorder 3 Post traumatic stress disorder 4 Social phobia 5 Panic attack

Correct Answer: Panic disorder Show Explanation Explanation The clinical picture is suggestive of a panic disorder due to the symptoms of recurring palpitations, shortness of breath, sweating, and numbness. Generalized anxiety disorder is not correct because it would present with symptoms of constant worry and a hard time concentrating that are chronic and generalized. Post-traumatic stress disorder is not correct because the patient never described experiencing a terrifying event. Social phobia is not correct because patient did not describe that social interactions cause anxiety, palpitations, sweating, abnormal heartbeat, worry about embarrassment or humiliation, or concern about being judged. Panic attack is not the correct answer. Even though the patient presents with symptoms of a panic attack, the patient describes reoccurring episodes of the panic attacks, which is more descriptive of panic disorder. Therefore, panic attack is not the correct answer

A 30-year-old man presents with periodic sensations of choking, numbness in his feet, tingling in his legs, cold sweats, and dizziness. He states that he used to feel this way as a child whenever he went to the mall with his mother. The feelings have been increasing over the past few years; the episodes occur while checking out at the grocery store, while driving or walking over bridges, and while looking out his 19th-floor office window. What psychiatric diagnosis fits this patient best, after ruling out substance use and any precipitating medical condition? Answer Choices 1 Panic disorder with agoraphobia 2 Social anxiety disorder 3 Post-traumatic stress disorder 4 Generalized anxiety disorder 5 Obsessive-compulsive disorder

Correct Answer: Panic disorder with agoraphobia Show Explanation Explanation All of the answer choices are anxiety disorders; they present as anxiety far out of proportion to the actual situation. What distinguishes them is the pattern of each disorder's symptomatic manifestation. Panic disorder with agoraphobia is described as panic attacks not due to direct physiological effects of a substance or general medical condition. Phobias manifest as intense anxiety that is routinely elicited by specific situations (e.g., crowds, escalators, standing in lines, high places) or the presence of specific things (e.g., bees, water, snakes, spiders). A social anxiety disorder is a marked and persistent fear of 1 or more social performance situations in which the person is exposed to unfamiliar people or the possible scrutiny of others. Post-traumatic stress disorder would only be indicated if all of the fearful situations were related to the same general traumatic event(s). Generalized anxiety disorder is 'free-floating' and not relative to specific situations. Obsessive-compulsive disorder involves behavioral or ideational loops that seem intended to 'ward off' the experience of anxiety.

A 40-year-old man is referred by his primary physician for an evaluation of possible mental health problems. He was seen by the physician a month ago and presented with some bizarre behavior, such as recurring thoughts that his wife is having an affair. He is preoccupied with the idea that his friends are following him. His wife claims that he never confides in others and carries a grudge regarding his peers. He has no medical condition that would explain his behavior, and he does not use alcohol or drugs. His wife describes his behavior as long-standing; she has noticed it ever since they were married 5 years ago. Question What personality disorder is present in this case? Answer Choices 1 Schizoid personality disorder 2 Paranoid personality disorder 3 Schizotypal personality disorder 4 Antisocial personality disorder 5 Borderline personality disorder

Correct Answer: Paranoid personality disorder Show Explanation Explanation Paranoid personality characteristics consists of the following: unjustified distrust and suspicion of others, the inability to confide in others, and the tendency to carry grudges and resent peers or colleagues for no founded reason. People with the disorder appear cold, calculating, and see suspicious meanings in everything. They usually have occupational difficulties, and they only do well if they have a solitary job. Schizoid personality characteristics include: being lifelong loners, having a restricted emotional range, exhibiting unsociable behavior, appearing cold and reclusive, and enjoying few activities. Most people with the disorder do not marry or have romantic relationships. They often daydream and carry an unusual attachment to animals, but not to people. They are unaffected by praise or criticism, and they have no interest in sexual behavior. Schizotypal personality characteristics include: behavior that is influenced by magical thinking, telepathy, and/or aliens; unusual perceptions or bodily delusions; odd behavior and appearance; extreme anxiety in social situations; and an affect that is blunted or inappropriate to the topic at hand. Antisocial personality characteristics include: frequent bullying and threatening others, the tendency to start fights, and the tendency towards physical cruelty to animals and later humans. People with the disorder often steal and force sex on other individuals. Borderline personality characteristics include: unstable impulse control, early adult life instability in interpersonal relationships, frantic attempts to prevent abandonment, identity disturbance, self-damaging behavior, self-mutilating behavior, severe reactivity to moods, chronic feelings of being no good, and angry and paranoid behavior that may last for short or long periods of time.

A 25-year-old woman has a 2-month history of panic attacks that occur more than 3 times a week. After a thorough history and examination of the patient, she is diagnosed with a panic disorder. What is the first-line drug used in the pharmacological management of a panic disorder, in association with psychotherapy? Answer Choices 1 Alprazolam 2 Clonazepam 3 Paroxetine 4 Imipramine 5 Clomipramine

Correct Answer: Paroxetine Explanation The correct response is paroxetine. Panic attacks frequently start in the late teenage years or early adulthood. These attacks can be very distressing and debilitating, with feelings of derealization and depersonalization occurring. Other common symptoms are dizziness, nausea, other gastrointestinal discomfort, and a feeling of choking or imminent death. The goal of treatment is to reduce the intensity of these attacks and to decrease the frequency of their occurrence. Selective serotonin reuptake inhibitors (SSRIs) are the first-line agents for the treatment of a panic disorder since SSRIs are better tolerated than other drugs. The SSRIs that are used in the treatment of panic disorder include paroxetine, fluoxetine, fluvoxamine, sertraline, and citalopram. The mechanism of action of SSRIs is the selective inhibition of presynaptic reuptake (reabsorption) of serotonin. As a result, more serotonin is available in the brain; this enhances the neurotransmission and improves mood. Paroxetine is administered in a dose of 10 - 40 mg daily. Adverse effects include agitation, restlessness, nausea, diarrhea, headache, nervousness, diaphoresis, and weight gain. Alprazolam and clonazepam belong to the benzodiazepine class; they are also used in the treatment of panic disorders. They are used as adjuncts to SSRIs in the initial treatment. Clonazepam is the benzodiazepine of choice; alprazolam use has been discouraged because of a higher potential of dependency. Tricyclic antidepressants (TCAs) (e.g., imipramine and clomipramine) are the second-line drugs for panic disorders. Some severe adverse effects (e.g., cardiotoxicity and autonomic disturbances) may occur. Patients taking TCAs may also experience weight gain, constipation, headache, photosensitivity, blurred vision, and urinary retention.

A 42-year-old woman presents for a routine appointment. She is a relatively new patient; she was seen for the 1st time for her annual gynecologic examination 2 months ago. At that time, she was noted to be tearful and appeared sad. Although she is a professional chef, the patient describes little interest in eating. She has difficulty concentrating, and she has long been described as "irritable" by her co-workers and her husband. She feels tired during the day and is having difficulty sleeping at night. Despite the success of her restaurant, the patient reports feeling sad and hopeless most days for the past several years. She initially thought that she was menopausal, but her menses are regular. She now feels that she is depressed, and she would like to discuss her treatment options. She denies any current or past symptoms of mania. Physical examination is unremarkable. Labs (drawn during 1st week of menstrual cycle/follicular phase): • FSH 10 mU/ml (menopausal range 30-100) • LH 8 mU/ml (menopausal range 16-166) Chemistry panel and CBC values all within normal limits. Question What is the most likely diagnosis? Answer Choices 1 Cyclothymic disorder 2 Persistent depressive disorder (Dysthymia) 3 Major depression 4 Menopause 5 Schizophrenia

Correct Answer: Persistent depressive disorder (Dysthymia) The diagnosis of Persistent Depressive Disorder (Dysthymia), includes the following DSM 5 criteria: "Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years." While the patient is depressed, he/she must experience 2 of the following: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration and/or difficulty making decisions, and/or feelings of hopelessness. Dysthymia has symptoms in common with major depression, such as a depressed mood, difficulty with sleep, fatigue, changes in appetite, and a decrease in concentration. The symptoms of major depression are usually more severe and may include feelings of guilt and thoughts of suicide. Major depression, as stated above, has symptoms in common with those of dysthymia. The symptoms associated with depression are generally more severe; the diagnosis requires 5 symptoms instead of 2, and they may also include anhedonia (decreased pleasure in usual activities) and psychomotor symptoms, which are generally not present with dysthymia. Patients with schizophrenia may present with either positive or negative symptoms. Positive symptoms include hallucinations, delusions, and disorders of movement or thought. Negative symptoms include lack of pleasure in everyday activities (which may also be a symptom of depression), paucity of speech, and a flat affect. This patient is past the usual presenting age for schizophrenia; more importantly, she does not show signs of delusional thought or behavior. Cyclothymia is a mild form of bipolar disorder. A dysthymic mood is part of the disorder, but the diagnosis also requires hypomania. This patient has no history of manic or hypomanic symptoms (elation, inflated self-esteem, agitation, or risky behavior). This patient is unlikely to be menopausal; she has regular menses and her labs are not in the menopausal range. The patient's depressive symptoms should be addressed whether or not she is menopausal.

A 29-year-old man presents with bouts of severe depression; the depression is accompanied by suicidal thoughts. Although he is well-educated, he has been unable to get a job that fits his training because of his illegal status in this country. He has been doing odd jobs, and he has barely been making a living. His relationship with his girlfriend has become stormy over the last few months, and he confesses that he wants to kill his girlfriend. You believe his intent to kill his girlfriend to be serious and suspect that the underlying cause of his fury and homicidality, is untreated depression. For his own safety, you recommend admitting himself to a psychiatric hospital for further evaluation and treatment. He vehemently refuses. Under these circumstances, considering your professional obligations, what should you do? Answer Choices 1 Having thoroughly explained to the patient the risks and benefits involved in his decision, and having deemed him to be a competent adult, leave the decision regarding hospitalization up to him. 2Call the girlfriend and other friends and relatives in the hope of influencing the patient to change his mind and consent to hospitalization. 3 Proceed with the procedure for involuntary hospitalization. 4 Call the police to have patient arrested. 5 Call a responsible adult who can assure the safety of patient and his girlfriend.

Correct Answer: Proceed with the procedure for involuntary hospitalization. Show Explanation Explanation The relationship between the physician and the patient is protected by the concept of confidentiality or privileged information. No information shared with the physician may be released to another party without the explicit and written consent of the patient. This includes release of medical information to other physicians and health care facilities. The right of the patient to confidentiality is protected by law. It is both illegal and unethical to notify the authorities of the patient's illegal status. The doctor's sole task in this case is to evaluate and treat the patient. The exception to this rule concerns information released to the physician that may threaten the life of the patient or others. Under these circumstances, the physician is required to assure safety of the patient in the case of suicidal plans and to notify the victim and the police in the case of homicidal plan. This is generally known as the Tarasoff rule, which was named after a case in California in 1976 in which a therapist was found guilty for failure to inform the victim of a planned homicide. The physician has the responsibility to proceed with emergency detention of a clearly dangerous patient. In the presence of mental illness, the patient is to be detained in the hospital with the intention of providing treatment for the condition that led to the threat to self or others. If the patient refuses to admit himself to the hospital, the physician, in most states, is given jurisdiction to hospitalize the patient against his will for 48 hours. This allows the judicial process to be initiated so that further treatment can take place.

A 16-year-old girl presents with a 4-hour history of loss of consciousness. Her older sister states that the patient has been depressed and was found with an empty medication bottle containing what she can only describe as prophylaxis for tuberculosis. The patient has now begun having generalized tonic-clonic seizures. Examination reveals a developed teenage girl responsive only to painful stimuli; there are intermittent tonic-clonic movements of the extremities. Question Besides the general care of an unconscious patient with seizures, what should be given as a specific antidote in this case? Answer Choices 1 Atropine 2 Diphenylhydantoin 3 Methylene blue 4 Pyridoxine 5 Vitamin K

Correct Answer: Pyridoxine Show Explanation Explanation Isoniazid (INH) is an antibiotic commonly used for tuberculosis prophylaxis. It binds to pyridoxal-5-phosphate, the active form of pyridoxine, which is a cofactor in GABA synthesis. An overdose of INH can result in decreased GABA levels, causing cerebral excitability and seizures. Seizures in acute INH overdose are frequently refractory to standard anticonvulsants. Pyridoxine (Vitamin B6), administered on a gram for gram basis with the amount of INH ingested, is usually needed for seizure control. Atropine is used for ingestion of agents with cholinergic activity, such as organophosphate pesticides. Diphenylhydantoin is not a specific antidote to isoniazid, and, in fact, isoniazid decreases diphenylhydantoin metabolism, placing such a patient at risk for phenytoin toxicity as well. Methylene blue is used to treat methemoglobinemia. Vitamin K is used to treat Coumadin toxicity.

A 35-year-old woman is reluctant to try an antidepressant for fear of becoming a drug addict. How should the physician respond? Answer Choices 1 Respect her scruples and treat her with psychotherapy alone 2 Give her the medication and refer her to a 12-step program 3 Reassure her that antidepressants are not drugs of abuse because of oral administration, lack of immediate reward, and lack of tendency to cause tolerance 4 Prescribe lower than recommended doses to avoid inducing a "high", explain to the patient she will not become addicted as long as she stops the drug after a few weeks 5 Tapering to avoid withdrawal symptoms

Correct Answer: Reassure her that antidepressants are not drugs of abuse because of oral administration, lack of immediate reward, and lack of tendency to cause tolerance Show Explanation Explanation You should reassure the patient that antidepressants are not drugs of abuse because of oral administration, lack of immediate reward, and lack of tendency to cause tolerance. Drugs can be screened in animals for abuse potential. Abusable drugs are rewarding (animals will self-administer them in preference to eating/drinking) and tend to induce both tolerance and withdrawal. The more rapid the onset of the sought for changes, the more likely the drug will be abused. Rapidity of onset is related to the particular drug taken and to the mode of administration. Drugs that are injected or inhaled are especially quick in action. Inhalation, in particular, bypasses first pass metabolism in the liver. Therefore, IV use of heroin or snorting of cocaine (especially highly concentrated forms known as crack) quickly leads to abuse. Conversely, patients may be reassured that most prescribed medications, even psychotropics (except benzodiazepines), are not abusable drugs and patients do not become addicted to them. Giving lower doses of antidepressants or prescribing them for a few weeks would be incorrect, since the onset of action is delayed up to 3 or 4 weeks, and the drugs should be continued for at least 4 months. (Short courses followed by tapering would be correct for a benzodiazepine). Antidepressants, especially cyclic antidepressants, may precipitate a withdrawal syndrome if stopped abruptly, but this alone does not make them abusable.

A 6-year-old boy is performing poorly in school. According to his teacher, he can perform some schoolwork and answer test questions, but he has difficulty understanding the instructions. He has to ask for detailed help regarding instructions, and his teacher sometimes has to demonstrate it to him with action so that he can proceed with his lessons. He is the 2nd among 3 siblings, and he is in kindergarten at the present time. Except for language skills, developmental milestones are appropriate for his age. At 15 months, he could not respond to simple instructions like "no" and "give me". At the time, his mother thought, "He's just a little different than the other siblings." He has had difficulty with school ever since he started. Question What is the most likely diagnosis? Answer Choices 1 Problems with Phonology 2 Semantic Deficit 3 Weak Metalinguistics 4 Expressive Language Dysfunction 5 Receptive Language Dysfunction

Correct Answer: Receptive Language Dysfunction The clinical picture is suggestive of Receptive Language Dysfunction, which mainly affects understanding. Those afflicted may have serious difficulty with following instruction, understanding verbal explanation, and interpreting what they have read. Receptive Language usually precedes Expressive Language, so before infants can speak their first words, they should be able to appropriately respond to simple commands such as "no," "bye-bye," and "give me." A strong familial incidence of language and learning problems would indicate a probable genetic component, especially in the absence of other disorders such as intellectual disability, hearing loss, motor disorder, socioemotional dysfunction, or frank neurologic deficits. A multidisciplinary evaluation consisting of a pediatric health care provider or nurse, child psychologist or psychiatrist, and a psychoeducational specialist is recommended. Phonology problems involve an unclear understanding of the English language sound; this is especially true if the child in question has his own native language. This has a negative effect on reading. Children may have trouble with letter combinations and manipulating language sounds in their minds. Semantic Deficits are also common language disorders in which children have trouble learning and using new words. They have a hard time developing a semantic network where words relate to each other in their meanings. Weak Metalinguistics is a form of semantic deficit in which they have an underdeveloped sense of how language works. Children with Expressive Language Dysfunction have difficulty communicating. They have problems with articulation, verbal fluency, and word retrieval. Despite having an adequate vocabulary, they have a hard time finding words to say when they need them, such as during classroom discussion. They also have difficulty forming sentences and using correct grammar. They are usually passive and non-elaborative in their communication.

A 16-year-old boy is brought in by his mother. According to her, he mistakenly cut his wrist with a kitchen knife. She states that he has been a good student until recently, has never taken drugs, and does not drink alcohol. He has never been under psychiatric care or had counseling. She is sure that this was an accident. You examine the patient alone; he presents with 2 superficial lacerations on the left wrist. The boy is right-handed. No suturing is necessary, so you clean the wounds and update his tetanus status. While talking to him, you ascertain that his schoolwork has dropped 2 grade levels; he tells you that he is not sleeping and not eating well. Recently, he has taken to drinking alcohol he stole from his parents' liquor cabinet, and last week he started thinking he "wanted it all to end". An on-call psychiatrist is contacted and will be there in about 1 hour. You tell the mother that you are concerned about her son's mental status and you want him to see a psychiatrist in about an hour. She wants to take her son home, and she appears anxious. Question What action should you take? Answer Choices 1 Have the mother sign an AMA (Against Medical Advice) form and take her son home 2 Agree to release the patient if the mother agrees to take him to a psychiatrist within 24 hours 3 Arrange for the patient's transfer to a psychiatric hospital 4 Refuse to release the patient until he is evaluated by the psychiatrist 5 Tell the mother to get her husband and you will release her son to both parents

Correct Answer: Refuse to release the patient until he is evaluated by the psychiatrist Show Explanation Explanation The correct response is to refuse to release the patient until he is evaluated by the psychiatrist. The 1st patient advocate is the physician. In that role, he/she must do no harm and always act to protect the patient; nowhere else is this more evident than in the case of minors. Laws vary from state to state. There are instances in which the adolescent's level of maturity plays a significant role in his legal rights and his ability to give or deny consent, even when a parent is present; however, in the case of suicide or possible suicide, the physician must act in the best interests of the patient, even to the point of denying the parents' requests or demands. Laws have been changing regarding adolescent rights as far as consent is concerned, and much more responsibility is now given to the patient. The statistics regarding suicide methods and age and sex differentiation is voluminous. In this case, it was rightly decided that this young man attempted suicide, and a psychiatric evaluation is necessary prior to disposition. The most important aspect of this case is the refusal to capitulate to the parent.

A 6-year-old boy presents with gradually progressive complaints about his behavior. His mother notes that her son does not interact or play with other children in school and behaves indifferently to loved ones entering and exiting rooms. He screams and cries inconsolably at times upon exposure to loud sounds, and he reacts angrily to bright lights and when family members hug him. He appears to not be as talkative as his peers, and he has difficulty in speaking in the first person when trying to communicate his desires. The physical exam reveals a 6-year-old boy with poor eye contact who is observed turning the water faucet on and off incessantly in the office, intently focused on the water stream. When asked to point to a particular object in the room, the patient is unable to do so. Question What agent would be most useful in controlling this patient's irritability and repetitive behavior? Answer Choices 1 Haloperidol 2 Methylphenidate 3 Fluoxetine 4 Clonazepam 5 Risperidone

Correct Answer: Risperidone This patient's most likely diagnosis is autism spectrum disorder. Neuroleptic medications, particularly the atypical neuroleptics, are effective in decreasing stereotypic behavior and agitation. The second-generation antipsychotic agents risperidone and aripiprazole provide beneficial effects on challenging and repetitive behaviors in children with autism spectrum disorder, although these patients may experience significant adverse effects. Risperidone and aripiprazole have been approved by the United States Food and Drug Administration (FDA) for irritability associated with autistic disorder. Additionally, the second-generation antipsychotic agent ziprasidone may help to control aggression, irritability, and agitation. Haloperidol is a first-generation antipsychotic medication not indicated in the treatment of autism spectrum disorder. Hyperactivity often improves with stimulants such as methylphenidate. Serotonergic drugs, such as fluoxetine, are reportedly beneficial for improving behavior in autistic disorder. SSRIs are widely prescribed for children with autistic disorder or a related condition. These agents are used off-label to help with intractable repetitive behaviors (e.g., compulsion), but not with irritability, rage, or agitation. At this time, benzodiazepines are not used to treat autistic manifestations in humans; improved social interaction, decreased repetitive behaviors, and better spatial learning were observed in mice treated with clonazepam.

A 27-year-old woman presents with excruciating back pain. She states that the pain started earlier that morning and caused her to miss work. She has had similar pain like this before, but no doctor has ever found anything wrong. She is currently on fluoxetine for depression and periodic ibuprofen for pain. On physical exam, tissue texture changes are noted at L1 to L3, with no additional findings. However, the woman seems to be in an immense amount of pain and continues to insist that something is horribly wrong with her. Diagnostic results are negative, and a pain medication is prescribed. She returns later in the week with the same complaint but no new findings. History shows episodes similar to this involving joint pain, abdominal pain, headaches, bloating, diarrhea, a 'lump in the throat' feeling, and menstrual cramps. What is the best way to manage this patient? Answer Choices 1 Tell her it is all in her head and not to worry 2 Make sure that appointments are only made when new symptoms arise 3 Order all diagnostic tests and lab work to rule out physical causes of her pain 4 Refer her to specialists for the wide array of pain symptoms and make sure all the physicians are involved in ordering exams and prescribing medications 5 Schedule frequent visits and involve her in deciding what should be accomplished at each appointment 6 Treat the comorbid psychiatric problems and the pain symptoms will abate 7 Discourage group therapy since it typically reveals more problems; treat the comorbid psychiatric problems and the pain symptoms will abate

Correct Answer: Schedule frequent visits and involve her in deciding what should be accomplished at each appointment This patient has Somatic Symptom Disorder (SSD). Many persons, who were previously diagnosed with somatization disorder under the old DSM-IV TR, could now be diagnosed with Somatic Symptom Disorder. In the DSM 5 there is no requirement for a particular number of somatic symptoms or type/group of symptoms, however they must be significantly distressing or disruptive to daily life. The somatic symptoms also have to be accompanied by excessive thoughts, feelings, or behaviors. The onset of the disorder is typically before the age of 30. The complaints need not occur at the same time, but the pain is characterized to be out of proportion to the actual physical disturbance. These patients feel that they truly have a medical disturbance and are best managed by frequent visits where the patient chooses a single complaint to focus on. It is best to avoid statements similar to "it's all in your head." Additionally, diagnostic and lab work should only be ordered if the physical exam indicates such. It is best for 1 physician to coordinate care and prescribe medication instead of having several physicians on the case. Finally, group therapy is helpful for patients with somatic symptom disorder because it provides a social support and may make them less reliant on medical assistance

A 23-year-old woman comes to see you because her mom told her she should see a doctor for "her problem". When asked about "her problem", the woman states that she just does not like being around people and prefers to be alone. Her mom does not believe that this is normal. When asked how long she has felt this way, the client states that she started progressively isolating herself more and more about 6 years ago. She does not have any hobbies, and she prefers to just sit in her room or maybe put together a puzzle. She wishes that she could just disappear sometimes so that she would not have to talk to anyone. The woman has no history of alcohol or drug use, and she has never had sexual intercourse. She states that she has no desire to have intimacy with another person. She denies having any delusions or hallucinations. She has never experienced mania or depression. She states that she does not really feel anything at all. The client expresses very little emotion throughout the course of the interview. Question What is the most likely diagnosis? Answer Choices 1 Autism spectrum disorder 2 Psychotic disorder not otherwise specified 3 Schizoid personality disorder 4 Paranoid personality disorder 5 Avoidant personality disorder

Correct Answer: Schizoid personality disorder Show Explanation Explanation This client expresses a lack of desire for social relationships, a preference for solitary activities, little interest in most activities or intimacy, and has demonstrated a flattened affect. These symptoms are all characteristic of schizoid personality disorder. Furthermore, this woman's symptoms had an onset around the beginning of adulthood, and she is not experiencing any psychotic symptoms, which further lends support for this diagnosis. Schizoid personality disorder can be differentiated from autism spectrum disorder by the age of onset. In autism spectrum disorder, symptoms must have been present before the age of 3. It can be differentiated from paranoid personality disorder by the lack of suspicious or paranoid ideation. In avoidant personality disorder, a person isolates himself or herself due to a fear of social interactions; in contrast, people with schizoid personality disorder isolate themselves from social interactions due to a lack of desire.

A 28-year-old man presents for a checkup. Medical records indicate a 3-year history of hospitalizations for mania and depression. The last admission occurred 7 months ago and was due to a suicide attempt after a major depression. The patient has been taking lithium since the last hospitalization; there have been no further mood disturbances, but his mother relates that the patient continues to remain convinced that the "city officers" poisoned the water system. He refuses to drink tap water. His mother heard him talking alone in his room, and she found many bottles of water under his bed. On examination, the patient appears disheveled; he experiences auditory hallucinations and persecutory delusions. Question What is the most likely diagnosis? Answer Choices 1 Bipolar disorder type I 2 Delusional disorder 3 Schizoaffective disorder 4 Schizophreniform disorder 5 Schizophrenia

Correct Answer: Schizophrenia Schizoaffective disorder is diagnosed when patients with a clinical picture of a mood disorder also have psychotic symptoms that resemble schizophrenia. The requirement for diagnosis is that the psychotic symptoms have to persist more than 2 weeks after the mood disturbances resolve. This patient has been taking lithium, which resolved the mood problems, but he also manifests persistent positive symptoms for schizophrenia for more than 2 weeks. Treatment involves antipsychotics associated to a mood stabilizer, antidepressants, and electroconvulsive therapy. Although this patient has a history of mania and major depression, which are characteristic symptoms of bipolar I disorder, having psychotic symptoms for more than 2 weeks after the resolution of the mood disorder makes the diagnosis of a mood disorder with psychotic features unlikely. Patients with delusional disorder do not have psychotic symptoms, and their delusions are not bizarre and may happen in real life. Poisoning of the water system by "city officers" is a bizarre delusion that is unlikely to happen, and it makes the delusional disorder an unlikely diagnosis for this patient. Schizophreniform disorder is diagnosed when patients have psychotic symptomatology similar to schizophrenia; however, the duration must be less than 6 months. Patients with schizophreniform disorder do not appear socially withdrawn, and the clinical course may be self-limited or progress to either schizophrenia or bipolar disorder. This patient has had psychotic symptoms for more than 6 months; therefore, a diagnosis of schizophreniform disorder is not possible. Schizophrenia is diagnosed when patients have attenuated or absent positive symptoms (hallucinations, delusions) with persistent residual negative symptoms. This patient has persisting hallucinations and delusions.

A 70-year-old woman has been refusing to leave her room at the nursing home facility where she resides. She says that people are following her, and she even refuses to go out with her daughter. She has a long history of mental illness; her ex-husband had her committed to a state hospital, which is where she had resided for over 30 years. On interview, it is difficult to obtain a history; her thinking is disordered. When asked why he committed her, she says that she believes her husband was trying to kill her. Question What is the most likely diagnosis? Answer Choices 1 Delusional disorder 2 Schizophrenia 3 Schizotypal personality disorder 4 Substance-induced psychotic disorder 5 Psychotic disorder due to a medical condition

Correct Answer: Schizophrenia The most likely diagnosis is schizophrenia. Schizophrenia requires the presence of at least 2 of the following symptoms: 1) delusions; 2) hallucinations; 3) disorganized speech; 4) disorganized or catatonic behavior; and 5) diminished mood or expression of emotion. These symptoms must be persistent for at least 6 months and cause a significant impairment in work and social function. A delusional disorder requires the presence of delusions that persist for at least 1 month. Delusions are defined as fixed beliefs that are not amenable to change in light of conflicting evidence. The patient in this example is exhibiting a persecutory delusion (i.e., belief that one is going to be harmed or harassed by another person or group). In order to make the diagnosis of delusional disorder, the patient must not meet criteria for the diagnosis of schizophrenia. Patients with schizotypal personality disorder are often considered odd and eccentric due to their unusual beliefs and way of dressing, as well as difficulty relating to people. They are often suspicious of other people. Nevertheless, they may experience anxiety or even be depressed at their inability to form relationships with other people. Delusions and hallucinations are not prominent; therefore, this patient's symptoms are more consistent with the diagnosis of schizophrenia. Substance-induced psychotic disorder is diagnosed when a patient presents with delusions and/or hallucinations and there is a history of substance abuse. The symptoms may occur during intoxication or withdrawal from drug use. There is no history of drug use in this patients and the symptoms have persisted for decades, making this diagnosis unlikely. Psychotic disorder due to a medical condition is diagnosed when a patient exhibits delusions and/or hallucinations as a consequence of a known pathophysiological event or condition, such as a malignancy. There is no history of medical disease in this patient. Furthermore, this is an unlikely diagnosis in a patient whose symptoms have been present for decades.

A 25-year-old man presents with beliefs that the government is reading his mail and having satellites spy on him. He is wearing dirty clothes and broken eyeglasses. He claims that for the past 45 days he has been hearing his mother's voice; she is warning him to be careful, especially of those around him, because he is being followed. His mother died 5 years ago. The man does not appear depressed or euphoric, and any past history of medications or drug abuse could not be elicited. He admits that he consumed alcohol every day for 5 years until about 6 years ago. He claims he broke the habit and has not consumed alcohol since. He refuses to cooperate with further examination. He was treated with haloperidol and sent home on risperidone. When the patient presents for a follow-up visit after 3 months, he appears to be in remission. He denies hearing voices and being spied on. Question What is the most likely diagnosis? Answer Choices 1 Brief psychotic disorder 2 Schizophrenia 3 Schizophreniform disorder 4 Schizoaffective disorder 5 Substance/medication-induced psychotic disorder

Correct Answer: Schizophreniform disorder The diagnosis in this client is schizophreniform disorder. For diagnosis, schizophreniform disorder requires the presence of schizophrenic symptoms, namely delusions, hallucinations, speech disturbances, and negative symptoms for a period of more than 1 month but less than 6 months. Diagnosis is straightforward and does not require very many symptoms if the delusions are bizarre enough, which is the case in this patient. Once the diagnosis is confirmed, treatment (including psychotherapy and antipsychotics) is started. Atypical antipsychotics are preferred today because they have fewer side effects.; however, in emergent care situations, traditional antipsychotics (e.g., haloperidol) are used because the newer ones are given orally and take longer to act. The newer ones include risperidone, olanzapine, quetiapine, and aripiprazole. Brief psychotic disorder consists of similar symptoms that are present for less than 1 month. Schizophrenia requires the presence of similar symptoms for a period more than 6 months. Schizoaffective disorder includes symptoms of both schizophrenia and a mood disorder. The patient here is said to have a neutral mood. Substance/medication-induced psychotic disorder may be seen in acute intoxication, during withdrawal, and in idiosyncratic reactions to alcohol. The main symptoms would be hallucinations or delusions. According to the patient history, he stopped alcohol intake 6 years ago. DSM 5 criteria require the hallucinations or delusions to develop during or within 1 month of substance intoxication or withdrawal, so there is minimal possibility that this could be the diagnosis. Chronic alcoholism, malnutrition, and co-existing drug abuse are the contributing factors to this condition.

A 32-year-old woman lives alone, has no friends, dresses strangely, and talks in an unusual manner. Although odd, she is able to maintain employment and has not been known to have trouble with the law. Question What is the most likely diagnosis? Answer Choices 1 Obsessive-compulsive personality disorder 2 Avoidant personality disorder 3 Alcohol abuse 4 Narcissistic personality disorder 5 Schizotypal personality disorder

Correct Answer: Schizotypal personality disorder Show Explanation Explanation This patient's presentation is most consistent with schizotypal personality disorder, which is a condition characterized by a lifelong pattern of indifference to others as well as odd behavior and thinking, and/or unconventional beliefs, detachment, and the need for social isolation. Although isolated, patients are not usually unhappy with their lack of social contact. Patients with avoidant personality disorder usually demonstrate a pervasive pattern of social inhibition, fear of being rejected ("not understood"), mistrust in others, and avoidance of social interaction. Avoidant personality disorder usually manifests in early adulthood. Narcissistic personality traits include an overblown sense of self-importance and self-centeredness; they typically have little concern for the needs of other people. Irresponsible or erratic behavior is uncommon in patients with this condition. Obsessive-compulsive personality disorder is characterized by the restricted ability to be warm and tender, perfectionism with demands of perfectionism in others, as well as dedication to work and accomplishment. Alcohol abuse is usually marked by episodes of disinhibition and irresponsible behavior, which may compromise relationships and job security.

A 12-year-old girl presents with symptoms of anxiety. Her parents report that she has always been an anxious child, but her anxiety levels have escalated greatly during the past school year. The girl frequently resists going to school in the morning, and once there, her symptoms often escalate to a point that involves the school nurse. At that point, they are usually alleviated by telephone contact with her mother. The symptoms are not limited to school days. They also occur on the weekends when her mother has to work. Her daughter telephones her frequently on those weekends. The mother describes her daughter as her "sidekick", believing she is most happy at her side. The girl becomes distressed when she does not know her mother's whereabouts. The girl has a normal circle of friends, but rather than go out with them, she prefers to be with them at her home. She has never slept away from home. When at home, she spends a considerable amount of time alone in her room, but she will often come out to "check up" on her mother. Question What diagnosis best fits the patient's symptoms? Answer Choices 1 Post-traumatic stress disorder 2 School phobia/refusal 3 Depression 4 Separation anxiety disorder 5 Panic disorder

Correct Answer: Separation anxiety disorder Show Explanation Explanation The defining features of separation anxiety disorder include distress when away from an attachment figure, usually a parent, and pervasive worry that some unknown event threatens the integrity of the family. There is an unrealistic worry of harm coming to an attachment figure, avoidance of being alone, resistance to go to school, resistance to go to sleep, nightmares about separation, and distress when separated from the attachment figure or in anticipation of separation. Adolescents report physical complaints on school days as a primary symptom. The ability to attend school without resistance is variable. Affected adolescents are generally able to attend school, but they may seek frequent telephone contact with the attachment figure throughout the day. Post-traumatic stress disorder occurs after an individual faces a catastrophic event involving threat of death or serious injury, witnesses such an event, or is aware of such events occurring in the community. The event is a singularity, meaning that it is outside the scope of usual day-to-day experience. The event is re-experienced through intrusive recollections of the event, recurrent dreams, and flashbacks. Adolescents with school phobia/refusal persistently refuse to attend school. In a sense, the name is a misnomer; those affected do not fear school; rather, they fear a situation encountered in school. Anxiety may relate to evaluation of performance. There is intense worry about doing poorly. It may also relate to social situations and fears that others will critically evaluate social performance in the negative. Panic attacks associated with panic disorder can be associated secondarily with separation anxiety disorder in both children and adults. Depression involves the presence of at least 5 of the following 9 symptoms on a regular basis: depressed or irritable mood; diminished interest or pleasure in daily activities; weight loss or weight gain; insomnia or hypersomnia; agitated or reduced physical behaviors; fatigue or loss of energy; perceptions of worthlessness or inappropriate guilt; diminished ability for cognitive thought and decision making; and recurrent thoughts of death or suicide. For all of the above, treatment is multimodal, involving combinations of individual therapy and medication; success rates vary.

A 45-year-old man suffers from chronic insomnia. When he lost his job 3 years ago, he was prescribed triazolam 0.25 mg HS, which he continues to take. He has found another job, but he has not been successful in gaining the same type of managerial position for which he was once paid a six-figure salary. Initially, the insomnia was the only problem he had, in addition to having 2 or 3 drinks with dinner. Recently, he has developed further behavioral problems. Although he continues to take 0.25mg HS triazolam, he is still suffering from sleep problems. He does not have a significant past medical history. The family physician has refused to refill the prescription, so he has found a series of physicians who have given him prescriptions for triazolam (Halcion) and alprazolam (Xanax). His mood has deteriorated to the point that he finds himself becoming verbally aggressive toward coworkers, which is causing serious problems on the job. The patient's boss is concerned that his work has fallen off, and he seems to have problems remembering customers' orders; he is also missing deadlines. He is frequently bumping into furniture and appears to be poorly coordinated. He is now becoming disturbed because he cannot seem to remember things that he did during the day and is having more fights with his wife. Question What is the most likely diagnosis? Answer Choices 1 Intermittent Explosive Disorder 2 Dependent Personality Disorder 3 Major depressive disorder 4 Substance/medication-induced mood disorder 5 Dysthymic disorder

Correct Answer: Substance/medication-induced mood disorder Show Explanation Explanation Substance/medication-induced mood disorder is the correct response. A personality disorder is only diagnosed when there is a persistent pattern of behavior, without any association to a particular medical illness or substances. In this case, there is no evidence of a personality pattern that was pathologic, but there is evidence of several substances being used for a lengthy period of time, with a change of mood and behavior as a result. The substances (i.e., alcohol, triazolam, and alprazolam) are directly related to the insomnia, poor orientation and coordination, irritability, job dysfunction, and interpersonal impairment. The DSM 5 contains 3 substance/medication-induced disorders (previously considered substance-induced mood disorder): substance-induced bipolar disorder, substance-induced depressive disorder, and substance-induced anxiety disorder. Common to each of these disorders is "clinically significant distress or impairment in social, occupational, or other important areas of functioning". In the above case, there is some evidence of a substance-induced ataxia, and possibly intoxication, but it is not sufficient enough to warrant a trip to the ER. The patient continues to function, albeit not well enough. Treatment for substance/medication-induced disorder should begin with a medical evaluation and medically supervised detoxification (if indicated) from the substance. It also includes psychotherapy and counseling. The patient's presentation is not consistent with intermittent explosive disorder, dependent personality disorder, major depressive disorder, or dysthymic disorder.

A 45-year-old woman presents with sweating, tremors, and insomnia. About 6 months ago, the patient divorced her husband of 15 years; she was placed on Xanax 0.5 mg daily due to frequent panic attacks. A week ago, her court proceedings were resolved. Question What is the most likely cause of the patient's symptoms? Answer Choices 1 The patient is experiencing common side effects of the medication from chronic usage 2 The patient has developed a tolerance to the medication 3 The patient abruptly stopped taking the medication 4 The patient requires a increase in dosage of medication 5 The patient has overdosed on the medication

Correct Answer: The patient abruptly stopped taking the medication The correct response is that the patient abruptly stopped taking the medication. Benzodiazepines, such as Xanax, can cause physical dependence. When alprazolam is stopped abruptly, the patient has signs and symptoms of withdrawal (e.g., sweating, tremors, and insomnia). Tolerance and side effects from the medication would result in signs and symptoms of anxiety (e.g., restlessness, irritability, and muscle tension). Since the patient has been on the medication for 6 months, an increase would not yet be required.

A 20-year-old woman presents with a rapid onset of nausea, headaches, fast breathing, and dilated pupils. Her sister thinks that the patient is exhausted from staying up several nights to study for final exams. The patient refused food several times, arguing that she didn't have time to spend on anything but her studying; she even became aggressive when her roommates insisted on her going out to dinner with them. Upon physical examination, the patient seems tired and has a dry mouth; her body temperature is 99.8° F and her blood pressure is 135/85. The patient states that she took 2 acetaminophen pills the night before and in the morning to get rid of her headaches. Question What would be recommended as the next step in the management of this patient? Answer Choices 1 Influenza diagnostic test 2 N-acetylcysteine 3 Oral rehydration solution 4 Pregnancy test 5 Urine drug test

Correct Answer: Urine drug test This patient should be administered a urine drug test since she presents with symptoms common to amphetamine users. Administration of an influenza diagnostic test is incorrect because increased blood pressure and dilated pupils are not common symptoms of flu. Administration of N-acetylcisteine is incorrect because NAC is an antidote medication for poisoning with acetaminophen. Even though the patient states that she took acetaminophen pills during the last 24 hours, she did not take an overdose. Administration of an oral rehydration solution is incorrect; although the patient presents with some symptoms associated with food poisoning (nausea, headaches, dry mouth) which would require rehydration measures, additional tests are necessary. Administration of apregnancy test is incorrect because even though morning sickness from pregnancy is possible, it does not account for all her symptoms (e.g., dilated pupils and the ability of the patient to stay up for long periods of time).

14) Case A 16-year-old obese girl has a BMI (Body Mass Index) of 32 kg/m² and a family history of diabetes; she has tried to lose weight before without success, so she is prescribed orlistat, which is taken after each meal. Within 2 weeks, she notices bowel movement changes, flatulence, oily discharge, and mild abdominal pain; she returns to the office. Because she lost some weight, she would like to continue the treatment if the side effects could be eliminated. Question In addition to telling her to reduce her fat consumption, you should prescribe what supplement? Answer Choices 1 Vitamin B12 2 Vitamin C 3 Vitamin D 4 Folic acid 5 Iron

Correct Answer: Vitamin D The correct answer is vitamin D because it is a fat-soluble vitamin. The patient takes orlistat, a gastrointestinal and pancreatic lipase inhibitor that induces weight loss by inhibiting dietary fat absorption, and as a consequence fat-soluble vitamins are also eliminated. Vitamin B12, vitamin C,and folic acid are incorrect because these are all vitamins that are water-soluble; there is no influence of the drug on the absorption of these vitamins. Iron is an incorrect response. A lack of iron in the blood causes anemia, which can be also induced by a deficiency in vitamin K. Even though a decrease in vitamin K might be noticed, as it is also a fat-soluble vitamin, studies have shown that the decrease in vitamin K is only significant when orlistat is administered in combination with warfarin.

A female patient of yours is a dramatic actress. She is good at her work, but she might be so talented because she is dramatic in her life as well. All of her emotions are expressed to the extreme, whether she is preparing dinner or reacting to stress. She is also sexually provocative, and she tells you that she is the "life of the party". What is the most likely diagnosis? Answer Choices 1 Paranoid personality disorder 2 Schizoid personality disorder 3 Schizotypal personality disorder 4 Antisocial personality disorder 5 Histrionic personality disorder

Correct Answer: Histrionic personality disorder Show Explanation Explanation Excessive emotionality and attention-seeking behaviors characterize individuals with histrionic personality disorder. 5 of the following symptoms must be present: a need to be the center of attention, inappropriate sexual behavior such as seductiveness or provocativeness, shallow emotions that change quickly, excessively emotional speech, exaggerated emotional expression, and a history of believing that relationships with others are more intimate than they really are. Paranoid personality disorder is characterized by distrust and suspicion that leads the individual to assume that others' motives are malicious. At least 4 symptoms must be present to diagnose an individual with this disorder. These include suspicion without cause, preoccupation with the loyalty or trustworthiness of others, reluctance to confide in others, misinterpretation of benign events, and a perception that remarks made to them are threatening. Although superficially similar to paranoid personality disorder, schizotypal personality disorder is characterized more by pervasive social and interpersonal deficits that result in extreme discomfort with close relationships. 5 or more of the following symptoms are present in the typical individual with schizotypal personality disorder: ideas of reference (but not full-blown delusions), odd beliefs or magical thinking, illusions or unusual perceptual experiences (but not classic hallucinations), odd thinking and speech, eccentric behavior or appearance, paranoid thinking or suspiciousness of others, no close friends, and social anxiety that is related to paranoid fears, rather than to negative feelings about oneself. Although these symptoms are also similar to those experienced by individuals with schizophrenia, they are not nearly as severe; as odd as the individual may behave, he or she is not disorganized. Individuals with schizoid personality disorder tend to be socially isolated, they display restricted affect (expression of mood), and they almost always prefer to be alone. These individuals appear to others to be introverted and preoccupied, and they do not do well in jobs that require social performance. An individual must display at least 4 of the following symptoms to be diagnosed with schizoid personality disorder: few activities are pleasurable, close relationships are shunned - even those with family members, a clear preference for solitude (activities are usually chosen accordingly), indifference to praise or criticism, and a profound lack of displayed emotions. Antisocial personality disorder is characterized by persistent patterns of disregard for others and violations of the rights of others. Symptoms usually begin before age 15 years, but the diagnosis cannot be officially established until the age of 18. There must be at least 3 of the following current symptoms: nonconformity to social norms and lawful behavior, deceit, impulsivity, pervasive irritability or aggression, a reckless disregard for the safety of themselves or others, irresponsibility, and lack of remorse. Individuals with antisocial personality disorder are also sometimes referred to as sociopaths. Prognosis is poor for antisocial personality disorder, and men are more likely to be affected than women.

A child crawls up stairs, builds a tower of 3 cubes, follows simple commands, and hugs his parents. He cannot yet walk up and down stairs 1 step at a time, build a tower of 7 cubes, or use a spoon well. What is the age of the child? Answer Choices 1 6 months old 2 15 months old 3 24 months old 4 30 months old 5 36 months old

Correct Answer: 15 months old Show Explanation Explanation The concept of developmental milestones highlights how more complex skills build on simpler ones. Development in each of the 4 domains (i.e., gross motor, fine motor, cognitive, and emotional) affects functioning in all of the others. An average 15-month-old can crawl up stairs, build a tower of 3 cubes, follow simple commands, and hug his parents. At 6 months, an average child can put weight on hands when prone, respond to his/her name, start babbling, and has stranger anxiety. An average 24-month-old can walk up and down stairs 1 step at a time, build a tower of 7 cubes, and use a spoon well. At 36 months, an average child can ride a tricycle, copy a circle, dress and undress (except buttons).

A 25-year-old man has been experiencing a lot of anxiety; the anxiety is associated with difficulty concentrating, fatigue, difficulty falling asleep, and a general feeling of edginess to some degree on most days for the past 8 months. After other medical conditions are ruled out, he is seen by a psychiatrist who diagnoses him with General Anxiety Disorder (GAD). He is started on sertraline (Zoloft) 50mg daily, which provides almost complete resolution of his anxiety. After 6 months, against medical advice, he decides to stop the medication because he has been feeling so well. Question What are the patient's chances of relapse within the following year? Answer Choices 1 None; he is cured 2 5-10% 3 15-25% 4 60-80% 5 100%

Correct Answer: 60-80% Show Explanation Explanation Generalized Anxiety Disorder (GAD) is defined as a psychiatric illness during which patients have excessive and persistent worries associated with 3 or more of the 6 symptoms listed by the DSM-IV-TR: restlessness or feeling keyed up, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance. Patients tend to present during their 20's, but GAD can be diagnosed at any age. It is important while diagnosing GAD to rule out any medical disorders that could cause similar physical symptoms. The most effective treatment for patients with GAD is a combination of pharmacotherapeutic and psychotherapeutic approaches. However, complete relief of symptoms is rare, and treatment can take quite a long time. Common pharmacotherapeutic agents include buspirone, the benzodiazepines, serotonin-specific reuptake inhibitors, tricyclic antidepressants, antihistamines, or β adrenergic antagonists. Psychotherapy for patients with GAD is usually with a cognitive-behavioral approach, but it could also be supportive therapy or insight-oriented psychotherapy. When patients with GAD are given a platform to discuss their anxieties, they usually experience a marked lessening of anxiety. However, all treatment approaches considered, GAD is a chronic disorder. Therefore, the idea that the patient would be "cured" of his GAD is unrealistic, especially after only 8 months of therapy. 25% of patients will relapse within 1 month of discontinuing a 6-12 month course of treatment. 15-25% would have been correct if the question asked what the patient's chances were for recurrence during the next month. However, his chances for recurrence during the next year is 60-80%.

A woman presents with a history of nightmares, initial insomnia, inability to concentrate, and feeling irritable towards her family and friends. Her symptoms began after an accident at work 2 weeks ago; a construction beam crashed into the lobby where she sat as a receptionist. A construction worker was killed in the accident. She states she is worried another beam could fall and cannot stop thinking about seeing the worker after he fell. She has stopped bowling with her bowling league and avoids driving by construction sites. She visibly jumps when she hears a noise. Question What is the most likely diagnosis? Answer Choices 1 Agoraphobia 2 Social anxiety disorder 3 Generalized anxiety disorder 4 Post-traumatic stress disorder 5 Acute stress disorder

Correct Answer: Acute Stress Disorder Show Explanation Explanation Acute stress disorder must occur within 1 month following exposure to an extreme trauma. The symptoms are similar to post-traumatic stress disorder and must last at least 2 days and no more than 4 weeks. Agoraphobia is an anxiety disorder that involves fearfulness and avoidance of situations that may be difficult or awkward to escape from. It can be associated with panic attacks. The situations are not limited to social interactions and must involve more than one specific situation. Some common examples are standing in a line, being on a bridge, traveling in an airplane, and being in a crowd. Social anxiety disorder involves exposure to social and/or performance situations. The fearfulness is persistent over time; anticipation of a situation, as well as being in the situation, can elicit intense symptoms of autonomic arousal. Avoidance behavior is common. Examples include speaking to authority figures, initiating conversations, dancing, eating in public, and speaking in public. Generalized anxiety disorder is characterized by excessive anxiety and apprehension associated with a number of activities or events. Persons often describe feeling they have no control over their worries and anxiety, and they experience symptoms of restlessness, poor concentration, fatigue, muscle tension, irritability, and sleep disturbance. The symptoms must be present a majority of the time over a period of at least 6 months. Post-traumatic stress disorder is defined as re-experiencing an extremely traumatic event with physiological arousal and psychological distress. It is associated with avoidance of the stimuli that provoke memories of the trauma. The re-experiencing may take the form of recollection, dreams, or flashbacks. There are persistent vegetative symptoms which include an exaggerated startle response, sleep difficulties, poor concentration, irritability, and hypervigilance. The symptoms must be present for more than 1 month. Acute post-traumatic stress disorder is defined with symptoms lasting 1 - 3 months; chronic post-traumatic stress disorder is when symptoms have been present longer than 3 months. A delayed onset qualifier is added when the onset of symptoms is more than 6 months after the trauma.

A 33-year-old woman presents after being found unresponsive in the bedroom of her home. She has a past medical history of depression, and her mother found an empty bottle of amitriptyline by her bedside. Otherwise, the patient has no other medical or surgical history. She is a nonsmoker and does not drink alcohol. On physical exam, her pulse is 138/minute, blood pressure is 80/60 mm Hg, temperature is 101.2° F (38.4° C), and respirations 6/minute. Her heart sounds are normal and she has thready pulses. Her breath sounds are normal, but with shallow effort. The abdomen is soft and nontender. Neurologically, she moves her limbs from painful stimuli. Her skin is flushed; there are no needle marks. Her chest X-ray is normal, and the electrocardiogram demonstrates a wide complex tachycardia without ectopy. The patient is intubated and hyperventilated. Question What is the next best step in the patient's management? Answer Choices 1 Administer intravenous lactated Ringer's solution 2 Administer phenytoin 3 Administer physostigmine 4 Administer sodium bicarbonate 5 Hemodialysis

Correct Answer: Administer sodium bicarbonate Show Explanation Explanation The correct response is to administer sodium bicarbonate. The patient has taken amitriptyline, which is a tricarboxylic acid antidepressant (TCA); her set of symptoms are consistent with TCA toxicity. The mechanisms of action of TCA are via anticholinergic effects, norepinephrine reuptake blockade, a quinidine effect, a sodium channel blocker, and peripheral alpha blockade. TCA cardiotoxicity may be demonstrated on an electrocardiogram via sinus tachycardia, QRS complex prolongation >100 milliseconds, right bundle branch block, ventricular tachycardia, ventricular fibrillation, and QT prolongation. Sodium bicarbonate is the drug of choice for the treatment of ventricular dysrhythmias and/or hypotension, secondary to tricarboxylic acid antidepressant (TCA) poisoning. Hyperventilation and hypertonic saline (i.e., lactated Ringer's) may also be useful, but clinical and experimental experience with these modalities is less extensive than with sodium bicarbonate. In patients with severe toxicity, bicarbonate needs to be given in order to achieve a serum pH of 7.50 - 7.55. Intermittent boluses of sodium bicarbonate are preferred to a constant infusion. Procainamide is not recommended due to similarity in action of TCAs as class 1A antiarrhythmics. Sodium bicarbonate works by alkalinization of blood, thereby promoting protein binding of drugs; this results in less of the toxic drug in circulation. It improves conduction through sodium channels, and treats acidosis that results from seizure activity. After treatment with sodium bicarbonate, peripheral maneuvers to improve the TCA-induced hypotension include placing the patient in the Trendelenburg position, administering intravenous fluids, administering pressor agents (e.g., norepinephrine) for the treatment of alpha-blockade-induced hypotension, and administering dopamine. Intermittent dosing of dopamine stimulates beta-receptors, allowing increases in cardiac output; higher dosing stimulates alpha-blockade. TCA-associated seizures should be aggressively treated in order to avoid cardiotoxicity resulting from acidosis. Benzodiazepines, phenobarbital, and intubation are the mainstay of treatment. In general, phenytoin is not efficacious for the treatment of toxic seizures. Physostigmine in a hemodynamically unstable patient is not the first-line drug; it may even be contraindicated. It should be considered if there are severe life-threatening anticholinergic effects. Hemodialysis and hemoperfusion are not effective in TCA poisoning because small amounts of free TCA are present in the serum (mostly bound to serum proteins); they are not recommended.

A 6-month-old healthy infant presents with an inability to sleep through the night. He has 3 - 4 nighttime awakenings, and his parents spend a long time getting him to go back to sleep. Both parents work and their sleep continues to remain disrupted, which affects their work performance the next day. Question What best describes the physiology of sleep in this patient? Answer Choices 1 The longest nighttime sleep period during the 1st 3 months is approximately 6 - 8 hours long and lengthens to 10 - 12 hours at 4 - 6 months of age 2 The 2 key sleep milestones in infancy are sleeping in a separate room and having dreams 3 The 3 distinct stages of non-REM sleep emerge by the end of the 1st year of life 4 Approximately 25% - 50% of 6 - 12-month-olds, and 30% of 1-year-olds, have problematic night waking 5 Infants develop the ability to consolidate sleep by 8 - 12 months of age

Correct Answer: Approximately 25% - 50% of 6 - 12-month-olds, and 30% of 1-year-olds, have problematic night waking Show Explanation Explanation The correct response is that approximately 25% - 50% of 6 - 12-month-olds, and 30% of 1-year-olds have problematic night waking. Both transient and chronic sleep problems are common in infancy. The longest nighttime sleep period during the 1st 3 months is approximately 3 - 4 hours long, and it lengthens to 6 - 8 hours at 4 - 6 months of age. The 2 key sleep milestones in infancy are sleep consolidation and sleep regulation. Sleep consolidation is defined as the ability to sleep for a continuous period of time (concentrated during the nocturnal period), which is supplemented in young children by shorter periods of diurnal sleep (naps). This is commonly referred to as sleeping through the night. The 3 distinct stages of non-REM sleep emerge by around 6 months of age. Infants develop the ability to consolidate sleep in the 1st 8 - 12 weeks of life; by 9 months of age, approximately 70% - 80% of infants will have achieved this milestone. Sleep regulation, or the ability of the infant to 'self-soothe', begins to develop in the 1st 3 months of life; it is defined as the ability to master the sleep-wake transition at sleep onset, as well as to return to sleep independently after normal night arousals/awakenings.

A 30-year-old man presents for a routine follow-up; he has a documented history of intermittent chronic symptoms over the past year including headache, low back pain, knee pain, and dysuria. Additionally, he notes nausea, diarrhea, poor libido, and extremity numbness. He admits to feelings of worthlessness; he also admits to daily alcohol use in an attempt to feel better. Lab studies, urine testing, plain radiographs, CT scans, and MRIs have failed to explain the source of these symptoms; however, he is consumed by worry about his illness. Question What is correct regarding this patient's condition? Answer Choices 1 The typical onset occurs in the elderly with underlying vascular disease 2 Associated personality disorders and depression are common 3 The cornerstone of treatment is benzodiazepines 4 Highly-educated, married, Caucasian men are the most likely to be afflicted 5 Serological antibody testing is the most specific diagnostic test available

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

A 3-year-old boy has been found face down in a swimming pool during the summer. He was unresponsive when removed from the water, and CPR was started by a neighbor. The child remains apneic and pulseless when the EMS team arrives. Resuscitative efforts, including tracheal intubation and intraosseous epinephrine, are continued during transport; however, ECG shows asystole and he remains pulseless. Despite continued resuscitative efforts, he continues to remain asystolic. Question What would be the most appropriate action concerning his mother in this situation? Answer Choices 1 Ask a staff member to direct the mother to a waiting room until you can talk to her alone 2 Describe the resuscitative process in detail to ensure she understands all that has been done 3Tell her there have been stories of children surviving submersion accidents 4 Begin to introduce the possibility of a poor prognosis 5 Try to obtain a detailed accounting of how the child got into the pool

Correct Answer: Begin to introduce the possibility of a poor prognosis Show Explanation Explanation This child is unlikely to respond to resuscitative efforts because he continues to be in pulseless arrest despite basic and advanced life support. Pediatric studies in the pediatric intensive care unit (PICU) show that children requiring specialized treatment for drowning experience at least a 30% mortality rate; an additional 10-30% experience severe brain damage. Successful resuscitation after prolonged submersion has been documented in only very small children pulled from very cold water. The mother should be gradually prepared for the eventuality of a poor outcome. If family members are not interfering with resuscitative efforts and are not causing harm to themselves, it is acceptable for them to stay if they so choose. This will also help the mother grasp the reality of a child's unexpected death and also allows the opportunity to say goodbye. While it is helpful and appropriate to let the mother know the interventions that have been or are being undertaken, it is not appropriate to stop to provide a detailed description, especially not one using complex terminology. Since this child is unlikely to respond to resuscitative efforts, it would be unacceptable to create false hope. Trying to obtain a detailed accounting of the sequence of events would imply that the child's submersion was the mother's fault.

A 48-year-old woman has a history of poor interpersonal relationships, chronic headaches, and previous suicide attempts. She has an extremely demanding attitude and often directs her anger towards others. Question What personality disorder is the most likely diagnosis? Answer Choices 1 Narcissistic 2 Avoidant 3 Borderline 4 Histrionic 5 Antisocial

Correct Answer: Borderline Show Explanation Explanation The clinical picture is suggestive of a borderline personality disorder. These patients typically present with the following clinical findings: they are impulsive, have unstable interpersonal relationships, are suffused with anger and fear, lack self-control, are suicidal, and demonstrate aggressive behavior. Narcissistic personalities are exhibitionists, grandiose, preoccupied with power, and have poor social interactions. Avoidant personalities fear rejection, have low self-esteem, and hyper-react to rejection and failure. Histrionic personalities are dependent, immature, seductive, vain, and egocentric. Antisocial personalities are described as selfish, callous, impulsive, associated with having legal problems, and are promiscuous.

A 26-year-old woman is having marital difficulties with her husband; she is a flight attendant, and he is a pilot for another airline. The woman dropped out of college during her senior year, occasionally smokes marijuana, and has had breast implants. Frequently, she and her husband get into violent fights over little things at home, primarily his not being attentive enough to her. At these times, she engages in self-mutilating activities. The next morning, she awakens in an amorous mood and wants to make love, feeling that he is the most wonderful man on this earth. More than once, she has made a suicidal gesture when she thought her husband would leave her. She constantly fears that her husband is going to abandon her someday. When stressed, she becomes paranoid and has a feeling of being able to step outside her body and watch herself. She also has a terrible sense of emptiness and a tendency for binge eating. She is very impulsive and often goes off on shopping sprees. Question What is the most likely diagnosis? Answer Choices 1 Histrionic Personality Disorder 2 Dependent Personality Disorder 3 Borderline Personality Disorder 4 Avoidant Personality Disorder 5 Narcissistic Personality Disorder

Correct Answer: Borderline Personality Disorder Show Explanation Explanation Borderline Personality Disorder individuals show a persistent pattern of undermining their efforts to succeed and destroying good relationships. There may be multiple attention-seeking suicidal gestures, minor self-inflicted wounds, psychotic symptoms, feelings of depersonalization or derealization, sexual conflicts, mood disturbance, and a tendency to see people as either bad or good. With few, if any, close friends, they lead a life of isolation and are continuously looking for love and affection or for someone to show them they are attractive. According to the DSM-5, the diagnostic criteria for Borderline Personality Disorder include the following: A pattern of pervasive instability of interpersonal relationships, affects, and self-image along with marked impulsivity beginning by early adulthood and presenting in a variety of other contexts, as indicated by 5 (or more) of the following: (1) Frantic efforts to avoid real or imagined abandonment (Does not include suicidal or self-mutilating behavior covered in Criterion 5). (2) A pattern of very unstable and intense interpersonal relationships that are characterized by alternating extremes of idealization and devaluation. (3) Identity disturbance that is characterized by marked and persistent unstable self-image or sense of self. (4) Acts of impulsivity that are potentially self-damaging in at least 2 areas of the following: spending, sex, substance abuse, reckless driving, binge eating (does not include suicidal or self-mutilating behavior covered in Criterion 5). (5) Recurrent suicidal attempts, gestures, threats, or self-mutilating behavior. (6) Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). (7) Feeling of chronic emptiness. (8) Inappropriate or intense expressions of anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). (9) Transient, stress-related paranoid ideation or severe dissociative symptoms. Histrionic Personality Disorder is characterized by attention seeking and overly dramatic behavior. These individuals are overly dramatic even in minor situations, exhibiting wild swings in emotions. They become easily bored with normal routines and have a craving for new, novel situations and excitement. Relationships are formed quickly, but the relationships are often shallow, with the person demanding increasing amounts of attention. Dependent Personality Disorder is characterized by lack of self-confidence or inability to function independently, resulting in passively allowing others to assume responsibility for major areas of one's life. This leads to dependency on the person. While everyone is dependent on others in some aspects, those with dependent personality disorder are dependent in almost all major areas of their lives and view themselves poorly, seeing good only as extensions of others. Narcissistic Personality Disorder is characterized by a sense of grandiose self-importance, preoccupation with fantasies of unlimited success, and a driven desire for attention and admiration. They have an intolerance towards criticism and disturbed self-centered interpersonal relations. They are often referred to as being conceited and selfish. Persons with Avoidant Personality Disorder exhibit an extreme fear of rejection, and they consequently suffer from a high level of social discomfort. They enter into relationships only where uncritical acceptance is almost guaranteed, undergo social withdrawal, suffer from low self-esteem, but have a great desire for affection and acceptance. However, they do not want the affection as much as they fear the rejection.

A 7-year-old boy presents for an evaluation of a 6-month history of behavioral problems in school; the evaluation was recommended by his teacher. Although the boy tests at grade level, he seems to make careless mistakes on schoolwork, has trouble paying attention to instructions, does not finish homework, and often loses his homework, pencils, and books. The boy is often seen fidgeting at his desk; he blurts out answers and has difficulty awaiting his turn. The parents agree that they have seen similar traits at home (e.g., forgetting to do daily activities and easy distractibility) for several years. They view him as a happy, bright boy who is very active; he has had normal vision and hearing screenings. The father reports that he was very similar to his son when he was a child, and still struggles with focus and concentration as an adult; the father never received any help. The parents deny any major changes in the family situation. They would like medical help to improve their son's performance in school. The boy has been seen regularly for his well-child exams and has always met milestones. Today, he quickly moves about the exam room looking at a book for a few moments, then to the window, then interrupting his parents. Question What has been identified as the primary neurotransmitter responsible for this child's likely disorder? Answer Choices 1 Acetylcholine 2 Dopamine 3 Gamma-aminobutyric acid (GABA) 4 Glutamate 5 Histamine

Correct Answer: Dopamine Show Explanation Explanation This child meets the criteria for attention deficit hyperactivity disorder (ADHD), a disorder most associated with dopamine abnormality. Medications such as methylphenidate, a central nervous system stimulant, are considered a first-line therapy for ADHD; the drugs work by regulating dopamine and norepinephrine levels. Acetylcholine was the 1st neurotransmitter to be discovered. It has several roles in central and peripheral neurologic actions and within the parasympathetic system. It is not directly linked to ADHD. Gamma-aminobutyric acid (GABA), an amino acid, plays a major inhibitory role as a neurotransmitter. Some anticonvulsants are thought to work through the GABA receptors. GABA has some links to schizophrenia and panic disorder but is not currently thought to have a major role in ADHD. Glutamate, derived from glutamine or aspartate, is the major excitatory neurotransmitter in the central nervous system. Much attention has been focused on N-methyl-d-aspartate (NMDA), a glutamate receptor. Overstimulation of NMDA receptors is thought to lead to excitotoxicity of the cells and play a role in neurodegenerative disorders (e.g., Alzheimer's and Huntington's diseases). Glutamate is not directly linked to ADHD. Histamine is commonly associated with its role in immune/inflammatory responses and gastric acid secretion; however, it is also a neurotransmitter associated with stimulated wakefulness, suppressed appetite, and enhanced cognition. It is not associated with ADHD.

A 28-year-old woman presents with obsessive concerns about gaining weight. Physical exam reveals a slightly overweight woman with poor dentition, enlarged parotid glands, and scars on the dorsal side of her hands. Upon further questioning, she admits to binge eating and then self-induced vomiting to prevent weight gain. What is the most likely diagnosis? Answer Choices 1 Bulimia nervosa 2 Anorexia nervosa 3 Obesity 4 Hyperphagia 5 Pica

Correct Answer: Bulimia nervosa Show Explanation Explanation The correct answer is bulimia nervosa. Bulimia is an eating disorder in which patients gorge on food (binge eating) and then purge, either by self-induced vomiting or with the use of laxatives. Some of the health problems associated with Bulimia include laceration of the gastrointestinal tract, discoloration of the teeth, hernias in the esophagus, kidney damage, and hormonal imbalances. Treatment for bulimia focuses on getting patients to monitor their eating habits and then helping them to extinguish the urge to vomit. Anorexia nervosa is another eating disorder. Anorexia afflicts mainly teenage girls; however, older women and men can suffer from the disorder as well. It affects approximately 1 out of 200 women. Patients typically starve themselves to the point where they are dangerously thin. They consume low-calorie food, if any, and engage in strenuous exercise for several hours a day. The body weight of anorexic patients is often less than 50% of the statistical ideal. Other symptoms include cessation of menstruation, tooth loss, hyperactivity, and the avoidance of sex. It is fatal in approximately 10% of cases. Its etiology does not involve organic factors, but it does involve psychological factors such as fears of being sexually unattractive, fears of sex, and rebellion against parents. It is unclear whether the hormonal disturbances that are found in anorexic patients are a cause of or result of the psychological problems and starvation diet. A culturally-prescribed obsession with slimness is thought to be one of the contributing psychological factors. Initial treatment for anorexia involves getting the patient back to normal weight and better health, and it should be followed by resolving the patient's psychological conflicts through counseling. Obesity is a term used to describe the condition in which an individual's body weight is more than 20% above normal for their height and build. As it is neither a term used for an eating disorder nor a condition characterized by binge eating and purging, it is also an incorrect answer. Hyperphagia is defined as excessive eating and is an incorrect answer. Pica is defined as an abnormal desire to eat substances that are normally not eaten (such as chalk, ashes, paint, etc). It is not characterized by binge eating and purging; therefore, it is an incorrect answer.

A 27-year-old man underwent pre-employment urine drug testing of hospital employees. The test returns positive. He states that he was "clean" for 2 weeks. Question What substance is the man most likely abusing? Answer Choices 1 Cannabinoids 2 Nicotine 3 Amphetamine 4 Cocaine 5 Opiates

Correct Answer: Cannabinoids Show Explanation Explanation The only drug from the list that is detectable in urine after 2 weeks is marijuana (cannabinoids). Approximate duration of detectability in urine of chronic heavy use of marijuana is 36 days. Single use is detectable for 1 - 2 days and moderate (daily) use is about 10 days. Nicotine is detectable in urine for about 12 hours Amphetamine is detectable in urine for 2 - 3 days Cocaine is detectable in the urine for about 6 - 8 hours The approximate duration of detectability in urine of opiates and their metabolites does not exceed 3 - 4 days. More precisely, 6-monoacetylmorphine stays for 2 - 4 hours; morphine, codeine, and dihydrocodeine stay for around 1 day; morphine glucuronides stay for around 2 days; and codeine glucuronides stay for 3 days.

The sister of a 20-year-old man is concerned because her brother has not been himself lately; his mood has been alternating from happy and euphoric to irritable and depressed. The man states that he is adjusting to his new life at college, which has so far been stressful. He states that he does not smoke, does not do recreational drugs, and only drinks socially at parties. Physical examination reveals marked nasal congestion, dilated pupils, heart rate of 120 beats/min, and a blood pressure of 155/92 mmHg. Question What is the best diagnosis? Answer Choices 1 Narcotic overdose 2 Acute anxiety 3 Panic attack 4 Cocaine intoxication 5 Bipolar disorder

Correct Answer: Cocaine intoxication Show Explanation Explanation The clinical picture is suggestive of cocaine intoxication. Presenting symptoms of cocaine intoxication can include hypertension, tachycardia, diaphoresis, anxiety, dilated pupils, agitation, nasal congestion, and psychosis. A narcotic overdose may present with symptoms of miotic pupils and decreased pulse and blood pressure. Acute anxiety, a panic attack, and bipolar disorder are all psychiatric disorders. They would not cause changes such as pupillary dilatations or nasal congestion.

A 42-year-old man is found unconscious in his apartment. A friend states that the patient is in treatment for depression, but he does not know what kind of medicine his friend is taking. Physical examination reveals that the patient has a BP of 90/58, pulse of 100/min (irregular), and respiratory rate of 12/min. The patient is lethargic and has dry skin, mydriasis, irregular cardiac rhythm at auscultation, superficial respiration, absent bowel sounds, urinary retention, decreased motor power in his extremities, and absent tendon reflexes. Question What is the most likely diagnosis? Answer Choices 1 Lithium toxicity 2 Cyclic antidepressant overdose 3 Cerebrovascular accident 4 Acute psychosis 5 Cocaine overdose

Correct Answer: Cyclic antidepressant overdose Show Explanation Explanation The patient above presents clinical manifestations of cyclic antidepressant overdose; his antecedent of treatment for depression helps to make the diagnosis. Cyclic antidepressants are the leading cause of death by intentional overdose of a prescription medication. Most cyclic antidepressants have an anticholinergic effect which is characterized by xerostomia, dry skin, blurred vision, mydriasis, urinary retention, and delirium. Agitation and myoclonic jerks are also common findings. In severe poisonings, hypotension, seizures, respiratory depression, and cardiac dysrhythmias are classic findings. In advanced poisonings, findings include adult respiratory distress syndrome (ARDS), rhabdomyolysis, and disseminated intravascular coagulation (DIC). In lithium toxicity, the CNS signs are the most common, especially tremors, fasciculations, movement disorders, and a Parkinsonian-like syndrome. Cerebrovascular accident and acute psychosis are not probable diagnoses in this patient. Patients with cocaine overdose may be euphoric, anxious, paranoid, and agitated; they may experience chest pain, hypertension, and cardiac dysrhythmias.

A 6-year-old boy presents for an evaluation of what his mother describes as 'odd behaviors'. The family recently moved and the boy started public school. Although the mother had asked her previous health provider for testing, no evaluation was done; she now reports that her son's teacher agrees that the child exhibits odd behaviors. The boy has limited language skills, and even when he correctly verbalizes words the content often does not make sense; he repeats words and phrases. He does not socialize appropriately, preferring to watch his hand wave in front of his face repeatedly. He seems particularly obsessed with rubber bands, collecting them and studying them. He does not play with his toys. The child throws tantrums when his daily routine is disrupted and covers his ears when there is even a moderately loud noise. The mother has noted these problems since his infancy. The boy is an only child. The mother denies pregnancy or birth complications; the boy has been healthy (other than common childhood illnesses), with no identified health conditions. The history is not suspicious for abuse, and the psychosocial environment appears stable. The mother reports her husband has an uncle with some type of intellectual disability, but does not know any details. On physical exam, the same behavioral abnormalities are observed, but the remainder of the exam is normal. Question What test would be most appropriate in the evaluation of this boy's condition? Answer Choices 1 DNA test for fragile X syndrome 2 Karyotyping for trisomy 21 3 MRI or CT of the head 4 Rubella antibody testing 5 Sweat chloride test

Correct Answer: DNA test for fragile X syndrome Show Explanation Explanation This boy's behaviors suggest an autism spectrum disorder (which includes Asperger syndrome). Autistic disorder is characterized by impaired social functioning, communication/language problems, and restricted and/or repetitive behaviors. There is no laboratory or imaging test to confirm autistic disorder, but the patient should be evaluated for other similar disorders, especially with a family history of intellectual disabilitites. A DNA test for fragile X syndrome would be appropriate, as about 1/4 of those with fragile X have autistic disorder. Fragile X syndrome is the most common genetic disease associated with intellectual disabilities; it is most often seen in male patients. Affected individuals may appear physically normal or have prominent foreheads, jaws, and ears. Young boys may have macro-orchidism after puberty. Karyotyping for trisomy 21 (Down syndrome) is not indicated for this patient. If Down syndrome is not identified prenatally, it is usually recognized very early in infancy by its classic phenotypic appearance (e.g., flat facial profile and nasal bridge, protruding tongue, short neck, short broad hands, and slanted palpebral fissures). Down syndrome is associated with intellectual disabilities, but not classically the language, social, and behavioral issues described in this child. There are no characteristic/diagnostic findings on MRI or CT of the head in autistic disorder. Furthermore, a brain tumor would not be suspected in a patient with no neurological physical exam findings and no recent development of symptoms. Maternal infection with rubella (German measles) is associated with a congenital syndrome that includes deafness, heart defects, retinopathy, intellectual disability, and even autistic disorder. Rubella antibody testing is not indicated for this patient; his mother denies any complications during her pregnancy, and the child has no other indicators of congenital rubella. A sweat chloride test would be indicated when looking for cystic fibrosis, a genetic disease affecting multiple organs (most typically the lungs and respiratory tract). Behavioral abnormalities are not directly associated with cystic fibrosis.

A 55-year-old woman presents with severe abdominal pain. In the course of interviewing her, she discloses that she has been hospitalized 3 times within the previous 2 years with similar symptoms. Although she describes her symptoms vaguely, she mentions problems with her pancreas and with her liver. She appears underweight and has hand tremors. She resists any suggestion of further hospitalization for observation, saying, "they won't even let me have a drink in there to calm my nerves." Question In stating that drinking is a way for her to treat her pain and is not the cause of any of her symptoms, what mental mechanism might she be using? Answer Choices 1 Displacement 2 Denial 3 Rationalization 4 Regression 5 Resistance

Correct Answer: Denial Show Explanation Explanation Denial is a defense mechanism that results in a refusal to accept some aspect of reality. In this case, it is the refusal to accept a causal relationship between alcohol and its symptomatic consequences. Displacement might cause a patient to blame someone else for his/her problems. Rationalization might manifest in the creation of logical reasons (other than drinking) for the occurrence of each of the symptoms, but when taken together, lack parsimony. Regression manifests as a return to former behaviors that may have once been appropriate but are now immature. Resistance is the tendency of patients, even though they are asking for help and for relief, to want to stay the same. Correct Answer: Denial Show Explanation Explanation Denial is a defense mechanism that results in a refusal to accept some aspect of reality. In this case, it is the refusal to accept a causal relationship between alcohol and its symptomatic consequences. Displacement might cause a patient to blame someone else for his/her problems. Rationalization might manifest in the creation of logical reasons (other than drinking) for the occurrence of each of the symptoms, but when taken together, lack parsimony. Regression manifests as a return to former behaviors that may have once been appropriate but are now immature. Resistance is the tendency of patients, even though they are asking for help and for relief, to want to stay the same.

A 6-year-old boy's parents are concerned about their son's behavior. There have been complaints from his teachers that he is frequently fidgeting and disruptive in class. His parents state that he is extremely active at home and requires frequent disciplining. After a complete history and physical exam, your suspected diagnosis is Attention Deficit Hyperactivity Disorder (ADHD). Question In addition to behavioral therapy, what drug should be considered as first-line therapy for the management of this disorder? Answer Choices 1 Pemoline 2 Dextroamphetamine 3 Imipramine 4 Diazepam 5 Clonidine

Correct Answer: Dextroamphetamine Show Explanation Explanation The 2011 AAP guidelines for the treatment of a school-going child (6-11 years of age), include prescribing US Food and Drug Administration-approved medications for ADHD and/or evidence-based parent and/or teacher-administered behavior therapy as treatment. Particularly strong evidence exists for the use of stimulant medications. Dextroamphetamine and methylphenidate are commonly used. Although these agents are stimulants, in patients with ADHD, they paradoxically improve attention and reduce symptoms of hyperactivity. Less strong, however sufficient evidence, exists for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order).

A 35-year-old woman, with no significant past medical history, presents with a feeling of constant worry for the past year. She states that she is anxious about numerous elements in her life (e.g., constant deadlines at her job, obligations to her family, financial constraints, repairs to her car, and the health of her 2 young children). She denies any cigarette, alcohol, or drug use. She also reports fatigue, restlessness, and muscle tightness, especially around her neck. She denies any chest pain, shortness of breath, palpitations, cough, edema, diaphoresis, or changes in weight, diet, or caffeine intake. Her physical exam reveals cervical myospasms. Otherwise, she has normal vital signs, a nontender and nonenlarged thyroid gland, a normal skin exam, and a normal cardiovascular exam. Question What medication is expected to induce the most rapid clinical response in this patient? Answer Choices 1 Escitalopram 2 Oxazepam 3 Lithium 4 Buspirone 5 Diazepam

Correct Answer: Diazepam Show Explanation Explanation This patient demonstrates manifestations consistent with generalized anxiety disorder (GAD). A combination of pharmacologic and psychotherapeutic interventions is most effective in GAD. Diazepam is a benzodiazepine that is lipid-soluble, is absorbed rapidly, and has a rapid onset of action. Certain SSRIs (e.g., escitalopram) are effective, but typically only after being taken for at least a few weeks. Unlike diazepam, oxazepam is a benzodiazepine that has a slow onset of action. Buspirone is also effective; however, it can take at least 2 weeks before it begins to help. Lithium is the mainstay of treatment in bipolar disorder, and as prophylaxis in recurrent mania and depression. The therapeutic effects of lithium may not appear until 7 - 10 days of treatment.

An 89-year-old man presents with pneumonia. You suspect lung cancer, which would require surgery and possibly chemotherapy. Upon hearing the news regarding his diagnosis, the patient becomes tearful and sad. He confides his thoughts of suicide. You notice the patient seems confused at times; he does not know the place or people who surround him. When the patient is asked to sign the informed consent for scheduled thoracotomy, he vehemently refuses any and all treatments of his condition, stating he is going to die anyway. What should you do? Answer Choices 1 Respect the patient's decision to receive no further treatment of his lung cancer, since the patient is clearly competent to make decisions about his medical care. 2 Disregard the patient's stated wishes and proceed with surgery because the patient is demonstrating impaired judgment (as evidenced by his suicidality). 3 Request psychiatric consultation; only psychiatrists are capable of verifying decision-making capacity in depressed patients. 4 Evaluate the patient for the presence of depression and delirium, as both of these conditions may impair judgment and decision-making capacity. 5 Refuse to treat the patient due to patient's lack of cooperation and refer him to a colleague.

Correct Answer: Evaluate the patient for the presence of depression and delirium, as both of these conditions may impair judgment and decision-making capacity. Show Explanation Explanation When considering a patient's right to refuse or ability to consent to treatment, several issues must be addressed. One needs to consider the competence, or the decision-making capacity, of the patient in question. Other considerations include the emergent nature of the condition, informed consent, and the ethical principles guiding current practice of medicine. First, in assessing a patient's refusal of treatment, the physician must ascertain whether the patient is capable, both mentally and psychologically, of making that decision. Conditions that are known to temporarily or permanently cloud a person's ability to make decisions must be evaluated and treated, with the emphasis being on restoration of the patient's competence. The factors necessary to consider in competency evaluations are the patient's understanding of the nature of his or her illness and the proposed treatment, the side effects of the treatment, the availability of alternative treatments, and the ramifications of no treatment. A decision based on a thorough understanding of these issues is referred to as informed consent. Pervasive depressed mood, clouding of consciousness, and states of intoxication and withdrawal from drugs and alcohol all may affect a patient's capacity to make decisions. Therefore, conditions that can be treated or reversed must be eliminated prior to obtaining informed consent. In the case of the 89-year-old mathematician, suicidal thinking may point toward the diagnosis of depression, and confusion might indicate delirium. Both conditions have to be treated prior to further assessment of his decision-making capacity. The ethical principle guiding the current practice of medicine is based on autonomy theory. Based on the writings of Immanuel Kant, autonomy theory postulates that the relationship between the physician and the patient is that of 2 responsible parties. This presumes responsibilities and obligations on the part of both people. Thus, a normal adult patient is deemed capable of making responsible decisions concerning his or her life and health, even if the decisions contradict the physician's recommendations based on consideration of the patient's best interest. Paternalism can be defined as performing actions for others' benefit without requiring their consent. Paternalism in medicine is currently an acceptable practice only if the patient is incapable of making decisions due to mental illness, psychological distress, or cognitive impairment. In that case, the physician is obligated to seek other sources who would be familiar with the patient's belief system and be able to tell what the patient would have wanted if he or she were able to make decisions. Only in cases of life-threatening emergencies, unavailability of family members, or uncertainty on the part of the doctor about the motivations of family members, is the physician allowed to make decisions for the patient. The physician must keep the patient's best interests in mind. The utilitarian principle demands maximizing the benefit to the greatest number of people in making decisions. It operates in medicine in the mandatory reporting of a number of communicable diseases and in quarantines. When an adult is deemed competent to make medical decisions, no other considerations, such as age, family wishes, or benefit to society, are relevant in his or her refusing or consenting to treatment. If the physician perceives that actions requested by a patient contradict the physician's own ethical code, the physician has the right to refer the patient to someone who would feel comfortable providing services in accordance with the wishes of the patient. This is commonly the case in requests for elective abortion.

A mother seeks medical attention for her 7-year-old son because for the last 8 months he has not acted like his 3 older brothers. The mother indicates that her son has said on repeated occasions he wants to get rid of his male genitalia and he would prefer to be a girl. She has found him wearing his sister's clothing on numerous occasions. More history shows that he prefers to play with dolls and only spends time with female friends. Teachers relate that he turns down invitations from the boys in the class to join in sports activities. His male classmates are now teasing and embarrassing him in class, and it has begun to affect his schoolwork. Question What is the child's most likely diagnosis? Answer Choices 1 Hyposexual desire disorder 2 Gender dysphoria 3 Body dysmorphic disorder 4 Oppositional defiant disorder 5 Paraphilic disorder

Correct Answer: Gender dysphoria Show Explanation Explanation The most likely diagnosis is gender dysphoria. For greater than 6 months he has had a marked incongruence between his experienced and assigned gender expresses the following criteria of gender dysphoria: a strong desire/presence be the gender different from that assigned; for cross-dressing in or simulating female attire; for cross-gender roles in make-believe play; for toys, games, or activities stereotypically played by the other gender; for playmates of the other gender. The patient has a strong rejection of typically masculine toys and games and a strong dislike of his sexual anatomy. This has caused impairment in school. Male hyposexual desire disorder refers to the symptomatic criterion of low sexual desire and absent sexual fantasies or thoughts. To be diagnosed with body dysmorphic disorder, DSM 5 criteria specifies an individual must be preoccupied with one or more slight or nonexistent physical flaws in their appearance and at some point, the individual must perform repetitive, compulsive behaviors in response to their concerns about their appearance. Symptoms of oppositional defiant disorder manifest as irritability and anger. Patients often argue and disobey figures of authority and may not follow rules or cooperate. Patients may seem malicious, accusing others of things they themselves have done. Paraphilic disorders include a number of behaviors that society often regards as "distasteful, unusual, or abnormal". Persons with paraphilic disorders have recurrent sexual urges which they may act upon in order to obtain pleasure. Paraphilic disorders are male predominant.

A 40-year-old woman who has been referred by a psychiatrist presents for a general medical evaluation. While lying down on the examination table, she states that she is feeling light-headed. She is wearing a low-cut blouse and spandex pants. She notes that she has had a difficult year and was very depressed after her lover left her without warning; she begins crying and states that she has autoimmune problems from breast implants she received to please her lover. When asked if the referring psychiatrist treated her for depression, she smiles and states that he saved her life and she does not know what she will do if he ever retires. The patient also presents with fatigue, recurrent ear infections with bleeding, irritable bowel, and fibromyalgia. She has a diagnosis of recurrent major depression, in remission. Question From what personality disorder does this patient also suffer? Answer Choices 1 Narcissistic personality disorder 2 Antisocial personality disorder 3 Histrionic personality disorder 4 Paranoid personality disorder 5 Borderline personality disorder

Correct Answer: Histrionic personality disorder Show Explanation Explanation Histrionic personality disorder is typified with attention-seeking behavior and melodramatic emotional displays. Relationships are often exaggerated and characterized by attempts at emotional manipulation and assuming a role (e.g., 'martyr' or 'princess'). Suicidal gestures to gain attention or coerce a response place persons with this disorder at risk for a completed suicide. Criteria include inappropriate seductive or provocative behavior, suggestibility, impressionistic speech, and shallow, shifting emotions. Histrionic personality disorder is associated with higher rates of major depression, somatization disorder, and conversion disorder. Narcissistic personality disorder is defined by a need for excessive admiration, a grandiose sense of self-importance, and a lack of empathy. A person with narcissistic personality disorder usually has a fragile self-esteem and is vulnerable to criticism or failure. Narcissistic traits can be a normal component of adolescent behavior. Criteria include arrogant behaviors or attitudes, poor recognition of other's feelings, preoccupation with fantasies of success, beauty, power or ideal love, interpersonal exploitation, and a sense of entitlement. There may be associated depression, social withdrawal, eating disorders, or substance abuse. The disregard for, and violation of, the rights of others characterize antisocial personality disorder. It is associated with urban settings and low socioeconomic status. Criteria include repeated breaking of laws, impulsivity, lying, other deceitful behaviors, irresponsibility in work and financial obligations, and lack of remorse. There must also be evidence that conduct disorder was present before the age of 15. Persons with antisocial personality disorder are more likely to die prematurely by violent means than the general population. There may be associated anxiety and depressive disorders, substance abuse, and impulse control disorders (e.g., pathological gambling). Paranoid personality disorder is defined as a pervasive distrust and suspiciousness of others. There is usually an absence of meaningful relationships due to extreme preoccupation with loyalty and trustworthiness. Persons with paranoid personality disorder are often focused on issues of power and authority and have negative stereotypes of others. Perceived slights result in hostile counterattacks and persistent grudges. Criteria include suspicions of deception and exploitation from others, suspicions of infidelity in a spouse or sexual partner, and reluctance to confide in others. Brief psychotic episodes may occur in response to stress. It can be associated with major depression, agoraphobia, obsessive-compulsive disorder, and substance abuse. Borderline personality disorder has instability of interpersonal relationships and self-image as its central features. It is characterized by impulsive behaviors and frantic attempts to avoid real, or perceived, abandonment. An environmental hypersensitivity coupled with the loss of external structure or rejection by another can result in extreme deterioration in affect, cognition, and self-image. Typical reactions to such situations are rage, panic, self-mutilating behavior, and suicidal gestures. The risk of suicide is greatest in the young adult years. Criteria include identity disturbance, chronic feelings of emptiness, mood lability, impulsive behaviors (e.g., spending, sexual activity, reckless driving, binge eating), and a pattern of unstable, intense interpersonal relationships. Associated disorders are major depression, substance abuse, bulimia, post-traumatic stress disorder, and attention-deficit/hyperactivity disorder.

An 8-year-old boy presents for evaluation of problems at school and at home. His parents report that he does not pay attention in class; he is frequently in trouble for disrupting the class, and he often forgets to do his schoolwork. He has had similar problems since starting school (in kindergarten), but they are becoming more problematic; his teacher suggested medical evaluation. The teacher reports the patient often seems distracted. He rarely sits still at his desk; he fidgets often, and when he does pay attention to the class discussions, he blurts out comments without waiting his turn. His parents report that the boy has always been 'on the go' and talks excessively; he does not seem to listen when spoken to. He seems capable of doing his schoolwork, but he appears to make careless mistakes. The parents feel the boy is generally well-adjusted; he enjoys sports, has friends, and sleeps well. The parents deny any known medical history, and his prenatal course and delivery were unremarkable. He has never had any surgeries; he takes no medications and does not have any allergies. He lives at home with his biological parents and a younger sister. On physical exam, the boy appears normally developed. Some increased motor activity is noted, but the physical exam is otherwise normal. Question What is the best intervention for this patient's condition? Answer Choices 1 Change patient's diet to eliminate all refined sugars 2 Initiate short-acting benzodiazepines 3 Initiate stimulant medication 4 Order electroencephalogram 5 Refer for biofeedback

Correct Answer: Initiate stimulant medication Show Explanation Explanation This patient is presenting with attention deficit hyperactivity disorder (ADHD). Patients with ADHD may have inattentive, hyperactive, and/or impulsive behaviors. To meet the criteria for ADHD, some symptoms must have been present by age 7 years. When the diagnosis is clear and parents are agreeable, the first-line treatment for ADHD is to initiate stimulant medication. These medications come in short and long-acting formulations, and they have shown the best efficacy for ADHD. This patient's symptoms are not attributable to dietary factors; elimination diets are not recommended for patients with ADHD. It would not be necessary to change this patient's diet to eliminate all refined sugars. Sometimes, anxiety symptoms can mimic ADHD symptoms; however, it would be inappropriate to initiate short-acting benzodiazepines, both because of this patient's age and his lack of anxiety symptoms. While benzodiazepines would likely 'slow down' this patient due to their sedation effects, they are risky to use in a pediatric population; there is no support for their use in cases of ADHD. Absence (or petit mal) seizures are characterized by brief (5 - 30 seconds) episodes of staring and then a rapid return to normal, with the affected individual unaware of his/her seizure. This patient's inattention could possibly be attributed to such seizures, but the hyperactivity and impulsivity are not explained by absence seizures. It is unnecessary to order an electroencephalogram. Some forms of psychotherapy are useful for ADHD, especially if there are associated behavior problems; however, it would not be helpful to refer this patient for biofeedback, a relaxation/stress-reduction technique that allows the patient to control his or her body through mental exercises. Biofeedback may be difficult to master for young children, and it has not been shown to be particularly useful for ADHD.

A 23-year-old man with no known significant past medical history is brought in by emergency medical services in an unconscious state. He was reported by friends to be out partying in a club and was noted to be carrying a prescription bottle during this time; the patient's father has a known history of severe spinal stenosis, for which he takes analgesia. His physical exam reveals slow and shallow respirations, bradycardia, hypotension, cyanosis, and miosis of both pupils. Additionally, he is comatose, has diminished bowel sounds and distension with dullness to percussion over the suprapubic abdominal area, and has flaccid musculature. Question What is the preferred intervention for this patient at this time? Answer Choices 1 Intravenous naloxone 2 Intravenous nitroprusside 3 Intravenous diazepam 4 Intravenous N-acetylcysteine 5 Intravenous flumazenil

Correct Answer: Intravenous naloxone Show Explanation Explanation This patient presents with clinical symptomatology consistent with opioid intoxication. An initial dose of naloxone, 2 milligrams IV, should be administered to patients presenting with apnea or near-apnea and cyanosis. Repeated doses of 2 milligrams IV every 3 minutes are recommended until a maximum of 10 milligrams IV is reached or respiratory depression is reversed. Exposures to synthetic opioids, such as fentanyl, pentazocine, or dextromethorphan, and to sustained-release preparations may require these larger-than-ordinary doses. Other general manifestations include miosis, central nervous and cardiovascular system depression, ileus, and sphincter contraction. Intravenous nitroprusside or phentolamine would be most appropriate to treat hypertension associated with an amphetamine overdose. Benzodiazepines should not be administered since they potentiate inhibitory gamma-aminobutyric acid (GABA) neuronal activity in the CNS. Pharmacologic effects include reduction of anxiety, suppression of seizure activity, CNS depression (including possible respiratory arrest when benzodiazepines are given rapidly intravenously), and inhibition of spinal afferent pathways to produce skeletal muscle relaxation. N-acetylcysteine is indicated in a suspected acetaminophen overdose. Flumazenil is a specific benzodiazepine receptor antagonist. Benzodiazepine toxicity is suggested by the presence of lethargy, slurred speech, ataxia, coma, hypothermia, and respiratory arrest. Generally, patients with benzodiazepine-induced coma have hyporeflexia and midposition or small pupils. Coma and small pupils due to benzodiazepine overdose will not respond to naloxone but will reverse with the administration of flumazenil.

A 9-year-old boy presents with episodes of severe impulsivity, lack of attention, poor listening skills, as well as obsessive and compulsive characteristics; symptoms have been evident to his mother and multiple teachers at school. There have been numerous episodes. The patient has had mild evidence of these signs since he was in kindergarten, but they have become substantially worse in the last 4 months. Question Considering the differential diagnosis, what is an associated feature that would support the most likely diagnosis? Answer Choices 1 Weight loss 2 Low frustration tolerance 3 Racing heart 4 Stable mood 5 Headache

Correct Answer: Low frustration tolerance Show Explanation Explanation The correct response is low frustration tolerance. According to the DSM-5, the patient described above is experiencing multiple signs and symptoms that are consistent with the diagnosis of attention deficit/hyperactivity disorder (ADHD). Basic key components include strong evidence of inattention, as well as hyperactivity and/or impulsivity (with many factors being categorized as 1 or the other); these are all considered diagnostic features. Associated features that support the diagnosis of ADHD include the following: mild delays in language, motor, or social development that is not specific to ADHD, low frustration tolerance, irritability, mood liability, and impaired academic/work performance. Racing heart, stable mood, headache, and weight loss are not directly associated symptoms that support the diagnosis of ADHD

A patient presents with deteriorating work and feelings of worthlessness and hopelessness; symptoms have been worsening over the past month. The patient also gives history of excessive fatigue and loss of interest in pleasurable activities. He also has trouble eating and sleeping, and he is increasingly withdrawing from his wife and friends. These symptoms have been present for more than 2 months. He has no history of depression and no history of other mood disorders or manic episodes. He has no other significant past medical history and is not on any medication. Question What is the most likely diagnosis? Answer Choices 1 Major depressive disorder 2 Bipolar disorder 3 Persistent depressive disorder (dysthymia) 4 Cyclothymic disorder 5 Unspecified depressive disorder

Correct Answer: Major depressive disorder Show Explanation Explanation The clinical presentation is consistent with major depressive disorder. It is characterized by the presence of 1 or more major depressive episodes and the absence of any history of manic episodes. Functioning is significantly impaired in most areas. Individuals with major depression experience at least 5 related symptoms. These include depressed mood, loss of interest or pleasure, eating disturbance, sleep disturbances, or suicidal ideation. According to DSM-5, the diagnostic criteria for major depressive disorder include the following: A) At least 5 of the following symptoms have been present during the same 2-week period and represent a change from previous functioning, and at least 1 of the symptoms is either a depressed mood or loss of interest or pleasure: • Depressed mood most of the day, nearly every day, as indicated by either • Subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 percent of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. • Insomnia or hypersomnia nearly every day. • Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). • Fatigue or loss of energy nearly every day. • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B) The symptoms do not meet the criterion for diagnosing mixed episode. C) There is clinically significant distress or social, occupational, or other important areas of functioning impaired due to these symptoms. D) The symptoms are not due to a general medical condition such as hypothyroidism or due to direct physiological effects of a drug or substance. E) In addition, for a diagnosis of major depression to be made, the symptoms should not be better accounted for by bereavement; the symptoms persist for longer than 2 months or are characterized by marked functional impairment, suicidal ideation, morbid preoccupation with worthlessness, psychotic symptoms, or psychomotor retardation. When a manic episode is present with or without depression, or if there is a history of mania in an individual who is depressed, bipolar disorder is the most likely diagnosis. A manic episode is defined as a period of at least 1 week during which an individual's mood is abnormally elevated, expansive, or irritable, and such symptoms as grandiosity, decreased need for sleep (as opposed to insomnia), increased talking, flight of ideas, distractibility, and/or excessive risk-taking are present. Social and occupational functioning is usually significantly impaired as well, and in some cases hospitalization is required. Psychotic symptoms sometimes occur. Persistent Depressive Disorder (Dysthymia) is characterized by depression that is less severe than that which is associated with major depression and it has a chronic course. A general depressed mood must be present for at least a 2-year period in order to qualify an individual for this diagnosis, and there will likely be sleep and/or eating disturbances, low self-image, low energy, difficulty concentrating, and hopelessness. Daily functioning is usually not seriously impaired; however, dysthymic disorder may, on occasion, exacerbate into an episode of major depression. The term double major depressive disorder refers to individuals who have both major depression and dysthymia. Individuals with this are more likely than others to attempt suicide, are more severely depressed, and are less likely to have a full recovery. Cyclothymic disorder, like dysthymia, is characterized by a depressed mood that lasts at least 2 years (or 1 year in children), but in this case the individual alternates between periods of depression and periods of hypomania. The depressive episodes are not severe enough to be considered major depression, and the hypomanic episodes are not severe enough to be consideredmanic episodes. Like dysthymia, daily functioning is not usually significantly impaired. Mood disorders that do not fit the diagnostic criteria for a specific disorder are diagnosed asunspecified depressive disorder. These include depressive disorders that may be superimposed on other disorders, such as major depressive episode superimposed on schizophrenia.

An elderly patient who resides in an assisted living facility has been on a regimen of sertraline 20mg daily for the treatment of depression. Recently, the staff has noted a change in his behavior. The change is marked by agitation and irritability. Friends have observed him to be withdrawn; he refuses to participate in recreational activities and rarely appears for meals. There are concerns about his symptoms, and the medical director at the facility requests a psychiatry consultation. What test would you most likely want to use in the evaluation of this patient? Answer Choices 1 Abnormal Involuntary Movement Scale (AIMS) 2 Weinberg Screening Affective Scale (WSAS) 3 Mini Mental State Examination (MMSE) 4 Montgomery Asberg Depression Rating Scale (MADRS) 5 Brief Psychiatric Rating Scale (BPRS)

Correct Answer: Montgomery Asberg Depression Rating Scale (MADRS) Show Explanation Explanation The psychiatric evaluation of this patient would most likely include a measure of the severity of this patient's depressive symptoms as well as an assessment of current antidepressant drug therapy. The most appropriate tool for these purposes is the Montgomery Asberg Depression Rating Scale (MADRS). The MADRS is designed to be used in patients with major depressive disorder to measure the change in symptom severity during the treatment of depression. It is also a sensitive measure of the degree of severity of depressive symptoms. The Abnormal Involuntary Movement Scale (AIMS) is used to assess the occurrence of dyskinesias in patients receiving neuroleptic treatment. The Weinberg Screening Affective Scale (WSAS) is a self-reported questionnaire used to evaluate the presence of depressive symptoms in children and adolescents. The Mini Mental State Examination (MMSE) is a tool used to screen for cognitive impairment. It consists of 11 questions that test orientation, registration, attention and calculation, recall, and language. The Brief Psychiatric Rating Scale (BPRS) is designed to assess psychopathology, which includes positive, negative, and affective symptoms in patients with diagnosed or suspected schizophrenia or other psychotic illnesses.

A world famous trial attorney, who defends cases that you feel strongly against, recently discovers that he has Hodgkin's Lymphoma. The attorney seeks advice and treatment from you. You have never established a patient-physician relationship with this individual in the past. Based on your personal beliefs, you refuse to treat the patient. Question Have you violated an ethical code of conduct with your actions? Answer Choices 1No, because a physician can refuse to treat and care for a patient under any circumstances. 2 Yes, because physicians must treat patients who are ill and in need of assistance, regardless of their personal or political beliefs. 3 Yes, because to not treat a patient in this scenario would be to violate the patient-physician relationship. 4 No, because any physician can refuse to treat any patient unless the patient-physician relationship has been established. 5Yes, because it is the legal right of the patient to receive treatment by any physician they wish. 6 No, because the physician dictates care under the patient-physician relationship and can choose not to treat a patient or terminate a clinical relationship without cause.

Correct Answer: No, because any physician can refuse to treat any patient unless the patient-physician relationship has been established. Show Explanation Explanation The American Medical Association Code of Ethics states that physicians are free to choose whom they serve but they have an obligation to support continuity of care for their patients. Thus, once the patient-physician relationship has been established, physicians should not neglect their patients. In the case above, since the patient-physician relationship had not been established, the physician has a right to choose not to see or treat the patient.

A 35-year-old man presents for follow-up treatment. He states that he takes his medicine exactly every 8 hours and keeps a record of how many pills he takes at what time; he wakes up in the middle of the night worrying if he missed a dose. He is worried that maybe the medicine is not going to take effect because he took 1 of the pills 15 minutes late. Question What kind of disorder does this man most likely have? Answer Choices 1 Schizophrenia 2 Post-traumatic stress 3 Obsessive-compulsive personality 4 Schizoid 5 Histrionic

Correct Answer: Obsessive-compulsive personality Show Explanation Explanation Obsessive-compulsive personality disorder is characterized by being perfectionistic, inflexible, and unable to express warm and tender feelings. Those suffering from this disorder are too concerned about trivial details and rules, and they do not appreciate changes in routine. They have a preoccupation with details, rules, lists, order, organization, and schedules to the extent that the major point of the activity is lost. Any illness is perceived as a threat to their control; therefore, they may struggle with their physician for control. The patient must be allowed to take part in the decisions and details of his medical care (e.g., charting medication times). Schizophrenia is a disorder that consists of both positive and negative symptoms. Positive symptoms are delusions, hallucinations, and agitation; negative symptoms are characteristics of the patient that are subtracted from the clinical picture, including affective flattening, social withdrawal, apathy, anhedonia, and poverty of thought and content of speech. The diagnosis requires that symptoms be present for at least 6 months; however, the course varies widely among individuals. Post-traumatic stress disorder describes a syndrome of distress, re-experience, avoidance, and arousal. These symptoms develop after exposure to events that involve actual death or injury, or a threat to the physical integrity of oneself or others that brought on fear, helplessness, or horror. The symptoms may appear immediately after the trauma, or they may be delayed for 6 months or more. Symptoms can be re-experiencing the trauma through memories or dreams, avoidance of stimuli associated with the trauma, numbing of overall responsiveness, excessive arousal (e.g., insomnia), angry outbursts, hypervigilance, exaggerated startle response, and difficulty concentrating. Schizoid personality describes a person who has a pattern of detaching from social relationships and shows a restricted range of emotions that begins by early adulthood. These individuals usually do not desire or enjoy close relationships, they choose solitary activities, take pleasure in few activities, lack close friends, are indifferent to praise or criticism, and are emotionally cold. Histrionic personality represents people who are flamboyant, attention-seeking, and demonstrate an excess emotionality. Their emotions are shallow and shift rapidly. Typically, they are attractive, seductive, and overly concerned about their appearance.

A 45-year-old man comes to see you because he is feeling extremely stressed out. He is a middle manager in a large corporation, and he states that he has too many things to do and he cannot organize all of his tasks. He states that even his lists are no longer working for him. He has so many tasks to do that he spends half of his day writing and re-writing his lists until they are perfect. He has not taken a vacation for almost 5 years. His family complains that they never see him because he is always at work. During the interview, he keeps muttering to himself that he cannot take time off because there is too much work to do. His boss came in to talk to him the other day, and he blew up at him. The man says that he cannot handle the pressure anymore; he claims that he would delegate tasks to his staff, but they do not pay attention to the details the way he does and do not seem to put a high priority on the tasks. When his boss hands him a task to do, he does not leave the office until that task is perfectly completed. The client is stiff as he sits in your office, and he adjusts his tie several times to make sure it is perfectly centered. Question What is the most likely diagnosis? Answer Choices 1 Narcissistic personality disorder 2 Obsessive-compulsive personality disorder 3 Generalized anxiety disorder 4 Histrionic personality disorder 5 Acute anxiety disorder

Correct Answer: Obsessive-compulsive personality disorder Show Explanation Explanation This client experiences a preoccupation with lists and organization, excessive devotion to work, an inability to delegate tasks, and a need for perfectionism. These symptoms are characteristic of obsessive-compulsive personality disorder. This disorder can be differentiated from narcissistic personality disorder by the fact that many people with narcissistic personality disorder believe that they have achieved perfection; those with obsessive-compulsive personality, however, are overly self-critical. Those with generalized anxiety disorder do not necessarily experience the extreme attention to detail and the perfectionist attitude of those with obsessive-compulsive personality disorder. A person with histrionic personality disorder would, beginning by early adulthood and in many contexts, demonstrate an ongoing pattern of excessive emotionality and attention seeking.

A 20-year-old man presents because he is feeling nervous, cannot sleep at night, has a loss of appetite, a low-grade fever, a runny nose, and stomach cramps. On physical exam, the hair on his arms is standing on end, he is sweating, and his pupils are dilated. He states that he is accustomed to taking a certain drug, but he has not been able to obtain it for the last 72 hours. Question From what type of drug is this patient most likely withdrawing? Answer Choices 1 Barbiturate 2 Benzodiazepine 3 Opiate 4 Nicotine 5 LSD

Correct Answer: Opiate Show Explanation Explanation This patient is experiencing classic withdrawal symptoms of an opiate; these include flu-like symptoms, nausea and/or vomiting, runny nose, yawning, diarrhea, piloerection, fever, insomnia, goose bumps, sweating, and pupilary dilation (a clear, late withdrawal symptom). Supportive care and medications are the treatments for opiate withdrawal; this includes relief from physical symptoms. The most commonly used medication is clonidine. Barbiturates are prescribed as anticonvulsants, sedatives, and for general anesthesia. Drugs in the classification known as barbiturates depress the central nervous system and are often called sleeping pills. Since they contain characteristics similar to that of alcohol intoxication (including states of exhilaration, confidence, and unrestrained behavior), there is a risk factor for abuse. Symptoms of withdrawal from barbiturates will appear 12 - 20 hours after the last dose; they include anxiety, irritability, elevated heart and respiration rate, muscle pain, nausea, tremors, hallucinations, confusion, and seizures. Death will occur if treatment is avoided or not given. Barbiturate overdoses may occur because the effective dose of the drug is not too far away from the lethal dose. Benzodiazepines produce seizures, anxiety, delirium, tremor, and insomnia upon withdrawal. Nicotine has less severe withdrawal symptoms; these include weight gain, anxiety, headache, and irritability. LSD has no withdrawal symptoms. Most users of LSD voluntarily decrease or stop its use over time. LSD is not considered an addictive drug since it does not produce compulsive drug-seeking behavior (as oppossed to cocaine, amphetamine, heroin, alcohol, and nicotine).

Your patient is a 27-year-old woman brought to the ER by her husband because of bizarre behavior 4 days after the uncomplicated delivery of the full term healthy baby boy. Her personal and family history of mental illness is negative. The second day after delivery, she accused her husband of poisoning her food. She has problems falling asleep, generally sleeping only 2-3 hours nightly and complaining of unpleasant smells waking her up. She started arranging toys and the baby's stuff in a specific symmetrical order and became aggressive when someone moved them. She would stop the ongoing activity from time to time with a blank expression and was found several times staring at the wall and silently counting. Even simple tasks require the help of others, and she often forgets what she started doing. This makes her irritable and sometimes tearful. She feels guilty about being a terrible mother and states that she did not deserve to have a baby. The morning when her husband asked for your advice, she told him that she hears voices telling her to take her son and jump through the window. Question What is the most likely diagnosis? Answer Choices 1 Maternity blues 2 Psychomotor epilepsy 3 Postpartum depression 4 Postpartum psychosis 5 Obsessive-compulsive disorder

Correct Answer: Postpartum psychosis Show Explanation Explanation Your patient most probably has postpartum psychosis. Postpartum psychosis usually starts within the first 2 days after the delivery, and symptoms develop within the first 2 postpartum weeks. The onset is usually dramatic and includes: restlessness, insomnia, irritability, rapidly shifting depressed or elated mood, paranoid, grandiose, or bizarre delusions, mood swings, confused thinking, grossly disorganized behavior that represent a dramatic change from her previous functioning, and disorganized behavior. The mother may have auditory hallucinations that command her to harm herself or her infant. The condition is differentiated from the major depression by the presence of cognitive disturbance, hallucinations, and disorganized behavior. Postpartum psychosis is rare, but it is the most serious mental disorder in this period and must be recognized, as it is considered a medical emergency. Postpartum affective instability is met in the majority of women, with the usual onset of day 4; it is generally time-limited and spontaneously remits within the first 2 postpartum weeks. Postpartum blues are typically mild in severity. Symptoms do not interfere with a mother's ability to function and to care for her child. Therefore, postpartum blues is not likely in this patient. Unpleasant smells can be a part of aura and seizures can be provoked by the lack of sleep. However, lasting bizarre behavior and the rest of the symptoms do not align with epilepsy. Typically, postpartum depression develops insidiously over the first 3 months postpartum, but can occur anytime in the first year. Symptoms include include intense sadness, anxiety, or despair, anhedonia, insomnia, fatigue, appetite disturbance, suicidal thoughts, and recurrent thoughts of death. The mother can be obsessed about the infant's health and well-being or may have ambivalent or negative feelings toward the baby, including fears or thoughts about harming the baby. Risk factors are: personal history of depression, previous episode of postpartum depression, depression during pregnancy, recent stressful life events and daily stressors, lack of the support (especially from the partner), unintended pregnancy, insurance status, etc. Postpartum depression interferes with the mother's ability to care for herself or her child, but hallucinations are not typically part of postpartum depression. Obsessive-compulsive disorder is characterized by intrusive thoughts and compulsive, irresistible behaviors. Intrusive thoughts could focus on contamination, causing harm to the baby, and urges for symmetry. The compulsions may include urges to order objects and on mental rituals like counting. However, rational judgment is preserved, and patients prefer to avoid the situations that provoke anxiety, preferring to suffer discomfort rather than become aggressive. In contrast, psychotic patients are unable to discern reality and feel compelled to act on their delusional beliefs.

An 89-year-old man presents with pneumonia. You suspect lung cancer, which would require surgery and possibly chemotherapy. Upon hearing the news regarding his diagnosis, the patient becomes tearful and sad; he confides his thoughts of suicide. You notice the patient seems confused at times, not knowing the place and people who surround him. When the patient is asked to sign the informed consent for a scheduled thoracotomy, he vehemently refuses any and all treatments for his condition, stating he is going to die anyway. What is the ethical principle for obtaining informed consent in this case? Answer Choices 1 Principle of benign paternalism 2 Principle of autonomy 3 Utilitarian principle 4 Principle of justice 5 Principle of beneficence

Correct Answer: Principle of autonomy Show Explanation Explanation The correct response is the principle of autonomy. When considering a patient's right to refuse or ability to consent to treatment, several issues must be addressed. One needs to consider the competence, or the decision-making capacity, of the patient in question. Other considerations include the emergent nature of the condition, informed consent, and the ethical principles guiding the current practice of medicine. In assessing a patient's refusal of treatment, the physician must first ascertain whether the patient is capable, both mentally and psychologically, of making that decision. Conditions that are known to temporarily or permanently cloud a person's ability to make decisions must be evaluated and treated, with the emphasis being on the restoration of the patient's competence. The factors necessary to consider in competency evaluations are the patient's understanding of the nature of his/her illness and the proposed treatment, the side effects of the treatment, the availability of alternative treatments, and the ramifications of no treatment. A decision based on a thorough understanding of these issues is referred to as informed consent. A pervasive depressed mood, clouding of consciousness, states of intoxication, and withdrawal from drugs and alcohol all may affect a patient's capacity to make decisions; therefore, conditions that can be treated or reversed must be eliminated prior to obtaining informed consent. In the case of this patient, suicidal thinking may point towards the diagnosis of depression and confusion might indicate delirium. Both conditions have to be treated prior to further assessment of his decision-making capacity. The ethical principle guiding the current practice of medicine is the autonomy theory, based on the writings of Immanuel Kant. The autonomy theory postulates that the relationship between the physician and the patient is that of 2 responsible parties. This presumes responsibilities and obligations on the part of both people; therefore, a normal adult patient is deemed capable of making responsible decisions concerning his/her life and health, even if the decisions contradict the physician's recommendations based on consideration of the patient's best interest. Paternalism can be defined as performing actions for another's benefit without requiring his/her consent. Paternalism in medicine is currently an acceptable practice only if the patient is incapable of making decisions due to mental illness, psychological distress, or cognitive impairment. In such a case, the physician is obligated to seek other sources who would be familiar with the patient's belief system and arre able to state what the patient would have wanted (if he/she were able to make decisions). Only in cases of life-threatening emergencies, unavailability of family members, or uncertainty on the part of the doctor about the motivations of family members, is the physician allowed to make decisions for the patient. The utilitarian principle demands maximizing the benefit to the greatest number of people in making decisions. It operates in medicine by the mandatory reporting of a number of communicable diseases, and also in quarantines. When an adult is deemed competent to make medical decisions, no other considerations (e.g., age, family wishes, or benefit to society) are relevant in his/her refusing or consenting to treatment. If the physician perceives that the actions requested by a patient contradict the physician's own ethical code, the physician has the right to refer the patient to someone who would feel comfortable providing services in accordance with the wishes of the patient. This is commonly the case in requests for an elective abortion.

A 9-year-old boy presents with episodes of severe impulsivity, lack of attention, poor listening skills and organization, as well as obsessive and compulsive characteristics that have been evident to both his mother and teachers. He has had mild evidence of these signs since he was in kindergarten, but they have become substantially worse in the last few years. The patient is diagnosed with attention deficit hyperactivity disorder (ADHD) and is started on atomoxetine. Common side effects are described to the patient and his mother. Question What side effect most likely warrants the need to investigate an alternative treatment plan? Answer Choices 1 Weight loss 2 Abdominal pain 3 Racing heart 4 Nausea 5 Headache

Correct Answer: Racing heart Show Explanation Explanation The correct response is racing heart. Pediatric and adolescents patients with diagnosed ADHD may be started on the prescription atomoxetine to help alleviate the symptoms. This diagnosis must always be primarily approached as a comprehensive treatment plan; other measures such as psychological, education, and social interventions must be taken along with the medication approach. In general, atomoxetine can be an alternative for treatment of ADHD. The pharmacokinetics of atomoxetine in children and adolescents are similar to those in adults, but overall use of atomoxetine in children younger than 6 years old has not been investigated. After considering the clinical need and the potential risks, initiation of atomoxetine can begin. Common side effects reported with use of this medication seen in clinical trials includes abdominal pain, vomiting, nausea, fatigue, irritability, weight loss, headache, and dizziness. Significant side effects that the prescriber health care provider should be notified about immediately include a clinically significant blood pressure increase, terminal insomnia, flushing, mydriasis, sinus tachycardia, mood swings, and dyspepsia. A black box warning that all patients and parents must be educated about is the possibility of suicidal ideations.

A 18-year-old woman presents with weight loss. Her friend has been worried about the patient's weight loss and provides most of the patient's history; the patient remains quiet and reserved. The friend notes that the patient has become very thin over the past several months and her attitude is "listless". The patient's mother died 5 years ago, and the patient admits not feeling comfortable with her father's new wife. She is starting college and admits that she never feels hungry. She is not interested in food; she avoids social situations that involve meals and frequently worries about her appearance. She feels she is not "good enough" for anybody. She denies suicidal thoughts. Physically, she states that she is "okay" and denies symptoms. Her reported weight 7 months ago was 132 lb. She has not had a menstrual period for 4 months, and she has never been sexually active. Her vitals are: Weight 106 lb Height 65" Body mass index 17.6 Pulse 98 Blood pressure 108/72 mm Hg Temperature 97.1°F/36.1°C On physical exam, the patient is thin and somewhat pale. Her affect is flat, and she is soft-spoken. The remainder of her physical exam is normal. Labs results are as follows: CBC - Normal TSH - Normal UA - Normal Question What is the best intervention in this case? Answer Choices 1 Initiate potassium supplement 2 Prescribe bupropion hydrochloride (Wellbutrin) 3 Prescribe dronabinol (Marinol) 4 Recommend daily protein bars or drinks 5 Refer for psychotherapy

Correct Answer: Refer for psychotherapy Show Explanation Explanation This patient's weight loss is explained by anorexia nervosa, an eating disorder characterized by preoccupation with physical appearance, food restriction, weight loss, and social withdrawal. This patient has lost an alarming amount of weight rapidly, and the anemia, hypoalbuminemia, and mild electrolyte disturbances are common with malnutrition. The best intervention for this patient is a referral for psychotherapy. Appropriate psychotherapy can address the psychiatric illness, and the associated deficiencies should improve with improved food intake. Even though this patient exhibits a very mild hypokalemia, it is not necessary, nor an adequate treatment, to initiate a potassium supplement. The underlying disorder of anorexia nervosa must be addressed, and the potassium should normalize with improved nutrition. This patient exhibits some depressive symptoms, and antidepressant medication may be useful in patients with anorexia nervosa; however, it would be inappropriate to prescribe bupropion hydrochloride (Wellbutrin), as decreased appetite and weight loss are common side effects with this medication. Psychotherapy is the mainstay of treatment, and an antidepressant without weight loss potential may be useful. Although approved for AIDS-associated weight loss and anorexia, it would not be appropriate to prescribe dronabinol (Marinol) for this patient, both because it is a nonindicated use and because it would not address the primary problem of her anorexia nervosa. Dronabinol is a cannabinoid which increases appetite. This patient has a mild hypoalbuminemia, most likely from overall malnutrition and lack of adequate intake. Simply recommending daily protein bars or drinks is not an appropriate intervention; doing so overlooks the patient's inability to consume more food. Treatment of weight loss from anorexia is not to merely tell patients to eat more. Referral to a dietician experienced in eating disorders may be useful for ways to consume more nutrient-dense foods; this would be an adjunct treatment to psychotherapy.

A 42-year-old man with a known past medical history of schizophrenia has begun to demonstrate new and unusual behavior over the past 2 weeks. The patient has been compliant with taking risperidone 2mg for the past year. The patient's son reports that his father has been acting "silly" and exhibiting inappropriate behavior, such as removing his clothes, repeating odd noises and gestures, and speaking incoherently with random loud and violent outbursts. This morning, the patient was observed to have used a knife to cut himself; his son stopped him. Question What is next most appropriate step in the management of this patient at this time? Answer Choices 1 Increase the risperidone to 4 mg per day 2 Draw a CBC, chemistry panel, and urinalysis 3 Refer the patient to the hospital for inpatient monitoring 4 Discontinue risperidone and begin quetiapine 5 Prescribe both diazepam and paroxetine

Correct Answer: Refer the patient to the hospital for inpatient monitoring Show Explanation Explanation This patient is exhibiting symptoms that suggest disorganized schizophrenia. Disorganized schizophrenia is characterized by social behavior that is out of context, with marked incoherence and an incongruous or silly affect. The patient's appearance may be bizarre, and motor activity may escalate to frenzied excitement. Inappropriate behavior, including stereotypy, echopraxia, and disturbed interpersonal relationships, may occur. Verbal changes such as echolalia, neologisms, concrete language, clanging, incoherent speech, and verbigeration are common. When the patient's behavior shows gross disorganization, hospitalization is often necessary, especially when the behavior is coupled with evidence or threat of harm to self or others.

A 16-year-old, slightly overweight girl presents because she wants to lose weight. She has learned from the internet that diet pills called amphetamine salts (Adderall) are available to lose weight. She wants to know if these are safe to take. She is told to avoid them because they can become habit-forming and their effectiveness is short-lived. Question Which of the following correctly describes the mechanism of action of this drug? Answer Choices 1 Releases dopamine and norepinephrine stores 2 Enhances effect of GABA 3 Interferes with sodium and potassium transport 4 Blocks the effect of serotonin 5 Blocks binding of acetylcholine to nicotinic receptors

Correct Answer: Releases dopamine and norepinephrine stores Show Explanation Explanation Amphetamines act by causing the release of stores of dopamine and norepinephrine from the nerve endings; this is achieved by converting the respective transporters into open channels. Reuptake is also inhibited, so that large amounts of the neurotransmitters are present at the synaptic cleft; this, in turn, enhances neuronal transmission. Serotonin is also released from synaptic vesicles. Amphetamines (alpha-methyl-phenethylamine) are drugs mainly used for the treatment of attention deficit disorder (ADD); they are homologues of phenethylamine. The medical drug is a racemic mixture of equal amounts of "dextro" and "levo" forms. Dextroamphetamine, levoamphetamine, and methamphetamine are together called amphetamines. The physiological effects seen are decreased appetite, increased energy, and a state of arousal. Increased serotonin is said to have a role in their hallucinogenic and anorexic effects, psychosis, and aggressive behavior. Amphetamines are used to treat ADD and narcolepsy. Due to the potential side effects and risk of addiction, they are no longer the preferred method for weight reduction in the United States. These drugs carry several side effects, the most well-known (acute) being cardiac irregularities and gastric disturbances. Chronic use can cause insomnia, hyperactivity, and aggression. Amphetamine-induced psychosis and development of tolerance are other problems associated with long-term use. Tolerance develops rapidly, which results in patients seeking a dosage increase. Abusers take more of the drug during withdrawal, setting up a vicious cycle. Illegal use of the drug is rampant due to the euphoric effects. Enhanced effect of GABA at its receptor is seen with barbiturates, not amphetamines. Amphetamines do not interfere with sodium or potassium transport. They cause serotonin release at synaptic vesicles and do not affect the binding of acetylcholine to nicotinic receptors.

Police officers found a 27-year-old man walking aimlessly and shouting the names of former presidents. Urine toxicology is negative, and the man appears to be oriented with respect to person, place, and time. He has had 5 similar admissions over the past year. Attempts to interview the patient are fruitless; he is easily derailed from his train of thought. A phone call to a friend listed in the chart provides the additional information that the man is homeless and unable to care for himself. Question This patient's signs and symptoms are characteristic of what pathology? Answer Choices 1 Schizoaffective disorder 2 Schizoid personality disorder 3 Schizophrenia 4 Schizophreniform disorder 5 Schizotypal personality disorder

Correct Answer: Schizophrenia Show Explanation Explanation The patient is suffering from schizophrenia. The key to the diagnosis of psychosis is that there has been a marked decline in the level of functioning (i.e., the man is homeless and cannot care for himself). Although hallucinations or delusions are not mentioned in the case history, the presence of disorganized speech, grossly disorganized behavior, and the duration of symptoms (longer than 6 months) suggest a diagnosis of schizophrenia. In schizoaffective disorder, alterations in mood are present during a substantial portion of the illness. Although schizoid personality disorder produces detachment from social relationships and is characterized by restriction of emotional expression, it is not accompanied by a marked decline in occupational functioning. Schizophreniform disorder is characterized by schizophrenic-like symptoms, but the duration of symptoms is, by definition, less than 6 months. Schizotypal personality disorder is characterized by eccentricities of behavior, odd beliefs or magical thinking, and difficulties with social and interpersonal relationships. Unlike schizophrenia, schizotypal personality disorder is not characterized by a formal thought disorder.

A 15-year-old boy presents for a follow-up of Asperger syndrome (AS); the patient is accompanied by his mother. He is considered high functioning; he attends a public school, goes to daily cognitive/behavioral sessions, and attends weekly counseling sessions with a provider who specializes in treating adolescent patients with a diagnosis within the autism spectrum disorder. The mother states she has noted a significant increase in the patient's anxiety symptoms that has become detrimentally disruptive to daily activities. Question What would be your initial choice of pharmacologic treatment to help decrease the effects of this patient's anxiety? Answer Choices 1 Sertraline 2 Duloxetine 3 Atomoxetine 4 Clonidine 5 Methylphenidate

Correct Answer: Sertraline Show Explanation Explanation Adolescents with Asperger syndrome will have varying degrees of impairment in their social and behavioral function; therefore, treatment must be individualized based on the patient's age and their needs. Family education, behavioral and educational interventions, and counseling have a significant place in this treatment plan. Pharmacotherapy may be considered, but should be used as adjunctive therapy.. Children and adolescents with AS are treated via pharmacotherapy mainly to assist in control of their psychiatric symptoms; these patients are much more sensitive to medication effects. It is suggested to initially start the patient on a selective serotonin reuptake inhibitor (SSRI) (e.g., sertraline or fluoxetine) for anxiety symptoms. Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI). SNRIs are utilized in a multitude of patients, including those who are diagnosed as having major depressive disorder, for treatment of musculoskeletal pain in osteoarthritis, peripheral neuropathy, and even fibromyalgia. Although duloxetine is seen as a pharmacologic option for patients with generalized anxiety disorder, there is no hard recommendation for usage in AS patients to treat their anxiety symptoms. Patients who express symptoms consistent with hyperactivity and inattention would be treated with methylphenidate, atomoxetine, or clonidine, but these symptoms are not seen in this patient. When beginning any pharmacotherapy for these patients, having a 'start low and go slow' regimen is strongly recommended, with consistent follow-up visits for evaluation of alleviation of the symptoms.

A 56-year-old man has terminal cancer. During therapy, the man tells you that he is changing his ways. He claims that he is going to be kinder to people and give to charities, and if only he could get out of the hospital for a couple of weeks, he would spend every waking minute with his family. He states that he knows he was not around for his family the way he should have been, but he now wants the chance to make up for this. Question According to Kübler-Ross, what stage of dying is this man in? Answer Choices 1 Stage 1, denial 2 Stage 2, anger 3 Stage 3, bargaining 4 Stage 4, depression 5 Stage 5, acceptance

Correct Answer: Stage 3, bargaining Show Explanation Explanation Kübler-Ross described 5 stages that dying patients experience. In the 3rd stage, bargaining, the person is no longer angry; he or she will often try to make bargains with God or others, and the person will promise to be a better person and do good things if given a little more time to live. The 1st stage, denial, occurs when a person is in denial about the severity of his or her disease or that s/he is dying. This stage gives way to the 2nd stage, anger. During the anger stage, the person begins to acknowledge that s/he is going to die and becomes angry, resentful, and even bitter. The patient may become angry with those who are not sick and resent the fact that others are going to live and they are going to die. In the 4th stage, depression, the patient comes to the full realization that s/he is going to die and there is nothing that can be done about it. The patient may, at this point, begin to give in to death and begin the process of mourning. The 5th and final stage is acceptance. During this stage, a person begins to develop a sense of peace. The person often wants to be left alone and no longer has a desire for others to take care of them. This stage is usually reached in the person's final days of life. It should be noted that a patient will not necessarily progress through the stages in this order, and the patient is not "required" to do so according to the Kübler-Ross theory.

A 45-year-old man presents after throwing up repeatedly; the emesis looks like coffee grounds. The man is a known alcoholic who recently lost his job. He notes that his stool has been dark for the last few weeks. He has felt sick since the previous morning and has not had a drink since then; he feels very shaky. Physical examination reveals a yellowish appearance of skin and sclerae, extended abdomen, 3 spider nevi on the neck, and dilated cutaneous veins around the umbilicus. The liver is palpable 1 hand width beneath the rib cage, and there seems to be free fluid in the abdomen. Pupils are midsize and reactive. BP is 160/65 mm Hg, heart rate is 90 BPM; respiratory rate is 20/min, weight is 75 kg (165 lb), height is 185 cm (6 feet), and blood glucose is 50 mg/dL. There is concern about his alcoholism and low blood sugar. Question What is the most appropriate next step in this patient's management? Answer Choices 1 Thiamin IV 2 Dextrose IV 3 Benzodiazepines 4 Blood transfusion 5 Haloperidol

Correct Answer: Thiamin IV Show Explanation Explanation The correct response is thiamin IV. Thiamin is administered before dextrose in order to prevent Wernicke's encephalopathy. Since there are no signs of withdrawal which could lead to delirium tremens, there is no need for haloperidol or benzodiazepines. A blood transfusion would be indicated if there had been large blood loss with signs of hypovolemia; the patient's hemoglobin level would also be a factor.

A court orders a psychological evaluation of a 22-year-old man. The man was charged with reckless endangerment of another person. You learn that this is not the only time he has been in trouble; in fact, he was diagnosed with conduct disorder as a child. He does not seem to have any feelings about his history or of the current event. "It's just who I am, that's all." Question What is the most likely diagnosis? Answer Choices 1 Paranoid personality disorder 2 Schizoid personality disorder 3 Schizotypal personality disorder 4 Antisocial personality disorder 5 Histrionic personality disorder

Correct Answer: Antisocial personality disorder Show Explanation Explanation Antisocial personality disorder is characterized by persistent patterns of disregard for others and violations of the rights of others. Symptoms usually begin before age 15 years, but the diagnosis cannot be officially established until the age of 18. There must be at least 3 of the following current symptoms: nonconformity to social norms and lawful behavior, deceit, impulsivity, pervasive irritability or aggression, a reckless disregard for the safety of themselves or others, irresponsibility, and lack of remorse. Individuals with antisocial personality disorder are also sometimes referred to as sociopaths. Prognosis is poor for antisocial personality disorder, and men are more likely to be affected than women. Paranoid personality disorder is characterized by distrust and suspicion that leads the individual to assume that others' motives are malicious. At least 4 symptoms must be present to diagnose an individual with this disorder. Symptoms include suspicion without cause, preoccupation with the loyalty or trustworthiness of others, reluctance to confide in others, misinterpretation of benign events, and a perception that remarks made to them are threatening. Although superficially similar to paranoid personality disorder, schizotypal personality disorder is characterized more by pervasive social and interpersonal deficits that result in extreme discomfort with close relationships. 5 or more of the following symptoms are present in the typical individual with schizotypal personality disorder: ideas of reference (but not full-blown delusions), odd beliefs or magical thinking, illusions or unusual perceptual experiences (but not classic hallucinations), odd thinking and speech, eccentric behavior or appearance, paranoid thinking or suspiciousness of others, no close friends, and social anxiety that is related to paranoid fears, rather than to negative feelings about oneself. Although these symptoms are also similar to those experienced by individuals with schizophrenia, they are not nearly as severe; as odd as the individual may behave, he or she is not disorganized. Individuals with schizoid personality disorder tend to be socially isolated, they display restricted affect (expression of mood), and they almost always prefer to be alone. These individuals appear to others to be introverted and preoccupied, and they do not do well in jobs that require social performance. An individual must display at least 4 of the following symptoms to be diagnosed with schizoid personality disorder: few activities are pleasurable, close relationships are shunned - even those with family members, a clear preference for solitude (activities are usually chosen accordingly), indifference to praise or criticism, and a profound lack of displayed emotions. Excessive emotionality and attention-seeking behaviors characterize individuals with histrionic personality disorder. 5 of the following symptoms must be present: a need to be the center of attention, inappropriate sexual behavior such as seductiveness or provocativeness, shallow emotions that change quickly, excessively emotional speech, exaggerated emotional expression, and a history of believing that relationships with others are more intimate than they really are.

A 15-year-old boy with a diagnosis within the autism spectrum disorder presents for a follow-up appointment. He is considered high-functioning; he attends a public school, goes to daily cognitive/behavioral sessions, and attends weekly counseling sessions with a provider who specializes in treating adolescent patients with a diagnosis within the autism spectrum disorder. Despite these interventions and activities, his mother states that she has noted a significant increase in episodes of what she can only describe as temper tantrums; there is also severe irritability and quickly changing moods. The occurrences have become so severe that they have begun to disrupt the patient's daily routine of activities. Question What would be the most appropriate pharmacologic agent to treat this patient? Answer Choices 1 Sertraline 2 Paroxetine 3 Atomoxetine 4 Clonidine 5 Aripiprazole

Correct Answer: Aripiprazole Show Explanation Explanation Adolescents classified as having a diagnosis within the autism spectrum disorder (ASD) will have varying degrees of impairment in their social and behavioral function. Family education, behavioral and educational interventions, and counseling have a significant place in this treatment plan. Pharmacotherapy may be considered, but should be used as adjunctive therapy. The drug aripiprazole has been found to ease symptoms of irritability, aggression, temper tantrums, rapidly changing moods, and even self-injuring behavior in both children and adolescents with autism spectrum disorder. This is a FDA-approved drug treatment for behaviors specifically associated with ASD; the drug risperidone has also been used. When beginning any pharmacotherapy for these patients, having a 'start low and go slow' regimen is strongly recommended, with consistent follow-up visits for evaluation of alleviation of the symptoms. Pharmacologic agents known as selective serotonin reuptake inhibitors (SSRI) (e.g., sertraline or fluoxetine) are generally introduced to help alleviate anxiety symptoms. The patient in the above scenario is currently not experiencing or expressing any excessive anxiety. Although paroxetine is a type of SSRI that is used to treat patients with depression, obsessive-compulsive disorder, anxiety disorder, post-traumatic stress disorder, or premenstrual dysphoric disorder, it is currently not a recommended first-line treatment option for symptomatic behavior in ASD patients. Patients who express symptoms consistent with hyperactivity and inattention should be treated with methylphenidate, atomoxetine, or clonidine; these are not the symptoms discussed in this patient.

A 21-year-old woman is markedly thin, and she describes being worried she is going to fail her college finals and not graduate. She presents because she cannot eat or sleep; she feels like she would be better off dead. She was doing well in classes until after a spring break trip to Europe. When queried about previous psychiatric treatment, she tells you that she went 'a little nuts' when she was a freshman; it was her 1stsemester and the 1st time she had lived so far from home. She stayed up for a week trying to write a novel, and during that time she bought 2 computers and an entire new wardrobe with her father's credit card. Question What is the most likely diagnosis? Answer Choices 1 Major depressive episode 2 Manic episode 3 Mixed episode 4 Bipolar I disorder 5 Cyclothymic disorder

Correct Answer: Bipolar I disorder Bipolar I disorder is a mood disorder characterized by the occurrence of 1 or more manic or mixed episodes alternating with 1 or more major depressive episodes. Approximately 60 - 70% of manic episodes are associated with either a preceding or subsequent major depressive episode. Major depressive episode symptoms develop over a period of days or weeks. A prodromal period may be present with both anxiety and mild depressive symptoms. For the majority of the time, there must be at least 5 symptoms present over at least a 2-week period; the symptoms include depressed or irritable mood, loss of interest and pleasure in activities, weight fluctuation of 5% or more corresponding to an increased or decreased appetite, insomnia or hypersomnia, observable psychomotor retardation or agitation, anergia, predominant feelings of guilt or worthlessness, poor concentration and memory, recurrent thoughts of death, suicidal ideation, and a suicide attempt. In both major depressive episodes and dysthymic disorder, there is significant impairment in occupational and social functioning. A manic episode is a period of mood disturbance lasting a minimum of 1 week. The mood may be elevated and expansive or irritable. 3 - 4 symptoms must be present that include grandiosity, decreased need for sleep (e.g., the person feels rested with less than normal periods of sleep), pressured or excessive speech, distractibility, increased drives (e.g., work, sex, creativity), and unrestrained involvement in pleasurable activities (e.g., spending sprees, sexual indiscretions, monetary investments). There is an accompanying significant impairment in social and occupational functioning. Psychotic symptoms may also be present. A mixed episode is a period of mood disturbance that lasts a minimum of 1 week; symptom criteria for both a major depressive episode and a manic episode must be met. There must also be marked impairment in social and occupational functioning. Cyclothymic disorder describes a condition involving numerous periods of hypomanic symptoms and numerous periods of depressed symptoms over a 2-year period; these symptoms cause significant impairment in social and occupational functioning. In addition, there is never a period longer than 2 months that there is an absence of symptoms. Hypomanic symptoms include inflated self-esteem, decreased need for sleep, pressured or excessive speech, racing thoughts, distractibility, increased drives, psychomotor agitation, and unrestrained involvement in pleasurable activities.

An 80-year-old man presents with depressed mood, insomnia, and the inability to deal with the loss of a daughter who died of cancer. He is already on an antidepressant therapy. Question What adjunct treatment might be considered for social skills and interaction? Answer Choices 1 Case management 2 Family therapy 3 Interpersonal therapy 4 Bereavement group 5 Behavior management

Correct Answer: Interpersonal therapy The correct response is interpersonal therapy. Unless a good alliance is made between the older adult, the family, and the physician, older adults may fail to take antidepressant therapy as prescribed. Psychotherapy is a good treatment of choice for mild to moderate depression, but of all the treatments, once a month interpersonal therapy plus an antidepressant has been shown to be the most effective. Psychiatric treatment of older adults differs from the treatment of younger adults. Exercise is considered a good treatment for depression; however, it is considered an adjunct therapy. Many older adults are not able to participate because of physical problems; for those who can, running or walking is a good adjunct. Group, behavior, and cognitive therapy are indicated for some, but they are usually not treatments of choice for older adults. Seriously depressed older adults tend to shy away from being in a group or day treatment; however, day treatment has shown to be effective in dementia management and schizophrenia. Sometimes, depressed or demented older adults do not seek diagnosis or treatment because they either forget or do not want to have the stigma of having a mental health problem. Supportive family members, friends, and/or other caring individuals, in addition to the consideration and correct intervention of health care professionals, are key in improving the well-being of individuals suffering from Alzheimer's disease, depression, and other psychiatric-related illnesses.

A 38-year-old woman has lost 10 pounds over the past year, but still weighs 185 pounds (the patient is 5 feet 3 inches and has a BMI of 32.8). She has been working hard on a diet and exercise program. She has no other medical problems, and she would like to lose more weight. Question What is the most appropriate next step? Answer Choices 1 Bariatric surgery 2 Continue current diet and exercise program 3 Ephedra 4 Hoodia 5 Orlistat

Correct Answer: Orlistat Show Explanation Explanation The correct response is orlistat. Obesity is an ever-growing problem in the United States. Weight loss can be achieved by 1 of 3 methods: decreasing appetite; decreased absorption of nutrients; or increased energy expenditure. Weight-loss medications are recommended, unless contraindicated, for patients who have a BMI ≥30 kg/m2 or >27 kg/m2 with obesity-related comorbidities. Many weight loss drugs cause only a modest loss of weight (around 5 - 10% of body weight), and patients often gain the weight back once the drug is discontinued. This phenomenon may be a result of the body's complex regulatory system designed to prevent starvation. Weight-loss medication should be combined with dietary education, behavioral intervention, an exercise program, and a long-term weight-maintenance plan. The addition of these lifestyle modifications to weight-loss medication results in increases of weight loss and treatment satisfaction. Centrally-acting weight loss drugs work by decreasing appetite and the desire for food, which theoretically leads to less food intake and weight loss. Orlistat reduces the absorption of dietary triglycerides by inhibiting gastric and pancreatic lipase. In clinical trials, orlistat combined with dietary modifications has been shown to lead to modestly increased weight loss (compared to dietary changes alone). Orlistat's side effects include frequent oily bowel movements, diarrhea, bloating, and abdominal pain. Side effects may be lessened with the ingestion of a low-fat diet. This patient meets the criteria for weight loss drugs, and Xenical would also be a good choice for treatment (in conjunction with lifestyle modification). This patient does not meet the criteria for bariatric surgery at this time, but she may meet the criteria in the future. Indications for bariatric surgery are: BMI >40 with no co-existing medical conditions, or BMI >35 with additional medical problems (e.g., diabetes, hypercholesterolemia, sleep apnea, and hypertension). The patient should continue her current diet and exercise program, but since she is asking for more assistance and meets the criteria for weight loss drugs, she can be treated further. Ephedra is an amphetamine-like plant compound. Also known as ma-huang, it has been marketed as a weight-loss product; it has also been proposed that it increases energy and improves athletic performance. The FDA banned the sale of ephedra products in April of 2004. Concerns about elevated blood pressure, an increased strain on the heart, and risk of stroke, in the absence of good evidence of the drug's efficacy for weight loss, prompted the recall. This recommendation would not be medically sound. Hoodia is a plant stem that is traditionally eaten by Bushmen to decrease hunger and thirst; it is marketed as an over-the-counter weight-loss medicine. It has not been evaluated in clinical studies for effectiveness or safety, so it would not be a good recommendation.

A 58-year-old man presents for further evaluation after being brought in by the local police because of an unstable gait and disheveled appearance; his breathalyzer test is 0.08 g/dL. On exam, the man is gaunt and clearly malnourished; he is semiconscious and unable to respond to questioning. His right elbow and knee are bruised, but he appears to have no other significant injuries; however, his eye movements are uncoordinated and he is unable to fixate his gaze. Vital signs are as follow: Blood pressure 138/89 mm Hg Pulse 109 Temperature 35.7° C Question What diagnosis is most consistent with the patient's signs and symptoms? Answer Choices 1 Acute alcohol intoxication 2 Delirium tremens 3 Wernicke's encephalopathy 4 Korsakoff's syndrome 5 Beriberi

Correct Answer: Wernicke's encephalopathy Ethanol has myriad effects on the central nervous system. Wernicke's encephalopathy is a medical condition resulting from thiamin deficiency. It is most commonly observed in individuals who drink heavily but consume little food. Since the metabolism of alcohol requires this nutrient, the body's stores of thiamin can become depleted under these conditions. The signs and symptoms of Wernicke's encephalopathy are similar to acute alcohol intoxication; they include altered conscious, altered memory, and incoordination. The feature that distinguishes Wernicke's encephalopathy, however, is ophthalmoplegia, which reverses rapidly following intravenous infusion of thiamin. Patients with Wernicke's encephalopathy who remain untreated often develop permanently impaired memory and confusion, a condition known as Korsakoff's syndrome. Beriberi is also a condition resulting from a deficiency of dietary thiamin. Acutely, patients experience high-output cardiac failure with vasodilation, edema, and cardiac enlargement. Symptoms resolve with thiamin infusion. The symptoms of acute alcohol intoxication vary by the amount consumed. At low levels, alcohol causes relaxation and a slowing of fine motor function. As more is consumed, speech becomes slurred, eyesight becomes blurry, and balance becomes unstable. Once the blood alcohol level exceeds 0.20 g/dL, the anesthetic properties of alcohol become prominent; the individual is likely to lose consciousness. Delirium tremens describes a condition associated with acute alcohol withdrawal. The symptoms include agitation, tremor, and hallucinations (classically tactile in nature). Untreated, seizures may also result. As seen with this patient, high pulse and blood pressure are early indicators of acute alcohol withdrawal that warrant attention. Benzodiazepines are most commonly used to prevent delirium tremens.

A 32-year-old man mentions several times that he feels exploited by his employees and that he doubts their loyalty to his company. "In fact," he says, "I have even overheard them talking about how they would change the company if I were no longer in charge". He says he is consequently reluctant to confide in others, especially in his business partner, and he even wonders if he should be telling you all of this since you have just met. Question What personality disorder is this man displaying? Answer Choices 1 Paranoid personality disorder 2 Schizoid personality disorder 3 Schizotypal personality disorder 4 Antisocial personality disorder 5 Histrionic personality disorder

Correct Answer: Paranoid personality disorder Show Explanatione Explanation Antisocial personality disorder is characterized by persistent patterns of disregard for others and violations of the rights of others. Symptoms usually begin before age 15 years, but the diagnosis cannot be officially established until age 18 . There must be at least 3 of the following current symptoms: nonconformity to social norms and lawful behavior, deceit, impulsivity, pervasive irritability or aggression, a reckless disregard for the safety of themselves or others, irresponsibility, and lack of remorse. Individuals with antisocial personality disorder are also sometimes referred to as sociopaths. Prognosis is poor for antisocial personality disorder, and men are more likely to be affected than women. Paranoid personality disorder is characterized by distrust and suspicion that leads the individual to assume that others' motives are malicious. At least 4 symptoms must be present to diagnose an individual with this disorder. These include suspicion without cause, preoccupation with the loyalty or trustworthiness of others, reluctance to confide in others, misinterpretation of benign events, or perception that remarks made to them are threatening. Although superficially similar to paranoid personality disorder, schizotypal personality disorder is characterized more by pervasive social and interpersonal deficits that result in extreme discomfort with close relationships. 5 or more of the following symptoms are present in the typical individual with schizotypal personality disorder: ideas of reference (but not full-blown delusions), odd beliefs or magical thinking, illusions or unusual perceptual experiences (but not classic hallucinations), odd thinking and speech, eccentric behavior or appearance, paranoid thinking or suspiciousness of others, no close friends, and social anxiety that is related to paranoid fears, rather than to negative feelings about oneself. Although these symptoms are also similar to those experienced by individuals with schizophrenia, they are not nearly as severe; as odd as the individual may behave, he or she is not disorganized. Individuals with schizoid personality disorder tend to be socially isolated, they display restricted affect (expression of mood), and they almost always prefer to be alone. These individuals appear to others to be introverted and preoccupied, and they do not do well in jobs that require social performance. An individual must display at least 4 of the following symptoms to be diagnosed with schizoid personality disorder: few activities are pleasurable, close relationships are shunned - even those with family members, a clear preference for solitude (activities are usually chosen accordingly), indifference to praise or criticism, and a profound lack of displayed emotions. Excessive emotionality and attention-seeking behaviors characterize individuals with histrionic personality disorder. 5 of the following symptoms must be present: a need to be the center of attention, inappropriate sexual behavior such as seductiveness or provocativeness, shallow emotions that change quickly, excessively emotional speech, exaggerated emotional expression, and a history of believing that relationships with others are more intimate than they really are.

A 15-year-old boy presents with anxiety, depression, and impulsive behavior that started after the death of his grandmother several weeks ago. During the interview, he reports that since the age of 5 or 6, he has wished to be a girl. He had been dressing up in his mother's clothes, likes to play with dolls, and prefers the company of girls at school. He used to live with his grandmother because his mother was often away. His grandmother involved him in cooking, housework, and gardening. After she died, he desperately wanted to continue doing the same things he did with her. However, his mother strongly opposes such behavior. Recently, he met a boy who seems to share the same interests as he does, but he refuses to talk more about his current relationship with him. Question What should you do next? Answer Choices 1 Ask him about his sexual orientation 2 Determine his Tanner stage 3 Ask him about his attitude towards homosexuality 4 Ask him about his sexual behavior 5 Assure him that his confidentiality is protected

Correct Answer: Assure him that his confidentiality is protected

A 19-year-old man with a family history of schizophrenia is receiving medical attention for his 1st presentation of psychosis. After ruling out organic causes and substance abuse as etiologies of his symptomatology, antipsychotic therapy with haloperidol is initiated. Within 48 hours, the patient begins to experience involuntary spasmodic contractions of the muscles in his face and neck. Question Inhibition of what neurotransmitter/receptor is causing the patient's symptoms? Answer Choices 1 Histamine 1 (H1) 2 Serotonin (5-HT2A) 3 Dopamine (D2) 4 Muscarinic cholinergic (M1) 5 Alpha-adrenergic (α-1)

Correct Answer: Dopamine (D2) Show Explanation Explanation Typical antipsychotic drugs (e.g., haloperidol) are often used in the acute management of psychosis in schizophrenia as well as other psychotic disorders. These medications are direct dopamine D2-receptor antagonists, occupying receptors in each of the dopamine pathways, including the mesolimbic, mesocortical, nigrostriatal, and tuberoinfundibular tracts. Blockage of the mesolimbic tractis crucial to the efficacy of antipsychotic therapy because excessive dopamine transmission here is believed to cause the positive symptoms of schizophrenia (hallucinations, delusions, agitation, and disorganized behavior/speech). However, blockage of the other dopaminergic tracts can lead to unwanted side effects, including cognitive dysfunction (mesocortical tract), hyperprolactinemia (tuberoinfundibular tract), and extrapyramidal symptoms (nigrostriatal tract). Extrapyramidal symptoms (EPS) are usually dose-dependent, and they are divided into acute and delayed effects. The early effects include a Parkinson-like syndrome (bradykinesia, rigidity, and tremor), akathisia (restlessness and psychomotor agitation), and dyskinesias (intermittent spasmodic or sustained involuntary contractions of muscles in the face, neck, trunk, pelvis, and extremities).Thesedystonic reactions can occur within 48 hours of the initiation of neuroleptic drug therapy. While these symptoms are rarely life threatening, they are very uncomfortable and often produce significant anxiety and distress for patients. Delayed EPS are tardive dyskinesia (choreoathetoid movements of the muscles of the lips and buccal cavity) and tardive dystonia (late onset involuntary muscle contractions). Typical antipsychotic medications also have variable affinities for other neurotransmitter receptors, including histamine, muscarinic cholinergic, and alpha-1-adrenergic receptors, further adding to the side effect profile of these medications. • Antagonism of histamine 1 (H1) results in sedation and weight gain. • Muscarinic receptor blockade can cause common anticholinergic side effects such as blurred vision, dry mouth, urinary retention, constipation, and decreased cognition. • Inhibition of alpha-1 adrenergic receptors can lead to sedation, orthostatic hypotension, and reflex tachycardia. Serotonin (5-HT) receptors are targeted primarily in the treatment of depression. However, recent interest in the role of serotonin (5-HT) in antipsychotic drug action is based mainly upon the fact that atypical newer antipsychotic drugs are potent 5-HT2A receptor antagonists and relatively weaker dopamine D2 antagonists. These agents share in common low extrapyramidal side effects at clinically effective doses and possibly greater efficacy to reduce negative symptoms. As a class, they also have a superior effect on cognitive function and greater ability to treat mood symptoms in both patients with schizophrenia or affective disorders than typical antipsychotic drugs.

A 35-year-old man presents with hair loss on the side of his head. He states that during long office working hours he has a habit of pulling his hair at a certain area; this behavior increases with stress. He also states that he has been subjected to a severe work load lately. He does not take any medications. On examination, an area of normal skin with no hair over the right temporal area of the scalp, measuring 1 cm x 1 cm in size, is seen. No exclamation mark hairs are found. Question What is the most likely diagnosis? Answer Choices 1 Alopecia areata 2 Trichotillomania (hair-pulling disorder) 3 Cicatratial alopecia 4 Androgenetic alopecia 5 Drug-induced alopecia

Correct Answer: Trichotillomania (hair-pulling disorder) Show Explanation Explanation Based on the history and examination, this patient has trichotillomania (hair-pulling disorder), which is hair loss with a normal scalp due to the uncontrollable urge to pull out the hair. Baldness (alopecia) is the loss of hair; it is either scarring or non-scarring. The cause of hair loss is based upon the history, the distribution of hair loss, and the appearance of the skin. Baldness due to scarring is irreversible and permanent, so it is important to start treatment as soon as possible. Non-scarring baldness may occur with systemic diseases (e.g., systemic lupus erythematosus and iron-deficiency anemia). Since this patient's hair loss is not idiopathic, as is the case with alopecia areata, there are no exclamation mark hairs. There is no scarred skin, so the diagnosis would not be cicatricial alopecia. The course and shape of this patient's hair loss does not match that of androgenetic alopecia. The patient did not take any drugs that would have induced drug-induced alopecia.

A 44-year-old man lives alone in a rooming house; he is generally suspicious of everyone's motives towards him, and he usually finds malevolence in even the most ordinary comments and actions. He has never married because he has yet to find a woman who could remain faithful to him for 'even a month or 2, let alone a lifetime'. The man's older sister tells you that her brother has been that way since he was a child. He thinks everyone is mean to him, and he never forgets any wrongs done. He feels that he is being watched and followed, but he is nonetheless able to work consistently. Question Based on this information, what is the most likely diagnosis? Answer Choices 1 Schizophrenia 2 Paranoid personality disorder 3 Schizoid personality disorder 4 Schizotypal personality disorder 5 Antisocial personality disorder

The correct response is paranoid personality disorder. Personality disorders can be described as: • enduring patterns of behavior that are rigid and pervasive across situations • characterized by the generally maladaptive styles or unsuccessful 'ways of being' in the world of these patients, rather than being defined by circumscribed symptom sets • long-lasting (can be traced back through childhood or adolescence) • not a result of substance use or a general medical condition • relative to culture and not diagnosed if explainable by social factors (e.g., people emigrating to an unfamiliar environment and culture may naturally have long-lasting difficulties and resistance to cultural assimilation that would not be termed personality disorders) There are 10 types of personality disorders grouped into 3 clusters: Paranoid, schizoid, and schizotypal personality disorders make up cluster A (i.e., the eccentric group). Cluster B includes the antisocial, borderline, histrionic, and narcissistic personality disorders, a group that may tend to distress others by their behavior and may not necessarily be distressed by it themselves. Cluster C is made up of the avoidant, dependent, and obsessive-compulsive personality disorders (i.e., the anxious, fearful group). Within cluster A, paranoid personality disorder manifests as a pervasive distrust of others and constant suspiciousness toward others' motives. Interpretations of others' behaviors made by these patients will usually include maliciousness, hidden meanings, jealousy, and long-term grudges. Schizophrenia has some similarities to the cluster A personality disorders, but it is characterized by acute psychotic episodes, in addition to chronic symptoms of eccentricity. The most common age for the onset of adult schizophrenia is in the mid-20s. Schizoid personality disorder is characterized by detachment, indifference towards others, and marked coldness of emotion. These patients are often life-long loners. Schizotypal personality disorder manifests as odd beliefs, magical thinking, social anxiety, unusual perceptual experiences, odd speech, and peculiar appearance. Antisocial personality disorder is a cluster B disorder. These individuals exhibit traits that often involve them with the criminal justice system; traits include a lack of remorse or regret for (even) violent and hurtful acts, an artificial charm turned on for purely manipulative purposes, reckless disregard for the rights and safety of others, deceitfulness, impulsivity, and irresponsibility.

A 43-year-old man presents with jaundice, weight gain, enlarged abdomen, and swollen legs for the last several weeks. He complains about fatigue, malaise, and sleeplessness. His wife and adult son are with him, and they tell the ER physician that his oral intake has been limited to excessive alcohol ingestion and very little food in the last few weeks. He has a history of hypertension and is on amlodipine 5 mg for this. Family history is significant for his father having hypertension and having an older brother with alcoholism. He has smoked 1 pack of cigarettes daily since he was 18 years old, and he has been drinking 12-24 cans of beer daily for the last 15 years. On examination, his temperature is 99.2°F, BP 140/86 mm of Hg, pulse 86/minute; respiratory rate is 18/minute, and his sclerae are icteric. Lungs have decreased air entry at the bases, and heart sounds are normal. Abdominal exam shows ascites and caput medusae without hepatomegaly. He has pitting pedal edema bilaterally and a fine tremor in his hands. He is alert and fully oriented. Labs are ordered and are pending. 171) Question In the management of this patient, what is the most important factor in regards to his liver disease? Answer Choices 1 Compliance with medical management 2 Smoking cessation 3 Nutritional support with carbohydrates and vitamins 4 Time lapse in arranging liver transplant 5 Alcohol abstinence

Correct Answer: Alcohol abstinence Show Explanation Explanation This patient has alcoholic cirrhosis of the liver. The 4 signs of decompensation are jaundice, encephalopathy, ascites, and variceal hemorrhage, of which he has 3. He is therefore gravely ill and needs intense management by a team of doctors. The most important prognostic consideration is alcohol abstinence. Continued drinking is very likely to hasten his demise from liver failure and its complications. On the contrary, abstinence can halt or in some cases reverse liver injury. Compliance with medical management, including diuretics and steroids, is also a key issue in management of the condition; however, abstinence is more important. Patients treated in a hospital tend to go back to drinking alcohol once they get better and go home. Smoking cessation is advisable in the long-term prevention of several types of cancer, but it is less relevant to the progression of liver injury caused by alcohol. Nutritional support is essential in these patients, since they tend to be malnourished and it improves survival. Carbohydrates and calories should be given in adequate amounts to reduce protein catabolism, promote gluconeogenesis, and prevent hypoglycemia. Folic acid and thiamine must also be replenished. Nutritional support will fail if the patient continues to drink. Liver transplant is offered to patients only if they have a 6-month period of abstinence from alcohol, and it is contraindicated if the patient is unable to abstain from drinking.

A 19-year-old woman presents with her parents. She is 5'5" in height and weighs 100 lbs. Her parents state that she has been dieting seriously for the last 6 months and refuses to eat most meals with the rest of the family. Normally, she eats only small amounts of vegetables and an occasional piece of fruit; recently she has started to self-inflict vomiting if she feels she has eaten too much. Her parents say that they are tired of arguing with her about her thinking that she's too fat; recent hypothermia, amenorrhea, and fainting spells led them to seek medical care for her. Question What disorder does this woman display? Answer Choices 1 Bulimia nervosa 2 Anorexia nervosa 3 Pica 4 Rumination 5 Unspecified feeding or eating disorder

Correct Answer: Anorexia nervosa Show Explanation Explanation Anorexia nervosa is characterized by: • A refusal to maintain a minimally normal body weight (defined as 85% of what is expected) • An intense fear of gaining weight • A disturbance in one's subjective experience of body weight or shape • A denial of the seriousness of low weight and self-starvation • In female patients, amenorrhea for at least 3 consecutive cycles 90% of patients reported with this disorder are girls/women, although the incidence in male patients is growing. This case shows evidence of purging, so it is considered the 'binge-eating/purging type' of anorexia and not bulimia; this is due to the low body weight. The purging common to bulimia (i.e., self-induced vomiting, misuse of laxatives and diuretics, or enemas) can be present in anorexia also, as may other inappropriate compensatory behaviors (e.g., fasting, excessive exercise). Pica and rumination are usually seen earlier in childhood; they involve, respectively, the eating of non-nutritive substances and the regurgitation and rechewing of food. The DSM-V designation of unspecified feeding or eating disorder applies when the patient's behaviors do not meet the criteria for any specific eating disorder. In this case, it would have been used if all the criteria for anorexia nervosa were met except that the patient still had regular menses. Refer to the image for an example of anorexic perception. Research has found that anorexics have a highly distorted perception of what they see in the mirror, which is similar to what happens in body dysmorphic disorder; however, when this distortion occurs only with reference to 'fatness', it is classified as an eating disorder.

A 60-year-old woman is referred to you for a bizarre fixation. She has become preoccupied with the issue of having breasts that are too small, and she has been shopping for plastic surgeons to fix the problem. She has become so fixated on her problem that she stays in the house, does not socialize with others, and tries to constantly hide the perceived problem by wearing clothes that enhance her breasts; sometimes, she even wears prosthetic breasts. She has become paranoid about what people are saying about her appearance. Question What is the most likely diagnosis? Answer Choices 1 Pseudocyesis 2 Total environmental allergy syndrome 3 Chronic fatigue syndrome 4 Body dysmorphic disorder 5 Factitious disorder

Correct Answer: Body dysmorphic disorder Show Explanation Explanation Body dysmorphic disorder is a very rare disorder in which an individual becomes preoccupied with the fixation that a body part is wrong in appearance and requests medical procedures, becomes dissatisfied with the results, avoids social situations, sometimes becomes housebound, and sometimes tries to commit suicide over a perceived abnormality in their appearance. Pseudocyesis is a very rare disorder in which patients believe they are pregnant when they are not. They may even develop signs and symptoms of a pregnancy, such as a protruding stomach and nausea; they may even have false labor pains. Total environmental allergy syndrome is a disorder in which patients claim to be allergic to most or all foods, gases, clothing, or other materials with which they come into contact; they generally keep asking for appointments that they can use to prove their point, or they keep asking for medical testing. Chronic fatigue syndrome has received extensive attention in health and medical science over the last decade, and there are long-standing fatigue states for which there are few laboratory findings or few effective treatments. Some physicians believe it is an autoimmune disease, and others view it as a pseudo-depressive or psychiatric disorder. Others see it as a form of arthritis. It is a very controversial disease state. Patients with factitious disorder play the "sick role" in order to gain attention. They intentionally make up mental or physical signs and/or symptoms of disease.

A 25-year-old woman presents for an annual physical examination that is required by her new employer. As you progress through the history and review of systems, you come across very few positive responses. However, when completing the physical examination you note following: 25 year old female appearing her stated age of normal size and weight; large calluses on many fingers of both hands; and severe discoloration of teeth with some having exposed dentin. Question What is the most likely diagnosis? Answer Choices 1 Pica 2 Body Dysmorphic Disorder 3 Bulimia nervosa 4 Anorexia nervosa 5 Rumination

Correct Answer: Bulimia nervosa Show Explanation Explanation Bulimia nervosa is characterized by binge eating and purging. Patients are often at a normal weight. Physical examination findings that should heighten a clinician's suspicion of bulimia nervosa includes the following: calluses on backs of multiple fingers of bilateral hands, discolored teeth, and loss of dental enamel, exposing the dentin. These consistently show a longstanding behavior pattern that is consistent of bulimia nervosa. Pica is characterized by a child eating nonnutritive substances for 1 month or longer. It is usually associated with another mental disorder, such as an intellectual disability (intellectual developmental disorder). Body dysmorphic disorder is diagnosed when a person has an exaggerated preoccupation with a physical defect, which may be real or imagined. Anorexia nervosa is a disorder in which a person refuses to maintain a healthy body weight, has a distorted perception of body shape and size, and has an intense fear of gaining weight. Although it typically affects female adolescents, men and older women can also suffer from Anorexia Nervosa. Rumination is the repeated regurgitation of one's food that has persisted for at least 1 month. It is usually associated with another mental disorder, such as intellectual disability (intellectual developmental disorder).

A 36-year-old man with a history of diabetes and obesity presents with weakness and flu-like symptoms. His girlfriend reports that he had taken several caffeine pills the day before, but he denies a suicide attempt. During evaluation at the hospital, he experiences vomiting and seizures. A laboratory work-up is within normal limits. He is admitted to the hospital and improves over the course of his 3-day admission. He is subsequently released with no lingering effects. Question What is the most common treatment for this patient after hospital discharge? Answer Choices 1 Anti-anxiety medication 2Decrease caffeine intake 3 Steroids 4 Levothyroxine 5 Antidepressant medication

Correct Answer: Decrease caffeine intake Explanation This patient is demonstrating symptoms of caffeine intoxication caused by the consumption of large amounts of caffeine. Symptoms of caffeine intoxication can include insomnia, nervousness, restlessness, tachycardia, diuresis, and agitation. Caffeine is not considered to be a drug by many people; therefore, they do not consider excessive consumption to be a problem. Many food and drinks contain caffeine, and people consume them unaware that it is present. It becomes easy to ingest large quantities without realizing it. When caffeine is ingested, it enters the bloodstream and can lead to an increase in the secretion of norepinephrine in the brain. This causes an increase in activity in neurons. It binds to adenosine receptors and can block the sedative effect that adenosine can produce. As a result, people become more alert and feel less tired. Anti-anxiety medications are not appropriate since the patient is not suffering from anxiety. They are not used to treat caffeine intoxication. Steroids would not be used in treating a patient with caffeine intoxication. Levothyroxine would be used in a patient with hypothyroidism, which this patient does not have. The patient's laboratory results were within normal limits. Antidepressant medications would not be helpful, since the underlying disease is not depression.

During therapy, your client begins to reveal what appears to be distinct personalities, and identities appear to repeatedly take control of the patient's behavior. You know she is an incest survivor. Question You have tentatively diagnosed her with a post-traumatic stress disorder; however, you wonder if she may have what condition? Answer Choices 1 Dissociative Amnesia 2 Dissociative Fugue 3 Dissociative Identity Disorder 4 Depersonalization/Derealization Disorder 5 Unspecified Dissociative Disorder

Correct Answer: Dissociative Identity Disorder Show Explanation Explanation Dissociative disorders (e.g., dissociative amnesia, depersonalization/derealization disorder, dissociative identity Disorder, other specified, and unspecified dissociative disorder) are characterized by sudden or gradual change in consciousness, identity, memory, or perception. These changes may be chronic or transient, and they are not associated with physiological problems. Dissociative identity disorder, formerly called multiple personality disorder, is a severe condition in which an individual has at least 2 distinct identities that can take over his or her behavior. Stress is thought to bring on the personality changes, and the disorder is believed to have its origins in severe childhood trauma. Abuse during childhood has been documented in many cases of dissociative identity disorder. Dissociative identity disorder is controversial as a diagnosis, and it is often incorrectly diagnosed. Encouraging healthy coping behaviors, logging and monitoring emotions, and developing a crisis plan are included in the primary goals of therapy. The ultimate goal of psychotherapy involves bringing together all of the facets of the individual into 1 person. Dissociative amnesia is diagnosed when an individual is unable to remember important personal information that is too extensive to be explained by normal forgetfulness. The information is often stressful or traumatic in nature. Dissociative amnesia normally takes the form of a retrospective forgetting of a stressful event (i.e., an event of the past is forgotten). Dissociative fugue is a specifier of dissociative amnesia and not a separate diagnosis. It is most commonly seen after an individual experiences war or a natural disaster. Usually, the individual travels suddenly and unexpectedly away from home or work during the fugue state, experiences confusion, and may take on a new identity. It normally lasts only a short time, and typically the individual is unable to remember things that happened during the fugue state. Depersonalization disorder is characterized by feeling unconnected to oneself, such as feeling "unreal", and/or having unusual body sensations. While perceptions of time, other people, or of objects may be impaired, reality testing is essentially intact among individuals with depersonalization disorder. Like other dissociative disorders, acute stress is thought to be responsible for depersonalization disorder. When an individual experiences symptoms of dissociative disorders that are not sufficient to make a particular diagnosis, the diagnosis of 'dissociative disorder not otherwise specified' may be made.

A 32-year-old woman presents for follow-up after being seen in the emergency department 2 days prior; her mother brought her in after she witnessed the patient having a seizure. While in the ED, the patient was observed having another seizure; she appeared to be shaking with nonparallel movement of her right and left arms, and she remained conscious throughout the episode. EEG monitoring was negative for any seizure-like activity. The patient was also seen in the ED 3 months ago following a sexual assault. The patient notes poor sleep and difficulty motivating herself to complete her daily activities. On examination, the patient appears tearful. Neurological examination is normal. Question Of the following, what is the most appropriate medication for this patient? Answer Choices 1 Levetiracetam 2 Lamotrigine 3 Lorazepam 4 Fluoxetine 5 Oxycodone

Correct Answer: Fluoxetine Show Explanation Explanation The correct response is fluoxetine. The patient's history describes seizures, but the episode observed in the ER is not consistent with a seizure; the lack of synchronous movement and absence of EEG findings shows that this patient is not having seizure-like activity. This, paired with her recent history of sexual assault, is suggestive of conversion disorder. Conversion disorder is a somatoform disorder in which psychological stress is converted into physical symptoms. The recommended treatment is therapy; if medications are used, antidepressants or antianxiety medications are recommended. The patient appears to be exhibiting signs of depression; fluoxetine would be an appropriate choice. The patient should undergo therapy with close follow-up, in addition to taking fluoxetine. Levetiracetam and lamotrigine are anticonvulsant medications. The patient does not exhibit any clinical signs of actual seizure activity, and the use of levetiracetam or lamotrigine would be inappropriate. Lorazepam has many uses, including antiepileptic and sedative effects. This patient is not suffering from seizures; furthermore, sedative medications are often overused in patients with somatoform disorders. Its use should be avoided. Oxycodone is incorrect. The patient is not currently complaining of pain, so oxycodone should not be prescribed. Patients with somatoform disorders are at higher risk of drug dependence and abuse due to the potentially long duration of their condition. Addictive medications should be avoided in this population.

A 14-year-old boy is brought to your medical office by his mother for a physical examination. According to the mother, the child was diagnosed with intellectual disability (intellectual developmental disorder) 2 years ago. They have just relocated from another state, and he requires a physician's clearance to start at a new special education school. She states that he has been in good physical health since birth. His past medical history includes a few mild headaches and upper respiratory tract infections, but no chronic conditions, hospitalizations, operations, or medications. The mother has brought his vaccination records with her, and they show all immunizations are current. Family history is positive for a maternal grandmother that developed dementia at age 55 and an autistic maternal uncle. Pertinent findings on the physical examination include an unusually narrow face, a prominent forehead, large protruding ears, a prominent jaw, and unusually large testes. Question What chromosomal abnormality is the most likely diagnosis? Answer Choices 1 Cri du chat syndrome 2 Down syndrome (trisomy 21) 3 Fragile X syndrome 4 Klinefelter syndrome (XXY) 5 Turner syndrome (XO)

Correct Answer: Fragile X syndrome Show Explanation Explanation Males with Fragile X syndrome (FXS) are generally more severely affected than females, but females sometimes do show neuropsychological symptoms, such as autistic disorder, learning disabilities, and mild MR/ID. However, physical signs in females are very rare. It is the most common cause of intellectual disability (intellectual developmental disorder) in boys. FXS is an X-linked condition caused by the expansion of a trinucleotide repeat (CGG repeats) in the FMR1gene. Once the number of repeats goes beyond 52, chance of further expansion during oogenesis or spermatogenesis is great. An increase in the size of the trinucleotide repeat from the normal size (usually less than 50 CGG repeats) to 52-200 repeats is associated with more extensive somatic mosaicism in respect to the number of repeats in various cell types. Fragile X syndrome follows the genetic phenomenon known as "anticipation". Anticipation is characterized by a genetic condition becoming more severe or having an earlier age of onset in succeeding generations. Most genetic anticipation appears to be caused by expansions of trinucleotide repeats, such as is the case with fragile X syndrome. Consequently, the risk of clinical symptoms and the degree of cognitive impairment increases in succeeding generations. In this case, the maternal grandmother was likely a permutation. Individuals with the permutation are usually asymptomatic or only mildly affected. The maternal grandmother son's autistic disorder could represent a less severe manifestation of the syndrome. Cri du chat syndrome is characterized by a partial deletion of the short arm of chromosome 5 and is associated with severe intellectual disability (intellectual developmental disorder) Klinefelter syndrome (XXY) is associated with cognitive and emotional difficulties. Down syndrome (trisomy 21) is associated with intellectual disabilities and early Alzheimer's disease. Turner syndrome (XO) is a genetic anomaly in female patients; it is associated with various cognitive, physical, and behavioral problems.

A 15-year-old girl has been dieting for 6 months and has lost over 30 pounds. She tells you that she still feels fat despite the recent weight loss. She is afraid to eat for fear of becoming obese. Her last menstrual period was 3 months ago. On physical exam, the patient is cachectic and slightly pale. Her heart rate is 50 beats/minute, her blood pressure is 90/60 mm Hg, and her temperature is 95.5 F. Her weight is 92 pounds and her height is 5 feet 6 inches. Question What laboratory result is likely to be elevated? Answer Choices 1 Thyroid stimulating hormone (TSH) 2 White blood cell count (WBC) 3 Erythrocyte sedimentation rate (ESR) 4 Growth hormone level 5 Serum potassium level

Correct Answer: Growth hormone level Show Explanation Explanation The correct response is growth hormone level. This patient is suffering from anorexia nervosa (AN), an illness that has had a marked increase in incidence over the past 2 decades. Almost all organ systems are affected by AN. Death occurs in 10% of patients; it is usually caused by severe electrolyte disturbance, cardiac arrhythmia, or congestive heart failure. Bradycardia, postural hypotension, and hypothermia are common. EKG changes include low voltage; T-wave inversion and flattening; ST depression; and supraventricular and ventricular dysrhythmias. Amenorrhea occurs in most patients with AN. Growth hormone secretion is abnormally high. TSH levels are low, and thyroxine and triiodothyronine levels are low. Low ESRs are common, possibly reflecting low fibrinogen production secondary to malnutrition. White blood cell counts are low due to bone marrow hypoplasia. Low potassium is very common due to vomiting and malnutrition.

A 37-year-old woman was diagnosed with AIDS 3 years ago; she is unable to work and is physically debilitated, so she asks you to provide her with medications with which to take her own life. Question What is the most common emotional disorder associated with such a request? Answer Choices 1 Bipolar I disorder, manic type 2 Borderline personality disorder 3 Factitious disorder 4 Major depressive disorder 5 Schizophrenic disorder

Correct Answer: Major depressive disorder Show Explanation Explanation Many people who request assisted suicide have 1 of 2 conditions present: either a poorly controlled painful condition or severe depression. If the painful condition is adequately treated or the depression is brought under good medical control, the request for assistance in terminating the situation is typically withdrawn. It is important to note that bringing these conditions under control requires the intervention of caregivers who are specifically trained in the management of these 2 conditions; primary care providers usually are not adequately trained to address these difficult presentations. While patients who are diagnosed with bipolar disorder, borderline personality disorder, and schizophrenic disorder often make suicide attempts (and frequently complete those attempts), they do not generally ask their physician for assistance in the suicide. Persons with factitious disorder are seeking primary gain, often for dependency needs, and are seeking to enter the 'sick role' and not the 'dead role'

A 49-year-old woman presents for a consultation 1 month after her 22-year-old son was killed in a fall at a construction site near her home. The patient is upset, restless, and wrings her hands frequently. She lies awake at night, she does not feel like eating, and she cries easily and frequently. She is totally preoccupied with thoughts of her son, and she sometimes thinks she sees him walking just outside their home. She says she wishes she were dead, yet she denies any thoughts of killing herself. Question What is the best explanation for these findings? Answer Choices 1 Dysthymic disorder 2 Major depressive disorder 3 Normal grief reaction 4 Obsessive compulsive disorder 5 Schizophrenic disorder

Correct Answer: Normal grief reaction Show Explanation Explanation Grief or bereavement follows a loss or trauma. Restlessness, distractibility, numbness, sadness, apathy, and a need to talk of the dead are all part of the normal grieving process. Although grief has similarities to depression, the symptoms of grief usually dissipate over time and are not as pervasive as are those of depression. It is not uncommon for a normal grief response to last 6 months to a year. Patients with dysthymic disorder feel depressed, have difficulty falling asleep, and characteristically feel best in the morning. Symptoms must have been present at least intermittently for 2 or more years. It is similar to a major depressive disorder, but less severe. This disorder usually develops in the 20s and 30s. Major depression is a widely prevalent disorder. It can occur at any age, and it is characterized by at least 5 of the following: • Anhedonia • Lack of motivation • Worthlessness • Somatic complaints • Depressed mood • Thoughts of death • Suicidal thoughts • Psychomotor agitation • Somatic complaints of decreased concentration • Changes in weight and appetite • Changes in sleep patterns (increased REM sleep with decreased amounts of stage 4 sleep) Obsessions are repetitive ideas, images, and impulses that intrude upon a patient who feels powerless to stop them. Most patients develop compulsions to ward off unwanted happenings or to satisfy an obsession.

A 2-year-old boy presents because of his mother's concerns about his sleep. She notes that he is easy to put to sleep, and he has a regular bedtime of 7:30 P.M. Most nights for the past 3 weeks, about 90 minutes after being put to sleep, he begins to thrash violently in the bed; at times, he lets out blood-curdling screams. He has his eyes open and seems to be talking, but he does not respond to either parent when spoken to. He sweats a lot. The episodes last about 15 minutes, and he then goes back to sleep; he seems fine in the morning. He naps for about an hour in the morning and an hour in the afternoon, but these episodes do not occur with naps. Question What is the most likely diagnosis? Answer Choices 1 Confusional arousal 2 Nightmares 3 Sleep terrors 4 Sleep association disorder 5 Sleep-wake transition disorder

Correct Answer: Sleep terrors Show Explanation Explanation Sleep terrors occur between 18 months and 6 years of age in about 3% of children; they are not indicative of a mental health problem. Stress, a full bladder, or loud noises may be precipitating factors. They occur more frequently in boys and also when there is a positive family history. They may occur for a few weeks, disappear for months, and then recur. The underlying cause is disordered arousal from stage III or IV sleep which occurs 60 - 90 minutes after going to sleep. Confusional arousals also occur about 60 - 100 minutes after going to sleep. The child may be sleeping very deeply so that as he/she transitions from stage IV to rapid eye movement (REM) sleep there may be thrashing and moaning that lasts between 5 - 15 minutes. The child may appear to be awake; he or she might have open eyes and seem confused or upset. The episodes are difficult to interrupt, and children do not respond to parental consoling. They may occur multiple times, but tend to decrease in intensity if they extend into the 2nd half of the night. They occur more commonly when the child's schedule has been altered, the child is overly tired, or the child is upset or ill. Nightmares, or scary dreams, occur during REM sleep and are more common early in the morning when REM sleep occurs more frequently. Unlike night terrors, the child is easily arousable and comforted when having a nightmare. They are most common between 3 and 6 years, which is when children develop their imaginations and do not easily distinguish fantasy from reality; however, children do dream at an earlier age. About 7% of children who have nightmares have a positive family history. It is more common in children with an intellectual disability (intellectual developmental disorder), depression, and certain CNS disorders. Sleep association disorders are the most common reason infants wake within the first 30 minutes of going to sleep. This is a situation in which an infant has an association with going to sleep, such as nursing or having a parent lie down in the bed. If the child wakes and does not have the association present, then the child does not have the skills to go back to sleep alone. Sleep-wake transition disorder, a type of circadian rhythm sleep disorder, is described by a disrupted sleep pattern that is persistent or recurrent. This leads to excessive sleepiness or insomnia; it is mostly due to a change in the body's circadian system or a misalignment between the rhythm and the person's schedule.

A 20-year-old female college student aspiring to become a professional ballet dancer reports to her primary care physician concerned about her ability to have children, since her menarche has not started yet. She is 5'8" tall and weighs 100 lb. She is overly concerned about being overweight, and diets almost every day of the week. She says that she has been vomiting frequently recently. She is fatigued and looks pale. Blood tests reveal a slight hypokalemia. Question What is the best initial step in management of this patient? Answer Choices 1 Cognitive-behavioral therapy 2 Restoration of normal electrolyte levels 3 A healthy eating plan 4 Encouragement to join an eating disorder support group 5 Treatment with antidepressants

Correct Answer: Restoration of normal electrolyte levels Show Explanation Explanation The correct answer is restoration of normal electrolyte levels. Based on the symptomatic description, the young girl most probably suffers from an eating disorder like bulimia nervosa or anorexia, complex disorders that require long, case-specific treatments that involve both medical care and psychotherapy. Treatments of such disorders are usually started if patients are in stable medical condition. Thus, controlling and stabilizing her electrolytes would be the first step for her treatment. The answers cognitive-behavioral therapy, a healthy eating plan, and encouragement to join an eating disorder support group are incorrect. Even though they can all be part of a treatment plan for someone suffering from eating disorders, they are not usually administered as a first treatment step to patients that show signs of other medical conditions. The answer treatment with antidepressants is incorrect. Certain antidepressant medications may help alleviate depression associated with eating disorders; however, as mentioned above, such disorders are treated through a combination of psychological counseling, behavioral therapy, and medical treatment according to the patient's needs once the patient is in stable medical condition.

A 30-year-old woman has been acting strangely for several weeks. She attends conscientiously and regularly to her work, but lately she has been talking about her co-workers 'plotting against her'. She claims that she is the sole possessor of a digital encryption key that, if discovered by the wrong people, could result in the collapse of the entire economy. Despite the dangerous implications of this belief, if it were true, she appears to be oddly unaffected by it. Question In the absence of evidence of substance abuse or of a precipitating general medical condition, what psychiatric diagnosis might be suggested at this time? Answer Choices 1 Dementia 2 Schizophreniform disorder 3 Schizophrenia 4 Autistic disorder 5 Hypomania

Correct Answer: Schizophreniform disorder Show Explanation Explanation The correct response is schizophreniform disorder. Schizophreniform disorder has symptoms in common with schizophrenia: • Delusions (unrealistic beliefs such as grandeur or persecution) • Hallucinations (unrealistic sensations or perceptions) • Disorganized speech • Disorganized or catatonic behavior • Negative symptoms (flattened affect, alogia, avolition) The primary difference between the 2 is duration. Schizophreniform disorder is diagnosed when psychotic signs have been present less than 6 months; consequently, it is often designated as a 'provisional' diagnosis. Dementia is always correlated with a physiological condition. Autistic disorder is a developmental disorder that is primarily neuromuscular and is evident from early childhood. Hypomania refers to a disorder of elevated or irritable mood. Hallucinations and delusions are not symptoms of dementia, autism, or hypomania.

A 28-year-old woman begs to make the voices in her head stop arguing. She is very soft-spoken, polite, and well-groomed. She explains that she often becomes confused and finds herself in unfamiliar places. She believes that 1 of the voices might be trying to kill her. She has a history of alcohol abuse, but no drug abuse. She has an extensive medical history of unexplained injuries, stomach problems, and unusual bruising beginning in early childhood. The woman denies being physically or sexually abused as a child, but states that she has weird nightmares about a strange dark figure standing over the bed of a small child; she does not recognize the child or the man. The following week the patient's behavior is very different; she is speaking loudly, acts as if she never has seen you before, refuses to answer most questions, and is very uncooperative. According to the post-traumatic model, what is the most likely etiologic cause for this client's symptoms? Answer Choices 1 Severe child abuse 2 Genetics 3 Witnessing a traumatic event 4 The therapist planting dissociative suggestions 5 High score on hypnotizability scales

Correct Answer: Severe child abuse Show Explanation Explanation This patient's symptoms are consistent with dissociative identity disorder. Common symptoms of dissociative identity disorder are auditory hallucinations that come from within (as opposed to outside of the head), losing time (being unaware of how one ends up places), confusion, dramatic changes in personality, a history of somatic complaints, and nightmares. These patients almost always have a history of severe abuse, and although this patient does not recall abuse, her nightmares and medical history are consistent with abuse. There are 2 main theories for the etiology of dissociative identity disorder: the iatrogenic model and the post-traumatic model. The iatrogenic model basically states that DID does not actually exist, but it is often created by therapists and others of influence in the person's life. These influential people suggest dissociative symptoms to vulnerable individuals, and the symptoms are then reinforced through the use of hypnosis and role-playing. According to the post-traumatic model of dissociation, some people are genetically predisposed to express post-traumatic stress disorder in the form of dissociation. This model supports the contention that separate personalities are created as a defensive response to severe childhood trauma.

A middle-aged man feels anxious, angry, and hostile because he is stressed out due to work. He enrolls himself in the neighboring gym in order to relieve his tension. What is the primary defense mechanism that this man is using? Answer Choices 1 Projection 2 Denial 3 Rationalization 4 Repression 5 Sublimation 6 Reaction Formation

Correct Answer: Sublimation Show Explanation Explanation Sublimation is a defense process in which an unacceptable feeling is unconsciously replaced with a course of action that is constructive as well as personally and socially acceptable. The conscious use of work, sports, art, or hobbies to divert one's thoughts from a problem or from a rejected wish is an analog of this. Denial is the disclaiming and rejecting of any aspects of internal or external reality that, if acknowledged, would cause anxiety. Projection is the unconscious mechanism in which an unacceptable impulse or idea is attributed to others or the external world. Rationalization uses reasoning that may or may not be valid to explain away unconscious conflicts and motivations. It is an attempt to justify one's actions with an excuse rather than to admit one's failure or mistakes. Repression occurs when unacceptable thoughts, wishes, or impulses that would produce anxiety are pushed out of awareness or are blocked. Reaction formation is an unconscious mechanism in which unacceptable feelings, ideas, or impulses are transformed into their exact opposites.

A 25-year-old man has a long history of criminal behavior, and he has been in and out of prison for assaultive behavior, theft, armed robbery, and sexual assault. He shows no remorse for his behavior and states that he is the real victim. He also shows little emotion regarding his family history, and he prefers to brag about his sexual exploits. The patient denies a history of mood disorders or schizophrenia. Question What disorder commonly co-occurs with this patient's symptoms? Answer Choices 1 Anxiety disorder 2 Reactive attachment disorder 3 Substance abuse 4 Intellectual disability (intellectual developmental disorder) 5 Social anxiety disorder

Correct Answer: Substance abuse Show Explanation Explanation The patient clearly exhibits symptoms of antisocial behavior or antisocial personality disorder. Research has shown that as many as 75 percent of those with antisocial personality disorder have comorbid substance abuse problems. Skin conductance tests and heart rate monitoring have found that those with antisocial personality disorder have low resting heart rates and show little to no stress or anxiety in response to anxiety provoking stimuli. Those with antisocial personality disorder can have low or borderline intellectual functioning; however, antisocial personality disorder is contraindicated by a diagnosis of intellectual disability (intellectual developmental disorder). People with antisocial personality have been described as extroverts who use superficial charm to manipulate those around them, which would contradict a diagnosis of social anxiety disorder.

A 25-year-old man is referred to you for evaluation. He has no previous history of psychiatric disturbance, and there is no family history of psychiatric illness. During the evaluation, he states that he has seen people following him; additionally, he has been having difficulty concentrating. He believes that he is in danger and that the people following him are FBI agents. When asked about the onset of the symptoms, the patient states that they began about a month ago, and they have persisted ever since. The patient is not currently taking any psychiatric drugs, but he has been taking antihistamines to treat allergies for about 1 month. Question What is the mostly likely diagnosis? Answer Choices 1 Schizophrenia 2 Schizoaffective disorder 3 Schizophreniform disorder 4 Brief psychotic disorder 5 Substance/medication-induced psychotic disorder

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

A 68-year-old man presents with his wife of 38 years. She states that since her husband retired 3 years ago, he just sits home and drinks an entire bottle of either Jack Daniels or Chivas Regal every day, and he eats very little. She also mentions that she thinks he may have broken his hip in a fall last weekend, but he is too drunk to feel pain. Question In addition to detoxification with a benzodiazepine prior to repair of his hip fracture, what is needed to prevent neurologic sequelae? Answer Choices 1 Ascorbic acid 2 Beta-carotene 3 A daily bottle of whiskey 4 Pyridoxine 5 Thiamine 6 A daily case of beer

Correct Answer: Thiamine Show Explanation Explanation Thiamine must be provided intramuscularly for rapid systemic absorption in order to prevent damage to the central nervous system, including tremor, ataxia, and memory loss. Ascorbic acid, beta-carotene, and pyridoxine, while providing a boost to his general nutritional status, will not specifically prevent nervous system sequelae. Alcohol is potentially harmful and is not recommended. The alcohol, while perhaps preventing acute alcohol withdrawal syndrome (delirium tremens), will definitely yield more liver damage and more nervous system damage, both central and peripheral. After his alcohol detoxification with benzodiazepines and thiamine is completed, and after his hip surgery, the patient should be referred to a chemical dependency recovery program.

A child runs well, walks up and down stairs one step at a time, builds a tower of seven cubes, puts three words together, and handles a spoon well. He cannot go up stairs using alternating feet, build a tower of 10 cubes, or hop on one foot. Question What is the age of the child? Answer Choices 1 12 months old 2 24 months old 3 36 months old 4 48 months old 5 60 months old

Correct Answer: 24 months old Show Explanation Explanation The concept of developmental milestones highlights how more complex skills build on simpler ones. Development in each of the 4 domains (i.e., gross motor, fine motor, cognitive, and emotional) affects functioning in all of the others. An average 24-month-old can run well, walk up and down stairs 1 step at a time, build a tower of 7 cubes, put 3 words together, and use a spoon. Hopping on 1 foot is a 28-month skill. Going up stairs with alternating feet is a 30-month skill. Building a tower of 10 blocks is a 36-month skill.

A 23-year-old college student presents because her dean is concerned about her weight loss. The woman tells you that she enjoys cooking meals for her friends and that she 'feels fat'. Her friends say she is a go-getter. She enjoys running up to 10 miles a day, and she has not menstruated in 4 months. She has no fever, no lymphadenopathy, and no organomegaly. Her complete blood count (CBC) and her urinalysis (UA) are within the normal laboratory reference ranges. The results of the following tests are negative: pregnancy test, tuberculosis skin test, chest X-ray, mononucleosis test, and HIV antibody test. She takes no medications regularly, and she denies alcohol, marijuana, and cocaine abuse. She continues to do well academically, and she is planning to continue to participate in cross-country and track with consideration for a tryout for the Olympic Games. She is a highly efficient woman; she gets her work done in less time than the majority of her classmates. She is likable and pleasant; she likes and respects her dean and appreciates and respects his referral. She specifically denies any auditory or visual hallucinations. She is not concerned about her weight loss, and she denies inducing vomiting. Her teeth are intact; there is no erosion on the inner surface of the teeth. Question What is the most likely diagnosis? Answer Choices 1 Obsessive-compulsive disorder 2 Bulimia nervosa 3 Schizophrenia 4 Anorexia nervosa 5 Paranoid personality disorder

Correct Answer: Anorexia nervosa The most reasonable diagnosis for this patient is anorexia nervosa; this is indicated by her weight loss to the level of amenorrhea, her continued and excessive physical activity, and her continuing to state that she feels fat. The mortality rate of anorexia nervosa varies from 5 - 7%; this patient's referral from the dean may prove to be lifesaving. The patient should not be diagnosed with obsessive-compulsive disorder (OCD) since she gets her work done swiftly and efficiently; persons afflicted with OCD commonly spend from 4 - 7 hours doing their work repeatedly. The patient should not be diagnosed with bulimia nervosa because she denies inducing vomiting. In addition, she has no erosions of her teeth; if erosions were present on the inner surface of her teeth, they could be due to persistent regurgitation of acidic gastric contents. The patient should not be diagnosed with schizophrenia because of an absence of hallucinations. She is also an outgoing woman planning to try out for the Olympic Games; an individual afflicted with schizophrenia is rarely a 'go-getter'. The patient should not be diagnosed with paranoid personality disorder because she trusts and respects her dean; the major feature of paranoid personality disorder is distrust.

A 5-year-old boy presents because of his "behavior". His mother notes that the child gets extremely distracted and can only focus for 1 - 2 minutes at a time. He cannot seem to sit in his seat and be still. He is displaying extremely impulsive behavior at very inappropriate times, which is what is really concerns the mother. She describes impulsive behavior recently at a funeral as well as at an older sibling's music recital. Because the mother works full time, the patient attends daycare after he is done with kindergarten until she can pick him up, which is usually 1 - 2 hours after school ends. Both his kindergarten teacher and the daycare staff have expressed similar concerns; he is displaying the same behavioral issues in those settings and environments. Question What is the most likely diagnosis? Answer Choices 1 Oppositional defiant disorder 2 Autism spectrum disorder 3 Attention deficit hyperactivity disorder 4 Post traumatic stress syndrome 5 Depression

Correct Answer: Attention deficit hyperactivity disorder Show Explanation Explanation The most appropriate diagnosis for the patient being described above is attention deficit hyperactivity disorder (ADHD). The diagnosis of ADHD has become a very common one, with over 5.2 million children aged 3 - 17 years old having a diagnosis ADHD sometime in their lifetime. The American Academy of Pediatrics (AAP) have concluded that primary care providers should evaluate any pediatric patients between the ages of 4 through 18 years who have academic or behavioral problems, as well as if they are displaying signs of inattention, hyperactivity or impulsivity. These signs should be observed in more than 1 major setting, which is clearly present above, as well as a mix of reports of these characteristics from parents, guardians, teachers, or other school and mental health clinicians. Although all other choices above should be included on a differential diagnosis, each can be ruled out on basic evidence that is listed. Oppositional defiant disorder (ODD) is not the diagnosis due to the fact the patient lacks certain key characteristics; patients with ODD often lose their temper, argue with adults, actively defy or refuse to comply with adults' requests or rules, deliberately annoy people, and blame others for their mistakes or misbehavior; they are often easily annoyed by others, angry or resentful, as well as spiteful or vindictive. Our patient would have to have at least 4 of the aforementioned characteristics to be diagnosed with ODD. Autism spectrum disorder (ASD) diagnostic criteria's main focus has to do with deficits in social communication and social interaction in multiple settings (displaying social-emotional reciprocity) or deficits in nonverbal communication used in social interaction; there are deficits in developing, maintaining, or understanding relationships. These symptoms are not found in this patient. A child who has post-traumatic stress disorder (PTSD) will specifically display symptoms of intrusion and avoidance; they will also display negative alterations in cognitions and mood. Our patient does not fit in this category. Depression characteristics are also missing in this patient. He is not showing signs and symptoms of sadness; there are no feelings of guilt, worthlessness, or hopelessness. There has not been any loss of interests, somatic complaints, or anxiety.

An 8-year-old boy presents for evaluation of problems at school and at home. His parents report that he does not pay attention in class; he is frequently in trouble for disrupting the class, and he often forgets to do his schoolwork. He has had similar problems since starting school (in kindergarten), but they are becoming more problematic; his teacher suggested medical evaluation. The teacher reports the patient often seems distracted. He rarely sits still at his desk; he fidgets often, and when he does pay attention to the class discussions, he blurts out comments without waiting his turn. HIs parents report that the boy has always been 'on the go' and talks excessively; he does not seem to listen when spoken to. He seems capable of doing his schoolwork, but he appears to make careless mistakes. The parents feel the boy is generally well-adjusted; he enjoys sports, has friends, and sleeps well. The parents deny any known medical history, and his prenatal course and delivery were unremarkable. He has never had any surgeries; he takes no medications and does not have any allergies. He lives at home with his biological parents and a younger sister. On physical exam, the boy appears normally developed. Some increased motor activity is noted, but the physical exam is otherwise normal. Question What is the most likely diagnosis? Answer Choices 1 Asperger disorder 2 Attention deficit hyperactivity disorder 3 Panic disorder 4 Absence seizure disorder 5 Post-traumatic stress disorder

Correct Answer: Attention deficit hyperactivity disorder Show Explanation Explanation This patient is presenting with attention deficit hyperactivity disorder (ADHD). Patients with ADHD may have inattentive, hyperactive, and/or impulsive behaviors. To meet the criteria for ADHD, some symptoms must have been present by age 7 years. There are several suspected risk factors, but a genetic factor has shown to be 1 of the strongest associations for ADHD. Asperger disorder is considered within the autism spectrum disorders; it involves impairments in social interactions and communication, and repetitive behaviors. This patient communicates normally; he also lacks the repetitive behaviors and has good social interactions. A panic disorder is characterized by panic attacks occurring episodically. Patients with panic attacks may describe a sudden feeling of impending doom, shortness of breath, palpitations, rapid breathing, and overwhelming fear. This patient's history does not suggest a panic disorder. An absence seizure disorder (also known as petit mal seizures) is characterized by brief (5 - 30 seconds) episodes of staring and then a rapid return to normal, with the affected individual unaware of his/her seizure. This patient's inattention could possibly be attributed to such seizures, but the hyperactivity and impulsivity are not explained by petit mal seizures. If the patient witnessed a traumatic event, he may present with signs and symptoms of post-traumatic stress disorder (PTSD). Sometimes, when they are experiencing flashbacks, patients with PTSD can appear distracted. Often, there is hypervigilance, anxiety about the event, disrupted sleep, and hyperarousal. This patient's symptoms have been present for several years, and they fit a diagnosis of ADHD.

A 26-year-old man recently graduated from college with an advanced degree; he presents with the inability to communicate coherently. His 24-year-old brother states that the patient's family has been noticing a gradual deterioration in the patient's behavior and thinking over the past 14 months. He often speaks nonsensically, hears voices undetectable to others, reports bizarre sensations such as feeling worms crawling beneath his skin, and is becoming unable to go to work most of the time. He occasionally enters a trancelike state in which he is thoroughly unresponsive to environmental stimuli or to events that previously aroused strong emotions. Testing rules out vascular pathology, AIDS, head trauma, Parkinson's disease, Huntington's disease, Pick's disease, Creutzfeldt-Jakob disease, other general medical conditions, or substance abuse. Question On the basis of this information, what DSM-V diagnosis might be suggested at this time? Answer Choices 1 Schizophrenia 2 Dementia 3 Schizophreniform disorder 4 Dissociative disorder 5 Bipolar disorder

Correct Answer: Schizophrenia Explanation Continuous signs of disorganization across several behavioral systems for at least 6 months is the basis for a diagnosis of schizophrenia. The characteristics of schizophrenia are as follows: • Delusions (unrealistic beliefs such as grandeur or persecution) • Hallucinations (unrealistic sensations or perceptions) • Disorganized speech • Disorganized or catatonic behavior • Negative symptoms (flattened affect, alogia, avolition) Refer to the image. Speech patterns associated with this disorder have sometimes been described as a 'word salad' due to loose associations and a random flight of ideas. Dementia is characterized by the development of multiple cognitive deficits as a direct effect of some physiological condition (i.e., vascular pathology, AIDS, head trauma, Parkinson's disease, Huntington's disease, Pick's disease, Creutzfeldt-Jakob disease, other general medical conditions, or substance abuse). Schizophreniform disorder is diagnosed when the symptoms last more than 1 month, but less than 6 months. Dissociative disorder manifests as disconnection between, rather than disorganization within, behavioral systems. Bipolar disorder is essentially limited to mood; it presents both extremes of depression and mania, but not flattening of affect.

A 7-year-old boy presents because he is fidgety, impulsive, and unable to sit still. The patient is observed running around; there is no evidence of any hallucinations or delusions. The mother notes that the child speaks excessively and loudly, makes simple arithmetic errors, and has short-term memory deficiencies. He finds it difficult to wait in lines or wait his turn in games or group situations. Question What is correct regarding this patient's condition? Answer Choices 1 Serological lab tests are confirmatory for the illness 2 Stimulant medications are considered first-line pharmacologic therapy 3 The onset must be over 13 years of age to qualify the suspected diagnosis 4 This disorder is more common in female patients and resolves completely in adulthood 5 Thought content disturbances and a heightened suicide risk are expected

Correct Answer: Stimulant medications are considered first-line pharmacologic therapy Show Explanation Explanation This patient is demonstrating manifestations of attention deficit hyperactivity disorder (ADHD). Stimulants (e.g., methylphenidate, dextroamphetamine) are first-line therapy and probably the most effective treatment. For related areas of functioning such as social skills and academic performance, medications combined with behavioral treatments may be indicated. The diagnosis of ADHD is based on clinical evaluation. No laboratory-based medical tests areavailable to confirm the diagnosis. ADHD is a developmental disorder that requires an onset of symptoms before age 7 years. In children, ADHD is 3 - 5 times more common in boys than in girls; some studies report an incidence ratio of as high as 5:1. The predominantly inattentive type of ADHD is found more commonly in girls than in boys. After childhood, symptoms may persist into adolescence and adulthood, or they may ameliorate or disappear. The percentages in each group are not well established, but at least an estimated 15 - 20% of children with ADHD maintain the full diagnosis into adulthood. As many as 65% of these children will have ADHD or some residual symptoms of ADHD as adults. Thought content should be normal, with no evidence of suicidal, homicidal, or psychotic symptoms.

A 10-year-old boy has a history of problems at school and at home. Teachers report he rarely can focus on one task for longer than a few minutes, and describe his behavior as chaotic. His mother states that he never gets tired of running, talking, and playing around the house; she usually has to repeat instructions over and over because he seems to not listen. She also reports that he failed at school and is now repeating the 4th grade. A psychostimulant, an indirect-acting adrenergic receptor agonist that centrally releases dopamine (DA), serotonin (5-HT), and norepinephrine (NE) to the synaptic cleft, is prescribed. Question What drug is most likely the medication prescribed for this patient? Answer Choices 1 Dextroamphetamine 2 Imipramine 3 Selegeline 4 Atomoxetine 5 Fluoxetine

Correct Answer: Dextroamphetamine This patient has classical symptoms of attention deficit hyperactivity disorder (ADHD); dextroamphetamine is most likely the drug prescribed. Dextroamphetamine is a dextrorotary stereoisomer of amphetamine; it releases stored dopamine (DA), norepinephrine (NE), and serotonin (5-HT) from the presynaptic neuron, increasing their level at the synaptic cleft. Dextroamphetamine, together with methylphenidate, are the mainstay stimulant drugs used for the treatment of ADHD. The most common side effects of these stimulant medications are insomnia, appetite suppression, weight loss, stomach upset, and headache. Growth suppression in children is a concern, but decreases in expected height early in treatment are usually compensated for later in life. Other physical adverse effects of stimulants include tachycardia, pupil dilation, blurred vision, dry mouth, difficulty urinating, constipation (anticholinergic effects), cardiac arrhythmia, Raynaud's phenomenon (reduced blood flow to extremities), nausea, sweating, dizziness, and reduced seizure threshold. Psychological adverse events include mood swings (lethargy, irritability), akathisia (restlessness), repetitive or obsessive behaviors, and changes to the libido. Stimulants above the recommended dose level are associated with substance abuse and psychosis. Imipramine, a tricyclic antidepressant (TCA), is also considered an indirect-acting adrenergic receptor agonist, but it has a slightly different mechanism of action than dextroamphetamine. Imipramine inhibits reuptake of 5-HT and NE into the presynaptic neuron, increasing their concentrations in the synaptic cleft. Imipramine is not indicated for ADHD. This TCA is indicated for patients with narcolepsy that present with cataplexy (sudden weakness and collapse after a laugh). It is also used for childhood nocturnal enuresis (2nd after desmopressin acetate). Anticholinergic effects (see above) are among the common side effects; serious side effects include orthostatic hypotension, high blood pressure, arrhythmia, heart attack, stroke, seizures, and hepatitis. Selegeline is a selective monoamine oxidase B (MAO-B) inhibitor that metabolizes dopamine over NE and 5-HT, thereby increasing the availability of dopamine in the CNS. Amphetamine and methamphetamine are active metabolites of selegeline. Selegeline is not indicated for ADHD; it is an adjunct treatment of L-dopa for Parkinson's disease and may enhance the adverse effects of L-dopa (as arrhythmias from increased peripheral formation of catecholamines). Atomoxetine is a non-stimulant NE reuptake inhibitor used for the treatment of ADHD. There has been some suggestions that atomoxetine might be a helpful adjunct in major depression, especially when associated with ADHD. Atomoxetine has side effects in common with dextroamphetamine and methylphenidate (stimulant ADHD drugs) including nausea, dry mouth, insomnia, and headache. Fluoxetine is the prototype of the selective serotonin reuptake inhibitor (SSRI) drug class and specifically inhibits 5-HT receptors; fluoxetine is not indicated for ADHD. This SSRI is mainly used for depression and has several other indications (e.g., bulimia nervosa, obsessive compulsive disorder, panic disorder, and premenstrual dysphoric disorder). Adverse effects are sexual dysfunction, agitation, anxiety, gastrointestinal symptoms (nausea, vomiting, and diarrhea), sedation, and seizures (with overdose).

The mother of a 5-year-old girl walks into her daughter's bedroom without knocking and discovers the girl stimulating her genitals. The girl's parents are concerned, but seem to be receptive to advice. Question What is the best response a physician could give? Answer Choices 1 "Do you think that someone's been molesting her?" 2 "Don't you think you should knock before going into her room?" 3 "She probably has a vaginal infection. Bring her in so I can examine her." 4 "This is not normal behavior for a child this age." 5 "What disturbs you about this behavior?"

Correct Answer: "What disturbs you about this behavior?" Show Explanation Explanation The correct response is "What disturbs you about this behavior". Before the physician can provide guidance for the parents, the parents' concerns need to be understood. While the described behavior is perfectly normal for a 5-year-old, and it is appropriate for parents to knock on the door of their child's room before entering to teach children respect for privacy through modeling, the parents' concerns must first be understood. To immediately assume there is something physically wrong with the child, or that the child has been sexually abused, suggests that the physician may have some personal issues with children's normal sexuality.

A 10-year-old boy is brought in by his mother for a camp physical. He has been fairly well; however, he occasionally feels short of breath with only light exertion. He has become more sedentary in his activities, spending most of his time indoors on the computer, watching TV, or playing video games. His appetite has increased, and it has been accompanied by progressive weight gain. His last physical was 4 years ago; his weight was at the 75th percentile. His weight today is 132 lb (60 kg), which is > 95th percentile, and his height is 57 inches (145 cm) at the 90th percentile. His BP is 105/60 mm Hg. On exam, he appears as a well-developed, moderately obese boy. Heart and lung exam are normal; his abdomen is large, protuberant, and without hepatosplenomegaly. His skin is normal. You review the patient's growth chart with him and his mother, and you express your concerns about his rapidly rising weight gain. His mom asks you what they should do. You discuss different management strategies. Question What may be the most important facet of his obesity treatment? Answer Choices 1 Exercise regimen 2 Dietary management 3 Behavioral intervention 4 Bariatric surgery 5 Anorectic agents

Correct Answer: Behavioral intervention Show Explanation Explanation Behavioral intervention is ideally provided through frequent group or individual treatment sessions, and it provides possibly the most important facet of obesity treatment. Better outcomes are produced by frequent monitoring and feedback. Treatment also needs to be long term due to the chronicity of the condition and frequent relapse. A good treatment program should screen for readiness to change and consist of controlling the environment, self-monitoring, and contracting for reasonable goals. High-risk foods need to be removed from the home environment. Shopping and cooking routines need to be developed toward the prescribed diet. The patient needs to be taught how to regulate behavior, and realistic and achievable goals should be set. The family needs to be involved in counseling and ongoing support. Referral for psychotherapy and possibly pharmacotherapy may be necessary. An exercise program should be put into place; its goals should be to assist in weight control via increasing caloric expenditure, resting metabolic rate, and lean muscle mass. However, exercise alone is rarely successful in achieving meaningful weight loss. Combined with diet, this can be a powerful tool to enhance well-being and self esteem. Aerobic activity often is recommended; sometimes, a 1-mile walk can be used as an initial benchmark of fitness, and the patient should gradually increase the distance of the walk and speed at which he is walking. Home aerobic activity may be prescribed; lifestyle exercise that attempts to build more exercise into regular activities may be easier to sustain long-term. Dietary management should not compromise a child's growth and development by excessively restrictive dieting. Weight maintenance over a period of time can change the body mass index of a growing child significantly. Eliminating snacking and reducing high-sugar/high-fat foods and drinks can result in some weight loss. Keeping a food journal is usually recommended because both children and families tend to underreport intake. This can provide insight into the source of additional calories. A popular diet is the traffic light diet; it categorizes food into 'green' foods that can be eaten in unlimited quantities because they are non-fat or low-fat foods, 'yellow' foods that should be eaten with more caution due to their fat content, and 'red' foods that should be eaten rarely because they are high in fat. This diet has shown long-term success when combined with both behavioral and exercise components. In cases where obesity is more than 100% of ideal body weight or life-threatening, bariatric surgery has emerged as an option. Both gastroplasty, which involves the formation of a 15 to 30 mL stomach pouch, and gastric bypass surgery, which bypasses the duodenum to deliver food directly to the jejunum, have gained popularity in adults. A plethora of complications were found in a small study, including renal disorders, gallstones, and nutritional deficiencies. Surgery for the pediatric population is not recommended by most experts. Drug intervention with anorectic agents is associated with significant adverse effects; it has shown limited benefit in adults, and it is not recommended for children.

A 23-year-old man presents with an unspecified personality disorder; although his group and individual therapy sessions are going well, he wants to gain even more improvement with his diagnosis. He feels that his mood, self-image, and personal relationships have improved overall; however, he specifically states he wants to have better anger management. When he becomes angry, for whatever reason, he still becomes extremely irritated, hostile, and even aggressive. Question What pharmaceutical therapy would be most beneficial for this patient? Answer Choices 1 Methylphenidate 2 Lithium 3 Sertraline 4 Topiramate 5 Fluoxetine

Correct Answer: Topiramate Show Explanation Explanation The correct response is topiramate. Although it is not stated specifically, this patient most likely has the diagnosis of borderline personality disorder (BPD). BPD is commonly seen in all psychiatric and medical settings. Distinctions of this disease process include instability of self-image, mood, behavior, and relationships. BPD patients are hypersensitive and become very easily angered; they very frequently will express inappropriate and intense anger. Treatment for patients with any 1 of the personality disorders (which includes BPD) should consist of a multi-faceted approach: psychosocial therapy (individual, group) and (usually) the addition of other components, which includes pharmacotherapy. Mood stabilizers such as lamotrigine and topiramate are extremely useful in anger management and mood stability in these patients. Methylphenidate is a central nervous system stimulant utilized in patients who are diagnosed with attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), and narcolepsy. Lithium is most commonly utilized in patients diagnosed with bipolar disorder, specifically to treat the manic episodes of manic depression. Sertraline and fluoxetine are both selective serotonin reuptake inhibitors (SSRI) antidepressants; they are used to treat major depressive disorder, bulimia nervosa, panic disorder, obsessive-compulsive disorder, as well as other psychiatric diagnoses.

A 13-year-old girl has a history of being found by her mother consuming a large amounts of high calorie food on several occasions, and then vomiting what she ate. For the past 2 days, the patient has experienced pain in her throat, which was diagnosed as esophagitis. Upon physical exam, the patient is dehydrated, has abnormal electrolyte imbalances, and appears to have eroding front teeth. Question What is the most likely explanation of these findings? Answer Choices 1 Anorexia 2 Binge eating 3 Bulimia nervosa 4 Night eating syndrome 5 Obesity

Correct Answer: Bulimia nervosa The clinical picture is suggestive of bulimia nervosa, as she has clinical characteristics of consuming a large amount of food and then purging afterwards. Additionally, she has physical signs of eroding teeth and esophagitis. Lastly, electrolyte disorders such as hypokalemia can be found in patients with bulimia, due to patients repetitive vomiting and excessive use of laxative. Anorexia is not the correct answer, because the patient is still consuming high calorie food, which is not characteristic of anorexia. Binge eating is not the correct answer because it is consuming a lot of food in a short period of time, but without the added behavior of vomiting the food up. Without the cycle of binging and purging as well, the clinical findings demonstrated in this patient would not likely be found. Night eating syndrome is not the correct answer, because it is defined as consuming 25% or more of your food intake after the evening meal, which is not described in the stem of the problem and would not cause eroding teeth, abnormal labs, and esophagitis. Obesity is not the correct answer because this patient is consuming food and immediately throwing the food she ate up. While bulimic patients may be overweight, obesity in itself is not sufficient to explain the clinical findings. Obese patients consume in a high caloric intake, however they do not generally throw up afterwards.

Intoxication with a particular substance can occur within minutes to hours and may persist or reoccur for 12 - 24 hours. There is a typical high feeling that is followed by symptoms of euphoria or dysphoria, sedation, lethargy, inappropriate laughter, and the sensation that time is passing slowly. Although less common, anxiety and social withdrawal may occur. Potential objective signs are injected conjunctivae, dry mouth, and tachycardia. Question Intoxication with what drug causes the aforementioned symptoms? Answer Choices 1 Cannabis 2 Lysergic acid diethylamide (LSD) 3 Cocaine 4 Alcohol 5 Barbiturate

Correct Answer: Cannabis Show Explanation Explanation Cannabis intoxication can occur through inhalation or ingestion. As most cannabinoids are fat-soluble, the effects may persist or recur for 12 - 24 hours after ingestion from a slow release from fatty tissue, or due to enterohepatic circulation. Lysergic acid diethylamide is a hallucinogen and typically produces behavioral changes of anxiety, depression, or paranoia, with hallucinations and autonomic arousal. Cocaine is a stimulant and does not produce a sensation that time is passing slowly. Alcohol and barbiturates are central nervous system depressants; intoxication is not characterized with recurring symptoms. A major complication with intoxication with central nervous system depressants is respiratory depression.

A 30-year-old man presents with a constantly depressed mood and a 3-year history of a decreased interest in pleasure. He is preoccupied by his state of mind, and he would like to have a prescription so that he can return to his normal mood. Although the patient describes about 2 or 3 episodes of "feeling high" and an increased libido, he then returns to the constantly depressed mood after each of these episodes. His mood does not interfere with his work; he denies any suicidal thoughts or disturbances in appetite or sleep. His weight is within normal limits, and there are no variations for the last 3 years. The patient also denies the use of drugs or medications. Physical examination and lab results are within normal limits. Question What is the most likely diagnosis? Answer Choices 1 Major depressive disorder 2 Bipolar I disorder 3 Bipolar II disorder 4 Persistent depressive disorder (dysthymia) 5 Cyclothymic disorder

Correct Answer: Cyclothymic disorder Cyclothymic disorder has an equal incidence in men and women; it is defined as a chronic, recurrent disorder that lasts for at least 2 years in which there are oscillations between dysthymia and hypomania. A single episode of hypomania is sufficient to diagnose cyclothymic disorder. This patient does not meet the criteria for either major depression or for manic disorder, and his mood disturbances have been recurrent for 3 years. Treatment involves psychotherapy, mood stabilizers, and antidepressants. Major depressive disorder is diagnosed when 5 or more symptoms have been present for at least 2 weeks; 1 symptom must be depressed mood or anhedonia. The symptoms have to provoke distress and impairment. The criteria used to diagnose major depressive disorder are depressed moods, anhedonia, sleep disturbances, appetite changes, psychomotor retardation or agitation, feelings of excessive guilt or hopelessness, impaired memory or concentration, and suicide preoccupation. Bipolar I disorder is considered the most serious bipolar disorder, and at least 1 episode of mania is necessary for a diagnosis. To diagnose a manic episode, the general criteria have to be persistent and last 1 week, or the patient has to require hospitalization for an elevated, expansive, or irritable mood disturbance. Patients with bipolar I disorder characteristically have major depressive episodes alternating with mania. Bipolar II disorder is diagnosed when patients have hypomania and episodes of major depression. The hypomanic episodes are not severe and do not require hospitalization. Persistent depressive disorder is characterized by a chronic and less severe form of major depression for a minimum period of 2 years.

A woman presents because she worries a lot and wishes she could stop. She has perspiration on her upper lip, and relates that she does not like to go out because she tires easily. She is worried that she and her husband are not saving enough money, and that she is scared something bad is going to happen to her husband in his job as a firefighter. He has never been injured during his 5 years as a firefighter, and she admits she was also afraid when he worked at his prior job on a construction crew. The husband states that his wife is 'out of control' and is 'constantly fretting'; according to him, she has been that way for their entire marriage. She does not dispute his portrayal. The husband says things were really rough a month ago after lightning hit a tree in their yard; the patient does not mention the lightning strike. She shakes your hand at the end of the appointment and then apologizes because her hand is cold. Question What is the most likely diagnosis? Answer Choices 1 Agoraphobia 2 Social anxiety disorder 3 Generalized anxiety disorder 4 Post-traumatic stress disorder 5 Acute stress disorder

Correct Answer: Generalized anxiety disorder Show Explanation Explanation Generalized anxiety disorder is characterized by excessive anxiety and apprehension associated with a number of activities or events. Persons often describe feeling they have no control over their worries and anxiety; they experience symptoms of restlessness, poor concentration, fatigue, muscle tension, irritability, and sleep disturbance. The symptoms must be present a majority of the time over a period of at least 6 months. Agoraphobia is an anxiety disorder that involves fearfulness and avoidance of situations that may be difficult or awkward to escape from. It can be associated with panic attacks. The situations are not limited to social interactions and must involve more than 1 specific situation. Some common examples are standing in a line, being on a bridge, traveling in an airplane, and being in a crowd. Social anxiety disorder involves exposure to social and/or performance situations. The fearfulness is persistent over time; anticipation of a situation, as well as being in the situation, can elicit intense symptoms of autonomic arousal. Avoidance behavior is common. Examples include speaking to authority figures, initiating conversations, dancing, eating in public, and speaking in public. Post-traumatic stress disorder is defined as re-experiencing an extremely traumatic event with physiological arousal and psychological distress. It is associated with avoidance of the stimuli that provoke memories of the trauma. The re-experiencing may take the form of recollection, dreams, or flashbacks. There are persistent vegetative symptoms which include exaggerated startle response, sleep difficulties, poor concentration, irritability, and hypervigilance. The symptoms must be present for more than 1 month. Acute post-traumatic stress disorder is defined as having symptoms lasting 1 - 3 months; chronic post-traumatic stress disorder is when symptoms have been present longer than 3 months. A delayed onset qualifier is added when the onset of symptoms is more than 6 months after the trauma. Acute stress disorder must occur within 1 month following exposure to an extreme trauma. The symptoms are similar to post-traumatic stress disorder, and they must last at least 2 days and no more than 4 weeks.

A 7-year-old boy presents for evaluation of behavior problems in school; the problems have been occurring for over 6 months. The boy's teacher recommended he be evaluated. She reports that he tests at grade level, but he seems to make careless mistakes on schoolwork and has trouble maintaining attention to instruction; he does not finish his homework, and he often loses his homework, pencils, and books. The boy is seen often fidgeting at his desk; he blurts out answers and has difficulty waiting his turn. The parents tell you that they have seen similar traits at home, such as forgetting to do daily activities; for the past several years, he has been easily distracted. They view him as a happy, bright boy, and they report that he is very active. He has had normal vision and hearing screenings. The father reports that he was very similar as a child and still struggles with focus and concentration as an adult, but he has never received any help. The parents deny any major changes in the family situation. They would like medical help to improve their son's performance in school. The boy has been seen regularly for his well-child exams, and he has always met milestones and had normal exams. Today, he is quickly moving about the exam room; he looks at a book for a few moments, and then he looks out the window for a short time before interrupting his parents. Question What is the most appropriate intervention in this case? Answer Choices 1 Advise the parents to hold the child back 1 year in school 2 Contact child protective services for suspected abuse 3 Initiate medication 4 Order head magnetic resonance imaging (MRI) 5 Referral for counseling

Correct Answer: Initiate medication Show Explanation Explanation This child meets criteria for attention deficit hyperactivity disorder (ADHD), and it would be most appropriate to initiate medication at this time. If the diagnostic criteria are met with no concerning presentation for other disorders, treatment can begin immediately. The treatment of choice is prescription stimulant medications. ADHD is often seen (diagnosed or undiagnosed) in the family history. Often, young children may be less mature than their peers and could benefit from being held back a year in school; however, the patient is testing at the appropriate grade level. If he repeats the year in school, this intervention will do nothing to address the root problem of ADHD. It is likely that he would continue having the same problems with inattentiveness and hyperactivity. A behavior change in a child could indicate some type of abuse or stressful situation for the child; however, nothing in this child's history is indicative of child abuse. The behavioral problems have been present for longer than 6 months; they have been seen at home and at school, and nothing in his history or physical suggests abuse. Contacting child protective services is not appropriate at this time. ADHD is a clinical diagnosis. It is primarily based upon patient history; neither imaging nor blood tests are routinely recommended. This boy's history and exam do not demonstrate any neurologic deficits suggestive of a brain tumor or other anatomic defect. Therefore, MRI is not recommended. A counseling referral would be reasonable if the child had a history suggestive of anxiety, depression, or psychosocial stressors. However, counseling has very little-to-no role in the treatment of ADHD, especially in grade-school-aged children. Other forms of psychosocial intervention, such as parent training and classroom interventions, are recommended for children with ADHD.

A 50-year-old woman has trouble making any decisions in her life without asking others what she should do; she cannot assume responsibility for anything. She fears that disagreeing with others will cause her to lose their approval. She has trouble doing things on her own because she feels she is incompetent and stupid. She will volunteer to do things that hurt her in order to receive nurturing and support. She cannot be alone because she feels she needs someone to take care of her. When she was sick and in the hospital, the nurses objected to the fact that she was very demanding and complained all the time. Question What type of personality disorder does this woman have? Answer Choices 1 Dependent personality disorder 2 Avoidant personality disorder 3 Narcissistic personality disorder 4 Borderline personality disorder 5 Antisocial personality disorder

Correct Answer: Dependent personality disorder Passive individuals characterize dependent personality disorder; they let others guide their lives because they feel they are unable to guide their own lives. Spouses or parents make all the major decisions of their lives, including where they should live and what type of employment they should obtain. Their needs are secondary to the people on whom they depend. They see themselves as helpless or stupid, and they avoid having to be self-reliant. They have an extreme need to be taken care of, which is shown by their clinging behavior and fear of separation. They have an inability to make everyday decisions without advice from others, and need others to take responsibility for their lives. They do not initiate projects because of a lack of self-confidence, and they go to the extreme to get nurturing. In addition, they have exaggerated fears of being helpless, they seek close relationships quickly when the one before has ended, and they have an extreme fear of having to take care of themselves. In the medical setting, their fear of abandonment increases. They become needier; therefore, they complain and demand. The physician in this case, along with the nurses and staff, must plan what kind of care should be given to this patient, and advise the patient how often, and when, they will check on her so that the patient has set limits. If limits are not set, the patient can become extremely demanding. An individual who is shy but wants to have friends characterizes avoidant personality; these individuals fear rejection and avoid social contact. If given strong guarantees that they are truly accepted, they will make friends. They have low self-esteem, are hypersensitive to criticism, and feel inadequate (these feelings usually begin by early adulthood). In addition, they avoid activities in which they may be ridiculed or rejected; they do not want to get close to anyone unless they are certain they will be liked, and they keep away from close relationships so they will not be shamed. They are preoccupied with worrying about being criticized or rejected in social situations. They are also withdrawn in new social situations due to feelings of inadequacy, and they believe that they are inferior to others. They are unwilling to take risks because they do not want to be embarrassed. In the medical setting, these patients are good patients because they are undemanding and cooperative. They allow others to take care of them, but they are very sensitive to criticism. They can interpret remarks as being hurtful and then withdraw emotionally. A person who thinks of himself or herself highly, but is at the same time sensitive to criticism, characterizes narcissistic personality disorder. These individuals cannot empathize with others and are more interested in the superficial. They see themselves as superior and exaggerate their achievements. They have fantasies of unlimited power, success, beauty, or ideal love. In addition, they believe they should only associate with certain people of high status or from certain institutions, and they require admiration. They believe people should go with their expectations, and they take advantage of others to achieve something for themselves. They do not consider the needs or feelings of others. They are usually jealous of others or think others are jealous of them, and they are arrogant. In the medical setting, these patients see illness as destroying their perfection; they demand special attention. They see the physician as all good or all bad and have a tendency to show anger or boredom in a hospital setting. A person who is on the border between neurosis and psychosis characterizes borderline personality disorder. This person has unstable personal relationships and unstable moods. These individuals have an identity crisis; they are confused about their sexual orientation, goals, self-image, and friends. The symptoms begin in early adulthood. They try to avoid abandonment and have intense relationships which go from idealization to devaluation. They have a distorted sense of self and are reckless in areas that are self-damaging (e.g., sex, substance abuse, reckless driving, and binge eating). They have recurrent suicidal threats or self-mutilating behavior. In addition, they have intense feelings such as euphoria, irritability, or anxiety lasting only a few hours or a few days. They feel very empty and can display intense anger or lack of control of anger. They can display paranoia under stress or severe dissociative symptoms. This disorder is seen twice as often in female patients. 90% of those diagnosed with this disorder also have a psychiatric disorder. It can be caused by severe physical, verbal, or sexual abuse in childhood. They also have decreased levels of serotonin. In the medical setting, these patients have extreme amounts of stress which can lead to paranoia and the other symptoms this disorder entails; they become even more emotionally unstable. They will cause the physicians and nurses to take sides and see things as either all good or all bad. This is called splitting because they cannot see a person as having both; they have to label people into categories, and certain people are all good while certain others are all bad. An individual who continually violates the rights of others characterizes the antisocial personality disorder. These individuals are unable to control their impulses or to postpone immediate gratification. They are insensitive, usually selfish and demanding, and are free of fear and guilt. They start showing symptoms before the age of 15. They fail to conform to social norms, and they are irritable and aggressive. They are irresponsible in finances or in work behavior because they do not plan. In addition, they deceive others by lying for pleasure or personal gain; they do not care about their safety or others around them, and they are indifferent to having hurt someone. This disorder is more common in male patients. Children exposed to family problems, such as alcoholism, are at increased risk for developing antisocial personality disorder. It can also be caused by head trauma or encephalitis. Inconsistent and/or impulsive parenting are also factors. In the medical setting, it is possible to see fights, suicides, or other injuries done by these types of people. They usually are charming when under stress, but then they become manipulative if given a chance. They usually have difficulty with authority figures; therefore, they may be noncompliant in taking their medicine and following the doctor's orders. They usually leave the hospital when they feel like it

A 31-year-old woman presents with recurrent episodes of palpitations, tachycardia, dyspnea, and impending dread that began shortly after the birth of her first child. Question Based on her most likely diagnosis, what is best for the sustained treatment of her condition? Answer Choices 1 Lorazepam 2 Hydroxyzine 3 Buspirone 4 Phenobarbital 5 Paroxetine

Correct Answer: Paroxetine Show Explanation Explanation Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment options for chronic, sustained treatment of panic disorder. Some SSRIs like paroxetine (Paxil) can be used in conjunction with a benzodiazepine, such as lorazepam or clonazepam, for short periods of time for acute panic attacks. Hydroxyzine is used primarily as an antihistamine and can be used for sleep. Buspirone is an anxiolytic used for anxiety. Phenobarbital is a barbiturate used to control seizures as well as anxiety.

A 37-year-old man presents with a 1-year history of speech disturbances which include confusing and repetitive speech and the use of unrelated words without meaning. He is prone to unprovoked outbursts, self-described auditory commands, and an overall deterioration in functioning. Question What represents an appropriate health care maintenance recommendation for this patient? Answer Choices 1 Adherence to pharmacotherapy does not contribute to illness relapse prevention 2 Daily cigarette smoking will lessen abnormal behavioral symptoms 3 High dietary fat intake and a limited exercise regimen will enhance treatment response 4 Monitoring for diabetes, cardiovascular, and pulmonary illnesses is unnecessary in the patient 5 Social skills training, cognitive-behavioral therapy, and cognitive remediation are essential

Correct Answer: Social skills training, cognitive-behavioral therapy, and cognitive remediation are essential Show Explanation Explanation This patient's symptoms are most consistent with schizophrenia. Psychosocial treatment is essential for people with schizophrenia and includes a number of approaches (e.g., social skills training, cognitive-behavioral therapy, cognitive remediation, and social cognition training). Studies have suggested that in conjunction with medications, patients who were treated with nonpharmacologic interventions (e.g., psychoeducation, family intervention, skills training, and cognitive-behavioral therapy) were more compliant with their medications, had fewer repeat hospitalizations, and experienced better quality of life after 1 year. Antipsychotic medications (also known as neuroleptic medications or major tranquilizers) diminish the positive symptoms of schizophrenia and prevent relapses. Approximately 80% of patients relapse within 1 year if antipsychotic medications are stopped; only 20% relapse if treated. Most patients with schizophrenia smoke. Smoking may be a result of previous conventional antipsychotic treatment since nicotine may ameliorate some of the adverse effects of the drugs. Smoking may also be related to the boredom associated with hospitalizations, the peer pressure from other patients to smoke, or the anomie associated with unemployment. Whatever the cause of the high incidence of smoking, the health risks from smoking are well-known; all schizophrenic patients should be encouraged to stop smoking. Many psychotropic medications can cause weight gain and changes in glucose or lipid metabolism. Occasionally, a person with schizophrenia develops odd food preferences. Many persons with schizophrenia have limited funds, do not cook for themselves, and live in areas where fast food outlets are abundant; therefore, nutritional counseling is difficult, but important. Because many psychotropic medications are associated with weight gain, and because of the many beneficial effects of exercise, persons with schizophrenia should be encouraged to be as physically active as possible. It is important not to neglect the medical care of the person with schizophrenia. Obesity, diabetes, cardiovascular disease, and lung diseases are prevalent with schizophrenia; the person with schizophrenia often does not receive adequate medical care for such conditions.

A 30-year-old man presents for a routine follow-up; he has a documented 10-year history of intermittent chronic symptoms including headache, low back pain, knee pain, and dysuria. He also notes nausea, diarrhea, poor libido, and extremity numbness. He admits to feelings of worthlessness, as well as daily alcohol use in an attempt to feel better. Lab studies, urine testing, plain radiographs, CT scans, and MRIs have failed to explain the source of these symptoms; he is consumed by worry about illness. Question What healthcare maintenance is most appropriate for this patient? Answer Choices 1 He should be cared for by multiple general practitioners simultaneously 2 It is unnecessary to screen for organic disease in the future 3 Further symptom-driven invasive diagnostic testing should be ordered 4 Reassurance that a cure is probable due to traditional insight-oriented psychotherapy 5 He should not be told that his symptoms are psychogenic or "all in his head"

Correct Answer: He should not be told that his symptoms are psychogenic or "all in his head" Show Explanation Explanation This patient's most likely diagnosis is somatic symptom disorder. The somatizing patient should not be told that his symptoms are psychogenic or "all in his head". Such comments are almost inevitably rejected and destroy therapeutic rapport; also, they may be inaccurate. Medical or surgical care should be coordinated by one primary care physician. Psychiatric consultation, however, is often valuable in helping the primary care physician formulate a treatment plan for the patient. The clinician must remain vigilant to the possibility that the patient has covert physical disease and may develop physical disease during the course of treatment for his or her somatization. Invasive diagnostic or therapeutic procedures for the somatizing patient should be initiated only for objective signs and symptoms, not for subjective complaints. Somatization is often a chronic condition (i.e., "illness as a way of life"), and a cure is improbable. Somatizing patients require ongoing management using techniques that reduce the risk of iatrogenic complications. Chronic somatization is rarely responsive to traditional insight-oriented psychotherapy, but behavioral modification techniques are often useful in modifying patients' illness behavior.

A healthy 24-year-old man has an intense fear of snakes. His behavioral therapist has him imagine a large room full of all kinds of snakes. Question This technique is an example of what? Answer Choices 1 Implosion 2 Flooding 3 Systematic desensitization 4 Relaxation training 5 Interpretation

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

A mother states that her 7-year-old male child was recently diagnosed with attention deficit hyperactivity disorder (inattentive type). What symptom would best support this diagnosis? Answer Choices 1 Difficulty organizing tasks, fidgets with hands, and has difficulty waiting his turn 2 Interrupts others, talks excessively, and does not seem to listen when directed 3 Makes careless mistakes, does not seem to listen when directed, and has difficulty sustaining attention 4 Has difficulty waiting his turn, makes careless mistakes, and talks excessively 5 Displays persistent deficits in social communication and social interactions in multiple settings

Correct Answer: Makes careless mistakes, does not seem to listen when directed, and has difficulty sustaining attention Show Explanation Explanation The only choice that is all-inclusive is "Makes careless mistakes, does not seem to listen when directed, and has difficulty sustaining attention." According to the DSM 5 criteria, the choice specifically refers to Attention-Deficit/Hyperactive Disorder with the specifier of Predominantly inattentive presentation.

From the time she was a child, a 24-year-old woman has always had a problem with her peers. She has never had a friend in whom she felt she could confide because she suspects the motives of everyone. When any remark is made as a joke, she takes it personally and has a tendency to carry a grudge. She feels that she is the constant butt of attacks on her reputation and this has caused a great deal of difficulty in any on-going relationship she has had with a man. She is always questioning their fidelity without grounds to do so. It has resulted in most of the relationships breaking up rather quickly, and she feels she's been cheated by life. There is no history of psychotic illness, no mood disorder, no familial history of psychosis, or serious medical illness. She is in good physical health for her age. What is this woman's diagnosis? Answer Choices 1 Paranoid Personality Disorder 2 Dependent Personality Disorder 3 Borderline Personality Disorder 4 Brief Reactive Psychosis 5 Narcissistic Personality Disorder

Correct Answer: Paranoid Personality Disorder Show Explanation Explanation Although most prevalent in men, Paranoid Personality Disorder is found in 0.5 to 2.5% of the general population of the US. Its characteristics include an unknown etiology starting in childhood, but some evidence links it to chronic Schizophrenia and Delusional Disorder, Persecutory Type. These individuals believe that others are constantly making unjust remarks about them, berating their reputation, attempting to exploit them, and they cannot trust their friends, mates, and sexual partners.

A 19-year-old woman presents for a psychiatric evaluation. She has never been to a psychiatrist before, and she has no reported history of psychiatric illness. During the evaluation, she states that she keeps hearing frightening voices that tell her to hurt people she loves; she is very disturbed by this. She also states that she becomes confused; sometimes when people are talking to her, the words do not make sense. She says she can only hear 1 word at a time, and when a person is finished with a sentence she forgets the 1st words of that sentence. She notes that 'the world no longer feels real'. The patient denies drug and alcohol use, and she is not currently under the care of a physician. She is not taking any medications at this time. She tells you that the symptoms have persisted for approximately 2 months. What is the most likely DSM-V diagnosis for this patient? Answer Choices 1 Schizophrenia 2 Schizoaffective disorder 3 Schizophreniform disorder 4 Brief psychotic disorder 5 Substance/medication-induced psychotic disorder

Correct Answer: Schizophreniform disorder Show Explanation Explanation The patient is experiencing auditory hallucinations and disorganized thinking, both of which are congruent; the symptoms have persisted for at least 1 month, but less than 6 months. These symptoms are consistent with a diagnosis of schizophreniform disorder. Schizophrenia and schizoaffective disorder can be ruled out at the present time because the symptoms have not persisted for at least 6 months. The patient does not present with any symptoms of a mood disorder, which further supports ruling out schizoaffective disorder. A brief psychotic disorder can be ruled out because the symptoms have persisted for at least 1 month. Substance/medication-induced psychotic disorder can be ruled out due to the lack of any reported substance use.

A middle-aged man is angry, frustrated, disillusioned, and disappointed with his wife's involvement with his best friend. He enrolls himself in a men's tennis club to relieve his negative emotions. What defense mechanism is he using? Answer Choices 1 Projection 2 Reaction formation 3 Denial 4 Dissociation 5 Sublimation

Correct Answer: Sublimation Sublimation is a defense process by which an unacceptable feeling is unconsciously replaced with a course of action that is constructive and personally and socially acceptable. The conscious use of work, sports, art or hobbies to divert one's thoughts from a problem or from a rejected wish, is an analog of this. Dissociation is the conscious or unconscious separating off of mental contents (i.e.: thoughts, feelings, and fantasies) from the individual's awareness, which is disowned and separated from one's personality. Projection is the unconscious mechanism where an unacceptable impulse, or idea, is attributed to others or the external world. Denial is the disclaiming and rejecting of any aspects of internal or external reality that, if acknowledged, would cause anxiety. Reaction formation is an unconscious mechanism in which unacceptable feelings, ideas, or impulses are transformed into their exact opposites.