Dr. Rozsa Andras Kenya

Q&A

Case Histories and Explanations

Questions 1 and 2

A29-year-old man with a history of bipolar disorder presents to the psychiatric emergency department saying that he is the king of “Pumbar” and needs everyone’s allegiance for the upcoming war with the Martians. In the past few days, he has slept a total of 3 hours but says that he is not tired. He has spent all of his money. Now, he is agitated, demanding, and threatening.

1. What is the best treatment for this patient in the acute setting?

(A) hydroxyzine (Atarax)

(B) lithium

(D) haloperidol (Haldol)

(E) carbamazepine (Tegretol)

2. After treating the patient acutely, a medication is needed to control his bipolar disorder. You find that he has a history of agranulocytosis. Which of the following is the best choice for a mood stabilizer?

(A) lithium

(B) carbamazepine

(D) antipsychotic medication

(E) lorazepam (Ativan)

Answers

1. (D) Antipsychotics are indicated for acute treatment of agitation and violence sometimes seen in manic patients. Haloperidol works quickly doses (20–30 minutes). Doses of 2–5 mg by mouth (PO) or intramuscularly (IM) are usual initial. It may be given IV as well, especially in the intensive care unit (ICU). Hydroxyzine is an antihistamine; it is not effective in mania. Lithium, divalproex sodium, and carbamazepine have all been shown to control mood fluctuations in manic patients. However, these agents take days to work and are not effective in the acute management of this patient.

2. (A) Lithium is not associated with significant blood dyscrasias, although it can cause a modest benign increase in the white blood cell (WBC) count. Carbamazepine is commonly associated with reduced WBC count, but the incidence of agranulocytosis is approximately 1 in 10,000. Agranulocytosis is a rare complication with divalproex sodium, a bit more common is benign thrombocytopenia. Antipsychotic medication is occasionally associated with a decrease in leukopoiesis, but the WBC count usually returns to normal with continued treatment. Agranulocytosis can also occur in the setting of antipsychotic medication use in approximately 1 in 10,000 cases (clozapine has a higher incidence). Lorazepam is not associated with WBC abnormalities.

Questions 3 and 4

A 44-year-old woman presents to her primary care doctor with multiple complaints, including weakness in her lower extremities, bloating, headaches, intermittent loss of appetite, and back pain. A careful review of symptoms reveals many other vague symptoms. Her complaints date back to adolescence and she has seen many doctors. Thorough workups, including an exploratory laparotomy, have failed to uncover any clear, organic cause.

3. What is the best approach to this patient?

(A) Tell her any physical workup is unnecessary.

(B) Tell her to come back in 1 month and, if the symptoms are still present, you will initiate a physical workup.

(D) Assess her for other psychiatric illnesses.

(E) Initiate a physical workup and arrange for follow-up in a year’s time.

4. Which statement regarding this patient’s diagnosis is correct?

(A) It has a good prognosis.

(B) It is most common in high socioeconomic groups.

(D) Conversion symptoms are uncommon.

(E) Regularly scheduled, frequent visits with a primary care doctor will exacerbate symptoms.

Answers

3. (D) This patient is most likely suffering from somatization disorder, which often coexists

with other psychiatric illnesses such as anxiety, depressive, and personality disorders. The suspected presence of a somatization disorder should prompt a search for other treatable illnesses. In managing patients with somatization disorder, it is important to accept that symptoms are not consciously produced and to let patients know that you realize their symptoms are a source of great consternation. Regardless of history, any patient presenting to a physician with physical complaints deserves a reasonable physical investigation; patients with somatization disorder are as likely, if not more likely, to develop identifiable medical

conditions. However, rather than repeat tests, it may be necessary to contact previous treaters.

Sending this patient away for a year would not be helpful; rather regular, frequent checkups and fostering a therapeutic alliance and support are in order.

4. (C) Women are as much as 20 times more likely to receive the diagnosis of somatization disorder than are men. Rarely will any therapy or intervention “cure” the patient of somatization disorder; at best, patients learn to minimize the impact somatization has on their lives. Somatization disorder is common in lower socioeconomic groups. Conversion symptoms are common in somatization disorder and are included in the diagnostic criteria. Patients with this disorder benefit from regular, scheduled visits that allow them to forge a trusting therapeutic alliance.

Questions 5 and 6

A 25-year-old man is a concern to his neighbors. He dresses in odd, outdated clothes; seems to utter his own language; and although he tends to keep to himself, he has told neighborhood children that witches who live down the road have it in for him.

5. Which of the following statements about the personality disorder from which this patient is most likely suffering is true?

(A) Auditory hallucinations are common.

(B) Visual hallucinations are common.

(D) This diagnosis is found overwhelmingly in men.

(E) Onset of symptoms is usually in the second or third decade of life.

6. The patient’s brother brings him to a doctor after the death of their mother. Since then, the patient’s paranoia has caused him to question his neighbors’ activities. He moved into a hotel he could not afford to get away from the “spies” living next to him. What is an appropriate intervention?

(A) no treatment

(B) psychoanalysis

(D) a neuroleptic

(E) a selective serotonin reuptake inhibitor (SSRI)

Answers

5. (C) This patient is most likely suffering from schizotypal personal disorder. This personality disorder with its attendant social isolation and subtle distortions of reality may indeed resemble schizophrenia in remission; the diagnosis can be sorted out by a thorough history. Frank hallucinations of any type are uncommon; only subtle distortion of environmental cues is seen. Although men may be slightly more at risk for being diagnosed with schizotypal personality disorder, the disparity is not stark. As with any personality disorder, schizotypal personality disorder represents a lifelong maladaptive

approach to life and does not suddenly express itself well into adulthood.

6. (D) In schizotypal personality disorder, the subtle disconnection from reality, which may be exacerbated in times of stress as in this case, can be treated with low doses of neuroleptics. These patients lack the capability, stable sense of self, and trust to be able to engage in, or benefit from, psychoanalysis. Antidepressant medication of any type, including tricyclics and SSRIs, are helpful in the schizotypal patient who displays significant affective (mood) symptoms, which is not seen in this case. There is no evidence of anxiety that would make benzodiazepines useful.

Questions 7 and 8

A 25-year-old female college graduate is brought to her doctor by her mother. Described as “odd” since she lost her job a year ago, the patient has complained of hearing voices and believes that her body is a receiving antenna for a foreign spy operation. Her mother notes she has been isolating herself in her room. She is alert and oriented but suspicious and guarded on examination. Her affect is flat and her speech reveals loose associations. A complete medical workup is negative.

7. Which of the following symptoms is considered a “negative symptom” with regard to her illness?

(A) auditory hallucinations

(B) delusions

(D) flat affect

(E) loose associations

8. The patient is started on medication and many of her symptoms improve. She begins a new job and does well. One year later, she is brought to her doctor floridly psychotic, actively hearing voices, and extremely paranoid. She thinks her boss is trying to kill her. She has an upper respiratory viral illness that she believes to be the work of a foreign government. She discontinued her medication 4 weeks ago because she felt too sedated. In the past year, her cigarette smoking habit has decreased to one pack per day. What is the most likely cause of her exacerbation?

(A) stress from work

(B) a reaction to the viral illness

(D) medication side effects

(E) decreased cigarette smoking

Answers

7. (D) This patient is most likely suffering from schizophrenia. Symptoms of schizophrenia are commonly divided into positive and negative symptoms. Flat affect, a negative symptom, represents an absence, in this case, of a normally reactive and variable affect. Auditory hallucinations, delusions (including paranoid delusions), and loose associations are all positive symptoms.

8. (C) The exacerbation seen is most likely precipitated by medication noncompliance. Stress

from work or a viral illness may indeed contribute to a relapse, but they are less strongly predictive of a reemergence of psychotic symptoms than medication noncompliance. Nicotine has been shown to lower neuroleptic levels, which has been offered as a reason cigarette smoking is rampant among patients with schizophrenia. However, this patient’s smoking decreased, which if anything would be expected to increase neuroleptic levels.

Questions 9 and 10

A 44-year-old man complains to his doctor that he is always tired and is having difficulty getting out of bed in the morning. Upon questioning, he reveals he has three or four drinks each night and perhaps more on the weekends, but denies he has any problem with alcohol.

9. A diagnosis of alcohol dependence is made and the patient comes to your office in acute alcohol withdrawal. He has a withdrawal seizure. What might be found on laboratory investigation?

(A) thrombocytosis

(B) elevated or depressed liver enzymes

(D) hypermagnesemia

(E) a high blood alcohol level

10. Which of the following statements regarding this patient is true?

(A) Cerebellar degeneration is uncommon.

(B) He is at risk for developing a peripheral neuropathy.

(D) He is at decreased or normal risk for heart disease.

(E) Immune function should remain relatively intact.

Answers

9. (B) Classically, patients with hepatitis secondary to alcohol abuse or dependence have elevated liver enzymes (such as gamma-glutamyl transpeptidase, aspartate transaminase, or alanine transaminase). However, in advanced alcoholism, the liver may be “burnt out” and liver function tests may reveal low or normal levels of these enzymes. As a result of liver damage, prothrombin time is typically increased. Hypomagnesemia, not hypermagnesemia, is more likely to be found in alcoholism, usually as a result of dietary deficiency. In the patient having a withdrawal seizure, the problem is absence, not presence, of alcohol. His blood alcohol is expected to be zero. The alcoholic is more likely to have thrombocytopenia than thrombocytosis.

10. (B) As a result of vitamin deficiencies and the direct insult alcohol exacts on the nerve function, peripheral neuropathy can be seen in 10% of heavy drinkers. Another important nervous system effect of alcohol and its metabolites is cerebellar degeneration, which can be suggested by an unsteady gait and nystagmus. Alcoholic fatty liver—a swollen liver resulting from the deposition of fats and proteins in the hepatocytes—reverses with abstinence from alcohol. Although there is some evidence that a glass of wine each day may impart some protective cardiac effects, heavy drinking is certainly destructive to the cardiovascular system. It raises the blood pressure and levels of triglycerides,

thereby increasing the risk of myocardial infarction. Heavy drinking also lowers WBC count and interferes with many specific aspects of the immune system; for example, it compromises T-cell function.

Questions 11 and 12

11. During an examination to evaluate muscle rigidity, a male patient is somewhat resistant to

movement of his arms but maintains the arm in the position in which you place it. This is an example of which of the following?

(A) catalepsy

(B) cataplexy

(D) dystonia

(E) malingering

12. A67-year-old woman with a history of depression presents to your office for evaluation. Her symptoms of poor appetite, insomnia, and feelings of hopelessness have worsened recently. She has been on SSRIs, which you learn have failed in several previous trials. She has not tried a tricyclic antidepressant (TCA). The pharmacology of TCAs involves which of the following?

(A) 5-hydroxytryptamine-2a (5-HT2a) antagonism

(B) 5-HT2a agonism

(D) inhibition of norepinephrine and serotonin reuptake

(E) inhibition of dopamine reuptake

Answers

11. (A) Catalepsy is a general term for the assumption of an immobile position that is constantly maintained, especially after an examination. Cataplexy is a sudden and brief loss of muscle tone involving either a few muscle groups or most of the antigravity muscles of the body. Dystonia is a stiffening of muscle groups sometimes seen after administration of typical neuroleptics. The patient does not seem to have a secondary gain for his symptoms making malingering unlikely.

12. (D) TCAs inhibit reuptake of norepinephrine and serotonin to varying degrees. Structurally, they can be divided into tertiary amines (amitriptyline, clomipramine, doxepin, imipramine, and trimipramine) and secondary amines (desipramine, nortriptyline, and protriptyline). Tertiary amines tend to inhibit reuptake of serotonin to a greater degree than

norepinephrine, and secondary amines primarily inhibit reuptake of norepinephrine. Bupropion is an antidepressant that inhibits both norepinephrine and dopamine reuptake.

Questions 13 and 14

A 29-year-old woman presents to the emergency department with her 3-year-old child reporting that the child suffered a seizure while at home. Hospital records verify that this is the third emergency department visit in as many weeks for the same presentation.

Neurologic workup for seizure disorder was negative. Initiation of an anticonvulsant has been ineffective.

13. Which of the following statements is likely to be true?

(A) The child suffers from a conversion disorder.

(B) The child is experiencing separation anxiety.

(D) The child does not have a therapeutic level of anticonvulsant.

(E) The child suffers from a seizure disorder.

14. The mother is most likely to suffer from which of the following?

(A) schizophrenia

(B) bipolar disorder

(D) epilepsy

(E) posttraumatic stress disorder (PTSD)

Answers

13. (C) This scenario represents a case of Munchausen syndrome by proxy, in which one person feigns illness in another to vicariously gain medical attention. Commonly, the victim is a child and the perpetrator is the child’s mother. Apparent bleeding, seizures, and central nervous system (CNS) depression are typical presentations. The disorder is underdiagnosed and typically takes more than a year to diagnose due both to the elusive and crafty planning of the perpetrator and the unwillingness of health-care providers to accuse the ostensibly caring parent. Conversion disorder is characterized by the presence of one or more neurologic symptoms that are left unexplained by a known medical or neurologic disorder. It is associated with such comorbid psychiatric disorders as MDD, anxiety disorder, or schizophrenia, and adolescents and young adults suffer from this disorder most commonly.

Paralysis, blindness, and mutism are the most common conversion disorder symptoms. The diagnosis requires the association of psychological factors to the initiation and exacerbation of conversion symptoms. In this case, there are no data to support this diagnosis.

14. (C) The mental status of the mother has been described as depressed, anxious, and suicidal. Borderline and histrionic personality disorders are the most common Axis II diagnoses associated with Munchausen syndrome by proxy and most sufferers demonstrate a dissociation of affect. Schizophrenia has been reported in only a few cases. Of the choices listed, depression is the most likely; bipolar disorder and PTSD have not been clearly described in the literature. Epilepsy is not associated with the disorder to

any significant extent.

Questions 15 and 16

A26-year-old man is being evaluated in the emergency department for sudden onset of chest pressure and dyspnea. This is his third emergency department visit for similar symptoms for which he reports “I feel like I’m going to die.” An electrocardiogram (ECG) and stress test were normal. The patient denies risk factors for heart disease and does not have a family history of heart disease. Urine toxicology was negative.

15. Which of the following is the most likely diagnosis?

(A) delirium

(B) panic disorder

(D) acute myocardial infarction

(E) hypochondriasis

16. Which of the following medications is most useful in the initial treatment of this disorder?

(A) sertraline (Zoloft)

(B) propranolol

(D) haloperidol

(E) lithium

Answers

15. (B) Panic disorder is characterized by the sudden unexpected occurrence of panic attacks and periods of intense anxiety or fear accompanied by somatic symptoms, commonly causing the misdiagnosis of a medical illness such as myocardial infarction. The frequency of panic attacks varies widely from many per day to a few per year. Panic disorder is often associated with agoraphobia, the fear of being alone in public places. The lifetime prevalence is up to 3%. Concerns of death from cardiac or respiratory disorders occur frequently. Delirium is

characterized by the sudden onset of a disturbance of consciousness with cognitive changes caused by a general medical condition. Acute stress disorder is diagnosed in individuals who have experienced a traumatic event and subsequently develop symptoms within 4 weeks of the event that remit after 1 month. The traumatic event must be reexperienced by the patient, and this causes the patient to avoid stimuli that arouse recollections of the trauma.

Other criteria necessary for the diagnosis are the presence of dissociative symptoms and marked anxiety or increased arousal not better accounted for by other medical or psychiatric illnesses.

16. (A) Tricyclic and tetracyclic medications, MAOIs, SSRIs, and the benzodiazepines are effective in the treatment of panic disorder. Beta-adrenergic drugs like propranolol are not effective for the treatment of panic disorder. Haloperidol, an antipsychotic agent; lithium, a mood stabilizer; and clonidine, an alpha-2-adrenergic agonist, are ineffective. Of the choices listed, sertraline, an SSRI, is most effective.

Questions 17

17. A woman being treated for major depression is brought to the emergency department after being found unconscious by a neighbor. The neighbor said that over the past few days the woman had been complaining of severe headaches. She also said the woman enjoys red wine. The woman’s blood pressure is recorded as 220/110 mm Hg. This emergency is best managed by intravenous (IV) administration of which of the following?

(A) an alpha-blocking agent

(B) a beta-blocker

(D) bromocriptine (Parlodel)

(E) a calcium channel blocker

Answer

17. (A) Hypertensive crisis is a potentially lifethreatening complication that occurs when patients taking an MAOI eat tyramine-containing foods such as wine, beer, pickled foods, and aged cheese. Clinical features include hypertension, severe occipital headache, stiff neck, nausea, vomiting, and sweating. IV phentolamine, an alpha-adrenergic receptor-blocking drug, is given to control hypertension. It has been shown to be more effective than betablockers or calcium channel blockers. Admission to an ICU and supportive measures are indicated. Although muscle rigidity can occur, the use of dantrolene, a muscle relaxant, is not indicated.

Questions 18 and 19

A 28-year-old man recently began taking clozapine Clozaril) to treat symptoms of schizophrenia. He does not suffer from any medical illness.

18. Which of the following adverse effects is associated with this medication?

(A) bradycardia

(B) hypertension

(D) galactorrhea

(E) seizures

19. Which of the following hematologic disorders associated with this medication can be lifethreatening?

(A) a decreased granulocyte count

(B) leukocytosis

(D) pancytopenia

(E) microcytic anemia

Answers

18. (E) Clozapine is an effective antipsychotic medication that has been associated with fewer extrapyramidal side effects than the conventional antipsychotics (which primarily act by blocking dopamine type 2 receptors). About 5% of patients taking more than 600 mg/day of clozapine experience clozapine-associated seizures. Tachycardia, hypotension, sedation, fatigue, and weight gain have all been associated with clozapine treatment. Clozapine, unlike the conventional antipsychotic agents, does not affect prolactin secretion and thusdoes not cause galactorrhea.

19. (A) Agranulocytosis is a potentially lifethreatening side effect of clozapine treatment.

It is defined as a decrease in the number of WBCs, with a specific decrease in the number of neutrophil granulocytes. It occurs in 1–2% of all patients treated with clozapine. The other choices are bone marrow disorders that are not associated with clozapine.

Question 20 and 21

20. A 35-year-old patient exhibits odd beliefs and thinking, paranoid behavior, and has no close friends. Which of the following diagnoses is the most appropriate to consider?

(A) schizoid personality disorder

(B) avoidant personality disorder

(D) narcissistic personality disorder

(E) schizotypal personality disorder

21. A 28-year-old woman demonstrates a pervasive pattern of unstable relationships, poor self image, impulsiveness, and irritability. Which of the following is the most appropriate diagnosis to consider?

(A) histrionic personality disorder

(B) borderline personality disorder

(D) dependent personality disorder

(E) schizoid personality disorder

Answers

20. (E) Schizotypal personality disorder is characterized by a pervasive pattern of social and interpersonal deficits. Individuals demonstrate a reduced capacity to establish any close relationships, and eccentric behavior is present. The presence of odd beliefs or magical thinking separates schizotypal personality disorder from schizoid personality disorder. Paranoid ideation is common in both schizotypal and paranoid personality disorders but not in the others. Schizoid personality disorder represents a pervasive pattern of detachment from social relationships and a restricted range of expressed emotions. Avoidant personality disorder represents a pervasive pattern of behavior characterized by social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Narcissistic personality disorder represents a pervasive pattern of grandiosity, lack of empathy, and a need for admiration.

21. (B) Borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, affect, and marked impulsivity. Antisocial personality disorder describes individuals with long histories of disregard for the rights of others and often dishonesty used in attempts to gain something for themselves. Patients with histrionic personality disorder, like those with borderline personality disorder, may display excessive emotionality and attentionseeking behavior, but their core symptoms center around superficial seductiveness and theatricality. Those with dependent personality disorder require an excessive amount of advice, reassurance, and approval from others. Schizoid personality disorder represents a pervasive pattern of detachment from social relationships and a restricted range of expressed emotions.

Questions 22 and 23

A 30-year-old woman is brought to the emergency department by the police after being arrested for breach of the peace. The woman was observed acting irrationally at a local business where she demanded to speak with the president of the company claiming that she had new ideas for product development. The patient reports that she has not slept for days and that her mood is “fabulous.” Urine human chorionic gonadotropin is positive. Illicit substances were not detected.

22. Which of the following is most likely to be present on Mental Status Examination (MSE)?

(A) racing thoughts

(B) depressed mood

(D) daytime sleepiness

(E) weight loss

23. Which of the following medical disorders can present with similar symptoms?

(A) hyperglycemia

(B) thyroid disorder

(D) diabetes mellitus

(E) cirrhosis

Answers

22. (A) This patient is most likely suffering from bipolar I disorder. Racing thoughts, pressured speech, expansive mood, a decreased need for sleep, and an increase in goal-directed activity are all common manifestations of mania. The patient is usually energized during the day even after only a few hours of sleep. Weight loss and depressed mood are characteristic of a depressive disorder. Auditory hallucinations may be present in severe cases of mania but are usually a symptom of a psychotic disorder such as schizophrenia.

23. (B) Many disorders can mimic symptoms of mania. A complete history, physical examination, and routine laboratory tests can sufficiently rule out most medical causes of mania. They include endocrine disorders such as thyrotoxicosis and Cushing disease, hypoglycemia, electrolyte disorders, substance abuse and withdrawal, medications such as steroids and anticholinergic agents, nutritional deficiencies, and CNS insults.

Questions 24 and 25

A24-year-old man with a history of seizure disorder and polysubstance abuse has been incarcerated for assaultive behavior. The patient is evaluated by a neurologist, who prescribes phenytoin (Dilantin).

24. Which of the following conditions is associated with this medication?

(A) leukocytosis

(B) hypertension

(D) hepatic failure

(E) Ebstein anomaly

25. The patient returns 1 month later for a follow-up examination and reports that he experienced a generalized seizure. Laboratory investigation reveals that the phenytoin level is 6.5 mg/dL (normal, 10–20 mg/dL). Which of the following is the most appropriate intervention at this time?

(A) Increase the phenytoin dose to achieve a therapeutic level.

(B) Discontinue phenytoin and begin divalproex sodium.

(D) Ask the patient about compliance with medications.

(E) Add phenobarbital.

Answers

24. (C) Gingival hyperplasia is associated with administration of phenytoin. Other, doserelated symptoms include nystagmus, dizziness, slurred speech, ataxia, mental confusion, and decreased coordination. Hepatic failure is associated with divalproex sodium, and Ebstein anomaly is associated with lithium therapy.

25. (D) Before any pharmacologic changes are considered, the physician must assess compliance with medications. The subtherapeutic phenytoin level may be due to patient noncompliance, especially if side effects are being experienced.

Questions 26 and 27

26. A 24-year-old woman with a history of schizophrenia tells you that she would like to become pregnant. What is the chance for familial transmission of schizophrenia?

(A) 0.1%

(B) 1%

(D) 5%

(E) 10%

27. A 70-year-old man with a history of major depression is brought to the emergency department by his family, who is concerned because he was found wandering in the streets near his home. During the MSE, attention is best assessed by asking the patient to do which of the following?

(A) perform serial-sevens subtraction

(B) recite his ID number

(D) perform digit recall

(E) repeat the examiner’s first name

Answers

26. (E) The risk of schizophrenia among firstdegree relatives of patients with the disease

may be as high as 10%, compared with a 1% risk in the general population.

27. (D) Attention is the ability to focus one’s perception on an outside or inside stimulus. A simple test of attention is digit recall. Most people can recall a 7-digit number forward and 5–7 digits in reverse. Concentration refers to sustained attention to an internal thought process. The serialsevens examination, in which the examiner asks the patient to subtract 7 from 100 and continue the subtraction process for as many calculations as possible, is a good test of concentration. Another test of concentration is to have the patient spell a five-letter word forward and backward. Asking the patient to recall the examiner’s name is an example of recent memory, and asking him to recall his ID number is a test of remote memory.

Question 28 and 29

28. An 18-year-old patient experiences a sudden onset of euphoria, grandiose delusions, a decreased need for sleep, and paranoia. Which of the following conditions is most associated with these symptoms?

(A) schizophrenia, paranoid type

(B) cannabis intoxication

(D) schizoaffective disorder

(E) cocaine intoxication

29. A Malayan man experiences a dissociative episode characterized by an outburst of homicidal behavior toward his friend, whom he believed was insulting his appearance. Which of the following conditions is most associated with this presentation?

(A) substance intoxication

(B) dissociative identity disorder

(D) factitious disorder

(E) culture-bound syndrome

Answers

28. (E) Cocaine intoxication can appear like a manic episode associated with bipolar I disorder with an increase in energy, euphoria, grandiosity, and impaired judgment. The acute onset of symptoms makes the diagnosis of major depression unlikely. A diagnosis of schizophrenia requires the presence of symptoms during a significant portion of the previous month, which is not evident. In this case, the patient experiences a sudden onset of euphoria that is not characteristic of schizophrenia. Negative symptoms (e.g., flattened affect, avolition, alogia) are more common in schizophrenia. The diagnosis of schizoaffective disorder requires that during the period of illness there are symptoms that suggest a diagnosis of both schizophrenia and a mood disorder (major depressive episode, manic episode, or a mixed episode). Cannabis intoxication can present with euphoria, paranoia, and impaired judgment in association with physical symptoms of conjunctival injection, increased appetite, dry mouth, and tachycardia. A decreased need for sleep does not suggest cannabis intoxication.

29. (E) Culture-bound syndromes denote recurrent, locality specific patterns of behavior. The syndrome of amok is a culture-bound syndrome of Malayan origin that refers to a violent or furious outburst with homicidal intent. Four defining characteristics are prodromal brooding, a homicidal outburst, persistence in reckless killing without an apparent motive, and a claim of amnesia. The attack typically results in multiple casualties and is most common in young men whose self-esteem has been injured. Ganser syndrome is characterized by a patient who responds to questions by giving approximate or outright ridiculous answers. Additional features include altered consciousness, hallucinations, conversion phenomenon, and amnesia for the episode. Dissociative identity disorder is a chronic state in which two or more separate ongoing identities or personalities alternate in consciousness. It usually occurs in patients who experienced severe and repeated abuse as young children.

Questions 30 and 31

A26-year-old woman is diagnosed with schizophrenia. The psychiatrist decides to treat her symptoms with a high-potency antipsychotic medication. The patient experiences abnormal involuntary movements associated with the use of the antipsychotic drug she has been prescribed.

30. Realizing that side effects may affect further medication compliance, the psychiatrist should prescribe which of the following?

(A) clozapine

(B) risperidone (Risperdal)

(D) methylphenidate (Ritalin)

(E) a cholinergic agonist

31. Despite the intervention, the patient abruptly stops taking her antipsychotic medication. The psychiatrist decides to change the patient’s medication. Which of the following may be considered?

(A) haloperidol

(B) clozapine

(D) pimozide (Orap)

(E) perphenazine (Trilafon)

Answers

30. (C) Neuroleptic-induced extrapyramidal side effects due to the blockade of dopamine are

common in the treatment of psychosis. The higher potency neuroleptic drugs are more likely to cause extrapyramidal side effects than the lower-potency neuroleptics. Extrapyramidal side effects are diminished by agents such as benztropine, antihistamines, benzodiazepines, and dopamine agonists. There are four types of extrapyramidal side effects: acute dystonic reactions, akathisia (restlessness), pseudoparkinsonism, and tardive dyskinesia or tardive dystonia. In this case, the treatment of the involuntary movements involves evaluation of dose and type of neuroleptic. Reducing the dose, substituting with a higherpotency agent, or adding an antiparkinsonian drug are all feasible therapeutic interventions.

31. (B) Atypical antipsychotic agents are thought to act on various subpopulations of dopamine neurons as well as on various dopamine receptor subtypes and other neurotransmitter systems. They are considered atypical agents because they are associated with a lower risk of extrapyramidal symptoms. Clozapine, introduced to the

in 1989, is the first antipsychotic to be labeled atypical. The other choices are all considered typical antipsychotics.

Questions 32 and 33

A30-year-old woman with a history of unstable interpersonal relationships, suicidal gestures, and marked impulsivity is referred to you for dialectical behavioral therapy (DBT).

32. Which of the following disorders is this patient likely to be suffering from?

(A) avoidant personality disorder

(B) bipolar disorder

(D) borderline personality disorder

(E) schizoid personality disorder

33. The foundations of DBT include which of the following?

(A) The patient is doing the best that she can.

(B) The patient may fail in therapy.

(D) The patient should not learn new behaviors.

(E) The patient is responsible for causing all of her own problems.

Answers

32. (D) Borderline personality disorder is a pattern of instability in interpersonal relationships, selfimage, affect, and marked impulsivity. DBT, a manualized treatment for chronically parasuicidal patients that incorporates elements of cognitive, behavioral, and supportive therapies, is a form of cognitive-behavioral treatment for borderline personality disorder. Avoidant personality disorder represents a pervasive pattern of behavior characterized by social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Schizoid personality disorder represents a pervasive pattern of detachment from social relationships and a restricted range of expressed emotions. Bipolar disorder is an affective illness characterized by alternating periods of mania and major depression. Passiveaggressive personality disorder describes a pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance.

33. (A) General principles of DBT include believing that the patient wants to improve and is doing the best she or he can. The patient is encouraged to take responsibility and solve her or his own problems. Patients may not have caused all of their problems, but they are encouraged to solve them anyway. Patients learn new behaviors in a relative context and believe that they cannot fail in therapy.

Question 34 and 35

34. A 21-year-old man presents with a 4-week history of paranoid delusions and auditory hallucinations that comment on his appearance. After thorough evaluation, you diagnose him with schizophrenia, paranoid type, and prescribe haloperidol 5 mg bid. One week later, the patient returns for a follow-up examination and reports that, although his symptoms have improved, he now experiences muscle stiffness in his arms and neck. You prescribe benztropine 1 mg bid and schedule a follow-up appointment in 2 weeks. One week later, the patient’s mother calls you and reports that her son is more agitated and confused. Physical examination reveals tachycardia, dilated pupils, and flushed skin. The next appropriate measure would be which of the following?

(A) discontinue benztropine and prescribe amantadine (Symmetrel)

(B) increase haloperidol to 5 mg tid

(D) discontinue haloperidol and prescribe risperidone

(E) prescribe lorazepam 1 mg bid

35. A28-year-old male medical student is found to have an enlarged testicle during a routine physical examination. The student reports that it has been gradually enlarging for several months. The physician asks why he did not report these findings earlier. “I’m sure it’s nothing,” the student replies. This response is an example of which of the following?

(A) a mature defense

(B) a neurotic defense

(D) an immature defense

(E) confidence

Answers

34. (A) The patient is experiencing anticholinergic toxicity as evidenced by dilated pupils, dry or flushed skin, agitation, confusion, and tachycardia. Additional manifestations include disorientation and urinary retention. More severe toxicity may result in hyperthermia or coma.

In this case, the patient reported benefit from haloperidol but experienced extrapyramidal side

effects, common to the high-potency antipsychotic medications. Benztropine, an anticholinergic medication, is prescribed to alleviate extrapyramidal side effects, but in this patient it caused anticholinergic side effects. Amantadine is an antiviral medication that is used to help alleviate extrapyramidal side effects and should be instituted to replace benztropine.

35. (C) Denial, a narcissistic defense, is a common unconscious emotional defense mechanism used to avoid becoming aware of a painful aspect of reality. Denial can be used in both normal and pathologic states. As a defense mechanism it serves to keep internal or external reality out of the conscious to avert stress and anxiety. Regression, an immature defense, is an emotional and physical retreat from adult standards of behavior toward an infantile level of passivity and dependence. At times, regression represents a retreat from the arduous task of recovery. Rationalization is a neurotic defense mechanism in which unacceptable behavior, feelings, or thoughts are logically justified by elaborate and reassuring answers. Suppression, a mature defense, is a conscious act of controlling and inhibiting unacceptable impulses, emotions, or ideas.

Question 36 and 37

36. A 45-year-old woman is brought to the emergency department by her husband, who reports that for the past 3 days his wife has not been sleeping well, has been experiencing bad dreams, and appears “in a daze” with a sense of feeling “numb.” The patient endorses feeling anxious but does not know why. She has been unable to perform her usual activities of daily living. One week ago, the patient was discharged from the hospital after experiencing an anaphylactic reaction to IV contrast dye while undergoing an imaging procedure for sinusitis. Although she cannot recall specifics, her husband verifies the history, adding that the doctors “thought she was going to die.” Upon returning to the hospital, she experiences intense fear about revisiting the same hospital from which she was recently discharged. The most appropriate diagnosis to consider is which of the following?

(A) PTSD

(B) acute stress reaction

(D) adjustment disorder

(E) depressive disorder

37. A 40-year-old woman without a past psychiatric history is admitted to the hospital for treatment of depression. During morning rounds, the patient appears unresponsive and does not respond to verbal stimuli. There are no signs of trauma or overdose. A review of her chart reveals that the patient was well the night before and went to sleep without incident. You determine that the patient’s unresponsiveness is psychogenic. Which of the following findings is most likely to be apparent on examination?

(A) an abnormal electroencephalogram (EEG)

(B) nonsaccadic eye movements

(D) decreased respirations

(E) cold-caloric-induced nystagmus

Answers

36. (B) The essential feature of acute stress disorder is the development of anxiety and dissociative symptoms within 1 month of exposure to an extremely traumatic stressor. Diagnosis should be considered if the symptoms persist at least 2 days and cause significant distress or impairment. While experiencing the stressor, the individual must experience three of these five symptoms: a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization; or

dissociative amnesia. In addition, the person must reexperience the event in some way (e.g., bad dreams), must experience anxiety or increased arousal, and must experience a marked avoidance of the stimuli that arouse recollections of the traumatic event. The diagnosis of PTSD requires more than 1 month of symptoms. Adjustment disorder can be considered for those individuals who do not meet criteria for acute stress disorder but develop similar symptoms in excess of what is to be expected given the nature of the stressor. GAD is characterized by excessive anxiety and worry that occur for at least 6 months. MDD can exist in the context of an acute stress reaction. However, in this case, the symptoms are not suggestive of a depressive illness.

37. (E) Psychogenic unresponsiveness can be delineated from coma by obtaining an EEG, which is normal in a psychogenic state. On physical examination, deep tendon reflexes may be suppressed. In patients who are awake, cold water introduced into the ear produces nystagmus with the fast component away from the ear. In coma, the eyes either do not react or they may slowly and smoothly deviate toward the ear in which the cold water was introduced. Voluntary eye movements called saccades are rapid and smooth. Saccadic eye movements are elicited in patients by asking them to stare at an object at one side of the visual field and then ask them to shift their gaze to the opposite visual field. Typically, eye movements in coma or persistent vegetative states are spontaneous and random.

Question 38 and 39

38. A 24-year-old woman experiences fatigue, weight gain, and hyperphagia during the winter months. She reports a sad mood and “can’t wait” until her vacation to Florida. The most likely diagnosis is which of the following?

(A) dysthymia

(B) sundowning syndrome

(D) stress disorder

(E) seasonal affective disorder

39. A 27-year-old woman is brought to the emergency department by her parents, who report

that their daughter is unable to recall her name. The emergency department physician reports that a complete neurologic workup is within normal limits. Collateral information

reveals that the patient had episodes in which she would take unplanned trips, sometimes for days, without notice, and would return unable to recall the episode. A review of her medical chart notes a past history of possible sexual abuse as a child. Urine toxicology is negative and she does not take any medications. Which of the following is the most likely diagnosis?

(A) partial complex seizure disorder

(B) delirium

(D) PTSD

(E) depressive disorder

Answers

38. (E) Seasonal affective disorder describes a seasonal pattern of symptoms associated with

major depressive episodes in MDD, bipolar I disorder, and bipolar II disorder. The essential feature is the onset of depressive symptoms at characteristic times of the year. More common in women, most episodes begin in the fall or winter and remit in the spring. Major depressive episodes that occur in a seasonal pattern are typically characterized by anergy, hypersomnia, overeating, weight gain, and carbohydrate craving. Age is a strong predictor, with young persons at higher risk.

39. (C) The essential features of dissociative fugue are sudden and unexpected travel away from home or one’s usual place of daily activities with a subsequent inability to recall the episode accompanied by confusion about personal identity or the assumption of a new identity. The disorder is more common in women and is often associated with a childhood history of sexual abuse. Partial complex seizures tend to be brief and do not last as long as the clinical picture presents. Delirium is characterized by a disturbance of consciousness and a change in cognition that develops over a short period of time.

Question 40 and 41

40. A26-year-old female graduate student reports to you a 4-week history of a depressed mood that has caused her significant difficulty in attending her classes. The patient reports difficulty falling asleep at night, weight loss, and passive suicidal ideation. A careful review of her history reveals that for the past 2 years she also experienced brief and distinct periods of an elevated and expansive mood, a decreased need for sleep, and an increase in goal-directed activities. Which of the following is the most appropriate diagnosis to consider?

(A) MDD

(B) bipolar I disorder, current episode manic

(D) cyclothymic disorder

(E) dysthymic disorder

41. You are asked to evaluate a 30-year-old male prisoner who reports a depressed mood and suicidal ideation. During your examination, you note that the prisoner responds to your questions with approximate answers. Which of the following is the most appropriate diagnosis to consider?

(A) malingering

(B) Ganser syndrome

(D) Munchausen syndrome

(E) fugue state

Answers

40. (C) This patient does not meet full criteria for major depression (e.g., 4/5 Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [DSM-IV-TR] criteria), so she cannot be diagnosed with bipolar II disorder, which is characterized by the occurrence of one or more major depressive episodes accompanied by at least one episode of hypomania (a distinct period of a persistently elevated, expansive, or irritable mood that lasts at least 4 days). Bipolar II disorder differs from bipolar I disorder in that, although the manic and hypomanic episodes of these two disorders have identical list criteria, bipolar II disorder is not severe enough to cause marked impairment in social or occupational functioning or to cause hospitalization. Dysthymic disorder is also ruled out by the presence of manic symptoms making cyclothymic disorder the best choice.

41. (B) The hallmark of Ganser syndrome is that the patient responds to questions by giving

approximate or ridiculous answers. Often confused with malingering, Ganser syndrome is primarily described in the prison population. It involves the production of answers to questions that are relative but not quite correct (e.g., 4 — 5 = 19). It is classified in the DSM-IV-TR as a dissociative disorder not otherwise specified. Munchausen syndrome is a factitious disorder with physical symptoms. Capgras syndrome describes a content-specific delusion in which the patient believes that a significant other, usually a family member, has been replaced by an identical imposter.

Question 42 and 43

42. A 75-year-old man is admitted to the hospital following a serious suicide attempt. The patient exhibits clinical features of depression and has a past history of suicide attempts. The medical chart reveals that he is prescribed levodopa/ carbidopa, digoxin, aspirin, and a medication for cardiac arrhythmia. The most appropriate treatment at this time is which of the following?

(A) prescribe risperidone

(B) administer supportive psychotherapy

(D) prescribe diazepam (Valium)

(E) administer electroconvulsive therapy (ECT)

43. A 38-year-old woman presents to your office with a 2-week history of symptoms of depression characterized by hypersomnolence and reaction sensitivity. She reports to you that she recently enrolled in graduate school and is having trouble with many of her classes. Which of the following diagnoses should be considered?

(A) adjustment disorder

(B) major depression with atypical features

(D) major depression with melancholic features

(E) sleep disorder

Answers

42. (E) ECT provides safe and effective treatment of MDD in the elderly, especially in a patient with a high risk of suicide or medical contraindications (e.g., heart disease) to the use of psychotropic medications. Nortriptyline, a TCA, is lethal in overdose and should not be prescribed in an acutely suicidal patient. Cardiac arrhythmia is also a contraindication to TCA use.

43. (B) The specifiers of melancholic features and atypical features can be applied to a current or recent major depressive episode that occurs in the course of MDD and to a major depressive episode in bipolar I or bipolar II disorder. The atypical features specifier can also be applied to dysthymic disorder. The essential features of the atypical specifier are mood reactivity and two of the following four features: increased appetite or weight gain, hypersomnia, leaden paralysis, and rejection sensitivity. The essential feature of a major depressive episode with melancholic features is a loss of interest or pleasure in all or almost all activities or a lack of reactivity to usually pleasurable stimuli.

Question 44 and 45

44. A 33-year-old man changes his first name to honor a musician whom he idolizes. He recently bought the same guitar as the musician and formed a rock band to play his music.

During practice, the man dresses like his idol. This behavior is an example of which of the following?

(A) identification

(B) regression

(D) projection

(E) idealization

45. A 60-year-old man with schizophrenia sits motionless in his chair. The patient is mute and reacts very little to his environment. His eyes appear fixated on a distant object. At times, he assumes bizarre postures and imitates the movements of others. What is the best description of his behavior?

(A) partial complex seizure

(B) absence seizure

(D) cataplexy

(E) catalepsy

Answers

44. (A) Identification is an unconscious defense mechanism in which the person incorporates the characteristics and qualities of another person or object into his or her own ego system.

The defense serves to strengthen the ego. Regression, an immature defense, is an emotional

and physical retreat from adult standards of behavior toward an infantile level of passivity and dependence. Projection is the false attribution of one’s own unacceptable feelings to another. Fixation refers to an overactive attachment to a person or object; idealization is the attribution of near-perfect, unrealistic attributes to that person or object.

45. (C) The essential feature of the catatonia observed in patients with schizophrenia is a marked psychomotor disturbance involving motor immobility, excessive motor activity, mutism, negativism, peculiar voluntary movements, echolalia (parrot-like senseless repetition of words or phrases), or echopraxia (imitation of movementsof another person). Catalepsy is just one potential symptom of catatonia, and is not a complete answer. Cataplexy is a sudden and brief loss of muscle tone involving either a few muscle groups or most of the antigravity muscles of the body. The fact that the patient occasionally mimics the movements of others makes seizure activity unlikely.

Dr. Rozsa Andras Kenya

Monday, February 12, 2018

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