Comprehensive Review in Clinical Neurology: A Multiple Choice Question Book for the Wards and Boards

Chapter 13. Psychiatry

Question

Questions 1–2

  1. A 33-year-old woman is brought to a psychiatrist’s clinic by her husband. She was previously a quiet lady, but enjoyed social activities and loved her job. Over the past 4 weeks, she had stopped going to work and was spending most of her time at home, often in bed in her pajamas. She was constantly complaining of feeling tired. She was barely eating, and had lost 7 kg. Her husband would frequently find her lying in bed crying. She stated to him several times that she thought she would be better off dead. What is the most likely diagnosis in this patient?

      a.  Major depressive disorder

      b.  Major depressive episode

      c.  Dysthymic disorder

      d.  Bipolar disorder

      e.  Depressive personality disorder

  2. The woman in question 1 is treated with medications and her symptoms improve over a few months. She returns to work and resumes her social activities. Three years later, her symptoms recur: she stops going to work, cries frequently, sleeps most of the time, and stops eating. She attempts suicide unsuccessfully. What is the most likely diagnosis at this time?

      a.  Major depressive disorder

      b.  Major depressive episode

      c.  Dysthymic disorder

      d.  Bipolar disorder

      e.  Depressive personality disorder

  3. Which of the following statements regarding depression is incorrect?

      a.  Psychosis cannot be a feature of depression; if psychotic symptoms are present, a diagnosis of depression cannot be made

      b.  Depression may present with cognitive dysfunction, rather than the typical symptoms of depression, particularly in older adults

      c.  Excessive eating and sleeping are a feature of atypical depression

      d.  A seasonal pattern to depression can occur

      e.  Either insomnia or hypersomnolence may occur in depression

  4. Regarding the epidemiology of depression, which of the following statements is incorrect?

      a.  Depression is more common in females as compared to males

      b.  Depression is the most common mood disorder

      c.  Depression is more common in Caucasians compared to other races

      d.  Depression is more common among those of low socioeconomic status

      e.  Depression is more common among urban-dwelling individuals as compared to those who live in rural areas

  5. Which of the following statements regarding the genetics of mood disorders is incorrect?

      a.  Mood disorders are familial: depression and bipolar disorder are more common among family members of a patient with either depression or bipolar disorder

      b.  The mood disorders are genetically complex as compared to single-gene Mendelian dis-orders

      c.  Mood disorders are entirely explained by genetic factors, and environmental factors have little role to play in the occurrence of mood disorders

      d.  Alcoholism is more common in family members of patients with mood disorders

      e.  Specific polymorphisms of a serotonin transporter have been associated with an increased chance of developing a mood disorder

  6. Regarding the neuroanatomic substrates of major depression, which of the following is incorrect?

      a.  The subcallosal cingulate gyrus has been implicated in depression, and is a potential target for treatment of depression with deep brain stimulation

      b.  Hippocampal abnormalities have been demonstrated in patients with depression, and these relate to abnormalities in the hypothalamic-pituitary-adrenal axis

      c.  The pathophysiology of depression in part relates to dysfunction of cortical-subcortical circuits connecting the frontal cortex and limbic regions

      d.  Patients with untreated depression show hypometabolism of the orbitofrontal cortex

      e.  Hypometabolism of the dorsal prefrontal cortex occurs in depression

Questions 7–8

  7. A 39-year-old woman reports that over the prior month she has had several episodes that occur “out of the blue,” in which she develops, over a 5-minute period, pounding sensation in her chest, chest tightness, choking sensation, and sweating all over, associated with a sense of fear, “as if something terrible was going to happen.” She underwent an extensive cardiac work-up that did not show any abnormalities. She cannot identify any specific triggers for the episodes. She continues about her usual activities despite these attacks, but frequently worries about having more attacks and worries that one day the attacks will kill her. Which of the following is the most likely explanation for this patient’s symptoms?

      a.  She is suffering from post-traumatic stress disorder

      b.  She is a hypochondriac

      c.  She has generalized anxiety disorder

      d.  She is suffering from panic attacks

      e.  She is malingering

  8. A 41-year-old man suffers from similar episodic attacks as those described in question 7. He becomes so worried that one of these attacks will kill him that he has his wife undergo basic life support training, and he starts refusing to go anywhere without her. He also refuses to go to malls or other crowded places where he may not be able to get to help in sufficient time if one of these attacks occurs. What is the most likely diagnosis in this patient?

      a.  Generalized anxiety disorder

      b.  Post-traumatic stress disorder

      c.  Panic disorder with agoraphobia

      d.  Social phobia

      e.  Separation anxiety

  9. The mother of a 22-year-old man attempts unsuccessfully to reach him by telephone for 8 days. She finally goes over to his apartment building and finds him sitting on his couch. He appears disheveled, dazed, and has multiple bruises, abrasions, and dried blood on various body parts. She asks him repeatedly what had happened, but he does not know. In fact, the last thing he could recall was coming home from work 9 days prior. A police investigation is initiated, and from surveillance camera footage, it is surmised that a group of men had broken into his apartment and beaten him repeatedly and tortured him. This man’s inability to recall these events is known as:

      a.  Dissociative fugue

      b.  Dissociative amnesia

      c.  Depersonalization disorder

      d.  Dissociative identity disorder

      e.  Post-traumatic stress disorder

Questions 10–11

10. A 52-year-old man is brought for an urgent visit to a psychiatrist’s clinic. He was in general a level-headed, calculating person, but had changed over the prior 2 weeks. He had not slept more than a few hours in prior days, secretly quit the job he had as a bank manager for 15 years, and stayed up all night designing websites for three separate Internet companies he had decided to launch. His wife found out that he had invested their entire life’s savings in these companies during the prior week. His speech had become fast, and he was speaking almost constantly. He kept jumping from one topic to another and barely made any sense. This man’s history is most consistent with which of the following?

      a.  Acute depressive episode

      b.  Acute psychotic episode

      c.  Acute manic episode

      d.  Acute hypomanic episode

      e.  A mixed episode

11. The man depicted in question 10 had a history of depression, with one episode of severe depression associated with suicide attempt 7 years earlier, but had recovered well from that. What diagnosis can be made in this patient?

      a.  Bipolar I disorder

      b.  Bipolar II disorder

      c.  Cyclothymic disorder

      d.  Borderline personality disorder

      e.  Major depression and schizophrenia combined

12. A 44-year-old man, previously divorced twice, presents with his third wife for marriage counseling. They had been married for 10 years, and as far back as she could remember, living with him had always been “a roller coaster.” There were weeks to months that he would be happy and energetic, and would sometimes stay up all night working on many projects that eventually earned him promotions at work. There were other months during which he would be either irritable and unapproachable or sullen and disinterested in participating in social activities. What is the most likely diagnosis in this man?

      a.  He is normal; his wife is just too critical

      b.  Dysthymic disorder

      c.  Bipolar I disorder

      d.  Borderline personality disorder

      e.  Cyclothymic disorder

Questions 13–14

13. An 8-year-old girl is typically well behaved and rarely acts out. She loves visiting her neighbors’ houses, except for one neighbor’s house where she categorically refuses to go to because they have a dog. Whenever she sees a dog, she begins screaming, becomes flushed, starts sweating, and will not calm down until the dog is removed. Which of the following best describes this patient’s history?

      a.  Panic disorder

      b.  Generalized anxiety disorder

      c.  Post-traumatic stress disorder

      d.  Social phobia

      e.  Specific phobia

14. A 33-year-old woman has been particularly productive at work, and her boss asks her to present the data on her department’s performance at a meeting. This fills her with a sense of dread, as she has struggled with speaking in public all her life. During the days prior to the meeting, she is unable to sleep and stays up all night imagining all the possible things that could go wrong during her presentation. On the day of the presentation, she feels nauseous and can barely concentrate. As she begins the presentation, she starts to sweat, has palpitations, feels light-headed, experiences chest tightness, and has a syncopal event. What is the most likely diagnosis in this patient?

      a.  Panic disorder

      b.  Generalized anxiety disorder

      c.  Agoraphobia

      d.  Social phobia

      e.  Specific phobia

15. Which of the following is incorrect regarding penetration of medications into the CNS?

      a.  Serum concentrations of a medication are always a good indication of the CNS concentration

      b.  The blood-brain barrier and blood-CSF barrier result from tight junctions between brain capillary endothelial and choroid plexus epithelial cells, respectively

      c.  Uncharged particles and lipophilic substances have higher penetration into the CNS than ionized particles, drugs with low lipid solubility, and protein-bound drugs

      d.  The blood-brain barrier is absent in certain parts of the brain

      e.  Neurotransmitter metabolites are cleared through an acid transport system in the choroid plexus

16. A 33-year-old woman is brought to a psychiatrist’s office by her family. They report that for the past 3 months she has changed significantly, with several new and concerning occurrences. She has been trying to convince family members that she is a prophet sent to earth to spread the word of God. In the office, she appears to be speaking up at the ceiling, and when questioned, reports she is conversing with God. She has stopped bathing so as not to wash off any of her holiness. On mental status examination, her affect is blunted, she jumps from one topic to another in response to simple questions, and she uses unusual words that make no sense. What is the most likely diagnosis?

      a.  Obsessive-compulsive disorder

      b.  Brief psychotic disorder

      c.  Schizophreniform disorder

      d.  Schizoid personality disorder

      e.  Schizoaffective disorder

17. A 22-year-old man is brought to his family physician by his parents for worrisome behaviors. He wakes up at 6:03 AM every morning and spends more than 40 minutes making his bed so that “the lines on his cover align perfectly.” He then spends more than 2 hours in the shower, and his skin has multiple abrasions on it where he has scrubbed repeatedly. When he leaves his room in the morning, he always has to tap on the doorknob just the right way, and does so more than 100 times before it “feels right.” He has to skip specific steps on the staircase, and does not let anyone prepare his breakfast because he will eat only from unopened and perfectly sealed containers. Because of his morning routine, he has repeatedly been late to work and his boss has threatened to terminate his employment. He admits to a consuming fear of contamination and to an “indescribable urge” to arrange things in specific ways, but says he cannot help it. Which of the following disorders is most consistent with this history?

      a.  Generalized anxiety disorder

      b.  Post-traumatic stress disorder

      c.  Obsessive-compulsive personality disorder

      d.  Obsessive-compulsive disorder

      e.  Bipolar disorder

18. A 16-year-old is brought to a psychiatrist by her father. He reports that his daughter had always been a “worrywart,” but that things were getting out of control. She worried about “everything and everyone.” She was so concerned that her father would die unexpectedly that during the day she would call him at least once an hour to make sure he was okay. She constantly worried that she would not have enough to pay for her college education, though funds had already been secured for that. She admitted to being tired all the time, to neck pain because she was “tensed up” all day, to poor sleep because she stayed up most of the night worrying, and to difficulty with concentrating on her schoolwork. What is the most likely diagnosis in this patient?

      a.  Hypochondriasis

      b.  Post-traumatic stress disorder

      c.  Panic disorder

      d.  Social phobia

      e.  Generalized anxiety disorder

19. An 18-year-old girl is mugged by a tall blond man while walking on the streets of Cleveland. She is held at gunpoint, on her knees, while her purse, jacket, and watch are taken from her. She is hit on the head and left on the concrete bleeding until a police officer on patrol finds her and provides her with assistance. In subsequent months, she refuses to sleep alone in a room, and she constantly looks toward the window, scared that her assailant has found her again. On the rare occasion that she falls asleep, she wakes up screaming due to a terrible nightmare during which she sees the entire event unfold in front of her. She rarely leaves her house, and when she does, every time she sees a tall blond man, she experiences palpitations, diaphoresis, and an intense sense of fear. This woman’s history is most consistent with:

      a.  Acute stress reaction

      b.  Generalized anxiety disorder

      c.  Post-traumatic stress disorder

      d.  Night terrors

      e.  Panic disorder

Questions 20–22

20. A 29-year-old woman presents to the emergency department for the third time in 3 months. She reports severe abdominal pain of 2 years’ duration that had intensified earlier that day. On review of systems, she endorses multiple other complaints that have been present for years, including headache, knee pains, and eye pains. She also reports painful, irregular menses, and tingling and numbness in her hands, feet, and face. Review of her medical records reveals multiple visits to various specialists, with extensive diagnostic testing including CT of the chest, abdomen, and pelvis, pelvic ultrasound, full cardiac evaluation, MRI of the brain and spine, and EMG/NCS in addition to extensive laboratory evaluation for rheumatologic disorders, vitamin deficiencies, and endocrinologic disorders. After social work and psychiatric consultation, no secondary gain can be identified, but a history of physical abuse in childhood is revealed. What is the most likely diagnosis in this patient?

      a.  Hypochondriasis

      b.  Somatization disorder

      c.  Generalized anxiety disorder

      d.  Body dysmorphic disorder

      e.  Factitious disorder

21. A 42-year-old right-handed man is brought to the emergency department by ambulance. He had sudden onset of left hemiparesis earlier that day. On examination, he cannot move his left arm or leg and has no sensation to any modality. His plantar responses are flexor, and his reflexes are symmetric, and remain as such for several days. He has two MRIs of the brain, which show no abnormalities on diffusion weighted images or on any other sequences. During psychiatric consultation, he reports his fiancée had recently broken up with him. He is sincerely concerned about his deficits, and wants them to resolve so that he can return to work. No secondary gains can be identified. What is the most likely diagnosis in this patient?

      a.  Factitious disorder

      b.  Somatization disorder

      c.  Generalized anxiety disorder

      d.  Body dysmorphic disorder

      e.  Conversion disorder

22. A 33-year-old woman presents to a plastic surgeon for consultation. She reports that her nose is too large and insists that the surgeon correct it. On examination, her nose is small but deformed, with multiple scars apparent. She reports that she has had three prior surgeries, but that “not enough was taken off.” The patient’s driver license picture, taken prior to any of the surgeries, shows that the patient’s nose had been of normal size. The surgeon declines to offer her surgery; she storms out of his office and requests a second opinion from another plastic surgeon. What is the most likely diagnosis in this patient?

      a.  Hypochondriasis

      b.  Somatization disorder

      c.  Conversion disorder

      d.  Body dysmorphic disorder

      e.  Munchausen’s syndrome

23. Regarding the pathogenesis of depression, which of the following is incorrect?

      a.  The monoamine hypothesis of depression postulates that depression results from a deficiency of or dysfunction in cortical and limbic catecholaminergic pathways

      b.  Support for the monoamine hypothesis comes from evidence that reserpine, which depletes catecholamines, leads to depression

      c.  Data showing that carriers of specific serotonin transporter promoter gene polymorphisms are more susceptible to depression and suicidal behavior in response to stress support the monoamine hypothesis of depression

      d.  Deficiencies in the monoamines have unequivocally been demonstrated in patients with depression, proving the monoamine hypothesis

      e.  Antidepressants act by increasing availability of catecholamines and otherwise enhance catecholaminergic transmission

Questions 24–25

24. A 27-year-old man is brought to a clinic by his mother with a 1-year history of slowly, but distinctly, progressive changes in behavior. He had always been shy and had difficulty making friends at school, but over the past year, he had become significantly withdrawn. He never smiled anymore; he was “emotionless” according to his mother. His mother would find him sitting alone in his room seemingly talking to someone. He was also becoming increasingly paranoid, and was convinced that the government was controlling his mind with high-frequency satellite waves. What is the most likely diagnosis in this patient?

      a.  Delusional disorder

      b.  Brief psychotic episode

      c.  Schizophrenia

      d.  Schizoaffective disorder

      e.  Schizoid personality disorder

25. Regarding the disorder depicted in question 24, which of the following is incorrect?

      a.  It is more common in males

      b.  It usually manifests after the age of 40

      c.  Both positive and negative symptoms are seen, with negative symptoms prevailing later in the disease course

      d.  It affects 1% of the world’s population

      e.  It is more prevalent in lower socioeconomic populations

26. A 72-year-old woman suffers from a major depressive episode. She has a history of coronary artery disease, atrial fibrillation on anticoagulation therapy, sick sinus syndrome, glaucoma, and chronic obstructive pulmonary disease. Which of the following medications is most appropriate for the treatment of her depression?

      a.  Amitriptyline

      b.  Nortriptyline

      c.  Doxepin

      d.  Fluvoxamine

      e.  Escitalopram

Questions 27–28

27. A 13-year-old boy is seen by a psychiatrist while he is at a juvenile correctional facility. He had reportedly always been a troublemaker, but he had just gotten expelled from school and charged in court after for putting a dead rabbit on his teacher’s desk and then on the same day setting a fire in the school library. He had a history of multiple detentions and suspensions for getting into fights and bullying his classmates and for skipping school. At home, he had enucleated his sister’s pet gerbil’s eyes, and once, when his mother grounded him for staying out all night (though he had a 10:00 PM curfew), he had threatened her with a kitchen knife. He had robbed their 91-year-old neighbor, threatening to strangle her if she did not give him money, and had been arrested at the mall repeatedly for shoplifting. Which of the following disorders does this child’s history suggest?

      a.  Oppositional defiant disorder

      b.  Conduct disorder

      c.  Antisocial personality disorder

      d.  Acute manic episode

      e.  Borderline personality disorder

28. An 8-year-old boy is brought to a child psychiatrist by his parents. For the past 2 years, and increasingly over time, he had been showing significant hostility toward his parents and teachers. He was irritable, would lose his temper at the slightest things, would argue with his parents over everything, and would never abide by parents’ or teachers’ rules. He would blame his little brother for everything and frequently get his little brother in trouble. Which of the following disorders does this child’s history suggest?

      a.  Oppositional defiant disorder

      b.  Conduct disorder

      c.  Antisocial personality disorder

      d.  Acute manic episode

      e.  Borderline personality disorder

29. A 45-year-old man presents to a psychiatry clinic with complaints of depression. He reports that he has always been depressed since as far back as he could remember. He reports that although some days are better than others, for most days over the prior several years, he was always tired, and had difficulty falling asleep almost every night. He reports that he had not felt like leaving the house much and had to force himself to get out of bed to go to work, where he had difficulty concentrating and barely got by on performance measures. At the end of the interview, he states he is not sure why he even came to the clinic because he did not think anything could be done to change the way he feels. This man’s history is most consistent with:

      a.  Major depressive disorder

      b.  Chronic depression

      c.  Dysthymic disorder

      d.  Depressive personality disorder

      e.  Cyclothymic disorder

30. Which of the following is incorrect regarding the neurotransmitter serotonin?

      a.  Serotonin is synthesized from tryptophan, with the rate-limiting step being catalyzed by tryptophan hydroxylase

      b.  Serotonin is metabolized through action of monoamine oxidase (MAO) into 5-hydroxy-indoleacetic acid; the MAO-B isoform is the principle isoform involved in serotonin metabolism and is inhibited by selegiline

      c.  In the CNS, the highest density of serotonergic neuron cell bodies is in the raphe nuclei of the brain stem

      d.  There are multiple subtypes of the serotonin receptor, some that are ligand-gated ion channels and others that are metabotropic, linked to G-proteins

      e.  Serotonin has multiple actions, including platelet aggregation, increased intestinal motility, vasoconstriction, and bronchoconstriction

31. A 69-year-old man who went to college with the first lady has claimed for the past 3 months that she is madly in love with him. He tells everyone he meets about how much she is in love with him, and he is convinced that she winks at him and smiles just for him when she is giving speeches on television. He works as a bank manager, and is very productive at his job. He is liked by all, and has many friends, who take his supposed love affair with the first lady as an amusing joke. There really is nothing particularly unusual about him, except for his belief regarding the first lady. What is the most likely diagnosis in this case?

      a.  Brief psychotic disorder

      b.  Schizophrenia

      c.  Delusional disorder

      d.  Schizoaffective disorder

      e.  Atypical depression

32. Regarding the epidemiology and risk factors for suicide, which of the following is incorrect?

      a.  Death due to suicide is three times more common in males as compared to females, but females attempt suicide three times more than males

      b.  In Caucasians, suicide rates increase with increasing age

      c.  Native Americans have the highest rates of suicide among all ethnicities in the United States

      d.  More than half of all patients who commit suicide were suffering from a mood disorder prior to their death

      e.  Among patients with personality disorders, those with schizoid personality disorder are the most likely to attempt suicide

33. The selective serotonin reuptake inhibitors (SSRIs) are commonly used antidepressants. Which of the following is correct regarding the SSRIs?

      a.  The SSRIs act by inhibiting reuptake of serotonin and, through various pre- and postsynaptic effects, have antidepressant activity that may take several weeks to take effect

      b.  Unlike the tricyclic antidepressants, the SSRIs have no drug-drug interactions

      c.  The SSRIs are conveniently available in various formulations and can be administered through subcutaneous, sublingual, and intravenous routes

      d.  The SSRIs have little use beyond depression

      e.  The SSRIs have few systemic side effects because they only inhibit serotonin reuptake centrally

34. Regarding the pathophysiology of schizophrenia, which of the following is incorrect?

      a.  The dopamine hypothesis of schizophrenia postulates that in this disorder, there is excessive limbic dopaminergic activity

      b.  Support for the dopamine hypothesis comes from evidence that postsynaptic blockade of D2 (dopamine) receptors is useful in the treatment of schizophrenia

      c.  Overactivity of the nigrostriatal and tuberoinfundibular dopaminergic pathways forms the basis of the dopamine hypothesis

      d.  Patients with schizophrenia have increased dopamine receptor density, and imaging studies have shown increased striatal D2 receptor occupancy by extracellular dopamine

      e.  The dopamine hypothesis does not fully account for the manifestations of schizophrenia and other psychotic disorders

35. A 19-year-old man is arrested after he is denied seating at a restaurant and proceeds to break all the plates and glasses in his sight and push over tables and chairs. He has a long history of detentions at school for angry outbursts. He has gotten into multiple fights, and had been previously arrested for physical aggression against a classmate. After each of these occurrences, he expresses regret, though he often attempts to justify his actions. When not aggravated, he is usually a pleasant person. What is the most likely diagnosis in this man?

      a.  Antisocial personality disorder

      b.  Bipolar disorder

      c.  Intermittent explosive disorder

      d.  Oppositional defiant disorder

      e.  Borderline personality disorder

36. A 16-year-old girl has always been considered short tempered and “moody,” but does well in school. One day, she is arrested at the mall for attempted theft of a pair of shoes. When contacted, her distraught parents, wealthy and prominent members of society who have always given their daughter everything she wants, admit that she has a history of multiple prior thefts. The patient is taken to a therapist, to whom she admits to theft over the years on almost a daily basis because it gives her a “rush.” She reports that she usually has no specific interest in the objects she has stolen. She knows her parents could buy these objects for her. Which of the following best describes this patient’s disorder?

      a.  Borderline personality disorder

      b.  Antisocial personality disorder

      c.  Trichotillomania

      d.  Kleptomania

      e.  Pyromania

Questions 37–38

37. A 17-year-old girl is brought to the emergency department after being found unconscious on the floor of her dormitory. She is found to have a potassium level of 2.2 mmol/L (normal 2.5-5.0) and a sodium level of 120 mmol/L (normal 135-148). Her body mass index (BMI) is 16 (normal 18.5-24.9). Her roommate, who had been friends with her for several years, reported the patient had always been thin, but had a dramatic weight loss over the prior 2 years. The patient frequently ate; in fact, she would binge on junk food several times a day, and though she never admitted to it, her friends had noticed several signs, indicating the patient was self-inducing vomiting multiple times a day. She had not menstruated in over 1 year. What is the most likely diagnosis in this patient?

      a.  Bulimia nervosa

      b.  Anorexia nervosa, restricting type

      c.  Anorexia nervosa, binge eating/purging type

      d.  Eating disorder not otherwise specified

      e.  Impulse control disorder

38. An 18-year-old woman is referred to her college’s health counselor after a pharmacist detects several unusual prescriptions for laxatives purchased by the patient. Her body mass index had been in the range of 23 to 24 since adolescence (normal 18.5-24.9). The patient admits to an intense fear of being fat for years, wishing to be thinner. She reported trying not to eat, but then gets so hungry that several times a week she would binge for hours, would subsequently feel guilty, and would take 30 to 40 pills of laxatives at once. What is the most likely diagnosis in this patient?

      a.  Bulimia nervosa

      b.  Anorexia nervosa, restricting type

      c.  Anorexia nervosa, binge eating/purging type

      d.  Eating disorder not otherwise specified

      e.  Impulse control disorder

39. Tricyclic antidepressants are commonly used to treat depression. Which of the following statements is correct regarding the tricyclic antidepressants?

      a.  The mechanism of action of all types of tricyclic antidepressants includes inhibition of reuptake of both norepinephrine and serotonin

      b.  They have effects at muscarinic, histaminergic, and α1-adrenergic receptors

      c.  They directly inhibit reuptake of dopamine

      d.  The action of tricyclic antidepressants is relatively specific, and there is little activity at noncatecholaminergic receptors

      e.  They have little use beyond the treatment of depression and anxiety

40. A 16-year-old boy, a star athlete at his school, is noticed by his teachers to significantly struggle in activities that require reading. He is further assessed and found to be reading at less than the 10th percentile of normal for his age. He does relatively well in other subjects that do not heavily rely on reading, such as mathematics and geography, and his intelligence quotient is determined to be 90. What is the most like diagnosis in this boy?

      a.  Reading disorder

      b.  Mild mental retardation

      c.  Mathematics disorder

      d.  Disorder of written expression

      e.  Acquired dyslexia

Questions 41–43

41. A 42-year-old man works as an accountant. As a child and adolescent, he made a few friends, but has lost touch with most of them because he always felt that they were friends with him only because they wanted money from him. He would frequently have arguments with the friends he maintained because he felt they were always making fun of him and criticizing him. As a student in college, he had multiple issues with his teachers, who he accused of grading him poorly because they hated him or were judging him. He had a few girlfriends, but only for brief periods, because he was convinced each of them was having an affair. At work, he had requested that human resources add a lockable door to his cubicle, because he was convinced that fellow office employees went through his drawers, stole his supplies, and logged into his computer and read his e-mails. Which of the following disorders best describes this man?

      a.  This man does not have a diagnosable disorder

      b.  Schizoid personality disorder

      c.  Schizotypal personality disorder

      d.  Schizophrenia, paranoid subtype

      e.  Paranoid personality disorder

42. A 38-year-old man had always been a “loner.” He had few friends in childhood, and as a teenager and young adult, he had no interest in getting to know others. He stuck to a strict daily schedule, consisting mainly of meals, work, and sleep. He visited his parents once a week, for Sunday dinner. He rarely went to social events, and when he had to, he would spend most of his time staring at the floor and would appear annoyed if someone attempted to converse with him. He had no interest in romantic relationships or friendships. Which of the following disorders best describes this man?

      a.  This man does not have a diagnosable disorder

      b.  Schizoid personality disorder

      c.  Schizotypal personality disorder

      d.  Schizophrenia, paranoid subtype

      e.  Paranoid personality disorder

43. A 61-year-old woman has always been told she was weird. She is a fortune teller and is convinced that the spirits speak to her. She is very superstitious, and creates significant annoyance among family members because of all the rituals she makes them follow when they visit her house to avoid the wrath of the “evil eye.” She has not had a haircut in over 10 years because she feels her hair gives her healing powers, and wears several necklaces and bracelets all the time, because she thinks they bring her good luck. She has few friends, and although she loves her siblings and spends time with them, she is always paranoid that they are planning to try to take away her spiritual powers. Which of the following disorders best describes this woman?

      a.  This woman does not have a diagnosable disorder; she is just eccentric

      b.  Schizoid personality disorder

      c.  Schizotypal personality disorder

      d.  Schizophrenia, paranoid subtype

      e.  Paranoid personality disorder

44. A 48-year-old woman, mother of six troublemaking children and an unloving husband, presents to the emergency department with severe abdominal pain. She is a poor historian and offers only vague information about time of onset and nature of the pain. General surgical consultation is immediately requested for her presentation of acute abdomen. She seems almost pleased when an exploratory laparotomy is suggested to her. During examination, she screams when her abdomen is initially palpated, but when she is distracted, deep palpation of her abdomen does not seem to bother her. Her husband and children gather around her bed, with concerned, guilty looks on their faces, tears streaming down their faces. When family members or physicians are in her room, she writhes in pain and cries, but when she is alone and thinks she is not being observed, she appears comfortable and makes a few phone calls and watches television. Extensive laboratory and radiologic testing is normal. What is the most likely diagnosis in this patient?

      a.  Factitious disorder

      b.  Malingering

      c.  Hypochondriasis

      d.  Ischemic bowel

      e.  Generalized anxiety disorder

45. Regarding the subtypes of schizophrenia, which of the following is correct?

      a.  In the catatonic subtype, patients most commonly have psychomotor agitation with restlessness, excessive movement, and nonsensical speech

      b.  The residual subtype is marked predominantly by disorganized speech and behavior and flat, inappropriate affect

      c.  The disorganized subtype is diagnosed when visual and auditory hallucinations are the most prominent residual symptoms after an acute psychotic exacerbation

      d.  The paranoid subtype is characterized by prominent auditory hallucinations and delusions with relative preservation of cognitive function and affect

      e.  Undifferentiated schizophrenia is diagnosed when the diagnostic criteria for schizophrenia have never been met but there are some psychotic symptoms

Questions 46–48

46. A 33-year-old man is brought to a psychologist by his mother. His mother reported that her son is “crazy” and that she wanted the psychologist to “talk some sense into him.” Apparently, the man had been offered a promotion at work into a more prestigious, higher paying job with several perks that he had declined because he was scared that as soon as his work load increased, his employers would start criticizing him, think he could not handle it, and fire him. His mother reported he had always been like that: always avoided any situation where he might get criticized, was overly sensitive, and was convinced that people hated him. As a teenager, he was shy and made only a few friends because he felt no one would want to hang out with him, though there were many people in his class he wished he could have been friends with. He would date girls only after his mother repeatedly ensured him that they would like him. She said she was tired of having opportunities pass him because he felt he was never good enough for them. Which of the following disorders best describes this man?

      a.  Schizoid personality disorder

      b.  Panic disorder with agoraphobia

      c.  Dependent personality disorder

      d.  Obsessive-compulsive personality disorder

      e.  Avoidant personality disorder

47. A man meets a woman, and in a whirlwind romance, they are married within 4 weeks of meeting; he justifies this to his friends by stating that she is “very low maintenance,” never arguing with him and letting him do things his own way. However 2 months later, he is cursing the day he ever met her. She apparently could not make any decision on her own, and had to consult with him on everything. Within weeks of being married, he found himself doing almost everything for her because she would say she did not know how or was scared of messing things up. He would become upset and yell at her and insult her, but she would just sit there and take it because she did not want him to leave her. According to the woman’s family members, she had always been very clingy, and “couldn’t take care of herself.” Which of the following disorders best describes this woman?

      a.  Schizoid personality disorder

      b.  Panic disorder with agoraphobia

      c.  Dependent personality disorder

      d.  Obsessive-compulsive personality disorder

      e.  Avoidant personality disorder

48. A 52-year-old man is asked to assume the role of a team leader at his office. The team members dread the experience; they have known the man for years. He is best known for having his entire office filled with filing cabinets because he files every single paper he has ever come across, regardless of whether or not it is important or needed for the future. As expected, during the first 2 days of his leadership, he makes all the team members reorganize their offices so that everything is in order and there is no clutter on any of the office desks. During meetings, he has everyone write down the minutes of the meeting and then at the end of the meeting, has every person read them out in order to make sure they are all accurate and as similar to each other as possible. By the end of the day, little has been done in terms of productive work because of the time spent on such activities. He makes everyone in the office stay over hours, is dismissive if anyone suggests that they should spend their time more efficiently, and when one of the team members tells him she needs to leave to pick her children up from day care, he scoffs at her for not having good work ethic and having deranged priorities. Which of the following disorders best describes this man?

      a.  Schizoid personality disorder

      b.  Obsessive-compulsive disorder

      c.  Dependent personality disorder

      d.  Obsessive-compulsive personality disorder

      e.  Avoidant personality disorder

49. A 32-year-old man wakes up one morning convinced that he had been abducted by aliens overnight. He reports that sperm was extracted from him and injected into the queen of the galaxies, and that she is now carrying his baby. He meets a 28-year-old woman, and when she hears his story, she is skeptical, but interested. Soon after they meet, they marry, and she soon becomes convinced of his story. The couple travels around the country trying to lobby for funding for a space mission to rescue the man’s extraterrestrial son from outer space. Which of the following statements is correct?

      a.  They both have schizophrenia

      b.  They are both just eccentric, but do not meet criteria for any one type of psychiatric dis-order

      c.  They both have histrionic personality disorder

      d.  They suffer from a somatoform disorder, which can be contagious

      e.  They have shared psychotic disorder (folie à deux)

50. Which of the following is not an adverse effect of tricyclic antidepressants?

      a.  Overactive bladder

      b.  Xerostomia

      c.  Sedation

      d.  Weight gain

      e.  Seizures

51. A 7-year-old boy, Matt, and his 9-year-old brother, Tom, are being seen by their pediatrician for their annual checkup. Their mother appears worn out and reports to the physician that her sons have always kept her busy, but that over the past year, Matt has been giving her extensive trouble with his school work. She thinks he is smart, but he just cannot seem to pay attention to anything, cannot seem to concentrate for more than 5 minutes on his homework, is easily distractible, and never does what he is told, is constantly misplacing things, and even forgets to brush his teeth and shower sometimes if she does not remind him. Tom is also giving her trouble with his school work, but his main problem is that he “just can’t seem to sit still.” At home, he fidgets at the dinner table and while doing homework, and at school there have been multiple complaints about him leaving his seat and even the classroom. He talks constantly, jumping from one topic to another, cannot wait in turn, and is constantly butting into conversations. What is the most likely diagnosis in Matt and Tom?

      a.  There is no diagnosis; their behavior is age appropriate

      b.  Conduct disorder

      c.  Oppositional defiant disorder

      d.  Attention-deficit/hyperactivity disorder

      e.  Generalized anxiety disorder

52. Which of the following are potential side effects of selective serotonin reuptake inhibitor therapy?

      a.  Nausea

      b.  Irritability

      c.  Suicidal thoughts, particularly in younger age groups

      d.  Erectile dysfunction

      e.  All of the above

Questions 53–55

53. Which of the following is incorrect regarding the first generation of antipsychotics, so-called typical antipsychotics or neuroleptics?

      a.  Chlorpromazine and thioridazine are examples of low-potency typical antipsychotics, and have higher levels of side effects related to antagonism at nondopamine receptors

      b.  The typical antipsychotics exert their antipsychotic effect predominantly by antagonism at D2 receptors

      c.  Haloperidol and other high-potency typical antipsychotics, such as fluphenazine, have the highest risk of extrapyramidal side effects among the antipsychotic agents

      d.  Some of the typical antipsychotics are available in intravenous or intramuscular formulations

      e.  The typical antipsychotics are rarely used in the treatment of schizophrenia and other psychotic disorders because newer, more efficacious, and cost-effective medications are now available

54. An 18-year-old man is diagnosed with schizophrenia and started on an antipsychotic agent. Six weeks later, he has multiple complaints, including dry mouth, sleepiness, and dizziness when he stands from a seated position. Which of the following medications is he most likely being treated with?

      a.  Chlorpromazine

      b.  Haloperidol

      c.  Fluphenazine

      d.  Perphenazine

      e.  Prochlorperazine

55. A 32-year-old man has been treated with typical antipsychotic medications for more than 10 years. He has been well controlled on medications, with only residual negative symptoms. During a routine follow-up visit with his psychiatrist, he is noticed to have constant chewing movements, occasional tongue protrusion, and jaw thrusting. His medication is stopped, but these movements persist. Which of the following medications is most likely to lead to these manifestations?

      a.  Chlorpromazine

      b.  Haloperidol

      c.  Thioridazine

      d.  Benztropine

      e.  Prochlorperazine

56. The fiancé of a 32-year-old woman ends their relationship of 4 years’ duration. In the following 2 months, she can barely sleep at night, and some nights she will stay up all night watching romantic movies and crying. She continues to go to work, but can barely concentrate, and is frequently found at her desk crying. She finally seeks psychologic counseling, and within 4 months of the breakup, she starts to feel better again and is able to date. What disorder was this woman exhibiting?

      a.  Bereavement

      b.  Major depressive episode

      c.  Adjustment disorder

      d.  There is no disorder; this was a normal reaction to a breakup

      e.  Acute stress reaction

57. Regarding the anxiolytics, which of the following statements is incorrect?

      a.  Benzodiazepines may be used for brief periods of time in the treatment of anxiety disorders

      b.  Chronic use of benzodiazepines leads to tolerance and dependence

      c.  Selective serotonin reuptake inhibitors are used for chronic therapy of anxiety disorders

      d.  Buspirone is an anxiolytic that acts as a dopamine D1 receptor antagonist

      e.  Benzodiazepines are available in various oral, sublingual, intravenous, and intramuscular formulations

58. Which of the following is correct regarding imaging findings in schizophrenia?

      a.  Slit-like ventricles, due to reduced volume of the lateral ventricles, is often seen

      b.  There is evidence of gyral hypertrophy with sulcal narrowing

      c.  There is atrophy of areas of the frontal and temporal lobes

      d.  Positron emission tomography studies have shown significant hypermetabolism at rest in the cingulate cortex

      e.  There is bilateral symmetric caudate head atrophy

59. A 69-year-old man is brought to the emergency department by his family for altered mental status. For the prior few weeks, he had been increasingly sleepy, and that morning, he could barely be aroused. He has a chronic history of depression and was started on fluoxetine 2 months earlier. He also suffers from coronary artery disease, hypertension for which he is on a thiazide diuretic, and cirrhosis. In the emergency department, his serum sodium is found to be 118 (normal 132-148 mmol/L). Which of the following statements is incorrect in relation to this patient’s presentation?

      a.  Hyponatremia occurs as an adverse effect from selective serotonin reuptake inhibitors (SSRIs)

      b.  Coadministration of an SSRI with a diuretic increases the risk of hyponatremia

      c.  The hyponatremia occurring with SSRIs is thought to be due to syndrome of inappropriate antidiuretic hormone

      d.  Treatment of hyponatremia due to SSRIs involves discontinuation of the SSRI as well as other usual measures for hyponatremia

      e.  Hyponatremia resulting from SSRIs typically occurs after 3 months of therapy

60. Regarding the genetics of schizophrenia, which of the following is correct?

      a.  Family members of patients with schizophrenia are not at a higher risk of developing schizophrenia than the general population

      b.  Schizophrenia is likely a result of the presence of predisposing genes combined with exposure to various environmental factors

      c.  Schizophrenia is a monogenic, autosomal dominant disorder that localizes to chromosome 4

      d.  Monozygotic twins and dizygotic twins have similar concordance rates for schizophrenia

      e.  No specific genetic abnormalities have been associated with schizophrenia as yet

61. A 52-year-old woman has a long history of depression. She has had a partial response to fluoxetine combined with duloxetine, but continues to feel depressed, so her psychiatrist adds amitriptyline to her regimen. Two weeks later, she is brought to the ED where she is found to be obtunded, diaphoretic, and tachycardic. On examination, multifocal myoclonus and sustained ankle clonus are noted. What is the most likely diagnosis in this patient?

      a.  Neuroleptic malignant syndrome

      b.  Thyroid storm

      c.  Serotonin withdrawal syndrome

      d.  Serotonin syndrome

      e.  Psychogenic coma, due to her depression

62. A 38-year-old man was brought to the emergency department by his family for a 3 day history of auditory hallucinations, paranoid delusions, and disorganized speech. Symptoms had started after he had witnessed the murder of his wife. He was admitted to an inpatient psychiatry unit and treated with medications. His psychotic symptoms resolved over 8 days. At the time of discharge, he was appropriately mourning the death of his wife. At 1-year follow-up, he continued to express sadness about the death of his wife, but showed no features of depression, psychosis, or any other psychiatric conditions. He did not have further recurrences of psychosis. The occurrence of psychotic symptoms in this man is most consistent with a diagnosis of:

      a.  Schizophrenia

      b.  Schizophreniform disorder

      c.  Delusional disorder

      d.  Schizoaffective disorder

      e.  Brief psychotic disorder

63. Regarding the neurotransmitter GABA, which of the following is incorrect?

      a.  GABA is the main excitatory neurotransmitter in the central and peripheral nervous system, along with glycine

      b.  The GABAA receptor is an ionotropic receptor and the GABAB receptor is a metabotropic receptor

      c.  The medication baclofen is a selective agonist at GABAB receptors

      d.  Benzodiazepines act at the GABAA receptor

      e.  GABA is an example of an amino acid that acts as a neurotransmitter

Questions 64–67

64. A coworker of yours is disliked by everyone who works in the office because, as is frequently said, he is “so full of himself” and “thinks he’s God’s gift to women.” He thinks he is smarter than everyone and constantly takes credit for all successes within the company. He acts as though he is doing others a favor when he speaks to them and tells stories of how women throw themselves at his feet. When others make comments to him about his conceitedness, he claims that they are jealous of him and not even worth his time. Which of the following disorders best describes this man?

      a.  Antisocial personality disorder

      b.  Borderline personality disorder

      c.  Histrionic personality disorder

      d.  Narcissistic personality disorder

      e.  This man does not have a diagnosable disorder; he is just too conceited

65. The distraught parents of a 23-year-old man bail their son out of jail for the fourth time. He had always been “a troublemaker,” but this had worsened over time, and in the prior 6 years, he had been arrested for assaulting a police officer, theft, reckless driving, and most recently for vandalism. He had dropped out of school at the age of 16 and had never maintained legitimate employment for more than a few weeks. He sustained his income by stealing, selling drugs, selling weapons, and conning older frail and ill women in their neighborhood out of thousands of dollars. He expressed no remorse or regret for any of his actions and seemed amused by his parents’ tears and pleas. Which of the following disorders best describes this man?

      a.  Antisocial personality disorder

      b.  Borderline personality disorder

      c.  Histrionic personality disorder

      d.  Narcissistic personality disorder

      e.  Conduct disorder

66. The boyfriend of a 19-year-old woman broke up with her because “there’s just too much drama” in their relationship. Two days later, she called him and told him she was calling to say goodbye because she was planning to take 100 pills of acetaminophen to “end the pain” because she loved him and could not imagine living without him. After she is treated in the hospital for suicidal ideation and released, she vandalizes her ex-boyfriend’s house and assaults him, yelling at him repeatedly about how much she hates him. She has had two other suicide gestures previously, once when another boyfriend had broken up with her and another time when she had a fight with her best friend. She has multiple scars on her arms and chest from self-inflicted cuts with a knife, and when asked about them states, “I feel empty and dead, and it makes me feel alive.” She is sexually promiscuous, and engages in sexual activity with strangers because they “help fill the emptiness.” Which of the following disorders best describes this woman?

      a.  Antisocial personality disorder

      b.  Borderline personality disorder

      c.  Histrionic personality disorder

      d.  Narcissistic personality disorder

      e.  Impulse control disorder

67. A 26-year-old woman frequents several bars and clubs on a regular basis, and prides herself on being the “life of the party.” At social events, she frequently partially undresses and then dances on tables and chairs in a dramatic and sometimes indecent manner. When a man that she has danced with starts speaking with another woman, she may confront the woman for “stealing her man” (though often she has not known the man for more than a few hours). When she does not receive the attention she would like, she becomes tearful and creates a scene about the smallest occurrence, until the majority of those present have contributed efforts in soothing her and calming her down. Which of the following disorders best describes this woman?

      a.  Antisocial personality disorder

      b.  Borderline personality disorder

      c.  Histrionic personality disorder

      d.  Narcissistic personality disorder

      e.  Impulse control disorder

68. Which of the following statements is incorrect regarding the mechanism of action of the antidepressants listed?

      a.  Duloxetine and venlafaxine strictly inhibit reuptake of norepinephrine

      b.  Mirtazapine, by acting as an antagonist at presynaptic α2-receptors, enhances presynaptic release of norepinephrine and serotonin, and also acts as an antagonist at 5-HT2 and 5-HT3 receptors

      c.  Bupropion may act by inhibiting reuptake of norepinephrine and dopamine, and increases presynaptic release of norepinephrine and dopamine

      d.  Trazodone works primarily through antagonism at the 5-HT2 receptor

      e.  Phenelzine and isocarboxazid are monoamine oxidase inhibitors and are rarely used in clinical practice

69. A 27-year-old man is living with his parents after losing his job. His parents notice that he has started collecting different types of wires and antennas, claiming that he has assembled a device that is communicating with extraterrestrial beings, which have designated him as their leader on earth. His parents would find him carrying on discussions while he was alone in his room. At the time of onset of these delusions and hallucinations, he did not show any depressive symptoms, but 2 months later, he began to show significant symptoms of depression, in addition to the psychotic symptoms. Three months later, he attempts suicide. He is admitted to an inpatient psychiatric unit and is treated pharmacologically; his depression resolves, but his delusions persist, though attenuated, and he continues to have occasional hallucinations for several months. What is the most likely diagnosis in this patient?

      a.  Major depressive disorder

      b.  Depression with psychotic features

      c.  Schizophrenia

      d.  Schizoaffective disorder

      e.  Bipolar disorder

70. An 83-year-old man with moderate Alzheimer’s disease is brought to his neurologist by his daughter. She reports he has been waking up at night and trying to leave the house. He has been very agitated at night, and once claimed that there were burglars digging a tunnel under his house, and began searching for his rifle so that he could protect his family. A few times, he has become so agitated that he pushed his daughter, and once mistook his wife for an intruder and hit her. During the day, he is less agitated, but does have hallucinations that seem to frighten him tremendously. The family wants to keep the man at home, despite the difficulties in his care. The neurologist discusses with the family therapeutic options, including an atypical antipsychotic agent. Which of the following statements is incorrect regarding use of atypical antipsychotic agents in patients with dementia?

      a.  There is an increased risk of mortality in patients with dementia being treated with atypical antipsychotic agents

      b.  There is an increased risk of stroke in patients with dementia being treated with atypical antipsychotic agents

      c.  Atypical antipsychotic agents can be effective in the treatment of agitation or hallucinations and other behavioral and psychotic symptoms in dementia

      d.  There is an increased risk of thromboembolic events in patients with dementia treated with atypical antipsychotic agents

      e.  Because of the risks associated with atypical antipsychotics in patients with dementia, they are absolutely contraindicated in this patient population

71. A 62-year-old man with a history of depression presents to the psychiatrist with his first episode of major depression. He has not been sleeping well, and has had significant weight loss. He is suffering from erectile dysfunction, and complains of poor memory. Which of the following is incorrect regarding management of this patient?

      a.  Optimal treatment for depression involves both pharmacologic therapy and psychotherapy

      b.  Regardless of the antidepressant selected, a trial of 2 weeks of therapy is warranted before the medication is deemed ineffective

      c.  Electroconvulsive therapy can be effective for both psychotic and nonpsychotic forms of depression, but side effects include cognitive impairment

      d.  If a patient does not respond to the initial antidepressant chosen, he has an approximately 50% chance of response to an antidepressant from a different class

      e.  In the treatment of depression, among the various antidepressants, clear superiority of one agent versus another has not been unequivocally demonstrated for the treatment of depression

Questions 72–74

72. Which of the following is correct regarding the second generation of antipsychotics, so-called atypical antipsychotics?

      a.  They function primarily by antagonizing D2 receptors

      b.  They are more efficacious that the typical antipsychotics

      c.  They do not lead to extrapyramidal side effects

      d.  They differ from the typical antipsychotics in that they are antagonists at serotonergic 5-HT2A receptors, and exert their action primarily at that receptor

      e.  They are available only in oral or sublingual preparations

73. Regarding the adverse effects of atypical antipsychotic medications, which of the following is incorrect?

      a.  Patients being treated with atypical antipsychotics should be regularly monitored for diabetes and dyslipidemia

      b.  These medications can lead to arrhythmias

      c.  The atypical antipsychotics have little activity at muscarinic and histaminic receptors

      d.  Weight gain is a significant concern with these agents

      e.  Amenorrhea can occur with exposure to atypical antipsychotics

74. Some of the individual antipsychotics are more likely to lead to specific side effects than others. Which of the following medication-side effect pair is least likely to be of concern in clinical practice?

      a.  Clozapine and seizures

      b.  Quetiapine and sedation

      c.  Olanzapine and urinary retention

      d.  Clozapine and agranulocytosis

      e.  Aripiprazole and QT prolongation

75. A 33-year-old woman is brought to the emergency department after being found on the floor of her apartment with an empty bottle of oral diazepam on the floor next to her. She had filled the prescription the prior day, and there is a high suspicion that she had ingested more than 20 tablets in suicidal intent. On examination, she is comatose, and respiratory rate is 8. Which of the following medications should be administered in the treatment of this patient?

      a.  Naloxone

      b.  Naltrexone

      c.  Flumazenil

      d.  Thiamine

      e.  Dextrose

76. Which of the following is incorrect regarding the neurotransmitters glutamate and aspartate?

      a.  Overactivity at glutamate receptors leads to the phenomenon of excitotoxicity

      b.  Glutamate and aspartate are the principle excitatory neurotransmitters in the CNS

      c.  NMDA acts as an agonist at subtypes of glutamate receptors

      d.  Memantine is an example of an NMDA agonist

      e.  NMDA receptors are involved in the phenomenon of long-term potentiation

77. Which of the following psychotropic medications has been associated with an increased risk of seizures?

      a.  Bupropion

      b.  Clozapine

      c.  Olanzapine

      d.  Flumazenil

      e.  All of the above

Questions 78–79

78. Which of the following medications is not used in the treatment of bipolar disorder?

      a.  Lithium carbonate

      b.  Valproic acid

      c.  Lamotrigine

      d.  Risperidone

      e.  Levodopa

79. A 33-year-old woman is brought to a psychiatrist by her family for severe depressive symptoms, including insomnia, reduced appetite with weight loss, and anhedonia. By history, it is apparent that she has suffered several manic episodes in the past. She is started on an antidepressant as well as a mood-stabilizing agent. Her depressive symptoms improve somewhat, but she continues to have reduced appetite and reduced oral intake. On follow-up 6 weeks later, she has multiple complaints, an eruption of acne on her arms and face, and a tremor. On routine laboratory testing, her serum sodium is noted to be 155. Which of the following medications is she most likely being treated with?

      a.  Lithium carbonate

      b.  Sertraline

      c.  Lamotrigine

      d.  Risperidone

      e.  Topiramate

Answer Key

1. b

2. a

3. a

4. c

5. c

6. d

7. d

8. c

9. b

10. c

11. a

12. e

13. e

14. d

15. a

16. c

17. d

18. e

19. c

20. b

21. e

22. d

23. d

24. c

25. b

26. e

27. b

28. a

29. c

30. b

31. c

32. e

33. a

34. c

35. c

36. d

37. c

38. a

39. b

40. a

41. e

42. b

43. c

44. a

45. d

46. e

47. c

48. d

49. e

50. a

51. d

52. e

53. e

54. a

55. b

56. c

57. d

58. c

59. e

60. b

61. d

62. e

63. a

64. d

65. a

66. b

67. c

68. a

69. d

70. e

71. b

72. d

73. c

74. e

75. c

76. d

77. e

78. e

79. a

Answers

 1. b, 2. a

This woman’s initial presentation is consistent with major depressive episode; following her second episode of depression 3 years later, a diagnosis of major depressive disorder can be made.

The diagnostic criteria for major depressive episode include the following (Diagnostic and Statistical Manual—Text Revision (DSM-IV-TR, 2000)):

A. Five or more of the following symptoms present over a 2-week period, nearly every day, that represent a change from previous function, with at least one symptom including either depressed mood or loss of pleasure:

–  Depressed mood for most of the day nearly every day, either subjective or as observed by others

–  Diminished interest or pleasure

–  Significant unintentional weight loss or weight gain

–  Insomnia or hypersomnia

–  Psychomotor agitation or retardation as observed by others

–  Fatigue or loss of energy

–  Feelings of worthlessness or excessive/inappropriate guilt

–  Diminished ability to think or concentrate

–  Recurrent thoughts of death, suicidal ideation, or suicide plan or attempt

B. Symptoms do not meet criteria for a mixed episode

C. Symptoms cause significant distress or functional, social, and/or occupational impairment

D. Symptoms are not due to a substance, medical condition, or bereavement

Major depressive disorder is diagnosed after the occurrence of two or more major depressive episodes that occurred at least 2 months apart. Dysthymic disorder is discussed in question 29 and bipolar disorder in questions 10 and 11. The DSM-IV no longer includes depressive personality disorder as a diagnosable personality disorder.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Hales RE, Yudofsky SC, Gabbard GO (Eds). The American Psychiatric Publishing Textbook of Psychiatry. Arlington, VA: American Psychiatric Publishing Inc; 2008.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

 3. a

The occurrence of psychotic features does not preclude a diagnosis of major depressive episode. Depression with psychotic symptoms, such as delusions and even hallucinations, may occur, particularly in older adults, but the psychotic symptoms develop during the course of the depression, and the diagnostic criteria for schizophrenia (discussed in questions 24 and 25) or schizoaffective disorder are not met (discussed in question 69). The occurrence of psychotic symptoms in depression is a sign of higher severity of depression and a higher risk of recurrence.

In older adults, depression may masquerade as cognitive impairment, what has also been termed “pseudodementia.” Diminished appetite and insomnia are the more common neurovegetative symptoms in depression; with atypical depression, hyperphagia (excessive eating) and hypersomnolence (excessive sleeping) occur. Up to 30% of patients with major depressive disorder have a seasonal pattern to their symptoms, with episodes of depression and remission temporally related to specific seasons.

 Hales RE, Yudofsky SC, Gabbard GO (Eds). The American Psychiatric Publishing Textbook of Psychiatry. Arlington, VA: American Psychiatric Publishing Inc; 2008.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

 4. c

There are no differences in the occurrence of depression among different races if social class, education, and area of residence are controlled for. Depression is the most common mood disorder. Depression carries with it significant morbidity, and is a common cause of disability. It is approximately twice as common in females as compared to males across all age groups. Its incidence peaks in the third and fourth decades of life, but it can occur at any age. It is more common among lower socioeconomic populations and in those living in urban as compared to rural areas.

 Hales RE, Yudofsky SC, Gabbard GO (Eds). The American Psychiatric Publishing Textbook of Psychiatry. Arlington, VA: American Psychiatric Publishing Inc; 2008.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

 5. c

Genetic factors explain approximately 50% to 70% of the etiology of mood disorders, but environmental factors also play a large role. Mood disorders are familial, and both unipolar depression and bipolar disorder are more common among family members of patients with mood disorders, as is alcoholism. Linkage studies have identified several chromosomal regions linked to bipolar disorder. Genes associated with mood disorders include the genes that encode for serotonin and dopamine transporters, the gene for brain-derived neurotrophic factor, and the cyclic-AMP response element-binding protein gene. Studies have found that patients with specific polymorphisms of a serotonin transporter have an increased chance of developing a mood disorder following negative life events.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

 6. d

The dorsolateral prefrontal cortex has been shown to be hypometabolic in patients with depression, whereas the orbitofrontal cortex is hypermetabolic, and pharmacologic therapies have been shown to reverse these changes. The pathophysiology of depression is clearly complex, and dysfunction of one specific brain area does not account for the occurrence of depression. Rather, depression results from alterations in neuronal function in many brain areas and their connections. The subcallosal cingulate gyrus is one of the potential targets for deep brain stimulation for the treatment of depression; it is a central component of the limbic system and the connections between frontal and subcortical circuits, and is metabolically overactive in depression. Other potential targets include the ventral portion of the anterior limb of the internal capsule. While gross hippocampal volume is likely preserved in depression, hippocampal abnormalities have been demonstrated, and these at least in part relate to abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis and the effects of glucocorticoids on the hippocampus. Patients with depression have elevated levels of corticotrophin-releasing hormone and other abnormalities of the HPA axis.

 Malone DA Jr, Dougherty DD, Rezai AR, et al. Deep brain stimulation of the ventral capsule/ventral striatum for treatment-resistant depression. Biol Psychiatry. 2009; 65:267–275.

 Mayberg HS, Lozano AM, Voon V, et al. Deep brain stimulation for treatment-resistant depression. Neuron. 2005; 3(45):651–660.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

 7. d, 8. c

The episodes described in question 7 are most consistent with panic attacks. Panic attacks are discrete episodes of symptoms that include a sense of intense fear associated with four or more of the following symptoms: palpitations, diaphoresis, trembling, dyspnea, feeling of choking, chest discomfort, nausea or abdominal pain, dizziness, derealization (a feeling of unreality) or depersonalization (a feeling of being detached from oneself), fear of losing control, fear of dying, paresthesias, and/or chills or hot flashes. Other types of panic attacks are cued, being situationally bound: occurring in relation to a specific internal or external trigger.

Panic disorder is diagnosed when recurrent panic attacks occur, associated with concern for having additional attacks, concern over the implications of these attacks, and changes in behavior as a result of the occurrence of these attacks. Panic disorder may occur in isolation or may be associated with agoraphobia. Agoraphobia is characterized by a fear of being in places or situations where escape would be difficult or embarrassing, or in which help would be difficult to obtain, as depicted in question 8. Agoraphobia may occur in isolation as well. The course of panic disorder is typically variable, with periods of exacerbations and remissions. Improvement occurs with age.

The differential diagnosis of panic disorder includes several medical conditions that need to be excluded on the basis of the history and examination, including but not limited to thyroid disorders, pheochromocytoma, and arrhythmias or other primary cardiac conditions.

Separation anxiety disorder is an anxiety disorder of childhood characterized by excessive and inappropriate fear of being away from home or from familiar figures such as parents or siblings. It usually presents around 6 months of age and declines by ages 2 to 3 years, but may persist and/or recur during ages 6 to 12 years.

Borderline personality disorder is discussed in questions 64 to 67, cyclothymic disorder in question 12, post-traumatic stress disorder in question 19, and generalized anxiety disorder in question 18.

 Mayberg HS, Lozano AM, Voon V, et al. Deep brain stimulation for treatment-resistant depression. Neuron. 2005; 3(45):651–660.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

 9. b

This man’s history is consistent with dissociative amnesia. Dissociative amnesia is one of the dissociative disorders and is characterized by inability to recall a personal experience, with the amnesia being too extreme to be attributed to ordinary forgetfulness. The information forgotten usually relates to a stressful event. Some patients regain memory of the event, whereas others remain chronically amnestic for it.

Depersonalization disorder is another dissociative disorder in which there are intermittent or constant feelings of detachment from oneself as if a person is viewing him- or herself as an outside observer.

In another dissociative disorder, dissociative identity disorder (commonly known as “multiple personality disorder”), a person exists in two or more distinct identities or states, with these identities each unaware of the other and with each separately taking control of the person’s behavior over different time periods.

Patients with dissociative fugue suddenly and unexpectedly travel away from their environment and are then unable to recall their past or their identity, and may assume a partial or completely new identity.

Post-traumatic stress disorder (PTSD) is discussed in question 19; patients with dissociative amnesia may subsequently develop PTSD.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

10. c, 11. a

This man’s presentation is consistent with an acute manic episode. The diagnostic criteria for acute manic episode include the following (Diagnostic and Statistical Manual—Text Revision (DSM-IV-TR, 2000)):

A. A distinct period of abnormally elevated or irritable mood of at least 1-week duration

B. During the mood disturbance, three or more of the following symptoms have been persistently present:

–  Inflated self-esteem or grandiosity

–  Decreased need for sleep

–  Increased talkativeness and pressured speech

–  Flight of ideas or racing thoughts

–  distractibility

–  Increased goal-directed behavior

–  Excessive involvement in pleasurable activities with the potential for negative consequences

C. Symptoms do not meet criteria for a mixed episode (see below)

D. The mood disturbance is severe enough to cause marked functional impairment or require hospitalization

E. The mood disturbance is not due to a substance or general medical condition

In a mixed episode, criteria for both an acute manic episode and an acute depressive episode are met over at least a 7-day period, with rapid shifts between or combinations of manic symptoms, psychotic symptoms, and/or depressive symptoms.

In acute hypomanic episode, there is a persistently elevated mood for at least 4 days, in addition to the symptoms of mania described above under diagnostic criterion A, but in contrast to an acute manic episode, symptoms are milder and the patient characteristically has insight, without significant functional impairment.

Bipolar I and II disorders are diagnosed when one manic or hypomanic episode have occurred, respectively. A prior history of depression is not required for the diagnosis. However, in a patient with a depressive episode, a diagnosis of bipolar disorder is not made unless there is a history of symptoms meeting diagnostic criteria for acute manic or hypomanic episode as well.

Bipolar disorder is equally common in males and females. The first episode of either mania or depression typically occurs in young adulthood.

Borderline personality disorder is discussed in question 64 to 67 and cyclothymic disorder in question 12.

 Hales RE, Yudofsky SC, Gabbard GO (Eds). The American Psychiatric Publishing Textbook of Psychiatry. Arlington, VA: American Psychiatric Publishing Inc; 2008.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

12. e

This man’s history is consistent with cyclothymic disorder. This disorder can be thought of as a clinically attenuated form of bipolar disorder with symptoms spanning over several years. It is a disorder characterized by periods of hypomania and separate periods of depressive symptoms (which do not meet criteria for major depressive disorder) that have been occurring for at least 2 years. There are infrequent intervening periods of euthymia (normal mood). These patients often have pervasive conflicts in interpersonal relations. Bipolar I and II disorders are discussed in questions 10 and 11; borderline personality disorder is discussed in questions 64 to 67.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Sadock BJ, Sadock VA (Eds), Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

13. e, 14. d

These patients’ histories are consistent with phobias, which are classified under anxiety disorders. A phobia is an excessive fear of an object or situation. The phobias include agoraphobia (discussed in question 8), social phobia, and specific phobia.

The main features of phobias include a fear of a clearly identifiable object or situation, with exposure invariably leading to an anxiety response (which may or may not meet diagnostic criteria for panic attack). The phobia is severe enough to affect function and active avoidance of the object or situation occurs.

There are five types of specific phobias: (i) animal type (phobia of animals in general or a specific animal, such as a dog, or spiders (arachnophobia); (ii) natural environmental type (phobia for specific environmental or natural occurrences such as heights (acrophobia), thunderstorms, or water (hydrophobia)); (iii) blood-injury type (fear of blood (hemophobia) or of a bloody injury, or fear of needles (such as fear of venipuncture)); (iv) situational type (fear of specific situations or experiences such as fear of being in a closed space (claustrophobia) or transportation on airplanes or trains); and (5) residual type (when the phobia does not fit into the latter four categories).

Social phobia is characterized by fear of social or performance situations, such as fear of speaking in front of an audience or fear of eating in front of others. There is often a fear of potential embarrassment. The anxiety or fear is severe enough to affect function. Patients with social phobias may force themselves into the phobic situation but experience significant symptoms during that time.

Phobias are among the most common psychiatric disorders. They are more common in females. Adults with phobias often recognize their phobias as being excessive or unreasonable, though children with phobias may not. Fear of blood is often familial, and may be associated with recurrent vasovagal attacks on exposure to blood. Comorbid anxiety disorders often occur. Situational phobias may also be familial, and are epidemiologically similar to panic disorder with agoraphobia.

Generalized anxiety disorder is discussed in question 18. Panic disorder and agoraphobia are discussed in questions 7 and 8. Agoraphobia is a type of phobia, but differs from social phobia in that agoraphobia is fear of being in a social situation in which escape would be difficult, whereas social phobia is a fear of the social situation itself and its implications.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

15. a

Serum concentrations of a medication do not necessarily reflect brain concentrations. This is in large part related to the blood-brain barrier (BBB) and blood-CSF barrier, which are selectively permeable barriers to diffusion or transport of substances from the bloodstream into the CNS. The BBB is formed from continuous tight junctions between brain capillary endothelial cells and also results from unique characteristics of pericapillary glial cells. The blood-CSF barrier is formed from tight junctions between epithelial cells in the choroid plexus. When intact, the BBB limits diffusion of most macromolecules and allows selective permeation of some small charged molecules (including neurotransmitter precursors and metabolites, and some drugs) through specific transport systems. Nonionized molecules and lipophilic (lipid-soluble) drugs have higher penetration into the CNS. Transport systems may also allow penetration of drugs into the CNS. The BBB also contains transport systems that allow efflux of substances out of the CNS. Metabolites of neurotransmitters are cleared through an acid transport system in the choroid plexus. The BBB does not exist in the peripheral nervous system, and is absent or less prominent in the circumventricular organs: the median eminence, area postrema, pineal gland, subfornical organ, and subcommissural organ. The BBB is disrupted by ischemia and inflammation, or can be intentionally disrupted with drugs such as mannitol, allowing access of substances that would not normally penetrate into the brain.

 Brunton LL, Lazo JS, Parker KL (Eds). Goodman and Gilmans’ Pharmacological Basis of Therapeutics, 11th ed. New York: McGraw-Hill; 2005.

16. c

This woman’s history and examination are consistent with schizophreniform disorder: she exhibits multiple positive symptoms, including auditory hallucinations, grandiose delusions, disorganized thoughts, neologisms, and poor hygiene. Schizophreniform disorder is diagnosed when diagnostic criteria A, D, and E of schizophrenia are met (discussed in questions 24 and 25), but when symptom duration is more than 1 month and less than 6 months. These patients are managed similar to those with schizophrenia. Of patients with schizophreniform disorder, two-thirds eventually meet diagnostic criteria for schizophrenia and one-third recover within 6 months of symptom onset. Predictors of good prognosis include occurrence of psychotic symptoms within 4 weeks of change in behavior or functioning, presence of prominent positive symptoms, disorganization of thought, confusion, and good premorbid function.

Symptom duration distinguishes brief psychotic disorder (<1 month of symptoms) from schizophreniform disorder. Schizoid personality disorder is discussed in questions 41 to 43; the symptoms are more pervasive than in schizophreniform disorder. Schizoaffective disorder, characterized by both psychotic and affective symptoms, is discussed in question 69.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

17. d

Obsessive-compulsive disorder (OCD) is one of the anxiety disorders, and the main features of it are obsessions and compulsions. Obsessions are persistent ideas, thoughts, or impulses that provoke significant anxiety and distress. Compulsions are repetitive physical or mental acts that are meant to counteract the distress caused by an obsession. In order for a patient to meet diagnostic criteria for OCD, the individual (if an adult) must have recognized that these obsessions or compulsions are unreasonable or excessive, and the obsessions or compulsions must cause significant distress, be time consuming (more than 1 hour a day), and/or significantly affect function.

OCD typically begins in adolescence or early adulthood, but can begin in childhood. It is equally common in males and females, though males have an earlier age of onset. Other psychiatric conditions that are frequently comorbid with OCD include depression, attention deficit hyperactivity disorder, and eating disorders. Approximately 50% of patients with Tourette’s syndrome also suffer from OCD. Deep brain stimulation of the ventral portion of the anterior limb of the internal capsule for the treatment of OCD is being studied with promising results.

Generalized anxiety disorder is discussed in question 18, post-traumatic stress disorder in question 19, obsessive-compulsive personality disorder in questions 46 to 48, and bipolar disorder in questions 10 and 11.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Greenberg BD, Gabriels LA, Malone DA, et al. Deep brain stimulation of the ventral internal capsule/ventral striatum for obsessive-compulsive disorder: Worldwide experience. Mol Psychiatry. 2010; 15:64–79.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

18. e

This patient suffers from generalized anxiety disorder. The diagnostic criteria for this disorder include the following (Diagnostic and Statistical Manual—Text Revision (DSM-IV-TR, 2000)):

A. Excessive anxiety and worry occurring on most days for at least 6 months about various issues

B. Difficulty controlling the worry

C. Anxiety is associated with at least three of the following symptoms

–  Restlessness or feeling keyed up or on edge

–  Easy fatigability

–  Difficulty concentrating

–  Irritability

–  Muscle tension

–  Sleep disturbance

D. The focus of the anxiety is not related to another psychiatric disorder (such as worry about having a panic attack or worry about weight gain in patients with anorexia nervosa)

E. and F. The symptoms lead to functional impairments and are not due to substances or a medical condition

Generalized anxiety disorder is more common in females as compared to males, and usually begins in adolescence or young adulthood. Unlike panic disorder, which often improves with age, anxiety is significant during adulthood and older age.

Post-traumatic stress disorder is discussed in question 19, hypochondriasis in questions 20 to 22, social phobia in questions 13 and 14, and panic disorder in questions 7 and 8.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Hales RE, Yudofsky SC, Gabbard GO (Eds). The American Psychiatric Publishing Textbook of Psychiatry. Arlington, VA: American Psychiatric Publishing Inc; 2008.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

19. c

Post-traumatic stress disorder (PTSD) is an anxiety disorder characterized by the occurrence of specific symptoms after experiencing a traumatic event involving threat of death or injury to oneself or others, resulting in intense fear or horror. These symptoms include re-experiencing the traumatic event (such as through nightmares or flashbacks), avoiding any stimuli associated with the event, and experiencing symptoms of autonomic arousal (such as increased startle reflex, insomnia, hypervigilance, and irritability). A diagnosis of PTSD is made only after symptoms have been occurring for more than 1 month; within a 1-month period of symptom onset, a diagnosis of acute stress reaction is made. The majority of patients with PTSD develop complete remission; however, up to a fourth of patients develop a chronic disorder.

Generalized anxiety disorder is discussed in question 18, panic disorder in questions 7 and 8, and night terrors in Chapter 5.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

20. b, 21. e, 22. d

The somatoform disorders encompass disorders in which psychologic stresses manifest as physical symptoms. The somatoform disorders include somatization disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder.

As with the patient in question 20, somatization disorder is characterized by the occurrence of multiple recurrent somatic complaints that cannot be explained by a general medical condition or substance. This disorder typically begins prior to the age of 30, results in excessive nondiagnostic testing and unnecessary medical treatments, and/or significantly affects function. The symptoms must include pain related to at least four different sites (such as head, abdomen, joints, or chest) or functions (such as menstruation, sexual intercourse, urination, or sleep), at least one sexual or reproductive system complaint other than pain (such as irregular menses or erectile dysfunction), in addition to two gastrointestinal symptoms besides pain (such as nausea and bloating). In order for the diagnosis to be made, there must also be history of at least one symptom other than pain that is suggestive of a neurologic condition (such as weakness, dysphagia, urinary retention, paresthesias, or loss of consciousness). An undifferentiated form of somatization disorder, in which only one or more symptoms are present that cannot be fully explained by a medical condition, has also been defined.

As with the patient depicted in question 21, conversion disorder is characterized by acute loss of motor or sensory function that cannot be explained by a neurologic or other medical condition. The symptoms often resemble neurologic syndromes, such as hemiparesis, cerebellar ataxia, or seizures. Nonneurologic symptoms such as blindness, deafness, or false pregnancy (pseudocyesis) also occur. Conversion disorder is also classified as a dissociative disorder in some texts.

Pain disorder is diagnosed when there is the presence of pain as the most prominent symptom and the pain cannot be explained by an identifiable medical condition.

In hypochondriasis, there is pervasive preoccupation with physical symptoms and fear of having a serious disease for at least 6 months, often resulting from misinterpretation of physical symptoms, even after diagnostic testing and exclusion of the condition of concern or any other identifiable medical condition.

As with the patient in question 22, patients with body dysmorphic disorder experience an intense preoccupation with a perceived defect of appearance or overconcern with minor physical abnormalities, with symptoms present for at least 6 months. Such patients often seek unnecessary and repeated surgical procedures to correct their perceived deformity.

Somatoform disorders are more frequent in women. Patients with somatoform disorders often have a history of physical and/or emotional abuse and neglect. They frequently have comorbid psychiatric disorders, including mood and anxiety disorders, personality disorders, and substance abuse. For example, one-third of patients with conversion disorder suffer from a mood or anxiety disorder, and half from a personality disorder.

The key point distinguishing somatoform disorders from factitious disorder is that with somatoform disorders, symptoms are not intentionally feigned, whereas with factitious disorder, symptoms are voluntarily feigned for secondary gain. Factitious disorder, including Munchausen’s syndrome, is discussed further in question 44.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

23. d

The monoamine hypothesis of depression postulates that deficiencies or dysfunctions in the monoamines serotonin, dopamine, and norepinephrine are implicated in the pathogenesis of depression. Although there is evidence to support this hypothesis, this is yet to be unequivocally proved, and some studies have not found alterations in monoamines in depressed patients. Evidence to support the monoamine hypothesis includes the induction of depression by reserpine, which depletes monoamines, increased risk for depression in carriers of specific serotonin transporter promoter gene polymorphisms, and response of depression to medications that increase levels of monoamines. However, another theory of depression pathogenesis, the neurotrophic hypothesis, holds that depression results from loss of neurotrophic support by nerve growth factors such as brain-derived growth factor.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

24. c, 25. b

This patient’s history is consistent with schizophrenia. Schizophrenia is a psychotic disorder characterized by both positive symptoms, such as hallucinations, delusions, and disorganized thought, and negative symptoms, such as emotional blunting, alogia (empty speech), apathy, and reduced communicativeness. The diagnostic criteria for schizophrenia include the following (Diagnostic and Statistical Manual—Text Revision (DSM-IV-TR, 2000)):

A. Two (or more) of the following present for a significant portion of time over a 1-month period:

–  Delusions

–  Hallucinations

–  Disorganized speech (e.g., frequent derailment or incoherence)

–  Grossly disorganized or catatonic behavior

–  Negative symptoms, i.e., affective flattening, alogia (empty speech), or avolition (or only one of five if the delusions are bizarre and auditory hallucinations consist of a running commentary or a conversation between two or more voices)

B. Social and occupational dysfunction in work, interpersonal relations, or self-care since onset of the symptoms

C. Continuous symptoms for at least 6 months

D. D and E. Schizoaffective disorder, mood disorder, and disturbance due to substance or general medication condition have been excluded as the cause

E. In patients with a prior history of pervasive developmental disorder, prominent delusions and hallucinations of at least 6 months’ duration must be present

Schizophrenia affects 1% of the world’s population. It is more prevalent in lower socioeconomic populations, but the relationship between schizophrenia and socioeconomic status is complex. Low socioeconomic status is likely an effect rather than a cause of schizophrenia, relating to the “downward drift” effect, in which during the prodromal phase of schizophrenia an individual drifts down into a lower socioeconomic class. Schizophrenia is equally common in males and females, though males typically have a younger age of onset. Schizophrenia typically manifests in adolescence and early adulthood, though late-onset forms, with symptom onset after the age of 45, have also been described. Premorbidly (prior to the onset of positive symptoms), 25% of patients have abnormalities in social or cognitive function, with some features of schizoid personality disorder (discussed in question 42). Positive symptoms predominate in the earlier stages of the illness and may diminish overtime; positive symptoms are more responsive to typical antipsychotics compared to negative symptoms.

Delusional disorder is discussed in question 31, brief psychotic episode in question 62, schizoaffective disorder in question 69, and schizoid personality disorder in question 42.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Hales RE, Yudofsky SC, Gabbard GO (Eds). The American Psychiatric Publishing Textbook of Psychiatry. Arlington, VA: American Psychiatric Publishing Inc; 2008.

 Kirkbride JB, Barker D, Cowden F, et al. Psychoses, ethnicity and socio-economic status. Br J Psychiatry. 2008; 193:18–24.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

26. e

In older adults, selection of antidepressant medication should be done with various considerations in mind, most notably side effects and risk of drug-drug interactions. The tricyclic antidepressants (TCAs), as discussed on question 50, have various side effects including cardiac conduction abnormalities and drug-drug interactions that make them undesirable for the treatment of depression in older adults. A selective serotonin reuptake inhibitor is more favorable than a TCA in this patient. Fluvoxamine has a high risk for drug-drug interactions, whereas escitalopram does not. Fluvoxamine also has high protein binding, and can therefore interact with anticoagulant medications, such a warfarin. Therefore, of the medications listed, escitalopram is the most appropriate in this patient. In older adults, psychotropic medications should be started at a low dose and titrated up slowly to the lowest effective dose.

 Brunton LL, Lazo JS, Parker KL (Eds). Goodman and Gilmans’ Pharmacological Basis of Therapeutics, 11th ed. New York: McGraw-Hill; 2005.

27. b, 28. a

The disruptive behavior disorders include conduct disorder and oppositional defiant disorder. Question 27 depicts conduct disorder, which is characterized by a pervasive violation of rules, of others’ rights, and age-appropriate societal norms for at least 12 months, including aggression to people or animals, destruction of property, deceitfulness or theft, and serious violation of rules. Individuals with this disorder show little empathy or remorse. Conduct disorder is more common in males. Risk factors for conduct disorder include psychopathology in parents, dysfunctional family environment and poor parenting practices, exposure to physical, sexual, or emotional abuse or neglect, and exposure to violence. A diagnosis of antisocial personality disorder, discussed in questions 64 to 67, cannot be given to those younger than 18 years of age; some individuals with conduct disorder go on to meet criteria for antisocial personality disorder in adulthood, whereas in others, the conduct disorder remits and they are able to achieve adequate social and occupational adjustment. Management of conduct disorder centers primarily around institution of early multimodal psychosocial interventions to prevent conduct disorder when there are early signs of aggression or deviance in a child.

Question 28 depicts oppositional defiant disorder, in which there is a pattern of hostile and defiant behavior present for at least 6 months, not occurring as part of a mood or psychotic disorder, affecting function, and including at least four or more of the following: frequent loss of temper, frequent arguing with adults and defying or refusing to comply with adults’ requests or rules, deliberately annoying others, blaming others for mistakes or misbehaviors, angry and resentful behavior, oversensitivity, and spiteful or vindictive behavior. Oppositional defiant disorder most frequently emerges between ages 6 and 8, and is more common in males and those of lower socioeconomic status and in urban dwellers.

Acute manic episode is discussed in questions 10 and 11, borderline personality disorder in questions 64 to 67 (note: personality disorder cannot be made in individuals younger than 18 years of age), and antisocial personality disorder in questions 64 to 67.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

29. c

Dysthymic disorder is a mood disorder characterized by insidious and chronic symptoms of depression that have been present for at least 22 months over a 2-year period. It is different from major depressive episode and chronic depressive disorder. In the former, there is a clear-cut episode of depression with a relatively clear time of onset, and in the latter, there are persistent residual symptoms of depression after onset of a clear-cut major depressive episode. Rather, dysthymic patients often report they have always been depressed and express significant symptoms of depression, including hopelessness and anhedonia. Suicidal ideation, however, is not a common occurrence in dysthymic disorder, being much more common in severe depression. Dysthymic disorder is chronic and often difficult to treat pharmacologically. Depressive personality disorder is not a diagnosis on the basis of Diagnostic and Statistical Manual IV. Cyclothymic disorder is discussed in question 12.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Hales RE, Yudofsky SC, Gabbard GO (Eds). The American Psychiatric Publishing Textbook of Psychiatry. Arlington, VA: American Psychiatric Publishing Inc; 2008.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

30. b

Serotonin, or 5-hydroxytryptamine (5-HT), is synthesized in a two-step process. The first step is catalyzed by tryptophan hydroxylase, which converts the essential amino acid tryptophan into an intermediate that is subsequently converted into serotonin by action of the enzyme aromatic L-amino acid decarboxylase. Serotonin is metabolized by action of monoamine oxidase (MAO), predominantly the MAO-A isoform. MAO-B, along with MAO-A, metabolizes dopamine and tryptamine; low-dose selegiline is a selective inhibitor of MAO-B. There are at least seven classes and fourteen subtypes of 5-HT receptors. The 5-HT1, 5-HT2, and 5-HT4 subtypes are coupled to G-proteins (which either inhibit or activate adenylyl cyclase, depending on the subtype). The 5-HT3 receptor is a ligand-gated ion channel.

In the CNS, the principle site of serotonergic neuronal cell bodies is in the raphe nuclei of the brain stem, with diffuse projections to the brain and spinal cord. Serotonin has various actions both in the CNS and systemically. In the CNS, serotonin has a role to play in the sleep-wake cycle; serotonin deficiency leads to insomnia, and tryptophan (a serotonin precursor) promotes sleep. Serotonin has also been implicated in violent behavior; low CSF levels of the serotonin metabolite 5-hydroxyindole acetic acid (5-HIAA) have been associated with aggressiveness and violent impulsivity. Serotonin deficiency has also been implicated in both anxiety and depression. Regarding the nonpsychotropic effects of serotonin, the 5-HT1B receptors elicit vasoconstriction and the 5-HT1D receptors inhibit neuronal transmission and trigeminal neurogenic inflammatory peptide release. Triptan medications such as sumatriptan are agonists at these latter receptors. Action of serotonin at 5-HT2A receptors leads to platelet aggregation. Serotonin acts at 5-HT3 in the area postrema and the antiemetic ondansetron is an antagonist at this receptor. Serotonin is released by enterochromaffin cells in the intestines where it increases intestinal motility. It also induces bronchoconstriction, and patients with malignant carcinoid syndrome, in which there is excessive production of serotonin, manifest many of the symptoms of a hyperserotonergic state, including wheezing and diarrhea.

 Brunton LL, Lazo JS, Parker KL (Eds). Goodman and Gilmans’ Pharmacological Basis of Therapeutics, 11th ed. New York: McGraw-Hill; 2005.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

31. c

This gentleman has had a fixed delusion of greater than 1-month duration, without any other psychotic symptoms. The most likely diagnosis is delusional disorder. The diagnostic criteria for delusional disorder include the following (Diagnostic and Statistical Manual—Text Revision (DSM-IV-TR, 2000)):

A. Nonbizarre delusions of at least 1-month duration

B. Criterion A for schizophrenia has never been met (see questions 24 and 25)

C. Apart from the impact of the delusion or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre

D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods

E. The disturbance is not due to the direct physiologic effects of a substance or a general medical condition

This man is convinced that a famous personality is in love with him. His delusional disorder can therefore be classified as the erotomanic type. Other types of delusional disorder include the following:

–  Grandiose type, in which there are delusions of inflated worth, power, knowledge, or identity

–  Jealous type, in which there are delusions that an individual’s significant other is unfaithful

–  Persecutory type, in which the delusion is one of being persecuted by someone

–  Somatic type, delusions of having a physical defect or medical problem of some sort

The absence of psychotic features such as hallucinations, bizarre delusions, changes in affect, and changes in function distinguish delusional disorder from other psychotic disorders such as brief psychotic episode (discussed in question 62) and schizophrenia (discussed in questions 24 and 25). Schizoaffective disorder is discussed in question 69 and atypical depression in question 3.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

32. e

Suicide is unfortunately a common cause of death worldwide. It is a more common cause of death in males, though females attempt suicide more often than males. The rate of suicide increases with increasing age among Caucasians; in African-Americans beyond the fourth decade, the rate of suicide decreases. Caucasians have a higher rate of suicide as compared to African-Americans. Native Americans have the highest rate of suicide among all ethnicities in the United States. Approximately 60% to 70% of patients who have committed suicide were suffering from a mood disorder; patients with schizophrenia are also at an increased risk of suicide. Substance abuse and panic disorder are frequent comorbidities in patients who commit suicide. Among patients with personality disorders, those with borderline personality disorder (discussed in question 66) are most likely to attempt suicide.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

33. a

The selective serotonin reuptake inhibitors (SSRIs) have various systemic side effects related to action of serotonin at various receptor subtypes. The SSRIs include fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram, and escitalopram. They inhibit reuptake of serotonin through inhibition of the serotonin transporter, leading to increased availability of serotonin at the postsynaptic membrane. The antidepressant and/or anxiolytic effect of SSRIs may not become apparent for several days to weeks because their mechanism of action involves pre- and postsynaptic receptor changes that are not immediate.

They lead to various systemic effects due to the action of serotonin at various receptor subtypes (see question 30). They are used to treat mood disorders, including depression, premenstrual dysphoric disorder, and seasonal affective disorder; a variety of anxiety disorders, including generalized anxiety disorder, post-traumatic stress disorder, obsessive-compulsive disorder, and eating disorders, such as bulimia. The SSRIs are metabolized by the hepatic cytochrome P450 system and have various drug-drug interactions, with the extent varying with each of the SSRIs. Citalopram and escitalopram have the least potential for drug-drug interactions. At the time of this publication, the SSRIs were available only in oral formulation in the United States.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

34. c

Schizophrenia (discussed in questions 24 and 25) and other psychotic disorders are thought to result, at least in part, from overactivity in dopaminergic pathways. Dopaminergic pathways include the mesolimbic and mesocortical pathways (which project from the midbrain to the limbic system and neocortex), nigrostriatal pathway (which consists of neurons projecting from the substantia nigra to the dorsal striatum, including the caudate and putamen), and tuberoinfundibular system (which arises from the hypothalamus and projects to the pituitary; dopamine released by these neurons inhibits prolactin release from the pituitary). It is the limbic and cortical-subcortical pathways (mesolimbic and mesocortical pathways) that are thought to be overactive in psychosis, rather than the nigrostriatal and tuberoinfundibular pathways.

There are five dopamine receptors identified, D1 to D5. It is mainly the D2 receptor that is implicated in the dopamine hypothesis of schizophrenia. Support for the dopamine hypothesis comes from evidence that there is increased dopamine receptor density in the brains of schizophrenics postmortem and increased D2 receptor occupancy in the brains of schizophrenics on functional imaging. Improvement of psychosis with D2 antagonism and worsening of psychosis with dopaminergic agonists such as levodopa, amphetamines, and dopamine agonists further lend support to this theory. However, the dopamine hypothesis only partially explains the many features of schizophrenia and other psychotic disorders. For example, reduced dopaminergic activity in specific cortical areas including the medial temporal lobe and dorsolateral prefrontal cortex as well as the hippocampus is thought to underlie the negative symptoms of schizophrenia. The serotonin hypothesis of schizophrenia postulates a role for excessive serotonergic activity, particularly at serotonergic 5-HT2A receptors, in the pathogenesis of hallucinations and other symptoms of psychosis. The occurrence of hallucinations with exposure to lysergic acid diethylamide (discussed in Chapter 17), a serotonin agonist, lends support to this theory, as does the efficacy of atypical antipsychotics, which have serotonergic antagonism in addition to antidopaminergic activity. Underactivity of glutamate pathways, which normally excite inhibitory GABA pathways, has also been implicated in the pathogenesis of schizophrenia and other psychotic disorders, as evidenced by the ability of phencyclidine and ketamine (noncompetitive NMDA receptor antagonists, discussed in Chapter 17) to exacerbate cognitive dysfunction and psychosis in patients with schizophrenia.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

35. c

This patient’s history is consistent with intermittent explosive disorder (IED), an impulse control disorder characterized by several episodes of verbal or physical aggression that is out of proportion to an instigating event. In between episodes, patients may express remorse or regret for their actions. IED typically starts in adolescence or early adulthood and is more common in men. Treatment of IED includes psychotherapy, as well as pharmacotherapy with mood stabilizers (discussed in questions 78 and 79), antipsychotics (discussed in questions 53–55 and 72–74), or selective serotonin reuptake inhibitors (discussed in questions 33).

Oppositional defiant disorder is a disorder of childhood and is discussed in question 28; antisocial personality disorder and borderline personality disorder are discussed in questions 65 and 66.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

36. d

Kleptomania is an impulse control disorders and is defined as recurrent impulses to steal objects because of a sense of pleasure or gratification from the act of stealing, with the object being of little personal use or value. Kleptomania typically begins in adolescence, and is more common in women.

Other impulse control disorders include trichotillomania (recurrent pulling of one’s hair resulting in hair loss and a sense of pleasure or gratification), pyromania (deliberate setting of fires, a fascination with fire, and pleasure or gratification when setting fires or observing their aftermath), and pathologic gambling. Borderline personality disorder and antisocial personality disorder are discussed in questions 64 to 67; kleptomania or pyromania can occur as part of these personality disorders, but other features of these personality disorders are not depicted in question 36.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

37. c, 38. a

The eating disorders include anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified. The case in question 37 depicts anorexia nervosa, a disorder characterized by intentional maintenance of body weight below 85% of expected, an intense fear of gaining weight, an impaired self-perception of weight (such as denial of the seriousness of low body weight), and amenorrhea. Anorexia nervosa is of two types: The first is a restricting type, which occurs in approximately 50% of patients, in which there is self-induced starvation and often compulsive exercising without binge eating or purging behaviors. The second type is a binge eating/purging type, in which the patient regularly engages in binge eating followed by purging. Anorexia nervosa is treated at least initially in the inpatient setting to allow for medical stabilization and initiation of nutrition under close supervision. Later, outpatient therapy revolves mainly around psychotherapy, with pharmacologic management of comorbid mood or anxiety disorders.

In bulimia nervosa, depicted in question 38, patients binge eat over a discrete period of time at least twice a week for 3 months, with a sense of lack of control over the extent of food intake during that time period, and subsequently partake in compensatory behaviors to prevent weight gain such as excessive exercise, induction of emesis or misuse of laxatives, diuretics, or other medications. Treatment of bulimia nervosa involves psychotherapy combined in some cases with selective serotonin reuptake inhibitors (discussed in question 33). Bulimia nervosa is a common comorbidity seen in persons with borderline personality disorder (discussed in question 66).

In patients with eating disorder not otherwise specified, patients may avoid food, binge with or without purging or participating excessively in exercise, and partake in other methods of minimizing weight loss, but the patient’s weight is maintained within the normal range, the episodes of binging occur less than twice per week for 3 months, and menstruation remains regular. The binge eating form of eating disorder not otherwise specified is the most common eating disorder, followed by bulimia and anorexia nervosa.

Peak onset of eating disorders is in the teenage years, though they may begin at any age. Eating disorders are more common in females than in males, with a 3: 1 ratio, though males are likely underdiagnosed. The pathophysiology relates to be both environmental and genetic factors; there is a 50% to 80% concordance rate among monozygotic twins. Comorbid mood, anxiety, and personality disorders are common among patients with eating disorders.

The impulse control disorders are discussed in questions 35 and 36.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

39. b

The tricyclic antidepressants (TCAs) are among the oldest antidepressants and are still commonly used to treat depression. The TCAs with a tertiary amine side chain such as amitriptyline, doxepin, and imipramine inhibit reuptake of both serotonin and norepinephrine, whereas some such as clomipramine predominantly inhibit reuptake of serotonin. The TCAs do not directly inhibit reuptake of dopamine, though they may indirectly facilitate the effects of dopamine. All TCAs have some activity at muscarinic, histaminergic, and α-adrenergic receptors, though to varying degrees. Because of these effects at noncatecholaminergic receptors, they are used for various disorders not limited to depression and anxiety, including urinary retention and neuropathy. TCAs are also useful in the treatment of neuropathic pain.

 Brunton LL, Lazo JS, Parker KL (Eds). Goodman and Gilmans’ Pharmacological Basis of Therapeutics, 11th ed. New York: McGraw-Hill; 2005.

40. a

This boy exhibits features of reading disorder. The learning disorders include reading disorder, mathematics disorder, and disorder of written expression. In reading disorder, there is difficulty with learning to read (as opposed to loss of previously acquired reading skills), with reading achievement as measured by standardized tests being lower than would be expected for an individual’s age and measured intelligence.

In mathematics disorder, an individual’s mathematical abilities, as measured by standardized tests, are below that expected (and are manifested, for example, by impairments in rapid retrieval of number facts such as multiplication tables), whereas in disorder of written expression, performance in written expression is impaired (such as avoidance of writing, writing incomplete sentences, limited use of vocabulary, improper punctuation, and misspelling).

In individuals with specific learning disorders, capabilities in other domains are typically average or may be above average, though the various learning disabilities frequently co-occur. Mental retardation is defined by significantly subaverage general intellectual functioning, in more than one domain, as assessed by standardized tests. Mild mental retardation is defined by an intelligence quotient (IQ) of 55 to 70, moderate mental retardation by an IQ of 35 to 55, severe mental retardation by an IQ of 20 to 35, and profound mental retardation by an IQ of less than 20 (see also Chapter 14). Acquired dyslexia is a loss of language skills that were previously acquired, as may occur in patients with traumatic brain injury.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

41. e, 42. b, 43. c

The personality disorders consist of 10 distinct entities that share in common a pervasive and inflexible pattern of inner experiences, thoughts, and behaviors. They affect the domains of cognition, impulse control, affectivity, and interpersonal functioning. Features are present in adolescence or early adulthood and persist over time. They deviate from accepted societal culture and norms and lead to distress or impairment. The caveat to the diagnosis of personality disorders is that the features do not occur in the context of signs or symptoms that are part of a mood, anxiety, impulse control, or psychotic disorder, or any other psychiatric disorder as the primarily underlying illness. Personality traits are patterns of behavior or thinking about oneself and the environment that are relatively consistent over time, but they do not lead to a diagnosis of personality disorder unless they are maladaptive or cause functional impairment or distress. The personality disorders are categorized into clusters A, B, and C. Different personality disorders may co-occur in the same individual.

Questions 41 to 43 depict people that would be classified under cluster A of the personality disorders. This cluster includes paranoid, schizoid, and schizotypal personality disorders. Paranoid personality disorder, depicted in question 41, is marked by a pervasive distrust and suspiciousness of others, with convictions that others intend to exploit or harm, preoccupation with paranoid thoughts, distrust of others’ intentions, and interpretation of benign actions or remarks as criticism or harm. Persons with paranoid personality disorders have an increased risk of comorbid major depressive disorder (discussed in questions 1 and 2), substance abuse, and agoraphobia (discussed in question 8). Paranoid personality disorder is more common in males and may be an antecedent to paranoid type of delusional disorder (discussed in question 31).

Schizoid personality disorder, depicted in question 42, is marked by a blunted range of affect and emotions, and a lack of interest in social relationships and little pleasure in social activities, with a preference for solitude, and lack of close friends outside of the immediate family. Schizoid personality disorder is more common in males, and may appear as an antecedent to delusional disorder (discussed in question 31) or schizophrenia (discussed in questions 24 and 25).

Schizotypal personality disorder, depicted in question 43, is marked by a pervasive pattern of discomfort with and inability to participate in close relationships, and odd, peculiar, and eccentric ideas, beliefs, and/or behaviors such as magical thinking (such as superstitiousness or belief in clairvoyance or telepathy), paranoid ideation, constricted affect, lack of close friends outside of immediate family members, and social anxiety. Patients with schizotypal personality disorder have comorbid major depression in 30% to 50% of cases.

See the last paragraph to the discussion to questions 64 to 67 for a brief overview of the treatment of personality disorders.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

44. a

In factitious disorders, symptoms or signs are intentionally feigned, motivated by an intention to assume the role of the patient. The key feature is fabrication of subjective complaints, such as abdominal pain, or falsification of signs, such as intentional heating of a thermometer such that it shows an elevated reading. Munchausen’s syndrome is a chronic, severe form of factitious disorder in which extensive deceptive means are often employed in feigning physical signs, resulting in recurrent hospitalizations in various geographic locations. In factitious disorder by proxy (also called Munchausen’s syndrome by proxy), physical signs or symptoms are intentionally produced in another individual who is under the direct care of the perpetrator.

In malingering, the secondary gain is an external incentive (such as money). In comparison, the secondary gain in factitious disorder is assumption of the role of a patient.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

45. d

Five subtypes of schizophrenia have been defined: catatonic, residual, disorganized, paranoid, and undifferentiated. Diagnostic criteria for schizophrenia are discussed in questions 24 and 25.

Catatonia is defined as an extreme motor state, whether it be lack of movement or excessive movement. Patients with the stuporous catatonic subtype of schizophrenia show reduced movements and reduced communicativeness with mutism or even stupor occurring in severe cases. However, they may also exhibit outbursts and sometimes unprovoked violent behavior. Patients with the catatonic subtype also exhibit echolalia (echoing the words of others) and echopraxia (imitation of the gestures of others). In some cases, waxy flexibility is present. There is also a less common excited form of catatonia, marked by psychomotor agitation and sometimes continuous speaking.

The residual subtype of schizophrenia is diagnosed when the patient once met all criteria for schizophrenia, but when there continues to be only some symptoms, such as mild hallucinations, blunting of affect, or social withdrawal, which no longer meet diagnostic criteria.

Disorganized schizophrenia is characterized by prominent disorganization in thought, behavior, and speech, and with a blunted or inappropriate affect, whereas delusions and hallucinations are less prominent.

Patients with paranoid-type schizophrenia exhibit prominent delusions, frequently persecutory or grandiose. They also have prominent auditory hallucinations and are paranoid, but with relative preservation of cognitive function and affect.

In undifferentiated schizophrenia, the patient meets all diagnostic criteria for schizophrenia, but cannot be categorized into any of the specific subtypes.

 Hales RE, Yudofsky SC, Gabbard GO (Eds). The American Psychiatric Publishing Textbook of Psychiatry. Arlington, VA: American Psychiatric Publishing Inc; 2008.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

46. e, 47. c, 48. d

See the first paragraph of the discussion for questions 41 to 43 for the definition of personality disorders. Questions 46 to 48 depict people that would be classified under cluster C of the personality disorders. This cluster includes avoidant, dependent, and obsessive-compulsive personality disorders.

Avoidant personality disorder, depicted in question 46, is marked by hypersensitivity to criticism, feelings of inadequacy, and social inhibition, including avoidance of any occupation or other activity that will involve contact with others because of fear of criticism or rejection, restraint in personal relationships because of fear of being ridiculed, willingness to get involved with people only if certain of being liked, and viewing self as socially inept and inferior to others. Unlike persons with schizoid personality disorder (depicted in question 42), those with avoidant personality disorder want relationships but avoid them because of fear of criticism, whereas those with schizoid personality disorder prefer social isolation. Avoidant personality disorder shares features with panic disorder with agoraphobia (discussed in questions 7 and 8) but in the latter condition, avoidance is of specific social situations that lead to panic attacks. Avoidant personality disorder begins at an early age, without clear precipitants, and is stable over time. Social phobia (discussed in questions 13 and 14) and avoidant personality disorder may co-occur.

Dependent personality disorder, depicted in question 47, is marked by an excessive need to be taken care of, leading to clingy, submissive behavior and intense fear of separation, including difficulty making day-to-day decisions without advice and reassurance from others, a need for others to assume responsibility for major areas of life, avoidance of disagreement with others for fear of loss of approval, lack of self-confidence leading to avoidance of initiating projects or doing things independently, excessive need for support and nurturance by others, even if this entails doing or bearing unpleasant things, helplessness when alone because of fear of being unable to care for self, and urgent seeking of one relationship as a source of care if another relationship ends. Dependent personality disorder is equally common in males and females, and is one of the most common personality disorders.

Obsessive-compulsive personality disorder, depicted in question 48, is marked by a dysfunctional preoccupation with orderliness, perfection, and control at the expense of flexibility and efficiency, including preoccupation with details, rules, order, and schedules, to the point that the major purpose of an activity is lost. Other features include perfectionism that interferes with task completion, excessive devotion to work at the expense of leisure activities or friendship, inflexibility about moral matters and ethics, inability to discard worthless objects (to the extent of hoarding in some cases), reluctance to delegate tasks to others, frugal spending habits (money is seen as being something to hoard for future catastrophes), rigidity, and stubbornness. Although obsessive-compulsive disorder (discussed in question 17) may coexist with obsessive-compulsive personality disorder, distinct and definable obsessions and compulsions are absent in the latter, distinguishing the two.

See the last paragraph to the discussion to questions 64 to 67 for a brief overview of the treatment of personality disorders.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

49. e

This couple suffers from shared psychotic disorder, or folie à deux, a type of disorder in which a psychotic belief develops in an individual that is similar to that held by a close relation. The diagnostic criteria for schizophrenia are discussed in questions 24 and 25; on the basis of the history provided, a diagnosis of schizophrenia cannot be made in this man and woman. The features of somatoform disorder (discussed in questions 20-22) are not present in this case; it is not contagious. Histrionic personality disorder is discussed in questions 64 to 67; there is no evidence in the history to suggest that this man and woman have this type of personality disorder.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

50. a

Tricyclic antidepressants (TCAs) lead to urinary retention due to inhibition of detrusor function, rather than bladder overactivity. Because the TCAs all have, to varying degrees, activity at muscarinic, histaminergic, and α1-adrenergic receptors, they have various side effects. Antagonism at histamine receptors leads to sedation, xerostomia, and weight gain. Antimuscarinic activity leads to constipation, tachycardia, blurred vision (with increased risk of glaucoma), and urinary retention, and hence imipramine is used to treat overactive bladder and enuresis. α1-adrenergic antagonism can lead to postural hypotension, which can be particularly detrimental in older adults. Of the commonly used TCAs, amitriptyline has the highest anti-muscarinic activity and α1-adrenergic activity. Nortriptyline has the least α1-adrenergic antagonism and is therefore less likely to cause orthostatic hypotension. Doxepin has the highest anti-histamine activity, and is therefore the most sedating. At toxic doses, TCAs can cause confusion, seizures, and arrhythmias. TCAs are metabolized through oxidation by various cytochrome P450 isozymes and subsequently undergo glucuronidation. Because their metabolism is strongly dependent on cytochrome P450 enzymes, they have various drug-drug interactions.

 Brunton LL, Lazo JS, Parker KL (Eds). Goodman and Gilmans’ Pharmacological Basis of Therapeutics, 11th ed. New York: McGraw-Hill; 2005.

51. d

Matt and Tom, the boys depicted in question 51, exhibit the features of attention-deficit/hyperactivity disorder (ADHD). ADHD includes a predominantly inattentive type, as in Matt; a predominantly hyperactive type, as in Tom; or a combined type.

The diagnostic criteria for the inattentive type include six or more symptoms of inattention that have been present for the prior 6 months with at least some symptoms occurring before age 7 years that are leading to functional impairment and are not consistent with developmental level and include failure to pay attention to details in schoolwork or other activities, difficulty sustaining attention on a task or activity, not listening when spoken to and not following instructions, difficulty with organization, avoidance or dislike of tasks that require sustained mental activity, loss of objects necessary for tasks or activities, easy distractibility, and forgetfulness in daily activities.

The diagnostic criteria for the hyperactive type include six or more symptoms of hyperactivity and impulsivity that have been present for the prior 6 months with at least some symptoms occurring before age 7 years that are leading to functional impairment and are not consistent with the developmental level and include frequent fidgeting or squirming, leaving a seat in situations when remaining seated is expected, running about or climbing excessively in inappropriate situations, or feelings of restlessness, difficulty engaging quietly in leisurely activities, talking excessively, blurting out of answers, difficulty awaiting a turn, and interruption of others.

Although the etiology of ADHD is not clear, dysfunction in frontal-subcortical circuits has been implicated. Genetic studies have suggested involvement of genes involved in dopamine action or metabolism, though environmental factors play a role as well. Children of parents with ADHD and siblings of children with ADHD are more likely to be affected with ADHD than the general population.

Oppositional defiant disorder (discussed in question 28) is a distinct entity from ADHD, but the two are often comorbid. Similarly, generalized anxiety disorder, discussed in question 18, is also comorbid with ADHD, as are the disruptive behavior disorders (discussed in questions 27 and 28). Tic disorder also frequently occurs with ADHD. In childhood, academic failure and peer rejection are the major consequences of ADHD, whereas in adolescence, there is a threefold increase in substance use and abuse. Approximately 60% of patients with ADHD in childhood continue to be impaired in adult life; ADHD may also not be recognized until adulthood. Adults with ADHD typically show instability with employment and relationships.

The first line of treatment for ADHD are psychostimulants, including amphetamines and methylphenidates, of which there are various oral preparations. Common side effects include reduced appetite, weight loss, insomnia, and headaches. An electrocardiogram prior to initiation of stimulant medications is recommended to exclude underlying structural or conduction problems. Other medications used to treat ADHD include the nonstimulant atomoxetine, tricyclic antidepressants, antipsychotics, mood stabilizers, and the α2-agonist clonidine. Psychosocial treatment is also an important part of managing ADHD.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

52. e

The selective serotonin reuptake inhibitors (SSRIs) have various side effects. Gastrointestinal side effects, including nausea, result in part from action of serotonin at 5HT3 receptors in the area postrema, but also from increased serotonin at the level of the enteric nervous system. Tolerance to this side effect typically develops after a few days of therapy. SSRIs cause sexual dysfunction, particularly leading to erectile dysfunction in men. They can lead to irritability and increased suicidal thoughts, particularly in younger age groups. Some of the SSRIs can lead to insomnia, whereas others are more sedating. Sertraline is one of the least sedating SSRIs. Paroxetine has the highest anticholinergic activity and therefore causes several anticholinergic side effects, including xerostomia and urinary retention.

 Brunton LL, Lazo JS, Parker KL (Eds). Goodman and Gilmans’ Pharmacological Basis of Therapeutics, 11th ed. New York: McGraw-Hill; 2005.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

53. e, 54. a, 55. b

Despite the development of newer antipsychotic agents (see questions 72-74), the typical antipsychotics are still commonly used; randomized controlled trials have shown the typical antipsychotics to be efficacious and cost-effective. The antipsychotics are first-line agents in the treatment of schizophrenia, schizoaffective disorder, and other psychotic disorders, including depression with psychotic features. Antipsychotics are also used as augmentation therapy in major depressive disorder and in the treatment of delirium, Tourette’s syndrome (see Chapter 6), and behavioral and psychotic symptoms of dementia (discussed in question 70).

The typical antipsychotics, first brought into clinical use in the 1950s, include chlorpromazine and thioridazine, which have low potency at D2 (dopamine) receptors and higher antagonism at muscarinic, adrenergic, and histaminergic receptors. They are therefore more likely to cause side effects related to antagonism at these receptors, such as dry mouth, orthostasis, and sedation, respectively.

Those with higher potency at D2 receptors, such as haloperidol and fluphenazine, have activity at muscarinic, adrenergic, and histaminergic receptors as well and can lead to similar side effects, but are less likely to do so. On the other hand, they are more likely to lead to extrapyramidal side effects (EPS), which result from D2-antagonism in the nigrostriatal pathway. The EPS can be divided into acute reactions such as acute dystonia, which are in general reversible with treatment with anti-muscarinic agents such as benztropine, and tardive dyskinesia (such as the orolingual dyskinesias depicted in question 55, or tardive cervical dystonia), which are in general irreversible but may be treatable with botulinum toxin or deep brain stimulation to the globus pallidus interna (see Chapter 6).

Many of the typical antipsychotic agents can be administered orally, intravenous, or intramuscularly, making them convenient in the treatment of psychotic patients for whom oral administration is difficult. Prochlorperazine is an anti-dopaminergic agent used predominantly in the treatment of nausea.

 Brunton LL, Lazo JS, Parker KL (Eds). Goodman and Gilmans’ Pharmacological Basis of Therapeutics, 11th ed. New York: McGraw-Hill; 2005.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

56. c

This patient exhibits the features of adjustment disorder, which is a constellation of emotional and behavioral symptoms in response to a stressor that occurred within 3 months of symptom onset. This disorder is marked by distress that is in excess to what would be expected from the stressor, with impairment in social and occupational functioning, but that do not meet criteria for another disorder such as major depression (discussed in questions 1 and 2), and symptoms do not persist beyond 6 months of the stressor. Adjustment disorder may be further qualified as being accompanied by depressed mood, as in the patient depicted in question 56, or by anxiety.

Bereavement is a diagnosis that is made when an expectable response occurs in reaction to the death of a loved one. Adjustment disorder may subsequently be diagnosed if the bereavement reaction is more prolonged than would be expected (longer than 2 months) or more excessive than would be expected.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

57. d

The benzodiazepines belong to a class of medications known as the sedative-hypnotics by nature of their ability to induce an anxiolytic calming effect and sleep. They include alprazolam, midazolam, chlordiazepoxide, temazepam, triazolam, flurazepam, clorazepate, oxazepam, and diazepam. They act at GABAA receptors, facilitating the action of GABA and increasing chloride conductance.

The benzodiazepines may be used in the treatment of acute anxiety, as is seen in generalized anxiety disorder (discussed in question 18), panic disorder, and agoraphobia (discussed in questions 7 and 8). However, chronic use leads to tolerance (decreased response to a specific dose after repeated exposure) as well as physiologic dependence. Other adverse effects include memory disturbance, sedation, and respiratory depression in overdose (or even at therapeutic doses in those with pulmonary disease). Chronic therapy for anxiety disorders therefore includes medications such as the selective serotonin reuptake inhibitors, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors. The latter medications do not have acute effects on anxiety, and in the initial weeks of therapy, benzodiazepines are often used as adjuncts until the anxiolysis takes effect. Of the benzodiazepines, flurazepam and clorazepate have the longest half-lives. Triazolam has a rapid onset and short duration of action.

Besides the treatment of acute anxiety, benzodiazepines are also used in the treatment of seizures, alcohol withdrawal, spasticity and movement disorders, and insomnia. Benzodiazepines are available in various oral, sublingual, intravenous, and intramuscular formulations, making them useful in the treatment of emergencies such as status epilepticus, as well as in anesthesia.

Buspirone is an anxiolytic agent without sedative-hypnotic activity. Its mechanism of action includes partial agonism at serotonergic (5-HT1A) receptors as well as activity at dopaminergic D2 receptors.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

58. c

Whole-brain and CSF volume studies in patients with schizophrenia have shown reduced brain volumes and higher CSF volumes compared to normal controls. There is evidence of ventricular enlargement, particularly of the third and lateral ventricles, with sulcal widening. There is atrophy of areas of the frontal and temporal lobes, as well as the hippocampus and thalamus. PET studies have shown hypometabolism of the dorsolateral prefrontal cortex during activation tasks. PET studies have not shown resting regional cerebral blood flow abnormalities in patients with schizophrenia compared to controls. Bilateral caudate head atrophy occurs in Huntington’s disease, not schizophrenia.

 Hales RE, Yudofsky SC, Gabbard GO (Eds). The American Psychiatric Publishing Textbook of Psychiatry. Arlington, VA: American Psychiatric Publishing Inc; 2008.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

59. e

Hyponatremia is an established side effect of therapy with selective serotonin reuptake inhibitors (SSRIs). Risk factors include older age, female sex, and concomitant use of diuretics. Hyponatremia resulting from SSRIs typically occurs within the first month of therapy, but may not occur until several months after initiation of therapy. Among the SSRIs, fluoxetine and paroxetine are more likely to lead to hyponatremia. The pathophysiology of SSRI-induced hyponatremia is thought to at least in part be related to the syndrome of inappropriate antidiuretic hormone, resulting from excessive release of antidiuretic hormone mediated by activation of serotonergic receptors. Although there are no definitive data to support routine monitoring of serum sodium in patients started on an SSRI, any change in mentation or other symptoms potentially suggesting hyponatremia should prompt a laboratory evaluation for this complication. In isovolemic hyponatremia due to SSRIs, the treatment is discontinuation of the SSRI along with fluid restriction. In more severe symptomatic hyponatremia, treatment with intravenous sodium chloride may be indicated. Rechallenge with SSRIs may not necessarily lead to recurrent hyponatremia, though it can.

 Jacob S, Spinler SA. Hyponatremia associated with selective serotonin-reuptake inhibitors in older adults. Ann Pharmacother. 2006; 40:1618–1622.

60. b

Schizophrenia (discussed also in questions 24 and 25) is not thought to be a monogenic disorder; its genetics are thought to be more complex than simple Mendelian disorders, and it is not transmitted in an autosomal dominant fashion. Schizophrenia aggregates in families, and the results of epidemiologic studies, twin studies, adoption studies, and genetic linkage and association studies suggest that schizophrenia is a genetic disorder, with phenotypic expression of the disorder being influenced by a variety of environmental factors. The concordance rate (the rate of twins that are each affected) for schizophrenia is higher among monozygotic compared to dizygotic twins. Several schizophrenia susceptibility loci have been mapped to various chromosomes, with candidate genes including dysbindin on chromosome 6 and neuregulin-1 on chromosome 8. Other genetic abnormalities detected in schizophrenia include chromosomal deletions, trinucleotide repeat expansions, and copy number variants. As of 2009, genome-wide association studies have not identified single-nucleotide polymorphisms significantly associated with schizophrenia at a genome-wide level.

 Hales RE, Yudofsky SC, Gabbard GO (Eds). The American Psychiatric Publishing Textbook of Psychiatry. Arlington, VA: American Psychiatric Publishing Inc; 2008.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

61. d

This patient’s history and examination are consistent with serotonin syndrome. Serotonin syndrome results from overstimulation of brain stem serotonin receptors. Symptoms include encephalopathy, autonomic hyperactivity manifesting as hypertension, tachycardia, and diaphoresis, and myoclonus, hyperreflexia, and tremor. Serotonin syndrome can occur with any agent that increases serotonin, and has even been reported with monotherapy, but is more likely to occur with a combination of therapies that increase serotonin, and particularly with concomitant use of nonselective monoamine oxidase inhibitors. Treatment generally includes supportive care and withdrawal of the offending agent.

Serotonin withdrawal syndrome can occur with abrupt discontinuation of serotonergic medications such as selective serotonin reuptake inhibitors. Symptoms include dizziness, paresthesias, dysphoria, and in some cases encephalopathy. Therefore, gradual tapering of such medications is generally recommended.

Thyroid storm can lead to similar symptoms as in this patient, but given the history presented, serotonin syndrome is more likely.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

62. e

This man’s history is consistent with brief psychotic disorder. His symptoms started following a significant stressor and consisted of hallucinations, delusions, and disorganized speech, similar to the symptoms of schizophrenia. However, symptoms lasted less than 1 month, and did not recur, with a return to baseline. Brief psychotic disorder can also occur in the absence of an acute stressor, and can also occur postpartum.

The diagnostic criteria for brief psychotic disorder include the following (Diagnostic and Statistical Manual—Text Revision (DSM-IV-TR, 2000)):

A. Presence of one or more of the following: delusions, hallucinations, disorganized speech, and/or grossly disorganized or catatonic behavior

B. Duration of the episode is at least 1 day but less than 1 month, with eventual return to full premorbid function

C. Disturbance is not accounted for by other mood or psychotic disorders, and is not due to a substance or general medical condition

The duration of symptoms distinguishes brief psychotic disorder from the other choices listed. Schizophreniform disorder is discussed in question 16, schizophrenia in questions 24 and 25, delusional disorder in question 31, and schizoaffective disorder in question 69.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

63. a

GABA is an amino acid and the major inhibitory neurotransmitter in the CNS. Glycine is also an inhibitory amino acid neurotransmitter and plays a prominent role in the brain and spinal cord. GABA is synthesized from glutamic acid by action of the enzyme glutamic acid decarboxylase. Disorders of this enzyme lead to a deficiency in GABA and subsequently over-activation in the CNS, as is seen in stiff-person syndrome. The GABAAreceptor is an example of an ionotropic receptor, activation of which leads to opening of chloride channels. The GABAB receptor is an example of a metabotropic receptor, which is coupled to an inhibitory G protein, inhibiting adenylyl cyclase. Baclofen is an example of a selective GABAB receptor agonist; benzodiazepines act at GABAA receptors.

 Brunton LL, Lazo JS, Parker KL (Eds). Goodman and Gilmans’ Pharmacological Basis of Therapeutics, 11th ed. New York: McGraw-Hill; 2005.

64. d, 65. a, 66. b, 67. c

See the first paragraph of the discussion for questions 41 to 43 for the definition of personality disorders. Questions 64 to 67 depict people that would be classified under cluster B of the personality disorders. This cluster includes narcissistic, antisocial, borderline, and histrionic personality disorders.

Narcissistic personality disorder, depicted in question 64, is marked by pervasive grandiosity, demand for admiration, and a lack of empathy, including a sense of self-importance, preoccupation with perceived positive attributes such as success or beauty, a conviction of superiority over others, a sense of self-entitlement, manipulation of others to achieve ends, a lack of empathy, envy or beliefs that others are envious, fear of having flaws revealed, and arrogance. Narcissistic personality disorder is more common in males, and major depression (discussed in questions 1 and 2) and substance abuse are common comorbidities.

Antisocial personality disorder, depicted in question 65, is marked by a disregard for and violation of others since age 15, and includes disrespect of others and the law, deceptiveness, impulsivity, aggressiveness, recklessness, irresponsibility (in the workplace, financially, etc.), and lack of remorse, with indifference to harming others. Conduct disorder (discussed in question 27) is a prerequisite for the diagnosis of antisocial personality disorder; antisocial personality disorder cannot be diagnosed in those younger than 18. Impulse control disorder (discussed in questions 35 and 36) may occur in persons with antisocial personality disorder, but the other features of antisocial personality disorder discussed distinguish the two. Antisocial personality disorder is three times more common in males as compared to females.

Borderline personality disorder, depicted in question 66, is marked by pervasive impulsivity, instability in relationships, self-image, and affect, including dramatic efforts to avoid abandonment, unstable interpersonal relationships with alternations between idealization and devaluation (so-called splitting), unstable self-image, potentially self-damaging impulsivity (such as excessive spending, sexual promiscuity, or binge eating), recurrent suicidal gesture or threats or self-mutilation, marked reactivity of mood, feelings of emptiness, difficulty with control of anger, and self-related paranoia or dissociative symptoms. Borderline personality disorder is more common in females. Frequent comorbidities include major depression, eating disorder (particularly bulimia; discussed in question 38), and substance abuse.

Histrionic personality disorder, depicted in question 67, is marked by pervasive excessive emotionality and attention-seeking behavior, including constant need to be the center of attention, inappropriately seductive or provocative behavior, shallow and rapidly shifting emotions, use of physical appearance to draw attention to self, impressionistic and vague style of speech, theatricals and self-dramatization, with exaggerated expression of emotions, suggestibility, and consideration of relationships as being more intimate than they are. Histrionic personality disorder is more common in females, and common comorbidities include major depression, conversion disorder, and somatization disorder.

Patients with personality disorders lack insight into their pathology, but may be asked to seek care from a psychiatrist by family members or others in the setting of dysfunction in relationships, occupation, or otherwise. Treatment includes a combination of psychotherapy combined with pharmacotherapy aimed at the most prominent psychiatric symptoms (such as anxiolytics if anxiety is the main symptom, or mood stabilizers or antipsychotics if lability, aggression, or impulsivity are the most prominent symptoms).

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

68. a

Duloxetine and venlafaxine are selective serotonin-norepinephrine reuptake inhibitors (SNRIs): they inhibit reuptake of both serotonin and norepinephrine by inhibiting serotonin and norepinephrine transporters, respectively. The SNRIs and tricyclic antidepressants (TCAs), because they increase both norepinephrine and serotonin, are useful in the treatment of pain disorders. Unlike the TCAs, the SNRIs are selective and have little activity at muscarinic, histaminergic, and α-adrenergic receptors.

Mirtazapine has complex pharmacology; it acts as an antagonist at presynaptic α2-autoreceptors, increasing release of norepinephrine and serotonin, and also acts as an antagonist at 5-HT2 and 5-HT3 receptors. Its potent antagonism at histamine receptors accounts for its sedating effects. The mechanism of action of bupropion is not well understood, but animal studies have shown that it inhibits reuptake of norepinephrine and dopamine and increases presynaptic release of these neurotransmitters, without direct effects on the serotonin system. At high doses, bupropion increases risk of seizures. Bupropion, in addition to its use as an antidepressant, is used in smoking cessation. Trazodone and nefazodone act primarily by antagonism at the 5-HT2 receptor; trazodone was initially used as an antidepressant, but its primary use today is as a hypnotic (sedative) because it is highly sedating and little tolerance develops to its sedating effect over time. An adverse effect that may occur with trazodone therapy is priapism or prolonged painful erection. Phenelzine and isocarboxazid are monoamine oxidase inhibitors (MAOIs) and are among the oldest antidepressants that are rarely used in clinical practice today due to their side-effect profile. Because nonselective MAOIs block metabolism of tyramine, found in certain foods such as cheese and wine, a lethal reaction resulting from hyperadrenergic state can occur with use of MAOIs, particularly when taken with other agents that increase serotonin.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

69. d

Schizoaffective disorder is a psychotic disorder with a concomitant mood disorder. The main feature of this disorder is the occurrence of a depressive episode, manic episode, or mixed episode, concurrent with symptoms that meet criterion A for schizophrenia (see questions 24 and 25), all within an uninterrupted period of time. In addition, there must be delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. The time of onset of the mood and psychotic symptoms must be clearly discernable.

Schizoaffective disorder is distinguished from depression (discussed in questions 1 and 2) or mania (discussed in questions 10 and 11) with psychotic features in that in schizoaffective disorder, there must be at least a 2-week period during which psychotic symptoms are present without prominent symptoms of a mood disorder.

The diagnostic criteria for schizoaffective disorder include the following (Diagnostic and Statistical Manual—Text Revision (DSM-IV-TR, 2000)):

A. An uninterrupted period of illness during which at some time there is either a major depressive, manic, or mixed episode concurrent with symptoms that meet criterion A for schizophrenia (see questions 24 and 25).

B. During the same period of illness, there are delusions or hallucinations present for at least 2 weeks in the absence of prominent mood symptoms.

C. Symptoms that meet criteria for a mood episode are present for a significant portion of the total duration of the active and residual periods of the illness.

D. The disturbance is not explained by a general medical condition or a substance.

 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed., text revision, Washington, DC: American Psychiatric Association; 2000.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

70. e

Atypical antipsychotic agents (discussed in questions 72-74) can be efficacious in the treatment of behavioral and psychotic symptoms of dementia (BPSD), which include agitation and hallucinations. In this patient population, they carry significant risks, including increased mortality and increased risk of stroke and thromboembolic events. Despite these risks, in some patients, when BPSD poses a significant risk to the patient and his or her caregivers, as depicted in this case, their use may be indicated. Nonpharmacologic measures and medications besides atypical antipsychotic agents should be tried when feasible, though data regarding use of the latter in the treatment of BPSD are not robust. When necessary, atypical antipsychotic agents should be started at the lowest possible dose, and need for them should be reassessed regularly.

 Salzman C, Jeste DV, Meyer RE, et al. Elderly patients with dementia-related symptoms of severe agitation and aggression: Consensus statement on treatment options, clinical trials methodology, and policy. J Clin Psychiatry. 2008; 69:889–898.

71. b

Before an antidepressant is deemed ineffective, a trial of at least 6 weeks of therapy is warranted.

The treatment of major depressive episode includes both pharmacologic therapy and nonpharmacologic therapy, the latter mainly including psychotherapy. Electroconvulsive therapy can be effective after 8 to 12 sessions, but is often reserved for medication-resistant depression because of cognitive side effects.

Clear superiority of one antidepressant over another has not been demonstrated in meta-analyses, and choice of antidepressant may depend more on side-effect profile, risk of drug-drug interactions, cost, and other such factors unrelated to efficacy. For example, in the patient presented in question 71, a selective serotonin reuptake inhibitor may be undesirable because of the risk of erectile dysfunction; alternative antidepressants with less risk of sexual side effects include bupropion and venlafaxine. A sedating agent such as a tricyclic antidepressant or mirtazapine may help with his poor sleep. Venlafaxine can cause a dose-dependent increase in blood pressure, and may be best avoided in a patient with known hypertension.

Less than 50% of patients respond to the initial antidepressant selected, and augmentation with another agent or discontinuation with switching to an agent from another class is often necessary. Several algorithms have been developed to aid physicians in selection of the most appropriate antidepressant. The duration of therapy depends on the patient’s psychiatric history, response to treatment, and relapse rate. More than 80% of patients with an episode of major depression have at least one recurrence during their lifetime, and sometimes long-term and even life-long maintenance therapy with an antidepressant is required.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

 Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

72. d, 73. c, 74. e

The second generation of antipsychotics, so-called atypical antipsychotics, includes clozapine, olanzapine, quetiapine, risperidone, ziprasidone, and aripiprazole. These agents do have antagonistic activity at D2 (dopamine) receptors. However, their clinical antipsychotic effect results in large part from antagonism at serotonergic 5-HT2A receptors. Studies to date have not shown overall superior efficacy of the atypical antipsychotics over the typical ones, though atypical antipsychotics may be more effective at treating some of the negative symptoms of schizophrenia. Because they have less antagonism at D2 receptors, they are less likely to cause extrapyramidal side effects (EPS), but certainly can. As a class, the atypical antipsychotics carry with them an increased risk of weight gain, diabetes, and dyslipidemia. Patients being treated with these medications should therefore periodically be assessed for such side effects. Clozapine and olanzapine are most likely to lead to weight gain. Ziprasidone and aripiprazole are less likely to cause weight gain than the others.

Some of the typical and atypical antipsychotics including thioridazine, haloperidol, ziprasidone, and quetiapine have negative ionotropic action on the heart and a quinidine-like effect, leading to QT prolongation with the potential for arrhythmias. Aripiprazole is least likely to do so. Other cardiac side effects include myocarditis, which can rarely be seen with clozapine. The atypical antipsychotics also have activity at muscarinic, adrenergic, and histaminergic receptors, and several side effects result from activity at these sites. Clozapine can lead to agranulocytosis in 1% to 2% of patients, and patients being treated with this medication are required to have periodic complete blood counts checked. Clozapine also leads to a dose-dependent increased risk of seizures. Clozapine is least likely of all the atypical antipsychotics to lead to EPS. Because of the side-effect profile of clozapine, its use is usually limited to treatment of patients who have failed trials of other typical and atypical antipsychotics. Among the atypical antipsychotics, olanzapine has the highest antimuscarinic activity, and side effects resulting from this include dry mouth, urinary retention, confusion, and constipation. Clozapine also has significant antimuscarinic activity. Quetiapine has significant anti-histaminergic activity, and along with olanzapine, is the most likely to lead to sedation.

Dopamine inhibits prolactin release, and treatment with both typical and atypical antipsychotics can lead to hyperprolactinemia and amenorrhea resulting from dopaminergic antagonism in the tuberoinfundibular pathway. Some of the atypical antipsychotics are available in injectable forms, including long-acting depot formulations.

 Brunton LL, Lazo JS, Parker KL (Eds). Goodman and Gilmans’ Pharmacological Basis of Therapeutics, 11th ed. New York: McGraw-Hill; 2005.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

75. c

Flumazenil is an antagonist of benzodiazepines and other sedative-hypnotic agents such as zolpidem and eszopiclone (the latter two agents are used in the treatment of insomnia). Flumazenil does not however antagonize the action of barbiturates. Naloxone and naltrexone are used in the treatment of opioid overdose. Thiamine and dextrose are used in the treatment of thiamine deficiency and hypoglycemia as is seen in alcoholics or other chronic states of malnourishment (see Chapter 17).

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

76. d

Glutamate and aspartate are excitatory neurotransmitters. The glutamate receptors are divided into NMDA receptors, those at which NMDA acts as an agonist, and non-NMDA receptors, which include AMPA and kainic acid receptors, named according to the substances that act as agonists at these receptors. Specific patterns of activation of NMDA receptors can lead to induction of long-term potentiation, which is a prolonged increase in a postsynaptic response resulting from a finite presynaptic stimulus and is thought to be involved in memory formation. High concentrations of glutamate lead to neuronal cell death triggered by excessive glutamate receptor activation, with excessive calcium influx into cells. Glutamate excitotoxicity has been implicated in neuronal damage seen in ischemia and hypoglycemia. Memantine is an NMDA antagonist used in the treatment of dementia.

 Brunton LL, Lazo JS, Parker KL (Eds). Goodman and Gilmans’ Pharmacological Basis of Therapeutics, 11th ed. New York: McGraw-Hill; 2005.

77. e

Both bupropion (discussed in question 68) and clozapine (discussed in questions 72–74) have been associated with increased risk of seizure at higher dosages. Olanzapine (discussed in questions 72–74) is less likely to cause seizures, but can do so; other atypical antipsychotics rarely cause seizures. On the other hand, amitriptyline, which is a tricyclic antidepressant (discussed in question 39) is associated with increased seizure risk with acute toxicity. Flumazenil, by inducing a state of benzodiazepine withdrawal, can lead to increased risk of seizures, particularly in patients with a prior history of seizures.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.

78. e, 79. a

Levodopa is a dopaminergic agent used in the treatment of Parkinson’s disease and other movement disorders (see Chapter 6), and is not used in the treatment of mood disorders. Mood-stabilizing agents used to treat bipolar disorder include lithium carbonate, as well as the anticonvulsants including valproic acid and lamotrigine. Antipsychotic agents including risperidone are used as adjuncts in the treatment of acute mania. The depressive phase of bipolar disorder often warrants concurrent antidepressant therapy. Mood-stabilizing agents are also used in the treatment of schizoaffective disorder.

The mechanism of action of lithium carbonate is not clear, but does include inhibition of the inositol and glycogen synthase kinase 3 signal pathways and downstream enzyme activity. Valproic acid may similarly exert its effects. Serum levels of lithium should be monitored periodically. Common adverse effects of lithium include tremor, thyroid dysfunction, acne, and nephrogenic diabetes insipidus, which can lead to hypernatremia if there is not adequate oral intake of fluids, as in the case depicted in question 79. Lithium is contraindicated in patients with sick sinus syndrome because it has a negative chronotropic effect. The side effects of valproic acid, lamotrigine, and other anticonvulsants are discussed in Chapter 5.

 Katzung BG. Basic and Clinical Pharmacology, 11th ed. New York: McGraw-Hill; 2009.