Focus Flashcards

Question

Genetic studies of obsessive-compulsive disorder have revealed linkages to which of the following disorders? (A) Alcohol dependence (B) Schizophrenia (C) Shared psychotic disorder (D) Somatoform disorder (E) Tourette's syndrome

Answer 1

The correct response is option E: Tourette's syndrome Genetic studies of patients with obsessive-compulsive disorder have revealed h1glfemil0atesT6^aepril? SioH and ^ ] e t ^ i j p r d e r ^ f a n d Jdurerteysyndronief.

Answer 2

The correct response is option C: Obtain informed consent from the patient or from an appropriate proxy agent While obtaining explicit informed consent for any treatment is important, it is especially important when the treafmei]Lhas_noLbecome standard. When all available treatments have failed, a nonstandard approach basedjon. limited-evidence rnay_be all that j.s.ayajia.ble( provided that proper precautions,_are taken. Unless the psychiatrist's intent is to demonstrate generalizable knowledge; a nonstandard treatment is usually not considered research. Physicians routinely and permissibly use drugs for non-FDA-approved indications using their best clinical judgment. W h i l e it is probably wise to wait un*i] higher quality data" support the use of a nonstandard treatment, it is not a "must."

Answer 3

The correct response is option B: Find out whether there gre_areqs of suffering _mat_cgn be addressed by available palliative ^ e j n e c s u r e s While sometimes direct persuasion to accept a medically indicated treatment may be acceptable, the main issue is to identify the sources of the patient's suffering. Most patients who request assisted suicide eventually change their minds when the sources of their suffering are better addressed. To recommend assistance in suicide at this stage of the patient's cancer ignores the complexity of the situation. To use incapacity as a reason for paternalism (option D) is also unacceptable.

Answer 4

The correct response is option B: Asian Americans With regard to ethnicity, most studies have demonstrated that Caucasjajis^re_ajjTJ lowed in order by Native Americans, African Americans, Hispanic Americans, and Asian Americans.

Answer 5

The correct response is option A: Bupropion Bupropion is effectiyejn,ji)ejregtmenj oj_mgnyJypes oi_depressio.n. It is niejaj?pjjzed Jo^_g_number__pf amphetamine-like products, which are effective in the treatment of_A_DHD. Bupropion has also been demonstrafed to decrease nicotine use. In adolescents who have depression, nicotine dependence, substance abuse, and ADHD, bupropion might be the first-line treatment, as it has been shown to be effective in assisting with b o t h j m o j ^ j i e i ^ t h e _ £ o j ^ y r n p J o j n ^ ^ Citalopram and other SSRIs as well as trazodone have not demonstrated these added benefits. Venlafaxine and desipramine have been found to be effective in both childhood and adult ADHD, but they lack the pote_ntiglp.f_bupropjon fq_asj|sh^jjTijDkjng_ cessotion.

Answer 6

The correct response is option C: The., psychiatrist should be awqrejhat "strings attached" industry-sppnsored activities a re u nethjca I The American Medical Association Code of Mediccl Ethics states that " G i f t s _ j j } p u J d j o t _ b e _ a c ^ p J e j ^f strings are attached." In this question, the psychiatrist's attendance at a dinner whose purpose was educ a t j o n a j j y i ^ if there are implicit or explicit strings attached. Most psychiatrists would not consider the psychiatrist's behavior in this situation unethical, although it would be unethical to promise to prescribe a certain medication in return for drug company favors, such as free dinners or concert tickets. Clearly, the blurring of the boundaries between educational activities and pharmaceutical company promotions continues to be a d j f f i c j j ] H s j y j J g ^ g j he psychigtric community, and eihjcaj„pjjcjiiajrists may disagree about whether participation in any educational activities provided by pharmaceutical companies is ethical.

Answer 7

The correct response is option B: Attention deficit hyperactivity disorder More_severe and prolonged conduct disorder js.associated[ with early onset, comorbid ADHD, and conduct symptoms that are more frequent, numerous, and varied.

Answer 8

The correct response is option E: Fluoxetine Desipramine is a substrate for cytochrome P450 2D6. Of the drugs listed, only fluoxetine is a potent inhibitor of this enzyme. In this patient, taking fluoxetine resulted in a marked increase in his blood levels of desipramine, which accounted for his new physical symptoms

Answer 9

The correct response is option E: Pick's disease Pick's disease specifically affects the frontal and temporaljobes, accounting for the early signs of personality changes, loss of social skills, and emotional blunting. Other features of dementia, such as memory loss and apraxia, come later. Specific diagnosis of Pick's disease is usually made only on autopsy. The medical illnesses Huntington's disease, Parkinson's disease, and HIVjnfection precede those dementias. Creutzfeldt-Jakob disease often has a clinical triad associated with dementia, involuntary movement, and periodic EEG activity. Lewy body dementia often presents first with hallucinations_and psychosis

Answer 10

The correct response is option B: Decreased body weight Decreased body weight is a defining feature of cnorexia nervosa, whereas persons with bulimia nervosa typically have normal body weight. All of the other features listed may be present in both disorders.

Answer 11

The correct'response is option B: Speed of performance Speed of learning, p r o ^ ^ s m ^ j p e e d , ond speed of performance of cognitive tasks tend to decline with normal aging. The other functions listed do not decline with normol gging, gnd g decline in any of them may be an indication for a thorough or formal assessment for cognitive impairment.

Answer 12

The correct response is option C: Fragile X syndrome All of these disorders have evidence of genetic transmission, although only fragile X syndrome is due to a single gene. I

Answer 13

The correct response is option B: A forensic consultation Ethically, confidentiality is required in psychiatric treatment. However, there are someinstgnces irrwhich confidentiality is waived. When a psychiatrist is examining a patient for forensic p_ujjpgs.es, the individual must be informed that information collected during the examination will be shared with the partyjhat engaged the psychiatrist, such as the patientjJawyeior.Jhe_cp.urt. In addition, common situations that require a waiver of the confidentiality rule include mjej_ejDortingj^ and, in some states, elder abuse and spouse abuse. Also, in most states, the psychiatrist evaluating a potentjally violent patient is required t o w a r n a potential victim of violence. However, in most states, a psychiatrist treating an impaired physician, unlike the physician's colleagues, is not required to report the physician if the phys'?'an is a private patient of the psychiatrist. On the otfer hand, if the psychiatrist is treating the patient under the auspices of a state diversion program, the relationship becomes more complicated and depends on the arrangement with the specific state's diversion program. A patient who reveals p^sj^arjajejjOjjjness_buJJsj]ot cJJrx§Djy^j^gerojJi^ou]cL notjikely. meet_ requiremjnjsjor a b r e a c j W confidentiality. Finally, a minor's confidentiality woujd also be respected unlessjhere ^l_9£L?..rI16r9intsituation in which either the minor or another person was likely to be harmed. In summary, the rule of confidentiality is waived when there is a threat of harmjo the patient or another person.

Answer 14

The correct response is option D: 50 to 70 Up to 85% of persons with mental retardation have an IQ between 50 and 70, which is mild mental retardation. Patients with an IQ between 70 and 90 are not considered mentally retarded.

Answer 15

The correct response is option E: Reactive attachment disorder The girl's indiscriminate sociability is behavior typical of reactive attachment disorder, disinhibited type. DSM-IV-TR also specifies an inhibited type of this disorder. Often children with this disorder have experienced a series of caregivers or prolonged separation from a caregiver in early childhood. Symptoms of "markedly disturbed and developmentally inappropriate social relatedness" must be present before age 5 years

Answer 16

The correct response is option E: Pick's disease Pick's disease specifically affects the frontal and temporal lobes, accounting for the early signs of personality changes, loss of social skiljs, ond emotional blunting. Other features of dementia, such as memory loss and apraxia, come later. Specific diagnosis of Pick's disease is usually made only on autopsy. The medical illnesses Huntington's disease, Parkinson's disease, and HlV_.infec.tipn precede those dementias. Creutzfeldt-Jakob disease often has a clinical triad associated with dementia, involuntary movement, and periodic EEG activity, l e w y body dementia often presents first with hallucinations and psychosis.

Answer 17

The correct response is option A: Cognitive behavior therapy Cognitive behavior therapy has been demonstrated to benefit children with obsessive-compulsive disorder. Uncontrolled trials of cognitive behavior therapy have shown excellent response in up to three-fourths of p_ajdej]]sjregted. Many experts recommend cognitive behavior therapy as the first-line approach for the majority of children and adolescents with pbsessivecompujsj_/ e dlisorder.

Answer 18

The correct response is option B: Difficulty falling or staying asleep Difficultyjailing or staying asleep is a symptom of hypej^arousal. In the DSM-IV-TR, posttraumatic stress disorder symptoms are clustered into three categories: reexperiencing, avoidance and numbing, and hyperarousal. Options A and C are symptoms of reexperiencing the event. Option D falls into category C of the DSM-IV-TR criteria for PTSD, that is, "Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness."

Answer 19

The correct response is option B: Sertraline S e j I r c i l i n e J s j D A ^ PTSD. The other_ medications are less well established as beneficial. Clonazepam, widely used as an anxiolytic, has FDA approval p_nly for use as an anticonvulsant and frecfment for panic disorder, for which it is a second-line choice. Olanzapine has not been reported as a treatment for PTSD. Propranolol has been tried experimentally to diminish the autonomic arousal associated with the trauma. The rationale for its use is that it will curtail the body's emotional/autonomic response to the trauma by diminishing the body's "memory" of the heightened emotional state. The beta-blockers, theoretically, will prevent or at least minimize the PTSD syndrome.

Answer 20

The correct response is option C: Generalized anxiety disorder The worries that occur in generalized anxiety disorder |urgncej. Obsessive-compulsive disorder involves obsessions, which are intrusive unrealistic ideas that may be rjej;ognjze.d_as.being absurd

Answer 21

The correct response is option E: Venlafaxine jdjLejpromisjnq^as^t^oaj^ qesicWarMefazodb'nel? /nirjazapine, or Although the precise mechanism of action for analgesia is unknown, itjs^beljeyed thajagents that increase serojojjjrKmd norepinephrine are more effective than those jhgt onjyjncrease serotonin

Answer 22

The correct response is option C: Depression with catatonic features ^£h°l_^ia_£Di?Sh?P^?^-?an characterize catatonic depression. A mood disorder with catatonic features must have two or more of the following features: "^olo^lclirMoEp^,.. .e^eitTeiggitafiBn: extreme"negratmsrrf; JSICOIK^ and eTcfetqte?or ^^gra3_iGl>(APA Practice Guideline).

Answer 23

The correct response is option B: Methylenedioxymethamphetamine {MDMA) All of these drugs are commonly known as "club drugs" and are frequently used at all-night dance parties. MDMA has been reported in some instances to cause severe adverse effects, including altered mental status, convulsions, hypo- or hyperthermia, cardiovasc^ QrJDitability, he^LajpJoxicity, and death. a dopamine enhancer that causes euphoria. Higher doses j>[G_HB can make the user feel sleepy and may cause_Y_o.mili.pg, muscle spasms, and loss of consciousness. If mixed with alcohol, GHB can slow breathing to a dangerously low..rate, which..has caused a number of deaths. ' Bie^^Bm^SncSeTamm^are related substances. They belong to a class of drugs called &i$scoafivfc ^anestherjci" vv^dTjiaye^^ c e p H o n J r o m j e j } ^ At lpwej^dose^k^ojpinej:auses a j r e g j n y j e e i i n g j i r ^ ^ ajTajy^a^prpduce numbness,in_rjie_exlreinities. Higher doses of ketamine may produce a hallucinogenic effect. lium'trdzepom? a | F i ^ _ _ i 3 n _ _ g n ^ T S g n j 6 , also known a s j o h y p r j o f (a trade name) or |rjwfi&J," has been characterized as the l i ^ 2 a p e ^ r y § ' ' Flunitrazepam is prescribed in Latin America and Europe as a shorHean .treatment.for.insomnia arid as a preanesthetic medication. Flunitrazepam can cause a chemically induced amnesia and may cause decreased blood pressure, drowsiness, visual disturbances, dizziness, confusion, gastrointestinal disturbances, and urinary retention.

Answer 24

The correct response is option C: Loraze_pani Lorazepam, by a variety of routes of administration, imcjroves^atajonja^dramaticaIly, although temporarily. ffijS-^depressi^ and scES^fiSS&I(catatonic type) are the most frequently observed psychiatric disorders that are associated with catatonia. Possible medical causes include rca ana eTc^h"al6^"a"thy] Catatonia may also appear as an adverse drug effect of a neuroleptic medication or phencyclidine^(PCPI7 Neurological causes of catato

Answer 25

The correct response is option A: ' ^ d e p r e s s a n t medication plus psychotherapy Since the publication in 2000 of the APA Practice Guideline for the Treatment of Patients With Major Depression, additional studies now support combined psychotherapy and antidepressant therapy for chronic depression. The evidence for this approach in treating mild or moderate depression is less compelling. W h i le ECT is highly effective, ECT alone usually does not produce sustained improvement. There have been few controlled studies of ECT plus psychotherapy.

Answer 26

The correct response is option D: Right parietotemporal cortex Just as Wernicke's area in thedpminant hemisphere is inyolv^d_in_understanding language, the correspond] ncj_a_rea in the nondominant hemisphere interprets the emotional tone of speech, or prosody. Analogous to Broca's area in the left hemisphere, the right premotor cortex is involved in expressive language production, providing the "music" for the semantic content.

Answer 27

The correct response is option D: Cognitive, behavior psychotherapy The most effective commonly used treatment for social phobia is based on cognitive behavior therapy principles and techniques. Other theoretical approaches have been used, but little research has been done to establish their usefulness. The major problem in social phobia is njaj3tiye_ejfaJyjhlon. Mere exposure to the social interaction does not produce anxiety reduction. The individual with social phobia must alter dysfunctionaj^ belleis^arid,biased,perceptions. Therefore, cogn iliy^Jnpjjtjpj;^ Olej^ejTtjpjvfor treatment success.

Answer 28

The correct response is option C: LooJc_ajJ}ej3atient and_asJcjJ[Hoy/i^ ?" One should always address the patient directly while speaking in a regular manner. It is the job of the interpreter to translate the words into sign language and vice versa. The, interpreter is not jo be addressedjjjrecjly.

Answer 29

The correct response is option B: Re^jyJgjy^chejMed a pp^mt^ejTtsj^dW The management of hypochondriasis is a challenge for the internist. Regularly i scheduled appointments with limited reassurance appears to be the _ management strategy of choice. A more psychologically minded internist might facilitate dependency, which might result in more visits and greater preoccupation with the symptoms. The other approaches do not provide enough structure to help the patient contain his anxiety

Answer 30

The correct response is option C: TajgAej_sp^cjfic_symptoms that are currently causing disruption Of the options listed, C is the most germone to the management of borderline personality disorder. PajiejTJsj^ajjirjM^ taj3ejea[_a^p_roach. Many patients will need mulHpJe_clqs_Ses-of^medications to target_diffej^ent domajns_ofjJifficujty (affective, behavioral, and cognitive). Due to the heterogeneity of presentation, however, clinicians, must be flexible jn their pharrnacotherapeutic approach.

Answer 31

The correct response is option B: I n c j ^ g s ^ r e a b s o r p - t i o j i j n j h e j j r o x j ^ The patient has developed acjjtejjthjujj^^ after the administration of a thiazide diuretic. Lithium is excreted through the kidneys and is reabsorbed in the proximal tubules with sodium,and water. When the body has a sodium deficiency, such as occurs with the administration of sodium-depleting diuretics, theJddneys_comp_ensgje_ byj^gbs^rbing_^ a0 ^ 3 ! ° J } 9 J ! y i ! h j f' lithium. This,, and j he [oss of fluid volume, results in elevated j e i um lithium levels and toxicity. Lithium may induce nephrogenic diabetes insipidus. However, this would cause production of large volumes of dilute urine. Paradoxically, the administration of a hSjazjde^diuretic re^dy^ejjjnne^ojjtp_ut. Cumulative exposure to lithium may result in a tujpjjlojntej^ and_a d e g e j p j e j n j f } ^ however, this is an insidious rather than an acute process and is unrelated to the introduction of a thiazide diuretic. Finally, lithium may cause a glomerulonephritis, resulting in a nephrotic syndrome. This is characterized by the presence of large quantities of protein in the urine.

Answer 32

The correct response is option C: 25% men and 75% women Borderline personality disorder isjhiejnosj^mmoj^persoj3gjity_ disojde^ It is present in 10% o£jndividuj2|s^ i^^^^^^g^lnooM^ and 30%H50% of cljmcaJjDQpuJarjons with a personality disorder. It occurs i n an estimated 2% c j ^ j h e ^ e ^ ^ j ^ Borderline personality disorder is diagnosed predominajitjyjrrwomen, with an estimated female-to-male ratio of J3jJ_. The disorder is present in cultures around the world. It is approximately five t[mes_mo£e_common a n w i g ^ f i r s j ^ l ^ d i s p j d e j J } a n J n j T j e ^ There is also a g r e a J e H a j T i j I i ^ ^ antisodgJ^ p^s^n^jityjjspjder, and mood disorders.

Answer 33

The correct response is option B: Anxious/depressed A c j ^ s s ^ a J J j t u d i e ^ ^ 9ir j s _ s j ^ e j L J^ spjT^jc__compJa^ while boys were higher on attention problems, delinauejTt^ behavior, and ajjgjj5Sj>ive__be^^ Therej^/asjTo_signjficant differ_encej^jween boys and girls on thought problems.

Answer 34

The correct response is option C: Dja^ased^capacity f?Xi§lectjve_aJtej^ In persons with obsessive-compulsive disorder, a c]e£rej3$^a^cajDC^ is hypothesized to be related to the difficulties in dismissing obsessions. Persons with the disorder have negative beliefs about responsibility, memory biases for disturbing themes, and decreased confidence in their memory, and they may show dejidj^Jrx_jpatial rec^gj}itJon.

Answer 35

The correct response is option B: Anxious/depressed A c j ^ s s ^ a J J j t u d i e ^ ^ 9ir j s _ s j ^ e j L J^ spjT^jc__compJa^ while boys were higher on attention problems, delinauejTt^ behavior, and ajjgjj5Sj>ive__be^^ Therej^/asjTo_signjficant differ_encej^jween boys and girls on thought problems

Answer 36

The correct response is option E: Schizotypal Although all cluster A personality disorders (paranoid, schizoid, and schizotypal) are more common in the biological relatives of patients with schizophrenia than in control groups;,the greatest correlation has bejnjojjndjDeJ^ a.!li5ShizoroJ}renia. There is increasing evidence, primarily from twin studies, that genetJ£ja^tor^cont r i b y j e t p p e r s o n a l i t y disorders. Other evidence to support a genetic link is the relationship between certain axis I disorders and personality disorders.

Answer 37

The correct response is option B: Sodium lactate The patient is exhibiting the classic signs and symptoms of panic disorder. Women are two to three times more likely to be affected than men; the mean age at presentation is about 25 years, and onset is typically acute. A number of panic-inducing substances (panicogens) have been identified. Respiratory panicogens shift the acid-base balance. They include carbon dioxide, sodium lactate, and bicarbonate. Neurochemical panicogens act through specific neurotransmitter systems.

Answer 38

The correct response is option C: Paroxetine This patient is presenting with the classic symptoms of panjc_dT|order. All of the medications listed have been used in the treatment of this condition. In general, experience is showing tfje^y^ejjpjity_oMhe S J i R l s j D n d ^ d ^ monoamine bxidase inhibitors, and tricyclic and tetracylic drugs in terms of effectiveness and tolerance of adverse effects. The beta-adrenergic receptor antagonists have not been found to be particularly useful for panic disorder.

Answer 39

The correct response is option A: CyjpcJ¥qm_e_P450 enzymes: Inhibition Codeine's analgesic effect is a result of its metabolism to morphine. This transformation is accomplished by a cytochrome P450 enzyme, CYP2D6. If that enzyme is inhibited—such as occurs with some drugs, including paroxetine—thereby interfering with available substrate (codeine) for transformation to the active metabolite (morphine), the dose of codeine must be increased above usual levels.

Answer 40

The correct response is option E: Mirtazapine ^^ejih3jncj^ase and we]gh[_gain^iaye_beenjnore consistently associated with mirtazapine than with the other listed antidepressants, perhaps because of its p_otent_H! antihistamine effect a_nd its. antagonism .of thejerotonin 5-HT2 .receptor

Answer 41

The correct response is option D: 12 weeks ** The latency for responses to medications is longer in patients with obsessive-compulsive disorder than in those with depression; response may take 10 to 1.2 weeks. There_isJ.ess.agreement.on what .is acceptable qs an adequate,dose. Some fixed-dose trials suggest that h i g j i e j j i o j e j j ^ ^ Trials of medications used for obsessive-compulsive disorder indicate that a daily dose for 1 Q_ ]2 w e e b is optimal '(e.g., clomipramine,..150 mg; fluvoxgmine, 150 mg; fluoxetln^ jiQjng; sertraline, 150 mg; paroxetine^40mg).

Answer 42

The correct response is option A: Lamotngme According to the APA Practice Guideline for the Treatment of Patients With Bipolar Disorder (Revised), t h e j i r s t j i n e . phqrmacological^ej]tment_ for_bjpolar depression is the .initiation of either lithium or lamotrigine. The treatment goals are the remission of the symptoms of major depression and to avoidprecipitation_ of_a manic or hypomanic episode. Antidepressant monotherapy is not recommended given the risk of precipitating a switch into mania. Small studies have suggested that intirp^rsona^jherapy and cognitive behavior therapy may also be useful when added to pharmacotherapy during depressive episodes in patients with bipolar disorder.

Answer 43

The correct response is option C: Explain jo the patient that the treatment pjajv^ll^hayejo^change if she cannot keep the agreement Boundary issues are a significant aspect of treatment of patients with borderline personality disorder. Therapists should be alert to the occurrence of boundary violations and proactive in dealing with them — both in terms of ascertaining their meaning and in terms of restoring the boundaries to maintain the patient's safety a n d the effectiveness of therapy

Answer 44

The correct response is option E: Sertraline

Answer 45

The correct response is option E: Opposifiono! defiant disorder The features of oppositional defiant disorder include a recurrent, pattern of.negativistic, defiant, disobedient, and hostile behavior toward^ayfhqrity figures. Children with conduct disorder demonstrate a repetitive and persistent pattern of behavior in which the basic rights of others and major age-appropriate societal norms or rules are violated. Oppositional behavior js notpartof. the criteria of A D H D . These behaviors do not meet the criteria for antisocial personality disorder, which, moreover, cannot be diagnosed in an 11- year-old. These behaviors also do not fit the criteria of intermittent explosive disorder.

Answer 46

The correct response is option A: Major depression While various psychiatric symptoms can occur in hemodialysis patients, depressioni is the most prevalent.

Answer 47

The correct response is option A: Cp^njtiye-motivati ojTdjntej^ve n t i on s A review of 39 studies of psychosocial interventions for improving medication adherence showed that p_ro- QIoillijhsLi0^^!.?^ the qttitudinal and behavioral 9iJ2ecjs_oijaJ

Answer 48

The correct response is option A: Paranoid delusions Cocaine intoxication can produce hypjjjension, tachycardia, seizures, paranoid delusions, and ^delirium. Depersonalization is more commonly associated with hallucinogen intoxication

Answer 49

The correct response is option A: TaIkfjefly_wijhj_he n urse a b o j j t j j y h y j i e ^ o j^ impjDrjant The liaison process includes cajejinding and fosterinfl the deyelopmentof greater psychiatric knowledge inn_)j}pjyc_iatric_medicqlj:are^pipviders, as opposed *2_^!I!}R'y_ providing parient carejrecojmmendations wh^n_asked. The_discrepancy between the internist's ond thejiurse's perceptions suggests an opp^rtunity fojMe^chmg.

Answer 50

The correct response is option B: Umjtep^jo^us_and goals_ While brief therapy is intended to be shorter-term, it can v a r y from one to 40 jessions, wjth^the_ayerage dose to six. Brief therapy is not just a shorter version of long-term therapy but is structured to address a specific, limited focus with_the least-radical intervention and generally does not aim J o r character change. Outcome data have not demonstrated superior efficacy for time-unlimited therapy. Trans|erence_and countertransference occurjn all therapies, although they may be less emphasized in brief therapy. The therapist requires at least equal psychotherapeutic skills as in classical long-term dynamic therapy and must be muchmpreactive.

Answer 51

The correct response is option E: Xanthine bronchodilafors thine brojichpdilatgrs such as theophylline and aminophylline. Because the kidney excretes lithium, any medicationjhat^altersjenal funcjion_can^ajfecHih^m levels. Thiazide diuretics reduce lithium clearance and hence may increase lithium, levels. Certain nonsterojdd qnWnflammatpry medications, such as ibuprofen, may increase lithium levels. Beta-blockers do not affect lithium levels. Angiotensin-converting enzyme inhibitors may increaseJithium levels

Answer 52

The correct response is option C: Motivational ejihan^cement Bo^Wtional"enhancenielfflthgapyyis a form of psychotherapy that has been shown to be effective in the treatment gfWqstance use disorders. I] uses directive, em path ic, patienNcentered techniques fQ__address ambivalence and denial

Answer 53

The correct response is option E: Recurrent visual hallucinations Of the core criteria that are part of the consensus criteria for the diagnosis of dementia with Lewy bodies, visual hallucinations (usually well-formed) are a particularly important finding in the differentiation. Other core criteria are fluctuaHcmjnj^ and spontaneous motor features of parkinsonism. In a prospective study that aimed to validate these core criteria using neuropathology at autopsy, the sensitivity and specificity of these clinical criteria were 0 J J 3 a nd respectively.

Answer 54

The correct response is option D: Dissociation Fla^hbadcexj^ as^ dissociative states. Uncommonly, the individual suffering from PTSD experiences flashbacks that can last from a few seconds to h q u r s j ^ d a y s . During flashbacks, pdrts of the traumatic event are reexperienced and the patient behaves as though the event was occurring at .mat moment. There is no evidence of psychosis during flashbacks associated with PTSD. Flashbacks can also result from the toxic effects of LSD and othe_hollucinogenic apients. Flashbacks associated with hallucinogenic . agents are. usually characterized by repeated psychedelic experiences, usually visual, and occur after the drug use has stopped. Fugue states include sudden unexpected travel away from one's home or customary activities, with amnesia for some or all of one's past. Hyperarousal is described by persistent,sympJojns_of anxiety or increased arousal, including difficujryjalling or_ staying asleep, irritability, difficulty concentrating, hypervigilance, and exaggerated startle response.

Answer 55

The correct response is option C: Obsessive-compulsive disorder Resrjonse prevention^techniques that decrease the frequencyjsfjituals have been shown in several controlled clinical trials to be usefuljn the treatment of patients with obessiveoompujsiye disorder. The patient is prevented from engaging in compulsive acts, such as hand washing after exposure to situations that the patient considers contaminating. The pajienHs gra_duajly_exposed_to fhe_fea,red_siruation and is helped, to. abstain from engaging^in compulsive behavior after the exposure. The patient begins with the easiest situation and gradually _moves toward more difficult, tasks

Answer 56

The correct response is option D: Explore the reasons behind the request and explain wny this is something the psychiatrist is rejuctant to> do The issue of therapeutic benefit'to the patient must guide the manner in which the psychiatrist works within the limits of ethics and the law. M d o ^ a j a l s e i n s ^ is__bojJTjl[eg.q[^ndj^ thus options B and C are not appropriate. Option A considers only the letter of the law without an overall consideration of how to incorporate one's response into the therapeutic relationship

Answer 57

The correct response is option C: A feeling of worthiessness The symptoms that would prompt one to consider a diagnosis of major depressive episode include feelings of worthlessness and generalized guilt, not guilt about "missed opportunities" with the deceased. The usual signs of bereavement include feelings of sadness as we]l_as insomnia, poor appetite, and weight loss. The bereaved patient often believes_ that__the__depressed nL°°^_is _ ri9r m aL Additional symptoms of major depression include general_preqccupation with death (not wishes to die to join the deceased), psychomotor retardation, extended Junctional impairment, and hallucinatory experience^other than about the deceased.

Answer 58

The correct response is option D: Reticular activating system Tjiej^tjc^laj^a^^ is a collection of fibers and nuclei that include the main monoammejiuclej, extending from the r n ^ d y j j a _ p b l p n g a^ mus. Structures within the reticular acWwoWng system moduJaje_ajgusal, sleep-y^J<:e_cycles, and conscious activity. The amygdala is associated with fear, anxiety, and aggression. The hippocampus is associated with memory and anxiety. The_hypothalamus is re\a\e6 to hormonal regulation, eajin^and_drinking. The ventral striatum is associated with motivation.

Answer 59

The correct response is option C: Paroxetine The patient's history is consistent with a diagnosis of obessjye

Answer 60

The correct response is option E: Pick's disease Of the diagnoses listed, o n | ) ^ j c k ^ j s e ^ s ^ t h e j r o n j d e j n ^ ^ It typically begins insidiousjy, with oj}set.at an earlier, age .than, dementia, of thj^Jzheimejis_type. Incontinence and.abnormalities of_sp_eech gnd_la.nguage_pccur_relatively..eaHyjn the illness course. Sympk)ms_of_iLo.ntaJ.|gbe_ dysjynctipn, including apathy and soddly inappropriate behaviors, qrecpmmon. Unlike dementia of the Alzheimer's type, which is generally associated with more diffuse atrophy, changes seen on MRI and single photon emission computed tomography in Pick's disease.are more localized Jo the frontotemporal_ regions. With Huntington's disease and Parkinson'sjjsease, chara d e ^ t i c ^ n e u r o l o g ' i c a l . .findings are .prominent. Neurological findings are also observed in Creutzfeldt-Jakob disease, but the pJogressjon__pf dementia is more fulminant.thani.with.Pick'sdisegse and MRI may;_SJTOW changesjnjba_sql ganglia j n a d d i - ^i°JU°_^§Llbl9i9trophy.

Answer 61

The correct response is option B: Carbohydrate-deficient transferrin (CDT) CDT is more sensitive and specific than the other tests listed. However, better results may be obtained with combined tests (e.g., CDT and ga_mjpa-g[ujajny|transferase— GGT]. Because of interpatient variability in the C D T test result, the individual patient is best used as_his or her own baseline for CDT .levels.

Answer 62

The correct response is option D: Switchjc^adferent class_ of cntidep_res_s_gnt If a patient shows not even a partial response despite full therapeutic doses of a particular antidepressant, ajjgjn^njajionjsjio^recom Switching to a different drug, e.itheLwithin a class (if there has not been another_trial withi_ajhe_same class) or in a different class is warranted. The .addition of psychotherapy is also an option. Washing out by suddenly stopping all medications will probably precipitate discontinuation symptoms that will worsen the patient's status.

Answer 63

The correct response is option B: Suicide Of the answer choices, suiadejsjhg most common reason for malpractice,litigation against a psychiatrist. Documentation of a proper assessment with consultation helps to provide a reasonable defense. Sexual improprieties are viewed most often as torts and are not usually covered by malpractice, because a law has not been broken. Failure to obtain informed consent, especially when prescribing a conventional antipsychotic that could produce tardive dyskinesia, can be a cause for litigation. The best protection against malpractice is a documented comparison of risks versus benefits in the decision about treatment and an indication that this comparison has been shared with the patient or, if the patient is incompetent, wjth g member of the patient's family.

Answer 64

The correct response is option D: Obsessive-compulsive The association between personality disorders and other psychiatric disorders is important because of impljcationsjor treatment. Anorexia nervosa has been demonstrated to be associated with obsessive-compulsive personality disorder. Anorexia nervosa has not been associated with dependent, paranoid, schizotypal, or histrionic personality disorders.

Answer 65

The correct response is option C: Lithium Uthiy^rHnaj^ and r\X9^i9919^Y' r o j a W ^ _ a j e _ j j n c o ^ buJ^/eJUsJgbjijheo^ effedsa^ociafed wjtJxJithiujTijherapy. Both hyperplasia and-adenomas o f j h e parathyroid glands have been described in association with lithium therapy

Answer 66

The correct response is option E: Syjiderj^epispdes of muscle tone loss Cgtapjexy_ or sudden joss of_myscle tone, is__often broy^ht^orvby^.strong emotions^in-patients with narcolepsy. The other three components of the classic tetrad of narcolepsy are bouts of sleep attacks (that are refreshing), sleep paralysis, and hypnagogic or hypnopompic hallucinations that are abnormal intrusions of REM sleep.

Answer 67

The correct response is option D: A specific constellation of defense mechanisms The psychodynamic clinician views personality disorders as involving four major components: a_biologicajly based temperament, a set of internalized object relations, an enduring sense of self, and a specific constellation of defense mechanisms.

Answer 68

"""he correct response is option B: Chromc_pain The antidepressant duloxetine is a serotonin/norepinephrine reuptake blocker with ^dopamine. reuptake effects as.well. It has been shown in several 'studies to have efficacy in major depression. Major depression is frequently comorbid with chronic pain, often withouLorganic cause. Duloxetine appears to improve °othjjejDresjipn^ particularly bgckqche and shpyjder pain. It is thought that descending norepinephrine and serotonin fibers from the brain via the spinal cord serve to dampen peripheral pain signals. IncnejJsjdjTprepi^^^^ 5-HT "tone"_may thus simultaneously improve mood and comorbid pain. At this time, there are no studies to support duloxetine's use in treating panic attacks, flashbacks, psychotic symptoms, or night terrors

Answer 69

The correct response is option D: Akathisia from metoclopramide The description and observation of th_ejnai)il[tyJo_be still—that is, .motor restlessness—suggests,_akqthjsia rajherjhan a _simple anxiety or. adjustment disorder. Metoclopramide, an aliphatic phenothtazme and a cousin_of_chlorpromazine, is. the. mostJikely_culprit. Benzodiazepine withdrawal would be a second possibility, especially if the patient took lorazepam three times a day for 1 month and then stopped sev<.rol days before the evaluation.

Answer 70

The correct response is option C: History of a hypo- 4 manic episode in deciding on pharmacotherapy of a major depressive episode, it is most important to rule out a diaqnosis of a bipolar disorder. Ini such patients, initiation of either lithium or lamotrigine would be a reasonable option. Particularly in more seriously depressed individuals, some clinicians initiate simultaneous' treatment with lithium and anjintidepressgnt. In contrast to treatment of major depressive disorder, qntidepressant monotherapy is not recommended for treating depression in patients with oipojar disorder

Answer 71

The correct response is option B: Carbamazepine Lamojrigine, vvhich_has _been approved for the treatrpjnt_ of^bip_olar depression, i sjjietg bo I i zed through .the liver. Carbamazepine and oral contraceptives containing ethynyl estradiol, which induce hepatic enzyme systems, can rapidly decrease lamotrigine levels. Valproate, which inhibits these enzymes, could markedly increase lamotrigine levels. Olanzapine, topiramate, and lithium do not affect the hepatic enzyme system involved in the metabolism of lamotrigine

Answer 72

The correct response is option E: Thalamus Brain imaging studies suggest that obsessive-compulsive disorder involves abnormalities in a cortico-striatalthalamic circuit. A complementary model of obsessive-compulsive disorder has emphasized that the orbifqfronfal cortex plays a major role in the "worry circuit." Data have indicated that hyperactivity of the oj^itpjr^ntgUortex as well as the anterior cingujajejiorjex a^mimshesjA'.ith Jreatment.

Answer 73

The correct Response is option C: Major_ depressive disorder Anorexia nervosa is associated with depression in 65%_of cases, sqcial_ phobia in 34% of cases, and obs^siy^compulsive disorder in 26% of cases.

Answer 74

The correct response is option B: A psychiatrist in a remote area with no other psychiatrists is involved in a romantic relationship with a patient's adult grandchild ^ Psychiatrists have an obligation in general to avoid ^*f\9 roles that can compromise the primary fiduciary duty ;~jJLM they have to their patients as well as rojes that may i ncrease the* potential for exploitation of vulnerable patients. In option B, although a romantic relationship with a patient's adult grandchild may create a problematic dual role, the psychiatrist does not have the option of referring the patient to another competent clinician and thus lacks one possible w a y of avoiding the dual role. In options A and^C, the psychiatrist is entering into avoidable roles that involve interests of the psychiatrist that could potentially conflict..with, the interests of the patient. In option D, the psychiatrist f e e d s to distinguish between treatment and advocacy, the latter may not serve the patient while certainly s j r y j n g j h e p j s r s p j a i o r j j r o f a s ^ or convictions qfjh.e psychiatristjnjh is_case.

Answer 75

The correct response is option B: Ask_r.Qutine_guestions about battering while_ta|ting the history Domestic violence in general is underestimated, and it is particularly likely to.be overlooked, in lesbian couples becguse_of j h e stereotype .that_batt^nng_|s_only anjpjfense^of men.against women. Couples often do nPli^D9JLu p_sppnta.neously

Answer 76

The correct response is option A: Cognitive behavior 5pecific_pjwbras_.qre.iearsjaf JP_eciric_objects, situations, or activities. The treatment of choice for specific phobias is exposure, a type of cognitive behavior therapy. The patient is encouraged to discus_s_the irratjonajify of the phobia and.encouraged to expose himor herself to the reared_object. Interpersonal psychotherapy focuses on current interpersonal problems in depressed nonbipolar, nonpsychotic individuals. Insight p s y c h o l h e r ^ y attemp]s.tp,make what is out of awareness conscious, so that one can identify and work through patterns of behavior derived from childhood. Suppqrtiye_ psychotherapy emphasizes external evejTts_ajTdJs^ directed toward helping patients return to_their_preyjo^s bestJevel_ofJunctioning. Short-term anxiety-regulating psychotherapy uses psychodynamic principles and techniques to effect change

Answer 77

The correct response is option A: Language syntax_ Syntax, vocabulary, communication, and store of knowledge fend_ to.remain. stable with normal aging, but the other functions listed tend to decline with age.

Answer 78

The correct response is option B: Wilson's disease W i l s o n ^ d isease, or h e j ^ o j e j ^ f i a ^ g ^ is an autosomal recessive disorder.of. c^pgejMriefaholism characterized by C N S and hepatic manifestations. Copper deposition in the cornea results in the telltale r_g.yser^le.ischerjjng.

Answer 79

The correct response is option D: Bipolar disorder, not otherwise specified Recurrent hypomania in the absence of depressive periods would be classified as bipolar disorder not otherwise specified. According to DSM-IV-TR, a diagnosis of bipolar I disorder requires at least one manic or mixed episode; a diagnosis of bipolar II disorder requires recurrent major depressive episodes with hypomanic episodes; and a diagnosis of cyclothymic disorder requires periods of hypomanic symptoms and periods of depressive symptoms.

Answer 80

The correct response is option A: Alcohol dependence Dopaminergic and glutaminergic circuits in the tegmentum, accumbens, and prefrontal cortex are necessary in producing pleasure from drug use, in the development of addiction, and in the maintenance of drug craving, salience, and impaired control over use. The amygdala plays a more central role in anxiety disorders. The cnterior cingulate gyrus, the thalamus, the cerebellum, and the temporal lobe regions are involved in schizophrenia. The hypothalamus has been suggested as a site of dysfunction in anorexia. A wide range of structures and regions have been studied in the neurobiology of bipolar disorder

Answer 81

The correct response is option D: Ritonavir is decreasing blood lorazepam levels Ritonavir induces the enzyme that metabolizes lorazepam and some other benzodiazepines (oxazepam and temazepam] that rely on glucuronyl transferase activity for clearance. Some other benzodiazepines (e.g., midazolam) are dependent on CYP 3A4 for metabolism. Potent inhibitors of this CYP isoform, such as protease inhibitors, can decrease clearance of these drugs and result in increased sedation. Therefore, lorazepam remains a good clinical choice for short-term use in patients who need treatment for panic disorder who must also take ritonavir for treatment of HIV infection. Although the other options listed cannot be absolutely excluded, they are not as likely as the effect of ritonavir. Also, modern combination therapy in compliant patients tends to be quite effective in preventing secondary infections or lesions of HIV.

Answer 82

The correct response is option C: Reduced likelihood of psychotic relapse and rehospifalizafion Like most of the psychosocial treatments for schizophrenia, family therapy results in improved outcomes in important but discrete areas. Although studies of family interventions have used varying approaches to treatment, all effective family interventions include education about the illness and its course, training in coping and problem-solving skills within the family, improved communication, and stress reduction. By teaching practical educative and behavioral methods in highly structured programs that last 9 months to several years, these interventions are designed to elicit family participation and collaboration in treatment planning, goal setting, and, service delivery. They are also intended to complement and encourage the use of other treatments, such as having the patient adhere to a medication regimen, and to embed the psychiatrist's care within a multidisciplinary team approach to the patient and family. Meta-analyses and systematic reviews of such family programs have consistently shown reduced family burden and reductions in relapse rates, which are typically halved by structured family interventions compared with control treatments.

Answer 83

The correct response is option E: Somatization disorder Family members of individuals with antisocial personality disorder have an increased risk of having somatization disorder. This is especially true for females, although the rate of this disorder is also higher among male family members than in the general population. There is no association between antisocial personality disorder and autism, schizophrenia, narcissistic personality disorder, or bipolar disorder

Answer 84

The correct response is option D: Reduced renal excrefjon Lithium is a water-soluble element that is not metabolized and has no meaningful protein binding. There is no evidence that drug absorption is more efficient in the elderly, and the slight decreases in absorptive abilities with advanced age are not thought to be clinically meaningful. Lithium is excreted unchanged almost entirely by the kidneys. Because there is a tendency for the glomerular filtration rate to decrease with age, excretion of lithium becomes less efficient.

Answer 85

The correct response is option C: Grasping the patient's inner experience from the patient's perspective When a therapist empathizes, he or she understands the patient's feelings without getting involved in them. The empathic response would be to imagine thinking and feeling from the patient's level of insight. Empathy, a critical skill for psychotherapy, may be confused with sympathy, or just being nice, or avoiding anything that the patient dislikes. A common source of error is the "almost right" notion of imagining how one would feel if one were in the patient's shoes.

Answer 86

he correct response is option C: Ego-syntonic Although there may be elements of each of these options contributing to the patient's lack of distress, the one term that best describes this phenomenon is "ego-syntonic." Personality disorder symptoms are described as alloplastic (i.e., able to adapt to, and alter, the external environment] and ego-syntonic (i.e., acceptable to the ego). Because individuals with personality disorders do not find their behaviors distressing, these individuals often seem uninterested in treatment

Answer 87

The correct response is option D: Eating disorder not otherwise specified The ec-Kng disorder not otherwise specified category is for disorders of eating that do not fully meet the criteria for a specific eating disorder. This patient appears to have normal weight and thus does not meet the criteria for anorexia nervosa. She describes binges, but they do not occur frequently enough to meet the criteria for bulimia nervosa, which is on average at least twice a week.

Answer 88

The correct response is option C: Cardiomyopathy In patients with bulimia nervosa, cardiomyopathy as a result of ipecac intoxication may occur and usually results in death. Patients who binge and vomit may have parotid gland enlargement associated with elevated serum amylase levels. They are susceptible to hypokalemic alkalosis. Unlike patients with anorexia nervosa, those with bulimia do not have a high risk of osteopenia.

Answer 89

The correct response is option D: Hypothyroidism Hypothyroidism presents with fatigue, somnolence, weakness, dry skin, brittle hair, cold intolerance, and hoarse speech. Depression is common, and cognitive slowing can occur. Hypoparathyroidism and hyperparathyroidism can both result in anxiety, irritability, or depression. Hyperparathyroidism is commonly accompanied by weakness and anorexia, whereas hypoparathyroidism has mainly neuromuscular signs such as spasms, tetany, and hyperreflexia. Pheochromocytoma results in palpitations, panic attacks, headaches, and hypertension.

Answer 90

The correct response is option A: Autosomal dominant Three genes have been associated with early-onset Alzheimer's dementia: the ^-amyloid precursor protein gene (APP) on chromosome 21, the presenilin-1 (PS1) gene on chromosome 14, and the presenilin-2 (PS2) gene on chromosome 1. All three missense mutations are autosomal dominantly inherited and together account for only about 5% of all cases of Alzheimer's dementia

Answer 91

The correct response is option E: Selective serotonin reuptake inhibitors The patient's history is consistent with a diagnosis of social anxiety disorder, generalized type. While betablockers may be useful prior to occasional public speaking events, they are not effective foj generalized social anxiety disorder. Selective serotonin reuptake inhibitors (SSRIs) are well-established, effective treatments. Sertraline and paroxetine (as well as the non- * SSRI venlafaxine) are FDA-approved for the treatment of social anxiety disorder. There have been some studies showing benefit with benzodiazepines, but these agents are not preferred for long-term use and none are FDA-approved for this indication. Particularly in light of this patient's history of binge drinking, benzodiazepine use would be a relative contraindication. A v e r y small double-blind placebo-controlled study of olanzapine had promising results, but additional studies are necessary. Tricyclics have not been shown to be of benefit for social anxiety disorder.

Answer 92

The correct response is option E: Phencydidine The patient's presentation is consistent with phencydidine (PCP) intoxication. Hallucinogens such as LSD and psilocybin do not cause ataxia, dysarthria, and nystagmus. While miosis is characteristic of heroin intoxication, hypertension and agitation are not. Cannabis-induced psychosis is not characterized by miosis or the above-mentioned neurological findings.

Answer 93

The correct response is option D: Factitious disorder Factitious disorder is the most likely diagnosis for this patient because the negative workup and the discovery of the warfarin pill beneath the bed strongly suggest that her bleeding problems were self-induced. Such patients have a great need to be taken care of by physicians and even undergo serious procedures, such as a bone marrow bibpsy. The diagnosis is often elusive unless evidence is found that the illness was self-inflicted. No clear motive for the behavior is present; the motive most often identified is a desire to assume the sick role. In malingering, by contrast, an individual presents with d disability claim or an illness motivated by a goal of getting out of prison, collecting insurance money, or some other secondary gain. Somafizaiion disorder is a polysystem disorder that is characterized by a combination of pain, gastrointestinal, sexual, and psychoneurological symptoms. Hypochondriasis is the chronic fear that one has a serious illness. The anxiety may be generated by an exaggeration of an actual mild illness or concerns in the absence of medical causes. Body dysmorphic disorder is characterized by a significant preoccupation with imagined or exaggerated physical defects.

Answer 94

The correct response is option E: An SSRI Depression occurs in approximately 20% of patients who have had a myocardial infarction. Moreover, the mortality rate is much higher among posf-myocardial infarction patients w h o have depression. Several studies have established that the SSRIs constitute the safest antidepressants to use in such circumstances. They have little effect on conduction time and do not cause orthostatic hypotension. Various tricyclic antidepressants are not ideal because they may cause orthostatic hypotension, anticholinergic side effects, and effects on conduction. Bupropion has been implicated in hypertension in some patients. Trazodone presents problems of alpha-adrenergic blockade and postural hypotension. Finally, the monoamine oxidase inhibitors may cause a hypertensive response when certain foods are eaten, and they have orthostatic hypotension as a side effect as well.

Answer 95

The correct response is option B: Dopamine Cocaine is" known to inhibit dopamine reuptake and increase extracellular dopamine concentration. These effects, which occur in the nucleus accumbens, are considered to be related to cocaine-induced euphoria. Cocaine also blocks the reuptake of norepinephrine and serotonin, although the behavioral effects are mediated primarily by the dopaminergic system. The inhibitory neurotransmitter gamma-aminobutyric acid also interacts with dopamine neurons in the nucleus accumbens and the ventral tegmental area. The binding of cocaine to the dopamine transporter correlates best with its behavioral potency

Answer 96

The correct response is option D: Remembering appointments Instrumental activities of daily living (lADLs) include more complex daily tasks such as managing finances (e.g., writing checks), grocery shopping, preparing meals, keeping track of current events, remembering appointments, managing medications, using the phone, and traveling (e.g., taking the bus). A person's ability to manage these activities independently generally becomes impaired in the mild *to moderate stages of dementia. As dementia progresses, the more basic activities of daily living (ADLs) become impaired, and most people need assistance with them. ADLs include feeding, dressing, toileting, grooming, physical ambulation and transferring, and bathing.

Answer 97

The correct response is option B: Carbamazepine Hyponatremia can be an adverse reaction of carbamazepine. Hyponatremic coma has been attributed to the drug. If lithium use is associated with dehydration, hypernatremia may be a complication

Answer 98

The correct response is option A: Acuity of onset and level of consciousness Delirium is often confused with dementia or functional psychiatric disorders in elderly patients. Clinical features help in differentiating between delirium and dementia. Patients with delirium have an acute onset and exhibit fluctuation in the level of consciousness, cognition, and clinical symptoms, whereas patients with Alzheimer's dementia tend to have an insidious onset and an alert and stable level of consciousness, and cognitive and symptom fluctuation are infrequent. Orientation and memory are impaired in both disorders. Visual hallucinations are frequent in delirium and occur only occasionally in Alzheimer's dementia. EEG shows marked slowing in patients with delirium and either normal or mild slowing in patients with Alzheimer's dementia.

Answer 99

The correct response is option D: Sleep terror disorder Only option D is correct. The other disorders either have no gender differentiation or are more common in females

Answer 100

The correct response is option A: a-Adrenergic receptor blockade The tricyclic antidepressants block peripheral alphaadrenergic receptors, delaying the reflexive constriction of peripheral blood vessels when a patient goes from lying to standing, and through this mechanism induce orthostatic hypotension. In this particular vignette, the patient has a period of loss of consciousness on rising and objective evidence of orthostatic hypotension in light of a normal E C G . The signs, symptoms, and E C G suggest that the patient's fall is secondary to orthostatic hypotension. The tricyclic antidepressants may cause a variety of side effects, including 'anticholinergic, cardiovascular, and central nervous systerrTeffects. Anticholinergic effects include d r y mouth, constipation, urinary hesitancy, and blurred vision. Antihistaminic effects include sedation and weight gain. Cardiovascular effects tend to be the most worrisome. All tricyclics prolong cardiac conduction, much like quinidine or procainamide, and carry the risk of exacerbating existing conduction abnormalities, such as first-degree atrioventricular block.

Answer 101

The correct response is option A: Reporting the date ECT

Answer 102

The correct response is option A: Association study An association study looks for a statistically significant link between two variables in comparison with a control. Imaging genetics uses neuroimaging methodsstructural MRI, positron emission tomography (PET), functional MRI (fMRI), and magnetic resonance spectroscopy (MRS)—to assess the impact of genetic variation on the human brain in order to find aspects of brain function or structure that can be examined in association with genetic variations across individuals.

Answer 103

The correct response is option A: Comorbid major depression The goal of ECT in patients with borderline personality disorder is to decrease depressive symptoms in individuals with a comorbid axis I mood disorder. Although ECT is not a recommended treatment for borderline personality disorder per se, it can be useful in treating comorbid major depression. The decision to use ECT in this patient group should be guided by the neurovegetative symptoms more M a n the psychological symptoms of depression, which are chronically present in many persons with borderline personality disorder. There is, unfortunately, little research specifically testing ECT for treatment of depression in borderline personality disorder

Answer 104

The correct response is option B: Recommend ECT The patient is experiencing a treatment-resistant episode of depression that has accompanying suicidal ideation, somatic delusions, severe psychomotor retardation, and probable dehydration. These clinical features make this patient a candidate for ECT, which has been shown to be an effective treatment for patients with severe major depression. ECT is typically recommended for depressed patients with severe symptoms, including psychosis, marked suicidal intent, and refusal to eat. Given this patient's history of nonresponse to, or inability to tolerate, multiple antidepressants during the current episode, the likelihood that her depression will respond to ECT is significantly greater than the likelihood that it will respond to an increased dose of venlafaxine or to a change to a different antidepressant (e.g., mirtazapine) or augmentation with an anticonvulsant (e.g., lamotrigine). Although an occult carcinoma might also explain this patient's loss of weight, abdominal computerized tomography has not shown any hepatic abnormality, so obtaining a liver scan is not likely to be informative

Answer 105

The correct response is option B: Initial response to medication A better prognosis is indicated by late age at onset, good premorbid functioning, longer remission periods, and being married. The best predictor, however, is a good initial response to medication.

Answer 106

The correct response is option C: Schizoaffective disorder The DSM-IV diagnostic criteria for schizoaffective disorder, bipolar type, include at least one manic or mixed episode concurrent with symptoms of schizophrenia and with the persistence of delusions and hallucinations for at least 2 weeks when prominent mood symptoms are no longer present. Just hav:ng schizophrenic symptoms during a manic or mixed episode is insufficient for a diagnosis of schizoaffective disorder, because manic or mixed episodes in bipolar I disorder can be severe with psychotic features.

Answer 107

The correct response is option D: An identifiable focus While different models for short-term dynamic therapy stress different selection criteria, there is general agreement that traditional diagnostic categories or patient characteristics are less important than the ability of therapist and patient to agree on and maintain a defined focus for the treatment

Answer 108

The correct response is option C: Only with informed -consent of the custodial parent In order to share any clinical information with a third party, including the noncustodial parent, the psychiatrist needs the informed consent of the custodial parent. Although it may be clinically advisable to involve the child in the process, it is not required, since an 8- year-old cannot give legally valid informed consent.

Answer 109

The correct response is option A: Prominent negative symptoms Prominent negative symptoms are associated with cerebral ventricular enlargement. The phenomena listed in options B through D are more associated with nonenlarged ventricles in patients with schizophrenia. Other factors have been more directly associated with the risk of tardive dyskinesia than structural abnormalities.

Answer 110

The correct response is option A: Buprenorphine Buprenorphine is a partial opiate agonist or a mixed agonist-antagonist. Rapidly injecting high doses of a partial agonist in a highly dependent patient who has recently used a full agonist (e.g., heroin] can produce mild withdrawal symptoms. As the dose is increased, a drug effect ceiling is reached, both with respect to any drug-induced euphoria and with drug-induced respiratory depression. As the dose continues to rise, the opiate antagonist effects become more predominant. Naloxone is a full antagonist and would produce an immediate full withdrawal syndrome

Answer 111

The correct response is option A: Culture Personality disorders are defined as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's' culture. In general, intelligence, socioeconomic status, gender, and education have not been determined to be helpful in making a diagnosis of a personality disorder

Answer 112

The correct response is option D: EEG In most delirious patients, the EEG demonstrates slowing and may be helpful in confirming the diagnosis. During alcohol withdrawal, the E E G may show an ' increased frequency. None of the other options listed has value in the differential diagnosis.

Answer 113

The correct response is option C: 12-step programs Twelve-step programs have not demonstrated effectiveness in smoking cessation. All nicotine replacement therapies including gum, patch, nasal spray, and inhaler, have been found to be effective for smoking cessation. Brief advice techniques in which a personal benefit of cessation is identified and discussed in less than 10 minutes increase smoking cessation rates from 5% to 10%. Pharmacotherapy with bupropion has been shown to be effective.

Answer 114

The correct response is option'A: Couple relationships Shared psychotic disorder is more common in couples but is occasionally seen in groups. It often involves nonbizarre delusions and occurs more often in women than men. It has a low recovery rate

Answer 115

The correct response is option C: No patients, because of the nature of the psychiatrist-patient relationship While the psychiatrist could be more articulate in describing the pertinent difference between psychiatry and cardiac surgery in regard to boundary issues, a direct request by the treating psychiatrist can risk exploitation of the patient. The first option ignores the unique features of the psychiatrist-patient relationship. The remaining options raise only partial truths and ignore counterbalancing considerations.

Answer 116

The correct response is option B: The psychiatrist is responsible for making provisions for continuity of needed care even if additional days are not covered by the M C O Even if a managed care organization refuses to pay, once a psychiatrist determines that the patient needs further treatment, especially if the issue of safety is still a concern, the psychiatrist is ethically responsible for providing care or arranging for an acceptable alternative method of care. Gag clauses that limit physician disclosure to patients are unethical

Answer 117

The correct response is option B: Fragile X syndrome This boy's history and physical presentation are classic for fragile X syndrome. Fragile X syndrome is the most common inherited cause of mental retardation. Anxiety disorders are more common in fragile X syndrome than any other form of mental retardation. The key components of this vignette are a mentally retarded boy with specific physical stigmata who has developed an anxiety disorder. This youth is suffering from separation anxiety disorder. Although the typical age at onset is at the start of elementary school, separation anxiety disorder has a bimodal pattern of presentation, with a second peak emerging in adolescence and typically associated with the .transition into high school.

Answer 118

The correct response is option D: Interpersonal psychotherapy Interpersonal psychotherapy is a time-limited therapy that focuses on relationships and interpersonal interactions to effect change in symptoms and behavior. One aspect of interpersonal psychotherapy is that the patient is formally given permission to be in the "sick role," in that their feelings are framed in terms of a medical illness. The therapy focuses on the present and on real-life change more than on altering enduring aspects of the personality. Transference and genetic dream interpretations are avoided.

Answer 119

The correct response is option E: Schizotypal This vignette includes several features of each of the above personality disorders. Patients with paranoid personality disorder also fear being harmed by others. It is similar to avoidant personality disorder in the lack of close relationships, but the patient's indifference about' this rules out this diagnosis. She is overly dramatic in her presentation, which is suggestive of a histrionic personality disorder, which could include options D or E. However, the oddity of her other symp-roms suggests that this is unlikely. She seems to best fit into a cluster A personality disorder marked by oddity and eccentricity. Schizotypal personality disorder is distinguished from schizoid personality disorder by the presence of odd beliefs or magical thinking. Also, her comorbid diagnoses of a transient psychotic episode and depression are consistent with the diagnosis.

Answer 120

The correct response is option A: Sertraline Various medications have been shown to be effective for specific symptoms or behavior patterns in patients with borderline personality disorder. SSRIs are considered the treatment of choice for impulsive, disinhibited behavior in this patient group. Of the options listed, initial treatment with an SSRI for the symptoms of impulsivity and behavioral dysconfrol in patients with borderline personality disorder has the most empirical support. Use of antipsychotics is common for patients with borderline personality disorder, but given the potential side effects, these agents should not be used as a firstline therapy for impulsivity and behavioral dysconfrol. Only preliminary support is available to support the use of naltrexone for this cluster of symptoms in borderline personality disorder. Benzodiazepine treatment may be associated with an increase in impulsivity in patients with borderline personality disorder.

Answer 121

The correct response is option B: Clozapine i The 2-year International Suicide Prevention Trial (InterSePT) found that suicidal behavior was significantly less common in patients treated with clozapine than in those treated with olanzapine in the high-risk population studied. (The number of completed suicides was low for both patient groups: three for those treated with clozapine, and five for those treated with olanzapine.) While a substantial literature supports an antisuicide effect for lithium, the studies were not with schizophrenia patients.

Answer 122

The correct response is option B: Dopamine The patient has galactorrhea, which is probably due to antipsychotic drug-induced hyperprolactinemia. This is more common with the older, conventional antipsychotics and with risperidone among the newer atypicals. D2 receptor stimulation by dopamine has an inhibiting effect on prolactin secretion, and druginduced blockade of this receptor will lead to an increased release of prolactin. Various explanations have been proposed as to w h y atypical antipsychotics v a r y considerably with regard to their effect (or lack of effect) on prolactin.

Answer 123

The correct response is option B: Finding vectors to transfer genes into the nervous system is a challenge The greatest challenge to gene therapy for the treatment of psychiatric disorders is finding vectors to transfer genes into the nervous system. Neurons are fragile, and so are some of the more difficult genes on which to perform gene therapy. Viral vectors tend to infect only a subset of the cells around them. Potential target genes are still being delineated. It will be many years before gene therapy will be clinically applicable.

Answer 124

The correct response is option C: Quetiapine * If nonpharmacological interventions are ineffective, a trial of an atypical antipsychotic such as quetiapine or olanzapine may be initiated. Atypicol antipsychotics that have been studied with the geriatric population are clozapine, risperidone, olanzapine, and quetiapine. A patient with parkinsonism may not be able to tolerate even the minimal extrapyramidal side effects of risperidone.

Answer 125

The correct response is option A: Catatonic This patient has had persecutory delusions during previous episodes of illness and is now disorganized in his appearance. However, he is also exhibiting motoric immobility, mutism, echolalia, and grimacing, making his current presentation most consistent with the catatonic subtype of schizophrenia.

Answer 126

The correct response is option A: Dyspareunia Sexual pain disorders are not a common chief complaint in mental health settings. However, during psychotherapy a psychiatrist may become aware of the symptoms and should be able to recognize them. This is a classic description of dyspareunia

Answer 127

The correct response is option C: 50% Huntington's disease is inherited by an autosomal dominant transmission. With one affected parent and one unaffected parent, by chance, one could expect 50% of offspring would be affected and 50% unaffected, but each individual child has a 50% chance of developing the disease.

Answer 128

The correct response is option A: Alcohol The terafological effects of prenatal alcohol exposure have been well studied and are described by fetal alcohol syndrome. Alcohol is a direct neuroteratogen that affects not only fetal facial morphology and growth but also brain growth, structure, and function. As a result, children exposed to alcohol have an unusually high prevalence of intellectual impairment and disruptive behavior disorders. This young boy exhibits evidence of several psychiatric disorders in association with specific physical stigmata. His history suggests the presence of oppositional defiant disorder (ODD), Attention deficit hyperactivity disorder (ADHD), and overall impairment in intellectual functioning leading to deficits in academic functioning. In utero exposure to marijuana has been linked to mild problems with attention and impulsivify but has not been found to permanently affect intellectual functioning or cause craniofacial abnormalities. Cocaine may cause a relative stcte of hypoxia in fetuses that are small for gestational age and have a small head circumference. Some studies have shown attentional problems in children exposed to cocaine in utero, but no specific physical abnormalities have been demonstrated. Prenatal opiate exposure reduces birth weight and head circumference. However, studies have found no differences in early childhood between children who were exposed to opiates in utero and those who were not. In utero effects of nicotine have been linked to ADHD and growth retardation, but no other sequelae.

Answer 129

The correct response is option B: Multiple modalities of psychotherapy have proven effective for PTSD In meta-analyses of controlled trials of psychological treatments of PTSD, multiple forms of psychotherapy, including exposure therapy, cognitive behavioral therapy, and psychodynamic therapy, have been shown to be effective

Answer 130

The correct response is option B: Gender identity disorder This is a complicated disorder, but the scenario describes someone who has been struggling with gender identity disorder despite functioning in culturally' expected roles for a prolonged period.

Answer 131

The correct response is option B: Children have more efficient renal function than adults Children have more efficient renal elimination than adults and therefore will clear drugs using this pathway more quickly

Answer 132

The correct response is option D: Bupropion A large survey of primary care clinics found that the lowest risk of sexual dysfunction was with bupropion. ' Double-blind placebo-controlled studies found substantially more orgasm dysfunction with sertraline and with fluoxetine than with bupropion.

Answer 133

The correct response is option E: Stage 3 or 4—non- REM Sleep terror disorder is a parasomnia. It occurs in deep non-REM (i.e., stages 3 or 4) sleepi This stage of sleep occurs predominantly in the first third of the night. Although many parents assume that a child in this state is having nightmares, in fact he has sleep terror disorder. According to DSM-IV-TR, the awakenings from nightmares generally occur during REM sleep

Answer 134

The correct response is option D: Neuroleptic malignant syndrome Essential for the diagnosis of neuroleptic malignant syndrome in a patient on antipsychotic medication are rigidity and elevated temperature. Two or more of the following symptoms are also required: diaphoresis, tachycardia, elevated or labile blood pressure, dysphagia, incontinence, tremor, changes in the level of consciousness ranging from confusion to coma, mutism, leukocytosis, laboratory evidence of muscle injury (e.g., elevated creatine kinase).

Answer 135

The correct response is option B: Bipolar disorder with psychotic features The patient meets DSM-IV-TR criteria for a manic episode with mood-congruent auditory hallucinations. The psychotic symptoms occurring only in the context of a manic episode make the other diagnoses unlikely

Answer 136

The correct response is option A: Regulation of affect Dialectical behavior therapy is based on the theory that borderline symptoms primarily reflect dysfunction of the emotion regulation system. Cognitive behavior therapies view the problem as cognitive distortions, and behavior management views the issue as learned behavior. Empirical studies suggest that child abuse, incest, and early trauma may play a large role in development of borderline 'personality disorder. Options B, C, and D are related to psychological formulations of the disorder, and option E relates more to the biological concepts of .serotonergic dysfunction. Early psychodynamic formulations postulated a lack of object constancy and splitting of self and objects into "all good" or "all bad" as core problems in borderline personality disorder.

Answer 137

The correct response is option D: Unethical no matter how long it has been since the termination of the doctor- patient relationship While the issue of sexual relationships with former patients is not without controversy, psychiatrists should be aware of the current position of the American Psychiatric Association, which forbids sex with former patients.

Answer 138

The correct response is option A: Continue current dosage of clozapine and begin twice-weekly monitoring of the W B C and differential A prorocol has been established for monitoring the hematologic effects of clozapine. In this vignette, the patient's W B C and A N C have dropped from baseline, but the patient has demonstrated an excellent response .. to medication and has no signs or symptoms of infection. However, the drop in W B C and A N C are not considered large enough to disrupt treatment. Given the clinical response in a treatment-resistant patient, it is recommended that the patient be continued on the dose of clozapine that is effective and for the clinician to monitor the W B C and differential more frequently. For greater decreases in the W B C or A N C , it may be necessary to interrupt clozapine treatment temporarily until these values return to safer levels or to immediately and permanently discontinue clozapine treatment if there are concomitant signs of infection.

Answer 139

The correct response is option E: Antisocial Antisocial personality disorder cannot be diagnosed in individuals under the age of 18 years. The other personality disorders can be diagnosed if the maladaptive personality traits are pervasive, persistent, and unlikely to be limited to a particular developmental stage or episode of an axis I disorder. However, traits of a personality disorder that appear in childhood frequently change in adult life". To diagnose a personality disorder in an individual under age 18, the features must have been present for at least 1 year. The one exception to this is antisocial personality disorder, which cannot be diagnosed in individuals under age 18. This is because until that age, the behaviors associated, with antisocial personality disorder are better explained by conduct disorder, a diagnosis of childhood and adolescence

Answer 140

The correct response is option B: Psychotherapy The expert panel felt that for milder-severity acute PTSD, psychotherapy first was the treatment of choice, although the preferred first-line treatment for chronic PTSD or for more severe acute PTSD is either psychotherapy first or combined medication and psychotherapy. * This recommendation holds true for children, adolescents, adults, and geriatric pojients.

Answer 141

The correct response is option D: Paroxetine and phenelzine The patient's symptoms are consistent with a serotonin syndrome. Monocmine oxidase inhibitors, such as phenelzine, combined with serotonergic antidepressants pose a grave risk; hence, such combinations are contraindicated.

Answer 142

The correct response is option A: Lamotrigine The Practice Guideline recommends the initiation of treatment of bipolar depression with lithium or lamotrigine; it further states that monotherapy with conventional antidepressants is not recommended "given the risk of precipitating a switch into mania." A large double- blind monotherapy study of bipolar I depression found lamotrigine to be more effective than placebo on most outcome measures. There have been no published controlled studies of divalproex or gabapentin

Answer 143

The correct response is option C: Having honor roll grades A subset of African American culture that particularly affects male adolescents devalues academic performance and emphasizes aggressive and "street" behavior. The clinician should be aware of this phenomenon in the African American community and take this into account when assessing a student whose grades and behavior change.

Answer 144

The correct response is option A: Begin an antidepressant The patient has symptoms of a major depressive episode that have persisted for 2 weeks. Rather than addressing insomnia as a symptom in isolation, it is preferable to begin treatment for the depressive disorder. Previous investigations have suggested waiting 30 days after onset of abstinence before making a diagnosis of a mood disorder. However, recent data suggest that persistence of mood symptoms 2 weeks after cessation of drinking merits treatment.

Answer 145

The correct response is option C: Previous suicide attempt A previous suicide attempt is the most potent predictor of suicide in girls.

Answer 146

The correct response is option D: This is a conflict of interest for the psychiatrist Self-monitoring and self-regulation actions by the psychiatrist are important but usually are not seen as sufficient to prevent abuse due to conflicts of interest. Pharmaceutical company marketing to physicians affects physicians' behavior.

Answer 147

The correct response is option C: Association Association studies can examine whether a particular allele occurs more frequently than by chance by comparing affected and unaffected individuals. Twin, and family studies are not gene-mapping studies, Linkage . studies, a type of gene-mapping study, examine whether two or more genetic loci are co-inherited more often than expected by chance. A segregation analysis is used to determine mode of inheritance (dominant, recessive, etc.).

Answer 148

The correct response is option B: Depressive disorders Approximately one-half to two-thirds of adolescent suicide victims have a depressive disorder, with the odds ratio for increased suicide risk in those with an affective disorder ranging, in various studies, from 11 to 27. Substance use and abuse are highly comorbid, particularly in male suicido- completers, and conduct disorder has been reported in about one-third of male suicide victims. Few adolescent suicides are related to schizophrenia.

Answer 149

The correct response is option C: Paroxetine > Premature ejaculation is the persistent or recurrent onset of orgasm and ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. Typically it is a problem in young men, who eventually develop behavioral strategies to delay ejaculation. However, some men never develop the ability or lose if because of decreased frequency of sexual activity or performance anxiety or as a component of erectile dysfunction. It can be a problem in recovering substance abusers who have relied on the substances to delay ejaculation. SSRIs have been shown to be a good treatment for premature ejaculation, with paroxetine being the medication that delays ejaculation the most.

Answer 150

The correct response is option B: Sexual assault Assaultive violence, including sexual assault, produces the highest rates of PTSD, compared with other precipitating traumas (i.e., combat, natural disasters, and motor vehicle accidents).

Answer 151

The correct response is option A: Amylase Values for the other tests are often decreased in patients with anorexia nervosa.

Answer 152

The correct response is option C: Nausea Nausea, reported in 11 %-47% of patients, is the most common adverse effect of the cholinesterase inhibitors (donepezil, rivastigmine, and galantamine). Vomiting is the next most common side effect, reported in 10%-31% of patients. Diarrhea was reported in 5%-19% of patients, and anorexia in 4%-17%. Other, less frequent side effects include insomnia, muscle cramps, syncope, fatigue, abnormal dreams, incontinence, and bradycardia.

Answer 153

The correct response is option D: Psychoanalysis There is peer-reviewed evidence suggesting that interpersonal and social rhythm therapy, family therapy, and cognitive behavioral therapy may decrease cycling and decrease the severity of bipolar I disorder. There are no controlled studies demonstrating that psychoanalysis decreases the frequency or severity of episodes of mania or depre

Answer 154

The correct response is option B: Alcohol or sedativehypnotic withdrawal 1 The patient's tachycardia and symptoms of anxiety are consistent with the time frame for alcohol or sedativehypnotic withdrawal. Multiple drug use is common in patients with substance dependence. Rather than intentionally concealing polydrug use, a patient may be much more focused on a drug-ofchoice to the point that abuse of.other substances is not acknowledged

Answer 155

The correct response is option C: Lithium Analyses of the results of many studies support a marked reduction in suicide rates and suicide attempts during long-term lithium treatment.

Answer 156

The correct response is option C: Body dysmorphic disorder This patient demonstrates the diagnostic criteria for body dysmorphic disorder. She is preoccupied with a perceived defect in her appearance, and this concern affects her adaptation socially. On the basis of the information given, there are no signs or symptoms of a delusional disorder or an obsessive-compulsive disorder. She does not believe she has a serious illness, which usually is associated with hypochondriasis, and she does not have the list of physical complaints that define somatization disorder.

Answer 157

The correct response is option C: Lithium Lithium is the best studied augmentation agent in the treatment of unipolar depression. Most studies have been with lithium augmentation of tricyclic antidepressants. Fewer data are available on the effectiveness of T3 or stimulants, although both are used.

Answer 158

The correct response is option A: Delirium Visual hallucinations suggest the need to rule out an organic cause related to a delirium. Rarely, patients with schizophrenia, mania, or depression may experience visual hallucinations

Answer 159

The correct response is option C: Pulmonary hypertension Long-standing sleep apnea is associated with increased pulmonary blood pressure and eventually increased systemic blood pressure as well. These changes may account for a considerable number of cases in which the diagnosis is essential hypertension.

Answer 160

The correct response is option C: Gene finding Current psychiatric genetics can be organized into four paradigms of inquiry: basic genetic epidemiology, which is used to quantify the degree of familial aggregation and/or heritability; advanced genetic epidemiology, which explores the nature and mode of action of genetic risk factors; gene finding, which attempts to determine the genomic location and identity of susceptibility genes; and molecular genetics, which uses critical D N A variants to trace the biological pathways from D N A to disorder.

Answer 161

The correct response is option A: Refer the patient to another physician for consultation, specifically for the role of advocacy Separating the roles of advocate (one who reports the incident] and therapist (one who treats the patient) is a useful solution in this situation. A therapist must comply with the state statute that requires reporting a sexual abuse incident. However, such reporting may interfere with transference in that the patient mcy be inhibited from revealing other issues that she may want to be confidential but would hesitate to discuss because she fears her doctor would have to report the information. Either the first therapist who sees the patient reports the incident and then refers the patient to another therapist for treatment or the first therapist sends the patient to another psychiatrist for the role of advocate to report the incident. The patient then returns to the first therapist for further treatment.

Answer 162

The correct response is option A: Clozapine In individuals with schizophrenia or schizoaffective disorder, several lines of evidence suggest that rates of suicidal behaviors, including suicide, are diminished by clozapine treatment. For example, analyses of data from the clozapine national registry show decreased rates of suicide compared with expected rates for individuals with schizophrenia. In addition, the International Suicide Prevention Trial (InterSePT) compared clozapine and olanzapine in 980 patients over a 2-year period and found that the clozapine group had substantially fewer suicide attempts and fewer hospitalizations related to suicidality. Lithium maintenance treatment is associated with a substantial decrease in rates of suicide among individuals with mood disorders, particularly bipolar disorder, but if has not been adequately studied in terms of suicidal behaviors in individuals with schizophrenia.

Answer 163

The correct response is option A: Absence of positive psychotic symptoms Paranoid personality disorder is marked by pervasive distrust and suspiciousness of others. This may be present in paranoid schizophrenia, a delusional disorder, or a mood disorder with psychotic features. The age at onset of symptoms, degree of impairment, duration of symptoms, or pervasive nature of the symptoms may be of little help in differentiating paranoid personality disorder from the other disorders listed. However, in paranoid personality disorder, positive psychotic symptoms should not be present, whereas they are key diagnostic criteria for each of the other disorders.

Answer 164

The correct response is option B: Electroconvulsive therapy Catatonic features may be present in as many as onethird of patients during a manic episode. While the patient may be responsive to benzodiazepines, electroconvulsive therapy is believed to be the most effective treatment for catatonia, "regardless of etiology."

Answer 165

The correct response is option D: Skills training Relapse prevention is a behavior therapy that combines skill training with cognitive intervention techniques. In this approach, patients are taught behavioral and cognitive skills such as changing thoughts and beliefs, resisting social pressure, increasing assertiveness, and improving interpersonal comi munication. Relaxation and stress management techniques are also emphasized. The effectiveness of these cognitive behavioral techniques appears to have longer-lasting benefits than some other treatment modalities. They are particularly effective when a cooccurring psychiatric disorder such as anxiety or depression is present.

Answer 166

The correct response is option C: Premature ejaculation Data from the National Health and Social Life Survey showed that almost one-third of men said they had recurring problems with ejaculating too early, making it the most common sexual disorder in men. Premature ejaculation is defined as persistent or recurrent ejaculation with minimal sexual stimulation or before, on, or shortly after penetration and before the person wishes it, resulting in marked distress or interpersonal difficulty.

Answer 167

The correct response is option D: Recommend that she reduce her drinking by about 50% The physician should assess the patient for alcoholrelated problems and definitely recommend that the patient decrease her drinking to safer levels. This level of alcohol consumption puts the patient at risk of alcohol- related problems. Nonhazardous drinking for women is seven standard drinks per week, with no more than three per occasion. Without a history of more alcohol-related problems, outside referral is not necessary. The patient will likely respond well to brief office-based intervention.

Answer 168

The correct response is option D: Intellectualization rationalization All defense mechanisms, by definition, are outside of the patient'^ awareness. They function to ward off anxiety ana conflict. Rationalization is the use of seemingly logical explanations to make untenable thoughts or feelings more acceptable. In the case of Mr. B, his verbal facility and educational accomplishment make this a likely characteristic of his personality. Regression refers to a partial return to earlier levels of functioning or adaptation in order to avoid painful or conflicted feelings or thoughts. Altruism is a higher-order defense mechanism. Projection is considered a primitive defense mechanism that is frequently found in patients with significant suspiciousness and that consists of attribution of conflicted feelings, wishes, or thoughts to another person or group. Dissociation is characterized as the splitting off of threatening thoughts or feelings.

Answer 169

The correct response is option B: Transference A current definition of transference is a combination of a real current relationship and relationships from the patient's past. Reaction formation is the transformation of an unwanted thought or feeling into its opposite. Splitting is the experiencing of others as being all good or all bad (i.e., idealization or deidealization). Suppression is not a defenses mechanism since it is the conscious attempt to control unacceptable feelings and wishes. Transference is also outside of the patient's awareness during the initial phase of treatment. Mr. B is offended by the therapist's lateness and expresses his disappointment by characterizing all doctors as_ being unavailable. There is a likely transference to the patient's father, w h o was unavailable to the patient during his formative years

Answer 170

The correct response is option C: Countertransference Countertransference is defined broadly as all of the feelings of the therapist evoked by the patient within the therapeutic relationship. Although the term originally referred to a process outside the therapist's awareness and therefore an indication of conflict, it is now used frequently to describe all of the therapist's feelings and behavior stimulated by the patient. Denial is a primitive defense mechanism characterized by a refusal to appreciate information about oneself or the other. Regression refers to a partial return to earlier levels of functioning or adaptation in order to avoid painful or conflicted feelings or thoughts. Deidealization minimizes the other. Dissociation is characterized as the splitting off of threatening thoughts or feelings

Answer 171

The correct responsv is option D: Establish a therapeutic or working alliance It is true in all types of psychotherapy that the initial task of treatment is to establish a therapeutic or working alliance, without which treatment is unlikely to progress. This alliance represents the willingness of patient and therapist to work collaboratively toward the patient's understanding and changing problematic feelings and behaviors. It would be premature to prescribe any medication at this point in the treatment relationship because the nature and extent of the patient's symptoms remain unclear. Since Mr. B is seeking treatment, it would be inappropriate to bring another person—his wife, from whom he is separated—into the treatment process. Setting limits on behavicr is clearly inappropriate and would undoubtedly establish an adversarial relationship with the patient.

Answer 172

The correct response is option A: Bulimia nervosa Bulimia nervosa is considered to be a culture-specific syndrome, occurring predominantly in females in industrialized cultures that value slimness.

Answer 173

The correct response is option E: The wish to die While anergia, anorexia, somatic complaints, and diminished concentration commonly accompany medical illnesses in older patients, psychological symptoms, including suicidal ideation, decreased self-esteem, and guilt, do not. These symptoms should suggest the diagnosis of depression.

Answer 174

The correct response is option A: Major depressive disorder In the primary care setting, major depressive disorder most commonly presents with multiple somatic symptoms, with back pain among the most frequent complaints

Answer 175

The correct response is option C: Projective identification Otto Kernberg described the defense mechanism of projective identification as it occurs in patients with borderline personality disorder. In this primitive defense mechanism, intolerable aspects of the self are projected onto another with the aim of inducing the person to play the projected role, and the two act in unison. It is important that therapists be aware of the process and act neutrally toward such patients.

Answer 176

The correct response is option B: Gabapentin Gabapentin has not been approved by the FDA for treating any aspect of bipolar disorder. Lithium, chlorpromazine, and divalproex were the first agents approved by the FDA for the treatment of acute mania. Since then, five newer antipsychotics—olanzapine, risperidone, quetiapine, ziprasidone, and aripiprazole—have been approved for acute mania. The extended-release formulation of carbamazepine, an anticonvulsant, has also been approved for acute mania.

Answer 177

The correct response is option B: What a patient/plaintiff must prove to win a malpractice suit The four D's of negligence refers to: duty, dereliction, direct, and damages. The physician owes a duty to the patient. W h e n negligence occurs, there is a dereliction of this duty, which directly results in damage to the patient. To win a malpractice suit, a patient/plaintiff must prove by a preponderance of the* evidence that the physician owed.a duty of care to the patient and that negligence (a dereliction of this duty) occurred, which directly resulted in damage to the patient. Option D refers to the standard of c a r i ,

Answer 178

The correct response is option C: Frotteurism This scenario best describes the disorder of frotteurism according to DSM-IV-TR criteria-sexual arousal caused by rubbing up against a nonconsenting person.

Answer 179

The correct response is option D: Certain types of trauma are more likely jo cause PTSD Extreme stressors (such as rape, torture, and combat) significantly increase morbidity of PTSD. W h e n the type of trauma is controlled for, women appear to be at higher risk of developing PTSD compared with men. In one nationwide survey, the highest current (17.8%) and lifetime (38.5%) rates of PTSD were in women who had been exposed to physical assault or rape. PTSD is more common in younger than in older individuals, probably because of the higher incidence of physical violence and accidents in the younger population. Individuals who respond to the initial trauma with high levels of anxiety (e.g., a panic attack), also have a higher risk of developing PTSD after trauma, as are those who perceive an external (vs. internal) locus of control.

Answer 180

The correct response is option A: 50% if twin is monozygotic Between 50% and 60% of monozygotic twin pairs are concordant for schizophrenia. In several studies over recent decades, the concordance in dizygotic twins has ranged from 4% to 15%.

Answer 181

The correct response is option A: Partial hospitalization or brief inpatient hospitalization Of the options listed, long-term partial hospitalization has the most empirical support. Studies of mood stabilizers have been mixed. Although not a listed option, dialectical behavior therapy also has substantial empirical support for the treatment of borderline personality disorder.

Answer 182

The correct response is option B: Behavior therapy Behavior therapy has been documented to be helpful as a component of the treatment of A D H D , especially parent training and classroom behavioral modification approaches.

Answer 183

The correct response is option E: Substance use disorder Substance use or abuse is an important diagnosis to consider in adolescents who present with symptoms consistent with bipolar disorder, both as a possible cause of the symptoms and as an important potential coexisting problem. This diagnosis has significant implications for treatment planning.

Answer 184

The correct response is option C: Amnesia Acute herpes simplex encephalitis damages the medial, temporal, and orbitofrontal regions of the cortex. Amnesia is the. most common residual deficit. The regions of the brain for language, speech, and discrimination of touch are usually not affected

Answer 185

The correct response is option B: Exposure and response prevention Exposure and response prevention is most effective for the psychotherapeutic treatment of obsessive-compulsive disorder. Relaxation techniques alone are not helpful and are often used as the control in research on obsessivfrcompulsive disorder.

Answer 186

The correct response is option A: Alprazolam Abrupt withdrawal of any benzodiazepine will cause some degree of rebound anxiety and insomnia. Shortacting compounds have been found to have a greater effect on rebound insomnia on discontinuation. The elimination half-life of alprazolam is intermediate (6 to 20 hours) and is the shortest in comparison to clonazepam, long (>20 hours); diazepam, long (>20 hours); quazepam, long (>20 hours); and chlordiazepoxide, intermediate (6 to 20 hours) but with long (>20 hours) metabolites (demoxepam and nordazepam).

Answer 187

The correct response is option D: Derealization/ depersonalization Derealization and depersonalization are listed as criteria for acute stress disorder in DSM-IV-TR.

Answer 188

The correct response is option B: Malingering Malingering, the conscious attempt to fake or exaggerate an illness or symptom for personal gain, is the correct answer. Factitious disorder is a self-induced medical problem where the personal goal is not evident. Somatization disorder is a polysympfomatic disorder that begins before age 30, extends over a period of years, and is characterized by a combination of pain and gastrointestinal, sexual, and pseudoneurological symptoms. Hypochondriasis is the fear of having a serious disease based on misinterpretation of somatic signs or symptoms.

Answer 189

The correct response is option D: Difficulty recalling important aspects of the event Difficulty recalling is a form of avoidance. In the DSMIV- TR, posttraumatic stress disorder symptoms are clustered into three categories: reexperiencing, avoidance and numbing, and hyperarousal. Option A is a symptom of hyperarousal, while options B and C are symptoms of reexperiencing the event.

Answer 190

The correct response is option B: Lamotrigine When lamotrigine was compared with valproate in a monotherapy study on epilepsy, weight remained stable among patients using the former but not the latter medication (at 32 weeks, mean weight gain was 12.8 pounds on valproate and 1.3 pounds on lamotrigine). Weight gain is a well-established side effect of lithium, divalproex, and olanzapine.

Answer 191

The correct response is option C: Young adulthood According to Erikson, the primary task at the life stage of young adulthood, between ages 20 and 40, is to form strong friendships and to achieve a sense of love and companionship or a shared identity with another person. Feelings of loneliness or isolation are likely to result from an inability to form friendships or an intimate relationship.

Answer 192

The correct response is option C: Habit reversal Probably the best described and most effective psychotherapeutic technique for the trectment of trichotillomania is habit reversal. The technique has been adapted to both individual and group therapies. Habit reversal includes 13 components, including such things as self-monitoring, relaxation training, habit interruption, overcorrection, and habit inconvenience.

Answer 193

The correct response is option C: Young adulthood According to Erikson, the primary task at the life stage of young adulthood, between ages 20 and 40, is to form strong friendships and to achieve a sense of love and companionship or a shared identity with another person. Feelings of loneliness or isolation are likely to result from an inability to form friendships or an intimate relationship.

Answer 194

The correct response is option C: Major depressive disorder Two-thirds of patients who have obsessive-compulsive disorder will sometime in their life have an episode of major depression, with about one-third meeting the criteria for current comorbid depression, making it the most common comorbid disorder. All of the other anxiety disorders may be comorbid as well. Finally, obsessive-compulsive disorder can be comorbid with schizophrenia, often making the treatment more difficult.

Answer 195

The correct response is option B: Decreased size of the caudate This patient is suffering from obsessive-compulsive disorder. Functional brain imaging (e.g., positron emission tomography) has demonstrated increcsed metabolism and blood flow in the basal ganglia, especially the caudate. Interestingly, structural studies (e.g., computed tomography and magnetic resonance imaging] have found bilaterally smaller caudates in patients with obsessive-compulsive disorder

Answer 196

The'correct response is option E: Schizophrenia Studies have demonstrated that patients diagnosed with schizophrenia have decreased prefrontal gray matter, decreased prefrontal white matter, and increased ventricle size. The cognitive deficits persist in patients who are not actively psychotic or experiencing negative symptoms.

Answer 197

The correct response is option B: Rule out medical problems and substance use Medical problems and substance use must be considered and carefully assessed during the evaluation of male erectile disorder.^ From twin studies, the heritability of the risk of dysfunction in having an erection is estimated to be 35%, and of maintaining an erection, 42%. The efficacy of the three available PDE-5 inhibitors (sildenafil, vardenafil, and tadalafil) is approximately 70%, and the three have similar side effect profiles. Caution should be exercised with PDE-5 inhibitors in patients with hypotension and uncontrolled hypertension. The prognosis of male erectile disorder has improved over the years by several groundbreaking treatments: sex therapy, penile prosthesis, intracavernosal injection, and oral PDE-5 inhibitors.

Answer 198

The correct response is option E: Side effects from carbidopa-levodopa The encephalopathic side effects of carbidopa-levodopa are essentially those of the levodopa. Nearly 30% of patients with Parkinson's disease taking i-dopa have vivid dreams and 7% have night terrors. Delirium occurs in 5%, and a delusional syndrome develops in as many as 3% of patients who take L-dopa for 2 or more years.

Answer 199

The correct response is option C: Dialectical behavior therapy Mindfulness is considered a core skill in dialectical behavior therapy, along with tolerance, emotion regulation, and interpersonal effectiveness. Dialeciical behavior therapy is well studied and frequently cited as an effective approach to the treatment of patients with borderline personality disorder. Mindfulness training addresses attentional control, described by Linehan as being "in control of attentional processes."

Answer 200

The correct response is option A: Heart rate The arousal in PTSD is largely due to an increased autonomic response. Therefore, increased heart rate would be a natural occurrence. Constricted pupils, on the other hand, as well as weight gain and an increase in tidal volume would more likely be associated with parasympathetic stimulation. Other physiological findings associated with arousal in PTSD include muscle tension as measured by electromyography and increased sweating.

Answer 201

The correct response is option D: Major depressive episode Mixed episodes contain features of both mania and depression. While mixed episodes have been defined by a number of different criteria, DSM-IV-TR requires at least a week during which criteria are met for both a manic episode and a major depressive episode.

Answer 202

The correct response is option C: Haloperidol An elderly patient who develops acute mental status changes while in the hospital for another problem (this patienj is on the surgical service) is most likely suffering from delirium, which is a medical problem (thus options A, B, and D will likely turn out not to be the eventual intervention). Indeed, elderly postsurgical patients pre especially at high risk of delirium. Although benzodiazepines can be useful in the management of agitated delirium, the mainstay of delirium management is dopamine blockade with an agent such as'haloperidol. Of course, the most important intervention is to identify and treat the cause of the confusional state.

Answer 203

The correct response is option A: Educational level The formerfy used cutoff score of 23 to identify cognitive impairment has been shown to have poor sensitivity for detecting cognitive impairment in better-educated cdults. At the same time, individuals with lower educational attainment will be overidenfified as cognitively impaired when this cutoff is used. Age- and education-based norms have since been developed for the MMSE

Answer 204

The correct response is option E: Sleep terror disorder The presentation is most consistent with sleep terror disorder. The most pertinent parts of this vignette are a young child awakening during the early part of sleep in a state of heightened arousal,^ along with the lack of recall of the event. This would suggest an incident most likely occurring in stages 3-4 of sleep, as this is the most prominent pattern in the early hours. 'Therefore, consideration would be given to some type of parasomnia associated with deep sleep. The lack of recall for what is happening during the episode suggests that this is not a nightmare. The symptoms are *lot consistent with the presentation of narcolepsy or a breathing disorder, such as apnea.

Answer 205

The correct response is option E: Rett's disorder In this vignette, development is normal until the age of 8 months and then goes awry, with specific delays and deviance in social, communicative, and cognitive development. Rett's disorder, which occurs only in females, is characterized by an early onset of developmental delays, with deceleration of head growth, loss of purposeful hand movements and stereotypies, and incoordination of gait and trunk movements. The early age at onset suggests the presence of a pervasive developmental disorder rather than schizophrenia, which typically does not present until closer to or during adolescence. In autistic disorder, qualitative impairments are seen in social interaction and communication, along with repetitive and stereotyped patterns of behavior, interest, and activities, but head growth does not decelerate or stagnate, nor is there deterioration in neurological functioning. The same is true for Asperger's syndrome, which presents with many of the signs and symptoms of autistic disorder but without impairments in language or cognitive development. Children with disintegrative disorder develop an autistic- like condition after a longer period (2 or more years) of unequivocally normal development.

Answer 206

The correct response is option D: Prematurely discharging a patient from the hospital According to Simon (2001], any of the following actions can be construed as abandonment of the patient: failure to inform the patient about medication side effects, failure to admit the patient to the hospital when indicated, not attending (or arranging appropriate attending] to the patient during a hospitalization, prematurely discharging the patient from the hospital, inappropriate or improper referral of the patient, sexual relations with a patient;, anU termination of the treatment based only on denial of benefits by a thirdparty payer. Abandonment is a breach of the fiduciary duty of the psychiatrist to act in the patient's best interest. When the therapeutic relationship between the psychiatrist and the patient is "unilaterally and prematurely terminated by the psychiatrist without reasonable notice," abandonment may have occurred. Terminating the treating relationship when a patient threatens to sue may be in the patient's best interest because of the countertransference that almost invariably would occur (it is also difficult to imagine that a patient who has threatened to sue would want to continue in treatment with the same psychiatrist).

Answer 207

The correct response is option E: nausea and sexual dysfunction Common side effects of SSRIs include anxiety, nausea, insomnia, sedation, and sexual dysfunction. Trazodone can cause priapism. Seizures are associated with bupropion. Confusion and disorientation may occur with toxic levels of antidepressants. Orthostatic hypotension and dry mouth occur more commonly with tricyclic antidepressants.

Answer 208

The correct'response is option D: Selective serotonin reuptake inhibitors (SSRIs) Selective serotonin reuptake inhibitors are recom- 'mended as first-line pharmacological treatment for posttraumatic stress disorder. SSRIs have been found to be effective not only in reducing PTSD symptoms but also in treatment of comorbid disorders and associated symptoms. Double-blind placebo-controlled studies support the use of SSRIs as first-line agents for the treafme'nt of PTSD. Sertraline and paroxetine have been approved by the FDA for the treatment of PTSD. Other SSRIs are currently being studied for efficacy. Open-label trials have suggested that nefazodone may be useful for reducing PTSD symptoms. The monoamine oxidase inhibitors and tricyclic antidepressants have been shown in a number of doubleblind placebo-controlled studies to be effective, but they are considered second- or third-line agents because of their side effect profiles. Mood stabilizers should be considered, especially when there is accompanying impulsivity or aggressiveness, although further studies are needed to determine the effectiveness of these agents for patients with PTSD.

Answer 209

The correct response is option A: Increase the maintenance dose of methadone An oral methadone dose of 40 mg is a low dose. Better outcomes have been achieved with higher doses. There is no reason to change to L A AM at this point. Decreasing or discontinuing tredtment would likely lead to even poorer patient outcomes. Buprenorphine may precipitate withdrawal in opioid-dependent patients..

Answer 210

The correct response is option A: Circadian rhythm sleep disorder Circadian rhythm sleep disorder is a persistent pattern of sleep disruption from a mismatch of the patient's endogenous sleep-wake cycle. There are four varieties: delayed sleep-phcse type, jet lag typ^e, shift work type, and unspecified type. In jet lag type, the degree of difficulty the patient has is usually related to the number of time zones crossed. A dissociative fugue is characterized by sudden travel away from one's home with an inability to recall some or all of one's past. A dyssomnia is characterized by a disturbance in the amount, quality, or timing of sleep. A parasomnia is characterized by abnormal behavioral or physiological events occurring in association with sleep or the components of sleep. Narcolepsy is one type of dyssomnia. It involves repeated attacks of refreshing sleep, cataplexy, and recurrent attacks of REM sleep in the form of hypnagogic or hypnopompic hallucinations.

Answer 211

The correct response is option E: Myoclonus Myoclonus is a typical manifestation in the early stages of Creutzfeldt-Jakob disease. Extrapyramidal symptoms are found in Parkinson's disease; dysarthria is a sign of head injury; choreoathetosis is a sign of Huntington's disease; and frontal release signs are found in Pick's disease.

Answer 212

The correct response is option B: Delusional disorder According to DSM-IV-TR, nonbizarre delusions in the absence of markedly impaired function and bizarre or odd behavior would qualify for a diagnosis of delusional disorder. Both schizophrenia and schizophreniform disorder are characterized by features such as prominent hallucinations, disorganized speech and behavior, ana1 negative symptoms. An episode of brief psychotic disorder must have a duration of less than 1 month

Answer 213

The correct response is option A: 5-HT2 receptor The short form of the promoter for the serotonin (5-HT). transporter has been reported to predict poor response or intolerance ;o SSRIs in Caucasians.

Answer 214

The correct response is option D; Choose an option that reflects what most reasonable persons in that situation would do The currently accepted standards relevant to an individual's capacity to make medical decisions do not include whether or not the patient makes the "correct" choice. It is still possible for a fully competent patient to choose an option that few "reasonable" persons would choose. While standards for assessing the capacity to make a decision vary from state to state, the abilities to communicate a choice, to understand, and to appreciate are commonly accepted standards

Answer 215

The correct response is option A: Avoidant personality disorder A number of personality disorders are characterized by a paucity of interpersonal relationships. The cluster A personality disorders (paranoid, schizoid,. and schizotypal] are often described as "loners." However, patients with these disorders are not particularly bothered by the lack of relationships. Individuals with an avoidant personality disorder are hypersensitive to rejection by others. Their main personality trait is timidity. Although they desire human companionship, their inordinate fear of rejection prevents them from developing relationships. Their hypervigilance about rejection causes them to lack self-confidence and to speak in a self-effacing manner. In contrast, individuals with dependent personality disorder have a pattern of seeking and maintaining connections to important others rather than avoiding and withdrawing from relationships

Answer 216

The correct response is option A: Interpretive and explanatory tool There are several ways to look at the function of culture in contemporary psychiatry. Culture as interpretive and explanatory tool allows for describing nonpathologic behaviors within the context of an individual's culture. Culture as pathogenic and pathoplastic agent demonstrates that some psychopathology can result from cultural practices. Culture as diagnostic and nosologic factor frames a specific disease as unique to a culture. Culture can also be therapeutic and protective to one's mental health. Culture as a management and service instrument allows for cultural factors to piny a role in the way mental health services are delivered.

Answer 217

The correct response is option D: Requires dissociative symptoms for a diagnosis The DSMIV-TR criteria for the diagnosis of acute stress disorder include the presence of at least three dissociative symptoms (a sense of being in a daze, depersonalization, derealization, a sense of numbing or detachment, or dissociative amnesia). Hyperarousal symptoms are a common feature of both acute stress disorder and PTSD. The duration criteria for acute stress disorder state that the disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event. Acute PTSD requires a duration of symptoms less than 3 months, and a diagnosis of chronic PTSD requires that the symptoms have been present for at least 3 months.

Answer 218

The correct response is option D: Partial complex seizures Olfactory hallucinations are most commonly associated with partial complex seizures, although they can be reported in patients with psychosis or somatization disorders. Olfactory tumors must also be ruled out. Other types of hallucinations, such as taste or kinesthetic hallucinations, may also occur with partial complex seizures. Olfactory hallucinations may also occur in psychotic depression and typically involve odors of decay, rotting, or death.

Answer 219

The correct response is option A: Not acceptable because it does not put the patients' interests first Referrals need to be based on the patients' need, in order to preserve trust in the health care system. The financial arrangement described in this question creates a financial incentive for the psychiatrist that could be in opposition to what is necessary for the welfare of the patient. For instance, there will be situations in which the referral to the therapist may be of financial interest for the psychiatrist but not congruent with the patient's needs. Also, the therapist could try to recoup the costs for referrals by charging more for the services

Answer 220

The correct response is option C: Emotionally engage with the memory of the trauma For successful processing of traumatic events, three processes must be accomplished: the person must engage emotionally with the memory of the trauma; the trauma story must be organized and articulated in a sequenced and coherent fashion; and the dysfunctional thoughts that commonly occur after trauma must be addressed^and corrected.

Answer 221

The correct response is option C: Using suicide prevention contracts in emergency settings is not recommended Suicide prevention contracts are only as reliable as the state of the therapeutic alliance. Thus, with a new patient, the psychiatrist may not have had sufficient time to make an adequate assessment or to evaluate the patient's capacity to form a therapeutic alliance, creating little or no basis for relying on a suicide prevention contract. As a result, the use of suicide contracts in emergency settings or with newly admitted and unknown inpatients is not recommended.

Answer 222

The correct response is option D: He gets significant support from his two best friends Option D indicates a capacity for meaningful object relationships, a crucial indicator for psychodynamic psychotherapy. The other items listed are significant to his history but are not as relevant to suitability for psychotherapy. Success at work is a positive indicator to some extent, but it might also indicate that the patient was a workaholic who avoids painful feelings or awareness by plunging himself into his work.

Answer 223

The correct response is option C: Hepatic conjugation is unaffected by age Lorazepam is primarily metabolized by conjugation, and diazepam by oxidation. Conjugation is unaffected by age, whereas oxidation decreases with age, leading to increases in the half-life of diazepam. Volume of distribution increases with acje, whereas glomerular filtration rate and hepatic blood flow decline—all of which would affect both drugs similarly

Answer 224

The correct response is option D: Continuing to see the patient until acute depression-related crises are resolved and then discharging the patient to the local state-funded community agency clinic While an advance notice of termination can sometirnss be sufficient, it is inadequate in the case presented in this question, because the patient's condition is severe and may be worsening. Option B will not provide the close monitoring that is necessary for adequate treatment of severe depression with suicidal ideation. Option C describes a bartering arrangement that is highly questionable, as it creates a relationship (artist-patron) that may not always coincide with the goals of the doctor-patient relationship

Answer 225

The correct response is option E: Native American The University of Michigan's annual Monitoring the Future Study (MTF] is a survey of tens of thousands of students in grades 8 through 12. The MTF documents recent trends in substance use, among them a progressively younger age of initiation, particularly for girls. Among girls, drug use is highest in Native Americans and lowest in African Americans and Asian Americans. These differences are thought to be attributable to sociocultural and genetic factors.

Answer 226

The correct response is option B: 3 months Someone who has suffered a life-threatening traumatic event will be diagnosed as having an acute stress disorder in the first month after the trauma. If the duration of the symptoms is less than 3 months, the diagnosis is acute PTSD, and if it is 3 months or more, chronic PTSD

Answer 227

The correct response is option B: Major depressive disorder The diagnostic criteria for major depressive disorder are the same for children and adolescents as adults, except that youths are more likely to present with an irritable mood. This boy exhibits loss of interest in school or play, difficulty sleeping, impaired appetite, fatigue, feelings of worthlessness, and suicidal ideation with an attempt, in the presence of dysphoria and irritability. This is consistent with major depressive disorder. [

Answer 228

The correct response is option E: Schizophrenia His diminished social function, evidence of delusional thinking, and behavior related to delusjons are indicative of late-onset schizophrenia. Delusional disorder would be the second most likely diagnosis, but patients with this disorder generally do not have hallucinations or such extreme loss of social function.

Answer 229

h e correct response is option B: 2 months T h e diagnosis of major depressive disorder is not usually m a d e until the symptoms of the disorder persist for 2 months after the death. Studies h a v e indicated that if d e p r e s s i o n is not treated a r o u n d this time, it'is still present 9 months to 1 year after the death.

Answer 230

The correct response is option A: T h e patient hears a voice that he cannot resist telling him to kill himself If the patient's voices are telling him to kill himself and he feels he must act on these commands, then, although it involves taking a w a y the patient's liberty (or autonomy), the psychiatrist m a y act in the patient's best interests (beneficence) a n d hospitalize the patient against the patient's wishes. Involuntary hospitalization of mentally ill individuals brings together the often conflicting ethical principles of autonomy, beneficence, and informed consent, among others. The patient w h o is hearing voices felling him to kill himself may or may not require involuntary hospitalization. The current standard for involuntary li. .spitalization in most states is that of dangerousness to stl'- or others. Initially the specified amount of time of hospitalization is determined by the state's law. T h e psychiatrist's judgment of dangerousness is necessarily dependent on an adequate and appropriate clinical examination, w h i c h must be well d o c u m e n t e d . W h e t h e r or not a third-party p c y e r or g o v e r n m e n t a g e n c y deems hospitalization the appropriate care, the psychiatrist's ethical obligation is to the patient. A p p e a r i n g dirty and disheveled does not in a n d of itself mean that the patient is unable to care for himself. T h e concept of g r a v e disability, if it is a result of mental illness, can be cause for involuntary hospitalization in some states. G r a v e disability is usually defined as the inability to p r o v i d e for one's o w n f o o d , clothing, or shelter.

Answer 231

The correct response is option' D: Topiramate The package insert for topiramate states that 1.5% of adults exposed to the drug during its development had kidney stones, an incidence two to four times that of the general population. The formation of kidney stones may be related to reduced urinary citrate excretion as a result of carbonic anhydrase inhibition by the drug. The association was noted almost exclusively in patients with epilepsy, although it has also been reported in a patient with bipolar II disorder. Although lithium can adversely affect the kidneys in several ways, the formation of kidney stones is not associated with lithium therapy.

Answer 232

The correct response is option B: A beta-blocker The beta-adrenergic blockers have been used successfully for management of this specific social phobia. Both public speakers and music performers have found them helpful because of the drugs' effectiveness in decreasing manifestations of anxiety in the autonomic nervous system. They have an advantage over benzodiazepines because the beta-blockers do not impair concentration or coordination. The length of time for fhercpeutic effect of the other agents (SSRIs, SNRIs, and buspirone) makes them impractical for occasional use

Answer 233

The correct response is option A: Aripiprazole Weight gain and metabolic syndromes are potential side effects of the atypical antipsychotics. Weight gain tends to occur most frequently with olanzapine and clozapine, occurs moderately with quetiapine and risperidone, and is least likely to occur with ziprasidone. Aripiprazole tends to be weight neutral. Of these medications, risperidone is the most likely to cause extrapyramidal side effects. Ziprasidone may cause QTc interval prolongation and should be used with caution in patients with a family history of sudden cardiac death. Because it is weight neutral, aripiprazole is the next drug of choice for treating this patient's schizophrenia.

Answer 234

The correct response is option B: Hemodialysis Severe lithium toxicity, as evidenced in this case by the markedly elevated serum level together with the level of neurologic impairment, is best treated with hemodialysis, which is the most effective way of removing lithium rapidly from the body.

Answer 235

The correct response is option A: Akathisia The most common extrapyramidal side effect of antipsychotic medications is acute neurolepficinduced akathisia, which consists of a subjective feeling of restlessness along with restless movements, usually in the legs or feet. Patients often pace continuously or move their feet. Over a third of patients treated with high-potency dopamine receptor antagonists experience akathisia, particularly when these medications are administered in high doses. Akathisia appears to be less common when lower doses or lower-potency dopamine receptor antagonists are administered and is even more infrequent with atypical antipsychotic agents. Dystonic reactions (including torticollis and oculogyric crises) occur in up jo 10% of patients treated with high-potency dopamine receptor antagonists, whereas tardive myoclonus and neu- * roleptic malignant syndrome are relatively rare

Answer 236

The correct response is option A: The documentation of the patient's risk factors for suicide recorded in the chart The best legal protection is thorough documentation of a patient's risk factors for suicide. This should include always asking a patient about suicidal ideation and recording chronic and acute risk factors as well as facilitating versus inhibiting factors. It has been noted that as many as 25% of suicidal patients deny having suicidal ideation, so the risk assessment must go beyond simply recording the patient's answer to a question about suicidal thoughts. The psychiatrist should take appropriate steps, if indicated, such as increasing the frequency of visits or even hospitalizing the patient involuntarily. W h i l e a comorbid axis II disorder may, especially if it predisposes a patient to impulsivity or uncontrolled rage, represent a chronic risk factor for suicide, documentation of an axis II disorder in and of itself does not protect the psychiatrist from a malpractice allegation. A family's assurance that they will supervise a suicidal patient may be wellintentioned but does not mitigate the psychiatrist's duty to assess thoroughly a patient's risk factors for suicide. Although frequently used in psychiatric and mental health practice, a suicide prevention or "noharm" contract generally provides minimal legal protection for a psychiatrist accused of malpractice after a patient's suicide.

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