UWorld Review-Behavioral Med

- Lysergic acid diethylamide intoxication

18 yr old woman presents to the ED complaining of intense fear and dread. She states she can hear colors and taste sounds and her symptoms started after a friend gave her a pill at a party. Her pulse is 100 beats per minute respirations are 20 breaths per minute, temp is 98.7F and blood pressure is 140/90. Physical exam reveals mydriasis diaphoresis and mild psychomotor agitation. The patient is oriented to person and place. Which of the following is the most likely diagnosis?

- Anorexia nervosa

18 yr old woman presents with orthostatic hypotension, bradycardia and hypothermia. Her BMI is 17kg/m2. She runs 12 mils every day & eats less than 1,000 calories daily for fear that she may become fat. PE reveals lanugo, dry skin & teeth erosion. Which of the following is the most likely diagnosis?

- Amphetamine intoxication

20 yr old an presents to ED with acute delirium & agitation. Patient is combative & not able to give a history, but a friend accompanying him states he took "some drug" at a party. VS are temp is 100.1F, BP is 180/90, HR is 120/min and RR are 25/mon. PE reveals hyperhidrosis, generalized tremor & hyperreflexia. Which of the following is the most likely diagnosis?

E. Propranolol

20-year-old woman comes to the office at her parents' urging. She is a college student required to give presentations in front of the class, during which she experiences severe anxiety. The patient says, "My face turns bright red, my hands start shaking & I break out in a sweat. I had to leave the classroom in the middle of my last presentation." The patient is worried as she has several important presentations coming up in the next few weeks. The patient enjoys socializing with friends at parties. Mental status exam shows an initially anxious patient who relaxes as the interview progresses. Physical exam is unremarkable. Which of the following is the most appropriate pharmacotherapy for this patient? A. Bupropion B. Buspirone C. Lorazepam D. Paroxetine E. Propanolol

- Cognitive behavioral therapy

26 yr old woman has complaints of an intense fear of enclosed spaces, which she says is getting worse over time. She thinks it began when she got locked in a closet by accident as a child. She was recently hired at a new job & is starting to have anxiety about riding in the elevator to the floor where she works & sitting in a small cubicle during work hours. Which of the following is the most appropriate first line treatment for this patient considering the most likely diagnosis?

- Buprenorphine

26 yr old woman presents requesting substance abuse treatment She says that she has been injecting heroin daily for past 3 years, numerous attempts at quitting on her own have been unsuccessful & she has never tried any pharmacotherapy to address her symptoms. Which is the most appropriate therapy?

- Intravenous diazepam 2 mg

38 yr old woman presents to ED with nausea, vomiting, diaphoresis, HTN, tachycardia, muscle spasms & agitation. Emergency medical personnel state they administered naloxone to the patient 10 mins ago after finding her unresponsive. Friends relayed to the emergency personnel that she is a chronic heroin user & has overdosed. Which of the following is the best treatment for this patient's acute opioid withdrawal syndrome?

- Varenicline

38 yr old woman presents to the clinic to seek help with smoking cessation. She states that her mother was recently diagnosed with lung cancer & she is very motivated to quit smoking. She has tried nicotine replacement lozenges in the past and did not thin that they were effective. She has a past medical history of a seizure disorder & take levetiracetam. Which of the following clinical therapeutics would be best for this patient?

- Wernicke encephalopathy

55 yr old man with a Hx of EtOH use d/o presents to the ED by ambulance with confusion. He is very thing & appears malnourished. He is oriented to self only. On PE, he has sluggish pupillary reflexes & nystagmus & is unable to walk by himself without falling. He is given an intravenous dose of thiamine and his confusion improves rapidly. Which of the following is the most likely diagnosis?

B. Adjustment disorder Adjustment disorder involves symptoms occurring within 3 months of an identifiable stressor that causes significant distress &/or impairment. It is not diagnosed if a patient meets diagnostic criteria for another mental disorder. Onset within 3 months of stressor causing marked distress

62-year-old woman comes to the office due to insomnia & depressed mood. The patient states that she feels any & sad since her husband of 35 years unexpectedly announced that he wanted a divorce 2 months ago. She says, "I was devastated b/c I thought we had a pretty good marriage. My whole life has been turned upside down." The patient stays up late worry about living alone & supporting herself financially. She recently started drinking wine before bedtime to help her fall asleep. Although she was regular eating lunch with friends, the patient has cancelled multiple times b/c she "can't bear to go through the story again and again." She has no suicidal ideation. The patient is tearful when discussing the divorce but brightens when asked about her grandchildren. Which of the following is the most likely diagnosis in this patient? A. Acute stress disorder B. Adjustment disorder C. Generalized anxiety disorder D. Major depressive disorder E. Persistent depressive disorder (dysthymia)

C. Friend A health care proxy (medical power of attorney) is a legal document specifying a person chosen by the patient to make health care decisions in the event the patient becomes incapacitated &/or lacks decision-making capacity (as in this case). The proxy overrules all other possible surrogate decision-makers, including family members.

64-year-old woman is brought to the ED by her husband & a friend. The patient was diagnosed with aplastic anemia 1 year ago. She has responded poorly to immunosuppressive therapy & has required multiple blood transfusions. The patient is currently febrile, disoriented & unable to respond to questions. CBC shows pancytopenia (low counts of RBC, WBC & platelets). During the evaluation, the friend presents a notarized health care proxy document signed 1 months ago in which the patient designate the friend as her proxy. The friend tells the treating health care provider that the patient did not want to undergo any further blood transfusions. The husband adamantly insists the patient receive a blood transfusion & says that it is what she would have wanted. Who should make the decision regarding the transfusion? A. Courts B. Ethics committee C. Friend D. Husband E. Treating health care provider

C. Electroconvulsive Therapy ECT is a safe & effective 1st-line treatment for major depressive disorder with psychotic features. It is particularly appropriate for severely depressed patients who refuse to eat & drink or are acutely suicidal.

72-year-old woman is admitted to the hospital b/c of worsening suicidal ideation for the past month. The patient has been refusing meals in order to "sacrifice" herself for "the greater good." She has stopped communicating with her family & spends most of her days sleeping or staring at the TV. The patient has been treated with multiple antidepressants in the past for recurrent major depressive disorder. 2 weeks ago, she discontinued taking Venlafaxine b/c she felt it "interfered" with her plan to kill herself. BMI is 16.5kg/m2. Physical exam shows decreased skin turgor & dry mucous membranes. Which of the following is the best next step in management? A. Clozapine B. Cognitive-Behavioral Therapy C. Electroconvulsive Therapy D. Imipramine E. Olanzapine

- Oppositional defiant disorder

8 yr old boy presents to clinic with his mom. She states that he frequently exhibits defiant behavior & argues with his teachers. He seems to lose his temper easily & blames others for his actions. Which of the following is the most likely diagnosis?

- Prevalence rates of autism have seemingly increased independent of immunization schedules

Mother is concerned that her healthy 12-month-old child will develop autism following standard immunizations. Which of the following is appropriate advice founded on current clinical evidence?

- Hydrogen peroxide

Which of the following is an adulterant that may interfere with drug testing causing false-negative results?

- Diagnostic interview for attention-deficit/hyperactivity disorder in adults

Which of the following is the best diagnostic aid for attention-deficit/hyperactivity disorder in adults?

B. Conjunctival injection Marijuana contains THC, which stimulates cannabinoid receptors to produce mild euphoria with inappropriate laughter, increased appetite, slowed reaction time/motor speed & cognitive impairment. Physical symptoms of marijuana intoxication include conjunctival injection, tachycardia, increased appetite & dry mouth.

18-year-old boy is brought to the ED by his mother due to his strange behavior. The mother says that he laughs inappropriately & seems sluggish. The boy has recently been hanging out with a new group of friends & has also stopped attending family events. He appears apathetic about his schoolwork. When asked in private, the boy admits to smoking marijuana. This patient most likely has which of the following exam findings? A. Bradycardia B. Conjunctival injection C. Miosis D. Nystagmus E. Respiratory depression

- Hep B vaccination, HIV medication & human papilloma vaccination

21 yr old woman presents to ED approx. 12 hours after being sexually assaulted by an unknown assailant. She has no significant PMH but reports she is unsure of childhood immunization status. What type of postexposure prophylaxis should be offered?

- Education about the diagnosis

25 yr old woman with Hx of childhood sex abuse present w/ complaint of new-onset seizure-like activity. She says that episodes occur after conflicts with her boyfriend and involve jerking of her arms & legs along with shaking of her head. There is no loss of cowel or bladder control & after the episodes she has no memory impairment, confusion or change in mental status. Neuro exam is normal, vital signs are within normal range for her age, and lab workup is negative. Which of the following is the best next step?

- Take a test dose in advance of an event to assess effectiveness

25 yr old woman with a PMH significant for social anxiety disorder is concerned about her new job that involves frequent public speaking. She is prescribed benzos to take as needed before public speaking situations. Which of the following would be important to discuss with the patient regarding this medication?

- Psychotherapy

28 yr old man presents requesting mental health treatment. He is married & can only become sexually aroused when his wife wears leather boots while they have sex. Over the past year, their frequency of intimacy has decreased significantly as his wife is uncomfortable with this situation. Which of the following is the best next step in management?

- Prior unexplained somatic symptoms

30 yr old woman presents to PCP with chronic fatigue. She has had extensive lab tests w/o identified general medical condition. The fatigue ahs lead to severe anxiety, numerous health care visits & made it difficult to maintain a job. Which of the following additional findings supports the most likely diagnosis?

- Sexual masochism disorder

32 yr man intentionally participates in sexual activities where he is often bound, humiliated, beaten or abused. His urge for these activities has been present for the past 7 months & is so intense that his third marriage also ended in divorce. Which of the following is the most likely diagnosis?

E. Serotonin This patient has serotonin syndrome caused by serotonergic drug interaction with Tramadol.

42-year-old woman is brought to the ED by her husband for new-onset tremors & extreme restlessness. She feels nauseated & anxious. The patient recently injured her back & was prescribed Tramadol. She has major depression with psychotic features for which she takes Venlafaxine & Apripiprazole. Temp is 38.3C (101F); BP is 160/100; HR is 125/min; RR are 20/min. On exam, the patient is flushed & diaphoretic & her voice is tremulous. Mild rigidity & tremors are noted in her lower extremities. DTRs are 3+. Pupillary dilation & ocular clonus are present. Dysregulation of which of the following neurotransmitters is the most likely cause of this patient's symptoms? A. Acetylcholine B. Dopamine C. Gamma-aminobutyric acid D. Norepinephrine E. Serotonin

- Bupropion

49 yr old man presents with concerns for mood changes. He states that he has been feeling hopeless & fatigued & he has been having difficulty sleeping the last month. He has gained weight & lost interest in his usual exercise routine. He has had this happen in the past & was placed on a medication that cause significant sexual dysfunction. He wishes to avoid that if possible. Which of the following medications would be best for this patient?

- Continue psychosocial treatment for at least 6 months

Which of the following represents appropriate health maintanence for a patient with alcohol use disorder

- Small hippocampal volume

Which of the following structural changes can be seen in the brains of individuals diagnosed with long-standing and untreated depression?

- Bupropion

24 yr old woman with a medical history of bulimia nervosa presents to the clinic complaining of a depressed mood for the past month. She states she has felt excessively tired and has been disinterested in interacting with her friends and family. She also endorses recurrent feelings of worthlessness and insomnia. Which of the following medications is contraindicated?

- Cannabis withdrawal

25 yr old man presents to the ED with complaints of nervousness, anxiety, decreased appetite, HA & difficulty sleeping for the past 2 day. The patient has a mild fever & is sweating profusely. He has not been able to go to work for the past 2 days. Upon further questioning, he has a history of heavy alcohol & marijuana use. He also takes alprazolam regularly for anxiety and has been taking more since his symptoms started. He reveals that he lives at home with his parents & recently told that he would be evicted if he does not become sober. Although he stopped his drug use about 1 week ago, he continues to have 1 to 2 drinks daily, the last one being 3 hours ago. Which of the following is the most likely diagnosis?

C. Pressured speech Manic episodes in Bipolar I are characterized by euphoric/irritable mood, impulsivity, hyperactivity, decreased need for sleep, pressured speech, racing thoughts & grandiosity. They may occur with or without psychotic features.

28-year-old man is brought to the ED by his roommate, who is concerned about his change in behavior over the past 2 weeks. The roommate describes the patient as "a regular guy who is usually very responsible." Last week, the patient abruptly quit his job as a computer programmer & starting placing large bets on an online gambling site b/c he was "sure to make millions." The roommate says that the patient has been staying up most nights scribbling notes for his autobiography on small scraps of paper. The patient says, "My new mission is the spread understanding." He denies any alcohol or drug use, which his roommate affirms. This patient is most likely to exhibit which of the following findings? A. Flat affect B. Poor hygiene C. Pressure speech D. Social withdrawal E. Thought blocking

- Panic disorder

30 yr old woman presents to the clinic with recurrent episodes of chest pain, sweating, dyspnea & palpations that often occur abruptly. She has previously had similar episodes with the most recent occurring approximately 2 months ago. She reports a persistent concern about having additional episodes & has started to avoid exercising for fear of dying from a heart attack. On PE, she is noted to be tachycardic. ECG reveals sinus tachycardia with a normal axis & no acute ST-T abnormality. Lab studies are within normal limits. Which of the following is the most likely diagnosis?

- Recurrent distressing dreams

41 yr old man presents to the clinic complaining of anhedonia. He states this feeling started 2 months ago, after his wife was killed in a motor vehicle collision. Which of the following reported symptoms makes post-traumatic stress disorder more likely than major depressive disorder?

- Paranoid personality disorder

51 yr old man with a family history of colon cancer presents to the office for a routine physical exam. Which of the following mental health diagnosis is a barrier to the patient following through on colon cancer screening?

- Generalized anxiety disorder

63-year-old woman with chronic obstructive pulmonary disease presents to the clinic with poor sleep, easy fatigability, and muscle tension for the past 6 months. She reports no alcohol, caffeine, or illicit drug use. She describes excessive & persistent worrying about future events & her illness. Her worrying is so severe that it affects her performance at work. Lab studies are within normal limits. Which of the following is the most likely diagnosis?

B. Nightmare Disorder Nightmare Disorder involves recurrent awakenings from REM sleep associated with full alertness & dream recall. It should be differentiated from non-REM sleep terror, which are characterized by partial arousals, unresponsiveness & lack of dream content.

7-year-old girl is brought to the office by her mother. Over the past month, the girl has awakened almost every night, come into her parents' room & insisted on sleeping the remainder of the night in their bed. The girl wakes up abruptly in a panicky sweat, crying & screaming, "I'm so scared; monsters are chasing me." She breathes rapidly & shakes but is able to calm down after being consoled by her parents & hugging a favorite stuffed animal. The girl started a new school 1 year ago. Although the girl is shy, she enjoys school & has several good friends. Which of the following is the most likely diagnosis in this patient? A. Adjustment Disorder B. Nightmare Disorder C. Nocturnal Panic Attack D. Separation Anxiety Disorder E. Sleep Terror Disorder

E. Posttraumatic Stress Disorder PTSD in children may present with distressing dreams with vague content & reenactment of traumatic themes in play rather than clearly formulated memories. This is often accompanied by emotional dysregulation & behavioral difficulties.

a 6-year-old boy is brought to the office due to behavioral difficulties at school. He has been hitting other children & breaking their toys. The patient was adopted by his grandmother a year ago after his parents died in a motor vehicle accident. He attends the same school but no longer wants to play with his friends or join group activities. The patient wakes up a few times a week crying about monsters & asking to sleep in his grandmother's room. He is meeting appropriate developmental milestones. The patient is restless & rams a toy truck into a stuffed animal repeatedly while his grandmother speaks. He makes poor eye contact & answers most questions by saying "I don't know." Which of the following is the most likely diagnosis? A. Age-appropriate behavior B. Attention Deficit Hyperactivity Disorder C. Autism Spectrum Disorder D. Oppositional Defiant Disorder E. Posttraumatic Stress Disorder

A. Attention Deficit Hyperactivity Disorder This patient's blurting out to communicate, disorganized schoolwork, difficulty following directions & distractibility are characteristic of ADHD. Her inattentive symptoms include losing assignments, struggling to follow directions, forgetting to bring home schoolbooks, not following through on homework & being distractible. Hyperactive/impulse symptoms include interrupting others & blurting out of inner thoughts.

10-year-old girl is brought to the office by her mother due to daily behavioral problems for the past 7 months. The patient was sent to the principal's office last week after blurting out random comments in class. The patient's grades are poor & she does not do her homework. She loses the instructions for assignments & does not bring her schoolbooks home. The patient sleeps 9 hours every night & eats a balanced diet. During the eval, the patient interrupts her mother several times. She is easily distracted by noises from outside the exam room & questions must be repeated multiple times. Which of the following is the most likely diagnosis in this patient? A. Attention Deficit Hyperactivity Disorder B. Bipolar I Disorder, manic episode C. Conduct Disorder D. Oppositional Defiant Disorder E. Tourette Syndrome

A. Autism spectrum disorder high-functioning autism in children may come to attention only when social demands reveal social-emotional deficits during school-aged years. Features include social awkwardness, fixated interests, & unusual responses to sensory experiences.

13-year-old girl is brought to the office by her mother due to concerns about the girl's adjustment to a new school. The patient has always been shy & somewhat awkward. The new school emphasizes group projects, which the mother thought would help her daughter be more social but has instead made her extremely anxious. The patient is bright but underachieves at school & has few friends. She has an obsessive interest in horses. During the interview, the patient makes poor eye contact, interrupts questions by changing topics & mentions facts about different horse breeds. When her vital signs are checked, she touches the BP cuff repeatedly. Which of the following is the most likely explanation for this patient's behavior? A. Autism spectrum disorder B. OCD C. Schizoid personality disorder D. Schizotypal personality disorder E. Social anxiety disorder

A. Ask the patient is threatened either at home or school

14-year-old girl comes to the office for follow-up of asthma. After a review of the patient's respiratory symptoms, which have remained stable on her current medication regimen, she hesitantly says that she wishes she were a boy & that she has felt this way "my whole life." She has not told anyone due to fear of disapproval, saying, "My parents will kill me if they find out." She has tried to manage her feelings on her own but is becoming more distressed as pubertal changes, with increasing breast development & hair growth. She asks for advice about her situation. In addition to providing support, which of the following is the most appropriate? A. Ask if the patient is threatened either at home or school B. Inform the parents so they can decide how to proceed C. Psychotherapy referral to discuss gender conformity D. Reevaluate in a few years b/c gender identity can change E. Start hormonal treatment to delay puberty

B. Schizophrenia Early-onset schizophrenia (< 18 y/o) is associated with a more severe & impairing course. Youth commonly have a prodromal phase marked by social withdrawal & academic decline prior to the onset of active psychotic symptoms. Hallucinations are common & need to be differentiated from imaginary friends.

15-year-old boy is brought to the office by his mother due to "odd behavior." Since moving to a new school 8 months ago, the boy has started talking to his imaginary friend Henry again. His mother reports that he has this imaginary friend for a few months in kindergarten. The boy has been spending more time alone & he spends time laughing & talking to Henry. His teachers report that he has not been paying attention in class or completing homework. He no longer spends time with his siblings & says he "would rather play video games with Henry." The patient states, "Henry is always with me & like to comment on what I'm doing." He has tried Marijuana in the past but does not use other drugs. On mental status exam, the patient avoids eye contact & has a flat affect. Which of the following is the most likely explanation for this patient's behavior? A. Schizoid Personality Disorder B. Schizophrenia C. Schizophreniform Disorder D. Schizotypal Personality Disorder E. Substance-induced Psychotic Disorder

E. Sertraline This patient's intrusive & distressing mental images of stabbing her mother & subsequent countdowns to eliminate the images are characteristic of OCD. In addition to obsessional thoughts, other types of obsessions in OCD may include violent images or urges (as seen in this patient). Compulsions are repetitive acts performed in response to obsessions & may include washing, checking &/or counting; repeating words (countdowns from 5 to 1) to get rid of thoughts or images may also be seen (as in this patient). 1st line treatment of OCD = CBT & SSRIs

17-year-old girl comes to the office due to "disturbing images" she has seen over the past year. She says, "I'd be standing in the kitchen helping my mother chop vegetables & terrible images of stabbing her in the back with a knife would pop into my head." The patient is overwhelmed with anxiety each time this occurs, resulting in putting the knife down & running out of the kitchen. She counts down from 5 to 1 several times to try to "get rid" of the thoughts. The patient has a tense & anxious affect & becomes tearful when discussing how she would never want to hurt her mother. She reports no depressed mood or suicidal ideation. Which of the following is the most appropriate pharmacotherapy for this patient? A. Aripiprazole B. Buspirone C. Haloperidol D. Lorazepam E. Sertraline

E. Schizophreniform disorder This patient's 2-month history of progressive social withdrawal, paranoid ideation.& hallucinations (shouting at unseen ppl) suggestive schizophreniform disorder. Schizophreniform disorder is characterized by psychotic symptoms (delusions, hallucinations, disorganized speech & behavior, negative symptoms) lasting > 1 month & < 6 months.

18-year-old man is brought to the clinic due to increasingly bizarre behavior over the past 2 months. The patient is in his first semester at college & has had difficulty adjusting to being away from home. For the past few weeks, he has not been attending classes & he no longer socializes with friends. He spends most of his time alone & eats very little b/c he believes the cafeteria food is poisoned. He has no psychiatric history. He appears disheveled with unwashed hair, makes poor eye contact & shouts "leave me alone" in response to unsee people. Which of the following is the most likely diagnosis in this patient? A. Adjustment disorder B. Brief psychotic disorder C. Major depressive disorder with psychotic features D. Schizophrenia E. Schizophreniform disorder

E. The slightly increased risk of suicidal thoughts with antidepressants in this age group should be weighed against the risk of completed suicide in untreated depression

19-year-old man is brought to the office by his mother due to sad mood & declining grades at college. The patient feels depressed & hopeless about the future. Based on a complete history, major depressive disorder is diagnosed & treatment is discussed. The patient is willing to take medication but his mother is concerned that antidepressants can cause ppl to become suicidal. Which of the following is the most appropriate response? A. Some classes of antidepressants have a lower risk of increasing suicidal thoughts & those are prescribed 1st to adolescents B. There is a slightly increased risk of suicidal thoughts in adolescents & antidepressants are prescribed only when therapy fails C. There is a slightly increased risk of suicidal thoughts in young ppl treated with antidepressants but only in those age < 18 D. There is no association between antidepressants & an increased risk of suicidal thoughts in adolescents E. The slightly increased risk of suicidal thoughts with antidepressants in this age group should be weighted against the risk of complete suicide in untreated depression

A. Catatonia Catatonia is a syndrome characterized by psychomotor signs/symptoms that occur in the context of a psychiatric or medical illness & include: immobility, mutism, negativism (proportional resistance to passive movement) & echolalia (meaningless repetition of another person's spoken words). It most commonly develops in the context of a mood disorder (bipolar, major depressive disorder); however it may occur in psychotic disorders (schizophrenia), autism spectrum disorder & general medical illness.

19-year-old woman is brought to the ED due to bizarre behavior. Her father found the patient this morning sitting up in bed, staring at the wall. The patient didn't respond to questions & was very stiff when her father tried to help her stand. The patient has Bipolar disorder & takes Lithium, Risperidone, Fluoxetine; her dosages of Risperidone & Fluoxetine were both increased recently due to residual depressive symptoms. VS are normal. When asked the date today the patient repeats, "date, date, date," repeatedly. She resists the examiner's mov't of her arms. Which is the most likely diagnosis in this patient? A. Catatonia B. Delirium C. Drug-induced Parkinsonism D. Neuroleptic Malignant Syndrome E. Serotonin Syndrome

B. Autism Spectrum Disorder

2-year-old boy is brought to the clinic by his mother, who is concerned about his language development. She says, "his speech isn't progressing & he does not interact with other children. His day care teacher says that he is shy & sits in a corner playing with his favorite truck." The family moved to a new home 3 months ago. In the exam room, the patient sits in a corner, avoids eye contact with the health care provider & repeatedly spins the wheels of a toy truck. He does not respond to his name. He makes occasional grunting sounds but says no fully formed words. When his mother tries to take his truck away, he begins screaming & pulls it back. Which of the following is the most likely diagnosis in this patient? A. Adjustment Disorder B. Autism Spectrum Disorder C. Normal variation in development D. Selective mutism E. Social Anxiety Disorder

E. Gender dysphoria Gender dysphoria is characterized by persistent distress due to the incongruence between gender identity & assigned gender. It is often accompanied by discomfort with the development of unwanted secondary sexual characteristics.

21-year-old woman comes to the office for a routine exam. The patient shares that looking in the mirror has been increasingly difficult due to feeling upset about "how my breasts look." The patient frequently imagines what it would be like to not have breasts & wears a chest binder to make them appear flatter. The patient says, "I've always wanted to change how I look. I don't want ppl to see me as a woman anymore bc I've never felt like one." The patient appears somewhat anxious & is wearing trousers & a loose shirt. Which of the following is the most likely explanation of this patient's condition? A. Adjustment disorder B. Body dysmorphic disorder C. Dissociated identity disorder D. Fetishistic disorder E. Gender dysphoria

D. Schizophrenia This patient's delusions, negative symptoms (apathy, abolition, flat affect, alogia/brief answers & social withdrawal), significant functional decline & continuous impairment last > 6 months are consistent with schizophrenia.

23-year-old man is brought to the office due to increasingly odd behavior & progressive social withdrawal over the past year. The patient dropped out of college last year b/c of failing grades. Since returning to live with his parents, he stopped going out with his friends & sits in his room all day. For the past few months, he has been watching the same videos over & over, telling his mother that he is "listening for messages from secret channels." The patient says, "I'm fine. I don't know why everyone's upset." His appetite, sleep & energy level are normal. On exam, the patient appears anxious, avoids eye contact & shows little emotion. His answers are very brief & he asks if the interview is being secretly recorded. The patient has no suicidal ideation, symptoms of mania or hallucinations. Which of the following is the most likely diagnosis in this patient? A. Delusional Disorder B. Schizoaffective Disorder C. Schizoid Personality Disorder D. Schizophrenia E. Schizotypal Personality Disorder

- Risperidone

24 yr old man presents to the psych clinic with recent elevated mood. He states he ahs been able to work 20 hrs/day for the past 4 days without feeling fatigued. He states he feels like his thoughts are racing & he has elevated self-esteem. During exam, he is easily distracted. He has a hx of depressive episodes & reports no drug use or psychotic features. Which is the recommended first line treatment?

C. Cocaine withdrawal This patient's acute onset of depression with pronounced fatigue following a period of increased energy is suggestive of cocaine withdrawal. Individuals often use cocaine in binges, taking the drug repeatedly over a short period of time to maintain a "high." Abrupt cessation is typically followed by a "crash," which can include severe depression with suicidal ideation & psychomotor slowing with milder symptoms that resolve within 1-2 weeks.

24-year-old woman is brought to the ED due to depression & recent suicidal thoughts. The patient has no suicidal ideation but feels depressed, exhausted & unable to concentrate. She appears distracted & speaks slowly. For the past 3 nights, the patient attended parties where drugs & alcohol were present. She was energetic & talkative at the parties; however, last night the patient slept for 18 hours & had difficulty getting out of bed & missed work. Her boyfriend says she has had brief periods of acute depression over the past several months that lasted a few days & were characterized by low energy; hypersomnia; vivid, unpleasant dreams & increased appetite. Vital signs & physical exam are normal. Which of the following is the most likely diagnosis? A. Alcohol withdrawal B. Bipolar disorder C. Cocaine withdrawal D. Major depressive disorder E. Opiate withdrawal

- Schizophreniform disorder

25 yr old man presents complaining that he has been hearing "voices" for the past 2 months. He is unable to provide answers to questions and often moves erratically form one topic to the next. Physical exam is unremarkable. No abnormalities are noted on laboratory studies. A urine drug test is negative. Which of the following is the most likely diagnosis?

- Disorientation

25 yr old man with a Hx of EtOH use d/o presents to the ED with palpitations, tremors & irritability. In the setting of alcohol withdrawal, which of the following additional findings is most specific for delirium tremens?

- Dialectical behavior therapy

25 yr old woman presents to the office requesting counseling. She reports difficulty with romantic relationships & has never had a long-term partner. She has been fired form several jobs due to conflicts with coworkers & supervisors. She also frequently cuts on her arms as a means of dealing with stress. Which of the following is the most appropriate clinical intervention?

- 12 months

25 yr old woman presents with complaints of "constant worrying." She states that she is worried about minor matter and has been finding it difficult to function for the last 7 months. She states that this occurs almost every day, and she has associated fatigue, muscle tension, and difficulty sleeping. After discussing treatment options, a medication is prescribed. How long should this medication be continued before attempting discontinuation if the patient has a good response to it?

D. Neuroleptic malignant syndrome NMS is an adverse reaction to antipsychotic medication characterized by severe "lead-pipe" rigidity, hyperthermia, sympathetic hyperactivity & mental status changes. NMS is characterized by severe rigidity rather than the neuromuscular irritability (hyperreflexia, myoclonus) seen in serotonin syndrome.

25-year-old man is brought to the ED due to severe agitation & aggressive behavior. He speaks loudly & rapidly, stating that he has "superpowers" of mind control & that violence is the only way to defend against "the conspiracy." The patient has bipolar disorder & is prescribed Olanzapine, Lithium & Fluoxetine, although it is unclear if he has been compliant. The patient requires several doses of meds in the ED to calm down & is admitted to the hospital for further psychiatric evaluation. The following night he is found lying very still on his bed & does not respond to questions. Temp is 40.6C (105.1F); BP 157/90; HR is 102/min & RR are 20/min. Exam is significant for diaphoresis & diffuse rigidity in upper & lower extremities. Which of the following is the most likely explanation for this patient's current symptoms? A. Acute dystonic reaction B. Drug-induced parkinsonism C. Lithium toxicity D. Neuroleptic malignant syndrome E. Serotonin syndrome

D. Dissociative Identity Disorder DID is characterized by switching among 2 or more distinct personality states & by an extensive inability to recall important personal information.

25-year-old woman is brought to the office by her husband due to intense mood swings & unusual behavior. She has rapid mood shifts that last a few hours. Although the patient is usually quiet & reserved, her husband says that she can suddenly become enraged without provocation. She does not remember these episodes. Her husband once found her at a local bar dressed in a seductive outfit; when he called her name, she did not respond & walked away. At home, the patient denied having been at the bar & hid behind a chair crying. When she was finally convinced to come out, she spoke in a childlike voice & said "leave me alone." The patient was sexually abused from age 5-16. She has difficulty giving a detailed history & has many gaps in her memory. The patient's mood is anxious & she hears voices that she describes as coming from inside her head. Which of the following is the most likely diagnosis? A. Bipolar Disorder B. Depersonalization/derealization Disorder C. Dissociative Amnesia D. Dissociative Identity Disorder E. Schizoaffective Disorder

- Body dysmorphic syndrome

26 yr old man is being seen in the outpatient family practice office for a routine visit. The patient does not have any acute complaints & has no significant medical history. The patient spends most of the visit discussing the appearance of his right eye. He is convinced that his right eye is misshapen & reports checking the symmetry of eyes at least 2 dozen times per day. He reports nor symptoms..... On exam, the right upper lid is slightly lower than the left eye, consistent with normal variation. Minimal variation in the shape of the eyes is observed. A full head, eye, ear, nose & throat exam is unrevealing. What is the most likely diagnosis?

- Cognitive behavioral therapy

26 yr old man presents with complaints of difficulty sleeping. He states that he is a war veteran & just returned from active duty a few months ago. Since that time, he has persistent thoughts about combat situations and has started to avoid events with crowds because of the disturbing memories. He states that he feels irritable and gets angry when his family pushes him to participate in activities that trigger these memories. Which of the following treatment options would be best for this patient considering the most likely diagnosis?

D. Psychotherapy This patient's suicidal threat in the setting of feeling abandoned is characteristic of borderline personality disorder. Patients with this condition frequently come to health care settings during interpersonal crisis & exhibit a persistent pattern of unstable relationships, mood lability & impulsivity. They may engage in non-suicidal self-injury (cutting, burning) to alleviate tension or feelings of numbness. 1st-line treatment for borderline personality disorder is psychotherapy, particularly dialectical behavioral therapy.

26-year-old man is brought to the office by his former girlfriend, who became alarmed after receiving a message in which he threatened suicide. The patient says he went into an overwhelming state of panic & depression when he heard that his former girlfriend was dating a new man and "wanted to get back at her." The patient has a history of "mood swings" since his teens & rage attacks when he feels that people are unsupportive. he has no suicidal intent or plan. He describes his mood as "a deep pit of emptiness." Physical exam is normal except for cigarette burns on his thighs that he explains as self-harming behavior performed to relieve tension. Which of the following is the best treatment for this patient? A. Citalopram B. Lithium C. Olanzapine D. Psychotherapy E. Venlafaxine

- Fluoxetine

27 yr old man is being evaluated for pervasive preoccupation with perfectionism, orderliness & inflexibility. He is excessively obsessed with work & productivity & has "no time for leisure activities or friends." As a supervisor he tends to control minute details of every project... He rarely spends money, believing that money should be save for future disasters. In addition to psychotherapy, which of the following is the most appropriate therapy?

E. Valproate This patient's euphoric mood, decreased need for sleep, hyperactivity, grandiosity & pressured speech lasting more than a week are characteristic of an acute manic episode of Bipolar I Disorder. This is a highly recurrent illness requiring maintenance treatment with meds that have mood-stabilizing properties to decrease the risk of recurrent mood episodes. Preferred meds for maintenance of Bipolar include: Lithium Anticonvulsants: Valproate & Lamotrigine 2nd generation anti-psychotic: Quetiapine (Seroquel)

27-year-old man is brought to the ED by his wife. She says he has been "acting crazy" for the last 2 weeks. He has hardly slept for the past 7 days & instead has worked on miscellaneous projects around the house. The patient spent several thousands dollars on new power tools to accomplish these tasks. When questioned, his speech is pressured. He feels "spectacular" & is creating an "architectural masterpiece." The patient has had 2 previous depressive episodes. Which of the following meds is the most appropriate for long-term management of this patient? A. Bupropion B. Chlopromazine C. Haloperidole D. Paroxetine E. Valproate

C. Inquire about suicidal thoughts This patient has several findings concerning for depression (hopelessness, motivation, low energy & weight gain). Patients with depression frequently have a somatic presentation & may have difficulty describing their emotions. Always assess for suicide in those with depression.

27-year-old woman comes to the office due to headaches & neck & back pain. She has been coping with pain symptoms for several years but notes that they have increased since she was recently let go from her job. The patient worries about finding another job but states that she is too tired or unmotivated to look for work on most days. She has been to the office twice in the past year for similar symptoms. At her last visit 4 months ago, lab testing including BMP, CBC & thyroid were normal. The patient says "I doubt that anything will ever improve for me." Vital signs & PE are normal. Which is the best next step in management of this patient? A. Examine for point tenderness B. Explore the relationship of her symptoms to stress C. Inquire about suicidal thoughts D. Obtain repeat TSH level E. Offer reassurance & schedule regular followup

D. Dependent personality disorder This patient's excessive dependency on her boyfriend, indecisiveness & fear of managing on her own are suggestive of dependent personality disorder. These patients need excessive reassurance & advice in making decisions & avoid taking initiative due to feelings of inadequacy.

27-year-old woman comes to the office due to intermittent abdominal cramping for the past few weeks. The patient has had no nausea, vomiting or changes in bowel movements. Her stress level has been higher than normal since her boyfriend broke up with her 1 month ago. The patient says, "I did everything to please him & make him happy, & he abandoned me. I don't know how to go on without him." Her boyfriend managed her finances & recently helped her apply for a new job. The patient is unsure about switching jobs now & canceled her interviews to "avoid more confusion." She recently moved in with a friend & hopes this person can help her "sort everything out." Physical exam is normal. Which of the following is the most likely explanation for this patient's behavior? A. Acute stress disorder B. Adjustment disorder with anxiety C. Borderline personality disorder D. Dependent personality disorder E. Somatic symptom disorder

B. Brief Psychotic Disorder Characterized by sudden onset of psychotic symptoms (paranoid, auditory hallucinations) lasting > 1 day & < 1 month. It is associated with a full return to previous level of function without the use of antipsychotic medication although may require a brief hospital stay.

27-year-old woman is brought to the ED by police after she became tearful & distraught when the officers refused to initiate an investigation of her former boyfriend. The patient recently broke up with the boyfriend. 1 week ago, she was fired from her job for frequent lateness. Since then, she has slept poorly & has become convinced that her ex-boyfriend plotted with her former supervisor to get her fired. She says she heard them whispering about her outside her apartment at night. The patient is admitted to the hospital & is d/c after several days with no medication. At a 2-week follow-up visit, she exhibits no paranoid beliefs & reports that she has started looking for a new job. Which of the following is the most likely diagnosis? A. Borderline Personality Disorder B. Brief Psychotic Disorder C. Delusional Disorder D. Paranoid Personality Disorder E. Schizophreniform Disorder

B. Major depressive disorder > 2 weeks with > 5 symptoms: (Sleep changes, Interest loss, Guilt, Energy loss, Cognition/Concentration loss, Appetite changes, Psychomotor (agitation or retardation), Suicide thoughts or attempts) = SIG E CAPS - may occur in response to a variety of stressor (loss of loved one) - marked social & occupational dysfunction - suicidality related to hopelessness & worthlessness

28-year-old man comes to the office b/c he is "not feeling like himself." This change began soon after his older brother died of cancer 3 months ago. The patient feels sad & has lost interest in work & going out with friends on weekends. He often awakens very early in the morning & is unable to fall back asleep. The patient feels "very down," especially when he first wakes up, but says that his mood rarely improves during the day. His poor energy & concentration have started to affect his performance at work. He has been eating less & has lost 5.4kg (12lbs) over the past few weeks. The patient has no psychiatric history. Which of the following is the most likely diagnosis? A. Acute stress disorder B. Major depressive disorder C. Normal grief reaction D. Persistent depressive disorder (dysthymia) E. Persistent complex bereavement disorder

C. Social anxiety disorder SAD is characterized by a fear of social situations & anxiety about embarrassment. In the performance-only subtype, anxiety occurs only in performance-related situations. SAD should be differentiated from panic disorder (unexpected panic attacks) & specific phobia (stimulus not related to social anxiety).

28-year-old woman comes to the office due to panic attacks. She was promoted at work 7 months ago & has experienced severe anxiety, trembling, sweating, chest tightness & SOB when giving presentations or meeting new clients. The patients says, "I have been anxious around people since I was a teenager, but it is getting worse. I know everyone can see that I'm extremely nervous in meetings & will think I'm incompetent. I'm afraid I'll make a fool of myself. The last time I had to speak, I became so anxious that I couldn't breathe & almost passed out." The patient is becoming increasingly concerned that she will lose her job, which is resulting in poor sleep. On mental status exam, she is visibly anxious throughout the interview & avoids eye contact with the healthcare provider. Which of the following is the most likely diagnosis in this patient? A. Generalized anxiety disorder B. Panic disorder C. Social anxiety disorder D. Somatic symptom disorder E. Specific phobia

D. Persistent Depressive Disorder (Dysthymia) This patient's chronic depression, fatigue & hopelessness are consistent with persistent depressive disorder (dysthymia). Requires depressed mood more days than not (persistent) for at least 2 years & at least 2 other symptoms (fatigue, feeling hopeless).

29-year-old woman comes to the office due to persistent fatigue over the last 4 years. She has also felt unhappy during this period, ever since being let go from her previous job. The patient says she has "little energy to do things." When asked what she enjoys, she replies that "everything in life is a chore" & that she feels hopeless that her life will improve. The patient has no suicidal thoughts, problems with concentration or changes in appetite or sleeping patterns. She drinks 1 or 2 glasses of wine on weekends. Detailed workup, including toxicology screen is negative. Which of the following is the most likely diagnosis in this patient? A. Adjustment disorder B. Borderline personality disorder C. Major depressive disorder D. Persistent depressive disorder (dysthymia) E. Substance-induced mood disorder

- Poor social-emotional reciprocity

3-yr old boy presents to pediatricition, brought by mom, who describes her son as being very withdrawn from social interaction with his family, peers or familiar adults. She describes he typically plays alone & has difficulty sustaining attention on any single task for very long times. At times, he moves quickly from 1 thing to another as if he is driven by a motor. He seems to ignore instructions from his parents, which become very frustrating recently. Which of the following is characteristic of autism spectrum disorder?

- Conversion disorder

30 yr old woman presents with weakness to the left arm for 1 day. She is alert and orientated but mildly anxious. She has no personal or family history of cardiac disease but does have a history of major depression & generalized anxiety disorder. She is recently divorced and a single mother. She now works 2 jobs to support her 3 children. Upon PE, the patient is unable to lift her left arm from her side, but you notice that she used her left hand to support herself when getting onto and off the exam table. A magnetic response imaging of her brain is negative and drug screen is pending. Which of the following is the most likely diagnosis?

E. Switch from Fluoxetine to Venlafaxine When major depression fails to respond to an initial SSRI trial, patients should be switch to another 1st-line antidepressant. Options include a different SSRI, SNRI, Bupropion, Mirtazapine or Serotonin modulators.

31-year-old woman comes to the office for follow-up treatment of major depressive disorder. 5 months ago, the patient attempted suicide after learning that her husband had filled for divorce. She was admitted to a psychiatric unit, where she was treated with Fluoxetine 20mg & d/c 2 months later. 1 month after d/c, the Fluoxetine dosage was increased. The patient now says that her suicide attempt was "stupid" & denies suicidal ideation. However, despite taking max doses of Fluoxetine for 8 weeks, she still feels very depressed & reports minimal improvement in her symptoms. She also has a history of bulimia nervosa. Mental status exam reveals poor eye contact, constricted affect & soft speech. Which of the following is the most appropriate management of this patient's depression? A. Continue Fluoxetine for an additional 4 weeks & reevaluate B. D/c Fluoxetine & refer for ECT C. Switch from Fluoxetine to Bupropion D. Switch from Fluoxetine to Nortriptyline E. Switch from Fluoxetine to Venlafaxine

D. Heroin Heroin withdrawal should be suspected in patients with muscle & joint aches, nausea, diarrhea, abdominal cramping, rhinorrhea & pupillary dilation. These subjective symptoms are often severe but generally not life-threatening.

32-year-old man comes to the ED saying, "I feel awful; I may need help." The patient says he was feeling fine until last night when he developed abdominal cramps that were initially mild but gradually worsened in intensity. Since this morning, he has had 4 loose stools. The patient has also had persistent nausea but no vomiting. Meds include Paroxetine & Clonazepam. Temp is 36.6C (97.9F); BP is 144/98; HR is 88/min; RR are 16/min. Physical exam shows a diaphoretic, thin man in considerable distress. The pupils are dilated. The patient's clinical presentation is most consistent with withdrawal from which of the following? A. Alcohol B. Clonazepam C. Cocaine D. Heroin E. Paroxetine

E. Venlafaxine SSRIs & SNRIs are 1st-line meds for treating generalized anxiety disorder. Benzos are reserved for non depressed patients without a history of substance abuse who fail to respond or cannot tolerate antidepressants.

32-year-old man comes to the office due to extreme nervousness, irritability, restlessness, muscle tension & insomnia for the past 6 months The patient fears making mistakes in his job as an attorney & often worries that he has said or done something wrong. His worrying makes it difficulty to concentrate or perform his duties efficiently. The patient is also engaged to be married & spends sleepless nights thinking about the responsibilities of married life. He worries that he will not be a good husband or father. Which of the following meds is most appropriate for this patient? A. Bupropion B. Diazepam C. Propranolol D. Quetiapine E. Venlafaxine

B. Cocaine use disorder Can present with anxiety, irritability, mood swings, grandiosity & psychotic symptoms such as paranoia & hallucinations Physical signs of sympathetic nervous system activation can help differentiate cocaine-induced symptoms from primary mood & psychotic disorders.

32-year-old man is brought to the office for an evaluation after he was placed on probation at work for frequent absences & arguing with his boss. For the past 9 months, he has had unpredictable mood swings with irritability, aggressive behavior & paranoia about his coworkers stealing his job. At other times, he is quiet & withdrawn. The patient is cooperative but tense, irritable & talkative. He says, "This is all an unfair plot to get ride of me. I have contributed more to that company than anyone, & my business plan is pure genius." BP is 160/100; HR is 108/min; RR are 16/min. Pupils are dilated & reactive to light. Which of the following is the most likely explanation of this patient's behavior? A. Bipolar disorder B. Cocaine use disorder C. Delusional disorder, grandiose type D. Paranoid personality disorder E. Schizophrenia

A. Cyproheptadine This patient was diagnosed with Major Depressive Disorder in which 1st-line pharmacologic treatment is an SSRI. Her apparent OD on the SSRI given & her resultant altered mental status, autonomic hyperactivity (hyperthermia, tachycardia, diaphoresis) & neuromuscular excitation (hyperreflexia, clonus, tremor) are characteristic of Serotonin Syndrome. Treatment includes supportive care. If supportive measures fail, Cyproheptadine is the serotonin antidote given.

32-year-old woman comes to the office bc she has felt sad & worthless for the past 3 months. The patient has difficulty sleeping, decreased appetite, & no longer enjoys spending time with friends. The patient is started on 1st-line pharmacologic treatment. 2 days later, the patient is brought into the ED after being found lying down next to an empty bottle of the prescription med. Temp is 38.9C ( 102F); BP is 146/92; HR is 118/min. The patient is disoriented, tremulous & diaphoretic. She has abdominal cramps & diarrhea. Bilateral lower extremities have hyperreflexia & inducible ankle clonus. The patient is admitted to the hospital for supportive therapy but she remains disoriented with only limited improvement. Which of the following is the antidote for this patient's condition? A. Cyproheptadine B. Flumazenil C. Haloperidol D. Naloxone E. Propanol

D. Identify a place the patient can go in an emergency Health care providers must assess the immediate & future safety of all patients with intimate partner violence by helping create a safety plan. Pressuring the patient to report the abuse or to leave the partner should be avoided.

32-year-old woman comes to the office due to increased urinary frequency & burning. Medical history is unremarkable except for 2 previous UTIs & several old injuries, including a broken arm & dislocated shoulder. She lives with her boyfriend of 3 years. During the exam, the provider notices bruises on the patient's arms, abdomen & breasts. At first, she explains that she slopped & fell in the shoer. When asked how things are at home, the patient mentions that her boyfriend has a bad temper & that they argue frequently. She reluctantly discloses that he has hit her several times when intoxicated; the last time was 1 week ago. In addition to acknowledging the abuse & providing support, which of the following is the most appropriate nest step in management of this patient? A. Ask why the patient remains in the relationship B. Encourage the patient to leave her boyfriend C. Encourage the patient to press charges D. Identify a place the patient can go in an emergency E. Refer the patient for counseling

C. Panic disorder This patient's recurrent, spontaneous anxiety attacks & development of avoidance behavior are most consistent with panic disorder. Patients typically have fears about future attacks &/or maladaptive behavior related to the attacks. Some patients will develop agoraphobia, which is the avoidance of more than 2 situations in which escape or obtaining help may not be possible.

32-year-old woman is brought to the office by her husband due to his concern about her increasing social withdrawal. The patient prefers to stay at home. When she must run errands, she insists that her husband accompany her. She stopped working 2 years ago due to severe episodes of anxiety that would occur unpredictably for no apparent reason. Since that time, the patient has continued to have these episodes several times a week & has become more socially isolated due to fears of having another episode. She avoids seeing her friends except for when they come to her home. The patient feels badly that she is no longer working & contributing to the household finances. She has occasional difficulty falling asleep & problems with concentration. Although she is not looking for work, she keeps her home clean, cooks nightly & enjoys watching TV. Which of the following is the most likely cause of this patient's social withdrawal? A. Avoidant personality disorder B. Dependent personality disorder C. Panic disorder D. Persistent depressive disorder E. Social anxiety disorder

E. Tapper & d/c risperidone Tardive dyskinesia is characterized by abnormal involuntary movements of the face, lips, tongue, trunk or extremities that develop due to prolonged exposure to antipsychotic medication. If possible, the causative med should be tapered & d/c.

32-year-old woman with bipolar disorder comes to the office for follow-up. The patient was diagnosed & treated for a manic episode at age 29 & has been stable on a combo of Lithium & Risperidone. Her mood has been "fine" overall, but she has been "stressed" about work. After a staff meeting a few weeks ago, her supervisor said she appeared angry b/c she was repeatedly frowning while others were presenting. Physical exam is significant for occasional grimacing & slow inversion & tapping movements of her right foot. Lithium level is 0.9mEq/L (normal: 0.6-1.2). Which of the following is the best next step in management of this patient? A. add benztropine as needed B. Add daily propranolol C. d/c lithium & start valproic acid D. Maintain current regimen E. Taper & d/c risperidone

- Cognitive behavioral therapy

34 yr old man presents with cyclic episodes of nausea and vomiting that often resolve spontaneously within 48 hours. Physical exam reveals tachycardia, dry mouth, conjunctival injection, and delayed reaction time. Urine drug screen is positive for dela-9-tetrahydrocannabinol. Which of the following therapies is the most appropriate for this patient?

D. Regular CBC Clozapine is a highly effective antipsychotic w/ a low occurrence of extrapyramidal symptoms (tar dive dyskinesia, akathisia) & is reserved for the treatment of REFRACTORY SCHIZOPHRENIA & Schizoaffective disorder. ADE of Clozapine include neutropenia/agranulocytosis, which can result in increased risk for potentially fatal infections. Mandatory CBC is performed routinely for absolute neutrophil count. Must d/c Clozapine if neutropenia occurs. Other ADE include: seizures, myocarditis & metabolic syndrome.

34-year-old man comes to the clinic for follow-up of schizophrenia. The patient has had multiple trials of antipsychotic meds with minimal improvement & is no taking Aripiprazole (Abilify). Despite adherence to his med regimen, he has persistent psychotic symptoms. The patient has been unable to work, hears voices throughout the day & is too paranoid to attend group therapy. He has no other medical conditions. After a discussion of the risks & benefits, the patient agrees to a trial of Clozapine. Which of the following should be performed with use of this medication? A. Baseline & periodic liver function tests B. Baseline ECG & serum electrolytes C. Period Clozapine plasma levels D. Regular CBC E. Regular thyroid & kidney function tests

B. Delusional Disorder This patient's persistent false, fixed belief that he has parasites despite multiple negative tests is consistent with Delusional Disorder, somatic type. Patients have fixed delusions without prominent hallucinations or other symptoms of psychosis.

35-year-old man returns to the office for his third visit in 6 months b/c he is convinced that he is infected with parasites. He has gained 1.4kg (3lbs) since his last visit 2 months ago & he believes he became infected with a tapeworm while on a business trip to Asia 6 years ago. Since then he has seen multiple health care providers for this same concern, with no evidence of infection. He has had several negative stool exams that he claims are false. The patient spends hours researching parasitic disease. Physical exam is normal. The patient's mood is anxious & his affect is tense. He has no auditory hallucinations but describes a sensation of parasites crawling under his skin. What diagnosis is most likely? A. Body dysmorphic disorder B. Delusional Disorder C. Generalized Anxiety Disorder D. OCD E. Somatic Symptom Disorder

- Aripiprazole

4 yr old boy presents to the clinic with his father, who is concerned with his pattern of repetitive head banging. He reports that the patient prefers solitary play and exhibits excessive sporadic aggression and irritability. During exam, the patient avoids eye contact and demonstrates hand flapping motions. Which of the following agents is most appropriate?

B. Agoraphobia Panic disorder consists of recurrent & unexpected panic attacks characterized by an abrupt surge of anxiety & distressing cardiopulmonary/neurologic symptoms. Agoraphobia, a common comorbid disorder, results in anxiety & avoidance situations where patients may feel trapped & helpless in the event of a panic attack (crowds, enclosed spaces, public transportation).

40-year-old woman comes to the ED fearing she is having a heart attack. While clutching her chest & breathing heavily, she says, "I feel like I'm dying." BP is 125/86; HR is 110/min & regular. Lab eval & ECG show no abnormalities. The pain resolves within 10 mins without treatment & the patient reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there & able to help me get to the hospital. What if she's not there next time?" She describes experiencing similar episodes that are characterized by a pounding heart, trembling, dizziness & sweating. The patient most likely has which of the following additional disorders? A. Acute distress disorder B. Agoraphobia C. Brief psychotic disorder D. Dependent personality disorder E. Separation anxiety disorder

C. Dissociative amnesia

42-year-old man is brought to the ED after he was found wandering aimlessly at an airport. The man is alert & answers questions appropriately; however, he appears to be confused about his identity & does not recognize the name on his Nevada driver's license in his wallet. The patient is perplexed & does not remember where he lives, how he got to the airport, his family members or his profession. His cognitive function is otherwise intact. A search of his personal belongings reveal an airline ticket from Las Vegas to Arlington, Virginia. An emergency contact on the patient's phone leads to his wife in Nevada, who reports that her husband "just disappeared" after he found out that his father had passed away that morning. Which of the following is the most likely diagnosis? A. Acute stress disorder B. Depersonalization/derealization disorder C. Dissociative amnesia D. Dissociative identity disorder E. Transient global amnesia

D. Meth use disorder This patient's paranoid delusions, tactile hallucinations (bugs crawling on his skin), aggressive behavior, severe insomnia & physical findings of poor dentition, teeth grinding (bruxism) & skin sores are suggestive of chronic meth use disorder.

42-year-old man is brought to the ED by his wife after he assaulted her. The patient has not slept or eaten for days; he became agitated & started accusing her of plotting of murdering him. The patient also feels as though bugs are crawling under his skin. He had a prior psychiatric hospitalization 8 months ago when he was admitted for paranoid delusions & visual hallucinations. He is uncooperative, speaks rapidly & loudly, gets up to pace during the interview & shouts, "I don't trust any of you; you're in this together." Temp is 37.8C (100F); BP is 140/90; HR is 104/min; RR are 20/min. Exam shows a thing, diaphoretic man with poor grooming & dentition. He clenches his teeth, picks at his skin & has multiple sores on his face & body. Which of the following is the most likely diagnosis in this patient? A. Alcohol withdrawal B. Bipolar I disorder C. Delusional disorder, somatic type D. Meth use disorder E. Schizophrenia

D. Schizophrenia Schizophrenia is characterized by delusions, hallucinations, disorganized speech, disorganized or catatonic behavior & negative symptoms of > 6 months in duration. Diagnosis requires ruling out medical causes & substance-induced psychosis & differentiation from mood disorders with psychotic features.

42-year-old man is hospitalized after threatening to jump off a second-floor balcony. The patient says he was attempting to fly & is "prepared to accept death if that is God's plan for me." He also explains that the CIA implanted a chip in his neck & has been monitoring his movements for many years. The patient's first psychiatric hospitalization was at age 23. He started using marijuana 10 years ago. The patient's affect is flat & he makes poor eye contact, looking mostly at the floor. When asked about his mood, he respond, "Garbage in the east. Nobody feels well when worlds end; people go heavenly." He says he does not hear voices. Which of the following is the most likely diagnosis? A. Bipolar Disorder with psychotic features B. Delusional Disorder C. Major depression with psychotic features D. Schizophrenia E. Substance-induced psychotic disorder

C. Factitious disorder This disorder involves conscious & deceptive feigning or self-production of physical or psychological symptoms to obtain attention & medical care from health care personnel.

45-year-old woman comes in to the office with multiple sores & abscesses on her left arm. She is worried bc the sores have been present for the past month, have not healed & have required her to miss work. The patient has no idea how the sores developed & is concerned that they will spread. She is a nurse who is well known to the staff from a similar presentation 2 years ago. At that time, she had similar skin lesions, many of which were severely infected & did not respond to usual treatment. Fecal bacteria were found in one of the sores. On another occasion, the patient had a spreading infection & cellulitis that required a prolonged hospitalization & IV ABX. Which of the following is the most likely cause of this patient's condition? A. Borderline personality disorder B. Conversion disorder C. Factitious disorder D. Malingering E. Somatic symptom disorder

C. The patient is medically stable & may return to work

46-year-old truck driver comes to the office for a follow-up visit for alcohol, amphetamine & opioid addiction. The patient reports a reduction in substance use & cravings over the last 3 months with Naltrexone therapy & participation in AA meetings. He has been on a medical leave of absence from work to help him abstain from substance use & focus on recovery. The patient feels ready to return to work & brings a letter from employer asking when he can return to work. The patient has signed a release of information. Which of the following is the most appropriate response to the employer? A. Patient confidentiality prohibits me from providing info on this case B. The patient is able to return to work but random urine drug testing is recommended C. The patient is medically stable & may return to work D. The patient may return to work & should do well provided he takes medication E. The patient's addiction is in remission & he is able to return to work.

C. Huntington disease Huntington disease presents with psychiatric symptoms (depression, irritability), cognitive impairment & chorea (random, involuntary movements of the face). HD is an autosomal dominant CAG trinucleotide repeat expansion disorder with no known treatment.

47-year-old woman comes to the office due to a recent change in mood. The patient has been feeling depressed for the past 3 months & is more irritable than before. She also reports that she has had increasing difficulty planning & organizing her day & has been missing multiple work deadlines. The patient has no history of psychiatric illness. Her father died in his mid-60s, 10 years after developing similar symptoms. VS are normal. She scores a 24/30 on the Montreal Cognitive Assessment (normal > 27), losing points on tests of executive function. On exam, she demonstrates abrupt & random jerking movements throughout the extremities & face. EOM testing reveals delayed initiation of saccades (quick simultaneous movement of both eyes), but slit lamp exam is normal. Gait is normal. The patient is unable to maintain her grip on grip testing. Sensation is intact in the distal extremities. Which of the following is the most likely diagnosis? A. Depression-related cognitive impairment B. Frontotemporal dementia C. Huntington disease D. Parkinson disease E. Wilson disease

- Superficial interpersonal relationships

50 yr old man who is a successful attorney presents to the clinic for eval of anxiety. During his discussion with the psychiatrist, he discuss his sense of self-importance, fantasies of unlimited success & his need to be the center of attention. Which additional feature supports the most likely personality disorder?

B. D/c Fluoxetine & begin Bupropion Nonresponders to an adequate trial of a SSRI should be switched to another antidepressant. Bupropion, a NDRI that does not cause sexual side effects, is preferred in patients with SSRI-related dysfunction.

53-year-old man comes to the office due to persistent fatigue. The patient started a therapeutic dose of Fluoxetine 2 months ago after being diagnosed with major depressive disorder. He says, "I still feel like I'm fatigued every day & have to force myself to go to work in the mornings. I haven't even wanted to have sex with my wife. It has been going on for almost a month, and it's really bothering me." The patient has had a 4-kg (9-lb) weight gain over the past 2 months. Vital signs & physical exam are normal. He appears depressed & speaks softly throughout the interview. Which of the following is the best next step in management of this patient? A. Continue Fluoxetine & add Sidenafil B. D/c Fluoxetine & begin Bupropion C. D/c Fluoxetine & begin Mirtazapine D. D/c Fluoxetine & begin Venlafaxine E. Increase Fluoxetine dose

A. Aripiprazole Antipsychotic meds are equally efficacious but have different side effect profiles. The 2nd-generation antipsychotic meds cause fewer extrapyramidal side effects than 1st-generation antipsychotics but may be associated with weight gain & metabolic syndrome. Among the 2nd-generation antipsychotics, Aripiprazole has a lower potential to cause weight gain & metabolic effects & is a preferred drug for minimizing these issues.

53-year-old man has been prescribed Chlorpromazine for many years for schizophrenia. His psychotic symptoms have been stable, but he has developed a tremor in his hands & he walks slower. His other medial conditions include obesity & hypercholesterolemia. The patient has been trying to exercise & has managed to lose 5kg (11 lbs) since his last visit. He is concerned about his hands shaking & would like to lose more weight. BMI is 37kg/m2. The patient has psychomotor retardation, slow speech & lack of facial expressions. A resting tremor of the hands is noted. He would like to switch to another medication. Which of the following meds would be most important for this patient? A. Aripiprazole B. Clozapine C. Haloperidol D. Lamotrigine E. Olanzapine

C. Major depressive disorder Anxiety is often a presenting symptom in patients suffering from major depressive disorder (MDD). MDD should be suspected in anxious individuals who have prominent mood symptoms & no previous history of anxiety.

54-year-old woman comes to the office due to anxiety, insomnia & muscle tension. The patient reports feeling depressed & overwhelmed by multiple stressors in her life, including her father's death a year ago & a high-pressure job. For the past 2 months, she reports frequent tension headaches, neck pain, fatigue & difficulty concentrating at work. At night she lies in bed worrying & has difficulty both falling & staying asleep. The patient has avoided socializing with her friends & says, "I just feel too down. Every time I am around them, I feel they must know I'm a failure." She has lost 5lbs & has lost interest in cooking & exercising. The patient has no prior psychiatric history. Physical exam & lab eval are unremarkable. The patient bursts into tears when speaking about her father. Which of the following is the most likely diagnosis? A. Adjustment disorder B. Generalized anxiety disorder C. Major depressive disorder D. Normal grief E. Social anxiety disorder

E. Serotonin Syndrome Combined use of SSRIs & MOAIs can lead to serotonin syndrome, a potentially lethal condition characterized by fever, mental status changes, clonus & hyperreflexia.

59-year-old woman is brought to the ED by her son, who found her confused, shaking, sweating profusely & unsteady on her feet. The patient has seasonal allergies, depression & anxiety. 2 weeks ago, Fluoxetine was d/c due to minimal improvement in her symptoms of depression; she was started on Phenelzine a few days ago. Her pulse is 116/min & RR are 24/min. The patient is orient to person & place but not time. She is agitated, diaphoretic & tremulous. Mucous membranes are dry. Abdominal exam shows increased bowel sounds, DTRs are increased. There is some muscular rigidity in the lower extremities. Which of the following is the most likely diagnosis? A. Anticholinergic toxicity B. Benzo withdrawal C. Fluoxetine withdrawal D. Neuroleptic malignant syndrome E. Serotonin syndrome

D. Persistent complex bereavement disorder This is characterized by prolonged grief, difficulty accepting the death persistent yearning for the deceased, & maladaptive ruminative thoughts & behaviors. Psychotherapy is the treatment of choice.

62-year-old woman comes to the office accompanied by her daughter, who is concerned that her mother is depressed. The patient has become more withdrawn & socially isolated after her husband's unexpected death from a heart attack 2 years ago. She still misses her husband terribly & thinks about him constantly. The patient says, "I can't believe he is gone." She feels guilty that she did not recognize his heart condition & blames herself form not insisting that he get medical care earlier. The patient does not have sleep or appetite disturbance but sleeps on the couch bc she cannot bear to lie in the bed that she & her husband shared. She has stopped playing golf & attending concerts (activities that they had enjoyed together). The patient has no suicidal ideation. She continues to work at her part-time job & help her daughter with the grandchildren. Which of the following is the most likely diagnosis in this patient? A. Dependent personality disorder B. Major depressive disorder C. Normal grief D. Persistent complex bereavement disorder E. PTSD

E. Preparation

63-year-old man comes to the office for a follow-up exam of HTN. At his last appointment, he revealed that he had increased his intake of 12-oz cans of beer from 3 to 6 cans a day due to stress at work. The patient was advise on his last visit to seek help for his alcohol use bc it could be causing his elevated BP & has many other negative health risks. Today, the patient states, "I thought about what you said. I know my alcohol use has gotten out of hand & is affecting my health. My wife & daughter also say that I need to stop drinking. I have decided to look into treatment to get some help." Which of the following best describes this patient's stage of behavioral change? A. Action B. Contemplation C. Maintenance D. Precontemplation E. Preparation

B. Escitalopram Depression-related cognitive impairment may be so severe in elderly patients that they appear to have dementia. Psychotherapy &/or antidepressant meds are the treatment of choice for elderly patients with depression & frequently result in reversal of cognitive deficits.

65-year-old woman comes to the office due to deteriorating memory. She used to pride herself on her sharp memory, but over the past 6 months, has been forgetting minor things. The patient has had to delegate household chores & cooking to her husband bc of her poor memory & "cloudy thinking." "I have been feeling useless & worthless since retiring last year." The patient used to garden every day, but now spends her days watching TV & barely has enough energy to eat. She's lost 5kg (11lb) over the last 2 months. On testing with the Montreal Cognitive Assessment, she scores 24/30 (normal >26) with deficits in delayed recall & attention. Lab results & MRI of the head are unremarkable. Which of the following is the best next step in management? A. Donepezil B. Escitalopram C. Memantine D. Memory training & Vitamin E E. Reassure that this age-related memory change

E. Reduce Carbidopa-Levadopa This patient's new onset of visual hallucinations is most likely related to Parkinson disease. Psychosis in Parkinson's is common & may be due to underlying disease process, medication or a combo of the two. The most common anti-Parkinson med classes associated with psychosis are dopamine precursors (Levodopa) & dopamine agonists (Pramipexole). The first step in management of psychosis in Parkinson's disease includes reviewing the patient's meds & considering a cautious dose reduction. Patients who do not improve with a reduction or who cannot tolerate a dose reduction due to resurgent motor symptoms can be treated with a low-potency, 2nd generation antipsychotic (Quetiapine).

72-year-old man is brought to the office due to visual disturbances that are causing significant distress. The patient describes seeing prowlers in the bushes outside of his windows at night that disappear when he moves in for a closer look. His daughter could not see these people. The patient has Parkinson's disease, for which he takes Carbidopa-Levodopa, & generalized anxiety disorder for which he takes Sertraline. Vital signs are normal. The patient is alert & oriented. He has a mild resting tremor & minimal rigidity. Movements are slightly slowed. Which of the following is the best next step in management of this patient's visual disturbances? A. Add Benztropine B. Add Pramipexole C. Increase Carbidopa-Levodopa D. Increase Sertraline E. Reduce Carbidopa-Levodopa

D. Rivastigmine Cholinesterase inhibitors such as Donepezil, Rivastigmine & Galantamine may provide symptomatic relief of cognitive symptoms & temporarily improve functioning of Alzheimer Disease. Key features of Alzheimer Disease: - dementia (m/c) - insidious onset (typically > 65) - early impairment of memory for recent events - executive dysfunction - visuospatial deficits (getting lost) - later language & behavioral changes - generalized cerebral atrophy on imaging Dementia: diagnosed in patients with progressive cognitive decline that impairs activities of daily living (bathing, dressing). Alzheimer Disease is the most common subtype of Dementia.

74-year-old woman is brought to the office by her daughter due to increasing forgetfulness & behavioral changes. Her daughter has noticed increasing forgetfulness over the past 3 years. Over the past year, the patient has stopped doing the daily crossword, has had difficulty remembering to eat & clean herself, & has occasionally failed to recognize her grandchildren. Over the past month, the patient has become more withdrawn. She no longer watches her favorite television shows & seems less interested in her family. Montreal Cognitive Assessment is 22/30 (normal > 26). Serum TSH, CBC, Vitamin B12 levels are all normal. MRI of brain shows age-appropriate cerebral atrophy. Which of the following is the best next step in management of this patient? A. Amantadine B. Fluoxetine C. Reassurance & follow-up only D. Rivastigmine E. Selegiline

C. Haloperidol Delirium is an acute-onset "confused state" & may manifest as acute changes in cognition & behavior (waxing & waning; impaired attention, disorientation, agitation, psychosis & sleep disturbance). Delirium occurs secondary to an underlying medical condition (UTI) therefore primary management is treating the underlying cause. The elderly & those with preexisting cognitive disorders at a higher risk for delirium & present with varying degrees of agitation. When non pharmacological interventions are ineffective, low-dose antipsychotics (Haloperidol) are the meds of choice to treat the behavioral (severe agitation) & psychotic manifestations of delirium.

83-year-old woman is sent to the ED from her nursing home for eval of mental status changes. At baseline, she has mild memory impairment but is otherwise cognitively intact, calm & cooperative. Over the past 24 hours, she has become increasingly combative & agitated & stayed up all night. Temp is 37.2C (99F), BP is 110/80, HR is 84/min, RR are 18/min. Neuro exam is normal but the patient is mildly disoriented. Without provocation, she strikes out at a nurse's aide standing next to her. UA is positive for nitrites & leukocyte esterase. Head CT is negative. In addition to starting ABXs, which of the following meds is the most appropriate to treat this patient's behavioral symptoms? A. Clozapine B. Doxepin C. Haloperidol D. Lithium E. Lorazepam

C. Obtain an emergent psychiatric assessment In children & adolescents with depression, considerations for inpatient treatment include suicidal ideation, poor psychosocial support & lack of psychiatric follow-up. Any child who has possible thoughts of suicide must undergo emergency assessments for safety. Suicide Assessment- Ideation: - wish to die, not wake up (passive) - thoughts of killing self (active) - frequency, duration, intensity, controllability Intent: - strength of intent to attempt suicide; ability to control impulsivity - determine how close patient has come to acting on a plan (rehearsal, aborted attempts) Plan: - specific details: method, time, place, access to means (weapons, pills), preparations (gathering pills, changing will) - lethality of method - likelihood of rescue

9-year-old girl is brought to the office by her mother for assessment of "bad stomach aches." The patient has missed 5 days of school in the past few weeks due to intermittent abdominal pain that is "achy all over" & worse in the morning. The girl used to be talkative & outgoing, but now does not visit with her friends & instead takes naps after school. The patient has been distracted in class lately & less engaged in group activities. Her father lost his job 3 months ago & has been home more often since then. When interviewed, the patient is withdrawn & makes poor contact. When asked if she feels depressed, she says, "Everything will be better soon since no one will have to take care of me anymore." She avoids answering further questions. Which of the following is the best next step in the management of this patient? A. Arrange for an in-home social work assessment B. Contact the patient's school for further information C. Obtain an emergent psychiatric assessment D. Recommend antidepressant treatment E. Recommend family therapy

A. Avoidant personality disorder Patients with APD typically limit their social relationships due to fears of being judged, embarrassed or rejected. They struggle with feelings of inadequacy & pursue relationships only when they feel assured of uncritical acceptance. Occupationally dysfunction due to difficulties interacting with coworkers or turning down promotions due to fear of criticism is common.

A woman brings her 19-year-old daughter to the office due to concerns that she is hypersensitive, depressed & socially isolated. The mother worries that her daughter is typically withdrawn, has few close friends & does not date. The girls is also moody & tends to overreact to the slightest criticism. The patient describes her mood as "unhappy" but has had no change in sleep or appetite. She works as a filling clerk & recently turned down a higher-paying job bc she prefers to work alone. When questioned about her social isolation she says, "Who would want to be friends with someone ugly & stupid like me anyway?" Which of the following is the most likely explanation for this patient's behavior? A. Avoidant personality disorder B. Borderline personality disorder C. Dependent personality disorder D. Persistent depressive disorder (Dysthymia) E. Schizoid personality disorder