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

Explanations - Test Number One

Question 1. D. Several cutaneous side effects are possible with lithium including acne, follicular and maculopapular eruptions. Alopecia has also been reported. Major side effects of lithium include gastrointestinal complaints, tremor, diabetes insipidus, hypothyroidism, weight gain, cardiac arrhythmia and edema. Lamotrigine is an anticonvulsant that is also used for mood stabilization. Side effects can include Stevens–Johnson syndrome, anemia, thrombocytopenia, liver failure, and pancreatitis. Lorazepam is a benzodiazepine, which causes sedation, respiratory suppression, and has a high addictive potential. Risperidone is an antipsychotic that can cause extrapyramidal side effects, neuroleptic malignant syndrome, metabolic syndrome, gastrointestinal upset, increased salivation and lactation, among others. Oxcarbazepine is an anticonvulsant that may cause leukopenia, thrombocytopenia, Stevens–Johnson syndrome, and several other side effects. With the exception of lithium, the other choices do not worsen acne.

  Psychopharmacology

  K&S Ch. 3

Question 2. D. Attachment, which is the emotional dependence of the infant on his mother, involves resources and security, because the infant depends on the mother for these things. Attachment theory was developed by John Bowlby, and says that a secure attachment between mother and child affects the child’s ability to form healthy relationships later in life. Attachment occurs when there is a warm intimate and continuous relationship between child and mother. The attachment gives the infant a feeling of security. Bonding is the mother’s feelings for her infant. In bonding, the mother does not rely on her baby for food and protection. Therefore bonding does not involve resources and security. It is thought that bonding occurs with skin to skin contact between infant and mother. All other choices given are true regarding attachment theory.

  Human Development

  K&S Ch. 4

Question 3. D. Serum polymerase chain reaction (PCR) is the test of choice to examine the number of trinucleotide repeats (>35 in adults and >50 in children) in order to diagnose Huntington’s disease (HD). The HD gene resides on the short arm of chromosome 4 at 4p16.3. A chromosomal karyotype can reveal only macroscopic defects in chromosomes such as deletions, translocations, or trisomies. Serum ceruloplasmin, when low, is diagnostic of Wilson’s disease. Urine porphobilinogens and aminolevulinic acid, when detected in urine in excessive amounts, are diagnostic of acute intermittent porphyria. Creutzfeldt–Jakob disease is diagnosed by cerebrospinal fluid assay for 14-3-3 proteinase inhibitor proteins.

  Neurology

  B&D Ch. 71

Question 4. A. Orbitofrontal lobe lesions cause patients to appear profane, irritable, and irresponsible. When presented with cases that involve personality changes, one should suspect pathology in the frontal lobes. Also, deficits in executive functioning usually involve the frontal lobes. Medial frontal lesions cause apathy, characterized by limited spontaneous movement, gesture, and speech. Left frontal lesions can cause depression. Right frontal lobe lesions can cause mania.

  Neurocognitive Disorders

  K&S Ch. 3

Question 5. C. This is an example of a delusion, which is a fixed false belief that is not accepted by members of the same cultural background. Delusions may be mood congruent or mood incongruent. They may have themes that are bizarre, persecutory, paranoid, grandiose, jealous, somatic, guilty or erotic. Coprolalia is the compulsive utterance of obscene words, as seen in Tourette’s disorder. Egomania is a pathological self preoccupation. Ailurophobia is a dread of cats. An obsession is the pathological persistence of an irresistible thought or feeling that cannot be eliminated from consciousness and is associated with anxiety.

  Psychotic Disorders

  K&S Ch. 8

Question 6. A. This is a description of a cohort study, in which a well-defined population is followed over a period of time. Cohort studies are also known as longitudinal studies. Cohort studies provide direct estimates of risk associated with a suspected causative factor. A case–control study is a retrospective study that examines persons without a particular disease. In a clinical trial, specially selected patients receive a course of treatment, and another group does not. Patients are assigned to either group on a random basis. The goal is to determine the effectiveness of the treatment. Cross-sectional surveys describe the prevalence of a disease in a population at a particular point in time. Crossover studies are a variation of the double-blind study in which the placebo and treatment groups switch at some point in the study.

  Statistics

  K&S Ch. 4

Question 7. D. Although all of the choices contributed to our understanding of child development, it is Winnicott who developed the concept of good enough mothering. This concept is based on the understanding that the mother plays a vital role in bringing the world to the infant and offering empathic anticipation of the infant’s needs. If she does these things well enough the baby will move towards the development of a healthy sense of self. Piaget described stages of cognitive development consisting of sensorimotor, preoperational thought, concrete operations, and formal operations. Freud was the founder of psychoanalysis, giving us the oral, anal, phallic and latency stages of development. Mahler developed stages of separation–individuation to describe how children develop identity that is separate from their mothers. Her stages were normal autism, symbiosis, differentiation, practicing, rapprochement and object constancy. Erikson developed an 8-stage life cycle. The stages are trust vs mistrust, autonomy vs shame and doubt, initiative vs guilt, industry vs inferiority, identity vs role diffusion, intimacy vs self absorption, generativity vs stagnation, and integrity vs despair and isolation.

  Human Development

  K&S Chs 2&6

Question 8. C. The clinical picture presented is that of Wernicke’s encephalopathy. Classically seen in alcoholics, the clinical triad is that of mental confusion, ophthalmoplegia and gait ataxia. The usual brain autopsy finding is that of microhemorrhages in the periventricular gray matter, particularly around the aqueduct and third and fourth ventricles. Frontal and temporal lobe atrophy is consistent with Pick’s dementia. Parkinson’s disease would result in depigmentation of the pars compacta of the substantia nigra in the midbrain. Diffuse Lewy bodies can be seen in both Parkinson’s disease and Alzheimer’s disease. Subcortical white matter lesions perpendicular to the ventricles (also called Dawson’s fingers) are consistent with a demyelinating disease such as multiple sclerosis.

  Neurology

  B&D Ch. 57

Question 9. C. Monoamine oxidase inhibitors (MAOIs) increase levels of biogenic amine neurotransmitters (serotonin, norepinephrine, and dopamine) by preventing their degradation. There are two types of MAO enzyme, MAO-A which breaks down serotonin, norepinephrine, and dopamine, and MAO-B which breaks down dopamine. It is contraindicated to give meperidine with an MAOI. Because these drugs increase intrasynaptic levels of biogenic amine neurotransmitters they should not be given with other drugs that do the same. There have been reports of death in patients given MAOIs and meperidine simultaneously. Patients should inform each of the doctors that they are seeing that they are taking an MAOI. Lithium can be given with MAOIs. When switching a patient from a selective serotonin reuptake inhibitor to an MAOI you need to allow a 14-day washout (28 days for fluoxetine). This is because the combination of these drugs in the system at the same time can potentiate a serotonin syndrome. Orthostatic hypotension is a major side effect of the MAOIs. Other side effects include weight gain, edema, sexual dysfunction, and insomnia. Moclobemide and selegiline are reversible MAO-A inhibitors and because they only weakly potentiate the pressor effects of tyramine they do not require a tyramine free diet at low doses.

  Psychopharmacology

  K&S Ch. 36

Question 10. E. The best choice for tranquilizing agitated patients is haloperidol. Given that the patient in question is elderly, starting with a small dose of haloperidol would be appropriate. Benzodiazepines should be avoided in cases of suspected delirium, which based on the question stem is a concern for this patient. Hence answer choices A and C are out. A benzodiazepine given to a delirious patient can worsen the delirium and further disinhibit the patient making them more agitated. In general one should use great caution in giving benzodiazepines to the elderly, and when used, they should be given in small doses. Aripiprazole, an atypical antipsychotic, only comes in oral form, which would likely be unfeasible in an acutely agitated patient. Other atypical antipsychotic drugs that come in intramuscular injectable form such as olanzapine or ziprasidone would be appropriate choices. Lithium is not standardly used to tranquilize patients. It is a mood stabilizer used in the treatment of bipolar disorder and can only be administered orally.

  Psychopharmacology

  K&S Ch. 10

Question 11. D. Oral meperidine has lower analgesic potency than intramuscular meperidine; therefore the same dose of the oral agent will not cover pain as well as the same dose of the intramuscular agent. There is no reason to suspect that the patient has low pain tolerance or a pain disorder as she is only very recently postoperative and would be expected to be in pain. There is no evidence of a personality disorder given. Conversion disorder presents with neurological symptoms which are not solely limited to pain and as such this is not a conversion disorder.

  Somatic Symptom Disorders

  K&S Ch. 12

Question 12. C. This is an example of countertransference, which refers to the conscious and unconscious feelings the therapist has towards the patient. Transference refers to the feelings the patient has towards the therapist. Resistance is when ideas that are unacceptable to the patient are prevented from reaching awareness. The term is usually used in reference to therapy where the patient withholds relevant information, remains silent, is late, or misses appointments. Confrontation is addressing an issue that the patient does not want to accept. Projection is reacting to unacceptable inner impulses as if they were outside the self. It may often take the form of perceiving one’s own feelings in another and then acting on that perception.

  Psychotherapy

  K&S Ch. 6

Question 13. B. Huntington’s disease is transmitted by an autosomal dominant inheritance pattern. If one parent is an affected carrier, the likelihood of transmission to any given child is 50%. The protein huntingtin is coded on the short arm of chromosome 4. The gene contains an expanded trinucleotide repeat sequence of CAG (normally less than 29 repeats occur).

  Neurology

  B&D Ch. 71

Question 14. D. Middle adulthood spans the years between ages 40 and 65. At the end of early adulthood people review the past and decide what the future will hold for them. In their occupation they start to see differences between early aspirations and what they have actually achieved. In middle adulthood people take stock of accomplishment, reassess commitment to family, work, and marriage, use power ethically, and deal with the illness of their parents. Hence, all of the choices are life tasks faced in middle adulthood except risk-taking behavior. This takes place traditionally in adolescence. Adulthood typically begins with selecting a mate, deciding on an occupation, and achieving independence and self sufficiency.

  Human Development

  K&S Ch. 2

Question 15. C. This is an example of tertiary prevention. Primary prevention is when a clinician does something to prevent the onset of a disease. This is done by reducing causative agents, reducing risk factors, increasing host resistance, or interfering with the transmission of a disease. Secondary prevention is when one identifies a disease in its early stages and seeks prompt treatment. Tertiary prevention involves reducing deficits caused by an illness in order to obtain the highest possible level of functioning. The other answer choices have nothing to do with prevention. Malingering is consciously faking illness for secondary gain. Noncompliance is a term that refers to not following a doctor’s instructions.

  Statistics

  K&S Ch. 4

Question 16. E. Lambert–Eaton myasthenic syndrome (LEMS) is a paraneoplastic abnormality of presynaptic acetylcholine release, often described in conjunction with small cell lung carcinoma. The likely mechanism is immune-mediated, directed against voltage-gated calcium channels. The clinical hallmark of the disorder is generalized weakness with initial improvement in strength after minimal exercise. The electromyogram (EMG) reveals a classic decrementing to 3 Hz stimulation in muscles of the hands or feet. Multiple sclerosis would be expected to cause numerous different deficits, motor, sensory, or both, that are diffuse in space and time. Guillain–Barré syndrome, also known as acute inflammatory demyelinating polyneuropathy (AIDP), is a rapidly occurring demyelinating disease that can present with ascending pain, paralysis, sensory loss, or any combination of these symptoms. The clinical hallmark of AIDP is a loss of deep tendon reflexes in the extremities. The test of choice is EMG and nerve conduction studies which usually reveal loss of H reflex and decreased nerve conduction velocities. Polymyositis is an inflammatory disease of the muscle.

  Neurology

  B&D Ch. 78

Question 17. B. This question is really asking which of the choices is not a projective test, as one of the purposes of a projective test is to detect psychosis. The only choice that is not a projective test is the Minnesota multiphasic personality inventory (MMPI), which is a self-report inventory used to assess personality and areas of psychopathologic functioning. The draw a person test consists of the patient being asked to draw a person. The level of detail is thought to correlate with intelligence and developmental level. Then the patient is asked to draw a person of the opposite sex. The patient is then questioned on what they drew. The assumption is that the drawing represents the expression of the self or the body in the environment. The sentence completion test consists of asking the patient to complete a series of incomplete sentences. The tester focuses attention on strong affect, repeated answers, humor, or unusual responses. The thematic apperception test is a series of pictures shown to a patient. The patient then generates a story to explain the pictures. The patient’s most accepted and conscious traits and motives are attributed to the character closest to the patient in sex, age, and appearance. More unconscious or unacceptable traits are attributed to those characters most unlike the patient. The Rorschach test is a series of 10 inkblots that serve as inspiration for free association. The patient’s responses to each card are recorded and closely interpreted.

  Psychological Theory and Psychometric Testing

  K&S Ch. 5

Question 18. C. Amyotrophic lateral sclerosis (ALS) is a disorder of the upper and lower motor neurons. The spinal cord lower motor neurons are also known as the anterior horn cells. These classically degenerate in ALS and can be demonstrated on autopsy. Callosal thinning and atrophy are hallmarks of multiple sclerosis. Frontotemporal atrophy can be seen in Pick’s dementia. Nigrostriatal depigmentation is a result of Parkinson’s disease. Dorsal column pathology can be seen in vitamin B12 deficiency polyneuropathy with loss of vibration and joint position sensation.

  Neurology

  B&D Ch. 74

Question 19. E. It is considered unethical for psychiatrists to participate in executions. According to the American Psychiatric Association, it is unethical to accept commission for patient referrals. It is unethical to have romantic or sexual relationships with patients. Psychiatrists are expected to report the unethical behavior of other psychiatrists. When retiring, the psychiatrist needs to give patients sufficient notice and make an effort to find them follow-up care. The above are ethical issues often questioned on standardized exams.

  Ethics

  K&S Ch. 58

Question 20. E. This patient is clearly delirious based on the description. While all of the other choices are logical steps, the first and most important is protecting the patient from harm. In this case that would involve sedating the patient before she gets harmed as a result of her own agitation. This is a good rule to keep in mind whenever dealing with an agitated patient. The first responsibility is to keep both patient and staff from getting harmed.

  Management in Psychiatry

  K&S Ch. 10

Question 21. A. The use of positive and negative reinforcement is part of operant conditioning developed by Skinner. In operant conditioning the animal is active and behaves in a way that produces a reward. Learning occurs as a consequence of action. The desired behavior reaps a positive reward. An undesired behavior gets a negative reward. Bandura is a proponent of social learning theory, which says we learn through modeling others and through social interaction. Attribution theory says that people are likely to attribute their own behavior to situational causes, and the behavior of others to personality traits. This then affects their feelings and behavior. Hull did work in the neurophysiologic aspects of learning, developing a drive reduction theory of learning. Learned helplessness is a model for depression developed by Seligman, in which an organism learns that no behavioral change can influence the environment. The organism becomes depressed and apathetic because no matter what it does its environmental circumstances never change. Kandel studied habituation and sensitization in snails. Habituation theory says that an animal can learn to stop responding to a repeated stimulus. Sensitization theory says that an organism can be taught to respond more easily to a stimulus, or be made more sensitive to that stimulus. Pavlov developed classical conditioning. In classical conditioning, a neutral stimulus is paired with one that evokes a response so that eventually the neutral stimulus comes to evoke the same response. He did the classic experiments with dogs salivating when hearing their master’s footsteps.

  Psychological Theory and Psychometric Testing

  K&S Ch. 4

Question 22. B. Ethosuximide is the treatment of choice for uncomplicated absence seizures, the clinical presentation depicted in this question. Failing ethosuximide, the next best choice would be valproic acid, which has efficacy in partial complex, primary generalized and absence seizure types. Carbamazepine would be a very poor choice to treat absence seizures, as it is ineffective in absence seizures and may even worsen the condition. Phenobarbital is not indicated for use in absence seizures. Diazepam is useful only for emergencies such as status epilepticus and usually in rectal, intramuscular, or intravenous forms. Phenytoin is indicated for partial and generalized tonic–clonic seizures; not for absence seizures.

  Neurology

  B&D Ch. 67

Question 23. D. The description in this question is that of narcolepsy. Narcolepsy consists of irresistible attacks of refreshing daytime sleep that occur daily for 3 months or more. The sudden loss of muscle tone described is known as cataplexy. One also sees increased intrusion of rapid eye movement (REM) sleep into the transition between sleep and wakefulness causing hypnopompic (while awakening) and hypnagogic (while falling asleep) hallucinations, as well as sleep paralysis. This disorder can be dangerous as it can lead to automobile or industrial accidents. Treatments can involve stimulants such as amphetamines, methylphenidate (Ritalin), or modafinil (Provigil), as well as structured napping times during the day. Modafinil is a non-stimulant medication FDA-approved for narcolepsy. Its mechanism of action is on histamine neurons in the reticular activating system in the pons. Sleep changes associated with depression include early morning awakening and difficulty falling asleep. Sleep apnea presents with daytime irritability and drowsiness with prominent snoring at night. Primary insomnia is characterized by difficulty initiating or maintaining sleep, or nonrestorative sleep for at least one month. Shift-work sleep disorder is a type of circadian rhythm sleep disorder that occurs in those that repeatedly and rapidly change their work schedules. This can lead to somnolence, insomnia, as well as somatic problems such as an increased likelihood of peptic ulcer.

  Sleep Wake Disorders

  K&S Ch. 24

Question 24. A. Dopamine is associated with the induction of aggression. Serotonin is associated with decreased aggression. In particular, the cerebrospinal fluid levels of 5-HIAA, a major serotonin metabolite, have been shown to be inversely correlated with the frequency of aggression. GABA is the major inhibitory neurotransmitter of the brain and is associated with decreased aggression. Norepinephrine is associated with decreased aggression and its functions are thought to be connected to that of serotonin, particularly in mood disorders. Glycine is an inhibitory neurotransmitter, and as such is not associated with increased aggression. As a general rule, it is thought that cholinergic and catecholaminergic mechanisms seem to be involved in the induction of aggression, and serotonin and GABA seem to inhibit such behavior.

  Basic Neuroscience

  K&S Ch. 3&4

Question 25. A. Carbamazepine induces its own metabolism. This effect decreases its 24-hour half-life by at least 50% during the first 3–4 weeks of therapy. Increments in dosages after the first few weeks of therapy are often necessary to maintain therapeutic serum levels. None of the other mentioned anticonvulsants have this unique pharmacokinetic profile.

  Psychopharmacology

  B&D Ch. 67

Question 26. C. This question reviews aspects of both operant and classical conditioning. In classical conditioning a neutral (or conditioned) stimulus is repeatedly paired with one that evokes a response (the unconditioned stimulus), such that the neutral stimulus comes to evoke the response. In operant (Skinnerian) conditioning, a random behavior is reinforced with reward. Initially, every desirable response is rewarded which enables the behavior to be learned. Giving positive reinforcement intermittently and variably is the best way to prevent a behavior from going extinct. Extinction occurs when the conditioned stimulus is constantly repeated without the unconditioned stimulus until the response evoked by the unconditioned stimulus eventually disappears. Generalization is the transfer of a conditioned response from one stimulus to another. For example, the dog that learned to salivate to a bell now salivates to the sound of a cabinet being opened. Discrimination is recognizing and responding to differences between similar stimuli. For example, a dog can be trained to respond differently to two similar bells. Transference that takes place during psychotherapy can be thought of as a form of stimulus generalization. Respondent conditioning is just another term for classical conditioning.

  Psychological Theory and Psychometric Testing

  K&S Ch. 4

Question 27. D. Tuberous sclerosis is an autosomal dominant neurocutaneous disorder with a prevalence of about 1 in 6000–9000 individuals. The classic neurologic features of the disease are seizures, mental retardation and behavioral problems. Cutaneous lesions include the ash leaf spot (hypomelanotic macule), adenoma sebaceum (facial angiofibromas) and shagreen spots (irregularly shaped, often raised or textured skin lesion on the back or flank). Retinal hamartomas can be observed in many patients. Neuropathologic lesions include subependymal nodules and cortical hamartomas. Down’s syndrome, or trisomy 21, frequently results in early onset Alzheimer’s type changes in the brain including neurofibrillary tangles and cholinergic deficits. Rett’s disorder, a pervasive developmental disorder seen only in girls, involves deceleration of head growth from ages 5 months to 4 years, loss of purposeful hand skills and development of stereotyped hand movements between ages 5 months and 2.5 years, loss of social engagement and acquired impairment in expressive and receptive language skills. Although seizures can be observed in up to 75% of Rett’s patients, there are typically no skin lesions associated with the disorder. Neurofibromatosis has two types: NF1 and NF2. NF1 (classic von Recklinghausen’s disease, with café au lait spots (6 or more to make the diagnosis), subcutaneous neurofibromas, axillary freckling, Lisch nodules (pigmented iris hamartomas), optic nerve glioma, neurofibromas and schwannomas) is caused by a mutation of the 60 exon NF1 gene on chromosome 17q. NF2 is caused by a mutation of the NF2 gene on chromosome 22. NF2 patients have few cutaneous lesions. The diagnostic hallmark of NF2 is bilateral vestibular (VIII nerve) schwannomas. Williams’ syndrome is an autosomal dominant mental retardation syndrome that occurs by a hemizygous deletion including elastin locus chromosome 7q11-23. Patients with the disorder have short stature, unusual facial features that include depressed nasal bridge (an upturned nose), broad forehead, widely spaced teeth, elfin-like facies, as well as thyroid, renal and cardiovascular anomalies. Psychiatric symptoms include anxiety, hyperactivity, hypermusicality. Seizures and skin lesions are not observed in Williams’ syndrome.

  Neurology

  B&D Ch. 65

Question 28. B. The mechanism described is that of the cholinesterase inhibitors used in Alzheimer’s disease. By potentiating cholinergic transmission, these drugs cause modest improvement in memory and goal-directed thought. These drugs include medications such as tacrine, donepezil, galantamine and rivastigmine. All of the answer choices in this question are cholinesterase inhibitors except for memantine. Memantine is also used for Alzheimer’s dementia, but works by binding to N-methyl-D-aspartate (NMDA) receptors, acting as an antagonist and thereby slowing calcium influx into cells. The slowing of calcium influx halts cell destruction.

  Psychopharmacology

  K&S Ch. 36

Question 29. E. Of the tests listed, the only one that tests executive function is the trail-making test. The trail-making test involves connecting letters and numbers in order, alternating between letters and numbers (i.e., connect A-1-B-2-C-3, etc.) Another acceptable answer would be the Wisconsin card sorting test, but is not an answer choice. The Wisconsin card sorting test evaluates abstract reasoning and flexibility in problem solving. The thematic apperception test is used to test normal personality and involves showing pictures and having the patient come up with stories. The patient’s most accepted and conscious traits and motives are attributed to the character closest to the patient in sex, age, and appearance. More unconscious or unacceptable traits are attributed to those characters most unlike the patient. The Halstead–Reitan battery helps find the location of brain lesions as well as differentiate between those who are brain damaged and those who are neurologically intact. It consists of a series of 10 tests. The Minnesota multiphasic personality inventory (MMPI) is a personality assessment used to find areas of psychopathologic functioning. It consists of more than 500 statements to which the patient must respond “true”, “false” or “cannot say”. The brief psychiatric rating scale (BPRS) is used to assess the severity of psychosis in schizophrenia.

  Psychological Theory and Psychometric Testing

  K&S Ch. 5

Question 30. E. The first four choices are all very important pieces in determining whether a person can make a will, including whether or not the person knows he is making a will. In order to have the capacity to make a will, three things are needed. The first is the ability to understand the nature and extent of one’s property. The second is that one must know that one is making a will. The third is that one must know to whom the property will be bequeathed. The last answer choice is part of the McGarry instrument which determines whether someone is competent to stand trial. It has nothing to do with making a will.

  Forensic Psychiatry

  K&S Ch. 57

Question 31. C. The average age of onset of puberty is 11 years for girls and 13 years for boys. All other answer choices are true. The onset of puberty is triggered by maturation of the hypothalamic–pituitary–adrenal–gonadal axis. This leads to secondary sex characteristics such as enlarged breasts and hips in girls and facial hair and lowered voice in boys. Primary sex characteristics are those involved in coitus – the external genitals and reproductive organs. Increases in height and weight occur earlier in girls than in boys. Sex hormones increase slowly through adolescence and correlate with bodily changes. Follicle-stimulating hormone (FSH) and leutinizing hormone (LH) increase through adolescence, being above normal adult values by age 17 or 18. Testosterone seems to increase around age 16 or 17 and then stabilize at adult levels in males.

  Human Development

  K&S Ch. 2

Question 32. A. Sumatriptan (Imitrex) is an antimigraine medication indicated for acute, abortive therapy of migraine headache. All drugs in the triptan class act as potent agonists at 5-HT 1B and 5-HT 1D receptors. Although these receptors reside principally on intracranial blood vessels, they may have an effect on the coronary arteries as well and could theoretically cause vasoconstriction, vasospasm and acute myocardial infarction. Therefore, these agents are contraindicated in patients with coronary ischemic heart disease, as well as with uncontrolled hypertension.

  Neurology

  B&D Ch. 69

Question 33. D. Antipsychotic drugs and methylphenidate increase tricyclic antidepressant (TCA) concentrations through their interaction with the cytochrome p450 system. Other drugs that increase TCA concentrations include acetazolamide, aspirin, cimetidine, thiazides, fluoxetine and sodium bicarbonate. Cigarette smoking decreases their concentration through its action on the 1A2 enzyme. Other drugs that decrease TCA concentrations include ascorbic acid, lithium, barbiturates, and primidone.

  Psychopharmacology

  K&S Ch. 36

Question 34. D. Completed suicide is most often associated with depression, not bipolar disorder. Adolescents most frequently commit suicide with guns, not by hanging. In recent years the suicide rate has gone up dramatically among adolescents, not among middle-aged adults. Previous suicide attempts are the best predictor of future risk of suicide. This is a very important factor which should be taken into account whenever taking a patient history. Men successfully commit suicide three times more often than women. Another factor contributing to completed suicides is age. For men, the highest risk period is after 45 years of age. For women, the highest risk period is after 55 years of age. Married people are less likely to commit suicide than single or widowed people. As far as religion is concerned, rates of suicide among Roman Catholics are less than those for Protestants or Jewish people. With race, whites are more likely to commit suicide than others, especially white males. Physical health may play a role. Thirty-two per cent of people who commit suicide have seen a doctor within the past 6 months. With regard to occupation, the higher a person’s social status, the higher the rate of suicide. A fall in social status also increases the risk.

  Depressive Disorders

  K&S Ch. 34

Question 35. D. Alexia without agraphia is seen with lesions involving the splenium of the corpus callosum. Gerstmann’s syndrome usually involves left parietal lobe damage. The clinical picture is the classic tetrad of acalculia, agraphia (without alexia), right and left confusion and finger agnosia (the inability to name the thumb, index, middle, ring and pinky fingers when called upon to do so). The lesion in Gerstmann’s syndrome localizes to the left angular gyrus.

  Neurology

  B&D Ch. 51

Question 36. B. Dialectical behavioral therapy (DBT) is a form of therapy developed by Marsha Linehan for the treatment of borderline personality disorder. The therapist is supportive and directive. Specific exercises are performed to help solve problems and improve interpersonal skills. The focus of therapy is on reducing impulses to self-mutilate.

  Psychotherapy

  K&S Ch. 35

Question 37. C. The clinical picture portrayed in this question is that of hyperprolactinemia induced by dopamine blockade in the tuberoinfundibular system by a neuroleptic medication. Conventional neuroleptics and risperidone can increase the volume of pituitary microadenomas by blocking dopamine and increasing serum prolactin levels. When an adenoma grows beyond 1.5 cm in diameter it can encroach on the medial portion of both optic nerves outside of the sella turcica. This optic nerve involvement results in the classic clinical sign of bitemporal hemianopsia. Appropriate treatment would be the discontinuation of the offending drug and possibly administration of bromocriptine. Some adenomas require surgical intervention if they are unresponsive to medication therapy.

  Psychopharmacology

  B&D Ch. 52

Question 38. C. The mental status examination is the description of the patient’s appearance, speech, actions, and thoughts during the interview. All of the choices are correct, with the exception of C. Content of thought includes such things as delusions, preoccupations, obsessions, compulsions, phobias, suicidality and homicidality. It is a common mistake to put hallucinations in the thought content section of the mental status exam. Hallucinations are false sensory perceptions and fall under the category of perception. The categories of the mental status examination are appearance, psychomotor activity, attitude, mood, affect, speech, perception, thought content and process, consciousness, orientation, memory, concentration, attention, reading and writing, visuospatial ability, abstract thought, information and intelligence, impulsivity, judgment and insight, and reliability.

  Diagnostic and Treatment Procedures in Psychiatry

  K&S Ch. 7

Question 39. B. This is a clear description of the Malaysian cultural syndrome of Amok. It consists of a sudden rampage including homicide and/or suicide, which ends in exhaustion and amnesia. Koro is an Asian delusion that the penis will disappear into the abdomen and cause death. Piblokto occurs in female Eskimos of northern Greenland. It involves anxiety, depression, confusion, depersonalization, derealization, ending in stuporous sleep and amnesia. Wihtigo is a delusional fear displayed by Native American Indians of being turned into a cannibal through possession by a supernatural monster, the Wihtigo. Mal de ojo is a syndrome found in those of Mediterranean descent involving vomiting, fever, and restless sleep. It is thought to be caused by the evil eye.

  Cultural Issues in Psychiatry

  K&S Ch. 14

Question 40. E. The patient has clearly suffered a left hemispheric stroke, possibly in the middle cerebral artery territory. Any hemispheric stroke that involves the corticospinal tract can result in an appearance of contralateral Babinski and Hoffman’s signs. The Babinski sign is the upward motion of the big toe and fanning of the other toes when the plantar surface of the foot is stroked upwardly from bottom to top with a noxious stimulus or blunt instrument like the butt of a reflex hammer. The Hoffman’s sign is positive when the adduction of the thumb is noted upon a fast downward flick being administered to the index or middle finger of the same hand. Hoffman’s sign is equivalent to the Babinski sign except it is in the upper extremity. The palmomental reflex and Meyerson sign are two of the classic so-called frontal release signs. The palmomental reflex is positive when the chin muscle contracts as the thenar eminence of the palm contralateral to the brain lesion is stroked with a blunt instrument. Meyerson sign is the presence of a persistence of the glabellar reflex of blinking upon confrontation of the forehead by tapping with a finger. The blinking normally should extinguish after several taps of the forehead, but in the presence of frontal lobe damage, the response does not extinguish as rapidly. Complete loss of the gag reflex would be expected only in a devastating stroke involving the brain stem or complete brain death.

  Neurology

  B&D Ch. 51

Question 41. B. Glutamate is the major excitatory neurotransmitter in the brain. Glutamate is the precursor to gamma aminobutyric acid (GABA). The major inhibitory neurotransmitters are GABA and glycine. Glutamate works on the N-methyl-d-aspartate (NMDA) receptor as well as four types of non-NMDA receptors. The NMDA receptor is bound by PCP. Glutamate is thought to be very important in learning and memory. Glutamate is also important in the theory of excititoxicity, which postulates that excessive glutamate stimulation leads to excessive intracellular calcium and nitric oxide concentrations and cell death. Under stimulation of the NMDA receptor by glutamate has been found to cause psychosis, therefore glutamate is thought to play some role in schizophrenia, although the exact nature of that role is yet unclear. Locations for glutamate in the brain include cerebellar granule cells, striatum, hippocampus, pyramidal cells of the cortex, thalamocortical projections, and corticostriatal projections.

  Basic Neuroscience

  K&S Ch. 3

Question 42. D. Alzheimer’s disease has been associated with defects in chromosome 21. The gene for amyloid precursor protein is found on the long arm of chromosome 21. This protein plays a significant role in the development of Alzheimer’s disease. These defects have been shown to run in families. Some studies have shown as high as 40% of Alzheimer’s patients have a positive family history for the disease. Turner’s syndrome results from a missing sex chromosome XO. The result is absent or minimal development of the gonads. No sex hormones are produced. Individuals with Turner’s syndrome are female, but with no secondary sex characteristics and an absence or minimal development of the gonads. Klinefelter’s syndrome is the presence of an extra chromosome, making the patient XXY. They have a male habitus because of the presence of the Y chromosome, but because of the extra X chromosome they do not develop strong male characteristics. They have small underdeveloped genitals. They are infertile, and can develop breast tissue during adolescence. Huntington’s disease results from the expansion of trinucleotide repeat sequences at chromosome 4p16.3. The disease typically presents with dementia and chorea. Parkinson’s disease results from the loss of dopaminergic neurons from the substantia nigra. It can present with dementia as well as a clear pattern of symptoms including shuffling gait, pill-rolling tremor, and masked facies. Other than Alzheimer’s the other diseases listed have nothing to do with chromosome 21.

  Neurodevelopmental and Pervasive Developmental Disorders

  K&S Ch. 10

Question 43. C. The diagnosis of brain death can be made only in the complete absence of the brainstem reflexes (i.e., absent gag, fixed pupils, absent oculocephalic and oculovestibular reflexes, absent corneal reflexes). The eyes may either be open or closed in the presence of brain death. The EEG pattern need not be flat line to diagnose brain death. There have been known cases of preserved cortical function and hence positive activity on EEG despite a complete lack of brainstem functioning.

  Neurology

  B&D Chs 5&55

Question 44. B. Of the drugs listed, diazepam is the one that needs oxidative metabolism by the liver. The other four are safe choices for patients with compromised liver function because they have no active metabolites or do not need oxidation by the liver. Patients with hepatic disease and elderly patients are at particular risk from adverse effects due to the benzodiazepines, especially if repeated high doses are given. Benzodiazepines should be used with caution in anyone with a history of substance abuse, cognitive disorders, renal disease, liver disease, central nervous system depression, or myasthenia gravis.

  Psychopharmacology

  K&S Ch. 36

Question 45. C. All of the answer choices are reasonable things to do with a family in family therapy, except focusing most of the attention on the most dysfunctional member. The focus of the therapy should be on the whole family as a system, in which everyone plays a role. The problems that the family are having should not be treated as one person’s fault.

  Psychotherapy

  K&S Ch. 35

Question 46. B. The neurotransmitters associated with anxiety are norepinephrine, serotonin, and gamma aminobutyric acid (GABA). Poor regulation of norepinephrine is thought to be involved in anxiety disorders. Noradrenergic neurons are found primarily in the locus ceruleus. Stimulation of the locus ceruleus increases anxiety, and ablation of the locus ceruleus blocks anxiety responses. Serotonin is also thought to be involved in anxiety, although its role is less clear. Serotonergic drugs have shown a clear propensity to decrease anxiety. Serotonergic neurons are located primarily in the raphe nuclei in the pons. The role of GABA in anxiety is clearly supported by the strong effect that benzodiazepines have on lessening anxiety. Benzodiazepines enhance the effect of GABA at the GABA receptor, thus decreasing anxiety. Those neurotransmitters not directly associated with anxiety include dopamine, glutamate, histamine, and acetylcholine. There is no evidence as yet that these neurotransmitters play a role in the pathophysiology of anxiety. Injection of epinephrine would worsen anxiety.

  Basic Neuroscience

  K&S Ch. 3

Question 47. B. Myasthenia gravis (MG) is an autoimmune neurologic disorder involving the production of autoantibodies against postsynaptic nicotinic acetylcholinergic receptor sites on muscle. There is passive transfer of the offending antibodies to the fetus across the placenta. The clinical picture is that of diplopia, dysarthria, dysphagia and other signs and symptoms of bulbar palsy, fatigue and muscle weakness. Mental status and cognition are usually intact. Deep tendon reflexes are generally preserved. There is a relationship between MG and thymoma. About 10% of patients with MG have thymoma. Edrophonium chloride (Tensilon), a short-acting cholinergic agent, is used to diagnose the disorder clinically and pyridostigmine (Mestinon) is used to treat the disorder on an ongoing basis. Other diagnostic tests include electromyography (EMG) and nerve conduction studies, which reveal a classic decrementing upon rapid repetitive muscle stimulation. Serum antibody levels can also be titered. Other therapeutic modalities include steroids, plasmapheresis, intra-venous immunoglobulin (IVIG) administration, immunosuppressive agents, for example, azathioprine (Imuran).

  Neurology

  B&D Ch. 78

Question 48. D. Generalized slow activity consisting of theta and delta waves with focal areas of hyperactivity is the EEG pattern of delirium. An important characteristic of this pattern is that the rhythm is slowed. Choice A is the pattern for absence seizures. This is a commonly asked pattern on exams. Choice B is normal adult drowsiness. Choice C is a normal pattern seen when the eyes are closed. Upon awakening, the posterior alpha rhythm is replaced by random activity. Right temporal spikes, choice E, are significant for a seizure focus. In addition to the above information, the appearance of delta waves is considered abnormal and should raise concern regarding a structural lesion, except if the patient is asleep.

  Neurology

  K&S Chs 3&10

Question 49. D. Gower’s maneuver or sign is a classic bedside indicator of muscular dystrophy or myopathy. Usually seen in children, the sign is present when a patient gets up from the floor or a chair by using the hands because of muscle weakness in the legs. Duchenne’s is called a dystrophinopathy because it is an autosomal recessive hereditary disease of muscle due to a lack of dystrophin, a protein found in muscle membrane. Duchenne’s is the most common of the childhood muscular dystrophies. Muscular weakness is usually greater proximally. Other features include diminished deep tendon reflexes (except the Achilles reflex), elevated CPK, mental retardation in about one third of cases and enlarged muscles, due to fat infiltration, particularly the calves.

  Neurology

  B&D Ch. 79

Question 50. B. The tricyclic antidepressants (TCAs), trazodone, and mirtazapine are all sedating drugs. Sedation is a common effect of the TCAs and can be a welcome one if the patient isn’t sleeping well. The most sedating of the TCAs are amitriptyline, trimipramine and doxepin. The least sedating are desipramine and protriptyline, with other TCAs falling between these two groups in the amount of sedation they cause. Trazodone is an antidepressant that can be extremely sedating. For this reason it is sometimes used independently for insomnia. Trazodone can also cause priapism, in which case the patient should be switched to another medication. The SSRIs and SNRIs in general are not very sedating.

  Psychopharmacology

  K&S Ch. 36

Question 51. D. The appropriate response to this situation is to examine your own behavior and countertransference. You should then share your observations about the patient’s behavior with the patient and examine the meaning of the patient’s behavior. Answer choice A is a bad idea as ignoring the problem will not make it go away. Flirting with the patient is inappropriate and having sex with the patient is a violation of ethics which is strictly forbidden for psychiatrists. Revealing personal information is also not appropriate for the therapist to do and does not address the patient’s underlying motivations.

  Psychotherapy

  K&S Chs 35&58

Question 52. B. This is an example of fetishism. In fetishism, a person, usually a male, obtains sexual arousal from an inanimate object such as women’s undergarments, a glove, a shoe, etc. This needs to go on for at least six months to qualify for the diagnosis, and often involves sexual fantasies involving the object. Exhibitionism involves being sexually aroused by exposing one’s genitals to a stranger. Frotteurism involves becoming sexually aroused by touching and rubbing against a nonconsenting person. Voyeurism is a pattern of obtaining sexual arousal from watching an unsuspecting person who is naked, disrobing, or engaged in sexual activity. Transvestic fetishism is a pattern of sexual arousal from cross-dressing, usually seen in a heterosexual male. The answer to this question is not transvestic fetishism because the patient was wearing women’s under garments only under his normal male work clothes. He was not going to work in a dress with makeup and high heel shoes. It is not dressing like a woman that arouses him, but a fantasy connected with an inanimate object, namely the panties.

  Paraphilias

  K&S Ch. 21

Question 53. C. The case above describes trigeminal neuralgia (tic douloureux). It is usually unilateral in about 90% of cases. It usually affects the upper two branches of the fifth nerve (V2 and V3). Treatments of choice are carbamazepine (Tegretol) and oxcarbazepine (Trileptal), which modulate pain centrally and peripherally. About 75% of patients respond to carbamazepine therapy. Other treatments include gabapentin (Neurontin), tricyclic antidepressants, tiagabine (Gabitril), opioid analgesics, nonsteroidal anti-inflammatory agents, lidocaine patches and benzodiazepine sedatives. Some patients opt for an invasive intervention, radiation therapy in the form of stereotactic gamma-knife treatment to alleviate the pain.

  Neurology

  B&D Chs 69&70

Question 54. D. This is the classic clinical picture of temporal (also called giant-cell) arteritis, a systemic vasculitis of the medium-sized vessels. Women are affected more often than men (about 3:1). The disease occurs in the elderly, usually over 50 years of age. Clinically, the disease can present as new onset or change in headache with fever, fatigue, myalgia, night sweats, weight loss, and jaw claudication (tiredness upon chewing). About 25% of patients have polymyalgia rheumatica. The temporal artery can demonstrate tenderness to palpation with induration and diminished or absent pulse. The most feared complication is irreversible and sudden vision loss as a result of central retinal artery occlusion. The initial test of choice is the serum erythrocyte sedimentation rate (ESR), which is virtually always elevated. Temporal artery biopsy is the gold-standard diagnostic test of choice in the face of an elevated ESR. The treatment of choice is prednisone. Brain imaging would not reveal the abnormality. Lumbar puncture for cerebrospinal fluid xanthochromia is done to diagnose subarachnoid hemorrhage. Carotid dissection does not involve systemic constitutional symptoms, but usually presents with ipsilateral stroke-like deficits due to arterial embolization.

  Neurology

  B&D Ch. 69

Question 55. D. The concept that mental disorders have different outcomes was pioneered by Emil Kraepelin. He was the first to differentiate between the course of chronic schizophrenia, and that of manic psychosis. He used the term dementia praecox borrowing it from the work of French psychiatrist Morel. Eugen Bleuler later renamed it as schizophrenia and stressed that it need not have a deteriorating course. Winnicott was one of the central figures in the school of object relations theory. He developed the concepts of the “good enough mother” and the “transitional object”. Sigmund Freud is the founder of classic psychoanalysis. Heinz Kohut is best known for his writings of narcissism and self psychology.

  History of Psychiatry

  K&S Ch. 13

Question 56. B. This is a clear case of hypochondriasis. The patient believes that he has a specific serious disease despite a negative workup and the reassurance of his doctors. Conversion disorder is when a patient has a neurologic symptom which is attributed to psychological conflict and cannot be explained medically. Body dysmorphic disorder is preoccupation with an imagined defect in appearance. Often slight physical imperfections cause markedly excessive concern. Somatization disorder (also known as Briquet’s syndrome) is a condition where a patient has multiple physical complaints involving several organ symptoms. These symptoms cannot be explained by a medical diagnosis. The symptoms are not intentionally produced. Symptoms can include pain, sexual symptoms, gastrointestinal symptoms, and pseudoneurological symptoms.

  Somatic Symptom Disorders

  K&S Ch. 17

Question 57. B. Cluster headache is a rare type of headache occurring in ≈0.5% of the population. Sufferers are usually males in their 20 s and 30 s. Most sufferers experience episodic cycles of 4–12 weeks’ duration that are predominant in the spring and fall seasons. Attack periods can be considered chronic, that is lasting 1 year or more without remission or with remission periods of less than 2 weeks’ duration. Attacks can last anywhere from 15 minutes to 3 hours in duration. They can occur as often as eight times a day, or as infrequently as once every other day. The attacks are generally nocturnal. Alcohol consumption is a common trigger. The attacks are excruciatingly painful and retro-orbital in location. Pain can radiate to the teeth, neck and temporal regions and can be accompanied by ipsilateral autonomic symptoms. Patients prefer moving their head or pacing rather than lying still. Abortive therapies include oxygen by nasal cannula at 8–10 liters per minute, sumatriptan subcutaneous injection and ergotamine. Prophylactic therapies include prednisone, verapamil, divalproex sodium, methysergide and lithium.

  Neurology

  B&D Ch. 75

Question 58. E. Seizure, anorexia, head trauma, and use of a MAOI in the past 14 days are all contraindications to using bupropion, because of the propensity of bupropion to lower the seizure threshold. One does not want to use this medication in a situation where the seizure threshold may already be lowered, or a seizure focus is present. The medication can also cause weight loss, so use in those who are under-weight is not a good idea. It can also lead to increased rates of seizures in patients with eating disorders. Although it can increase blood pressure in some patients, it does not cause hypertensive crises and is not contraindicated in patients with high blood pressure. Hypertension is a strong concern when using venlafaxine because of its ability to potentiate hypertensive crisis. Bupropion is also used for smoking cessation. Waiting for 14 days when switching to or from an MAOI is a hard and fast rule to prevent drug–drug interactions, which could lead to a serotonin syndrome. Bupropion is not associated with sexual side effects in the way that the selective serotonin reuptake inhibitors are.

  Psychopharmacology

  K&S Ch. 36

Question 59. B. Lithium and phentolamine are not contraindicated with MAOIs. Meperidine and selective serotonin reuptake inhibitors (SSRIs) cannot be given at the same time as MAOIs and this often comes up on standardized tests. There should be a 14-day washout period between giving an SSRI and an MAOI. Levodopa and spinal anesthetics containing epinephrine are also part of a long list of medications that should not be mixed with a MAOI.

  Psychopharmacology

  K&S Ch. 36

Question 60. C. There are numerous causes of acquired peripheral neuropathy. The more notable causes include: vincristine and INH therapies, excess B6 therapy, inhalant abuse such as toluene or nitrous oxide, heavy metal poisoning, hydrocarbon exposure, B12 deficiency, niacin deficiency, and complications of mononucleosis (Epstein–Barr virus infection). Autoimmune diseases such as lupus can also cause peripheral neuropathy. Acetaminophen overdose does not generally affect the peripheral nervous system.

  Neurology

  B&D Ch. 76

Question 61. C. Of all of the answer choices, the only one that is not true is C. Methylphenidate will increase tricyclic antidepressant (TCA) levels, as will some antipsychotics. Smoking decreases TCA levels. Antipsychotics and methylphenidate increase TCA concentrations through their interaction with the cytochrome p450 system. Other drugs that increase TCA concentrations include acetazolamide, aspirin, cimetidine, thiazides, fluoxetine and sodium bicarbonate. Cigarette smoking decreases their concentration through induction of the 1A2 enzyme. Drugs that decrease TCA concentrations include ascorbic acid, lithium, barbiturates, and primidone.

  Psychopharmacology

  K&S Ch. 36

Question 62. D. Of the selective serotonin reuptake inhibitors, fluoxetine has the longest half life, lasting 1–2 weeks, fluvoxamine has the shortest, lasting about 15 hours. All others have half lives of about 1 day.

  Psychopharmacology

  K&S Ch. 36

Question 63. A. Self-mutilation is most often associated with borderline personality disorder. Borderline patients often use this behavior to express anger, elicit help from others, or numb themselves to overwhelming affect. They have tumultuous interpersonal relationships and strong mood swings. They can have short lived psychotic episodes. Their behavior is often unpredictable. They can rarely tolerate being alone, and are known for splitting people into all good or all bad categories. They lack a consistent sense of identity.

  Personality Disorders

  K&S Ch. 7

Question 64. A. The clinical picture depicted in this question is that of dermatomyositis. Dermatomyositis is an autoimmune disease that affects skin and muscle. Skin rash appears generally with the onset of muscle weakness. The rash is classically purplish and is mainly seen on the face and eyelids. It can also appear on the neck, elbows and the knees which are often reddened and indurated. Serum CPK levels are often elevated. Needle electromyography (EMG) demonstrates myopathy and muscle irritability, with fibrillations, positive sharp waves and increased insertional activity. The hallmark finding on muscle biopsy is perifascicular atrophy and “ghost” fibers. There is a strong relationship between dermatomyositis and occult neoplasm in up to 50% of patients with the disorder. The usual neoplasm is carcinoma and can be in the lung, breast, stomach or ovary most typically. A cancer workup is essential in patients found to have dermatomyositis, including chest radiography, rectal and vaginal exams, hematologic studies and testing for occult blood in stool.

  Neurology

  B&D Ch. 79

Question 65. D. The case presented in this question is a common description of water intoxication. Symptoms include tremor, ataxia, restlessness, diarrhea, vomiting, polyuria, and eventual stupor. This is a problem that can be found in up to 20% of patients with chronic schizophrenia. When found, these patients need close monitoring of their electrolytes, and in many cases must be water restricted with close monitoring of their intake and output. The electrolyte disturbances that result from drinking enormous quantities of water can become serious medical issues and in some cases prompt medical hospitalization. Although the other questions could be useful in doing a thorough evaluation, the patient’s symptoms and psychiatric diagnosis should suggest water intoxication.

  Psychotic Disorders

  K&S Ch. 13

Question 66. A. This question stem describes paranoid schizophrenia. In paranoid schizophrenia, there are delusions and hallucinations most prominently, but specific behaviors suggestive of disorganized or catatonic schizophrenia are absent. The onset is usually later than other types of the disease, and they show less regression of their mental facilities and emotional responses. Disorganized schizophrenia has early onset and poor outcome. It is marked by a regression to primitive, disinhibited, and unorganized behavior and absence of catatonic symptoms. Patients display prominent thought disorder and their contact with reality is poor. Catatonic schizophrenia consists of negativism, rigidity, posturing, and alteration between stupor and excitement. Patients often exhibit stereotypies, mannerisms, and waxy flexibility. Residual schizophrenia presents with evidence of a schizophrenic disturbance with absence of a complete set of active symptoms and an absence of adequate symptoms to qualify as one of the other types of schizophrenia. It can consist of emotional blunting, social withdrawal, eccentric behavior, illogical thinking and mild loosening of associations.

  Psychotic Disorders

  K&S Ch. 13

Question 67. C. All of the answer choices are associated with good outcomes except early age of onset. The older the patient is at onset, the better the prognosis. Good prognostic indicators for schizophrenia include late onset, obvious precipitating factors, acute onset, good premorbid functioning, mood disorder symptoms, being married, family history of mood disorders, good support systems, and positive symptoms. Poor prognostic factors include young onset, no precipitating factors, insidious onset, poor premorbid functioning, withdrawn or autistic-like behavior, being single, divorced or widowed, family history of schizophrenia, poor support systems, negative symptoms, neurological symptoms, history of perinatal trauma, no remissions in early years, many relapses, and history of assaultiveness.

  Psychotic Disorders

  K&S Ch. 13

Question 68. E. The findings given in this question are descriptors of sleep patterns one would find in depression. One might also find increased awakening during the second half of the night and increased length of the first rapid eye movement (REM) sleep episode. Electroencephalography can be used to evaluate sleep, but in clinical psychiatry, it is most often used to separate temporal lobe seizures from pseudoseizures and to distinguish dementia from pseudodementia caused by depression. The other answer choices given are clear distractors. Tumor is unrelated to sleep changes and could potentially show up on an EEG as a seizure focus, but we have no history here of either seizures or seizure focus on EEG. Petit mal epilepsy has a classic 3-per-second spike and wave pattern, which is clearly not mentioned in the question. Hepatic encephalopathy would cause a delirium, making answer choices C and D very similar. EEG patterns in delirium would show generalized slow activity, i.e. theta and delta waves, with possible areas of hyperactivity. Hepatic encephalopathy often shows on EEG as bilaterally synchronous triphasic slow waves. None of that is mentioned in the question, as we are solely talking about sleep patterns. Therefore E is the only reasonable answer.

  Diagnostic and Treatment Procedures in Psychiatry

  K&S Ch. 15

Question 69. B. The genetics of Alzheimer’s dementia (AD) are the subject of ongoing research. A positive family history of the disorder is found in about one-quarter of cases. This type of Alzheimer’s dementia is further classified as familial AD or FAD. The most significant genetic risk factor is believed to be homozygosity for the inheritance of the E4 allele of apolipoprotein E (apo E). Other less significant risks may be mutations in Presenelin 1 (on chromosome 14) and Presenelin 2 (on chromosome 1) proteins and amyloid precursor protein (APP). Apo E4 genotyping may be useful in patients with cognitive deficits as it points very strongly to the clinical diagnosis of AD. Neurofibrillary tangles are a neuropathologic hallmark of AD and a major component of these tangles is the microtubule-associated protein, tau. Abnormal hyperphosphorylation of tau results in the destruction of the neuronal cytoskeleton and the aggregation of tangles. Trisomy 21 (Down’s syndrome) predisposes patients to early onset of Alzheimer’s dementia in as many as 90% of cases. Neuropathologic findings in these cases are identical to those seen in elderly patients. The reason for the early onset of the condition in Down’s patients is believed to be overexpression of the APP gene and thus increased β-amyloid deposition.

  Neurocognitive Disorders

  B&D Ch. 66

Question 70. C. The answer choices are all characteristics of narcissism, except C. Answer choice C describes characteristics of histrionic personality disorder. Histrionic personality disorder is marked by a pattern of excessive emotionality and attention seeking. Narcissism is marked by grandiosity, need for admiration, and lack of empathy.

  Personality Disorders

  K&S Ch. 27

Question 71. D. For post-traumatic stress disorder (PTSD) the duration of the disturbance must be at least one month. All other answer choices are correct. In PTSD the person was exposed to an event that involved either actual or threatened death or injury or a threat to their or others’ physical integrity. Their response involves intense fear, helplessness, or horror. The event is re-experienced as flashbacks or recurring dreams. Patients may act or feel as if the event was recurring. If they perceive things that remind them of the event, they are caused by intense psychological distress and show physiological reactivity. Patients with PTSD often spend great energy avoiding stimuli that remind them of the event. They can also demonstrate a numbing of general responsiveness as shown by inability to remember certain aspects of the trauma, loss of interest in significant activities, feelings of detachment from others, restricted affect, and feelings of a foreshortened future. They also show signs of increased arousal such as problems with sleep, irritability and outbursts of anger, poor concentration, hypervigilance, and excited startle response.

  Trauma and Stress Related Disorders

  K&S Ch. 16

Question 72. E. Uncomplicated grief is often manifested as a state of shock, numbness or bewilderment. It may be followed by sighing or crying. This may lead to weakness, decreased appetite, weight loss, problems concentrating, and sleep disturbances. This is all considered part of normal grief. Once a person begins to manifest worthlessness, suicidality, excessive guilt, hallucinations, or psychomotor retardation the grief is no longer normal. Pathological grief can take many forms ranging from absent or delayed grief, to excessively intense or prolonged grief, to psychosis and suicidality. Anticipatory grief is expressed in advance of a loss deemed to be inevitable. This grief ends at the time when the loss occurs, regardless of what happens after. The grief may intensify as time goes on and the person moves closer and closer to the loss, and turn to acute grief when the loss occurs. Delusional disorder and bipolar disorder are unrelated to the information in the question stem.

  Trauma and Stress Related Disorders

  K&S Ch. 2

Question 73. C. Numerous neuropathologic abnormalities accompany schizophrenia on both a microscopic and macroscopic level. Hippocampal neurons can be atrophic. Lamina III neurons in the hippocampus can be disorganized and scattered. This is not solidly replicated in neuropathologic specimens. One of the most replicable findings is enlargement of the cerebral ventricular system, particularly the lateral ventricles. This finding has been extensively replicated over numerous neuropathologic specimens. Other affected areas include the thalamus and the dorsolateral prefrontal cortex.

  Psychotic Disorders

  K&S Ch. 3

Question 74. E. The patient presented in this question is a clear case of anorexia nervosa. No single laboratory test can diagnose the disease, but a battery of tests is needed to properly evaluate the patient medically. Tests to order include serum electrolytes, renal function tests, thyroid function tests, glucose, amylase, complete blood count, electrocardiogram, cholesterol, dexamethasone suppression test, and carotene. Of these, one of the most important tests is the serum potassium level. Eating-disorder patients can commonly become hypokalemic, develop a hypokalemic hypochloremic alkalosis and have cardiac complications including arrhythmias and sudden death. Osteoporosis can be found in anorexic patients, but a bone scan is not a vital initial procedure. A head CT scan is not warranted. Delayed gastric emptying can occur with eating disorders, but a study to prove such is not urgent. Cholesterol is often increased in these patients, but again, not urgent.

  Feeding and Eating Disorders

  K&S Ch. 23

Question 75. D. All of the answer choices regarding delusional disorder are true except D. You do not have to have impairment of daily functioning to qualify for delusional disorder. The most prominent feature of the disorder is delusions. These delusions can be paranoid, grandiose, erotic, jealous, somatic, or mixed. These patients lack significant mood symptoms and they lack the bizarre delusions found in schizophrenia. “I’m being followed by the police” is a nonbizarre delusion, because it is possible that it could be true. “I’m being tracked by aliens” is a bizarre delusion and is not possible. The primary medication treatment is with antipsychotics, in addition to individual therapy, and sometimes family therapy.

  Psychotic Disorders

  K&S Ch. 14

Question 76. E. Female orgasmic disorder is the persistent absence of orgasm in women following a normal excitement phase. It is based on the clinician’s judgment that the women’s orgasmic capacity is less than would be reasonable for her age, sexual experience, and adequacy of sexual stimulation she receives. The overall prevalence is thought to be somewhere around 30%. It is true that the incidence of orgasm increases with age, attributed to less psychological inhibition and more experience. Psychological factors, like those listed in answer choice D, may play a role. It can be either lifelong or acquired depending on whether the patient has ever had an orgasm at any point in life. Answer choice E refers to vaginismus, which is an involuntary contraction of the outer third of the vagina preventing intercourse. It can occur following rape, or in women with psychosexual conflicts.

  Sexual Dysfunctions

  K&S Ch. 21

Question 77. D. The case described in this question is consistent with social anxiety disorder (social phobia). It involves certain specific social situations which provoke intense anxiety because of fear of embarrassment or humiliation. An important differential to consider would be avoidant personality disorder. In this disorder there is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. It leads to the avoidance of other people unless the sufferer is sure that he is going to be liked. Avoidant personality disorder leads to restraint of intimate relationships for fear of being shamed or ridiculed. These patients often view themselves as socially inept or personally unappealing. They avoid jobs with significant interpersonal contact. Very importantly, they desire the closeness and warmth of relationships but avoid them for fear of rejection. Borderline personality disorder is characterized by a pattern of instability of interpersonal relationships, self-image, and affect, as well as marked impulsivity. Obsessive–compulsive personality disorder is defined by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. Narcissistic personality disorder is defined by a pattern of grandiosity, need for admiration, and lack of empathy. Dependent personality disorder is defined by a pervasive need to be taken care of that leads to submissive and clinging behavior and fears of separation.

  Anxiety Disorders

  K&S Ch. 27

Question 78. E. Phenytoin (Dilantin sodium) is notorious for causing hirsutism in women, facial dysmorphism and gingival hypertrophy. The drug can also cause cerebellar atrophy when taken over a long period of time, resulting in cerebellar signs and symptoms, such as ataxic gait and dysmetria of the extremities. Carbamazepine has the distinction of inducing its own metabolism. It can also cause rash that can lead to Stevens–Johnson syndrome. Another side effect of carbamazepine includes hyponatremia by antidiuretic hormone-like effect. It can also cause leukopenia and toxic hepatitis. Valproate can cause leukopenia, liver failure, weight gain, hair loss, fetal neural tube defects such as spina bifida and polycystic ovary syndrome. Levetiracetam is an anticonvulsant with minimal side effects. One of the more worrisome, but infrequent side effects of levetiracetam is agitation or hyperactivity. Phenobarbital is a barbiturate anticonvulsant and shares the side effects of that class: central nervous system depression, sedation, respiratory compromise and depression. Phenobarbital can of course be deadly in overdose.

  Neurology

  B&D Ch. 67

Question 79. A. The clinical picture depicted in this question is known as a “Saturday night palsy”, which is synonymous for a radial nerve entrapment. Entrapment of the radial nerve at the axilla often results from prolonged armpit compression when the arm is draped over the edge of a chair or when a patient is on crutches. A radial nerve palsy of this kind results in weakness of the extensor muscles of the wrist and fingers, triceps weakness and supinator weakness. Such compression injury usually resolves in one to two months. Ulnar nerve entrapment can occur either at the elbow or at the wrist. Elbow trauma may result in ulnar nerve entrapment in the cubital tunnel. Other causes include arm compression during surgery under general anesthesia. Ulnar nerve compression results in weakness of the flexor carpi ulnaris, intrinsic hand muscles and fourth and fifth finger deep flexor weakness. Median nerve entrapment at the wrist can result in a classic carpal tunnel syndrome. This is the most common of the entrapment neuropathies. Tenosynovitis of the transverse carpal ligament places pressure on the median nerve in the tunnel resulting in nocturnal hand paresthesias of the thumb, index and middle fingers. There may be sensory loss, thenar atrophy and a positive Tinel’s sign, in about 60% of cases. Tinel’s sign is positive when percussion of the nerve over the wrist results in paresthesias in the median nerve territory. Flexing the hand at the wrist for about one minute or more is called the Phalen’s maneuver and can result in similar paresthesias. Injury to the median nerve is sustained with use of handheld vibrating tools and repetitive forceful use of the hands and wrists compromising the carpal tunnel. The diagnostic test of choice for carpal tunnel syndrome is needle electromyography (EMG) and nerve conduction studies which reveal delayed sensory latency across the wrist in 70–90% of cases. Musculocutaneous nerve injury can occur with brachial plexus injuries such as by shoulder dislocation, compression to the shoulder during surgical anesthesia or by repetitively carrying heavy objects over the shoulder (carpet carrier’s palsy). Biceps and brachialis weakness is the hallmark of musculocutaneous nerve injury. The suprascapular nerve is a pure motor nerve of the brachial plexus.

  Entrapment injury can occur after repetitive forward traction at the shoulder. Diffuse aching pain in the posterior shoulder is a usual symptom. EMG demonstrates denervation of the infraspinatus and supraspinatus muscles.

  Neurology

  B&D Ch. 76

Question 80. D. The case described shows loss of muscle tone in times of extreme emotion or physical exertion. This is found in association with narcolepsy. In narcolepsy, there are irresistible attacks of sleep that occur daily. They are characterized by either cataplexy, which is the loss of muscle tone described above, or the recurrent intrusions of rapid eye movement (REM) sleep into the transition between sleep and wakefulness, causing hypnopompic or hypnogogic hallucinations or sleep paralysis. Sleep apnea is a medical condition which can be either central or obstructive and leads to snoring, daytime drowsiness and irritability. It can have negative long term cardiac consequences as well. Primary insomnia is difficulty initiating or maintaining sleep, or nonrestorative sleep for at least one month. It is independent of any known physical or medical condition. It is often treated with benzodiazepines or zolpidem. Primary hypersomnia is excessive sleepiness for 1 month as demonstrated by prolonged sleep episodes at night or daily sleep episodes during the day. Treatment consists of stimulants such as amphetamines and the non-stimulant modafinil (Provigil). Sodium oxybate (Xyrem) is FDA-approved for cataplexy associated with narcolepsy. Xyrem is essentially a synthetic analog of gamma hydroxybutyrate (GHB), which is a drug of abuse notorious for being used as a date rape drug. Circadian rhythm sleep disorder is a persistent pattern of sleep disruption resulting from a mismatch between the sleep–wake cycle of the environment and the circadian sleep–wake pattern. It can be specified as delayed sleep phase type, jet lag type, or shift work type. Modafinil has a specific FDA indication in shift-work sleep disorder, as well as narcolepsy, obstructive sleep apnea and idiopathic hypersomnia.

  Sleep Wake Disorders

  K&S Ch. 24

Question 81. C. Conversion disorder usually involves neurologic symptoms. Multiple organ system complaints are found in somatization disorder. If symptoms are limited to pain, it is a pain disorder, not a conversion disorder. If symptoms are limited to sexual dysfunction, it is a sexual disorder, not conversion disorder. Conversion disorder symptoms are not intentionally produced.

  Somatic Symptom Disorders

  K&S Ch. 17

Question 82. D. The monoamine oxidase (MAO) type A inhibitors are contraindicated with levodopa/carbidopa repletion therapy. MAOIs are postsynaptic enzymatic metabolizers of dopamine. Concomitant use of MAO-A type inhibitors and levodopa/carbidopa can result in poor response to the levodopa repletion therapy and worsening of parkinsonian symptoms. MAOIs need to be discontinued 2 weeks prior to the initiation of levodopa repletion therapy to avoid a negative interaction. The antidepressants in the selective serotonin reuptake inhibitor class (fluoxetine and sertraline, among others) are not contraindicated with levodopa repletion therapy. Tricyclic antidepressants are also safe with levodopa repletion, as is gabapentin.

  Neurology

  B&D Ch. 71

Question 83. C. Piaget proposed four stages of cognitive development. They were the sensorimotor stage, the stage of preoperational thought, the concrete operations stage, and the formal operations stage. During the concrete operations stage the child begins to deal with information outside of himself and to see things from other’s perspectives. He also develops conservation, which is the idea that though objects may change, they can maintain characteristics that allow them to be recognized as the same (example: different leaves may be different shapes and colors but are all leaves). The concept of reversibility is also understood at this stage. It says that things can change form and shape and then go back again (example: ice to water to ice).

  Human Development

  K&S Ch. 4

Question 84. D. By 2–3 years of age, almost all children have a concept of being either male or female. Infants begin exploring their genitalia by 15 months of age. Children also develop interest in other’s genitals leading to exploration and exhibition. Sexual curiosity and sex play increase during puberty, but are normally present before puberty. They are not a sign of anything abnormal, nor is it a result of television, homosexuality, hormonal imbalance, or premature development.

  Human Development

  K&S Ch. 21.

Question 85. E. Short palpebral fissures are found in children with fetal alcohol syndrome, not fragile X syndrome. Fragile X syndrome presents with mental retardation, long ears, narrow face, short stature, hyperextendable joints, arched palate, macro-orchidism, seizures and autistic features. There is a high rate of attention deficit–hyperactivity disorder, and learning disorders. It is the second most common cause of mental retardation. It results from a mutation of the X chromosome.

  Neurodevelopmental and Pervasive Developmental Disorders

  K&S Ch. 38

Question 86. A. In normal attachment, a child at 18 months of age would use a transitional object in the absence of the mother. There would be less anxiety at separation than in pervious stages, but it would not be completely gone. The child would try to master strange situations when the mother was nearby. There is object permanence. It is not until 25 months of age that the child would be expected to tolerate the mother’s absence without distress. In the situations described in the other answer choices, the child would be scared, not violent. The child would not immediately run to you as he would have some stranger anxiety. He would not feel safe enough in the mother’s absence to become more inquisitive. The child would definitely notice the mother’s absence.

  Human Development

  K&S Ch. 4

Question 87. C. Valproate is the classic inhibitor of cytochrome P-450 3A4 which causes inhibition of enzymatic clearance of lamotrigine. Doses of lamotrigine need to be lowered and generally started at lower doses when administered concomitantly with valproic acid, to avoid lamotrigine toxicity. The other agents noted in this question do not have cyp-450 3A4 inhibitory properties in this fashion.

  Psychopharmacology

  K&S Ch. 36

Question 88. D. It is during adolescence that children move away from the family and the friend group provides the most important relationships. During this time, any deviation in appearance, dress, or behavior can lead to a decrease in self-esteem. For this reason the child would most likely suffer the most psychological impact from a deformity during adolescence.

  Human Development

  K&S Ch. 2

Question 89. D. Whereas some monoamine oxidase inhibitors (MAOIs) work on both MAO-A, and MAO-B, selegiline works solely on MAO-B. MAO-A is involved in the metabolism of serotonin and norepinephrine. MAO-B is involved in the metabolism of phenylethylamine. Both are involved in the metabolism of dopamine. MAO-A in the gastrointestinal tract is involved in the metabolism of tyramine. If you block these enzymes, tyramine is not broken down and can lead to hypertensive crisis.

  Psychopharmacology

  K&S Ch. 36

Question 90. E. Cocaine blocks dopamine reuptake from the synaptic cleft, leading to increased levels of dopamine. When chronically used, this disturbance of normal dopamine metabolism leads to depletion of dopamine. Cocaine has also been shown to be associated with decreased levels of cerebral blood flow. Patients recovering from cocaine addiction show a drop in neuronal activity and a decreased activity of dopamine which can persist for up to a year and a half after stopping the drug.

  Substance Abuse and Addictive Disorders

  K&S Ch. 12

Question 91. A. Neural tube defects are the most worrisome fetotoxic side effects of valproic acid in the pregnant patient. The classic presentation is that of fetal spina bifida. With formation of the neural tube early in gestation, spina bifida can usually be detected by fetal ultrasound in the first trimester. The other noted problems are not attributable to side effects of valproic acid.

  Psychopharmacology

  K&S Ch. 36

Question 92. B. Dopamine agonists are newer agents used to treat Parkinson’s disease. The classic agents of this class available for use in the United States are pergolide, bromocriptine, pramipexole and ropinirole. Ropinirole is now also indicated in restless legs syndrome and is one of the treatments of choice for that disorder. Worrisome side effects of the dopamine agonists include hallucinations, sedation and orthostatic hypotension. There is a much lower incidence of dyskinesias with the dopamine agonists than with levodopa therapy. Haloperidol and fluphenazine are conventional antipsychotic agents and hence are dopamine antagonists. Quetiapine is a second-generation atypical antipsychotic that has dopamine antagonist properties as well. Buspirone is approved for generalized anxiety disorder and is a 5-HT 1A partial agonist.

  Neurology

  B&D Ch. 71

Question 93. E. The frontal lobes are the seat of executive functioning. They also play a large role in the personality. Damage to the orbitofrontal region can cause disinhibition, irritability, mood lability, euphoria, lack of remorse, poor judgment, and distractability. Damage to the dorsolateral frontal regions leads to extensive executive functioning deficits. Damage to the medial frontal region leads to an apathy syndrome.

  Basic Neuroscience

  K&S Ch. 3

Question 94. B. Ziprasidone (Geodon) stands alone as the one atypical antipsychotic that inhibits serotonin and norepinephrine reuptake. All of the atypical antipsychotics block the serotonin 2A and dopamine D2 receptors. The reuptake inhibition seen with ziprasidone however, is unique, as is its blockade of the serotonin-1A receptor.

  Psychopharmacology

  K&S Ch. 36

Question 95. E. Aripiprazole (Abilify) is a partial dopamine agonist at the D2 receptor. It is postulated to work on positive symptoms of schizophrenia by competing with dopamine in the mesolimbic pathway, and negative symptoms of schizophrenia by being an agonist at dopamine receptors in the prefrontal cortex. It is also a partial agonist at the 5HT1A receptor and an antagonist at the 5HT2A receptor. All of the other antipsychotics available only block dopamine receptors. This blockade of dopamine receptors in the frontal cortex theoretically leads to a worsening of negative symptoms by the medication, particularly by the typical antipsychotics.

  Psychopharmacology

  K&S Ch. 36

Question 96. C. The prefrontal cortices influence mood differently. If one activates the left prefrontal cortex, mood is lifted. If the right prefrontal cortex is activated, mood is depressed. Therefore a lesion to the left prefrontal cortex would cause depression, and a lesion to the right prefrontal cortex would cause euphoria and laughter. The parietal and occipital lobes are not the predominant lobes involved in emotion.

  Basic Neuroscience

  K&S Ch. 3

Question 97. E. The raphe nuclei of the brainstem, predominantly in the pons, are the major sites of serotonergic cell bodies. The ventral tegmental area, substantia nigra, and nucleus accumbens are all dopaminergic areas and are parts of the major neuronal pathways involved in the pathophysiology of schizophrenia. The cerebellum is a distracter.

  Basic Neuroscience

  K&S Ch. 3

Question 98. C. The clinical picture depicted in this vignette is that of Wilson’s disease. Wilson’s disease is an autosomal recessive disorder of abnormal copper metabolism. It is linked to the q14-21 (ATP7B) region of chromosome 13. Prevalence is about 1 in 30 000. The disorder results in a problem with incorporation of copper into ceruloplasmin and with diminished biliary excretion of copper. This results in excessive deposition of copper in the brain, with a predilection for the basal ganglia. The most useful laboratory test is serum ceruloplasmin which is most often decreased to less than 20 mg/dL (normal range is 24–45 mg/dL). The most frequent neurologic manifestations are parkinsonism, flapping tremor, ataxia, dystonia and bulbar signs such as dysphagia and dysarthria. Signs of liver failure are usually present. The treatment of choice is penicillamine, a copper-chelating agent, which in many cases can reverse the deficits of the disease. Serum angiotensin-converting enzyme (ACE) level would be a screening test for sarcoidosis. Chromosomal analysis for CAG triplet repeats by polymerase chain reaction (PCR) would be the test of choice for Huntington’s disease. Lumbar puncture for cerebrospinal fluid oligoclonal bands and myelin basic protein would be a useful supportive test (in addition to brain and/or spinal cord MRI) for multiple sclerosis. The Tensilon test is for the diagnosis of myasthenia gravis.

  Neurology

  B&D Ch. 71

Question 99. C. The mesolimbic pathway of dopaminergic neurons, starting at the ventral tegmental area and projecting to the nucleus accumbens is thought to be highly involved in the sense of reward one gets from cocaine use, and is a major mediator of cocaine’s effects. It is very involved in amphetamine’s effects as well. The locus ceruleus of the brainstem contains a high number of adrenergic neurons, and mediates the effects of opiates and opioids.

  Basic Neuroscience

  K&S Ch. 12

Question 100. D. The therapeutic focus of motivational enhancement therapy is on the patient’s ambivalence toward staying off of their drug of abuse. It is a type of therapy specifically used with patients addicted to drugs of abuse.

  Psychotherapy

  K&S Ch. 35

Question 101. A. Of the many psychological tests used today, the reliability of the Wechsler Adult Intelligence Scale (WAIS) is among the highest. Retesting of people, even at later ages, rarely reveals higher IQ scores. The scores are consistent and repeatable. As such it is the most reliable of the choices given. It also has a very high validity in identifying mental retardation and predicting future school performance. There is also a childhood version of the same test, the Wechsler Intelligence Scale for Children (WISC).

  Psychological Theory and Psychometric Testing

  K&S Ch. 5

Question 102. E. Freud’s drive theory focused on basic instincts or drives that motivated human behavior. These drives were libido and aggression. In Freud’s model, a drive has four parts. The “source” is the part of the body from which the drive comes. The “impetus” is the amount of intensity of the drive. The “aim” is any action that discharges the tension. The “object” is the target of the action. The other theories listed have nothing to do with Freud. Self psychology is the theory of Kohut. Learning theory cannot be attributed to any one individual, but has many theories and contributors. Conflict theory is a distracter, as is the mesolimbic dopamine theory.

  Psychological Theory and Psychometric Testing

  K&S Ch. 6

Question 103. A. Numerous studies have shown the principal cause of intracerebral hemorrhage (ICH) to be hypertension. Chronic hypertension likely causes lipohyalinosis of the small intraparenchymal arteries and microaneurysms of Charcot and Bouchard that rupture due to increased vascular pressure. ICH accounts for about 10% of all strokes. The most common area of predilection for ICH is the putamen in about one-third of cases, followed by the thalamus in about 10–15% of cases. The other choices listed in this question are all less-frequent causes of ICH.

  Neurology

  B&D Ch. 51

Question 104. D. Aaron Beck is the originator of cognitive behavioral therapy (CBT). In this theory, patients’ assumptions affect their cognitions, which in turn affect their mood. As such, it would be cognitive distortion that Beck would most likely find as the cause of depression. The other answer choices may be things to which other theorists attribute depression, or are totally unrelated answer choices included to distract.

  Psychotherapy

  K&S Ch. 35

Question 105. A. A type I error occurs when the null hypothesis is rejected when it should have been retained. It is the equivalent of saying that a true difference exists between two samples when the difference is due solely to chance.

  Statistics

  K&S Ch. 4

Question 106. E. Randomization is the process by which each patient in a clinical trial has an equal chance to be assigned to a control group or an experimental group. This process protects against selection bias. Power is the probability of finding the difference between two samples. It is the probability of rejecting the null hypothesis when it should be rejected. Probability is the likelihood that an event will occur. A probability of 1 means it will occur, a probability of 0 means that it will not. Risk is a distracter.

  Statistics

  K&S Ch. 4

Question 107. C. The clinical picture here is that of cryptococcal meningitis in an AIDS patient with severe immunocompromise. About 10% of AIDS patients develop this infection by the encapsulated yeast Cryptococcus neoformans. CD4 count is generally less than 200/μL. Although MRI of the brain is a good test, in this case the results would be nonspecific. The scan might demonstrate meningeal enhancement with gadolinium, suggesting a subacute or chronic meningitis. There may also be multiple small abscesses seen on scan due to fungal invasion of the Virchow–Robin spaces surrounding meningeal vessels. Hydrocephalus due to obstruction of cerebrospinal fluid (CSF) flow may also be seen. In rarer cases a mass lesion, or cryptococcoma, with surrounding edema can be seen, due to consolidation of the infection. The most important immediate test is the lumbar puncture. Opening pressure should be measured and is usually elevated. CSF is most often colorless and clear. CSF analysis can reveal a leucocytosis of 50–1000 cells/mm3 with lymphocytic predominance. CSF protein is usually elevated from 50–1000 mg/dL. India ink staining of CSF viewed under the microscope will quickly reveal an identifiable capsule and budding yeasts and requires no special laboratory machinery or testing. CSF cryptococcal antigen assay is indeed more sensitive than India ink staining and should concomitantly be done, as it is now readily available in most centers. Chest radiography would only be helpful with a suspicion of lung involvement or pulmonary symptoms. Blood cultures are generally negative in fungal infection and should only be done if concomitant bacterial infection is suspected. Amphotericin B intravenous administration is the treatment of choice for central nervous system fungal infections. The problem with Amphotericin B is a high rate of up to 80% renal toxicity as a side effect.

  Neurology

  B&D Ch. 53

Question 108. D. Power is the probability of finding the difference between two samples. It is the probability of rejecting the null hypothesis when it should be rejected. Randomization is the process by which each patient in a clinical trial has an equal chance to be assigned to a control group or an experimental group. This process protects against selection bias. Probability is the likelihood that an event will occur. A probability of 1 means it will occur, a probability of 0 means that it will not. Risk is a distracter.

  Statistics

  K&S Ch. 4

Question 109. C. The number of people who have a disorder at a specific point in time is the point prevalence. It is calculated by dividing the number of people with the disorder at that time by the total population at that time. Randomization is the process by which each patient in a clinical trial has an equal chance to be assigned to a control group or an experimental group. This process protects against selection bias. Power is the probability of finding the difference between two samples. It is the probability of rejecting the null hypothesis when it should be rejected. Probability is the likelihood that an event will occur. A probability of 1 means it will occur, a probability of 0 means that it will not. Risk is a distracter.

  Statistics

  K&S Ch. 4

Question 110. A. One of the main criteria for anorexia is a failure to maintain body weight at or above 85% of what would be expected for the person’s height and age. Other criteria include a fear of becoming fat, even though the person is underweight, problems in the way one’s body is experienced, and undue influence of body weight on self-esteem. Anorexic patients also deny the seriousness of their being underweight, and often have amenorrhea. There are two types of anorexia, the restricting type, and the binge eating/purging type.

  Feeding and Eating Disorders

  K&S Ch. 23

Question 111. D. PCP can be found in the urine up to 8 days after use. Some other drugs of note include: cannabis – up to 4 weeks, cocaine – up to 8 hours, and heroin – up to 72 hours.

  Laboratory Tests in Psychiatry

  K&S Ch. 7

Question 112. C. Amyloid precursor protein is the protein that makes up the amyloid plaques found in the brain in Alzheimer’s disease. The protein is encoded by a gene found on chromosome 21. The amyloid deposits found in Alzheimer’s disease are the hallmark of the disease’s neuropathology. Wilson’s disease is the result of abnormal copper metabolism, not amyloid. Schizophrenia, bipolar disorder, and Huntington’s disease have nothing to do with amyloid.

  Neurocognitive Disorders

  K&S Ch. 10

Question 113. C. A complete blood count (CBC) would be the first test to order because of the risk of significant side effects on the hematopoietic system. Carbamazepine can cause decreased white blood cell count, agranulocytosis, pancytopenia, and aplastic anemia. Carbamazepine also has a vasopressin-like effect and can cause water intoxication and hyponatremia. Carbamazepine interacts significantly with the cytochrome P-450 system and as such has many interactions with many drugs. Great care should be taken when prescribing carbamazepine with other medications.

  Laboratory Tests in Psychiatry

  K&S Ch. 36

Question 114. E. Because the starvation associated with anorexia effects a multitude of organ systems, a battery of tests is warranted when working up the disease. These include electrolytes, renal function tests, thyroid tests, glucose, amylase, complete blood count, electrocardiogram, cholesterol, carotene level and a dexamethasone suppression test. There is not an indication for a head CT, as one would not find changes on the head CT of an anorexic patient that would differentiate it from a normal head CT.

  Laboratory Tests in Psychiatry

  K&S Ch. 23

Question 115. B. Creutzfeldt–Jakob disease (CJD) is one of a number of human spongiform encephalopathies and is associated with prion infection. The worldwide incidence of CJD is about 0.5 to 1 in one million per year. A new variant was thought to have developed during the later nineties resulting from consumption of meat from cattle infected with bovine spongiform encephalopathy. The clinical picture is that of a prodromal period of vegetative symptoms such as asthenia and sleep and appetite disturbances. This is followed by the onset of a rapidly progressive dementia with deficits in memory, concentration, depression, self-neglect and personality changes. The condition progresses to global dementia over time and death typically occurs from 2–7 months after onset of symptoms. The diagnostic test of choice today is lumbar puncture with cerebrospinal fluid assay of 14-3-3 and tau proteins, the specificity and sensitivity of which exceed 90%. CT scans of the brain are useless as they remain normal in a majority of cases. There may be atrophy seen on CT scan with ventricular enlargement, but this is nonspecific and diagnostically unhelpful. MRI of the brain may reveal atrophy with symmetrical increased signal intensity in the basal ganglia, which is again not particularly helpful in diagnosing CJD. Electroencephalogram is more helpful and is expected to reveal a characteristic one to two cycle-per-second triphasic sharp wave pattern superimposed on a background of electrical depression. This pattern is seen in up to 80% of cases at some point during the course of the illness.

  Neurology

  B&D Ch. 53

Question 116. D. Disorders of smooth visual pursuit and disinhibition of saccadic eye movements are commonly found in patients with schizophrenia. This has been proposed by some as a trait marker for schizophrenia, because it is found regardless of medication use and is also present in first degree relatives. It is thought that the eye movement disorders are the function of pathology in the frontal lobes.

  Psychotic Disorders

  K&S Ch. 13

Question 117. E. Many of the antipsychotic medications block dopamine in the tuberoinfundibular tract. Because of this dopamine blockade, the patient develops an elevated prolactin level. That elevated prolactin level leads to galactorrhea and amenorrhea. In the case given, the risperidone is the most likely cause of the patient’s symptoms. You would want to check the serum prolactin level and adjust the risperidone dose, or consider switching the patient to another medication.

  Laboratory Tests in Psychiatry

  K&S Ch. 7

Question 118. C. Patients with borderline personality disorder have frequent mood swings. They can develop short-lived psychotic episodes. They often cut or mutilate themselves to elicit help from others, to express anger, or to numb themselves to strong affect. Both men and women can have borderline personality disorder, though it is more common in women. The other answer choices do not fit the case as well as borderline personality disorder. Schizoaffective disorder patients do not usually self-mutilate. Dysthymic disorder is not consistent with psychotic symptoms. There is no description of mania, so bipolar disorder is unlikely. There is no acute stressor so adjustment disorder doesn’t fit well. Whenever a question involves cutting or self-mutilation, strongly consider borderline personality disorder.

  Personality Disorders

  K&S Ch. 27

Question 119. B. Of the choices given, the highest prevalence is for anxiety disorders. Over 30 million people in the United States have an anxiety disorder. About 17.5 million have depression. About 2 million have schizophrenia. About 5 million have dementia. About 12.8 million use illicit drugs.

  Anxiety Disorders

  K&S Ch. 4

Question 120. D. There is an association between pathological gambling and mood disorders, particularly major depressive disorder (MDD). There is also an association with panic, obsessive–compulsive disorder and agoraphobia, but the association with MDD is greater. Criteria for pathological gambling include preoccupation with gambling, gambling increased sums of money to obtain excitement, being unsuccessful at stopping or cutting back, gambling to escape dysphoric mood, lying to significant others about gambling, loss of important relationships over gambling, committing illegal acts in order to gamble, relying on others to pay the bills because of money lost gambling, and a desire to keep going back to break even.

  Disruptive, Impulse Control Disorders, Conduct Disorders, and ADHD

  K&S Ch. 25

Question 121. C. This is a case of delusional disorder. In delusional disorder the patient has nonbizarre delusions (i.e., they could be true, but are not). They do not meet criteria for schizophrenia. Their functioning in day to day life is relatively preserved. It may take various forms, such as erotomanic type, grandiose type, jealous type, persecutory type, somatic type, or mixed type. This patient does not meet criteria for schizophrenia. There are no mood symptoms, so this rules out depression. He is not confused, disoriented, and waxing and waning in consciousness, so this rules out a delirium. The wife is not a partner in the delusions, she thinks there is something wrong with him, so this rules out a shared psychotic disorder. Given all of this, the correct answer is delusional disorder.

  Psychotic Disorders

  K&S Ch. 14

Question 122. E. Hypochondriasis involves being convinced that one has a serious disease based on misinterpretation of bodily sensations. The preoccupation with having the illness persists despite reassurance by doctors. It causes clinically significant impairment in functioning. Somatoform disorders is a general category that includes somatization disorder, conversion disorder, hypochondriasis, body dysmorphic disorder, and pain disorder. Factitious disorder is when a patient feigns illness for primary gain (i.e., benefits of the sick role). Conversion disorder is the development of a neurological deficit as a result of psychological conflict. Pain disorder is the presence of pain as the predominant clinical focus, where the pain is thought to be substantially mediated by psychological factors.

  Somatic Symptom Disorders

  K&S Ch. 17

Question 123. E. There are multiple studies that all point to a genetic predisposition for alcoholism. The studies that separate environmental from genetic factors are some of the most convincing. Studies of adoptees clearly demonstrate that children whose biological parents were alcoholics are at increased risk for alcoholism, even when brought up by adopted families where neither parent has an alcohol problem. In addition, children whose biological parents do not have an alcohol problem are not more likely to become alcoholic if raised in a home with parents who have alcohol problems.

  Substance Abuse and Addictive Disorders

  K&S Ch. 12

Question 124. C. This is a psychogenic seizure (also called nonepileptic seizure). Keys to a psychogenic seizure, or pseudoseizure, are lack of an aura, no cyanotic skin changes, no self injury, no incontinence, no postictal confusion, asynchronous body movements, absent EEG changes, and seizure activity being affected by the suggestion of the doctor.

  Neurology

  K&S Ch. 10

Question 125. B. Internuclear ophthalmoplegia is a classic brainstem finding on neurologic examination of patients with demyelinating lesions of multiple sclerosis (MS). The lesion localizes to the medial longitudinal fasciculus (MLF) of the brainstem. The deficit involves abnormal horizontal ocular movements with absence or delayed adduction of the eye ipsilateral to the MLF lesion and coarse horizontal nystagmus in the abducting eye. Convergence is preserved. Bilateral internuclear ophthalmoplegia is highly suggestive of MS, but can also be seen with other brainstem lesions, particularly Arnold–Chiari malformation, Wernicke’s encephalopathy, vascular lesions and brainstem gliomas.

  Neurology

  B&D Ch. 54

Question 126. B. Paranoid schizophrenia is characterized by delusions of persecution or grandeur, as well as auditory hallucinations. Patients usually have their first break at a later age than other schizophrenic patients. They show more preservation of cognitive function than in other types of schizophrenia. Disorganized schizophrenia is marked by primitive, disinhibited, disorganized behavior. Patients have significant impairment in cognition. Catatonic schizophrenia is characterized by stupor, negativism, rigidity and posturing. Mutism is common, and cognition and communication are impaired. Undifferentiated schizophrenic patients do not fit easily into one of the other categories. Residual schizophrenia consists of the continued presence of some symptoms of schizophrenia in a person who no longer meets full criteria for the disorder.

  Psychotic Disorders

  K&S Ch. 13

Question 127. E. Pathological gambling is categorized by the DSM as an impulse control disorder. Criteria for pathological gambling include preoccupation with gambling, gambling increased sums of money to obtain excitement, being unsuccessful at stopping or cutting back, gambling to escape dysphoric mood, lying to significant others about gambling, loss of important relationships over gambling, committing illegal acts in order to gamble, relying on others to pay the bills because of money lost gambling, and a desire to keep going back to break even.

  Disruptive, Impulse Control Disorders, Conduct Disorders, and ADHD

  K&S Ch. 25

Question 128. E. Asperger’s disorder is characterized by the following clinical features. The patient has marked impairment in the use of nonverbal communication, failure to develop peer relationships, lack of desire to share experiences with others and restricted or stereotyped patterns of behavior. There can be preoccupation or obsessive focus on certain interests, rigid adherence to schedules, and stereotyped motor mannerisms. Unlike autism, there is not a delay in language or cognitive development. The child in this question clearly has Asperger’s disorder. He is not breaking rules and violating social norms as one would expect with a conduct disorder. He is not fighting authority figures as one would expect of oppositional defiant disorder. He does not show irritability, impulsivity, and hyperactivity as one would find in attention deficit–hyperactivity disorder. His language and cognitive development are not delayed as would be expected in a case of autism.

  Neurodevelopmental and Pervasive Developmental Disorders

  K&S Ch. 42

Question 129. D. If you thought this was the same as question 128 you need to read more carefully! This is a case of autism. In autism there is marked impairment in the use of nonverbal communication, failure to develop peer relationships, lack of desire to share experiences with others, and restricted or stereotyped patterns of behavior. There can be preoccupation or obsessive focus on certain interests, rigid adherence to schedules, and stereotyped motor mannerisms. But very importantly, there is delay in, or total absence of spoken language. There is an inability to maintain conversation. There is stereotyped use of language. There is a lack of spontaneous or make believe play. Cognitive development is significantly impaired. There is a lack of social or emotional reciprocity.

  Neurodevelopmental and Pervasive Developmental Disorders

  K&S Ch. 42

Question 130. B. Derealization is a subjective feeling that the environment is strange or unreal. Depersonalization is a person’s sense that they are unreal or unfamiliar. Fugue involves having amnesia for your identity and assuming a new identity. It usually also involves wandering to new places. Amnesia is the inability to recall past experiences. Anosognosia is an inability to recognize a neurological deficit that is occurring to oneself.

  Dissociative Disorders

  K&S Ch. 8

Question 131. E. Inhalants can cause a persisting dementia. It is irreversible except for the mildest cases. It may be the result of the neurotoxic effects of the inhalants, the metals they contain, or the effects of hypoxia. Inhalant use can also lead to delirium, psychosis, mood, and anxiety disorders. Signs of intoxication with inhalants include maladaptive behavior such as assaultiveness, impaired judgment, as well as neurological signs such as dizziness, slurred speech, ataxia, tremor, blurred vision, stupor, and coma. The other answer choices have various effects, but do not cause a persisting dementia.

  Substance Abuse and Addictive Disorders

  K&S Ch. 12

Question 132. E. Social skills training is an important part of psychiatric rehabilitation. Social skills are behaviors necessary for survival in the community. These are disrupted by severe illnesses such as schizophrenia. Social skills training has proven important in correcting deficits in patient’s behaviors. Severely ill patients make slow progress, but can learn some necessary skills that enable them to engage in conversation and decrease social anxiety. Social skills training can be done both in a group and an individual format. The other answer choices in this question consist of unrelated pairs, some of which border on the ridiculous and are distracters.

  Psychosocial Interventions

  K&S Ch. 35

Question 133. D. Multiple sclerosis (MS) is the most common inflammatory demyelinating disease. The classic onset of the disease is between the ages of 15 and 50 years. About two-thirds of patients have the relapsing–remitting form of the disease at onset, which is the most common form of the illness. Only about 20% of patients have primary progressive disease at onset. Optic neuritis (ON) is a common sign of multiple sclerosis and is frequently the cause of initial presenting symptoms. ON usually presents with eye pain that increases with eye movement followed by central visual loss (scotoma) in the affected eye. ON patients will have a relative afferent pupillary defect (Marcus Gunn pupil). This is tested by the swinging flashlight test which demonstrates that the abnormal pupil paradoxically dilates when a light is moved away from the normal to the affected eye. Internuclear ophthalmoplegia is a common sign of MS and involves a lesion in the medial longitudinal fasciculus of the brainstem that produces a characteristic eye movement abnormality. The eye ipsilateral to the lesions cannot adduct past the midline while the contralateral eye fully abducts and displays a coarse end-gaze nystagmus. The finding can sometimes be bilateral. Fatigue is a common complaint in patients with MS. It often has little to do with the amount of physical exertion carried out by the patient. It may occur upon waking despite a good night’s sleep the night before. Heat sensitivity is a well-described phenomenon in MS. Increases in core body temperature can bring on symptoms or worsen already existing symptoms. This is known as Uhthoff’s phenomenon. The condition occurs due to conduction block that occurs as body temperature rises. Lhermitte’s sign is a transient neurologic sign described by patients as a sensation of an electric shock that descends down the spine or the extremities upon neck flexion. It is most often suggestive of MS, but can also be seen in other conditions involving the cervical spinal cord, such as disk herniations, trauma and tumors.

  Neurology

  B&D Ch. 54

Question 134. C. Bulimia is categorized by a recurrent pattern of binge eating and self induced vomiting. Bulimic patients often develop a hypochloremic alkalosis, and are at risk for gastric and esophageal tears. Dehydration (hence low blood pressure) and electrolyte imbalances are likely. Many female bulimic patients have menstrual disturbances. Russell’s sign is positive when cuts or scrapes to the backs of the hands are noted which are a result of sticking the fingers down the throat to induce vomiting.

  Feeding and Eating Disorders

  K&S Ch. 23

Question 135. D. Amphetamine intoxication presents with euphoria, anxiety, anger, hypervigilance, and impaired judgment and functioning. The effects are similar to those of cocaine. There is a risk for an amphetamine-induced psychotic disorder as well, which is characterized by paranoia. One can also note visual hallucinations, hypersexuality, hyperactivity, confusion and incoherence.

  Substance Abuse and Addictive Disorders

  K&S Ch. 12

Question 136. B. Acute stress disorder is characterized by similar symptoms to post-traumatic stress disorder, but with a different time frame. Symptoms occur for a minimum of two days, and a maximum of 4 weeks, and begin within 4 weeks of the traumatic event. The patient must have undergone a traumatic event. The patient then experiences emotional numbing, lack of awareness of surroundings, derealization, depersonalization, dissociative amnesia, flashbacks, avoidance of stimuli that remind them of the event, anxiety, irritability, increased arousal, or poor sleep.

  Trauma and Stress Related Disorders

  K&S Ch. 16

Question 137. C. Children who are depressed can often present with irritability instead of, or in addition to depressed mood. Prepubertal children can report somatic complaints, psychomotor agitation, and mood-congruent hallucinations. Depressed children can also fail to make expected weight gains. Other signs of depression that children can present with include school phobia and excessive clinging to parents. Teens with depression often report poor school performance, substance abuse, promiscuity, antisocial behavior, truancy, and running away from home. They can withdraw from social activities and be grouchy and sulky.

  Depressive Disorders

  K&S Ch. 49

Question 138. D. Schizoid personality disorder is characterized by a pervasive pattern of detachment from social relationships. The patient neither desires, nor enjoys close relationships. They choose solitary activities. They lack close friends or romantic relationships. They are indifferent to the opinions of others and are emotionally cold and detached. Some of the other choices in this question are references to schizotypal personality disorder. In the schizotypal patient, there are ideas of reference, magical thinking, paranoia, and excessive social anxiety which is fueled by paranoid thinking.

  Personality Disorders

  K&S Ch. 27

Question 139. A. Beneficence is the duty to do no harm to the patient. Autonomy is the duty to protect a patient’s freedom to choose. Autonomy theory views the relationship between patient and doctor as between two adults, not as parent and child. Justice in this context means a fair distribution and application of services. Validity is a statistical word meaning that a test measures what it claims to measure.

  Ethics

  K&S Ch. 58

Question 140. D. Tourette’s disorder often involves both motor and vocal tics. The onset is usually around 7 years of age, but may come as early as 2 years. Motor tics usually start in the face and head, and progress down the body. Vocal tics are not done intentionally to provoke others, but are the result of sudden, intrusive thoughts and urges that the patient cannot control. These intrusive thoughts may involve socially unacceptable subject matter or obscenity.

  Disruptive, Impulse Control Disorders, Conduct Disorders, and ADHD

  K&S Ch. 46

Question 141. D. Substance abusers have the highest risk of becoming violent. Large doses of alcohol promote aggression, as do large doses of barbiturates. Paradoxical aggression can be observed with anxiolytics. Opioid dependence is associated with increased aggression. Stimulants, cocaine, hallucinogens, and sometimes cannabis can also lead to aggression. Aggressive behavior is more likely with those who have become acutely psychologically decompensated. More than half of people who commit homicide and engage in assaultive behavior are under the influence of significant amounts of alcohol at the time the crime is committed. Although many major psychiatric disorders can lead to aggression, you are more likely to face substance-induced aggression simply because of the sheer number of cases of aggression and violence that are substance-induced.

  Substance Abuse and Addictive Disorders

  K&S Ch. 4

Question 142. C. An ideal patient for psychodynamic psychotherapy should have the capacity for psychological mindedness, have at least one meaningful relationship, be able to tolerate affect, respond well to transference interpretation, be highly motivated, have flexible defenses and lack tendencies towards splitting, projection or denial. A useful screening tool for whether a patient has these characteristics is to understand the quality of their relationships, as the above-listed qualities often contribute to productive relationships.

  Psychotherapy

  K&S Ch. 35

Question 143. E. The clinical picture and scan are classic for multiple sclerosis (MS). The MRI scan reveals numerous subcortical white matter demyelinating lesions that are typical of MS. The lesions would be expected to enhance with gadolinium contrast early on during an attack and enhancement can persist up to 8 weeks following an acute attack. The treatment of an acute attack is generally with intravenous corticosteroids. The protocol is usually with intravenous methylprednisolone 500–1000 mg daily in divided doses for 3–7 days. This may or may not be followed with a 1- to 2-week oral prednisone taper. Antibiotics such as ceftriaxone have no place in MS. Intravenous immunoglobulin therapy and plasmapheresis are treatments for myasthenia gravis and Guillain–Barré syndrome and not for MS. Aspirin and heparin therapies are generally instituted in the emergency room setting for acute ischemic stroke when recombinant tissue plasminogen activator cannot be given.

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  Neurology

  B&D Ch. 54

Question 144. A. Borderline patients often cut, self-mutilate, and make suicide attempts. The patient in question has made past suicide attempts and past attempts are the best predictor of future attempts. She is emotionally labile following an interpersonal conflict. She is already doing harm to herself through cutting and is becoming psychotic. All of these factors add up to one very important point: this patient is highly unpredictable and could very easily kill herself. The only reasonable answer choice is hospital admission where her impulsive, self-destructive, and self mutilating impulses can be limited and her behavior observed. The other answer choices do not take her unpredictability and self-destructiveness seriously enough. The choice for extended inpatient stay is wrong because you have no way of knowing how long she is going to need to stay based on the information given. She could potentially stabilize in a few days and be safe for discharge. She could also be in the hospital for several months. There is no way to predict length of stay based on the question stem.

  Management in Psychiatry

  K&S Ch. 27

Question 145. E. Research in recent years has found that depression following a heart attack increases the likelihood of another heart attack. There has been evidence to suggest that there are serotonin receptors on the surface of platelets which can modify and reduce platelet aggregation and thereby reduce heart attack risk. The prescription of a selective serotonin reuptake inhibitor antidepressant following a myocardial infarction has been shown to increase the amount of serotonin in the body as a whole. This in turn modulates platelet serotonin receptors, thus decreasing platelet aggregation and making a future heart attack less likely.

  Somatic Symptom Disorders

  K&S Ch. 36

Question 146. B. Neurofibromatosus type 1 (NF1) is caused by a mutation in the 60 exon NF1 gene on chromosome 17q. NF1 is the most common of the neurocutaneous illnesses occurring in about 1 in 3000 individuals. NF2 is caused by a mutation in the NF2 gene on chromosome 22. It is less common than NF1 and appears in about 1 in 50 000 individuals. Patients with NF1 need to have any two of the following seven criteria to carry the diagnosis: six or more café au lait spots over 5 mm in diameter before puberty and over 15 mm if after puberty; axillary or inguinal freckling; optic glioma; two or more neurofibromas or one plexiform neurofibroma; a first-degree relative with NF1; two or more Lisch nodules (hamartomas of the iris); characteristic bony lesion such as thinning of long bones or sphenoid dysplasia. Patients with NF2 must have bilateral acoustic schwannomas in order to meet criteria for this condition. If the schwannoma is unilateral, the patient meets criteria only with a first-degree relative with NF2.

  Neurology

  B&D Ch. 65

Question 147. E. Both delirium and dementia can present with sleep problems, disorientation to place, violent behavior and hallucinations. The hallmark of delirium however is alteration of consciousness. Criteria include disturbance of consciousness with reduced ability to sustain attention, changes in cognition (memory problems, language disturbance, disorientation), and perceptual disturbances. These develop over a short period of time and can fluctuate during the course of a day. Dementia on the other hand consists of multiple cognitive deficits including memory loss, aphasia, apraxia, agnosia, and disturbance of executive function.

  Neurocognitive Disorders

  K&S Ch. 10

Question 148. D. The first step in treating a sleep problem is to rule out any problems in the environment that could cause insomnia and to alter the environment to make it more conducive to sleep. This approach starts with the rule that the bed is to be used for sleep and sex only. Reading in bed or watching television in bed should not be permitted. If this should fail, then pharmacologic aids can be pursued. A sleep study is not warranted by a simple complaint of insomnia. That would be overkill. Of course, a detailed history is the best tool to determine whether or not a more serious sleep disturbance is present.

  Sleep Wake Disorders

  K&S Ch. 24

Question 149. E. The American Psychiatric Association does not see homosexuality as a disorder. As such, there is no therapy that is warranted to change it. It is seen as a normal variant of human sexuality. There is good data to suggest that therapy to change homosexuality can be damaging to the patient. There is no evidence that supports attempting to change a patient’s sexual orientation. Such therapy should not be encouraged. Neither teens nor adults should be treated for being homosexual.

  Sexual Dysfunctions

  K&S Ch. 21

Question 150. D. Methylenedioxyamphetamine (MDMA) is also known as ecstasy. It is in the amphetamine family and is a common drug of abuse at clubs and raves. Symptoms of intoxication with amphetamines include euphoria, changes in sociability, hypervigilance, changes in interpersonal sensitivity, anxiety, anger and impaired judgment. Amphetamines can induce a psychosis which includes paranoia, hyperactivity and hypersexuality. Physical effects include fever, headache, cyanosis, vomiting (leading to dehydration), shortness of breath, ataxia, and tremor. More serious effects can include myocardial infarction, severe hypertension, and ischemic colitis. Cannabis intoxication presents as impaired coordination, euphoria or anxiety, sense of slowed time, social withdrawal and impaired judgment. Physical signs include conjunctival injection, increased appetite, tachycardia, and dry mouth. Ketamine is a relative of PCP. Intoxication presents as belligerence, impulsivity, psychomotor agitation, and impaired judgment. Physical signs include nystagmus, hypertension, ataxia, dysarthria, or muscle rigidity. Psychosis may be present and can persist for up to two weeks after intoxication. Diacetylmorphine is heroin. Intoxication results in euphoria followed by apathy, psychomotor agitation or retardation, impaired judgment, pupillary dilation, sedation, slurred speech and impaired attention or memory. Volatile inhalant intoxication presents as belligerence, assaultiveness, apathy, impaired judgment, dizziness, nystagmus, impaired coordination, unsteady gait, lethargy, tremor, psychomotor retardation, muscle weakness, euphoria or coma. Low doses of these substances can cause feelings of euphoria. High doses can cause paranoia, fearfulness and hallucinations.

  Substance Abuse and Addictive Disorders

  K&S Ch. 12