Psychiatry Test Preparation and Review Manual: Expert Consult, 2nd Ed.

Vignettes

Vignette One

Gabriel Matthews is a 42-year-old construction worker who comes to you for help. Six months ago he was working with a chainsaw on a construction site and didn’t realize that the gas cap on the saw was loose. The cap came off spilling gasoline all over his clothes and the saw. The heat from the engine ignited the gas setting his clothes on fire. He ran around the construction site ablaze until three other workers came to his aid and extinguished the fire by smothering it with clothing and dirt. He suffered severe burns and spent a significant amount of time in a burn unit.

Five weeks following the accident you are called to consult on him in the burn unit because he is having psychiatric symptoms which started 2 days after the fire and are progressively getting worse. He is having distressing nightmares about being on fire that wake him from sleep. His mood is low and he feels unable to be happy about anything. He is hopeless about the future and feels he has nothing to look forward to. He is getting more and more upset as his days in the unit go on and he has a short temper with the nurses. He keeps sending visitors away who come from his job and who were there the day that the accident happened. He has had several incidents of yelling at various family members when they came to visit. You meet his sister while on the unit who cries as she tells you how hostile Gabriel has been towards the family lately.

1. Gabriel’s most accurate diagnosis is:

Major depressive disorder

Adjustment disorder with depressed mood

Post-traumatic stress disorder

Mood disorder secondary to a medical condition

2. Gabriel inquires about treatment available for his condition. Which treatments would you consider? (choose 3 of 5)

Family therapy

SSRIs

Benzodiazepines

Cognitive behavioral therapy

Dialectical behavior therapy

3. Which of the following factors would be predictive of a poor prognosis for Gabriel? (choose 2 of 5)

Rapid onset of symptoms

Strong social supports

Absence of other axis I disorders

Duration of symptoms greater than 6 months

Borderline personality disorder

4. Which one of the following symptoms is commonly found in patients with Gabriel’s disorder?

Tactile hallucinations

Thyroid abnormalities

Decreased norepinephrine turnover in the locus coeruleus

Alexithymia

5. In addition to medication, which of the following would be considered appropriate treatment approaches for this disorder? (choose 4 of 5)

Overcome the patient’s denial of the traumatic event

Use of imaginal techniques or in vivo exposure

Encourage proper sleep providing medication if necessary

Promote full discharge of aggression as a cathartic exercise to relieve irritability

Teach the patient cognitive approaches to dealing with stress

6. Which of the following symptoms can be found in both schizophrenia and PTSD? (choose 2 of 4)

Hallucinations

Restricted affect

Decreased need for sleep

Sense of foreshortened future

7. Which of the following illnesses can present with decreased sleep? (choose 3 of 4)

Bipolar I disorder

Generalized anxiety disorder

Post-traumatic stress disorder

Obsessive–compulsive disorder

8. In Gabriel’s case he associated the trauma of the fire with chainsaws. For years afterwards he would have severe anxiety whenever he saw a chainsaw. He would avoid going near the outdoor power equipment whenever he was in a hardware store. This is a good example of which one of the following?

Operant conditioning

Learned helplessness

Classical conditioning

Premack’s principle

9. Which one of the following is not considered a symptom of increased arousal when diagnosing PTSD?

Poor concentration

Outbursts of anger

Feelings of detachment from others

Difficulty falling asleep

10. Which of the following should be considered in the differential for post-traumatic stress disorder? (choose 4 of 5)

Panic disorder

Substance abuse

Major depressive disorder

Borderline personality disorder

Schizotypal personality disorder

Vignette Two

A 65-year-old woman presents to your office with a complaint of longstanding symptoms that have plagued her since her adolescence. She reports chronic suicidal ideation, low mood, inability to focus or concentrate. Her memory is fairly good, but she doesn’t enjoy anything that she used to do. She used to play cards with friends, drive herself to the mall to go shopping, take trips to visit her children and grandchildren in various cities. She denies hearing voices or having paranoid or suspicious thoughts about people. Her sleep is very broken and she only gets about 4 hours each night. She has no motivation to shop, cook or clean for herself and she admits it to you. Her appetite is poor and she has already lost twenty pounds over the past year from not eating properly.

Her eldest daughter, age 42, accompanies her to your office. Her daughter is quite concerned for her mother because she has been on “every antidepressant you can imagine.” As a nurse, her daughter is able to rattle off a list of medications that her mother has tried in the past: imipramine, doxepin, phenelzine, fluoxetine, paroxetine, venlafaxine, duloxetine. None of these improved her back to her baseline. She has also had trials of several of these medications with other augmenting agents such as: methylphenidate, lorazepam, aripiprazole, lithium, and buspirone.

On examination in your office, the patient is conversant and coherent, but very slow to speak and her affect is blunted and speech is quiet and monotonous with marked alogia. She denies suicidal or homicidal thoughts or intentions at this time.

1. Your immediate clinical thoughts after interviewing this patient should be focused on:

Sending her home with a trial of bupropion and desvenlafaxine at high doses along with L-methylfolate for augmentation, since she has never been on these agents

Admitting her to the psychiatric hospital voluntarily for inpatient electroshock therapy

Getting her a bed in a local skilled nursing facility because she cannot manage her activities of daily living appropriately

Considering reporting her daughter to the authorities for elder abuse

Enlisting a local ACT team (assertive community treatment team) to pick up her care and service her needs in her home instead of in a clinic setting

2. You decide to admit her to the hospital and she agrees to go on a voluntary basis. Before considering electroshock therapy, which of the following would be appropriate to do as a pretreatment evaluation? (pick 3 of 6)

Bloodwork for blood count and comprehensive chemistry (CBC and chem-20)

Head CT scan or MRI

Thyroid function tests

Electrocardiogram

Electroencephalogram

Neck and spine radiography

3. Which of the following is a contraindication to electroshock therapy?

Pregnancy

Space-occupying brain lesion

Recent myocardial infarction within the past month

Hypertension

There are no absolute contraindications to electroshock therapy

4. In order for a seizure to be deemed effective in electroshock therapy sessions, its duration must be at least:

5 seconds

15 seconds

25 seconds

45 seconds

60 seconds

5. Which of the following are not generally considered to be adverse effects of electroshock therapy? (pick 2 of 6)

Death

Headache

Nausea and vomiting

Dizziness and lightheadedness

Hypertension

Delirium

6. Which of the following situations is an indication for maintenance electroshock therapy after an initial successful group of treatments? (pick 3 of 6)

Severe medication side effects and intolerance

Profound memory loss following the initial treatment sessions

Psychotic or severe symptoms

Rapid relapse after successful initial treatment sessions

Delirium resulting from initial treatment sessions

Pregnancy

7. Which of the following medications should be discontinued prior to electroshock therapy administration? (pick 3 of 6)

Venlafaxine

Phenelzine

Clozapine

Fluoxetine

Bupropion

Alprazolam

8. Which of the following agents is not generally used as an anesthetic agent in electroshock therapy because of its strong anticonvulsant properties?

Methohexital (Brevital)

Ketamine (Ketalar)

Etomidate (Amidate)

Propofol (Diprivan)

Alfentanil (Alfenta)

9. Which of the following is the typical course of electrode placement in electroshock therapy that is followed by most practitioners?

Start with bilateral electrode placement always, as this is more effective

Start with bilateral electrode placement, but move to unilateral placement if persistent memory loss occurs after 6 sessions

Start with unilateral electrode placement, but move to bilateral placement if no improvement is seen after four to six unilateral treatments

Start with unilateral electrode placement always, as this is safer and causes fewer side effects

Start with unilateral electrode placement always, making sure placement is over the nondominant hemisphere to avoid language and cognitive deficits

Vignette Three

Cathy Kelly is a 31-year-old computer programmer who works for a website design company. She comes to your office with reports of decreased mood, poor appetite, poor concentration, and feelings of worthlessness. She states, “I haven’t gotten a good night’s sleep in weeks and I’ve lost about 10 pounds recently.” These symptoms have been present for the past 5 weeks. On further questioning she describes a period 2 years ago when she “had some trouble” around her sister’s wedding. In the 4 days leading up to the wedding she was only sleeping 2 hours per night. She tells you, “I wasn’t tired and had enough energy to make pastries and gifts for the wedding guests. I was up working almost all night.” She recalls that “brilliant ideas for new projects” were running through her mind at that time. She continued going to work at her computer programming job during those 4 days and felt that she was very productive. When the wedding came she drank excessively and used her position as a bridesmaid to meet single friends of the groom. She took several men into a secluded bathroom and had sex with them during the wedding reception. When asked about substance abuse she reports using both cocaine and alcohol in the past to “make me feel better.” She denies any cocaine use around the time of her sister’s wedding however.

1. Which one of the following would be the most appropriate diagnosis for Cathy?

Bipolar I disorder

Major depressive disorder

Bipolar II disorder

Cyclothymic disorder

Substance induced mood disorder

2. Which one of the following is a key differentiating factor between mania and hypomania?

Irritable mood

Decreased need for sleep

Marked impairment in social or occupational functioning

Flight of ideas

3. Which of the following factors should impact your choice of medications for Cathy? (choose 4 of 5)

The presence of psychosis

The presence of rapid cycling

The severity of symptoms

Pregnancy

Age

4. In which of the following scenarios would you consider ECT for Cathy? (choose 2 of 4)

Cathy is pregnant and currently manic

Cathy has severe mania and psychosis that has responded poorly to medication

Cathy has mania secondary to a medical condition

Cathy has substance induced mania

5. Which of the following medical conditions can be associated with mania? (choose 3 of 4)

Glioma

Cushing’s disease

Multiple sclerosis

Thiamine deficiency

6. Which of the following medications can cause a manic episode? (choose 4 of 5)

Isoniazid

Cimetidine

Metoclopramide

Steroids

Oxazepam

7. During the periods when Cathy used cocaine which of the following were true concerning her brain? (choose 3 or 4)

Dopamine activity increased in the corpus striatum

Dopamine activity decreased in the mesocortical pathway

Dopamine activity increased in the mesolimbic pathway

There was both dopamine and norepinephrine reuptake inhibition

8. Which one of the following is not a potential sequelae of cocaine use?

Onset of hallucinations and paranoia

A significant appearance of lights in the central visual field

Hypersexuality

Itching and respiratory depression

9. Which of the following have a role in the treatment of cocaine overdose? (choose 3 of 4)

IV diazepam

Haloperidol

IV phentolamine

Clonidine

10. What percentage of patients with bipolar disorder have a co-occurring substance disorder like Cathy?

10%

30%

60%

80%

Vignette Four

Susan Walton is a 20-year-old college student. You interview her in the emergency room following an overdose of Tylenol. She reports that she was happily shopping with her boyfriend when he spotted an attractive woman on the other side of the street. “He’s such an asshole,” she tells you. She says he watched the woman closely as she walked away and Susan was certain that he was attracted to her. “I could tell by the way he was looking at her. She was such a whore. Is that what he wants? A whore like that?” she screams at you. According to her boyfriend Susan then reached into her purse, pulled out a bottle of Tylenol and swallowed as many pills as she could before her boyfriend wrestled the bottle from her hands. He became panicked and brought her to the emergency room. On the drive in she scratched up and down her arms using her fingernails, breaking the skin. She then began biting her forearms until they bled. He tried to pull the car over and stop her but she scratched his face when he tried to intervene. When she arrived in the emergency room she was crying hysterically and cursing at her boyfriend. When he attempted to comfort her she spat on him and smacked him in the face, scratching him again with her nails. She called him a “piece of trash” and insisted that he wants to cheat on her “with that whore” which he denied.

When she is calmer you take some further history from her. She tells you “I was severely sexually abused as a small child. But I didn’t tell anyone until I was a teenager. I started having sex at the age of 15. I used cocaine. I smoked. I really didn’t care. I was extremely self-abusive and it got to the point where I wanted to kill myself to rid myself of the anger, the hurt, the pain, the confusion.” She admits that she has made prior suicide attempts. She tells you “When I was seventeen I looked forward to getting my drivers license so I could run the car into a support column on the highway, or into a semi truck. I drove very recklessly; I didn’t want it to be an obvious suicide.” She informs you that when she was 18 she had a very severe car accident and ended up in the intensive care unit.

1. Which one of the following is Susan’s most likely diagnosis?

Major depressive disorder

Borderline personality disorder

Bipolar I disorder

Histrionic personality disorder

Social anxiety disorder

2. Which of the following are criteria for Susan’s diagnosis? (choose 4 of 5)

Chronic feelings of emptiness

Intense episodic dysphoria

Grandiosity

Severe dissociative symptoms

Transient stress related paranoia

3. Susan’s suicide attempt could best be attributed to which one of the following?

Severe depressed mood

Overwhelming anxiety

Perceived rejection

Grandiose self-importance

4. What is the treatment of choice for Susan’s condition?

Psychoanalysis

Family therapy

Dialectical behavior therapy

Supportive psychotherapy

5. Which of the following choices apply to patients with Susan’s condition? (choose 3 of 4)

They are in touch with reality only on a basic level

They have limited capacity for insight

They use many primitive defenses

They have an integrated sense of self

6. Which of the following defense mechanisms is Susan most likely to use based on her diagnosis? (choose 2 of 5)

Suppression

Sublimation

Humor

Acting Out

Splitting

7. Which of the following are legitimate reasons why borderline patients commit acts of self-mutilation? (choose 3 of 4)

To obtain social isolation

To express anger

To elicit help from others

To numb themselves to overwhelming affect

8. Susan takes intolerable aspects of herself and exports them onto her boyfriend leading him over time to accept and play that role. This phenomenon is known as which one of the following?

Displacement

Rationalization

Splitting

Projective identification

9. Which of the following are not considered part of Susan’s disorder? (choose 3 of 4)

Prolonged psychotic episodes

Marked peculiarity of thinking

Extreme suspiciousness

Impulsive behaviors

10. Which of the following medications may play a role in treating Susan’s condition? (choose 4 of 5)

Antipsychotics

SSRIs

Anticonvulsants

MAOIs

Stimulants

Vignette Five

Cathy Allen comes to Dr. Rupert Smith’s office for an initial appointment. Dr. Smith is a psychiatrist who comes highly recommended. With Cathy is her husband Bob. Dr. Smith meets them in the waiting area. Cathy introduces herself and asks if her husband Bob can come in to the appointment with her.

1. The most therapeutically appropriate response to Cathy’s request would be:

“No. I only want to meet with you because you’re the patient.”

“Nice to meet you Cathy. I’m Dr. Smith. Of course your husband can come in if you want him to.”

“I’m Dr. Smith. Cathy, you come in.”

“Sure your husband can come in.”

2. Following this interchange Dr. Smith is now about to start the interview. Which of the following would be the most appropriate way to begin? (Choose 2 of 4)

“Tell me about the problems you’ve been having.”

“You look depressed to me. What’s going on?”

“Where would you like to begin?”

“You’re very thin. Is this your normal weight? How is your appetite?”

Cathy gives a short sentence or two in response to Dr. Smith’s initial question. She then sits silently and says no more. He tries to get her to speak more but is unsuccessful. Her body language indicates that she is anxious and uncomfortable. She gives very little information in response to follow-up questions.

3. How should Dr. Smith proceed?

“You obviously don’t want to be here. Maybe we should stop the interview.”

“Bob, if she doesn’t tell me what’s wrong I can’t help her.”

“Do you have any pets? Tell me about them.”

“I can’t help but notice that you’re uncomfortable talking to me. Is there anything I could do to make you more comfortable?”

4. Following Dr. Smith’s intervention Cathy opens up and tells him more about the problems she’s been having. Being an astute psychiatrist, Dr. Smith pays attention to both the content and process of the interview. Which of the following would be considered process? (choose 3 of 4)

Cathy nervously tears a piece of paper into pieces

Cathy describes poor sleep for the past two weeks

Cathy changes the subject whenever the topic of her job comes up

Cathy’s body becomes tense and rigid while discussing her work

5. The interview moves forward and Cathy describes some feelings of depression she’s been having. Dr. Smith says “you say you haven’t been sleeping. How many hours per night are you getting?” This question is an example of:

Confrontation

Facilitation

Clarification

Explanation

6. After discussing current symptoms of Cathy’s illness Dr. Smith says “I think I understand your current symptoms pretty well. Now let’s talk about your medical history.” This comment is an example of:

Reassurance

Transition

Positive reinforcement

Advice

7. Following an hour long interview Dr. Smith seeks to wrap up. Which of the following are important steps he should keep in mind while concluding the session? (choose 4 of 5)

Give Cathy a chance to ask questions

Thank the patient for sharing information

Review any prescriptions to make sure the patient understands why she is to take them and how to take them

Be clear about what the next step in the treatment will be

Discourage Cathy from calling with questions between sessions

8. Which of the following are essential elements in order for Dr. Smith to develop rapport with Cathy during the interview? (choose 4 of 5)

Putting the patient at ease

Expressing compassion for pain

Showing expertise

Establishing authority as a physician

Know the answer to almost every question the patient asks

9. Which of the following variables are proven to be associated with decreased rates of patient compliance with treatment? (choose 2 of 4)

Intelligence

Increased complexity of treatment regimen

Increased number of behavioral changes

Socioeconomic status

10. In which one of the following models of the doctor–patient relationship does the physician behave in a paternalistic fashion?

Active–passive model

Teacher–student model

Mutual participation model

Friendship model

Vignette Six

You are asked to see a patient at your outpatient clinic. “Pearl” Probst comes to see you on a Monday morning. You quickly realize that “Pearl” is not a woman. She is a preoperative trans-sexual of 24 years of age. Her real name is Peter Probst and she lives alone in an apartment in the city where you work. Pearl tells you that she has felt like a woman trapped in a man’s body since her pre-teenage years. She began dressing as a woman in college and has begun the pre-operative transition from male to female by taking female sex hormones. She plans on following this up with sex-change surgery at some point in the future.

Pearl tells you that she and her girlfriend engage in sexual acts involving bondage, inflicting pain on each other and stepping and spitting on each other. She asks you if you have any concerns about this behavior. She also reveals that she and her partner enjoy taking showers together and urinating on each other.

You ask if Pearl considers herself to be heterosexual or homosexual and she states “I am a gay woman of course!”

1. Pearl probably meets criteria for which of the following DSM disorders? (Pick 3 of 6)

Transvestic fetishism

Gender identity disorder

Urophilia

Partialism

Sexual sadomasochism

Fetishism

2. Which of the following is not a poor prognostic factor in the paraphilias?

Onset of symptoms in middle-age

Frequent recurrent acts

Concomitant substance abuse

Lack of guilt or shame about the acts

The act of intercourse does not occur with the paraphilia

3. Which of the following are good prognostic factors in the treatment dynamic of paraphilias? (pick 3 of 6)

Substance abuse

Successful relationships and adult attachments

Normal intelligence

The presence of multiple paraphilias

The presence of concomitant axis one mental disorders

The absence of a personality disorder

4. Which of the following are not typically interventions that are used to treat paraphilias? (Pick 2 of 6)

Prison

Insight-oriented psychotherapy

Cognitive-behavioral therapy

Interpersonal psychotherapy

Twelve-step programs

Antiandrogen therapy

5. Which of the following factors, that is atypical of gender identity disorder, puts Pearl’s case among the minority of patients with this disorder?

The fact that she is an adult trans-sexual who wants gender-reassignment surgery

The fact that she is taking feminizing hormone therapy

The fact that she has felt like a woman trapped in a man’s body for years

The fact that she is a biological male wanting to become a female

The fact that she considers herself a “gay woman” and has a girlfriend

6. Which of the following facts is not true about gender identity disorder (GID)?

There is no evidence that psychological or psychiatric intervention for children with GID can affect the direction of later sexual orientation

There are well-established hormonal and psychopharmacologic protocols for GID in childhood

When patient gender dysphoria is severe, sex-reassignment surgery may be the best solution

No drug therapy has been shown to reduce cross-gender desires in adult patients with GID

Treatment of adolescents with GID may involve giving cross-sex hormones to slow down or stop pubertal changes of the birth sex and implement cross-sex body changes

Vignette Seven

You are a forensic psychiatrist working in private practice. You are faced with the evaluation of a fellow psychiatrist Dr. Dean Daniels, who is alleged to have had sexual relations with a former patient of his, Selena Victor. Dr. Daniels has already been arrested and charged and he is now out of jail on a 1 million dollar bond posted by his high-profile attorney, L. Lloyd Wolff Esq. As per his lawyer, he is charged with one count of rape and two counts of sexual assault. His lawyer informs you that Dr. Daniels has a history of depression and alcoholism and has been hospitalized psychiatrically in the past. Dr. Daniels has never had a malpractice case brought against him and his medical license has never been sanctioned in any way. Dr. Daniels is now back in his office practicing as usual until his first court date comes up next month.

1. If you agree to take this case on as an expert witness for the defense, what should be your next thoughts and maneuvers? (pick 3 of 7)

The defendant needs a thorough psychiatric evaluation

Neuropsychological testing is not necessary, as it is unlikely to reveal deficits, given that he was practicing his profession actively at the time of the alleged crimes

Dr. Daniels should not be practicing his profession now until his court appearance because he may incriminate himself further and ruin any chance at a proper defense at trial

Dr. Daniels should have a brain PET and functional MRI to see if brain damage can be used as a mitigating factor in his defense

Collateral information will be key in determining Dr. Daniels’ mental status at the time the alleged acts were committed

Competency to stand trial is an essential function of your evaluation as an expert witness for the defense

Ethically, you cannot defend Dr. Daniels because he is a member of your own profession and there is a conflict of interest in this regard

2. The legal components that will dictate if Dr. Daniels can or should be declared not guilty by reason of insanity by a jury are: (pick 3 of 6)

Duty to warn and protect

“Mens rea”

Competency to stand trial

“Actus reus”

The matter of Ford v. Wainwright

M’Naghten Rule

3. In order for you to declare him competent to stand trial, you must find Dr. Daniels able to: (pick 3 of 6)

Take the stand on trial in his own defense under the guidance of his attorney

Recognize and identify the persons involved in his case

Recall the various events surrounding the alleged crimes with accuracy

Collaborate with his attorney with a reasonable degree of rational understanding

Understand the charges that are being brought against him

State whether he would prefer a psychiatric plea or a regular plea of guilty versus not guilty

4. What role will alleged victim Selena Victor play in your defense of Dr. Daniels?

You will interview and examine her to destroy her credibility as a witness and support Dr. Daniels’ defense

The defense attorney can subpoena Selena for a psychiatric evaluation by you

The prosecution can protect Selena as a witness and can prevent you from examining her for the defense

If the prosecution obtains their own psychiatric expert to examine Selena, the defense team will be allowed to have you examine Selena as well. Barring that, the defense team will have the opportunity to have you review the report and write a critique of it and/or testify at trial in opposition to that report if the defense team deems it best to do so

The judge has the ultimate discretion and final word to determine Selena’s role in the judicial process

5. In a case such as Dr. Daniels’, what would be the possible sanctions if he were to go to trial and be found “not guilty by reason of insanity” by the jury on all three charges? (pick 3 of 6)

He could continue to practice psychiatry as before

He could lose his medical license and be remanded to outpatient treatment by the court

He could be allowed to retain his medical license and be remanded by the court to an intensive outpatient psychiatric day program for treatment

He could eventually practice psychiatry again after completion of appropriate treatment of his disorder, based on mandated future psychiatric evaluation

His name would be inscribed on a computer-based list of sex offenders if his state maintains such a list

He could continue to practice psychiatry as before, but not with female patients

Vignette Eight

Steven Geller is a 30-year-old male with paranoid schizophrenia. He stopped his medications 3 weeks ago. In response to the voices that followed, he then stopped eating and drinking. The voices have been telling him that his food is poisoned. “They put rat poison in your food” the voices told him. His mother became concerned when he wouldn’t eat for two days. She made him several of his favorite foods and tried to convince him to eat but he barricaded himself in his room and would not come out for 24 hours. His mother then called EMS. You interview him in the emergency room after he is brought into the hospital.

1. Which of the following statements would you include in Steven’s mental status exam given what you know at this point?

Thought content includes paranoid delusions

Thought content includes auditory hallucinations

Thought process includes flight of ideas

Perceptions include auditory hallucinations

On further interview Steven screams at you that he is “God’s chosen one” and further states that people are trying to poison him to prevent him from revealing his identity to the world. He states that he will be “raised into the heavens on clouds.” You question the veracity of this statement and he insists that it is true. He does not believe that it is a creation of his mind and is certain that those who doubt him are wrong. “I will burn the disbelievers” he tells you.

2. Where should this new information be included in the mental status exam?

Thought content

Perceptions

Attitude

Thought process

3. During your exam you notice that Steven is malodorous and is wearing dirty clothes. You note a rancid odor in the room and observe brown streaks on his pant legs. On closer inspection it appears to be feces. His family verifies that he has been failing to maintain hygiene since stopping his medication. Which of the following would be an accurate GAF score for Steven on Axis V?

20

10

40

60

You begin to perform a mini-mental status exam on Steven. You ask him to count backwards from 100 by 7s. He replies “93, 89, 81, 74.” You ask him if he can go further and he replies “Go to hell. I am the chosen one. I won’t do anything I don’t want to.”

4. How would you document this exchange? (choose 2 of 4)

Memory is intact

Concentration is impaired

Abstract thinking is intact

Attitude is hostile

5. Steven’s belief about being the chosen one would best be described as:

Pseudologia phantastica

Delusion of grandeur

Algophobia

Nihilistic delusion

6. The mesocortical pathway which is responsible for the __________ symptoms of schizophrenia begins at the _____________.

Positive; ventral tegmental area

Negative; nucleus accumbens

Positive; nucleus accumbens

Negative; ventral tegmental area

7. Which of the following are correct concerning schizophrenia? (choose 3 of 4)

Positive symptoms are associated with frequency of hospitalization

Cognitive symptoms are directly related to long-term functional outcome

Positive symptoms are directly related to long-term functional outcome

Schizophrenia is associated with a 10% suicide rate.

8. Which of the following would be consistent with a diagnosis of residual schizophrenia? (choose 3 of 4)

Command auditory hallucinations

Absence of prominent delusions

Unusual perceptual experiences in attenuated form

Absence of disorganized behavior

9. Which of the following are common aspects of appearance for schizophrenic patients? (choose 4 of 5)

Lack of spontaneous movement

Echopraxia

Agitation

Bizarre posture

Bright clothing

10. Which of the following are often found as part of thought form for schizophrenic patients? (choose 3 of 4)

Verbigeration

Ideas of reference

Word salad

Mutism

Vignette Nine

Judy Albanese, a local college student, is brought into the emergency room when her roommate called EMS after she collapsed at the gym. She appears malnourished and emaciated. Her roommate told EMS that she hadn’t been eating recently. She had cut down to one meal per day in order to lose weight. Yesterday the only thing she ate all day was a cereal bar. She has been spending 3 hours each day at the gym after classes in an effort to lose weight. Despite being emaciated she believes that she is overweight. She recently told her roommate “I’m so gross! I don’t know how anyone stands to look at me. All the skinny girls get the boyfriends, the attention, and what do I get?” When you ask her more questions she admits to you “I feel cold all the time. I have terrible headaches, and when I shower big clumps of hair fall out of my head.” She goes on to tell you “During class, instead of listening to lectures or taking notes, I think about what I have eaten that day, when I will eat again, what I will eat. I like to bake and bring the treats to school the next day, to give to my friends. I watch them eat. I’m really jealous of them when they eat. I read cookbooks for fun and have collected hundreds of recipes. I never look in the mirror without thinking, Fat.

1. Which of the following factors would you consider essential to make a diagnosis of anorexia nervosa? (choose 3 of 4)

Body weight less than 85% of expected for height and age

A disturbance in how body weight is experienced

Amenorrhea

Binge eating and purging behavior

2. Based on diagnostic criteria you determine that Judy has anorexia. Which of the following medical complications are likely to be associated with the diagnosis? (choose 5 of 6)

Bradycardia

Pancytopenia

Lanugo

Osteopenia

Metabolic encephalopathy

Ulcerative colitis

3. Which of the following would be considered indications that Judy should be admitted to a hospital? (choose 3 of 4)

Significant hypokalemia

Weight less than 75% of expected for height and age

Growth arrest

Osteopenia

4. As part of your evaluation of Judy you wish to calculate her BMI. How do you do that?

100 lbs for the first 5 ft in height + 5 lbs/inch over 5feet ± 10%

Height(m2)/weight(kg)

[Age(y) × .375 + height (m)] × 0.093/0.09[daily caloric intake(Cal)]

Weight(kg)/height(m)

5. You consider treatment options for Judy. Which of the following have proven efficacy in patients with anorexia? (choose 4 of 5)

Cognitive behavioral therapy

Family therapy

Fluoxetine

Olanzapine

Bupropion

6. Which of the following are possible complications of self-induced vomiting? (choose 3 of 4)

Russell’s sign

Mallory–Weiss syndrome

Spontaneous abortion

Atonic colon

7. Which of the following are possible complications of ipecac abuse? (choose 3 of 4)

Skeletal muscle atrophy

Rectal prolapse

Cardiomyopathy

Prolonged QTc interval

8. Which of the following statements are correct concerning anorexia? (choose 2 of 3)

Risk of anorexia increases when family members have anorexia

Patients with anorexia often demonstrate traits of paranoid personality disorder

Patients with anorexia are characterized by emotional flexibility

Adolescence is a time of increased risk for anorexia

9. Which of the following should be included in the differential diagnosis for anorexia? (choose 4 of 5)

Major depressive disorder

Anxiety disorders

Bulimia nervosa

Substance abuse

Brief psychotic disorder

10. Medical treatment for anorexia should include which of the following? (choose 3 of 4)

Combination estrogen and progesterone

Dental follow-up

Electrocardiogram

Correction of hypokalemia

Vignette Ten

Lisa is a 22-year-old barista at a local coffee shop who comes to your office seeking help after feeling that she did not get any better with her primary care physician. She gives a long history of anxiety around other people dating back to childhood. At one point while in high school her mother pressured her to become a camp councilor in order to “overcome shyness.” Lisa was able to force herself to do it for a few weeks but then became overwhelmed by the anxiety and quit. She also went through a period of time during her school years when she wouldn’t use public restrooms or would only use them if they were completely empty. She got into trouble for leaving class to go to the restroom all of the time. When the restroom was empty during classes she felt the most comfortable using it.

Now she reports being very anxious at work and at parties. She snuck out of the holiday party for her job because she was so uncomfortable. She worries that other people are judging her and won’t like her. She says that she feels stupid interacting with others, especially at work. She had quit a previous job because there were weekly meetings which she had to attend and speak in front of 30 people. Her anxiety about these meetings led her to quit the job. When you ask about her personal life she tells you “I’ve gone on dates once or twice but have never had any long-term relationships. Dates are excruciating for me. Making conversation with new people makes me so uncomfortable and anxious.”

Lisa’s primary care physician had tried her on sertraline in the past. She comes to you to see if there is anything else you can offer her.

1. Which of the following should be included in Lisa’s differential diagnosis? (choose 3 of 4)

Panic disorder

Schizoaffective disorder

Social phobia

Generalized anxiety disorder

2. Given Lisa’s medication history which other medications may be worth trying? (Choose 3 of 4)

Paroxetine

Clonazepam

Citalopram

Bupropion

3. Which of the following has the best evidence to support its use in Lisa’s condition?

Cognitive behavioral therapy

Supportive psychotherapy

Motivational interviewing

Psychodynamic psychotherapy

4. Lisa is most likely to be misdiagnosed with which of the following? (choose 2 of 4)

Schizoid personality disorder

Avoidant personality disorder

Schizotypal personality disorder

Dependent personality disorder

5. Which diagnosis best explains Lisa’s avoidance of public restrooms during her school years?

Specific phobia

Panic disorder

Social phobia

Agoraphobia

6. The non-generalized subtype of social phobia is most successfully treated by which one of the following?

Benztropine

Olanzapine

Propranolol

Lorazepam

7. The major concern of patients with social phobia is which one of the following?

Avoidance of relationships

The need for someone to be with them in stressful situations

Fear of rejection

Fear of embarrassment

8. If we changed Lisa’s age to 16 years old in the vignette above, how long would she need to have symptoms in order to meet DSM criteria for social phobia?

2 weeks

2 months

6 weeks

6 months

9. Which of the following are common side effects of Lisa’s condition? (choose 3 of 4)

Blushing

Dry mouth

Sweating

Fear of dying

10. As many as one third of patients with Lisa’s condition also meet criteria for which one of the following disorders?

Major depressive disorder

Agoraphobia

Cocaine abuse

Body dysmorphic disorder

Vignette Eleven

Carl Freeman is an obese 59-year-old male who is referred to you by his primary care physician for complaints of depression. Carl lives with his girlfriend Heidi Schmitz and her three children Blair, Denny, and Rao. He works as a customer service representative at a health insurance company. He tells you that “my co-workers resent me because I keep falling asleep at my desk during the day. I’ve even fallen asleep in the middle of phone calls with customers.” Because he has had difficulty at work he was referred for a medical evaluation. He reports decreased energy, fatigue, and poor sleep. He states that he had difficulty concentrating at work. He tells you “I’ve been irritable and fatigued. I’m having terrible headaches. I’ve been gaining weight recently and I can’t concentrate. Basically everything is going wrong right now.” He tried to sleep more at night but this did not make him feel any better. He tried taking naps in his car during his lunch hour but this didn’t help. His primary care physician felt that he was depressed and referred him to you. When you interview him on his sleep habits he reports that his wife stopped sleeping in the same room as him due to his snoring. He tells you that she calls him a “water buffalo” because of the noises he makes while he sleeps.

1. Which of the following should be included in the differential diagnosis for Carl? (choose 2 of 3)

Major depressive disorder

Sleep apnea

Klein–Levin syndrome

Narcolepsy

2. Which of the following would you include in a workup for this patient? (choose 2 of 3)

TSH

Periodic limb movements of sleep test

CPAP

Nocturnal polysomnography

3. Which of the following are possible complications of Carl’s condition? (choose 3 of 4)

Increased risk of cardiovascular complications

Decreased mood

Increased neck girth

Decreased cognition

4. Which one of the following statements is correct concerning Carl’s condition?

Carl has a parasomnia

Carl has a dyssomnia

Modafinil would be the treatment of choice for Carl

Carl’s condition places him at increased risk for Parkinson’s disease

5. Which one of the following is Carl most likely to be misdiagnosed with?

Pavor nocturnus

Somnambulism

Jactatio capitis nocturna

Gastroesophageal reflux

6. Which of the following choices are true concerning obstructive sleep apnea? (choose 2 of 3)

Airflow ceases during apnic episodes

Respiratory effort decreases during apnic episodes

Patients need at least 3 apnic episodes per hour to meet criteria

Respiratory effort increases during apnic episodes

7. Which of the following complications are common with obstructive sleep apnea? (choose 3 of 4)

Arrhythmias

Changes in blood pressure during apnic episodes

Pulmonary hypotension

Chronic increase in systemic blood pressure

8. Which of the following are true concerning REM sleep behavior disorder? (choose 2 of 4)

It occurs primarily in females

Loss of atonia during REM is a major component

Violent behavior can be a complication

Symptoms improve following treatment with stimulants or fluoxetine

9. Which of the following are symptoms of sleep-related gastroesophageal reflux? (choose 3 of 4)

Awakening from sleep

Cough

Chest tightness

Cessation of airflow

10. Which of the following would be considered sleep hygiene measures? (choose 3 of 4)

Avoid daytime naps

Exercise during the day

Use of zolpidem

Arise at the same time each morning

Vignette Twelve

Ryan Huang is a 35-year-old male who is unemployed and lives with his mother. He comes to your clinic with compliant of voices telling him to kill his mother because “She is the fiend. She is the devil.” He reports sleeping in his car for the past few days because he is trying to stay away from his mother so that he doesn’t hurt her. “I don’t want to go to jail” he tells you.

Ryan has a history of violence towards his mother. When he was in his 20s she took out an order of protection against him following an incident where he choked her in response to command auditory hallucinations. When the order of protection expired she did not renew it. In subsequent years he began to do better. Eventually she allowed him to move back into the home.

Ryan reported that the voices began when he was 16 years old. He doesn’t like them because they tell him to harm others as well as himself. During his first psychiatric hospitalization he developed oculogyric crisis from multiple PRN Haldol injections. Since this experience he has demonstrated an unwillingness to maintain compliance with medications. He is currently prescribed ziprasidone but has only intermittent compliance.

Ryan’s mother also tells you that he has a significant alcohol problem. She says he drinks daily. Ryan himself admits to periods of “the shakes” and previous blackouts. His drinking tends to get worse at certain points. He will go on binges and drink excessively for up to a week at a time.

Ryan’s trauma history includes being raped repeatedly by an older male cousin between the ages of 13 and 16. He admits that this has impacted him but has difficulty explaining how. He denies current flashbacks.

Medical history is significant for smoking 1 pack per day of cigarettes, hypertension, high cholesterol and poorly controlled diabetes. He endorses a head injury which happened when he was 13. When he tried to resist a rape attempt by his cousin, his cousin beat him until he was unconscious. On exam he recalls 1 out of 3 objects after 5 minutes. He is oriented to person, place, and time.

1. Which of the following should be considered in Ryan’s differential diagnosis? (choose 4 of 5)

Schizophrenia

Substance induced psychotic disorder

Post-traumatic stress disorder

Generalized anxiety disorder

Dementia NOS

2. Which of the following would you include in a medical workup for Ryan? (choose 5 of 6)

Thyroid function tests

Thiamine level

Head CT

EKG

Urine toxicology

Prolactin level

3. Which of the following are the most likely side effects Ryan will experience from treatment with ziprasidone? (choose 2 of 4)

Weight gain

Extrapyramidal symptoms

Sedation

Cardiac effects

4. Ryan’s history includes significant substance abuse. Heavy use of which one of the following drugs before the age of 16 has been correlated with an increased relative risk of schizophrenia?

Phencyclidine

Alcohol

LSD

Cannabis

5. If a patient presents with psychosis for more than one month but does not meet criteria A for schizophrenia what diagnoses are possible? (choose 2 of 4)

Schizoaffective disorder

Delusional disorder

Schizotypal disorder

Psychosis NOS

6. Which one of the following medications are not antagonists at the 5HT2A receptor?

Haloperidol

Aripiprazole

Olanzapine

Ziprasidone

7. Which of the following choices are true concerning delusional disorder? (choose 2 of 4)

Auditory hallucinations may be present

Memory impairment may be seen

Tactile hallucinations may be present

Unnecessary medical interventions may be part of the picture

8. Which one of the following is correct concerning brief psychotic disorder?

The patient will not return to normal functioning

Primary preventative measures can involve treatment with low dose risperidone

Hallucinations may be present but delusions are not

Symptoms last between one day and one month

9. Which of the following are true concerning psychotic symptoms? (choose 4 of 5)

Tactile hallucinations are more common in medical and neurologic conditions than in schizophrenia

Illusions are sensory misperceptions of actual stimuli

Delusions are fixed false beliefs which are not supported by cultural norms

Word salad is the violation of basic rules of grammar seen in severe thought disorder

Cataplexy is synonymous with waxy flexibility

10. A differential diagnosis for new onset psychosis may include which of the following medical conditions? (choose 4 of 5)

Systemic lupus erythematosus

Temporal lobe epilepsy

Neurosyphilis

Wilson’s disease

Phymatous rosacea

Vignette Thirteen

John Jameson, a 42-year-old man, is brought by ambulance, accompanied by police to your emergency room at 2:00am in the morning. Upon arrival, he is agitated and the police and emergency medical technicians cannot manage his aggression. He refuses to answer your questions and gives you a verbal tongue lashing when you try to approach him. Nobody else accompanies him and there are no collaterals present from whom you can obtain information. You discover he has never been to your hospital before, as there is no medical record at your facility in his name. Mental status examination is impossible at this time, as he is completely uncooperative with you. He shouts obscenities at you and yells out that his mother should be shot for what she has done to him.

1. What are your very next steps in management with respect to this patient? (pick 2 of 6)

Draw blood for basic labs and obtain a CT scan of the head to rule out organic causes for his agitation

Ask the police and emergency technicians why they brought him

Admit him to the psychiatry unit on an involuntary basis

Do your best to obtain his mother’s contact information and call her as soon as possible to find out what “she has done to him”

Have him restrained by police and/or hospital security so you can administer him an intramuscular injection of haloperidol and lorazepam to help calm him

Obtain medical consultation and clearance from the emergency room physician

2. Which of the following is not a predictor of dangerousness to others in violent patients, such as in the patient scenario depicted in this vignette? (pick 2 of 6)

Prior violent acts

Chronic anger, hostility, or resentment

Female gender

Numerous medical problems

Childhood brutality or deprivation

Access to weapons or instruments of violence

3. When attempting to interview this violent and agitated patient, the psychiatrist should do which of the following? (pick 3 of 6)

Conduct the interview in a quiet, nonstimulating area of the emergency room

Avoid asking the patient if he has weapons on him to avoid further anger and agitation.

Request that security personnel give their assistance during the interview, if needed.

Avoid any behavior that could be misconstrued by the patient as menacing, such as standing over the patient.

Explain to the patient that any refusal to answer questions will result in him being medicated and admitted to hospital over his objection.

Interview the patient in an enclosed locked room to prevent the patient from fleeing.

4. Once the patient is sedated, the emergency room medical physician completes a workup on the patient. The workup, including drug screen and head CT, is negative and the patient is cleared from a medical and surgical perspective. If you are unable to obtain any further history on this patient, your disposition for him should be to: (pick 3 of 6)

Discharge him home with outpatient psychiatric follow-up

Admit him to the psychiatric inpatient unit on an involuntary basis

Start him on aripiprazole and divalproex sodium in the emergency room

Contact police to return to the emergency room to arrest the patient

Obtain a social work consultation after holding him overnight in the emergency room pending further information

Attempt to call his mother and tell her about his feelings towards her

5. Once admitted to the psychiatric unit, it is discovered that the patient has a lengthy history of schizophrenia, paranoid type, since 17 years of age, and has been hospitalized in this fashion no less than 25 times since the onset of his illness began. These recurrent hospitalizations have mostly been due to his refusal to take medications upon discharge. Currently, he is refusing to take medication on the unit, when it is offered to him by nursing staff.

  Which of the following would currently be good choices of medication for this patient, on the inpatient unit? (pick 2 of 6)

Risperidone

Olanzapine

Asenapine

Ziprasidone

Quetiapine

Lurasidone

6. If the patient is given Risperidone (Risperdal Consta) biweekly intramuscular injection and is well stabilized in the hospital on this agent, which of the following would be the best discharge disposition for him for ongoing treatment and care once he is ready to leave the acute inpatient psychiatry unit? (choose 3 of 7)

State psychiatric inpatient facility (long-term admission)

Assertive community treatment team (ACT team) home visits

Partial hospital program

Continuing day treatment program

Outpatient mental health department of a university/teaching hospital

Outpatient freestanding mental health clinic

Mental health practitioner in the patient’s primary care physician’s group practice

Vignette Fourteen

Robert Bradbury is a 30-year-old male with a history of chronic paranoid schizophrenia who is being treated with clozapine. He goes to an outpatient psychiatry appointment and has the following discussion with his psychiatrist.

Doctor: How are things going Robert?

Robert: Fine. I’ve been working in the afternoons following my program and it’s going very well. I’m continuing to drool a lot, like I told you last time, but its manageable.

Doctor: How are your symptoms? Are you hearing any voices?

Robert: No. I haven’t heard voices in about a year now. I’m really glad about that (smiles).

Doctor: Good. Good. Tell me about this job you’ve been doing.

Robert: Well I’m doing a patient work program through the hospital. We move furniture, run errands, deliver mail within the hospital. Stuff like that.

Doctor: Do you like it?

Robert: I do, but there is this one woman that I work with who is so nasty (frowns). She talks down to the patient workers like she’s better than us or as if we’re not as good as other people. It gets me upset sometimes.

Doctor: How do you handle it?

Robert: My boss tells me just to ignore her, that it’s her problem, not mine, and that she’s not worth getting upset over.

Doctor: Are you able to do that?

Robert: Yeah. If she says something nasty I just walk away. I try not to let it bother me as much as it used to. There are plenty of people at work who are friendly so it doesn’t matter.

Doctor: Good. I like your attitude about this. Sounds like you’re handling it well.

Robert: Thanks. Oh, before we finish I need a refill on my clozapine. I went for bloodwork two days ago.

The next seven questions are regarding Robert’s mental status exam:

1. Robert’s attitude is best described as: (choose 2 of 6)

A Guarded

Hostile

Apathetic

Cooperative

Friendly

Ingratiating

2. Robert’s affect is best described as:

Incongruent

Within normal range

Constricted

Blunted

Flat

3. Robert’s thought process is best described as: (choose 2 of 6)

Flight of ideas

Tangentiality

Circumstantiality

Linear

Goal directed

Thought blocking

4. Robert’s impulse control is best described as:

Good

Fair

Poor

5. Robert’s insight is best described as:

Good

Fair

Poor

6. Robert’s judgment is best described as:

Good

Fair

Poor

7. Robert’s perceptions are best described as:

No auditory hallucinations

No visual hallucinations

No olfactory hallucinations

No tactile hallucinations

No gustatory hallucinations

8. What is the best feedback the doctor can give Robert about his excessive drooling?

It is expected. We should continue to follow it.

It will go away once his dose of clozapine is increased

It is a clear indication to stop the medication

It is most likely unrelated to his medications

9. If Robert is on clozapine for 8 months, how often should he have his WBC/ANC drawn?

Every month

Every week

Every two weeks

Every two months

10. In addition to monitoring Robert’s WBC/ANC which other tests would be appropriate to monitor on Robert over time? (choose 7 of 8)

EKG

Liver function tests

Clozapine level

Fasting glucose

Weight

Waist circumference

Triglycerides and cholesterol

Echocardiogram

Vignette Fifteen

A woman of 35 years of age presents to the emergency room in a state of acute anxiety and agitation. After administration of an intramuscular injection of 2 mg of lorazepam, she calms down a bit and is able to give you more of her history. For the past 10 years, she has been functioning as a bank teller and lives alone in a studio apartment and is self-sufficient. She reports that for the past decade she has felt that she is not one person, but three different persons. She feels that her self-states take over her being whenever she is in an extremely stressful situation. When asked about her parents and youth, she closes her eyes and begins to talk in a more youthful voice stating “I have to run away. I can’t be home when papa gets here.” She seems distant as if in a trance. When she finally comes to her senses, she admits that she was repeatedly beaten and raped from ages 5 to 11 years by her step-father. She admits to flashbacks and excessive easiness to startle and these symptoms persist even now in her. She states that this child-like voice is that of “Melanie” one of her self-states, who comes out when she is under stress at work or in her relationships with men. She denies suicidal or homicidal ideation. She denies experiencing auditory or visual hallucinations, past or present. No delusions or ideas of reference are noted. She is much calmer now in the emergency room after your intervention with her.

1. Which of the following clinical features of this patient’s disorder are correct? (pick 2 of 6)

Clinical studies report female to male ratios of up to 10 to 1 in diagnosed cases

Fifteen percent of cases are associated with childhood trauma and maltreatment

Psychotherapies of choice include dynamic, cognitive and hypnotherapy

Studies have shown a strong genetic component to the disorder

Inability to recall important personal information is not part of this disorder

About 10% of patients also meet criteria for somatization disorder

2. Which of the following would be expected to worsen the prognosis of this patient’s disorder?

Concomitant diabetes and hypertension

Concomitant eating disorder

Recommending clonazepam for anxiety symptoms

The patient forcing herself to maintain a high level of daily functioning despite having serious symptoms

Group therapy for patients with the same disorder only

Past traumatic brain injury from a motor vehicle accident

3. Which one of the following is not a recommended pharmacologic choice for this patient’s disorder?

Quetiapine

Fluoxetine

Divalproex sodium

Lithium carbonate

Zolpidem

4. Which of the following symptoms is not typically seen in this patient’s disorder?

Seizure-like episodes

Survivor guilt

Suicidal thoughts

Asthma and breathing problems

Manic episodes

5. Which of the following would help you rule out a factitious or malingered disorder in this patient’s case? (pick 2 of 6)

Marked inconsistencies in her story and symptom presentation

The patient prevents you from speaking to collaterals

Marked dysphoria about her symptoms

A significant history of legal problems

Feeling confused and ashamed about her symptoms

A history of poor work performance by the patient

Vignette Sixteen

Kevin Moran is a 75-year-old man who is brought to your office by his 38-year-old daughter Susan for a consultation. Mr. Moran has not been himself for at least a year his daughter states. He lost his wife to cancer 18 months ago and they were married for 50 years. Susan tells you that her father cannot live on his own anymore and she had to take him into her home where she has a spare bedroom for him. The reason for his inability to live independently is because he gets easily confused, forgetful, loses his sense of direction and starts to wander alone in the street with no purpose. The police brought him home once after they found him wandering in his neighborhood late at night and the poor man couldn’t find his way home. Luckily he was able to remember his own name and his daughter’s name, which helped police to trace him back to her home. Susan says her father cannot really cook or clean for himself because he forgets that he leaves the stove on and burns pots and pans which could result in a severe fire hazard. He can eat, but he forgets the names of common household items like forks and cups, and sometimes even forgets what they are used for.

His medical history is significant for coronary artery disease since age 68, hypertension controlled on medication, type II diabetes for which he takes oral medications only and a small stroke a few years ago for which he has been given aspirin. He also has high serum cholesterol and elevated serum triglycerides.

1. Given his history, the most likely diagnosis is: (pick 2 of 6)

Major depressive disorder

Generalized anxiety disorder

Vascular dementia

Diffuse Lewy body disease

Alzheimer’s dementia

Pick’s disease

2. What would be your next maneuver with respect to this patient in the outpatient setting? (pick 3 of 7)

Start sertraline 25 mg daily

Start trazodone 50 mg at bedtime

Start donepezil 5 mg daily

Obtain an electroencephalogram

Start risperidone 0.25 mg at bedtime

Obtain an outpatient brain MRI

Obtain neuropsychological consultation

3. His daughter is concerned that she cannot manage her father properly in the home. What suggestions can you make to help her with this situation? (pick 3 of 6)

Refer him to an ACT team for ongoing management

Obtain a visiting-nurse consultation

Refer her to caregiver support programming and groups

Convince her to get family members to provide coverage in the home to monitor the patient more closely

Consult a physiatrist to have the patient placed in a subacute rehabilitation facility

Seek skilled nursing facility or assisted-living facility placement for the patient

4. If the patient has a dementia of the Alzheimer type, what would be his expected prognosis if he were to remain untreated?

1 to 3 years

4 to 6 years

7 to 10 years

11 to 15 years

15 to 20 years

5. The treatment of choice for a case of dementia believed to have features of both Alzheimer and vascular type would be: (pick 3 of 7)

An antiplatelet aggregant agent

An atypical antipsychotic agent

A sedative–hypnotic anxiolytic agent

A cholinesterase inhibiting agent

Vitamin B complex supplementation

An antidepressant agent

An antihypertensive agent

6. Which of the following is not typically a complication of this man’s illness?

Agitation and sundowning

Personality changes

Aggression

Hallucinations and delusions

Depression

Mania

7. Which of the following drugs should be avoided in this patient? (pick 2 of 7)

Rivastigmine

Aspirin

Memantine

Benztropine

Diphenhydramine

Fluoxetine

Galantamine

Vignette Seventeen

Wanda Reardon is a 55-year-old woman who is hospitalized for acute relapse of a multiple sclerosis flare up. She has had the disease for 25 years and it has been classified as relapsing and remitting in variety. You are called to her bedside because she is in an acute confusional state. Upon admission to the hospital yesterday, her neurologist started her on intravenous methylprednisolone and omeprazole for the MS exacerbation. Her history reveals that she is a former cigarette smoker who quit 10 years ago. She also has a history of hypertension and gastritis. Her medications at home include enalapril, lansoprazole and interferon β1A (Avonex) weekly injections for her multiple sclerosis.

When you arrive at the bedside to examine Wanda after reviewing her chart, you find that she is unable to attend to you or your questions. She is talkative, but what she says makes no grammatical or logical sense. Her eyes are rolling back in her head and her eyelids are drooping frequently during your interaction with her. She is rocking side to side in her bed in a hyperactive manner. She is unable to engage you or answer any of your questions appropriately. She is disoriented to time, place and person. When you call her name, she is able to look at you briefly, but her attention wanes and in a brief moment she looks away and is unable to respond further to you. Her rocking behavior is quite severe and you fear that she may fall out of her bed, despite the fact that her bed rails are up.

1. Which of the following symptoms are not generally characteristic of Wanda’s present syndrome? (pick 2 of 6)

Mood stability

Irritability

Sleep–wake cycle disturbance

Language disturbance

Gradual onset over weeks to months

Memory impairment

2. Which of the following risk factors predispose this patient to the current condition you now find her in? (Pick 3 of 6)

Smoking history

Female gender

Her age

Her current medications

Her multiple sclerosis

Hypertension

3. The CNS area(s) believed to be most closely implicated in this patient’s present condition is (are) the:

Cerebellum

Frontal and parietal lobes

Midbrain and nigrostriatal pathway

Reticular formation and dorsal tegmental pathway

Hippocampus and amygdala

4. Which of the following neurotransmitters is probably the least likely to be implicated in the pathophysiology of delirium?

Norepinephrine

Dopamine

Serotonin

Acetylcholine

Glutamate

5. Which of the following electroencephalography findings would you expect to find in this patient?

Temporal lobe spikes

Hypsarrhythmia

Generalized background slowing

Triphasic waves

Periodic lateralizing epileptiform discharges (PLEDS)

6. Which of the following agents would not be appropriate treatment for Wanda’s current condition? (pick 2 of 6)

A Haloperidol

Risperidone

Diphenhydramine

Quetiapine

Benztropine

Olanzapine

7. Which of the following are true about the course and prognosis of delirium? (pick 3 of 6)

Prodromal symptoms can occur months prior to onset of florid symptoms

Symptoms usually persist as long as causally relevant factors are present

Delirium usually progresses to dementia according to longitudinal studies

Delirium does not adversely affect mortality in patients who develop it

Prognosis of delirium worsens with increased patient age and longer duration of the episode

Periods of delirium are sometimes followed by depression or post-traumatic stress disorder

Vignette Eighteen

Allan Newbold is a 30-year-old man who consults you at your private office for anxiety. He describes his anxiety as an excessive preoccupation with his appearance. He is always worried that he isn’t attractive enough to the opposite sex. He has no medical or surgical history at all. He has never seen a psychiatrist before. He denies depression, but he is very upset because he always feels his body could be better. He exercises twice a day and has a physique that is similar to most fit models or competitive bodybuilders. You ask him to identify his specific shortcomings and he tells you that his skin doesn’t tan evenly so he has to resort to artificial spray-on tans which “look fake” he says. He also feels that his body has hair in the “wrong places” and “I always have to go to the laser hair removal salon or get it waxed off. Even then, there’s always some left over.” He also feels that because he is a natural bodybuilder who doesn’t use artificial means of building muscle, like steroids, that his muscles are unable to develop evenly and symmetrically. He opens his shirt and shows you his bare chest pointing out to you how his abdominal muscles are uneven and lumpy and asymmetrical. To your eye and superficial glance, they look perfectly normal and you tell him so. He replies: “Of course you think they’re normal! Everyone I ask tells me they’re normal, but I know they’re just lying to me.”

Allan tells you he is actually a physical therapist by training, “I love my job because I work with kids mostly and help them in ways that no one else really can.” He also reveals that he does TV and magazine modeling on the side and has even posed nude in Playgirl magazine. He was named “man of the year” for that publication a few years back. He tells you he is heterosexual and has a girlfriend, Eve Chandler, who is a 24-year-old fitness model and hedge fund associate. He tells you that his sex life and sexual functioning “are fantastic! No problems there!” When you ask if Eve thinks his body has imperfections, he says “She tells me it’s all in my head and that my body rocks, but I know she’s only saying it to be kind to me!” He spends a huge amount of time and effort at esthetic salons, tanning salons, and with the dermatologist, looking for creams, lotions, injectables, and any other procedures that he feels might enhance his appearance. He spends at least $2000 a month on such products and services.

1. The basic pathophysiology of the disorder that Allan is suffering from is believed to be related to:

Dopamine

Norepinephrine

Epinephrine

Serotonin

Glutamate

2. The psychodynamic explanation of Allan’s disorder and behavior is best described as:

Early parental losses that lead to a self-focused neurosis

Acting out behavior due to poor impulse control and poor frustration tolerance

The displacement of a sexual or emotional conflict onto nonrelated body parts

Arrested development in the anal phase of psychosexual development

An unresolved oedipal complex

3. Which of the following factors are atypical of Allan’s most likely diagnosis? (pick 2 of 6)

The fact that he is man

The fact that the onset of his disorder presented prior to 30 years of age

The fact that Allan has never suffered a major depressive episode in the past

The fact that Allan is unmarried

The fact that Allan is a professional and is high-functioning

The fact that Allan spends an extraordinary amount of money on himself

4. Which of the following are considered appropriate treatments for Allan’s primary disorder? (pick 3 of 6)

Clomipramine

Bupropion

Fluoxetine

Modafinil

Phenelzine

Carbamazepine

5. Which of the following is typically true about the course and prognosis of Allan’s primary disorder?

It is usually gradual and insidious in onset

It is usually of short duration and self-limited

It has an undulating course with few symptom-free intervals

The part of the body on which concern is focused typically remains the same over time

The preoccupation with imagined defects is not usually associated with significant distress or impairment

Vignette Nineteen

Grace Hanover is a 50-year-old woman who is referred to you by her primary care physician. He has no clue what’s going on with Grace medically, because she comes for follow-up every single month with a new physical complaint despite the fact that he has told her so many times that there is nothing that he can find that’s wrong with her. Her physician tells you that Grace indeed does suffer from hypertension and hyperlipidemia for the past 3 years, but that she has been taking enalapril and simvastatin daily since then, which have normalized her blood pressure and serum lipid levels quite nicely. He tells you that her many complaints have been going on since he has known her, which is 20 years now, but he knows that these complaints predated her being his patient.

You ask her physician what symptoms she presents with and he runs off a ridiculously long shopping list that is overwhelming and implausible. Her biggest (and longest complaint) is sexual dysfunction on the order of low libido, poor sexual arousal, inability to orgasm either through masturbation or intercourse. This has been going on for 20 years, or even more. Gynecologic consultations have been multiple over the years and testing has never revealed any organic cause to these problems.

Over the years she has complained of gastrointestinal discomfort after eating, though not all the time, periodic dizziness and feeling weak in her legs for no particular reason, generalized body aches and pains, particularly in her neck, lower back, arms and legs, and chronic constipation despite drinking plenty of water every day and eating a very well-balanced diet.

Her physician says: “She’s just weird, and I never know what she’s going to come up with next when she comes to the office. I think it’s all in her head, but I’m not sure. I think her insurance company must hate her, because with all the tests she’s undergone over the past 20 years (and all of them were negative!), it must have cost them hundreds of thousands of dollars!”

Grace works in public relations and has a six-figure salary job. She is rarely absent from work, despite her many physical problems. She has never been married and has no children. She was an only child and was doted on by her father, while her mother was actually the breadwinner in the household and was more distant with Grace. Grace has no psychiatric history to speak of. She denies depression, mania, and psychosis. She does have some anxiety, but denies panic attacks or social phobia.

1. Which of the following symptoms would push your differential diagnosis away from a conversion disorder in Grace’s case? (pick 3 of 7)

A Backaches

Headaches

Anorgasmia

Dizziness

Constipation

Gastrointestinal discomfort

Arm and leg pain

2. Which of the following etiological theories are believed to be possible contributors to Grace’s primary problem? (pick 3 of 6)

Abnormal regulation of the cytokine system

Only personality disordered patients have Grace’s disorder

Decreased metabolism in the frontal lobes and nondominant hemisphere

Apoptosis and gliosis of brainstem neurons

Catecholaminergic deficits or imbalance in the central nervous system

Genetic predisposition of the disorder in first-degree female relatives of probands of patients with Grace’s disorder

3. Which of the following statements about the epidemiology of Grace’s primary disorder are not true? (pick 3 of 6)

Men outnumber women with the disorder about 5 to 20 times

The lifetime prevalence of somatization disorder among woman is about 1 to 2%

The disorder occurs more frequently in patients of upper class and higher socioeconomic status

The disorder usually begins in adulthood after the age of 30

Concomitant personality traits associated with somatization disorder include obsessive–compulsive, paranoid and avoidant features

Bipolar I disorder and substance abuse occur no more frequently in somatization disorder patients than in the general population at large

4. Which of the following facts are true about the course and prognosis of Grace’s primary disorder? (pick 3 of 6)

The course of the disorder is typical acute and static in its presentation

Patients with the disorder have a 20% chance of being diagnosed with this disorder 5 years later

Patients with the disorder are no more likely to develop another medical illness in the next 20 years than people without the disorder

The disease rarely remits completely

It is unusual for a patient with the disorder to be free of symptoms for greater than one year

The overall prognosis of the disorder is good to excellent in most cases

5. The only treatment maneuver for Grace’s primary disorder that seems to be able to decrease personal health care expenditure by about 50% is:

Atypical antipsychotics

Antidepressant medications

Electroshock therapy

Group and individual psychotherapy

Mood stabilizers like lithium and divalproex sodium

Opioid antagonists like naltrexone

Vignette Twenty

Kerry Fields is a 26-year-old man who comes to you because he is an extreme athlete and is addicted to opioid painkillers. He skis, snowboards, drives motocross motorcycles and all-terrain vehicles, and knows only too well how to abuse his body from all this physical activity. He has had a shoulder surgery for severe rotator cuff tear, and at least three knee surgeries on each knee for meniscal tears and repairs. He also has spinal scoliosis and has herniated two cervical and three lumbar intervertebral disks in the past. He has never undergone back surgery, though he has been used to living with chronic pain.

He tells you his problem is balancing pain with narcotic overuse. He is currently taking Roxicodone 30 mg daily two tablets QID and they are barely keeping him stable. He confesses to you that he also drinks every night, at least two or three vodkas with soda and sometimes more. He also smokes cannabis about an ounce a week on average. He tells you his back pain, neck pain, and knee pain is typically a 7 out of 10 most days, unless he is doing some extreme sporting activity or other, when his pain can climb to 9 out of 10, after the activity is over. He wants help from you and your honest recommendations.

1. Which of the following would be good recommendations for treating Kerry’s problems? (pick 3of 6)

Go to an inpatient facility for alcohol, narcotic and cannabis detoxification

Do an outpatient narcotic taper and switch Kerry to a Vivitrol (naltrexone) monthly injection

Send Kerry to a specialized pain clinic for appropriate recommendations and management

Continue the Roxicodone as prescribed for pain and give Kerry disulfiram (Antabuse) for alcohol relapse prevention

Send Kerry for orthopedic and neurologic consultation to determine the etiology of his pain

Consider a switch from Roxicodone to oral methadone to address both pain and narcotic dependence, along with acamprosate calcium to address alcohol relapse prevention

2. What is the correct dosing strategy if Kerry is going to begin taking disulfiram?

500 mg once daily

250 mg once daily

Start 500 mg once daily for 1 to 2 weeks, then reduce to 250 mg daily for maintenance

Start 250 mg once daily for 1 to 2 weeks, then increase to 500 mg daily for maintenance

500 mg twice a day

3. What are the disadvantages of buprenorphine/naloxone tablets for opioid relapse prevention in Kerry’s case? (pick 3 of 6)

The naloxone content of the tablet may trigger a precipitated withdrawal on its own

Buprenorphine/naloxone tablets cannot be taken with full opioid agonist painkillers

Buprenorphine/naloxone tablets are generally not as effective as full opioid agonist painkillers for the management of moderate to severe chronic pain

Buprenorphine/naloxone tablets can easily be diverted and injected for recreational purposes by intravenous drug users

Buprenorphine/naloxone tablets must be taken under the tongue and patients frequently complain that they have a bad taste

Buprenorphine/naloxone tablets can be abused and overused for its euphoric effects by recreational narcotic users who take excessive quantities of this medication

4. Which of the following agents decrease serum methadone levels?

Phenytoin

St. John’s Wort (hypericum)

Dextromethorphan

Erythromycin

Verapamil

Disulfiram

5. Which of the following substances of abuse causes a withdrawal syndrome when stopped abruptly that manifests with insomnia, irritability, drug craving, restlessness, nervousness, depressed mood, tremor, malaise, myalgia, and increased sweating?

Cocaine

Opiates

Phencyclidine (PCP)

Cannabis

Alcohol