Mental State/Intellectual Function/Behavioural Problems+Major Psychiatric Disorders/Drug & Alcohol Abuse Flashcards

Question

A 47-year-old homeless man is brought to the Emergency Department by the police after he was found agitated and fearful in the streets while carrying a bag full of rubbish. He says to you, as the treating doctor, that he was caught by special military forces because he did not returned the DVDs to a shop that belongs to the Jewish brotherhood. He also mentions that he has been followed by demons because he has not done his prayers. He does not seem to be drunk but looks exhausted and agitated. Which one of the following options is the **most appropriate next step** in management of this patient? A. Admit him to psychiatric unit for evaluation and treatment. B. Ask the police about him. C. Arrange urgent parenteral antipsychotics. D. Arrange admission to general ward for assessment of his medical status. E. Perform a urinary toxicology screen.

Answer 1

**Correct Answer Is B.** Psychiatric evaluation of the agitated patient includes: De-escalation (verbal de-escalation; medical deescalation [e.g. sedation] if necessary) Visual observation of the patient before direct patient interview and paying careful attention to the patient's verbal and nonverbal interaction with the examiner during de-escalation. Collecting collateral information - Collecting collateral information can be very helpful. While de-escalation is in process, another team member can obtain verbal reports from family, paramedics, or police officers or review written material that may accompany the patient. Medical records are also an important source of information, and electronic records, if available, can be readily accessed to determine previous diagnoses and medications. These sources of information can be invaluable in determining the cause of agitation. Of the given options, asking the police about him has the highest priority as it can provide additional information for further management. Once it is determined that the patient does not have an acute medical problem, there are several important questions, the answers to which will guide the next step in management of the patient. The first question is whether the patient has a delirium. It is not uncommon for a patient to go through initial screening and have a diagnosis of delirium overlooked. The patient may be mistakenly diagnosed as being psychotic, or the signs and symptoms of delirium may be subtle and easily overlooked. In delirium, the patient has an altered level of awareness and problems directing, focusing, sustaining, or shifting attention. The examiner must pay close attention to how the patient interacts during the encounter and recognize these often subtle signs. Does the patient seem confused and unable to focus? Are there perseverative behaviors? Does the patient appear to be responding to visual hallucinations? Are there signs of language impairment, problems naming, or other cognitive deficits? If agitation is associated with any of these findings, especially in the setting of drug or medication use or medical illness, the presumptive diagnosis is delirium. Risk of suicide or self-harm should be assessed and if presents managed accordingly. The possibility of substance intoxication/withdrawal should be borne in mind and investigated if indicated. Other measures include assessment of general medical condition, followed by a detailed formal psychiatric assessment if an underlying psychiatric condition is suspected. Antipsychotics may be used for treatment of an agitated patient if verbal de-escalation fails.

Answer 2

**Correct Answer Is D.** Unless contraindicated, oral phosphodiesterase type 5 (PDE5) inhibitors such as **sildenafil, vardenafil, tadalafil and avanafil are first-line therapy for erectile dysfunction, regardless of the etiology**. In patients refractory to oral PDE5 inhibitors, one of these agents can be combined with an injection of the prostaglandin PGE1. Although not proven, it is likely that erectile dysfunction can be prevented by good general health, paying particular attention to body weight, exercise, and cigarette smoking and alcohol consumption. These measures should be considered but are not first-line treatment plan. **TOPIC REVIEW** Impotence is defined as male erectile dysfunction (ED), that is, inability to achieve or maintain an erection sufficient for satisfactory sexual performance. ED usually has a multifactorial etiology. Organic, physiologic, endocrine, and psychogenic factors are involved in the ability to obtain and maintain erections. In general, ED is divided into 2 broad categories, organic and psychogenic. Although psychologic factors have been mostly implicated as the contributing factor, pure psychogenic ED is in fact uncommon; however, many men with organic etiologies may also have an associated psychogenic component. Conditions that may be associated with ED include diabetes, hypertension, and coronary artery disease as well as neurologic disorders, endocrinopathies, benign prostatic hyperplasia, sleep apnea, COPD, and depression. In fact, almost any disease may affect erectile function by altering the nervous, vascular, or hormonal systems. Various diseases may produce changes in the smooth muscle tissue of the corpora cavernosa or influence the patient’s psychological mood and behavior. Conditions associated with reduced nerve and endothelium function (e.g. aging, hypertension, smoking, hypercholesterolemia, and diabetes) alter the balance between contraction and relaxation factors. These conditions cause circulatory and structural changes in penile tissues, resulting in arterial insufficiency and defective smooth muscle relaxation. In some patients, sexual dysfunction may be the presenting symptom of these disorders. Given the multiplicity of possible etiologic factors, it may be difficult to determine how much any given factor is contributing to the problem. A thorough evaluation is necessary for correct identification of the specific cause or causes in any given individual. *NOTE – hypertension has been found to have the highest association with ED. Benign prostatic hyperplasia (BPH) has also a strong association. The cause exact mechanism, however, is unclear.* **The first step** in the management of ED is a thorough history that includes the following: * Sexual history * Medical history * Psychosocial history A physical examination is necessary for every patient, emphasizing the genitourinary, vascular, and neurologic systems. A focused examination entails evaluation of the following: * Blood pressure * Peripheral pulses * Sensation * Status of the genitalia and prostate * Size and texture of the testes * Presence of the epididymis and vas deferens * Abnormalities of the penis (e.g. hypospadias, peyronie plaques) **Management options for ED** include the following: * Sexual counseling, if no organic causes can be found for the dysfunction. Sexual counselling, however, can be used as an ongoing treatment along with other therapies * Oral medications * Injected, implanted, or topically applied medications * External vacuum and constriction devices * Surgery (penile prosthesis, vascular surgery)

Answer 3

**Correct Answer Is C.** The scenario, describes a condition of 2-year duration, with social withdrawal as the initiating event (dropping grades and poor school performance), refusing to home-learn, unkempt appearance, and more importantly conversations with an imaginary individual that is a strong pointer towards hallucinations. These features are characteristic of schizophrenia as the most likely diagnosis. To establish the diagnosis of schizophrenia the following criteria should be met: Two (or more) of the following symptoms: * Hallucinations * Delusions * Disorganized speech * Grossly disorganized or catatonic behavior * Negative symptoms **AND** * The symptoms are severe enough to cause significant social or occupation disability **AND** * The symptoms have lasted for at least 6 months **AND** * Other psychotic conditions such as schizophreniform disorder, brief psychotic episode, etc. are excluded **AND** * Drugs or medical conditions as the cause of symptoms are excluded **AND** * The condition could not be solely attributed to pervasive developmental disorders such as autistic disorders This young man's conversations with imaginary represents hallucinations. His lack of motivation, isolation, and poor self-care are examples of negative symptoms for 2 years or more. He has been like this for more than 6 months now and there is marked social or occupational dysfunction as evidenced by his poor school performance. These fulfill the criteria for schizophrenia as the diagnosis. (**Option A**) Major depressive disorder can present with psychotic symptoms occurring in the context of a major depressive episode. The patient's history does not suggest major depression. He has had 2 years of negative symptoms followed by positive symptoms, suggesting schizophrenia rather than major depression. (**Option B**) A medical or substance-related condition is always among the differential diagnoses in patients with psychotic features. There is no hint about a medical condition as the underlying cause in the scenario, and it is unlikely that substance abuse of a teenager who lives with his parents goes unnoticed for 2 years. (**Option D**) Brief psychotic disorder can share many features with schizophrenia. The distinctive feature; however, is the symptoms duration of less than one month with eventual return to premorbid functioning. **(Option E**) Although schizophreniform disorder shares many features with schizophrenia, the symptoms last no longer than 6 months in schizophreniform disorder.

Answer 4

**Correct Answer Is C.** Of the given options, previous ECT sessions are the most appropriate and justifying explanation to this man’s current problem that is forgetting past events i.e. retrograde amnesia. Electroconvulsive therapy (ECT) is a treatment option for several psychiatric conditions. Major depression associated with psychotic features, strong suicidal ideation, unresponsiveness to other therapies and previous favorable response to ECT are the most frequent indications. Most patients report some adverse cognitive effects during and after a course of ECT. The incidence depends upon electrode placement, stimulus type and dose, anesthesia, and the patient's pretreatment cognitive status. A systematic review found four studies in which the proportion of patients who reported any memory loss ranged from 51 -79%. **ECT can cause three types of cognitive impairment**: **Acute confusion** - the acute confusional state is the result of both the seizure and the anesthesia. It typically resolves 10 to 30 minutes after the procedure. **Anterograde amnesia** - anterograde amnesia is the decreased ability to retain newly acquired information. It occurs during a course of ECT and typically resolves within two weeks after completing the course. **Retrograde amnesia** - retrograde amnesia is defined as forgetting recent memories and is the most anxiety-producing and frightening cognitive effect of ECT. The affected memories are for events that occur during the course of ECT and a period of weeks to a few months prior to that. The deficits are greatest and most persistent for knowledge about public or world events compared with knowledge about the self (personal memory). Bilateral ECT causes more retrograde amnesia than right unilateral. Retrograde amnesia recovers more slowly than anterograde amnesia. Some of the lost memories of events prior to the course of ECT may be expected to return, while others may not. (**Option A**) Although dementia starts by disorientation, typically first to places, this man is young for dementia, and while dementia in a first-degree relative can be risk factor, a demented cousin does not appear to be of importance. (**Options B and E**) Neither the history of depression in itself, nor a relapse of depressive episode justifies dementia. (**Option D**) In Déjà vu is the sense familiarity with unfamiliar things. For example the patient feels that he/she has been in place before while he/she has not. This is not the case here.

Answer 5

**Correct Answer Is D.** Anorexia nervosa is characterized by failure to maintain a normal body weight, fear of weight gain and preoccupation with a distorted body image and unrealistic self-evaluation as overweight. There are two types: **(1) restrictive** and **(2) binge eating/purging.** In restrictive type, the patient strictly reduces food intake and maintains diets of low-calorie foods. In purging type, weight loss is achieved through vomiting, laxatives, diuretics, or enemas. Clinical manifestations of anorexia nervosa are mostly related to prolonged starvation and malnutrition, and include: * Hypothermia * Acrocyanosis * Resting bradycardia (resting heart rate often 40-49 beats per minute) * Hypotension * Orthostatic lowered blood pressure or pulse * Loss of muscle mass * Low blood glucose (impaired insulin clearance) * Low parathyroid hormone levels * Elevated liver function tests * Low white blood cell (WBC) count Since eating disorders are clinical diagnoses, no definitive diagnostic tests are available for anorexia nervosa; however, with negative impacts of starvation on different multiple organ systems, the following basic tests should be performed for every patient with anorexia nervosa as baseline tests: * Physical and mental status evaluation * Full blood exam (FBE) and ESR * Metabolic panel (Na, K, Bun, urea, Cl, BS, HCO3) * Urinalysis for ketones and specific gravity * Liver function tests * Pregnancy test (in patients of childbearing age) Both dehydration and increased fluid intake can occur in anorexia nervosa, leading to electrolytes imbalances with negative impacts on cardiac conduction system, central nervous system, etc. Therefore, electrolyte assessment (**option A**) should be considered in all patients with anorexia nervosa and bulimia nervosa. Cardiac problems is the leading cause of death in patients with anorexia nervosa and an ECG (**option E**) should be obtained in all such patients as a very important basic assessment. In anorexic patients with BMI less than 14kg/m2, an echocardiography is mandated. Urinalysis (**option B**) is another component of basic assessment. Specific gravity reflects hydration status, and ketonuria indicates starvation. Prolonged starvation has deleterious effects on liver function; hence, liver function tests (**option C**) are indicated as basic investigations in all patients with anorexia nervosa. Patients with anorexia nervosa and bulimia nervosa may have central hypogonadism and estrogen deficiency. Estrogen deficiency can result in osteopenia and osteoporosis. A Bones scan (DXA scan) is indicated for all patients with anorexia nervosa of longer than 6 months duration; this test however is not among base line investigations. It can be considered later in the course of management.

Answer 6

**Correct Answer Is E.** Features of mania versus hypomania is summarized in the following table: See table below. Elevated mood is seen both in mania and hypomania and does not help to differentiate between these two. Mania versus hypomania is the parameter by which bipolar disorder is classified into I and II. Patients with mania are calssified as bipolar I disorder, whereas those with hypomania are labeled as having bipolar II disorder.

Answer 7

**Correct Answer Is B.** The case scenario describes a typical case of bulimia nervosa, indicated by binge eating, compensatory behavior to lose weight, and normal BMI that differentiates it from binging/purging type of anorexia nervosa. There is no consensus on the causes of eating disorders. A combination of genetic, biologic, psychological, family, environmental, and social factors probably contribute to developing an eating disorder. Factors associated with the development of eating disorders include: * Genetics – genetic factors are involved in the pathogenesis of eating disorders. As an example, concordance for either anorexia nervosa or bulimia nervosa is greater in monozygotic twins compared with dizygotic twins. * Family distress – family characteristics associated with eating disorders may include high perceived parental expectations for achievement and appearance, families who communicate poorly, have members who are enmeshed with or estranged from each other, devalue the mother or maternal role, have marital tension, or have difficulty managing conflicts. * Sexual abuse * History of dieting * Preoccupation with a thin body and social pressure about weight * Athletic and artistic endeavors such as running, ballet, etc. that emphasizes leanness, and sports in which scoring is partly subjective (e.g., skating or gymnastics) Of the given options, sexual abuse is the most important risk factor for development of eating disorders, as well as other psychiatric conditions such as substance abuse, depressive disorders, and anxiety disorders. Sexual abuse can have many different effects on eating habits and body image of survivors. Sexual abuse violates the boundaries of the self so dramatically that inner sensations of hunger, fatigue, or sexuality become difficult to identify. Victims of sexual abuse may turn to food to relieve a wide range of different states of tension unrelated to hunger. It is their confusion and uncertainty about their inner perceptions that leads them to focus on the food. Many survivors of sexual abuse often work to become very fat or very thin in an attempt to render themselves unattractive. In this way, they try to de-sexualize themselves. Other survivors obsessively diet, starve, or purge to make their bodies “perfect.” A perfect body is their attempt to feel more powerful, invulnerable, and in control, so as not to re-experience the powerlessness they felt as children. Several studies have found that childhood trauma such as childhood sexual abuse is a risk factor for onset of bulimia nervosa as well as discontinuation of psychotherapy for bulimia nervosa; In addition, a history of childhood maltreatment in patients with bulimia nervosa is associated with comorbid depressive disorders, anxiety disorders, and borderline personality disorder. In all eating disorders, there is an increased genetic heritability and frequency of a family history. A family history of ‘leanness’ or ‘thinness’ or 'elite athleticism' (**option D**) may be associated with anorexia nervosa, whereas bulimic eating disorders are associated with a personal or family history of obesity (**option C**). Although these risk factors are specific to anorexia nervosa and bulimia nervosa, they are less likely to trigger the eating disorder compared to sexual child abuse. Substance abuse (**option E**) for weight reduction has been frequently observed among patients with anorexia nervosa and bulimia nervosa as a consequent of the disorder, but not as an underlying etiology. Alcohol abuse (**option A**) does not seem to increase the risk of developing anorexia/bulimia nervosa.

Answer 8

Correct Answer Is B Of the given options, sexual abuse is the most important risk factor for development of bulimia nervosa, anorexia nervosa and other eating disorders, as well as other psychiatric conditions such as substance abuse, depressive disorders, and anxiety disorders. Sexual abuse can have many different effects on the eating habits and body image of survivors. Sexual abuse violates the boundaries of the self so dramatically that inner sensations of hunger, fatigue, or sexuality become difficult to identify. Victims of sexual abuse may turn to food to relieve a wide range of different states of tension unrelated to hunger. It is their confusion and uncertainty about their inner perceptions that leads them to focus on the food. Many survivors of sexual abuse often work to become very fat or very thin in an attempt to render themselves unattractive. In this way, they try to desexualize themselves. Other survivors obsessively diet, starve, or purge to make their bodies “perfect.” A perfect body is their attempt to feel more powerful, invulnerable, and in control, so as not to re-experience the powerlessness they felt as children. Several studies have found that childhood trauma such as childhood sexual abuse is a risk factor for onset of bulimia nervosa as well as discontinuation of psychotherapy for bulimia nervosa. Studies show the connection between childhood sexual abuse and anorexia nervosa is not as strong as that observed in bulimia nervosa; however, child sexual abuse remains a very important risk factor for all eating disorders including anorexia nervosa. Two studies showed that a history of childhood sexual abuse was present in 47-50% of patients with bulimia nervosa and a less strong connection between childhood sexual abuse and anorexia nervosa when compared with that of bulimia nervosa (23-27%); In addition, a history of childhood maltreatment in patients with bulimia nervosa is associated with comorbid depressive disorders, anxiety disorders, and borderline personality disorder. In all eating disorders there is an increased genetic heritability and frequency of a family history. A family history of ‘leanness’ or ‘thinness’ or 'elite athleticism' (option D) may be associated with anorexia nervosa, whereas bulimic eating disorders are associated with a personal or family history of obesity (option C). Although these risk factors are specific to anorexia nervosa and bulimia nervosa, they are less likely to be trigger the eating disorder compared to sexual child abuse. Substance abuse (option E) for weight reduction has been frequently observed among patients with anorexia nervosa and bulimia nervosa as a consequent of the disorder, but it is not the underlying etiology. Alcohol abuse (option A) does not seem to increase the risk of developing anorexia/bulimia nervosa.

Answer 9

Correct Answer Is D Given the symptoms and their duration, a normal grief reaction is the most likely explanation to this woman’s problem. Sadness, despair, tearfulness, decreased sleep, decreased appetite, and decreased interest in life and the world are present as common findings in normal grief reaction. Visual and auditory hallucinations of the deceased person are common and may lead the bereaved person to fear he or she is ‘going crazy’. Guilt and shame are not common in normal grief reaction, yet possible. Suicidality is not usually a concern Patients with normal grief reaction return to normal social functioning within 2 months; the symptoms, however, might last up to one year with waxing and waning. Conventional support (e.g., family, social, religious, social) are usually sufficient to help the patient over her grief. Although there is normally little place for pharmacotherapy, anxiolytics and hypnotics can provide prompt relief where indicated due to excessive insomnia and anxiety. A short course of benzodiazepines (< 7 days) can be used to help with the insomnia and anxiety. The patient has no psychotic feature necessitating antipsychotics such as olanzapine (option C). Antidepressants such as venlafaxine (option A) and citalopram (option E) might be indicated in patients with complicated grief or grief associated with major depression, none of which is the case here. ECT (option B) might very infrequently be indicated in selected patients with complicated grief reaction.

Answer 10

Correct Answer Is A Patients with longstanding anorexia nervosa (>6 months) are at significantly increased risk of pathological fractures due to osteopenia and osteoporosis caused by malnutrition and estrogen deficiency. Osteopenia and osteoporosis is a complication of long-standing anorexia nervosa. These changes are often treated once anorexia nervosa are successfully treated and adequate weight gain is obtained. Vertebral column is the most common site of pathologic fractures due to osteoporosis. In this patient with long-standing anorexia nervosa, the pain and tenderness over thoracic vertebrae makes compression fracture the most likely diagnosis. Pneumonia (option B), pulmonary embolism (option C), and pericardial effusion (option D) may be associated with referred pain to the back, but there is be no tenderness. Metastatic bone lesions (option E) can cause pathologic fractures; however, with the presence of anorexia nervosa as a significant risk factor on one hand, and no pointers towards an underlying primary malignancy on the other, metastatic bone disease is less likely.

Answer 11

Correct Answer Is A Of the options, bradycardia is the most common finding in patient with anorexia nervosa. (Option B) Sexual characteristics in patients with anorexia nervosa are often absent or underdeveloped depending on time of the onset of the disease. (Option C) Calloused knuckles are seen in patients with binge eating and purging subtype of anorexia nervosa where vomiting induction frequently occurs as a compensatory means. It is not as common as bradycardia. (Option D) Hirsutism is not a feature of anorexia nervosa; rather such patients have lanugo (the fine thin hair covering the body) which is different from hirsutism. (Option E) Cold intolerance (not heat tolerance) is a feature of anorexia nervosa; however, shivering in the cold is not seen). TOPIC REVIEW Different complications associated with anorexia nervosa are as follows: Endocrine/metabolic Menstrual dysfunction Delayed menarche/ secondary amenorrhea Delayed growth and development Regression of secondary sexual characteristics Decreased metabolic rate and decreased resting energy expenditure Appetite and thirst dysregulation Low parathyroid hormone levels Elevated liver function Anemia Hypoglycemia Decreased white cell count Protein-calorie malnutrition Vitamin, mineral and essential fatty acids deficiencies Ketonuria Cold intolerance Depressed immune function Atrophied breasts Musculoskeletal Decreased bone mass Osteopenia Stress fractures Decreased muscle mass Cardiovascular Cardiac arrhythmias ECG abnormalities Bradycardia (HR<60bpm) Hypotension Orthostatic hypotension Decreased left ventricular mass and stroke volume Congestive heart failure Cardiac arrest Peripheral edema Gastrointestinal Parotid and submandibular gland hypertrophy (usually in binge eating/purging type) Delayed gastric emptying Constipation/obstipation Hypoactive bowel sounds Postprandial discomfort, bloating after small meals Psychoneurological Depression Anxiety Structural brain abnormalities/brain tissue loss Impaired concentration Lack of insight Sleep disturbances Dermatological / other Acrocyanosis Lanugo – fine soft hair Xerosis (dry, scaly skin) Brittle hair Hair loss Calloused knuckles (in binge eating/purging type where vomiting induction occurs as a compensatory behavior) Eroded enamel (in binge eating/purging type) Negative signs Normal fundi or visual fields No organomegaly No lymphadenopathy

Answer 12

**Correct Answer Is C.** The following are the investigations to consider in every patients presenting with anorexia nervosa: * Serum electrolytes (**option D**) * Blood urea nitrogen * Serum creatinine * Serum glucose * Serum calcium, phosphorous, and magnesium * Thiamine * Serum albumin * Liver function tests (**option A**) (aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase) * Internationalized Normalized Ratio (**INR**) * Complete blood count (CBC) including differential * Erythrocyte sedimentation rate * Thyroid stimulating hormone (TSH) * Electrocardiogram (ECG) (**option B**) * Urinalysis for specific gravity A dual energy X-ray absorptiometry (DXA) (**option E**) scan is also indicated for all patients with anorexia nervosa of longer than 6 months duration. For this patient with 2-year history of anorexia nervosa, a DXA scan should be performed to assess the presence of osteopenia or osteoporosis. An echocardiography should be performed on all patients with anorexia nervosa with body mass index (BMI) of less than 14 kg/m2. FSH and LH are not diagnostically valuable where diagnosis of anorexia nervosa is clear based on the presence of emaciation in conjunction with self-induced starvation and intense fear of weight gain. In such cases, amenorrhea is the result of the underlying malnutrition and estrogen deficiency (hypopituitary hypogonadism). Measurement of FSH/LH is only indicated if the diagnosis of anorexia nervosa cannot be clinched through physical exams and history and other cause of amenorrhea such as ovarian failure have been considered. *NOTE - If the diagnosis of anorexia nervosa is not clear, other causes that can present with weight loss, malabsorption, or amenorrhea should be investigated.* The following conditions are possible causes to consider: * Neoplasm * Chronic infections (e.g. tuberculosis or acquired immunodeficiency syndrome) * Uncontrolled diabetes mellitus * Hyperthyroidism * Malabsorption syndromes (e.g., celiac disease) * Inflammatory bowel disease * Pregnancy * Primary ovarian failure * Polycystic ovarian syndrome * Pituitary prolactinoma

Answer 13

**Correct Answer Is B**. With chronic alcohol use in this patient, the presentation is most likely due to **alcohol withdrawal syndrome (AWS)**. AWS is characterized by a range of signs and symptoms including tremor, sweating, nausea and vomiting, anxiety, agitation, headache, diarrhea, tachycardia, delirium, perceptual disturbances, tachycardia and hypertension. Seizures occasionally occur. In 50%, there is only one episode of seizure. Clinical presentation begins within the first 6 to 24 hours after last ingestion and typically persists 72 hours, but may last for weeks.When medications are indicated for treatment of AWS, **benzodiazepines are first-line**. **Diazepam 10-20 mg is given orally every 2 hours until symptoms subside or the maximum daily dose of 120mg is reached.** Diazepam can be given on subsequent days if symptoms persist. **In patients with severe liver disease**, however, a **short-acting benzodiazepine** without active metabolite such as **lorazepam or oxazepam** should replace diazepam. Diazepam is first metabolized by hepatic oxidation resulting in production of active metabolite. The drug then undergoes glucuronidation. In the elderly and patients with liver disease, benzodiazepine oxidation is decreased and can results in accumulation of the drug, resulting in excessive sedation and respiratory suppression. **Lorazepam and oxazepam** metabolism is minimally affected by age and liver disease; therefore, these drugs appear to be **safest choices among the various benzodiazepines for treating AWS in the elderly and patients with liver disease.** Haloperidol and droperidol are used when psychotic features or agitation persists despite treatment with benzodiazepine. `NOTE – Benzodiazepines and, to a lesser extent, haloperidol and droperidol, may worsen the symptoms of hepatic encephalopathy.`

Answer 14

Correct Answer Is A Depression is common among patients with ESRD and on dialysis. It is a major cause of treatment withdrawal in such patients. However, sudden decline associated with findings of fever and abdominal tenderness are against depression as the cause of treatment refusal in this patient. This patient’s fever is a pointer towards infection, as is the abdominal tenderness. Infections may cause delirium, especially in aging people. For delirium to be the underlying cause to this presentation, disorientation should be present on examination. Depressed mood (option B) is an unlikely finding in a patient who has been coping well so far, but all of the sudden refuses treatment. Blunted affect (option C), delusions (option D) and hypervigilance (option E) would have been expected in psychotic mental disorders. Such disorders usually have a more insidious onset making them less likely explanations in this scenario.

Answer 15

Correct Answer Is D Many drugs are capable of producing sexual dysfunction. The reported sexual issues by the patients include: decreased libido, erectile or ejaculatory problems, and decreased lubrication in women. The most important drug classes associated with such problems are: antihypertensives, antipsychotics, antidepressants and recreational drugs. Selective serotonin reuptake inhibitors (SSRIs) such as sertraline, fluoxetine, paroxetine, fluvoxamine, citalopram, etc are all well-known to be associated with sexual dysfunction as one of their most prominent adverse effects that could lead to noncompliance. The reported sexual adverse outcomes of SSRIs are: Decreased libido Delayed ejaculation (this effect has been used for treatment of premature ejaculation) Erectile dysfunction Painful ejaculation The issue of sexual dysfunction associated with antidepressants is complex. The problem may be caused by other factors than the medication, while strongly believed otherwise by the patient. There might be an unrecognizable interaction between the drug and psychological effects. Several strategies approaches have been proposed Where the medication is considered drug-induced, several strategies might be tried to reverse the condition including: Dose reduction Switching to another drug from a different drug group Drug holidays However, prescribing a phosphodiesterase type 5 inhibitor such as sildenafil or tadalafil in anticipation of intercourse has become the standard of care for men. In women, these drugs have shown some benefits such as increased lubrication. Switching to other SSRIs such as fluoxetine, fluvoxamine, paroxetine, etc is unlikely to resolve the problem because these drugs are associated with sexual dysfunction as well. Low-dose clomipramine has proven effective in treatment of premature ejaculation. Recent studies suggest that it could have an effect in delayed ejaculation; however, sildenafil remains the standard of care in most patients. ‘NOTE - For patients with depression who develop sexual side effects while on SSRIs, switching to **nafazodone, bupropion, or mirtazapine** is an alternative. These drugs have minimal, if any, impact on sexual function.’

Answer 16

Correct Answer Is C Selective serotonin reuptake inhibitors (SSRIs) such as sertraline, fluoxetine, paroxetine, fluvoxamine, citalopram, etc are all well-known to be associated with sexual dysfunction as one of their most prominent adverse effects that could lead to noncompliance to the treatment from the patients. The reported sexual adverse outcomes of SSRIs are: Decreased libido Delayed ejaculation (this effect has been used for treatment of premature ejaculation) Erectile dysfunction Painful ejaculation Strategies have been proposed for dealing with sexual adverse effects of SSRIs, including: Drug holidays Dose reduction Switching to other antidepressant with minimal or no impact on sexual functioning such as bupropion, mirtazapine, or nafazodone Use of phosphodiesterase type 5 inhibitors such as sildenafil or tadalafil Cognitive behavioral therapy Of these options, however, using a phosphodiesterase type 5 inhibitor such as sildenafil before intercourse has become the standard of care. (Option A) Switching to other SSRIs such as fluoxetine, fluvoxamine, paroxetine, etc is unlikely to resolve the problem because these drugs are associated with sexual dysfunction as well. (Option B) Cessation of sertraline will result in relapse of the recently-controlled depression. (Option D) Decreasing the current dose of sertraline in a patient who has just responded the incremental dose increase due to uncontrolled depressive symptoms is very likely to result in relapse; therefore, not an appropriate option. (Option E) Clomipramine is a tricyclic antidepressant used for treatment of premature ejaculation. Addition of clomipramine will deteriorate delayed ejaculation.

Answer 17

**Correct Answer Is B**. The clinical history of this patient is consistent with acute mania, probably due to bipolar I disorder. Bipolar I disorder is a mood disturbance characterized by manic symptoms of at least one week duration. The symptoms should be significant enough to cause considerable impairment or distress in the level of functioning. Characteristic features of bipolar disorder include: * Persistent abnormally elevated mood lasting for at least one week * Increased self-esteem and grandiosity * Distractibility * Excessive involvement in activities * More talkative than usual – pressured speech is often noticed on examination * Psychomotor agitation * Flights of ideas * Increased sexual activity * Increase in goal-directed activities Of the given options, lithium is the drug of choice for both acute treatment and maintenace therapy. Antipsychotics such as olanzapine, quetiapine (**option E**), risperidone and aripiprazole can be used in combination with lithium or alone for acute mania. Sodium valproate (**option A**) in combination with atypical antipsychotics is an alternative in specific patients. Haloperidole (**option D**) is used for patients with acute manic features, who need sedation. If the patient is not cooperative and acutely agitated, intramuscular haloperidol would be the best initial management. Carbamazepine (**option C**) and some other anticonvulsants has been used as a mood-stabilzer but evidence shows it is less effective than lithium or atypical antipsychotics in management of acute mania in bipolar disorder.

Answer 18

Correct Answer Is D Two points are of diagnostic significance in this case scenario. First is the delusional thought content evident by strongly-held bizarre false beliefs that the patient’s mother married God, and that she is planning to be conceived by him. Second is the presence of auditory hallucinations. These two together makes a psychotic episode the most likely diagnosis. Of the given option, the only one that can represent these is schizophrenia. (Option A) Antisocial personality disorder is characterized by continuous antisocial or criminal acts, inability to conform to social rules, impulsivity, disregard for the rights of others, aggressiveness, lack of remorse, and deceitfulness. There are no delusions or hallucinations, unless caused by another reason. (Option B) Opium abuse is not associated with delusions or hallucinations. (Option C) Acute alcohol intoxication presents varying manifestations depending on the severity, and can include slurred speech, nystagmus, disinhibited behavior, incoordination, unsteady gait, memory impairment, stupor or even coma. Hallucinations and delusions are not typical presentations. (Option E) Borderline personality disorder is often characterised by an unstable affect, mood swings, marked impulsivity, unstable relationships, recurrent suicidal behaviours and self-inflicted injures, chronic feelings of emptiness and boredom, identity disturbances, and inappropriate anger. If they are stressed they may become psychotic. They use splitting as their main defence mechanism.

Answer 19

Correct Answer Is B The behavioral pattern in this woman is most likely due to histrionic personality disorder. Remarkable findings are seductiveness and trying to be charming, exaggeration in paying compliments to you as a person she has met for the first time, and self-centeredness and selfdramatization. Individuals with histrionic personality disorder exhibit emotionalism, which is a tendency to regard things emotionally. They are attention seekers and uncomfortable in situations where they are not the center of attention. Behaviors may include constant seeking of approval or attention, selfdramatization, theatricality (acting out as if they are on the theatre stage), and striking selfcenteredness or sexual seductiveness in inappropriate situations including social, occupational, and professional relationships beyond what is appropriate for the social context. They may be lively and dramatic and initially charm new acquaintances with their passion, enthusiasm, apparent openness, or flirtatiousness. Personal interests and conversations will be self-focused. They use physical appearance to draw attention to themselves. Emotional expression may be shallow and rapidly shifting. Their style of speech is excessively impressionistic and lacking in detail. This patient is also using a splitting defense mechanism by seeing all white or black. Although splitting is commonly seen in individuals with borderline personality disorder, other behavioral findings are not consistent with the diagnosis. (Option A) This patient is unlikely to have a narcissistic personality disorder. Although obvious selfcenteredness in this patient may resemble grandiosity, the characteristic feature in narcissistic personality disorder, this personality disorder is associated with condescending behavior, while this woman is trying to be in the center of attention and charming at the same time. This makes histrionic personality disorder more likely. (Option D) Patients with personality disorders do not hallucinate. No hallucinations are evident in the presentation. (Option C) Schizophrenia is characterized by bizarre delusions and hallucinations, mostly auditory, none of which are present in this case. (Option E) A schizotypal personality disorder is characterized by significant difficulty in establishing and maintaining close relationships with others. A person with a schizotypal personality disorder may have extreme discomfort with such relationships. Someone with this disorder usually has cognitive or perceptual distortions as well as eccentricities in their everyday behavior. Individuals with schizotypal personality disorder often have ideas of reference (e.g., they have incorrect interpretations of casual incidents and external events as having a particular and unusual meaning specifically for the person). People with this disorder may be unusually superstitious or preoccupied with paranormal phenomena outside their subculture's norms.

Answer 20

Correct Answer Is C Of the options, borderline personality disorder (BPD) is the best explanation for this scenario. The excessive fear of being abandoned is one of the key features of BPD. These abandonment fears are related to intolerance of being alone and the need to have other people around. Frantic efforts are made to avoid imagined abandonment. Some of these efforts include impulsive actions such as self-mutilating or suicidal behavior. To this woman, discharge conveys abandonment, and she is making every effort to prevent it. (Option A) Narcissistic personality disorder is characterized by a sense of self-importance, grandiosity, and preoccupation with fantasies of success. Someone with this personality disorder believes they are special, require excessive admiration, and reacts with anger when criticized. They lack empathy, are envious of others, and are interpersonally exploitative. (Option B) Histrionic personality disorder is characterized by colorful, exaggerated behavior and shallow expression of emotions. People with this disorder use their appearance to draw attention, are sexually seductive and uncomfortable when they are not the center of attention. (Option D) Factitious disorder is characterized by the conscious production of signs and symptoms of medical or mental disorders with the main objective of assuming the sick role and eventually hospitalization. The motivation behind this behavior is not clear to the patient and occurs at a subconscious level. This patient is not producing any signs or symptoms. (Option E) Malingering is also the conscious production of signs and symptoms, but unlike factitious disorder, a clear gain such as money, avoidance of work, free bed and board, etc. is intended. Again, this patient is not producing any signs or symptoms. NOTE – although not an option, dependent personality disorder (DPD) can be another diagnosis. Individuals with DPD are preoccupied with the need to be taken care of. They have clinging behavior and are unrealistically worried about abandonment. They feel inadequate and helpless and avoid disagreements with others. They usually focus dependency on a family member or spouse and desperately seek substitutes if this person becomes unavailable. Associated features include self-doubt, excessive humility and humbleness, poor independent functioning, mood disorders, anxiety disorders, adjustment disorder, and other personality disorders. Patients with dependent personality disorder lack opinion and are distressed when they must make decisions for themselves. Studies suggest that over 50% of patients with BPD also meet the criteria for DPD. The prevalence of these comorbidities could owe to the fact that some of the features of DPD are very similar to the features of BPD. For example, people with BPD experience rejection sensitivity. They tend to feel desperate at even the slightest perceived rejection. Individuals with DPD may react similarly to criticism or perceived abandonment by loved ones.

Answer 21

Correct Answer Is A One in five Australian mothers of full-term infants suffers from a perinatal mental health disorder with depression and anxiety being more encountered. Postpartum blues is quite common, but often has a benign and self-limiting course. Postpartum psychosis and postpartum obsessions are other conditions encountered. Psychiatric problems pose both physiologic and psychologic risks to mother and the baby. Therefore, it is of paramount importance to check for the presence of such conditions in perinatal period. Depression and anxiety are common in postnatal period and are associated with poor parenting and attachment and adverse outcomes. Interestingly, many postnatal women will not identify themselves as depressed or anxious; rather they may visit for “other” reasons such as an inconsolable or unsettled babies (such as in this case). In such cases, healthcare professionals such as GPs or Child Health Nurses should routinely inquire about mood, anxiety, and how the woman is coping, and if deemed necessary, use Edinburgh Postnatal Depression Scale (EPDS) questionnaire as a screening tool. Marital conflicts, support from husband or partner, or other issues that might have triggered or exacerbated such a psychological breakdown should be inquired judiciously if indicated, but probing for mood problems, anxiety or other psychiatric issues take precedence over such matters. Previous attitude is another important point to be taken into consideration during evaluation. A woman may have a previous history of depression or anxiety posing her at greater risk of recurrences, but more important is her current condition. Weight loss, anorexia and decreased sleep time are frequently seen in depressed persons. Weight gain, an increase in appetite and increased sleep time are atypical features in some depressed patients, the presence of which is associated with an unfavorable outcome. Weight changes may be seen in depression, but it could be also physiologic or caused by other medical conditions. NOTE – Frequent visits to the GP or obstetrician can signal underlying depression. Common signs and symptoms of mental health problems which can be used to guide questioning at clinical interview include the following: Depressed / irritable / anxious mood most of the day nearly every day Mood swings Loss of interest, pleasure or motivation in usual activities Problems with thinking clearly, concentration, memory, making decisions Negative thoughts (death, disaster) Suicidal ideation or plans Feelings of worthlessness or guilt; low self-esteem Unusual change in weight or appetite Significant change in sleep Significant fatigue or loss of energy Significant speeding up or slowing down of psychomotor activity Excessive anxiety, panicky feelings, worry or rumination Avoidance (of people, places, things, activities) Misuse of alcohol or other substances Very unusual behavior or thinking: psychotic symptoms

Answer 22

**Correct Answer Is C** The history is completely consistent with postpartum obsessions as the most likely diagnosis. Women are at increased risk for obsessive-compulsive disorder (OCD) during or following pregnancy, including new-onset OCD, recurrent OCD, or exacerbation of a chronic OCD. The obsessional thinking and compulsive behaviors often focus on the pregnancy or baby. In postpartum period, obsessive thoughts or mental images of harming and fears of contamination of the baby are common. Examples of such thoughts or images include dropping the baby onto the floor, drowning the baby in bathtub, throwing the baby out of the window ,crushing the baby’s skull, microwaving the baby, etc. Prenatally, obsessions are often about fears of fetal death or contamination. An example of contamination is a mother's belief that she is infected and if she continues the pregnancy, the infection will pass on to her baby too. Compulsive behaviors may include the mother’s repeated requests for ultrasound to check fetal well-being prior to birth, or subsequent avoidance of touching the baby, or repeated washing or hanging diapers. Other examples are shown in the following table: By definition, patients with OCD have insight into their obsessions, recognizing them as intrusive and inappropriate, like in this women, by describing her thoughts as ‘silly’; however, their degree of insight can vary. When severe obsessive thoughts persist over a long period of time, they can resemble fixed delusional thinking. On very rare occasions, these thoughts can progress to psychosis, and the patient believes the ideas/thoughts are real. ``` NOTE - The likelihood that aggressive obsessions toward the baby results in harmful behaviors in not known, but generally is believed to be very small. ```

Answer 23

Correct Answer Is B Of the options, lithium is both the most effective and safest medication to be used for treatment of acute mania during pregnancy. Despite recent controversy about lithium’s efficacy, a series of meta-analyses confirms its value for both acute episodes and for prophylaxis, and lithium remains the cornerstone of therapy in patients with bipolar disorder (BPD). Although lithium use during the first trimester of pregnancy has been reported to be associated with fetal cardiovascular anomalies (e.g. Epstein’s anomaly) and midfacial and other defects, maternal benefits substantially outweigh the risks of fetal anomaly. Generally speaking, lithium can be used rather safely during all trimesters of pregnancy. However, if a pregnant woman has been exposed to lithium during the first trimester, an ultrasound and echocardiogram should be performed at 16-20 weeks gestation to exclude fetal anomalies, especially cardiac ones. Lithium is even safer during the second and third trimesters, because cardiogenesis has already occurred and the risk of fetal malformations is significantly decreased. If lithium has been tapered during the first trimester or before the conception, it can be safely resumed in second or third trimester if indicated. Lithium requirements increase in the third trimester; however, dose reduction by 25% is recommended before delivery to prevent possible neonatal toxicity that can present with a floppy baby syndrome (hypotonia, cyanosis, poor suckling). The dose should then be increased after delivery. NOTE - Lithium is contraindicated in breast-feeding women. Renal clearance of lihtium in infant is low and may result in high levels of lithium and life-threatening toxicity. (Option A) With a few exceptions, the quality of the randomized controlled trials (RCTs) of carbamazepine in acute mania has been surprisingly poor; therefore, it is not an appropriate option for treatment of acute mania in this patient. (Option D) Sodium valproate has significant teratogenic effect and should be avoided during pregnancy. (Options C and E) Clozapine or mirtazapine is not indicated or useful for treatment of an acute manic episode in bipolar disorder. NOTE – A recent meta-analysis has confirmed that the most efficacious acute treatments for mania are the antipsychotics rather than the traditional ‘mood stabilizers’ lithium, valproate and carbamazepine. Specifically, that report found that the preferred options – after taking into account both efficacy and tolerability – were risperidone, olanzapine and haloperidol. An added benefit of haloperidol in acute management of a pregnant woman is the rapid-onset therapeutic effect compared to a delayed effect of other mood stabilizers. These drugs, on the other hand, are associated with potential adverse effects such as metabolic syndrome with olanzapine and extrapyramidal side effects with haloperidol, requiring a careful balance between risks and benefits, often in consultation with an expert in the field. Generally, where antipsychotics (as mentioned above) are among options, it is safest to choose them as the preferred treatment options and correct answer for a pregnant woman, especially during the first trimester.

Answer 24

Correct Answer Is B Of the given options, lithium is the only acceptable one in terms of both safety and efficacy during pregnancy. However, it is contraindicated in breast feeding woman because reports suggest that there is low renal clearance of lithium in infants resulting in toxic levels of lithium. This may result in life-treathening infantile complications. Reportedly, lithium use during the first trimester of pregnancy has been associated with cardiovascular anomalies (e.g. Epstein’s anomaly), midfacial defects, and other defects; nonetheless, the benefits to the mother substantially outweigh the risks of fetal anomaly. However, if a pregnant woman has been exposed to lithium during the first trimester, an ultrasound and echocardiogram should be performed at 16-20 weeks gestation to exclude fetal anomalies, especially cardiac ones. Lithium is even safer during the second and third trimesters when cardiogensis has already occurred and the risk of fetal malformations is significantly decreased. If lithium has been tapered during the first trimester or before the conception, it can be safely resumed in second or third trimester if indicated. Lithium requirements increase in the third trimester; however, dose reduction by 25% is recommended before delivery to prevent possible neonatal toxicity presenting with floppy baby syndrome (hypotonia, cyanosis, poor suckling). The dose should then be increased after delivery. (Option A) Carbamazepine has been shown poor efficacy in controlling an acute manic episode in bipolar disorder. (Options C and E) Clozapine or mirtazapine is not indicated or useful for treatment of an acute manic episode in bipolar disorder. (Option D) Sodium valproate has significant teratogenic effect and should not be used during pregnancy. NOTE - A recent meta-analysis has confirmed that the most efficacious acute treatments for mania are the antipsychotics rather than the traditional ‘mood stabilizers’ lithium, valproate and carbamazepine. Specifically, that report found that the preferred options – after taking into account both efficacy and tolerability – were risperidone, olanzapine and haloperidol. An added benefit of haloperidol in acute management of a pregnant woman is the rapid-onset therapeutic effect compared to a delayed effect of other mood stabilizers. These drugs, on the other hand, are associated with potential adverse effects such as metabolic syndrome with olanzapine and extrapyramidal side effects with haloperidol, requiring a careful balance between risks and benefits, often in consultation with an expert in the field. Generally, where antipsychotics (as mentioned above) are among options, it is safest to choose them as the preferred treatment options and correct answer for a pregnant woman, especially during the first trimester or if the woman desires to breastfeed.

Answer 25

Correct Answer Is D Postpartum period is a critical time during which a woman is at increased risk of emotional challenges. The risk is particularly higher in those with bipolar disorder. In such women, postpartum period is the time they may experience exacerbations of bipolar disorder in forms of mania, depression and psychosis. Recurrence rate of BPD in the first 3 to 6 months is 20-50%. Recurrence rates without treatment may be as high as 70%. Symptoms often develop rapidly and may occur in late pregnancy or within the first few days to weeks after delivery. Lithium has been classically used for treatment of both manic and depressive espisodes as well as maintenance therapy in patients with bipolar disorder. It is considered safe for use in pregnant women, especially in the second and third trimesters of pregnancy. There are concerns regarding Epstein anomaly as well as other congenital defects if used in the first trimester. The absolute risk is insignificant though. Recently, haloperidol, risperidone and olanzapine have been proved more effective than lithium and other mood stabilizers for acute treatment of mania in bipolar disorder. There are concerns of adverse effects such as extrapyramidal effects of haloperidol as a firstgeneration antipsychotic and weight gain and metabolic derangements with risperidone and olanzapine as atypical antipsychotics. Sodium valproate is another drug used for treatment of manic episodes in bipolar disorder; however, it is not an effective treatment if psychotic features such as hallucinations or delusions are present. On making a decision as to whether which drug is prescribed, the clinician should balance risks and benefits of each, often in consultation with an expert in the field, and also consider specific circumstances such as pregnancy and breastfeeding. Of the options, sodium valproate is the only accpetable one for treatment of this patient. It hase been proven as efficacious as lithium for acute management of mania. Although its use is contraindicated in pregnancy, it can be effectively used in breastfeeding women. However, if there are psychotic features such as delusions or hallucinations, sodium valproate will not be an appropriate option either. (Option A) Thus far, carbamazepine has not been shown to be associated with harm to the breastfed baby, but studies suggest it is not more effective than placebo in management of an acute manic episode. (Options B and C) Lithium and clozapine are absolutely contraindicated in breastfeeding women. Furthermore, clozapine is not recommended or approved for treatment of mania, depression or maintenance therapy for bipolar disorder. (Option E) Lamotrigine has being increasingly used to prevent relapses of bipolar depression; however, the effects for treatment or prevention of manic episodes are minimal. It is also secreted in breast milk and should not be used in breastfeeding woman due to lack of data regarding its safety profile. NOTE - If a pregnant woman has been stable on lithium or another mood stabilizer or antipsychotic, with no contraindication in pregnant women, but not recommended during breastfeeding, withdrawal from the drug or switching to another drug that is safe in breastfeeding is not advisable, as any alteration in medication(s) may result in relapse of bipolar disorder. In such circumstance, the most appropriate approach is continuation of the drug, avoiding breastfeeding, and feeding of the baby with formula.

Answer 26

Correct Answer Is B The patient seems to have some characteristic features of a manic episode. According to DSM-IV, diagnostic criteria for a manic episode include: A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if the symptoms are severe enough to result in hospitalization). B. during the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood only irritable) and has been present to a significant degree: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (e.g. feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli) 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The symptoms do not meet criteria for a Mixed Episode. D. The mood disturbance is sufficiently severe to cause marked impairment in occupational or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. E. the symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication or other treatments) or a general medical condition (e.g. hyperthyroidism). NOTE - Manic-like episodes that are clearly caused by somatic antidepressants treatment (e.g. medication, light therapy) should not count toward a diagnosis of bipolar disorder. The patient’s symptoms do not appear to be severe enough to need hospitalization and the duration of the symptoms has not lasted for at least 7 days; therefore, hypomania will be the most likely diagnosis for now. A hypomanic episode has the same symptoms of a manic episode with 2 important differences: 1. The mood disturbances usually are not severe enough to cause problems with the person working or socializing with others, or to require hospitalization 2. There is no psychotic feature A hypomanic episode is characterized by a distinct period of persistently elevated, expansive, or irritable mood, lasting at least 4 days and present for most of the day nearly every day. This hypomanic mood is clearly different from the person’s usual mood. (Option A) In this scenario, engagement in excessive cleaning is different from what happens in obsessive-compulsive disorder which is repetitive cleaning (that might not be excessive). Obsessive-compulsive disorder (OCD) is characterized by recurrent intrusive thoughts, images, or urges (obsessions) that typically cause anxiety or distress, and by repetitive mental or behavioral acts (compulsions) that the individual feels driven to perform, either in response to an obsession or according to rules that he or she believes must be applied rigidly. (Option C) Some symptoms of hypomania overlap with those of histrionic personality disorder, including shallow emotions and flirtatiousness. However, flirting in hypomania is due to increased sexual drive, whereas, flirting in histrionic personality disorder is for attention seeking without any intention for sex. Features of a person with histrionic personality disorder include being selfdramatic, egocentric, immature, seductive and attention seeking. (Option D) Features of passive-aggressive personality disorder include childish stubbornness, argumentativeness, egocentricity, deliberate inefficiency, and hypercriticism of authority figures. The scenario is not consistent with passive aggressive personality disorder. (Option E) A minimum duration of 7 days is required for symptoms in order to make a diagnosis of mania. With symptoms present for only 4 days this patient has hypomania for now.

Answer 27

**C. Olanzapine** The scenario fulfills the classic definition of **hypomania**. In fact this woman can have her first hypomanic episode of a bipolar disorder (type II) disorder. A hypomanic episode is characterized by a distinct period of persistently elevated, expansive, or irritable mood, lasting throughout **at least 4 days** and present for most of the day nearly every day. This hypomanic mood is clearly different from the person’s usual mood. **Features seen in hypomania (as well as mania) include inflated self-esteem and grandiosity, decreased need for sleep, more talkativeness than usual and pressures speech, distractibility, increased goal-directed activities, increased sexual drive, and excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). ** Hypomania is distinct from mania by milder magnitude of symptoms and less interference with level of social and/or occupational. **Patients with hypomania are unlikely to require hospitalization.** Some symptoms of hypomania overlap with those of histrionic personality disorder, including shallow emotions and flirtatiousness. However, flirting in hypomania is due to increased sexual drive, whereas flirting in histrionic personality disorder is for attention seeking without any intention for sex. In this scenario, engagement in excessive cleaning is different from what occurs in obsessive compulsive disorder which is repetitive cleaning (that might not be excessive). `For patients with hypomania and mild to moderate manic episodes, monotherapy with risperidone or olanzapine is currently the first-line recommendation.` Reasonable alternatives are lithium, sodium valproate, carbamazepine, aripiprazole, quetiapine, ziprasidone and haloperidol. (Options A and D) According to a recent metanalysis, the antipsychotics risperidone and olanzapine are superior to lithium or carbamazepine for treatment of acute mania. Lithium, however, may be added for maintenance therapy. (Option B) Lamotrigine is an anticonvulsant successfully used for prevention of depression episodes in patients with bipolar disorder. Its effect in treatment or prophylaxis of mania or hypomania has not proved satisfactory. (Option E) Benzodiazepines are considered in manic patients who cannot tolerate any of other mood stabilzers. With the wide range of mood stabilizers available, monotherapy with benzodiaepines is almost never indicated; however, lorazepam and clonazepam are used in short term and in combination with mood stabilizers for rapid resolution of mania. Diazepam is not used for such purpose.

Answer 28

**E. Decrease alcohol intake.** Body dysmorphic disorder is characterized by the belief that some body part is abnormal, defective, or misshapen. Patients are preoccupied with an imagined defect in their appearance or excessive concern about even the slightest physical anomaly. This preoccupation causes significant distress or impairment in social, occupational, or other areas of function. This disorder affects women more than men, typically between ages of 15 and 20 years. The characteristic features of body dysmorphic disorder are as follow: * Preoccupation with alleged physical flaws - of all body parts, imagined facial flaws are most common * Constant mirror checking * Attempt to hide the imagined deformity * Housebound and avoiding social situations * Impaired levels of functioning The following comorbid conditions are often found as an association with body dysmorphic disorder: * Depression * Delusional disorders * Obsessive compulsive disorder * Social phobia * **Increased alcohol intake** Body dysmorphic disorder is not associated with decreased alcohol intake.

Answer 29

**B. Generalized anxiety disorder.** The scenario is a typical presentation of general anxiety disorder (GAD). GAD is characterized by experiencing excessive anxiety and worry, often about health, family, financial issues, or work. This worrying goes on every day, possibly all day long. It negatively interferes with social activities and is associated with impaired function at work, school, or family. GAD is diagnosed in adults when they experience at least **3 of the following** symptoms on more days for **at least 6 months**: * Restlessness or feeling keyed up or on edge * Being easily fatigued * Difficulty concentrating or mind going blank * Irritability * Muscle tension * Sleep disturbance (difficulty falling or maintaining, unrefreshing sleep, etc.) To make the diagnosis in children, only one symptom is required. (Option A) Major depression is associated with depressed mood which is not present in this woman. However, depression and dysthymic disorder can be seen in patients with GAD. (Option C) For adjustment disorder to be the diagnosis, one provocative event should be present. There is no recent stressor in the history. (Option D) Dysthymic disorder is characterized by *mild to moderate symptoms of depression lasting for at least 2 years.* (Option E) OCD is associated with obsessions and impulse. There is no clue in the history to suggest such diagnosis.

Answer 30

**E. Start risperidone immediately after delivery.** With either of the following conditions present in history, a woman is at increased risk of postpartum psychosis: * History of postpartum psychosis * History of bipolar disorder * Family history of postpartum psychosis * First pregnancy * Recent discontinuation of lithium or other mood stabilizers The risk of recurrence in woman with previous postpartum psychosis is high in subsequent pregnancies. **The period during which the recurrence risk of post-partum psychosis is the highest, is the first 28 days after delivery. The symptoms generally appear within days or even hours of delivery.** `It is strongly recommend that, in a woman with history of post-partum psychosis, prophylactic mood-stabilizers be started immediately after delivery to prevent relapse.` Choice of mood stabilizer depends on different factors including breastfeeding, or previous response. **Aida had desirable response to risperidone in the past**; therefore, commencement of risperidone immediately after delivery would be the most appropriate option for her. Risperidone has not been associated with increased risk to the breastfed baby; however, the data are limited. This approach prevents unnecessary treatment of an asymptomatic woman and potential adverse outcomes associated with psychotropic medications. (Option A) This woman should also be closely monitored for development of psychiatric problems throughout pregnancy; however, this does not prevent postpartum psychosis. (Option B) Antidepressants, either therapeutically or prophylactically, have no effect on postpartum psychosis. A mood stabilizer is indicated in such situations. (Option C) In an asymptomatic woman, who is currently stable, initiation of prophylactic treatment is not likely to be of significance benefit compared to immediately after delivery. (Option D) With a **high recurrence rate** as high as 30-50%, waiting for the postpartum psychosis to develop as an indication for starting treatment is not appropriate and prophylactic measures should be contemplated.

Answer 31

**E. High educational achievements.** The genetic linkage in schizophrenia is well-established. Although schizophrenia appears to be multifactorial, genetics plays a significant role. Winter births are statistically associated with increased occurrence of schizophrenia. This fact may augment the hypothesis that schizophrenia may be associated with viral infections. Antenatal and perinatal complications such as hypoxia, neonatal sepsis, neonatal jaundice, etc are associated with increased risk of schizophrenia. Advanced parental age at conception is associated with increased risk of development of schizophrenia in offsprings. High educational achievements are not risk factors for schizophrenia. In fact, they are **protective against schizophrenia**.

Answer 32

**B. Schizotypal personality disorder.** This patient's clinical and historical features are suggestive of schizotypal personality disorder. Schizotypal personality disorder is characterized by significant discomfort in social relationships; thought distortions, and eccentricity. Individuals with this disorder are **socially isolated and uncomfortable with others**. **The most differentiating feature of this disorder from schizoid personality disorder is the presence of particular patterns of thinking such as ideas of reference, persecution, and magical thinking that are absent in schizoid personality disorder.** **Bizarre preoccupations, odd affection, and peculiar speech** are other features. **Eccentric attire** is another commonly observed feature. (Option A) Schizoid personality is characterized by social withdrawal, isolation, and emotional coldness. Affected individuals usually remain absorbed and sunken in their thoughts and feelings. They fear closeness and intimacy with other people. They prefer theoretical speculations (such as math and physics) to practical action. However, the thinking pattern is normal. (Option C) Paranoid individuals find offense in even the most benign remarks or circumstances. These individuals are often defending an extremely fragile self-concept. (Option D) A person with an avoidant personality disorder is interpersonally sensitive, is afraid of being criticized, and is constantly concerned about saying or doing something foolish or humiliating. They have an intense desire to connect with others; however, they will never let anyone get close unless they are sure of being liked. (Option E) Individuals with dependent personality disorder are passive, submissive, and have the fear of abandonment. They need constant reassurance. Dependent patients assume that they are incapable of functioning independently and that being assertive will be experienced by others as aggressiveness.

Answer 33

**A. Selective serotonin re-uptake inhibitors.** Obsessive-compulsive disorder (OCD) is characterized by recurrent obsessions or compulsions that are recognized by the individual as unreasonable.There are two components in OCD: * Obsessions: obsessions are anxiety provoking, intrusive thoughts, commonly concerning contamination, doubt, guilt, aggression and sex. * Compulsions: peculiar behaviors that reduce the anxiety such as hand washing, organizing, checking, counting, etc. **Abnormalities of serotonin metabolism are most implicated as the underlying cause of OCD.** The prevalence is 2% in general population, and there is a 1:1 male-to-female ratio. The onset is insidious and occurs during childhood, adolescence, or early adulthood. The symptoms are usually of waxing and waning nature. Comorbid conditions such as depression, anxiety, and substance abuse are frequently seen. OCD is best treated with a specific form of behavior therapy - **exposure and preventive response and/or selective serotonin reuptake inhibitors (SSRIs) as the first-line medications.** All SSRIs have about the same efficacy. The TCA clomipramine has also been used as a treatment option and was the medication of choice before SSRIs take over. `NOTE - Antipsychotics have been shown to add to the benefits of SSRIs or clomipramine. Although adjunctive therapy with antipsychotics may be considered, they are not used for single therapy in OCD.` (Option C) Serotonin norepinephrine re-uptakes inhibitors (SNRIs) e.g., venlafaxine can be used as an alternative, but SSRIs remain the preferred option. (Option B) Among tricyclic antidepressants (TCAs), clomipramine is the only one that seems to have an impact on serotonin metabolism and can be used as *second-line management* in treatment of OCD. The side effects of clomipramine include sedation, urinary retention, confusion, delirium, and hypotension. (Option D) Occasionally benzodiazepines may be considered for anxiety relief in short term, but they are not effective in treatment of OCD. (Option E) Although alcohol consumption is associated with decreased compulsive behavior in short-term, its use is not recommended for treatment of OCD due to the high risk of dependence and abuse.

Answer 34

**B. Family history of obesity.** Based on the history and the BMI, **bulimia nervosa** is the most likely diagnosis. Both bulimia nervosa and binge eating/purging type anorexia nervosa are associated with episodes of binge eating, followed by compensatory purging with laxative or diuretic use, induction of vomiting, etc. Patients with bulimia nervosa, however, tend to have normal weight or even can be overweight. Of the given options, a family history of obesity is the most relevant finding in a patient with bulimia nervosa. In all eating disorders, there is an increased genetic heritability and frequency of a family history. A family history of leanness or athleticism may be associated with anorexia nervosa; whereas **bulimic eating disorders are associated with a personal or family history of obesity.** **Sexual abuse** (not an option) is also a significant risk factor for development of eating disorders as well as a wide range of other psychiatric disturbances. (Option A) Pica is defined as persistent ingestion of nonnutritive substances for at least one month at an age for which this behavior is developmentally inappropriate. Personal or family history of pica has not been shown to be a risk factor for eating disorders. (Option C) Family history of elite athleticism has been proposed as a risk factor for anorexia nervosa. (Option D) Although abnormal eating patterns can be seen in schizophrenic patients, family history of schizophrenia does not appear to be a risk factor for development of eating disorders. (Option E) Substance abuse is a comorbid conditions often noticed in family or personal history of patients with eating disorders; this, however, is less likely to be directly related to development of eating disorders.

Answer 35

**D. Lithium.** The scenario is classic for a **manic episode**. Features seen in mania (as well as hypomania) include inflated self-esteem and grandiosity, decreased need for sleep, more talkativeness than usual and pressured speech, flight of ideas, distractibility, increased goal-directed activities, increased sexual drive, and excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). Hypomania has the same symptoms but with milder intensity. **The presence of delusions in the scenario, however, is consistent with severe mania. In fact, this woman is very likely to have presented with a manic episode of bipolar disorder.** **Mood stabilizers are the cornerstone of management of a manic episode in mild to moderate disease.** Mood stabilizers include, the antipsychotic medication, such as haloperidole, risperidone, aripiprazole, quetiapine, ziprasidone, or lithium, or anticonvulsants such as carbamazepine and sodium valproate. According to a recent meta-analysis, antipsychotics, especially **risperidone, haloperidol and olanzapine (not among options) are recommended as first-line treatment of acute mania in bipolar disorder both in pregnant and nonpregnant patients.** Lithium can be used as well and is the most appropriate option among others, considering the fact that at 20 weeks gestation (second trimester) fetal cardiogenesis has already taken place and the risk of cardiac anomalies, a feared adverse outcome of lithium on the developing fetus, is minimal if any. Reportedly, lithium use during the first trimester of pregnancy has been associated with cardiovascular anomalies (e.g. Epstein’s anomaly), midfacial defects, and other defects; nonetheless, the benefits to the mother substantially outweigh the risks of fetal anomaly. **Lithium is even safer during the second and third trimesters when cardiogenesis has already occurred and the risk of fetal malformations is significantly decreased.** Lithium requirements increase in the third trimester; however, dose reduction by 25% is recommended before delivery to prevent possible neonatal toxicity that can present with a *floppy baby syndrome* (hypotonia, cyanosis, poor suckling). The dose should then be increased after delivery. (Option A) Sodium valproate has major teratogenic effects and is contraindicated throughout the pregnancy. (Option B) Although an atypical antipsychotic, clozapine is not among recommended medications for treatment of mania. (Option C) Benzodiazepines, mostly clonazepam or lorazepam are used as monotherapy for patients with mild to moderate manic or mixed episodes who cannot tolerate lithium, anticonvulsant or antipsychotics. This is very unusual to occur, given the large number of available options for treatment of bipolar disorder. However, benzodiazepines are generally used as adjunctive therapy for treatment of insomnia, anxiety and agitation in patients with elevated mood. (Option E) Carbamazepine is an antiepileptic medication used as a mood stabilizer in treatment of bipolar disorder. Recent studies, however, has questioned its efficacy. There is also concern about teratogenicity pregnancy due to reported cases of neural tube defects.

Answer 36

**A. Explain the pros and cons of lithium use during pregnancy and continue the medication.** Although lithium use during the first trimester of pregnancy has been reported to be associated with fetal cardiovascular anomalies (e.g. Epstein’s anomaly) and midfacial and other defects, benefits to the mother substantially outweigh the risks of fetal anomaly. For pregnant women stable on lithium, one approach can be careful withdrawal of lithium (or other mood stabilizers) to avoid potential risks to the developing fetus. Some authorities discourage this method because of the **risk or relapse**. In this patient, however, the history of **difficult-to-treat bipolar disorder** that has just recently responded to lithium after failed trials of other mood stabilizers makes such approach less favorable. **She should be maintained on lithium to avoid relapse.** In such situations, the woman should be fully informed of the risks, and decision making left to the patient. **If the woman decides to conceive, lithium should be continued throughout the pregnancy and an ultrasound and echocardiogram performed at 16-20 weeks gestation to exclude fetal anomalies, especially cardiac anomalies.** (Option B) Sodium valproate is teratogenic and contraindicated in pregnancy. Switching to sodium valproate can be associated with high risk of relapse as well as more harm to the fetus. (Option C) Lamotrigine is an option for prevention of bipolar depression. It is not effective in prevention or treatment of manic episodes. (Option D) According to a recent meta-analysis, antipsychotics, especially risperidone, olanzapine, and haloperidol are superior to other mood stabilizers such as lithium, sodium valproate, and carbamazepine for treatment of manic episodes and are recommended as first-line options for this purpose, but if the risk of relapse is high, lithium should be used concomitantly for a maintained therapeutic response. While this patient is stable on lithium, switching to withdrawal of lithium and commencement of antipsychotics is likely to result in a relapse. (Option E) As mentioned earlier, stopping medications in a stable patient might be considered, but for this patient such action is can result in a relapse of the disease.

Answer 37

**B. High resolution ultrasound at 16-20 weeks gestation.** The benefits of lithium prophylaxis during pregnancy, in cases of severe bipolar disorder, may outweigh the risks. For pregnant women stable on lithium, one possible approach is careful withdrawal of lithium (or other mood stabilizers) to avoid potential risks to the developing fetus. In this patient with **history of severe relapsing bipolar disorder**, however, **continuation of the treatment has been decided.** Lithium use during the first trimester of pregnancy has been reported to be associated with fetal cardiovascular anomalies (e.g. Ebstein’s anomaly) and midfacial and other defects. Ebstein's anomaly is a cardiac defect characterized by downward displacement of the tricuspid valve into the right ventricle. The absolute risk for Ebstein’s anomaly associated with lithium use in the first trimester is approximately 1 in 1000 to 2000 compared with 1 in 20000 in the general population. Despite significant increased risk (10-20 folds), the absolute risk is small (0.05%). Coarctation of the aorta and mitral atresia are other reported cardiac anomalies. `If a pregnant woman has been exposed to lithium during the first trimester, an ultrasound and echocardiogram should be performed at 16-20 weeks gestation to exclude fetal anomalies, especially cardiac anomalies.` Option A: While the patient is on lithium, *regular renal and thyroid and parathyroid function tests* as well as serum lithium levels are indicated. Liver function tests are not required to be monitored as lithium does not have an adverse effect on the liver. Option C: Lithium requirements increase in the third trimester; however, *dose reduction* (not increase) by 25% is recommended before delivery to prevent possible neonatal toxicity that can present with a floppy baby syndrome (hypotonia, cyanosis, poor suckling). The dose should then be increased immediately after delivery due to increased risk of relapse in postpartum period. Option D and E: Lithium is not associated with vitamin C or B12 deficiency. Supplementation of these vitamines are not recommended while the pregnant woman is on lithium, unless indicated for other reasons.

Answer 38

**E. Borderline personality disorder.** Of the given options, borderline personality disorder is most consistent with the history. Important clues to this diagnosis are frequent conflicts with colleagues, being irritated easily, bursts of anger represented by shouting at colleagues, failed marriage, and not being able to relax. Borderline personality disorder (BPD) is characterized by instability of interpersonal relationships, self-image, and emotions and by impulsivity. `BPD has three components:` **1- Impaired relatedness - unstable relationships with others, identity disturbance, and chronic emptiness** Patients with BPD usually have stormy relationships, especially in their close relationships. At one moment a friend or romantic partner may be viewed as trusted or an ideally perfect person, and then this same individual can suddenly be seen as cruel, betraying, very limited, and damaged. When the idealized person is present and supportive, the patient feels strong and solid. However, if the support person leaves (or is unable to meet the patient's needs) for a limited period of time, or if the patient thinks that the support person is about to leave, the patient can immediately become angry, demeaning, depressed, hopeless, and suicidal. Splitting, which is rigidly classifying other as good as bad, is common among patients with BPD and can lead the patient to shift between extreme points of view and to selectively attend to information in a way that confirms his or her current opinion. This tendency to "split" can impact treatment. Patients with BPD often interpret neutral events, words, or faces as 'negative'; therefore, the patient is prone to misinterpret relatively minor disagreements or adverse events as a sign that the caretaker wants to terminate the relationship. The patient often reacts with anger or threats of self harm, which can gradually alienate the support person, and result in their real tendency to end the relationship. This heightened sensitivity to actual or perceived rejection can lead patients to feel more comfortable or secure with a transitional object, such as a pet or stuffed animal, than with other people. **2- Affective dysregulation - affective lability, excessive anger, and efforts to avoid abandonment** Patients with BPD experience repeated and marked mood changes throughout the course of a single day, with moment to moment fluctuations often triggered by environmental stressors. Periods of euthymia alternate with intense, episodic dysphoria that includes depression, anxiety, and irritability. Angry outbursts triggered by dissatisfaction with a caregiver are often followed by feelings of shame, guilt, and worthlessness. **3- Behavior dysregulation - impulsivity, suicidality, and self-injurious behavior** Impulsive and self-damaging behavior is common and can take many forms. Patients abuse substances, binge eat, engage in unsafe sex, spend money irresponsibly, and drive recklessly. In addition, patients can suddenly quit a job that is promising or end a relationship that has the potential to last, thereby sabotaging their own success. Impulsivity can also manifest with immature and regressive behavior. The following are characteristic features of BPD and their prevalence: * Affective instability – 95% * Inappropriate anger – 87% * Impulsivity – 81% * Unstable relationships – 79% * Feelings of emptiness – 71% * Paranoia or dissociation – 68% * Identity disturbance – 61% * Abandonment fears – 60% * Suicidality or self-injury – 60% Option A: There are no symptoms indicating either mania/hypomania or depression to suggest bipolar disorder. Bipolar disorder is often characterized by shifting episodes of mania/hypomania and depression, none of which are present in the history. Option B: Cyclothymic disorder presents with many periods of depressed mood and many episodes of hypomanic mood for at least 2 years. Interestingly, the condition frequently coexists with BPD. In the scenario, however, there are no clues to indicate depression or mania. Option C: Generalized anxiety disorder (GAD) is characterized by excessive, poorly controlled anxiety about life circumstances that continues for more than 6 months. To establish the diagnosis, both physiologic and psychologic symptoms should be present. Option D: Major depression presents with at least a 2-week course of the following symptoms: 1. Depressed mood most of the day 2. Anhedonia during most of the day 3. Significant weight loss or gain 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy almost everyday 7. Feelings of helplessness/hopelessness or guilt 8. Diminished ability to concentrate 9. Recurrent thoughts about death Of these symptoms, the first two are necessary for major depression to be present. The history is not consistent with major depression as diagnosis.

Answer 39

**D. Decrease in goal directed activities.** Features of bipolar disorder include: * Inflated self-esteem or grandiosity * Decreased need for sleep (e.g. feels rested after only three hours of sleep) * More talkative than usual or pressure to keep talking * Flight of ideas or subjective experience that thoughts are racing * Distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli) * Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation * Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) These all must be associated with impairment of social or occupational functioning. Patients with bipolar disorder have **increased (not decreased) goal-oriented activities**.

Answer 40

**D. Propranolol.** Acute cocaine use is associated with arterial vasoconstriction and enhanced thrombus formation. It causes tachycardia, hypertension, increased myocardial oxygen demand, and increased vascular shearing forces. Chest pain is the presenting symptom in 40% of patients. The following cardiovascular complications can also occur: * Coronary vasoconstriction in a dose dependent fashion leading to myocardial ischemia * Acute left ventricular depression and heart failure at high blood concentrations * Supraventricular and ventricular arrhythmia (both through direct action or indirectly by producing myocardial ischemia) * Aortic rupture (rare) CNS manifestations of cocaine intoxication include: * Psychomotor agitation * Headache * Seizure * Coma * Intracranial hemorrhage * Focal neurological symptoms `NOTE - Cocaine-induced psychomotor agitation can cause hyperthermia due to peripheral vasoconstriction that prevents the body from dissipating the heat generated from persistent agitation. Hyperthermia in the setting of cocaine intoxication can have a mortality of as high as 33%.` Crack cocaine is associated with upper and lower airway injuries because its use in requires high temperatures for evaporation. Such injuries are not caused by direct toxic effects. Cocaine use can also have a variety of effects on gastrointestinal tract, eyes and muscles. In majority of cases with acute cocaine intoxication, **benzodiazepines are generally sufficient to improve cardiovascular symptoms** because most cardiovascular stimulation from cocaine is mediated by sympathetic nervous system. Benzodiazepines also help alleviate the agitation. **Intravenous diazepam is the treatment of choice if the patient is not hypoxic or hypoglycemic.** However, **in patients with severe, refractory, or symptomatic cocaine-induced hypertension other antihypertensive medications can be tried. Phentolamine**, given as an intravenous bolus, is the treatment of choice, but other medications used for acute management of hypertension such as hydralazine can be used as well. Aspirin is given to patients with pain associated with cocaine intoxication; after aortic dissection as potential cause has been excluded. As mentioned earlier, cocaine use is associated with enhanced thrombus formation. **Beta blockers should NOT be used** in the treatment of cocaine-induced cardiovascular symptoms and complications owing to the fact that beta blockers may result in unopposed alpha-adrenergic stimulation, resulting in coronary vasoconstriction and end-organ ischemia. In very rare occasion when use of beta blockers is inevitable, phentolamine should be given beforehand to prevent unopposed alpha-adrenergic stimulation.

Answer 41

Correct Answer Is B Without treatment, an episode of major depressive disorder in adults lasts from 6 months to 18 months (average 8 months). The course of the disease in adolescents appears to be different from that of adults. Although there is no solid evidence, it is suggested that major depression in adolescents may last from 2 weeks to many years. Based on such data, the most appropriate advice for this patient is that without treatment she is unlikely to recover until 6 months. (Option A) Depression has the most association with suicide. Lifetime risk of suicide among patients with untreated depression ranges from 2.2% to 15%. Most of depressed patients never commit suicide. (Option C) Most patients with major depression witll improve in 6 to 18 months even without treatment. Telling the patient that her symptoms will last for 5 years is incorrect. (Option D) Recovery from depression can be complete without residue; although the recurrence rate is significant. (Option E) It is unlikely that the patient's symptoms remit in 2 months without treatment. The minimum expected time for resolution of major depression is 6 months.

Answer 42

Correct Answer Is B This scenario suggests antisocial personality disorder (ASPD) as the most likely diagnosis. ASPD is characterized by a pattern of disregard for and violation of others’ rights, routine engagement in illegal activities (e.g., drug use, assault, and theft), endangering the well-being of others, and blatantly disregarding their legal rights. They also tend to be aggressive and impulsive and have difficulty maintaining employment. ASPD typically begins by mid-adolescence and continues into adulthood. Patients must be 18 years or older to fulfill the diagnostic criteria for the condition. Individuals with ASPD often have a history of conduct disorder in adolescence presented by aggression towards people or animals, destruction of property, deceitfulness or theft, or a serious violation of rules. Conduct disorder is considered a warning sign for the development of ASPD in the future and helps with the diagnosis in adulthood. Of the options, the history of trying to set fire to a neighbor’s car is consistent with conduct disorder in childhood as a risk factor and a warning sign for ASPD. (Option A) Non-accidental injury in childhood is a significant cause of mortality and morbidity, especially in infants and young children, and should raise suspicion of child abuse and neglect. Child abuse increases the risk of developing antisocial personality disorder but is not essential for establishing the diagnosis. (Option C) Amphetamines are considered unsafe to use during pregnancy. However, there is no evidence that in-utero exposure to amphetamines is a risk factor for ASPD. However, ASPD patients commonly are noted to abuse amphetamine. (Option D) Individuals diagnosed with ADHD during childhood are at greater risk for developing a personality disorder in late adolescence. Specifically, studies found elevated rates of narcissistic, paranoid, borderline, and antisocial personality disorders. Antisocial and paranoid personality disorder appears to emerge primarily when ADHD is persistent. (Option E) Some young people, who are not in school due to either truancy or exclusion, are particularly vulnerable to drug misuse. Others at risk include those who have been in foster care and those who are homeless. Moreover, people with antisocial personality disorder tend to start abusing their substance of choice at an earlier age than those who do not have the disorder. Truancy, however, is not a pointer towards ASPD or necessary to make such a diagnosis.

Answer 43

Correct Answer Is A Insomnia is a common problem in women with breast cancer with a prevalence of 23% to 61%. Insomnia may present as difficulty initiating or maintaining sleep, or non-refreshing sleep. If persistent enough, it can cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In approach to patients with insomnia, it is important to educate the patient about sleep hygiene, which is encouraging habits that promote good sleep and avoiding those that may inhibit sleep. Patients with anxiety can benefit from cognitive behavioral therapy (CBT). Behavioral therapeutic approaches for insomnia seem particularly suitable to use in the breast cancer populations because they have lower risk of interacting with the cancer treatment, do not burden the patients with additional pharmacological treatments, and can target the treatment towards ameliorating specific symptoms, like fatigue, that are characteristic in this population. If such measures fail or the patient requests immediate relief, pharmacologic therapy is indicated. Temazepam, zolpidem or zopiclone are first-line medications for such purpose. If they are prescribed, the duration of therapy should be for the shortest time possible. The duration of use should be determined and discussed with the patient. Also, patient should be fully informed of potential adverse effects and chances of dependence. This woman requests medication for immediate relief of insomnia, and of the options, temazepam is the most appropriate one to consider for her. (Option B) Diazepam is a long-acting benzodiazepine with unpredictable effects when used orally. It is not recommended for management of insomnia. (Options C) Fluoxetine and other SSRIs are used for pharmacological treatment of depression. This woman, although distressed and anxious, is not depressed and does not need antidepressants. SSRIs can cause sedation and improve sleep; however, they can induce insomnia as one of their adverse effects, particularly early in the course of treatment. (Options D and E) Haloperidol is a first-generation antipsychotic and olanzapine a secondgeneration one. This woman does not have psychotic features justifying the use of antipsychotics. Haloperidole in particular and olanzapine has sedative effects, but should not be used for the purpose of insomnia in the absent of other main indications to their use.

Answer 44

Correct Answer Is D The clinical scenario is most consistent with dementia. Dementia is a progressive decline in general cognitive function, with normal consciousness and attention. There is impairment of memory, abstract thinking, judgment, verbal fluency and the ability to perform complex tasks. It is associated with behavioral and psychological changes, and impairment of social and physical functioning. Behavioral and psychological symptoms of dementia include psychosis, depression, agitation, aggression and social disgrace. Of the given options, frontotemporal dementia (Pick disease) is most consistent with the clinical scenario. Frontotemporal dementia is characterized by focal degeneration of the frontal and/or temporal lobes. The typical age of onset is in the late 50s or early 60s, and the primary clinical manifestations are changes in personality and social behavior or language, progressing over time to a more global dementia. Other features include impaired initiation and planning, disinhibited behavior and social disgrace and mild abnormalities on cognitive testing. Apathy and memory deficits develop later in the course of the disease. A subset of patients may also exhibit symptoms of extrapyramidal or motor neuron involvement at some point in the disease process. (Option A) Delusional misidentification syndromes are rare psychopathologic phenomena that may occur within the context of schizophrenia or affective or organic illnesses. They include Capgras syndrome, Fregoli syndrome, intermetamorphosis syndrome, syndrome of subjective doubles, mirrored self, delusional companions, and clonal pluralization of the self. Misidentification syndromes show a great degree of overlap and do not represent distinctive syndromes. There is no clue in the scenario to point towards delusional syndromes. (Option B) Alzheimer disease is the most common cause of irreversible dementia and is characterized by forgetfulness early in the course of the disease. Behavioral changes develop late in the course. Anne’s presenting symptom is behavioral changes that are unlikely to develop early in Alzheimer disease. (Option C) Psychosis typically presents with hallucinations and delusions, the absence of which in the scenario makes this diagnosis unlikely. (Option E) Patients with paranoid type schizophrenia present with preoccupation with one or more delusions and/or hallucinations, usually involving grandeur or persecution.

Answer 45

Correct Answer Is D Cognitive and behavioral changes in aged people are frequently faced in general practice, with dementia and delirium being the most common underlying etiologies. Cognitive function is measured by various mental functions, including memory, concentration, praxis, language, executive functions, and visuospatial skills. Dementia refers to memory loss with impairment of any other cognitive function that can interfere with social or occupational functioning. A myriad of causes have been identified for dementia. These causes can be reversible or irreversible. The most common reversible causes of dementia include: Hypothyroidism Vitamin B12 deficiency Hepatic or uremic encephalopathy Vasculitides affecting CNS Space occupying brain lesions i.e. abscess/tumors either primary or metastatic Medications – anticholinergics in particular Normal pressure hydrocephalus Central or obstructive sleep apnea Subdural hematoma Trauma Depression Some of the most common irreversible causes of dementia are: Alzheimer disease (60-80% of cases ) Vascular dementia including multi-infarct dementia and Binswanger disease Lewy body dementia Frontotemporal degeneration (dementia) including Pick disease Multifocal leukoencephalopathy The case scenario describes a patient with social inappropriateness as the most concerning presenting symptom without memory being significantly involved. Of the options, the most consistent one with such scenario is frontotemporal dementia (Pick disease). In this disease, social disgrace is the earliest symptom with memory impairment and forgetfulness following later. Frontotemporal dementia is characterized by focal degeneration of the frontal and/or temporal lobes. The typical age of onset is in the late 50s or early 60s, and the primary initial clinical manifestations are changes in personality and social behavior or language, progressing over time to a more global dementia. Other features include impaired initiation and planning, disinhibited behavior and social disgrace and mild abnormalities on cognitive testing. Apathy and memory deficits develop later in the course of the disease. A subset of patients may also exhibit symptoms of extrapyramidal or motor neuron involvement at some point in the disease process. (Option A) Patients with depression may present with pseudodementia which is different from dementia in some aspects. It is less common for patients with pseudodementia to have disinhibition or social disgrace. The history of disturbances in pseudodementia is often short and abrupt onset, while dementia is more insidious. On cognitive testing, people with pseudodementia often answer that they do not know the answer to a question, and their attention and concentration are intact and they may appear upset or distressed. Those with true dementia will often give wrong answers, have poor attention and concentration, and appear indifferent or unconcerned. (Option B) In Alzheimer disease, forgetfulness is usually the presenting symptom. It is very unlikely for a patient with Alzheimer disease to present with disinhibition and social inappropriateness early in the course of the disease. (Option C) although misbehavior and disinhibition is a common early feature in patients with Lewy body dementia, the absence of other manifestations such as fluctuating cognition, hallucinations, extrapyramidal deficits (Parkinsonism) and repeat falls makes this diagnosis less likely. (Option E) Psychotic features such as hallucinations and delusion are a significant diagnostic component in schizophrenia that is absent here. Moreover, development of schizophrenia at this age is unusual.

Answer 46

Correct Answer Is A Some features in the scenario are of diagnostic importance. Recent onset forgetfulness and peculiar behavior and importantly visual hallucinations suggested by seeing people that do not exist. These features suggest Lewy body dementia as the most consistent diagnosis among other options. Lewy body dementia is a progressive, degenerative dementia of unknown etiology, presenting with dementia, motor signs, episodes of reduced cognition and visual hallucinations. Unlike Parkinson disease, in Lewy body dementia, cognitive impairment and dementia precedes extrapyramidal manifestations. In summary, Lewy body dementia presents with the following: Dementia and fluctuations in cognitive function with varying levels of alertness and attention during a day Episodes of long staring and disorganized speech Well-formed, detailed Visual hallucinations (or less commonly, auditory) Parkinsonian motor features Early extrapyramidal features Anterograde memory loss Visuospatial impairment (Option B) Although forgetfulness is a prominent feature and an early symptom in Alzheimer disease, spontaneous motor Parkinsonism, hallucinations and peculiar behavior develops late in the course of the disease, often in a matter of years. (Option C) There is no false belief in the scenario suggesting a delusional disorder. The imagined people entering his house are in fact visual hallucinations, not delusions. . (Option D) Although hallucinations are a characteristic feature is schizophrenia and other psychotic disorders, patients with schizophrenia usually have auditory rather than visual hallucinations. Moreover, the age of the patient is unusual for development of schizophrenia. (Option E) Despite the fact that early behavioral changes are a feature also seen in frontotemporal dementia, the presence of visual hallucinations makes Lewy body dementia the more likely diagnosis. Furthermore, forgetfulness is not a prominent feature early in the course of frontotemporal dementia.

Answer 47

**Correct Answer Is B** This patient has classic presentation of Alzheimer disease, and an MMSE score of 14 indicates moderate dementia in this patient. The maximum MMSE score is 30 points. A score of 20 to 24 suggests mild dementia, 13 to 20 suggests moderate dementia, and less than 12 indicates severe dementia. On average, the MMSE score of a person with Alzheimer disease declines 2 to 4 points per year. Currently available pharmacological treatments for Alzheimer disease are cholinesterase inhibitors (e.g., donepezil, rivastigmine and galantamine) and memantine. Patients with Alzheimer disease (AD) have reduced cerebral production of acetylcholine transferase, resulting in decreased acetylcholine production and impaired cortical cholinergic function. Cholinesterase inhibitors increase cholinergic transmission by inhibiting cholinesterase at the synaptic cleft. Cholinesterase inhibitors have a modest benefit to patients with dementia due to Alzheimer disease. These drugs improve alertness and function and maintain cognitive scores at or above the baseline for up to 12 months, but do not prevent disease progression. Cholinesterase inhibitors are associated with prominent adverse effects including: Gastrointestinal symptoms as the most prominent adverse effects, including anorexia, nausea, vomiting and diarrhea; Insomnia Fatigue Vivid dreams Hallucinations Asthma Bradyarrhythmias and cardiac conduction abnormalities hypertension Dizziness Cramps Headache Memantine is an N-methyl-D-aspartate (NMDA) receptor antagonist, with a distinct mechanism of action from that of cholinesterase inhibitors. It appears to be **neuroprotective**. Memantine may be helpful in patients with moderate to severe dementia who are deteriorating despite initial response to a cholinesterase inhibitor (e.g., donepezil), or in previously untreated patients with moderate to severe dementia. This patient has moderate dementia. **She also has a baseline bradycardia of 52 bpm**. Use of cholinesterase inhibitors for this patient, with pre-existing bradycardia, may result in profound bradycardia and cardiac complication; therefore, initiation of memantine in preference of a cholinesterase inhibitor would be the most appropriate treatment. (**Options A, C and E**) Donepezil, rivastigmine, and galantamine can be associated with severe bradycardia in this patient who already has bradycardia. (**Option D**) Haloperidol is not used for treatment of dementia.

Answer 48

**Correct Answer Is B**. Memory impairment and forgetfulness is an essential feature of Alzheimer disease and often its earliest manifestation. Even when not the primary complaint, memory deficits can be elicited in most patients with Alzheimer disease at presentation. Recent memory is affected early in the course of the disease while remote memory impairment develops later. Memory impairment in Alzheimer disease has a distinctive pattern. It starts with memory impairment for the time of facts and events. Loss or orientation to place follows. Recognizing familiar faces becomes affected later, as does memory for vocabulary and concepts. (Option A) Loss of visuospatial skills also occurs, but usually not before forgetfulness. It can be very prominent at presentation. Visuospatial impairments manifest as misplacement of objects and difficulty navigating in unfamiliar and then familiar places. A patient with Alzheimer disease becomes easily lost in unfamiliar places and then familial places such as the neighborhood or even at home. (Option C) Visual agnosia that is inability to recognize objects and prosopagnosia, defined as inability to recognize faces, are due to visuospatial skills. None of these features are common to precede forgetfulness and memory impairment. (Options D and E) Misbehavior, social disgrace and motor function deficits usually occur late in the course of the disease.

Answer 49

Correct Answer Is E They key findings of cognitive impairment and unorganized behavior followed by deficits in motor functions consistent with extrapyramidal involvement and visual hallucinations (snakes on the floor), make Lewy body dementia the most likely diagnosis. Lewy body dementia is a progressive, degenerative dementia of unknown etiology presenting with dementia, motor signs, fluctuating cognition, and visual hallucinations. In Lewy body dementia, cognitive impairment and dementia precedes extrapyramidal manifestations. In summary, Lewy body dementia manifests with the following: Dementia and fluctuations in cognitive function with varying levels of alertness and attention Episodes of long staring and disorganized speech Well-formed, detailed visual hallucinations Early extrapyramidal features Anterograde memory loss Visuospatial impairment (Option A) In Alzheimer disease, behavioral changes, hallucinations and motor deficits occur late in the course of disease. In this woman this features have occurred early which is against Alzheimer disease as a diagnosis. (Option B) In Parkinson, memory and cognition remain intact until late in the course of the disease. In Lewy body dementia, cognitive impairment and memory problems precede extrapyramidal manifestations. On the other hand, visual hallucinations are not a feature of Parkinson disease. (Option C) Schizophrenia is associated with hallucinations that are mostly auditory, delusions, and other psychotic feature for at least 6 months. Patients with schizophrenia do not have motor symptoms. In addition, the age of patient is unusual for development of schizophrenia. (Option E) In vascular dementia, there is often a history of stroke or cerebrovascular disease. The condition presents with focal neurological signs on examination, abrupt symptom onset related to stroke in a step-wise fashion, and evidence of old infarcts on CT scan. Risk factors for cardiovascular disease such as hypertension, diabetes, smoking, and atrial fibrillation are often present. It is more common in men.

Answer 50

Correct Answer Is E Many mood stabilizers (olanzapine here) have bimodal effect. They can be used for treatment of both depression and mania. If a patient, who has successfully been stable on prophylactic dose of a particular mood-stabilizer, develops acute depression, two approaches can be considered with about the same efficacy: Adding an antidepressant to the prophylactic mood stabilizer: the choices of the drug would be the same as for major depression. SSRIs are first line options. Increasing the dose of prophylactic mood stabilizer. Either addtion of escitalopram or increasing the dose of olanzapine can be effectively used for this patient. NOTE - Cessation or dose reduction of a mood stabilzer can result in relapse of mania and is not appropriate.

Answer 51

Correct Answer Is E Mini-mental status exam (MMSE) is a practical test performed for initial assessment of cognitive function. The total score is 30. An MMSE score≥25 makes dementia less likely, while scores less than 25 suggest dementia. Patients with dementia often have MMSE scores of less than 25. Alzheimer disease, Pick disease (frontotemporal dementia) and multi-infarct (vascular dementia) are associated with genuine dementia and decreased MMSE scores of less than 25. This patient has a MMSE score of 28 and is very unlikely to be demented. For him, pseudodementia could be the most likely diagnosis. Depressive pseudodementia is a term commonly used to describe a condition in a patient who experiences a cognitive deficit secondary to a primary psychiatric disturbance including major depressive disorder, bipolar disorder, schizophrenia, Ganser’s syndrome, and adjustment disorder. Pseudodementia mimics dementia, and is usually reversible once the primary diagnosis has been treated. (Options A, B and D) While an MMSE score of <25 is likely in both dementia and pseudodementia, a score of >25 almost excludes dementia. Alzheimer disease, Pick disease and multi-infarct dementia are often associated with a marked decrease in MMSE score. (Option C) Although tiredness can be seen in some patients with anxiety disorders, particularly in those with generalized anxiety disorder, forgetfulness in not a common feature. NOTE - The history of disturbances in pseudodementia is often short and of abrupt onset, whereas dementia is often more insidious. Clinically, people with pseudodementia differ from those with true dementia when their memory is tested. They typically answer that they do not know the answer to a question, and their attention and concentration are often intact, and they may appear upset or distressed when they fail to answer. Those with true dementia will give wrong answers, have poor attention and concentration, and appear indifferent or unconcerned.

Answer 52

**Correct Answer Is B** Borderline personality disorder (BPD), a member of cluster B (dramatic, emotional) personality disorders, is characterized by a pattern of unstable interpersonal relationships and marked impulsivity. Patients with this condition swing wildly between devaluing and idealizing others, labeling people as wholly good or wholly bad -a phenomenon known as ‘splitting’. Borderline patients generally have difficulty calming down and controlling anger once they have become upset. Such patients tend to be unpredictable. As a result, they frequently have anger outbursts and engage in impulsive behavior such as substance abuse, overspending, binge eating, and suicidal or self-mutilating behavior. Chronic feelings of emptiness are common. The first step in management is by building a positive therapeutic relationship that plays a central role in the management of BPD and that helps identify and break the self-defeating interpersonal patterns characteristic of the previous relationships. Referral for longer-term psychotherapy with a psychiatrist and/or clinical psychologist is an important consideration in long-term treatment planning. A specialized form of very intensive cognitive therapy, known as **dialectical behavior therapy (DBT)**, is currently considered to be the **treatment of choice for women (not approved for men or adolescents) with BPD** for whom reduction in self-harm, anger, anxiety, or depression are treatment goals. DBT significantly reduces self-harm and substance use disorder. People aged 14–18 years with BPD or clinically significant features of BPD should be offered time-limited structured psychological therapies that are specifically designed for BPD. For adolescents, younger than 14 years with features of BPD, clinical psychological support and monitoring and involving their families are recommended. Medicines should not be used as primary therapy for BPD, because they have only modest and inconsistent effects, and do not change the nature and course of the disorder. There is no current medication that is approved for the management of BPD, although there is some evidence that low-dose atypical antipsychotics and/or mood stabilizers may be effective in treating core symptoms. (Option A) Cognitive behavior therapy was adapted for use with personality disorders, but the results are still preliminary. Manual-assisted cognitive therapy failed to reduce the repetition of self-harm in borderline personality disorder. (Option C) Exposure therapy is one of the commonly used strategies of cognitive behavioral therapy (CBT). CBT has been found to be the most effective treatment for anxiety disorders. In exposure therapy, the psychologist guides the person through a series of real or imaginary scenarios to confront specific fears. Through a gradual process of exposure, the person learns to cope more effectively with these fears, and with practice, the anxious response naturally decreases. (Option D) Family therapy is a type of psychological counseling (psychotherapy) that helps family members improve communication and resolve conflicts. A psychologist or licensed therapist usually provides the therapy. It helps family members solve family problems and conflicts, through improved communication, greater awareness of childhood and adolescence issues, and a better understanding of special family situations such as separation, divorce, remarriage, serious illness, or death in the family as well as mixed marriages in terms of culture, race, or religion. (Option E) Interpersonal psychotherapy (IPT) is a time-limited, empirically validated treatment for mood disorders. IPT is an add-on therapy to antidepressant medication.

Answer 53

Correct Answer Is C In this case, the woman seems to malinger to obtain a secondary gain. The term denotes the deliberate simulation or exaggeration of symptoms for the purpose of obtaining some gain, such as financial compensation. The presence of a personality disorder is a risk factor for malingering. Malingering, her history of self-inflicted wrist cuts, and her behavior of difficulty controlling her anger suggest borderline personality disorder as the most likely diagnosis. Borderline personality disorder (BPD) is classified under cluster B (dramatic, emotional) personality disorders, and is characterized by a pattern of unstable interpersonal relationships and marked impulsivity. Patients with this condition swing wildly between devaluing and idealizing others, labeling people as wholly good or wholly bad-a phenomenon popularly known as ‘splitting’. Borderline patients generally have a hard time calming down, and they have difficulty controlling anger once they have become upset, their moods tend to be unpredictable. As a result, they frequently have anger outbursts and engage in impulsive behaviors such as substance abuse, overspending, binge eating, or suicidal or self-mutilating behavior. Chronic feelings of emptiness are common. (Option A) Malingering is not a medical diagnosis but a description of behavior. DSM-5 describes malingering as the intentional production of false or grossly exaggerated physical or psychological problems. Motivation for malingering is usually external (e.g., avoiding military duty or work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs). In other words, malingering is assuming a sick role for a planned gain. (Option B) Narcissistic personality disorder is classified under cluster B (dramatic, emotional) personality disorders, and is characterized by arrogance, grandiosity, a need for admiration, and a tendency to exploit others. Individuals with the condition are preoccupied with fantasies about success, power, brilliance, beauty, or the perfect mate. There is often a sense of excessive entitlement. They usually demand special treatment. (Option D) People with histrionic personality disorder are highly emotional and dramatic, have an excessive need for attention and approval, and may be obsessed with their appearance. Sexual seductiveness is another feature. (Option E) Factitious disorder (Munchausen syndrome) is characterized by the intentional production of false physical or psychological signs or symptoms to assume the sick role. Unlike patients with malingering, those with the factitious disorder receive no secondary gain. It is called Munchausen's syndrome when patients display symptoms of the factitious disorder that are predominantly physical in nature. Multiple tests usually show no abnormality, but they will not accept that they do not have an illness. They may undergo numerous surgeries resulting in scarring and adhesions.

Answer 54

Correct Answer Is B Apparently, this man has antisocial personality disorder (ASPD), which is characterized by a pattern of disregard for and violation of the rights of others, which typically begins by middle adolescence and continues into adulthood. Individuals with this condition are aged ≥18 years and have had conduct disorder in childhood. Individuals with ASPD routinely engage in illegal activities (e.g. drug use, assault, or theft), endanger the well-being of others, and blatantly disregard others’ legal rights. They tend to be aggressive and impulsive, and have difficulty maintaining employment. They frequently lie, and this explains the malingering behavior in this young man to obtain secondary gain to provide the court with. DSM-IV defines malingering as ‘the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives’. It stresses that clinicians should suspect malingering when two or more of the following conditions are present: The symptoms are reported within a forensic context They sharply contrast with objective findings There is lack of cooperation during diagnostic evaluation The patient meets criteria for ASPD The new edition of the DSM (i.e. the DSM-V) does not contain substantial revisions of how it portrays malingering. Despite these features, however, affected individuals frequently display a superficial charm that allows for the manipulation of others. (Option A) Antisocial personality disorder is a psychiatric diagnosis and is considered a risk factor for malingering. However, the question is asking about the behavior intention not the diagnosis. (Option C) Bipolar disorder is a mood disorder characterized by periods of mania and depression Manic episodes involve abnormally elevated mood, grandiosity, decreased need for sleep, racing thoughts, talkativeness, and impulsivity (e.g. spending exorbitant amounts of money, gambling, sexual indiscretion) This patient exhibits impulsivity and tension, which are specific to stealing. She demonstrates none of the other concurrent manic symptoms required for a diagnosis of bipolar disorder. (Option D) While this patient denies substance abuse, patients do not always tell the truth. A urine toxicology screen would be indicated if suspected. However, malingering is more likely here for evading criminal prosecution not for obtaining a drug. (Option E) Children and adolescents with conduct disorder often become adults with antisocial personality disorder. The diagnosis of conduct disorder requires at least three symptoms from the following: Aggression towards people or animals Destruction of property Deceitfulness Theft A serious violation of rules Adult patients have ASPD not conduct disorder, which is by definition a disorder of childhood and adolescence.

Answer 55

Correct Answer Is C This woman has started abusing substances in an early age, and has multiple jail stays due to drug issues and shop-lifting. At first glance, one might consider the diagnosis of antisocial personality disorder; however, this woman does not fulfill criteria for such a diagnosis. Evidence of conduct disorder with onset before age 15 is one of the criteria to make a diagnosis of antisocial personality disorder. Although this woman has left home at an early age (<15 years) and has been involved in drug use as well as criminal charges, these do not fulfill criteria for conduct disorder. For conduct disorder to be present, one of the important criteria is the presence of at least 3 out of the following 15 in the history: 1. Often bullies, threatens, or intimidates others. 2. Often initiates physical fights. 3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). 4. Has been physically cruel to people. 5. Has been physically cruel to animals. 6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery). 7. Has forced someone into sexual activity. 8. Has deliberately engaged in fire setting with the intention of causing serious damage. 9. Has deliberately destroyed others’ property (other than by fire setting). 10. Has broken into someone else’s house, building, or car. 11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others). 12. Has stolen items of nontrivial value without confronting a victim (e.g. shoplifting, but without breaking and entering; forgery). 13. Often stays out at night despite parental prohibitions, beginning before age 13 years. 14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period. 15. Is often truant from school, beginning before age 13 years. This woman only has had 2 from the above criteria that are (1) leaving home early at age 12 and (2) shop-lifting. So she did not have conduct disorder as an essential part for diagnosis of antisocial personality disorder in adulthood. Moreover, oshe lacks other aspects of antisocial personality disorder such as aggressiveness, recklessness towards self and others' safety. As a matter of fact, drug abuse appears to be the most likely cause of her presentation. Shop-lifting and prostitution are the most common crimes committed to fund drug habits (economic related crime). (Option A) The two most common personality disorders associated with substance use disorders are antisocial personality disorder and borderline personality disorder. This patient does not meet the criteria for none. (Option B) Obsessive-compulsive disorder (OCD) is characterized by obsessions or intrusive thoughts that cause significant anxiety, or forced engagement in repetitive compulsions in an attempt to avoid otherwise significant psychological stress. Patients with OCD often recognize the unreasonable nature of their thoughts and behaviors, but are unable to stop them due to anxiety. No points in the history favor OCD as a diagnosis. (Option D) People with histrionic personality disorder are highly emotional and dramatic, have an excessive need for attention and approval, and may be obsessed with their appearance. This disorder usually begins by late teens or early 20s and seems to be caused by genetic predisposition and early childhood events. This patient does not meet the criteria for histrionic personality disorder. (Option E) Narcissistic personality disorder is classified as a Cluster B (dramatic, emotional) personality disorder and is characterized by arrogance, grandiosity, a need for admiration, and a tendency to exploit others. They are preoccupied with fantasies about success, power, brilliance, beauty or the perfect mate. Patients with this condition often have a sense of excessive entitlement and may demand special treatment, Fifty percent of those with narcissistic personality disorder abuse alcohol and drugs, with many facing addiction and dependency. This patient does not meet the criteria for narcissistic personality disorder. TOPIC REVIEW Diagnosis of antisocial personality disorder: According to the DSM-5, there are four diagnostic criterion, of which Criterion A has seven subfeatures. (A) Disregard for and violation of others rights since age 15, as indicated by one of the seven sub features: 1. Failure to obey laws and norms by engaging in behavior which results in criminal arrest, or would warrant criminal arrest 2. Lying, deception, and manipulation, for profit or self-amusement 3. Impulsive behavior 4. Irritability and aggression, manifested as frequently assaults others, or engages in fighting 5. Blatantly disregards safety of self and others 6. A pattern of irresponsibility 7. Lack of remorse for actions The other diagnostic Criterion are: (B) The person is at least age 18 (C) Conduct disorder was present by history before age 15 (D) The antisocial behavior does not occur in the context of schizophrenia or bipolar disorder

Answer 56

**Correct Answer Is A** Compromises in interpersonal relationships and the inability to hold a job are most consistent with the diagnosis of borderline personality disorder. Borderline personality disorder is classified under Cluster B (dramatic, emotional) personality disorders, characterized by a pattern of unstable interpersonal relationships and marked impulsivity. Patients with this condition swing wildly between devaluing and idealizing others, labeling people as wholly good or wholly bad - a phenomenon known as ‘splitting’. Borderline patients generally have a hard time calming down, and they have difficulty controlling anger once they have become upset, their moods tend to be unpredictable. As a result, they frequently have anger outbursts and engage in impulsive behavior such as substance abuse, overspending, binge eating, or suicidal or self-mutilating behavior. Chronic feelings of emptiness are common. (Option B) Antisocial personality disorder is diagnosed in patients aged 18 years or older, who engage in illegal activities (e.g., theft or assault) and disregard others’ rights. These individuals often display evidence of conduct disorder as minors. (Option C) Although this woman admits to a lack of concentration, there is insufficient information to substantiate a diagnosis of attention deficit hyperactivity disorder (ADHD), characterized by hyperactivity, short attention span, and easy distractibility. (Option D) This patient has only one symptom of major depressive disorder which is ‘lack of concentration, but does not meet the full criteria including five or more of the following symptoms for at least two weeks: * Depressed mood * Loss of interest * Early-morning awakening * Weight loss * Low energy * Impaired concentration * Feelings of worthlessness * Excessive guilt (Option E) Patients with Asperger syndrome present in early childhood. It is four times more common in males. Patients with Asperger's have impairments in reciprocal social interactions and restricted interests. They often desire relationships but lack awareness of social conventions, including the use of nonverbal communication. The absence of language delay (not a feature in Asperger syndrome) helps distinguish Asperger syndrome from autism.

Answer 57

Correct Answer Is D The clinical scenario is consistent with narcissistic personality disorder as the most likely diagnosis. DSM-5 criteria for narcissistic personality disorder include most of all of these features: Grandiosity - an exaggerated sense of self-importance Fixated on fantasies of power, success, intelligence, attractiveness, etc. Self-perception of being unique, superior, and associated with high-status people and institutions Needing constant admiration from others Sense of entitlement to special treatment and to obedience from others Exploitative of others to achieve personal gain Unwilling to empathize with others' feelings, wishes, or needs Being envious of others and believing others envy him Pompous and arrogant demeanor Behaving in an arrogant or haughty manner (Option A) Paranoid personality disorder is characterized by distrust and fear. Individuals with this disorder frequently have unfounded suspicions and misinterpret the motives of others. They may find it difficult to confide in or forgive people. (Option B) Patients with obsessive-compulsive personality disorder have a preoccupation with orderliness and perfectionism that negatively impacts their functioning. They are often overly devoted to their work, are stubborn, and believe there is only one way to do things. They can have difficulty throwing out worn items, often have trouble with relationships because of their need for perfection, and even need to play games by following the rules precisely. They often do not see their behavior as a problem. Despite the similar names, There is no specific association between OCD and any specific personality disorder, including obsessive-compulsive personality disorder. (Option C) Antisocial personality disorder can be a diagnosis in patients aged 18 years or older, who engage in illegal activities (e.g. theft or assault) and disregard others’ rights. These individuals often display evidence of conduct disorder as minors. (Option E) Individuals with borderline personality disorder show a pattern of instability in relationships and marked impulsivity They swing wildly between scorning and idealizing people (with others considered wholly good or wholly bad, a phenomenon known as "splitting") They tend to be impulsive and reckless and may demonstrate suicidal or self-mutilating behavior. Feelings of anger and chronic emptiness are common.

Answer 58

Correct Answer Is C Intentional reclusiveness, odd beliefs about supernatural issues, and lack of interpersonal relationships make schizotypal personality disorder the most likely diagnosis. Schizotypal personality disorder is characterized by a pattern of odd and eccentric behavior and beliefs and a reduced capacity for close relationships. These patients usually exhibit ‘magical thinking’. They may have bizarre fantasies or believe in telepathy, clairvoyance, or the concept of a sixth sense. They often have paranoid ideation and unusual perceptual experiences. (Option A) Paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others in a way that their actions are interpreted as malevolent as indicated by: reluctance to confide in others, preoccupation with unjustified doubts, suspicions that others are being exploitative, and finding hidden meaning in benign remarks. (Option B) Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness and perfectionism that negatively impacts functioning. They are often overly devoted to their work, are stubborn, and believe there is only one way to do things. They can have difficulty throwing out worn-out and useless items, and often have trouble with relationships because of their need for perfection. They often do not see their behavior as a problem. (Option D) Schizoid personality disorder is characterized by the pervasive pattern of detachment from social relationships and restricted emotions, as evident by four or more of the following characteristics: Lack of desire for close relationships No interest in sexual experiences Indifference to praise or criticism Emotional coldness Choosing solitary activities NOTE - Schizoid personality disorder shares many features with schizotypal disorder. The distinctive features are bizarre and eccentric appearance and beliefs which are present in schizotypal personality disorder and absent in schizoid personality disorder. (Option E) Avoidant personality disorder is characterized by hypersensitivity to criticism, social inhibition, and feelings of inadequacy. Although these individuals want friendships, they avoid (as the name suggests) such intimate relationships because they fear ridicule. They also perceive themselves as inferior and are reluctant to engage in new activities or take risks for fear of being embarrassed.

Answer 59

Correct Answer Is A On average, people with schizophrenia have a lifespan 20 years shorter than the general population. More than two-thirds of people with schizophrenia, compared with about a half in the general population, die of coronary heart disease. This is partly due to factors such as smoking, increased rates of diabetes, and metabolic problems caused by the use of some antipsychotic medications. These factors often worsen once a cardiac condition arises because people with schizophrenia are less likely to make the necessary lifestyle changes, such as diet and exercise, to offset the problem. Although death due to suicide is a contributing factor, the lifetime risk of suicide in schizophrenia is usually quoted to be around 10%. However, overall, the evidence is for a lower rate (around 5%). The highest risk is soon after diagnosis.

Answer 60

Correct Answer Is A Of the options, delirium best explains the agitation and delusional state of mind in this man. Delirium, also called acute confusional state, is a decline from a previously attained baseline level of cognitive function due to organic causes. Delirium is characterized by a fluctuating course, attentional deficits, and generalized severe disorganization of behavior. It typically involves other cognitive deficits, changes in arousal (hyperactive, hypoactive, or mixed), perceptual deficits, and psychotic features such as hallucinations and delusions that are often short-lived. Delirium itself is not a disease, but a clinical syndrome. (Option B) Dementia is characterized by impairment of memory and at least one other cognitive domain such as aphasia, apraxia, agnosia, or executive function. These must represent a decline from previous level of function and be severe enough to interfere with daily function and independence. Although this patient may also have dementia, his current presentation of agitation and delusions are acute and most likely due to delirium. (Option C) Delusional disorder is an illness characterized by at least one month of delusions but no other psychotic symptoms. Delusions are false beliefs based on incorrect inference about external reality that persist despite the evidence to the contrary. These beliefs are not ordinarily accepted by other members of the person’s culture or subculture. (Option D) Drug abuse can cause delirium; however, it is an underlying cause of the condition, not a diagnosis. (Option E) Paranoid personality disorder is characterized by distrust and fear. Individuals with this disorder frequently have unfounded suspicions and misinterpret the motives of others. They may find it difficult to confide in or forgive people. Agitation, as in this man, is not a feature.

Answer 61

Correct Answer Is E Anxiety disorders are one of the most common psychiatric disorders encountered in general practice and at primary care level. In general, anxiety disorders are categorized into the following six groups: Panic disorder - sudden bursts of extreme anxiety that are accompanied by symptoms like a pounding heart, sweaty palms, and shortness of breath or nausea Agoraphobia - anxiety about being in places or situations from which it is difficult to escape if a panic attack occurs Social phobia (also called social anxiety disorder) - strong fear of social interaction or performance situations because of the potential for embarrassment of humiliation Generalized anxiety disorder (GAD) - long periods of uncontrollable worry about everyday issues or events, which is typically accompanied by feelings of fatigue, restlessness or difficulty in concentrating. Posttraumatic stress disorder (PTSD) - recurrent and intrusive memories of a trauma, feelings of emotional numbing and detachment, and increases in emotional arousal, such as irritability and disturbed sleep, resulting from a previous traumatic event Obsessive-compulsive disorder (OCD) - repeated thoughts, images or impulses that the person feels are inappropriate, and repetitive behaviors, designed to reduce the anxiety generated by the thoughts Of the above disorders, generalized anxiety disorder (GAD) is the most common anxiety disorder encountered in general practice and at primary care level. GAD is also the most common anxiety disorder among older population. Note that the question asks about the most common anxiety disorder faced in general practice setting, not the most common anxiety disorder overall. According to the ‘Mental Health of Australia’, a survey in 2007 showed that PTSD was the most common reported anxiety disorder in a 12-month period. NOTE - An estimated 12% of all general practice encounters are related to mental health. Of these mental conditions, depression is tne most common one (34%), followed by anxiety disorders (14.8%)

Answer 62

Correct Answer Is D The sleep disturbance described is characteristic of sleep paralysis. Sleep paralysis is a sleep disorder in which either during falling asleep or waking up, an individual temporarily experiences inability to move, speak and react. Sleep paralysis is a transitional state between wakefulness and sleep, characterized by an inability to move muscles, often accompanied by terrifying hallucinations to which no reaction can be made due to paralysis. These hallucinations are often described as a person or supernatural creature suffocating or terrifying the individual, accompanied by a feeling of pressure on one's chest and difficulty breathing. Another common hallucination type involves intruders (human or supernatural) entering one's room or lurking outside one's window, accompanied by a feeling of dread. Feelings such as being abducted by aliens have also been reported. The pathophysiology of sleep paralysis has been hypothesized to be a disrupted REM sleep that normally induces complete muscle atonia to prevent sleepers from acting out their dreams. Normally muscle tone is regained before the individual wakes up. In sleep paralysis the sequence is reversed resulting in the person regains consciousness while muscles are still in atonic state. Proposed risk factors for sleep paralysis (and other sleep disturbances) include sleep disruption, traumatic life events, anxiety and depression and use of antidepressants. This patient has developed sleep paralysis after he has been started on fluoxetine. Multiple studies have shown a link between antidepressants use and sleep architecture disturbances. Interestingly, selective serotonin reuptake inhibitors (SSRIs) have been used for treatment of some sleep disorders including sleep paralysis, while they can also induce such disorders. Less so are serotonin-norepinephrine reuptake inhibitors (SNRIs). In this scenario, sleep paralysis has developed after starting the patient on the SSRI fluoxetine, making the medication the likely cause of his problem. Considering this possibility, changing fluoxetine with another antidepressant with less likelihood of inducing sleep disturbances can be an appropriate management option. (Option A) Sleep paralysis is usually a horrifying experience and the patient cannot be reassured. No evidence suggests that the condition is temporary and resolves with time. (Option B) Addition of an antipsychotic has not shown to be of proven benefit for management of sleep paralysis. (Options C and E) In sleep paralysis the problem is not going to or maintaining sleep. It often occurs while the patient is falling asleep or is waking up; therefore, measures such as wearing a sleep mask or sleep hygiene and routine are unlikely to be useful.

Answer 63

Correct Answer Is C St. John’s wort (SJW) is a natural, herbal medicine that is reported to treat depression. It also has been reported to be useful for treatment of premenstrual syndrome (PMS), menopausal symptoms, anxiety, seasonal affective disorder (SAD), and even obsessive-compulsive disorder (OCD). Therapeutic ingredients of SJW include hypericin, pseudohypericin and various xanthones. Although the mechanism of action is not fully understood, it appears that the antidepressant activity of SJW is through a combination of mechanisms including inhibition of serotonin, norepinephrine and dopamine synaptic reuptake and via the neurotransmitters gammaaminobutyric acid (GABA) and glutamate. Studies have shown that SJW can be as effective as standard antidepressants in treatment of mild to moderate depression, but no more effective than placebo in severe depression. However, patients are more compliant because of less adverse effects. Despite these facts, SWJ has not been included in mainstream treatment guidelines due to uncertainty about appropriate dose, persistence of effects, variations in the nature of preparations that makes the effects unpredictable, and serious drug interactions. One major concern about SJW is its interactions with other antidepressants, mood stabilizers, and anticonvulsants. Serotonin syndrome is the most feared condition associated with such interactions. For this reason, concomitant use of St. John’s wort with such drugs is not recommended and should be discouraged. NOTE - Another concern is the fact that concomitant use of SWJ and oral contraceptives can reduce the efficacy of the contraceptives because SWJ is a liver enzyme inducer and, through this, increases the metabolism of oral contraceptives. It is recommended that concomitant use be avoided. This woman has been started on usual dose of SJW for depression (300mg, TDS), but her symptoms have failed to improve. Under such circumstance, the most appropriate approach is cessation of SJW and switching to a prescription antidepressant such as a selective serotonin reuptake inhibitor (e.g., fluoxetine) or a serotonin-norepinephrine reuptake inhibitor (e.g., venlafaxine). SJW should be withdrawn gradually and the prescription antidepressant started after the washout period of SWJ, which is one week, to avoid the risk of serotonin syndrome. (Option A) Lithium is a mood stabilizer used for treatment of bipolar disorder. It has no effect on unipolar depression. Moreover, addition of lithium to SWJ is associated with increased risk of serotonin syndrome. (Option B) Some research has shown that omega 3 has a slight effect on major depression compared to placebo. While this patient’s depressive symptoms have not improved with SJW, it is very unlikely that addition of omega 3 adds any benefits. (Option D) The recommended dose of SJW used for treatment of depression and mood symptoms by manufacturers is 300mg, 8-hourly. Increasing the dose to 600 mg, 8-hourly neither is safe nor likely to help this patient’s depression. (Option E) Addition of the selective serotonin reuptake inhibitor (SSRI) paroxetine (or other antidepressants) is associated with increased risk of serotonin syndrome and should be avoided.

Answer 64

**Correct Answer Is B** Post-stroke depression (PSD) is the **most common** neuropsychiatric consequence of stroke up to 6-24 months after the stroke onset. Elderly patients are at risk in particular. When depressive symptoms develop in the first few days after the stroke, remission is more likely, whereas later onset (i.e. after 3 months) is more likely to be associated with a prolonged course. PSD is less likely to present with dysphoria and more frequently is associated with signs and symptoms of vegetative state. Antidepressants are not generally indicated in mild PSD because the adverse effects outweigh the benefits, but are used often in conjunction with cognitive behavior therapy (CBT) for treatment of patients with moderate or severe PSD. Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment options for pharmacological treatment of PSD. Of SSRIs, the drug with the most randomized controlled trials (RCTs) supporting its use in PSD is fluoxetine both in terms of tolerability and effectiveness is fluoxetine that is often safe at a dose of 20mg/day. One concern with SSRIs, however, is the inhibitory effect of this drug class in the inhibition of serotonin reuptake into the platelets that may result in bleeding tendency of bleeding and increased incidence of gastrointestinal (most frequent), genitourinary, and intracranial hemorrhage. This effect can be more pronounced when the patient is concomitantly on ulcerogenic medications such as non-steroidal anti-inflammatory drugs (NSAIDs), aspirin and other antiplatelet medications, corticosteroids, etc. However, a recent study suggest that SSRIs are associated with only a slight increase in absolute risk of gastrointestinal bleeding with a number need to harm of 3177 in lowrisk and 881 in high-risk patients (the relative risk have been shown to be high, while the absolute risk is small). Considering this fact and in general, such risk does not preclude SSRIs from being used as first-line options for treatment of PSD. (Option A) The SSRI citalopram is highly selective but less potent. It is the second-choice option for treatment of PSD after fluoxetine. (Option C) Venlafaxine is a serotine-norepinephrine reuptake inhibitor (SNRI). This drug family have shown efficacy in treatment of depression as well increased bleeding tendency in few studies. Whether this class of antidepressants be considered a treatment option for PSD remains controversial. (Option D) This SSRI sertraline is the second most studies medication for treatment of PSD. The starting dose is 50mg/day with gradual increase up to 200mg/day if indicated and tolerated. It can also be considered a treatment option but not superior to fluoxetine. (Option E) Amitriptyline is a tricyclic antidepressant (TCA). SSRIs and tricyclic antidepressants are equally effective in treatment of PSD; however, grade A recommendations are in favor of SSRIs as the first-line treatment option due to better tolerability and their significantly lower adverse effects potentials. TCAs are associate with anticholinergic effects such as hypotension, dry mouth, constipation, urinary retention and confusion. NOTES – If SSRIs are considered a treatment option for PSD in patients with high risk of gastrointestinal bleeding, proton pump inhibitors should be prescribed for prevention of bleeding. No evidence supports prophylactic use of antidepressants for prevention of PSD. The effective duration of antidepressant therapy for PSD is 4 to 6 months with gradual tapering if appropriate.

Answer 65

Correct Answer Is D Exposure and response (or ritual) prevention (ERP) is the important and specific core element in behavior therapy for obsessive-compulsive disorder (OCD). OCD is characterized by distressing, intrusive obsessive thoughts and/or repetitive compulsive physical or mental acts often in form of rituals. The mainstays of treatment of OCD include the use of selective serotonin reuptake inhibitors (SSRIs) or the TCA clomipramine, ERP, some forms of cognitive behavior therapy), education and family interventions, and, in extremely refractory cases, neurosurgery. In ERP, the situations the patients perceive as threatening are ranked and then the patient is systematically exposed to symptoms triggers of gradually increasing intensity, and is taught to suppress his or her usual ritualized response. This is generally challenging and often quite distressing for the patient, but when effectively done, it promotes unlearning of the strong link that has existed between having an urge and giving into the urge.

Answer 66

Correct Answer Is E According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5), to meet the criteria for diagnosis of schizophrenia, the patient must have experienced at least 2 of the following symptoms: Delusions Hallucinations – almost always auditory Disorganized speech Disorganized or catatonic behavior Negative symptoms At least 1 of the symptoms must be the presence of delusions, hallucinations, or disorganized speech. Continuous signs of the disturbance must persist for at least 6 months, during which the patient must experience at least 1 month of active symptoms (or less if successfully treated), with social or occupational deterioration problems occurring over a significant amount of time. These problems must not be attributable to another condition. Of the given options, only auditory hallucinations are a criterion for a diagnosis of schizophrenia. (Option A) Flat affect is one of the negative symptoms that can be encountered in patients with schizophrenia but its absence dose not exclude such diagnosis. (Option B) Lack of insight is seen in schizophrenia as well as many other psychiatric conditions. It is not a diagnostic criteria for schizophrenia. (Option C) Suicidal ideation is a feature common in many psychiatric illnesses such as psychotic disorders, mood disorders, etc. It is not characteristic of schizophrenia and a diagnostic criterion. (Option D) Although hallucinations are one of the main criteria to establish a diagnosis of schizophrenia, such hallucinations are almost always auditory. With visual hallucinations alternative diagnoses should be considered first.

Answer 67

Correct Answer Is D There are a wide range of overwhelming negative emotions such as guilt, anxiety, confusion, frustration, helplessness, sadness and positive emotions such as anticipation, fulfillment, happiness and excitement that can be experienced during the pregnancy but more importantly and most commonly experienced in the postpartum period. This makes the postpartum period a highly vulnerable time for development of psychiatric disorders such as maternity blues, puerperal psychosis, and postnatal depression. Puerperium is the first 6 weeks after the delivery. The incidence of the above psychiatric conditions as well as relapse of pre-existing conditions such as schizophrenia or bipolar disorder necessitating active psychiatric treatment is highest during this critical period.

Answer 68

Correct Answer Is D This girl has characteristic features of anorexia nervosa (AN). AN is characterized by a markedly low body weight, intense fear of weight gain, and body image distortion. Although not central to the diagnostic criteria of AN, emerging evidence suggests additional deficits in key aspects of social functioning. AN (and other eating disorders) patients appear to be socially withdrawn, and they report having smaller social networks, less social interactions, and a reduced number of close friends. There is also evidence for premorbid social problems such as increased levels of loneliness, feelings of inferiority, and shyness, and comorbidity with anxiety disorders, such as social phobia. Of these, feelings of inferiority is most commonly cited by affected women during clinical interviews. Interestingly, feelings of inferiority is one of the most important factors leading to the development of eating disorders. Ideas of guilt (option A) and sleep disturbances (option C) might as well present in the history but not as commonly as feelings of inferiority. (Option B) Patients with eating disorders including AN are often socially withdrawn, feel lonely and may have no or few friends. Excessive socializing with friends is very unlikely to be present in the history. (Option E) Fatigue is common in AN patients due to a number of physical and psychological factors. Low calorie intake, malnutrition and electrolyte disturbances can all lead to fatigue. This girl may or may not be present in the history depending on the duration of the disease and severity of malnutrition, electrolyte disturbances, or other complications of the disorder, but feelings of inferiority are present in the past or current history.

Answer 69

Correct Answer Is B The adamant belief that the meat in his food is poisonous is an example of delusional thinking. Delusions are fixed false beliefs that are held despite contradictory evidence. Delusions are considered "bizarre" if they are clearly implausible and peers within the same culture cannot understand them. An example of a bizarre delusion is when an individual believes that his or her brain is replaces with someone else’s. An example of a nonbizarre delusion is the belief that one is under police surveillance, or like in this case the meat is poisonous despite lack of evidence. (Option A) A hallucination is a sensation or sensory perception that a person experiences in the absence of a relevant external stimulus. That is a person experiences something that does not really exist except in their mind. A hallucination can occur in any sensory modality — visual, auditory, olfactory, gustatory, or tactile. (Option C) Hypochondriasis (recently changed to the term illness anxiety disorder [IAD]) is a strong belief that one has a serious or life-threatening illness despite having no or only mild symptoms. (Option D) Malingering is the purposeful production of falsely or grossly exaggerated physical or psychological complaints with the goal of receiving a reward. (Option E) Illusions are wrong or misinterpreted perception of sensations. Illusions can occur in any sensory modality. The difference between a hallucination and an illusion is that in the former there is an external stimulus which is misinterpreted or perceived differently, while for hallucinations there is no external stimulus.

Answer 70

Correct Answer Is C OCD is a chronic illness that usually can be treated in an outpatient setting. The mainstays of treatment of OCD include pharmacotherapy with clomipramine or selective serotonin re-uptake inhibitors (SSRIs) or behavior therapy. Exposure and response (or ritual) prevention is the important and specific behavior therapy for OCD. In exposure and response prevention (ERP), the situations the patients perceive as threatening are ranked and then the patient is systematically exposed to symptom triggers of gradually increasing intensity and is taught to suppress his or her usual ritualized response. This is generally challenging and often quite distressing for the patient, but when effectively done, it promotes unlearning of the strong link that has existed between having an urge and giving into the urge. (Option A) Insight-orientation psychotherapy, also known as insight therapy, is a form of clientcentered therapy that guides patients towards developing an improved understanding of self. During each session, the person receiving the therapy will recall situations from his/her life. The therapist highlights observed patterns of behavior or feeling and encourages the patient to examine them more closely. This method works through examination and analysis of issues that have negatively affected the patient’s life, and helping the client understand and change destructive patterns. Insight-orientation therapy is not an effective treatment for OCD. (Option B) Patients with OCD are usually aware of and have adequate insight about their bothersome urge for compulsive behavior as a means to relief the anxiety caused the obsessions. Their problem is with the irresistible urge for such relief and not unawareness of their condition; therefore, explaining why their compulsive behavior occurs will not help them as a treatment. (Option D) Psychoanalytic therapy is used to bring unconscious or deeply buried thoughts and feelings to the conscious mind so that repressed experiences and emotions, often from childhood, can be brought to the surface and examined. Working together, the therapist and patient look at how these repressed early memories have affected the patient’s thinking, behavior, and relationships in adulthood. Psychoanalytic therapy is used for people suffering from depression, emotional struggles, neurotic behavior, self-destructive behavior patterns, personality disorders or relationship issues. Psychoanalytic therapy has not proved significantly effective in treatment of OCD. (Option E) Dialectic therapy, a very specialized form of intensive cognitive therapy, is currently considered the treatment of choice for women with borderline personality disorder. This treatment is not approved for treating male patients with borderline personality disorder. Dialectic therapy is not effective for treatment of OCD.

Answer 71

Correct Answer Is E Countertransference is defined as the unconscious development of feelings toward the patient from the treating doctor. Negative countertransference is when such feelings are negative and prevent appropriate empathy and communication. Studies suggest that countertransference is especially evident in the context of substance use, self-harm and anorexia. For substance use and self-inflicted injuries there is often an underlying undiagnosed borderline personality disorder as well as a comorbid condition. The pattern of behavior in patients with this co-morbidity further deteriorates the condition and makes the patientdoctor relationship more difficult and delays access to appropriate treatment. Recent research showed that the most important cause for the negative countertransference in treating personalities who causing self-harm is stigmatism and not socially being accepted. Stigma associated with patients with self-inflicted injury and harm (including anorexia nervosa) is high and in healthcare setting reflects a lack of skills and knowledge in relation to the specific needs of this population, as well as the negative countertransference commonly experienced in working with these patients. Indeed, it has been suggested that individuals with BPD constitute the ‘most psychologically challenging patients a primary care physician ever encounters’, and this is especially true when substance use is also prominent. Working successfully with patients with BPD requires many layers of support in order to prevent any negative countertransference adversely impacting treatment planning or the response to crisis presentations.

Answer 72

Correct Answer Is C Jane has the classical symptoms of panic attacks with some pre-existing anxiety. Panic attacks are defined as a period of intense fear with at least 4 of the following 13 symptoms: 1. Palpitations, pounding heart, or accelerated heart rate 2. Sweating 3. Trembling or shaking 4. Sense of shortness of breath or smothering 5. Feeling of choking 6. Chest pain or discomfort 7. Nausea or abdominal distress 8. Feeling dizzy, unsteady, lightheaded, or faint 9. Derealization or depersonalization (feeling detached from oneself) 10. Fear of losing control or going crazy 11. Fear of dying 12. Numbness or tingling sensations 13. Chills or hot flushes Other describes symptoms include: Headache Cold hands Diarrhea Insomnia Fatigue Intrusive thoughts Ruminations Symptoms must peak within 10 min and usually subside within few minutes, leaving little to observe, except the person's fear of another terrifying panic attack. Many people experience panic attacks without further episodes or complication. In some, however, panic attacks progress to panic disorder characterized by repeated panic attacks, combined with major changes in behavior or persistent anxiety of having further attacks. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, the following criteria must be met in order to make a diagnosis of panic disorder: Panic attacks must be associated with longer than 1 month of subsequent persistent worry about: 1. Having another attack or complications of attack 2. Significant maladaptive behavioral changes related to the attacks 3. The attacks cannot directly or physiologically result from substance use (intoxication or withdrawal), medical condition or another psychiatric disorder. Agoraphobia was traditionally thought to involve a fear of public and open spaces. However, it is now considered a complication of panic attacks. With agoraphobia, the person fears that they may have an attack in a situation where escape would be difficult or embarrassing.

Answer 73

Correct Answer Is A This young boy has presented with symptoms suggestive of depression after an identifiable stressor (the breakup). He has the criteria for ‘adjustment disorder’ as the most likely diagnosis. The DSM-5 diagnostic criteria for adjustment disorder are as follows: Emotional or behavioral symptoms develop in response to an identifiable stressor or stressors within 3 months of the onset of the stressor(s) plus either or both of (1) marked distress that is out of proportion to the severity or intensity of the stressor, even when external context and cultural factors that might influence symptom severity and presentation are taken into account and/or (2) significant impairment in social, occupational, or other areas of functioning. The stress-related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder. The symptoms do not represent normal bereavement After the termination of the stressor (or its consequences), the symptoms persist for no longer than an additional 6 months Royal College of Australian General Practitioners (RACGP) has proposed a model for interacting with patients with psychological distress and disturbances regardless of the underlying etiology. This approach model consists of three steps: STEP 1- Establishing rapport using active listening and empathy, non-directional supportive psychotherapy, and psycho-education. Then if required: STEP 2- Cognitive behavioral therapy (CBT), interpersonal psychotherapy and interpersonal counselling, structured problem solving, behavioral therapy, and family therapy. Then if required: STEP 3- Intensive therapy (e.g., use of medications) See photo below. For this patient establishing rapport in this session is a good start. Being empathetic about his breakup and what he is going through is the most appropriate next step at this stage. This builds therapeutic connection and builds up trust, and paves the path for further intervention. CBT (option B) can be an option, among others, to consider for this patient in the STEP 2 afterwards. Patients with depression in the setting of adjustment disorder usually respond to brief nonpharmacological interventions as mentioned above and do not require anti-depressants such as fluoxetine (option C) and fluvoxamine (option D). Referral to a psychiatrist (option E) is not often required for adjustment disorder. Even so, this should be considered after establishing an appropriate therapeutic relationship with the patient.

Answer 74

**Correct Answer Is C** Cognitive behavior therapy (CBT) (option A), dialectical therapy (option B), psychoanalytic therapy(option D), and anger management program (option E) are all therapeutic options with potential benefit for Monaro. For buried frustration from childhood, psychoanalytic therapy may be beneficial. He has spent 3 years in a correctional facility and is very likely to be suffering from post traumatic stress disorder (PTSD). His anger may respond properly to CBT and anger management program. These methods, however, take time to come to effect. In the meanwhile, Monaro has the acute problem of anger outbursts that are very likely to put him or others at risk. It is recommended that for patients in immediate risk of harm to self or others, or escalation of the current situation, medical therapy is started as a means of rapid stabilization while other non-pharmacological measures are planned and carried out. This is often true regardless of the underlying etiology that can be PTSD, depression, substance abuse, etc. For anger outbursts, antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) have the highest supportive evidence for efficacy, and should be considered acutely for Monaro while other forms of therapy are arranged. **TOPIC REVIEW** A summary on CBT, DBT, psychoanalytic therapy, and anger management: **Cognitive behavioral therapy (CBT)** CBT is a form of psychological treatment that has proven effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications. Advances in CBT have been made on the basis of both research and clinical practice. Indeed, CBT is an approach for which there is ample scientific evidence showing that it actually produce change. In this manner, CBT differs from many other forms of psychological treatments. CBT usually involves efforts to change thinking patterns. These strategies might include: * Learning to recognize one's distortions in thinking that are creating problems, and then to re-evaluate them in light of reality. * Gaining a better understanding of the behavior and motivation of others. * Using problem-solving skills to cope with difficult situations. * Learning to develop a greater sense of confidence is one's own abilities. CBT treatment also usually involves efforts to change behavioral patterns. These strategies might include: * Facing one's fears instead of avoiding them. * Using role playing to prepare for potentially problematic interactions with others. * Learning to calm one's mind and relax one's body. **Dialectical behavior therapy (DBT)** DBT is a type of talking therapy originally developed by an American psychologist named Marsha Linehan. DBT is based on cognitive behavior therapy (CBT), but has been adapted to meet the particular needs of people who experience emotions very intensely. It is mainly used to treat problems associated with borderline personality disorder (BPD), such as: * Repeated self-harming * Suicide attempt * Using alcohol or drugs to control emotions * Eating problems, such as binge eating and purging * Unstable relationships The goal of DBT is to help patients learn to manage their difficult emotions by letting themselves experience, recognize, and accept them. Then as they learn to accept and regulate their emotions, they also become more able to change their harmful behavior. To help patient achieve this, DBT therapists use a balance of acceptance and change techniques. **Psychoanalytic therapy** Psychoanalytic therapy is a form of in-depth talk therapy that aims to bring unconscious or deeply buried thoughts and feelings to the conscious mind so that repressed experiences and emotions, often from childhood, can be brought to the surface and examined. Working together, the therapist and client look at how these repressed early memories have affected the client’s thinking, behavior, and relationships in adulthood. People with depression, emotional struggles, emotional trauma, neurotic behavior patterns, self-destructive behavior patterns, personality disorders, or ongoing relationship issues, may benefit from psychoanalytic therapy. **Anger management** Anger management is a psycho-therapeutic program for anger prevention and control. It has been described as deploying anger successfully. Anger is frequently a result of frustration, or of feeling blocked or thwarted from something the subject feels is important. Anger can also be a defensive response to underlying fear or feelings of vulnerability or powerlessness. Anger management programs consider anger to be a motivation caused by an identifiable reason which can be logically analyzed, and if suitable worked toward. Drug addiction, alcoholism, mental disability, biochemical changes, and PTSD can all lead to a person committing an aggressive act against another person.

Answer 75

Correct Answer Is C Current guidelines recommend systematic desensitization for patients with specific phobias. Systematic desensitization is a type of behavior therapy based on the principle of classical conditioning. This therapy aims to remove the fear response of a phobia, and substitute a relaxation response to the conditional stimulus gradually using counter conditioning. There are three phases to the treatment: Phase 1 - The patient is taught a deep muscle relaxation technique and breathing exercises, e.g., control over breathing, muscle de-tensioning or meditation. This step is very important because of reciprocal inhibition, where once response is inhibited because it is incompatible with another. In the case of phobias, fears involves tension and tension is incompatible with relaxation. Phase 2 - The patient creates a fear hierarchy starting at stimuli that create the least anxiety (fear) and building up in stages to the most fear provoking images. The list is crucial as it provides a structure for the therapy. The following table is an example rated by a patient: (see photo below) Phase 3 - The patient works their way up the fear hierarchy, starting at the least unpleasant stimulus (thinking about a dog) and practicing their relaxation technique as they go. When they feel comfortable with this (they are no longer afraid) they move on to the next stage in the hierarchy. If the client becomes upset they can return to an earlier stage and regain their relaxed state. The client repeatedly imagines (or is confronted by) this situation until it fails to evoke any anxiety at all, indicating that the therapy has been successful. This process is repeated while working through all of the situations in the anxiety hierarchy until the most anxiety-provoking stimulus is reached. Based on this therapy, the first step in approaching Janet’s phobia would be teaching her relaxation techniques and methods to overcome the anxiety brought up by exposure to the graduallyintensifying stimuli. Other options are stimuli she should face after she learns how to overcome anxiety and relax in a hierarchical fashion.

Answer 76

Correct Answer Is B This woman is presenting significant yet unrealistic concerns about and is preoccupied with her weight and body size while she has a near healthy BMI (healthy BMI: 18.5-24.9 kg/m2). Also, there is no pointers towards other conditions such as anorexia nervosa or bulimia nervosa. One important diagnostic criterion for anorexia nervosa is a BMI of less than 17.5 kg/m2 . A BMI of 25 kg/m2 in this woman excludes anorexia nervosa (option C) as a diagnosis, and lack of binge eating and purging in history makes bulimia nervosa (option A) very unlikely. Given these, body dysmorphic disorder (BDD) is the most likely diagnosis in this scenario. Specific DSM-5 criteria for BDD are as follows: The individual is preoccupied with 1 or more perceived defects or flaws in physical appearance that are not observable by or appear slight to others At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning The appearance preoccupation cannot be better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder (option D) Hypochondriasis is associated with excessive and unduly concerns about a serious disease. This woman does not have any concerns about a disease rather is obsessively preoccupied with her physical appearance. (Option E) Generalized anxiety disorder (GAD) is a disorder characterized by excessive or unrealistic anxiety about two or more aspects of life such as work, social relationships, financial issues, etc., often accompanied by physical symptoms of anxiety such as palpitation, shortness of breath, chest pain, or dizziness. Although preoccupation with the weight can cause anxiety in this woman, given the absence of worry in other aspects, GAD cannot be a diagnosis.

Answer 77

Correct Answer Is D This case scenario is a clear example of denial defense mechanism. Sid has a clear diagnosis of severe depression, but he denies it and believes it is just the exhaustion and that he has just been through too much. Denial is one of the most common defense mechanisms. When a situation or fact becomes too much to handle, the person copes by refusing to experience it. By denying reality, one essentially protects himself from the need to face and deal with the unpleasant consequences and pain that accompany acceptance. Examples of denial are: A smoker denies that his habit has negative health consequences so he can continue smoking. A parent denies that her son has dropped out of college even though the school administrator has left her three voicemails telling her so. A business owner denies that her business is failing despite declining profits. A problem drinker denies his alcohol dependence and believes he is just a social drinker. Someone with failing marriage believes that every couple eventually loses the romance. (Option A) Displacement occurs when a person represses affection, fear, or impulses that they feel towards another person. Accepting that it is irrational or socially unacceptable to demonstrate such feelings prevents them from being converted into actions. However, the feelings are instead displaced towards a person or animal whom it is acceptable to express such feelings for. A person who dislikes their teacher after being given low grades may feel that they would be punished if they express their hostility towards them. Therefore, they may unconsciously displace their negative emotions onto their best friend. Examples of displacement defense mechanism are: A woman who is frustrated because her boss made her work late again comes home and yells at her son for asking what’s for dinner. A man who is mad that he can’t seem to get ahead at work constantly criticizes his wife for not making more money. An employer who is frustrated with his business’ losses blames his employees instead of rethinking his business strategy. (Option B) With reaction formation defense mechanisms, one goes beyond denial and behaves in the opposite way of which they think or feel. Typically, reaction formation is marked by a blatant display. For example, a man with strong homosexual desires, vigorously and overtly reasons against homosexuality.Other examples of reaction formation are: A woman cares for her aging mother by cooking her meals, cleaning her home and taking her to appointments while she secretly despises her. A person with a drinking problem preaches about the virtues of sobriety and not drinking alcohol instead of taking steps toward moderate drinking. (Option C) When we experience feelings or desires that cause anxiety, or that we are unable to act on owing to the negative impact that they would have on us or those around us, we may defend the ego from resulting anxieties by projecting those ideas onto another person. A person who is afraid of crossing a bridge with a friend might accuse them of having a fear of heights, for example, and in doing so, avoids accepting their own weaknesses. Examples of projection defense mechanism You really dislike your manager at work who treats you just like they treat everyone else. Instead of admitting your dislike, you tell everyone the manager has a grudge against you and is trying to sabotage your career. A woman is in a bad mood all day and comes home to her husband. After greeting her warmly and asking about her day, she instantly accuses him of being in a bad mood and ruining her evening. A father has body image issues but refuses to make lifestyle changes that would help him lose weight. Instead, he blames his daughter for her weight, projecting his lack of self-confidence onto her. (Option E) Rationalization occurs when a person attempts to explain or create excuses for an event or action in rational terms. In doing so, they are able to avoid accepting the true cause or reason resulting in the present situation. Examples of rationalization defense mechanism are: A man forgets to take out the garbage even though his wife has reminded him four times. Instead of apologizing, he rationalizes that she hasn’t loaded the dishwasher so it’s only fair that he not take out the garbage. A woman stands up her friend for lunch and tells herself it’s okay because her friend is always late for their morning yoga sessions. A student rationalizes cheating on a test by saying the test was too demanding anyway.

Answer 78

**Correct Answer Is B.** Base on the facts in the scenario, this man is most likely utilizing projection as a defense mechanism. Projection is the misattribution of a person’s undesired thoughts, feelings, or impulses onto another person who does not have those thoughts, feelings, or impulses. Projection is used especially when the thoughts are considered unacceptable for the person to express. For example, a man may be angry at their wife for not listening, when in fact it is the angry man who does not listen. Projection is often the result of a lack of insight and acknowledgement of one’s own motivations and feelings. In this scenario, the drought might really has caused his financial problems, but putting all the blame on the government and authorities and not accepting his share of irresponsibility helps him, subconsciously, to misattribute the root cause of this feeling on someone or something else. In other words, he is projecting the negative feelings of recklessness and irresponsibility elsewhere to protect his ego. In projection, in fact, some negative feelings or perceptions are completely or partially mirrored out. Some other examples of projection are: You really dislike your manager at work who treats you just like they treat everyone else. Instead of admitting your dislike, you tell everyone the manager has a grudge against you and is trying to sabotage your career. A woman is in a bad mood all day and comes home to her husband. After greeting her warmly and asking about her day, she instantly accuses him of being in a bad mood and ruining her evening. A father has body image issues but refuses to make lifestyle changes that would help him lose weight. Instead, he blames his daughter for her weight, projecting his lack of self-confidence onto her. (**Option A**) Denial is one of the most common defense mechanisms. When a situation or fact becomes too much to handle, the person copes by refusing to experience it. By denying reality, one essentially protects himself from the need to face and deal with the unpleasant consequences and pain that comes with acceptance. Examples of denial are: A smoker denies that his habit has negative health consequences so he can continue smoking. A parent denies that her son has dropped out of college even though the school administrator has left her three voicemails telling her so. A business owner denies that her business is failing despite declining profits. A problem drinker denies his alcohol dependence and believes he is just a social drinker. Someone with failing marriage believes that every couple eventually loses the romance. (**Option C**) Displacement occurs when a person represses affection, fear, or impulses that they feel towards another person because he/she beleives it is irrational or socially unacceptable to demonstrate such feelings. However, the feelings are instead displaced towards another person or animal. A person who dislikes their teacher after being given low grades may feel that they would be punished if they express their hostility towards them. Therefore, they may unconsciously displace their negative emotions onto their best friend, making excuses for treating them badly without justification. Examples of displacement defense mechanism are: A woman who is frustrated because her boss made her work late again comes home and yells at her son for asking what’s for dinner. A man who is mad that he can’t seem to get ahead at work constantly criticizes his wife for not making more money. An employer who is frustrated with his business’ losses blames his employees instead of rethinking his business strategy. (**Option D**) Rationalization occurs when a person attempts to explain or create excuses for an event or action in rational terms. In doing so, they are able to avoid accepting the true cause or reason resulting in the present situation. Examples of rationalization defense mechanism are: A man forgets to take out the garbage even though his wife has reminded him four times. Instead of apologizing, he rationalizes that she hasn’t loaded the dishwasher so it’s only fair that he not take out the garbage. A woman stands up her friend for lunch and tells herself it’s okay because her friend is always late for their morning yoga sessions. A student rationalizes cheating on a test by saying the test was too demanding anyway. A shoplifter blames the high price of sweets to justify their theft of a chocolate bar, when in reality they simply enjoyed the act of shoplifting. NOTE – The case scenario may be mistakenly interpreted as rationalization as he might sound as if he is rationalizing his problems by something else which in this case is the government. There is, however, a very fine differentiating factor between these two in this scenario; that is, he is attributing his exact recklessness and irresponsibility to an outer source. The key difference is the ‘mirroring process’ which is specific to projection defense mechanism. (**Option E**) Regression occurs when a person reverts to the types of behavior that they exhibited at an earlier age. Stress of adult life and the associated anxiety may lead to a person seeking comfort in things which they associate with more secure, happier times. They might regress by eating meals that they were given as a child, watching old films or cartoons, acting without thought for the consequences of their actions. Examples of regression are: A 9-year-old boy is in the hospital to get his tonsils removed and begins sucking his thumb like he did when he was a toddler. A woman gets in an argument with someone at work and starts sobbing uncontrollably. Instead of utilizing mature parenting techniques like empathy and boundaries, a father resorts to temper tantrums to scare his children into obedience.

Answer 79

Correct Answer Is C Insomnia disorder is characterized by inadequate sleep despite adequate sleep opportunity, accompanied by daytime dysfunction. Both pharmacologic and psychological interventions could be used for treatment of insomnia disorder; however, selecting the right treatment depends on the chronicity of symptoms, taking into account medical and psychiatric factors. Current guidelines recommend cognitive behavioural therapy for insomnia (CBT-i) as the gold standard and first-line treatment for insomnia. This may be complemented with short-term pharmacological intervention. The following diagram illustrates a stepwise approach to treatment of insomnia: see photo below. The very first step in management of patients with insomnia is gathering a detailed sleep history and treatment of any contributing factors and comorbidities. The second step is utilizing CBT-I. CBT-I includes the following components: Implementation of good sleep hygiene Sleep restriction* and stimulus control programs**, and relaxation procedures*** Cognitive therapy for insomnia Sleep hygiene and routine is a term that encompasses most of the above and is the next best step and in fact the most important arm of treatment for this patient. However, if CBT was an option, it would be a more exact and appropriate one to choose. Sleep hygiene and routing include the following pieces of advice for patients suffering from insomnia: Following a nightly routine: Budgeting 30 minutes for winding down before sleep (soft music, light stretching, reading and/or relaxation exercise Dimming the light Unplugging from electronics (e.g., TV, mobiles, tablets, etc.) Relaxation techniques Not tossing and turning in the bed and walking out of the bedroom if not fell sleep within 15- 30 minutes Cultivation of healthy daily habits: Adequate daytime light exposure Day time regular exercise Cutting down on alcohol Cutting down on caffeine in the afternoon and evening hours Smoking cessation Avoiding late dining Avoiding using the bed for anything but sleep and sex Bedroom optimization: Comfortable beddings Setting a cool yet comfortable temperature Blocking out noise and light in the bedroom Using calming scents (Option A) Supportive psychotherapy is a talking-based therapy designed to allow a person with mental health issues to voice their concerns and receive encouragement and help in finding practical solutions. Supportive psychotherapy is used to help people dealing with serious addiction, eating disorders, stress, and other mental health issues. This method works to build a person’s adaptability and resilience and better coping strategies for the future. Although this treatment could be beneficial to treatment the underlying mental issues associated with or underlying insomnia, it is not a recommended stand-alone therapy for it. (Option B): Interpersonal therapy focuses on the interpersonal relationships of the depressed person. The idea of interpersonal therapy is that depression can be treated by improving the communication patterns and how people relate to others. Techniques of interpersonal therapy include: Identification of emotion — Helping the person identify what their emotion is and where it is coming from. Example - Roger is upset and fighting with his wife. Careful analysis in therapy reveals that he has begun to feel neglected and unimportant since his wife started working outside the home. Knowing that the relevant emotion is hurt and not anger, Roger can begin to address the problem. Expression of Emotion - This involves helping the person express their emotions in a healthy way. Example - When Roger feels neglected by his wife, he responds with anger and sarcasm. This in turn leads his wife to react negatively. By expressing his hurt and his anxiety at no longer being important in her life in a calm manner, Roger can now make it easier for his wife to react with nurturance and reassurance. Dealing with emotional baggage - Often, people bring unresolved issues from past relationships to their present relationships. By looking at how these past relationships affect their present mood and behavior, they are in a better position to be objective in their present relationships. Example — Growing up, Roger’s mother was not a nurturing woman. She was very involved in community affairs and often put Roger’s needs on the back burner. When choosing a wife, Roger subconsciously chose a woman who was very attentive and nurturing. While he agreed that the family needed the increased income, he did not anticipate how his relationship with his own mother would affect his reaction to his wife working outside the home. (Option D) Motivational therapy/interviewing is a therapy technique that empowers patients to make actionable behavioral changes in their lives through an interview-style discussion with a licensed mental health professional. This technique focuses on change talk where patients verbalize their need and desire to make changes in their lives. Since the benefits of motivational interviewing for mental health are numerous, it has become a common treatment method for people struggling with various mental health problems and cooccurring disorders like substance abuse. This therapy technique identifies and accepts the fact that individuals who need to make changes in their lives approach counselling at different levels of readiness to change their behavior. In some cases, patients may have thought about making a behavior change but have not taken the necessary steps to make that change happen. During this fragile time, people may express a fear of change and deal with internal struggles that need to be broken down. This is where motivational interviewing steps in. A motivational interview allows individuals to learn how to effectively change unhealthy behaviors to aid the addiction recovery process. (Option E) Syntonic phototherapy (light therapy) uses visible colored lights to enhance visual attention and decrease the symptoms of stress and trauma. The goal of this therapy is to balance the autonomic nervous system which controls visual perceptual fields. Colored light delivered through the eyes helps control biological development and function. For example, red light activates the sympathetic nervous system (‘fight-or-flight’ responses such as heart rate and blood pressure) and blue/indigo stimulates the parasympathetic nervous system (‘rest and digest’ responses like salivation, urination, and even arousal). Syntonic phototherapy consists of patients focusing their eyes at a dot of color at the end of a 50cm tube. Patients view specific safe light frequencies for approximately 20 minutes at a time over a prescribed number of sessions (usually around 20, done over the course of 4-5 weeks). As light enters the eyes, it travels from nerves connected to the retina to brain centers that influence chemical, hormonal, and electrical balances. These centers control the balance of all body functions, and years of study have proven that selected light frequencies delivered through the retina can create favorable results that benefit the entire body. In addition to red and blue lights and their systemic healing of the parasympathetic and sympathetic nervous systems, green lights promote physiological balance. Once this balance is achieved, the effect is long lasting for most individuals. Because the practice affects the entire nervous system, the potential benefits of syntonic therapy are numerous and varied. Syntonics can enhance visual acuity by improving blurred vision, contrast, night vision issues, and light and allergy sensitivity. This therapy is also used to help alleviate pain, headaches, eyestrain, and mental and emotional stress levels. Based on lack of evidence for usefulness of this method for insomnia, it is not currently a recommended treatment option for sleep problems. *Sleep restriction – The aim of sleep restriction is to increase sleep drive and reduce the time awake in bed. Time in bed must be aimed to align with the patient’s sleep duration. Gradually, more time is spent in bed as sleep improves. Sleep restriction is typically administered by trained professionals and requires close monitoring of daily sleep–wake patterns. **Stimulus control – Behaviors that require wakefulness (e.g., watching TV, reading books) in bed could result in bed being associated with hyperarousal, thereby perpetuating sleep difficulties. Stimulus control helps to re-associate bed with being asleep. The patient is instructed to go to bed only when sleepy. This helps re-associate bed with sleepiness. Activities in bed should be limited to only sleeping and sex. The patient is instructed to leave the bed and bedroom if unable to fall sleep within what feels like 15–30 minutes (without looking at the clock). During the time out, the patient is instructed to complete a non-stimulating task, returning to bed when they feel comfortable. The same morning wake-time is recommended even if sleep the night before is poor. **Relaxation – Relaxation strategies can include progressive muscle relaxation and diaphragmatic breathing. The goal is to release tension and arousal; however, close monitoring of patients is important as relaxation may become sleep effort in disguise.

Answer 80

Correct Answer Is D Studies suggest that in patients with depression severe enough to mandate hospital admission, the highest risk of suicide is within 4 weeks post-discharge after inpatient care of a depressed patient. One study showed that 43% of those who were treated as inpatient for depression attempted suicide within 1 month of discharge and 47% died before first appointment. Overall, the risk of suicide within 4 weeks after psychiatric inpatient care is 100 higher compared to that of general population. A strong belief has long been held that during the early improvement phase after commencement of treatment, the risk of suicide is high because the apathy symptoms resolve but depressed mood remains; this believe, however, has been questioned according to recent studies. NOTE – In general, suicide risk in depressed patients is highest when there is an initial symptoms improvement brought about by treatment. In this period, the depressed patient is out of the low mood and apathy and more likely to act on a suicide plan. However, admitted patients are monitored and cared for during their stay and risk of suicide is lower compared to after discharge when patient is more likely to feel left on his/her own and there is no ongoing support or monitoring.

Answer 81

Correct Answer Is D At first glance, there might be diagnostic confusion because critical pieces of information in history and mental status exam (MSE) are missing. The question, however, asks about the most likely diagnosis based on the given information rather than a certain diagnosis. There are some pieces of the puzzle that can be elicited from the scenario. This patient has been having anger outbursts and fights over trivial issues that suggest ‘impulse control’ problems. He has been self-mutilating, self-cutting, and refusing to eat or drink. Moreover, his sanity writings on the cell walls indicates reassurance-seeking behavior. Since no one can reassure him, he is doing it himself. These features make borderline personality disorder (BPD) the most likely explanation with just this amount of available information (read the DSM 5 diagnostic criteria for BPD below). This patient has been in imprisoned, and this could suggest antisocial personality disorder (ASPT) as well. In ASPD there is a persistent display of impulsive, reckless, and aggressive behaviors and no remorse about them. There is often a history of violent relationships, legal challenges, and substance abuse if you have this personality disorder. BPD and antisocial ASPD share some similarities. Both ASPT and BPD belong to cluster B personality disorders (dramatic, emotional, and unpredictable behavior) and have disinhibited behavior as a presentation. They both also have impulsivity in common. However, in ASPT the person involves in violence and aggressiveness because they can (there is the element of control and decision) while in BPD it happens because it cannot be controlled. Another differentiating factor is that in ASPT the harm targets others while in BPD the harm is directed towards self. This makes ASPD less likely of a diagnosis. Psychosis (option A) and schizophrenia (as a psychotic disorder) (option B) are associated with features such as impaired speech, auditory hallucinations, and delusional thinking, none of which is present in the scenario. This makes them a less likely diagnosis. Factitious disorder (option E) is a falsification of illness in oneself or another person (factitious by proxy) without any obvious gain. By obvious gain, it is meant that the patient does not have a known external motivation or achievement for producing the symptoms. Features seen in factitious disorder are: Inconsistencies between patient history and medical observations. Vague details that seem plausible on the surface but that don’t hold up to scrutiny. Lengthy medical records with multiple admissions at different hospitals. Willingness to accept any discomfort and risk from many medical procedures, even surgery. Overdramatic or outlandish presentation of a factitious illness, or hostility when challenged. Although a detailed mental history might make this condition a diagnosis in this patient, later on, the absence of the above features in the scenario makes such a diagnosis less likely compared to BPD. DSM-5 diagnostic criteria for BPD A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) or the following: 1. Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5) 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3. Identity disturbance: markedly and persistently unstable self-image or sense of self 4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating) (Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5) 5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability , or anxiety usually lasting a few hours and only rarely more than a few days) 7. Chronic feelings of emptiness 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Answer 82

**Correct Answer Is B.** Jealousy a common yet complex emotion which has been well-recognized throughout mankind history. Jealousy is defined as ‘feeling or showing a resentful suspicion that one’s partner is attracted to or involved with someone else’. This definition indicates that it is a belief in the presence of rivalry that is the key issue and that whether or not such a rivalry truly exists is less important. While normal jealousy is considered a normal human emotion, morbid jealousy is pathological. Morbid jealousy is not a diagnosis rather it describes a range of irrational thoughts and emotions that is accompanied by unacceptable or extreme behavior, in which the dominant theme is a preoccupation with a partner’s sexual unfaithfulness based on unfounded evidence. The following features in morbid jealousy can distinguish it from normal jealousy: * Excessive amount of time taken up by jealous concerns * Difficulty in putting the concerns out of the mind * Impairment of the relationship * Limitation of the partner's freedom * Checking on the partner's behavior There are three forms of morbid jealousy: (1) delusional jealousy, (2) obsessional jealousy, and (3) overvalued jealousy. In **delusional jealousy** the characteristic feature is the presence of strong false belief of the partner being unfaithful (certainty) while in **obsessive jealousy** the affected individual suffers from unpleasant and irrational jealous rumination that the partner could be unfaithful (considering a possibility not in the form of a strong belief) which is followed by compulsive checking of the partner’s behavior. The difference between these two is the presence of a strong beliefs in unfaithfulness in delusional jealousy versus the bothersome lingering thoughts of the possibility of unfaithfulness. **Overvalued jealousy** shared many features with obsessional jealousy. In overvalued jealousy, there is an acceptable and comprehensible idea which is excessively pursued by the patient beyond the bounds of reason. The main difference could be lack of compulsions and compulsive behavior in overvalued jealousy. Morbid jealousy is not a diagnosis rather a comorbidity seen in many psychiatric conditions, personality disorders, and other settings including but not limited to drugs and alcohol abuse, psychotic disorders and schizophrenia, mania, depression, obsessive compulsive disorder (OCD), and anxiety disorders. A recent study showed that of all psychiatric illnesses, schizophrenia is most likely to be associated with morbid jealousy, most commonly in form of delusional jealousy. The study concluded that depression (**option D**) could be the second most significant condition associated with morbid jealousy. Interestingly, all three forms of morbid jealousy were identified across the patients with depression in the study. Other conditions identified to be potentially associated with morbid jealousy in order of strength of such association were drug and alcohol abuse (**option A**), bipolar mood disorders (**option C**), and lastly other conditions such as anxiety disorders, OCD (**option E**), dementia and other. The same study concluded that morbid jealousy in more common in men than woman, and also more common among married versus single men. Treatment of morbid jealousy is with psychotherapy (e.g., CBT) and pharmacotherapy (e.g., SSRIs or antipsychotics depending on the underlying condition and diagnosis). *NOTE - Of the personality disorders, borderline personality disorder is most prone to morbid jealousy.*