Módulo 2 Psiquiatra Flashcards
(50 cards)
A 35-year-old married man presents to his primary care physician 1 month after a recent hospitalization for a car accident, which left him with limited use of his arm and hand. The patient, who is a local contractor building houses, was instructed to avoid any gripping, arm raising, and other strenuous activities that his work had previously required. He continues to oversee his workers on the job but now complains that he finds himself anxious and despondent at times, with episodes of irritability and tearfulness and a decreased interest in his work. He still enjoys coaching his son’s baseball team, and he has had no sleep or appetite changes. He also feels that his sexual desire has diminished. The patient has no prior personal or familial history of a mood disorder or psychiatric disorder. Which of the following is the most likely diagnosis?
(A) Adjustment disorder with depressed mood
(B) Bipolar disorder, most recent episode depressed
(C) Conversion disorder
(D) Dysthymic disorder
(E) Major depressive disorder
Respuesta: A
The correct answer is A. The best diagnosis is adjustment disorder with depressed mood, as the patient had several stressors including a recent hospitalization, a debilitating injury, and an inability to perform his job duties as he had done previously. As a result of these changes, the patient developed some of the symptoms of depression without a full set of symptoms, such as insomnia or anorexia.
The patient does not have any history of manic episodes, which means bipolar disorder, most recent episode depressed (choice B), is not a possibility.
Conversion disorder (choice C) is a psychiatric disorder in which one or more physical symptoms or deficits affect voluntary motor or sensory function. The diagnosis requires that a symptom or deficit cannot be fully explained by a general medical condition, which is not the case for this patient.
Dysthymic disorder (choice D) is a disorder in which mood is depressed for most of the day, for more days than not, for at least 2 years. This diagnosis is not a possibility because the patient’s depressive symptoms are limited to this episode only.
Major depressive disorder (choice E) is not the appropriate diagnosis, as his symptoms have not lasted for more than a few weeks, and the patient does not have the full vegetative set of symptoms of major depressive disorder.
A 57-year-old Asian American man, accompanied by his wife, presents to a psychiatrist. The patient has no significant past medical or psychiatric history. He admits to depressed mood, decreased appetite, a 10-pound weight loss, initial insomnia, decreased ability to concentrate, and mild memory problems for the past 3 weeks. On further questioning, he states that he feels hopeless and helpless. On mental status examination, the patient appears calm and is cooperative. He has a sad affect. There is no evidence of a thought disorder. Which of the following would be the most appropriate next step in management?
(A) Assessment of suicidality
(B) Cognitive-behavioral therapy
(C) Initiation of a selective serotonin reuptake inhibitor
(D) Initiation of a benzodiazepine
(E) Urine drug screen
Respuesta: A
The correct answer is A. The patient has symptoms suggestive of major depressive disorder, and assessment of suicide risk is paramount in interviewing him. Depressed patients have a significantly higher risk of attempting and completing suicide compared with the general population. Therefore, determining whether a depressed patient is at high risk is essential early in their management.
Although cognitive-behavioral therapy (choice B) may be an important adjunct in treating depression, it is not the most appropriate next step in this patient’s management.
Although a selective serotonin reuptake inhibitor (SSRI) (choice C) would be an acceptable pharmacologic intervention in this patient with depression, assessing suicidality takes precedence.
A benzodiazepine (choice D) may be acceptable on a short-term basis in an individual who is acutely agitated or has significant symptoms of anxiety. This patient, however, appears calm and cooperates with the examiner, and there is no suggestion for the need for acute use of a benzodiazepine.
A urine drug screen (choice E) may prove helpful in differentiating a major depressive episode from a substance-induced mood disorder. However, even patients with a substance-induced mood disorder are at higher risk for suicide than the general population, and assessment of suicidality must occur early in management.
A 47-year-old Asian American man visits his physician for problems falling asleep. The man says he goes to bed every night at 11 PM and arises at 6 AM; however, he does not fall asleep until about 60 minutes after going to bed. He denies depressed mood or recent psychosocial stressors. When asked about his daily routine, he reports that he takes a brisk walk every morning and then goes to work. On the way to work, he drinks one cup of coffee, but denies any other caffeine intake during the remainder of the day. At around 9:30 PM, he eats dinner and then watches television until 11 PM, at which time he drinks 1 ounce of whiskey before retiring. Which of the following would be the best advice for this patient?
(A) Decrease the intensity of the morning exercise
(B) Eat dinner earlier in the evening
(C) Exercise vigorously just prior to going to bed
(D) Increase the amount of alcohol drunk before retiring
(E) Use zolpidem at bedtime as needed
Respuesta: B
The correct answer is B. The first step in evaluating insomnia in a patient, after ruling out a mood disorder, is to review the “sleep hygiene” activities that affect the sleep-wake cycle, such as going to bed and waking up at the same time every day. In this case, eating a large meal before retiring might be the reason why this patient is having difficulty falling asleep. Encouraging him to eat an earlier dinner would be an appropriate adjustment in his routine.
Increasing the intensity of the morning workout would likely improve his sleep; decreasing it would prove unhelpful (choice A).
Vigorous exercise just prior to going to bed (choice C) would likely exacerbate the insomnia.
Although a nightcap (choice D) may help the patient fall asleep initially, its effect on sleep architecture would likely keep him from feeling rested on awakening. Increasing his alcohol intake prior to retiring will probably exacerbate this problem.
The use of medication, such as zolpidem (choice E), is reserved for situations in which adjustments in sleep hygiene prove ineffective. In addition, hypnotics are intended to be used on a short-term basis only.
A 15-year-old high school sophomore is brought to the emergency department by his father because of bizarre behavior during the past week. Two weeks earlier, the patient’s twin brother was killed in a car accident. After the funeral, while helping to go through his brother’s things, the boy began screaming and flailing about wildly, saying that his brother’s guardian angel was coming to get him for not taking better care of his brother. The patient had been an excellent student and a popular athlete, with no previous psychiatric history. Which of the following is the most likely diagnosis?
(A) Brief psychotic disorder
(B) Delusional disorder
(C) Drug intoxication
(D) Grief reaction
(E) Schizophrenia
Respuesta: A
The correct answer is A. Brief psychotic disorder is a diagnosis that requires the sudden onset of a florid psychotic episode immediately after a marked psychosocial stressor in the absence of increasing psychopathology before the stressor.
Delusional disorder (choice B) is incorrect because this disorder requires nonbizarre delusions of at least 1 month’s duration, which has not occurred in this case.
Drug intoxication (choice C) often can present with symptoms similar to brief psychotic disorder, but there is no indication of substance use in this case.
Grief reaction (choice D) is an expected and normal reaction to the loss of a loved one. The patient’s behavior and psychosis are not within the realm of a normal reaction.
Schizophrenia (choice E) requires symptoms of psychosis for at least 6 months.
A 62-year-old Iranian American man is seen for the first time by a physician for complaints of abdominal pain. The patient states that the pain has been present for more than a year, is localized to the lower abdomen, and is “sharp and crampy” in character. He has brought with him a rather sizable stack of medical records. A careful review of the records reveals that the patient has had the same complaint for approximately 3 years, and several extensive and redundant evaluations by various physicians for pathology have been uninformative. When the physician asks the patient what he believes to be responsible for the pain, he replies, “I don’t believe it’s anything-know it’s cancer.” When confronted with the contents of his medical records, which reveal no malignancy, the patient states, “Colon cancer runs in my family. I know that if you run another test, it’ll show something serious.” Which of the following is the most likely diagnosis?
(A) Body dysmorphic disorder
(B) Conversion disorder
(C) Hypochondriasis
(D) Schizophrenia
(E) Somatization disorder
Respuesta: C
The correct answer is C. In hypochondriasis, the patient has the firm conviction of having a serious illness, despite repeated evidence to the contrary. Even when presented with definitive evidence, these patients remain convinced that they are ill. Oftentimes these patients make multiple visits to different physicians and undergo repeated diagnostic studies, but still remain certain that they have a serious affliction.
In body dysmorphic disorder (choice A), the preoccupation has to do with physical appearance, not a physical illness.
In conversion disorder (choice B), a deficit or symptom of voluntary motor or sensory function suggests a neurologic disease, which is not present.
Schizophrenia (choice D) involves delusions and/or hallucinations, and onset is usually much earlier in life.
Somatization disorder (choice E) is characterized by multiple somatic complaints. In hypochondriasis, there is the fear that one has a particular disease.
A 68-year-old Latina is seen in the emergency department because of complaints of anxiety. She states she has been taking medication for anxiety for the past 10 years; however, she ran out of medication 2 days ago. She denies the use of any illicit drugs or alcohol. She does not know the name of the medication she has been taking. Laboratory studies are remarkable for a urine drug screen positive for benzodiazepines. The physician should be most concerned about withdrawal from which of the following medications?
(A) Alprazolam
(B) Buspirone
(C) Chlordiazepoxide
(D) Clonazepam
(E) Diazepam
Respuesta: A
The correct answer is A. Of the four benzodiazepines listed, alprazolam has the shortest half-life and the greatest potential for precipitating withdrawal. Benzodiazepine withdrawal, which is indistinguishable from alcohol withdrawal, can be life-threatening.
Buspirone (choice B) is not a benzodiazepine and is not associated with a known withdrawal syndrome. It has FDA approval for generalized anxiety disorder.
Chlordiazepoxide (choice C), clonazepam (choice D), and diazepam (choice E) are all benzodiazepines with long half-lives. Although abrupt cessation of these medications may precipitate withdrawal, it would be less likely. Therefore, given the choices listed, one would choose the benzodiazepine with the shortest half-life as being the medication most likely to be of concern to the physician.
A mother brings her 4-year-old boy to the pediatrician because he has had trouble relating to children in his new preschool. His birth history was unremarkable, but he has been slow to develop language and has required speech therapy. In the office, the child rarely makes eye contact, and he flaps his hands. When given a doll, he does not engage in imaginary play. He has no dysmorphic features, and the rest of his examination is normal. Which of the following is the most likely diagnosis?
(A) Asperger syndrome
(B) Autism
(C) Dyslexia
(D) Fragile X syndrome
(E) Rett syndrome
Respuesta: B
The correct answer is B. The diagnosis of autism requires impairment in social interaction and language combined with repetitive or stereotyped patterns of behavior such as hand flapping. There must also be a history of delayed development, occurring prior to age 3 years, in one of the following domains: social interaction, communication, or imaginative play. The etiology is currently unknown, but studies of monozygotic twins suggest a strong genetic component. The most common genetic cause of autism is the fragile X syndrome.
Asperger syndrome (choice A) is similar to autism but spares language function. A patient must have normal language development in the presence of both repetitive or stereotyped behaviors and impaired social interaction.
Dyslexia (choice C) is a language disorder predominantly affecting reading. It may be heralded by a history of language delay in children who are not yet old enough to read, as in this case, but there should be no repetitive behaviors or impaired social interaction.
Fragile X syndrome (choice D) is a common X-linked recessive disorder involving a trinucleotide repeat. It affects boys much more severely than girls, who are usually normal or minimally impaired. It is a common genetic cause of both mental retardation and autism. In addition to symptoms of these two conditions, boys with fragile X often have dysmorphic features, most commonly a long face and enlarged ears.
Rett syndrome (choice E) shares many features of autism, but it affects only girls. In addition to the autistic features, girls with this disorder develop deceleration of head growth between 5 and 48 months of age, lose previously acquired hand skills, and show poor coordination of gait or trunk movements on exam.
A 43-year-old African American woman is discharged from a 4- week-long alcohol dependence treatment program. At the end of this program, the patient discusses with her physician possible pharmacologic modalities that may assist in preventing relapse. It is decided that she begin a trial of disulfiram (Antabuse™). She is told that she must avoid ingestion or dermal contact of any substances containing alcohol. The patient asks how the medication works and is told that disulfiram inhibits an enzyme that then causes accumulation of a noxious metabolite. Inhibition of which of the following enzymes accounts for the clinically significant effect of disulfiram?
(A) Acetylcholinesterase
(B) Alcohol dehydrogenase
(C) Aldehyde dehydrogenase
(D) Cytochrome P450
(E) Tyrosine hydroxylase
Respuesta: C
The correct answer is C. Disulfiram inhibits aldehyde dehydrogenase, which causes a marked increase in levels of acetaldehyde after consumption of alcohol, which in turn causes a wide range of unpleasant effects, such as vomiting, headache, and dyspnea. Its success is predicated on the degree of motivation on the part of the patient to abstain from alcohol, as its efficacy is entirely dependent on compliance.
Acetylcholinesterase (choice A) inhibitors used in psychiatry include donepezil and tacrine. These are used to treat Alzheimer type dementia.
Alcohol dehydrogenase (choice B) catalyzes the metabolism of ethanol to acetaldehyde. Disulfiram does not inhibit this first step in alcohol metabolism.
Several medications affect the cytochrome P450 (choice D) system, necessitating appropriate adjustments in dosing. Disulfiram’s mechanism of action, however, is at the site of the aldehyde dehydrogenase enzyme.
Tyrosine hydroxylase (choice E) converts tyrosine into DOPA, a neurochemical conversion unrelated to the mechanism of action of disulfiram
On Halloween, a group of teenagers decides to go to a new haunted house that they heard had extraordinary “scary” effects. At the entrance, they laugh loudly and tease each other. This is an example of which of the following types of behavior?
(A) Counterphobic behavior
(B) Denial
(C) Reaction formation
(D) Regression
(E) Undoing
Respuesta: A
The correct answer is A. Counterphobic behavior refers to seeking out situations or objects that are or were feared. The person actually takes a position of actively attempting to confront and master what he or she fears.
Denial (choice B) is the avoidance of awareness of a painful aspect of reality by negating sensory data and thus abolishing external reality. Denial may be seen in both normal and pathologic states.
Reaction formation (choice C) transforms an unacceptable impulse into its opposite. It is used in all stages of development and is typically seen in obsessive disorders.
Regression (choice D) is a type of behavior through which a person attempts to avoid tension and conflict at a present level of development by going to an earlier libidinal phase of functioning. It can be normal or can reflect the need to gain easier gratification at a less developed stage.
Undoing (choice E) is a secondary defensive operation that a person uses to undo or prevent the consequences that are anticipated irrationally as a result of unacceptable thought or impulse. It is mostly seen in obsessive disorders.
A 40-year-old man presents to the emergency department complaining of abdominal pain. He lives alone and states that he was otherwise healthy before this episode. He undergoes emergency abdominal surgery for the removal of a ruptured appendix. Three days after surgery, the patient becomes delirious, with fluctuations in his level of consciousness, but is afebrile. Which of the following would be the most likely source of this patient’s delirium?
(A) Delirium tremens
(B) Infection
(C) Pain medications
(D) Postoperative depression
(E) Stress of surgery
Respuesta: A
The correct answer is A. Delirium tremens is the most common cause of delirium in a patient who is suddenly admitted to the hospital for an unrelated condition and no longer has access to alcohol. It is a medical emergency, with a 20% mortality rate if left untreated. It usually occurs within 1 week after the patient stops drinking.
Infection (choice B) is a complication leading to delirium after surgery, but it is commonly associated with a high fever.
Pain medications (choice C) can cause delirium, but usually in elderly patients whose metabolic functions are compromised.
Postoperative depression (choice D) is not a known cause of delirium.
The stress of surgery (choice E) is a cause of postoperative delirium, but it is less common and usually occurs in procedures such as organ transplants.
A 40-year-old Caucasian man with chronic paranoid schizophrenia presents to his primary care physician’s office for his yearly physical examination. The physician notes that the patient currently weighs 220 pounds, whereas the previous year he weighed 197 pounds. The patient explains to the physician that his psychiatrist switched his medication about 5 months earlier, from risperidone to a new medication called olanzapine. The patient states that over the past few months, he has had a decrease in auditory hallucinations but has had some difficulty because he was laid off from his job and has been having increasing strain in his marriage. He states also that he has been drinking more alcohol lately, up to a case of beer a week. Which of the following is the most likely cause of this patient’s increase in weight?
(A) Alcohol use
(B) Decreased auditory hallucinations leading to increased appetite
(C) Discontinuation of risperidone
(D) Initiation of olanzapine
(E) Overeating due to familial stress
Respuesta: D
The correct answer is D. Olanzapine, an atypical antipsychotic, has been demonstrated to lead to weight gain in many patients with schizophrenia, with studies showing a gain of up to 27 pounds in the course of a year. Olanzapine affects the 5HT2 serotonin receptor in the brain, which is also thought to control satiety, in addition to decreasing auditory hallucinations and controlling mood symptoms.
Alcohol use (choice A) can lead to weight gain but would not have caused the significant gain in this patient, as he only recently began drinking more.
Decreased auditory hallucinations (choice B) have not been shown to have a significant correlation to appetite and subsequent weight gain.
There is no increase in appetite or weight associated with the discontinuation of risperidone (choice C).
Although some patients do overeat in response to stress, this activity is more common in female than in male patients. In addition, this patient describes his familial problems (choice E) as more recent in their onset; therefore, this would not be the most likely cause for his weight gain.
A 4th-year medical student is interviewing a 38-year-old woman who has schizophrenia, disorganized type. As part of the mental status examination, the student asks the patient to name the floor of the hospital she is on. In response, the patient begins to discuss the last hospital she was admitted to, the quality of the food while she was a patient there, and how attractive she thought her last physician was. Her speech is intelligible and normal in tone, and her vocabulary is good, but she never answers the student’s question. Which of the following best describes this patient’s behavior?
(A) Circumstantiality
(B) Tangentiality
(C) Thought blocking
(D) Verbigeration
(E) Word salad
Respuesta: B
The correct answer is B. Tangentiality is a disturbance in communication characterized by a lack of goal-directed association of thoughts. Patients cannot mentally get from a desired starting point to a desired goal (in this case an answer as to which floor of the hospital the patient is on), but instead jump from one topic to another.
Circumstantiality (choice A) is speech in which a patient eventually reaches the answer to a question, but frequently digresses along the way before arriving back at the central idea.
Thought blocking (choice C) is an abrupt interruption in a patient’s logical progression of thought before an idea or thought is finished.
Verbigeration (choice D) is the meaningless repetition of specific words or phrases.
Word salad (choice E) is a completely incoherent mixture of words and phrases that have no grammatical meaning in language.
A 35-year-old woman is admitted to the psychiatric unit for treatment. After a few days on medication, she complains of diarrhea, a metallic taste in her mouth, and polyuria. While examining her, the psychiatrist observes a fine intention tremor of her hands. The patients also complains that her psoriasis has flared up. Which of the following medications most likely caused these symptoms?
(A) Carbamazepine
(B) Fluoxetine
(C) Haloperidol
(D) Lithium carbonate
(E) Valproic acid
Respuesta: D
The correct answer is D. This patient is experiencing side effects associated with therapeutic or lower levels of lithium carbonate. These side effects are often troublesome and include sedation, cognitive difficulties, dry mouth, hand tremor, increased appetite, polydipsia and polyuria, nausea, diarrhea, psoriasis, and acne.
The most common side effects associated with carbamazepine (choice A) include dizziness, ataxia, sedation, dysarthria, nausea, hyponatremia, and cardiovascular conduction problems. Its most serious side effects are aplastic anemia and agranulocytosis. Rarely, it can cause rash and exfoliation.
Fluoxetine (choice B) causes nausea, dyspepsia, tremor, nervousness, and increased anxiety during the initial phase of treatment. It has no effect on fluid intake or worsening of dermatologic diseases.
Side effects associated with haloperidol (choice C) typically are a consequence of the blockade of dopaminergic D2 receptors. Apart from a spectrum of extrapyramidal symptoms, side effects include sedation, weight gain, hyperprolactinemia, and possible neuroleptic malignant syndrome.
Valproic acid (choice E) most commonly causes short-term nausea, vomiting, diarrhea, sedation, dizziness, and tremor. Alopecia and weight gain are long-term side effects.
A 47-year-old Caucasian man is seen by a psychiatrist for treatment of refractory depression. He has a 10-year history of severe depression, which has been treated with several different medications, as well as with electroconvulsive therapy. After careful consideration, the psychiatrist and the patient decide that he should try a monoamine oxidase inhibitor (MAOI). The psychiatrist gives him a list of foods and medications to avoid while taking the MAOI. Which of the following adverse outcomes is the psychiatrist trying to avoid?
(A) Agranulocytosis
(B) Hypertensive crisis
(C) Pigmentary retinopathy
(D) Priapism
(E) Serotonin syndrome
Respuesta: B
The correct answer is B. The monoamine oxidase inhibitors (MAOIs) used to treat depression inhibit the A form of the enzyme, which results in increased concentrations of norepinephrine, serotonin, and dopamine wherever the enzyme is present. Dietary tyramine, which is present in foods such as aged cheeses as well as in red wine, can enter the circulation unmetabolized (as alimentary MAO-A is also inhibited) and act as a pressor. If a patient on an MAOI eats foods rich in tyramine or takes certain medications bearing similarities to biogenic amines, a lifethreatening hypertensive crisis could develop.
Agranulocytosis (choice A) is an idiosyncratic adverse event associated with clozapine, among other drugs.
Pigmentary retinopathy (choice C) has been reported in patients taking high (>800 mg/day) doses of thioridazine.
Priapism (choice D) is associated with trazodone use.
Serotonin syndrome (choice E) can occur in individuals taking a serotonin-altering medication (such as an SSRI) in addition to an MAOI. This potentially life-threatening syndrome is characterized by autonomic instability and motor and behavioral abnormalities.
A 16-year-old girl is brought to the psychiatrist by her mother, who had noticed that her daughter pulls her hair and chews it. It is more evident now that she has several bald patches on both sides of her head. The daughter says that pulling her hair provides some sense of relief when she feels nervous or upset. She is doing well at school and denies any other symptoms. She has seen a dermatologist, who ruled out any medical causes for the alopecia. Which of the following is the most likely diagnosis?
(A) Bulimia nervosa
(B) Factitious disorder
(C) Major depressive disorder
(D) Obsessive-compulsive disorder
(E) Trichotillomania
Respuesta: E
The correct answer is E. Trichotillomania is an impulse control disorder. It is usually seen in childhood or adolescence and is most common in girls. It is manifested by repetitive pulling of one’s hair from any part of the body. The tension before pulling is usually relieved afterward. The disturbance is related to impulsive urges, making it different from goal-directed obsessional ideas. The disorder is not due to a general medical condition or the effects of any substance.
Bulimia nervosa (choice A) refers to episodes of binge eating characterized by a sense of lack of control. During those episodes patients take in an amount of food larger than most people would eat. It occurs at least twice a month for 3 months and includes inappropriate behavior to prevent weight gain, such as misuse of laxatives or self-induced vomiting. Bulimia may be comorbid with trichotillomania but does not include hair eating itself.
Factitious disorder (choice B) is intentional production of or feigning of symptoms of illness to assume the sick role. External motivation, like economic gain or avoidance of legal responsibility, is absent.
Major depressive disorder (choice C) requires symptoms of anhedonia and/or depressed mood every day for at least 2 weeks, along with associated symptoms of depression such as low energy, insomnia, weight loss, poor appetite, and poor concentration. It can be comorbid with trichotillomania.
Obsessive-compulsive disorder (choice D) is defined by recurrent intrusive thoughts or impulses that cause marked distress. The person tries to ignore or suppress them or to neutralize them with some action. The patient is aware that those ideas are the product of his or her mind and are unreasonable.
A 30-year-old Caucasian man has been treated with antipsychotic medications for the past 6 years. He has a chronic delusion that the FBI is constantly monitoring him through hidden cameras in his apartment and listening devices in his telephone. He also claims to hear the voice of the devil telling him not to eat certain foods because his neighbors are trying to poison him. Despite several hospitalizations and multiple trials of different antipsychotic medications, his symptoms are continuously present and are very distressing. Accordingly, his psychiatrist decides to start him on clozapine. Which of the following laboratory studies should be monitored at regular intervals?
(A) Complete blood count
(B) Prolactin level
(C) Serum glucose level
(D) Serum urea nitrogen and creatinine levels
(E) Thyroid stimulating hormone
Respuesta: A
The correct answer is A. There is a 1 to 2% risk of agranulocytosis in patients treated with clozapine. This idiosyncratic event can occur at any time in the course of treatment but is most likely to occur within the first 6 months. Subsequently, periodic examination of a white blood cell count with differential is essential while treating with clozapine.
Clozapine has no effect on prolactin levels (choice B) or serum glucose levels (choice C).
There is the possibility of renal toxicity (choice D) and hypothyroidism (choice E) with lithium treatment, not clozapine.
A 22-year-old African American woman visits a psychiatrist for “violent mood swings.” She reports that she experiences intense periods of “utter contentment” followed, often within minutes to hours, by intense feelings of depression. During these episodes, she feels she is useless and unloved by her parents and boyfriend. In addition, despite desperate attempts to engage in a long-term romantic relationship, she regrets that she can never seem to stay involved with anyone for very long, as she feels “no one understands me.” In assessing past thoughts of harm to herself, she admits that she has had more than 10 suicide attempts, usually involving superficial cuts to her wrists. The patient offers that “sometimes I feel so numb, I cut myself just to feel something.” Which of the following is the most likely diagnosis?
(A) Attention deficit/hyperactivity disorder
(B) Bipolar disorder
(C) Borderline personality disorder
(D) Intermittent explosive disorder
(E) Major depression
Respuesta: C
The correct answer is C. One of the hallmark characteristics of borderline personality disorder is affective instability, recognized as rapidly shifting mood states. Other symptoms include unstable and intense interpersonal relationships, chronic feelings of emptiness, and recurrent suicidal thoughts and gestures, often dramatic and attention-seeking in character.
Attention deficit/hyperactivity disorder (ADHD) (choice A) is associated with impulsivity, as is intermittent explosive disorder (choice D); however, mood swings and recurrent suicidality are not essential features.
Bipolar disorder (choice B) is also associated with extremes of mood; however, mood states usually last for days to weeks.
Major depression (choice E) is often comorbid in patients with borderline personality disorder; however, there is insufficient evidence to make such a diagnosis here.
A 38-year-old African American man with schizophrenia, chronic undifferentiated type, is evaluated by a psychiatrist. On mental status examination, he has a notable poverty of speech, along with poor eye contact, inattentiveness during testing, thought insertion, and flat affect. He does not appear to be actively responding to auditory hallucinations. Which of the above is the only positive symptom of schizophrenia in this patient?
(A) Flat affect
(B) Inattentiveness during testing
(C) Poor eye contact
(D) Poverty of speech
(E) Thought insertion
Respuesta: E
The correct answer is E. There is a clinical distinction in patients with schizophrenia between positive (or productive) symptoms of schizophrenia and negative (or deficit) symptoms. Although not accepted as part of the DSM-IV classification, the clinical distinction of the two types has significantly influenced psychiatric research. Positive symptoms of schizophrenia include delusions, hallucinations, thought insertion, and thought broadcasting.
Negative symptoms include affective flattening (choice A), deficits in attention (choice B), poor eye contact (choice C), and alogia, which is the lack of ability to produce normal fluent speech (choice D).
A 27-year-old man is brought to the emergency department in an agitated state by police. The man had been talking to himself and threatening people in the street, stating he was the son of God. On the psychiatric unit, he refuses to take medication. However, after engaging in several altercations with other patients, he is given an injection of haloperidol. The haloperidol is then ordered “as needed” in case of agitation over the next few days. The staff reports that he has started pacing down the hall and cannot sit still for more than 5 minutes. Which of the following disorders is this patient most likely experiencing?
(A) Akathisia
(B) Akinesia
(C) Festination
(D) Stereotypic movement disorder
(E) Tardive dyskinesia
Respuesta: A
The correct answer is A. Akathisia denotes a state of extreme motor restlessness. The patient cannot sit still and is constantly walking, shifting weight, and pacing. It is seen in encephalitic illnesses and as a complication of neuroleptic treatment.
Akinesia (choice B) is a term that refers to a failure of the patient to engage the limbs in customary activities. It results in poverty of movement, including small automatic postural adjustments, as well as in volitional movements. It is seen in Parkinson disease and related disorders.
Festination (choice C) is a gait disorder characteristic of Parkinson disease. The patient’s trunk is bent forward, the arms are slightly flexed, the legs are bent at knees, and steps are short and shuffling. With walking, the upper body advances ahead of the lower and steps become increasingly rapid to “catch up.”
Stereotypic movement disorder (choice D) is repetitive nonfunctional motor behavior (rocking, head banging, self-biting, picking) lasting at least 4 weeks. It is usually seen in mental retardation or pervasive developmental disorder, and it significantly interferes with normal activities.
Tardive dyskinesia (choice E) is a late-appearing disorder of involuntary, choreoathetoid movements of the orofacial region or trunk and limbs, following neuroleptic treatment. The movements are present at least 4 weeks. The neuroleptic treatment must last at least 3 months, or the movements must develop within 4 weeks after withdrawal from treatment
The 12th grade teacher of a 17-year-old girl is concerned about the girl’s behavior over the past school year. She has been talking to herself while looking off into the distance, isolating herself from her classmates, and wearing the same clothes daily for several weeks likely without washing them. However, she has been completing her homework assignments. The teacher calls the girl’s parents, who admit that she has been “acting strangely” for quite a while. The parents ask their daughter if anything is bothering her. She replies “I want to save Swedish children from persecution by the devil.” According to data from the National Institute of Mental Health Sponsored Epidemiologic Catchment Area, what is the lifetime prevalence of this girl’s disorder?
(A) 0.01%
(B) 0.1%
(C) 1%
(D) 5%
(E) 10%
Respuesta: C
The correct answer is C. This girl has schizophrenia, which has a lifetime prevalence of 0.6 to 1.9% (1% is most often cited as the average lifetime prevalence). About 0.025 to 0.05% of the total population is treated for schizophrenia in any single year. It is equally prevalent in men and women; however, the onset and course of illness differ between the sexes. Onset is earlier in men than in women. The peak age for men is 15-25 years, and the peak age for women is 25-35 years. In general, the outcome for patients with schizophrenia is better for women than for men; some studies have suggested that men are more likely to be impaired with negative symptoms and have poorer social functioning. Interestingly, the use of psychotherapeutic drugs, the deinstitutionalization of state hospitals, the emphasis on rehabilitation, and the community-based care for schizophrenic patients have led to an increase in the marriage and fertility rates among people with schizophrenia. Because of this, the number of children with at least one schizophrenic parent recently doubled.
The lifetime prevalence for major depressive disorder is 10 to 25% for women and 5 to 12% for men. The lifetime prevalence for dysthymic disorder is 6%. The lifetime prevalence for bipolar I disorder is 0.4 to 1.6%; for bipolar II disorder, it is 0.5%. The lifetime prevalence for cyclothymic disorder is 0.4 to 1.0%.
A 28-year-old pregnant woman attempts to drown herself and her three young children. She is brought to the emergency department, and her children are taken to their grandmother’s house. The woman is offered admission but she refuses, saying, “It doesn’t matter. It’s all going to end sooner or later.” Which of the following is the most appropriate next step in management?
(A) Admit her to a day program and order 15-minute observation checks there
(B) Admit her as an involuntary patient to an inpatient unit with high observation
(C) Arrange for outpatient follow-up to begin the following morning
(D) Create a contract with her to ensure that she agrees not to harm herself
(E) Call the police to report her as having endangered her children and unborn fetus
Respuesta: B
The correct answer is B. For a patient to be admitted involuntarily to an inpatient psychiatric unit, she must show evidence of either being harmful to others or to herself (either by a suicide attempt, self-mutilation, or selfneglect). This patient has clearly acted as a danger not only to herself but also to others. She may be suffering from depression, manic-depression, psychosis, substance abuse, obsessive-compulsive disorder, posttraumatic stress disorder, or other psychiatric conditions. She needs a thorough evaluation on a highly monitored inpatient psychiatry unit to better understand her condition.
Choices A and C are unacceptable because it is too dangerous for this patient to leave the hospital. Ultimately she may benefit from a day program and/or from outpatient care but certainly not at this point. Also, if the clinician believes that a patient is dangerous enough to require observation checks at the frequency of every 15 minutes, the patient most likely needs around-the-clock inpatient care.
Studies have shown that written contracts with psychiatric patients (choice D) are usually worthless. Their only consistently demonstrated value is for the evaluation of a patient who states that she is unable to contract for safety. Under these circumstances, it is made clear to the staff that the person does not trust herself to stay safe.
Calling the police to report her as having endangered her children and unborn fetus (choice E) may be necessary at some point, but the priority in the emergency department is to ensure the patient’s safety, and this must be through an involuntary hospitalization
A 40-year-old woman presents to the emergency department after having cut her arm on a knife. She states that she sleeps with a knife for protection from her neighbors, who she thinks are conspiring to rob her. The patient also tells the physician that she cannot hold a job because everywhere she works, her co-workers conspire to slander her for her political beliefs. Which of the following is the most likely diagnosis?
(A) Capgras syndrome
(B) Delirium
(C) Delusional disorder, persecutory type
(D) Paranoid schizophrenia
(E) Shared psychotic disorder
Resultado: C
The correct answer is C. The above symptoms are suggestive that this woman has delusional disorder, persecutory type, as her beliefs are not outside the realm of reason but are probably not based in reality. Her feelings that other people are out to hurt or injure her put the delusional disorder in the realm of persecutory type.
Capgras syndrome (choice A) is the delusion that others, or oneself, have been replaced by impostors. It typically follows the development of negative feelings toward the other person or self that the subject cannot accept and instead attributes to an impostor. The syndrome is frequently found in organic brain disease.
Delirium (choice B) requires an alteration of the state of consciousness, which this patient does not have.
Paranoid schizophrenia (choice D) is a diagnosis that requires that the patient have some of the symptoms of schizophrenia, including auditory hallucinations, thought blocking, or blunted affect. The patient’s age and her ability to obtain employment make schizophrenia an unlikely diagnosis in this case.
In shared psychotic disorder (choice E), the patient has a system of disordered thought that is assumed by another person. In most cases, this disorder is found among spouses; typically the spouse with the psychotic disorder is more dominant in the social relationship.
A 24-year-old physics student with a history of bipolar disorder presents to a clinic. He is dressed in new white suit and is wearing a hat. He goes around the waiting room, flirting with female patients, laughing, and talking loudly. Which of the following delusions is most consistent with his condition?
(A) “I created the bomb that killed people in Vietnam; I don’t deserve to live.”
(B) “I know that my family is going bankrupt; we won’t have anything to eat.”
(C) “I heard them talking about me on TV; they clearly said my name.”
(D) “My brain is melting inside; I know it.”
(E) “NASA called me to be the director of their new space program.”
Respuesta: E
The correct answer is E. The patient is presenting with a fullblown mania, in which delusions of grandeur are common and congruent with euphoric elevated mood.
Delusions of self-accusation (choice A) are false feelings of remorse and guilt frequently seen in depressive disorder with psychotic features.
Delusions of poverty (choice B) are false beliefs that one is bereft or will be deprived of all the material possessions.
Delusions of reference (choice C) are false beliefs that one is being talked about by others and that events or people have unusual significance in relationship to oneself.
Somatic delusion (choice D) is a false belief involving the function of one’s body and can be seen in psychotic disorders of schizophrenic spectrum, as well as in depressive disorder with psychotic features.
A 31-year-old man describes himself as “on top of the world” to strangers whom he meets in the street or on public transportation. He is considering running for president of the United States, since he views himself as more intelligent, handsome, and charismatic than anyone he knows. He has engaged in sexual activity with eight different women over the past 8 nights. He thinks his talents are unique and are the envy of all. He has been prescribed lithium by his treating psychiatrist, yet he has opted not to take the medication because he feels that it limits his creativity and genius. Which of the following symptoms would be seen in such a person during a manic episode but not during a major depressive episode?
(A) Anhedonia
(B) Decreased sleep
(C) Distractibility
(D) Flight of ideas
(E) Impairment of functioning
Respuesta: D
The correct answer is D. This patient has bipolar disorder. He is currently in a manic episode, characterized by at least a week (at least 8 days in his case) of inflated self-esteem, pressure to talk, and a goal-directed focus on a grandiose wish to be president. He also has engaged in excessive involvement in sexual indiscretions without regard for the potential dangerous outcomes. Further, although not described in the question, the patient likely has a decreased need for sleep, likely has a subjective feeling that his thoughts are racing, and likely has a wavering attention span. Flight of ideas is characteristic of mania but not of depression. A flight of ideas is a rapid jumping of thoughts through a series of tenuously related ideas that make more sense to the manic patient than to the examiner.
Anhedonia (choice A) is characteristic of depression but not mania. Anhedonia is characterized by the absence of pleasure from other persons, situations, or things that would ordinarily be pleasurable. During a manic episode, persons often experience the opposite of anhedonia by finding pleasure in things that do not typically evoke such a contented response.
Decreased sleep (choice B) is usually characteristic of both mania and depression. In mania, persons often do not feel as though they need a lot of sleep. In depression, persons have difficulty in both falling asleep and staying asleep. Early morning awakening with an inability to fall back asleep is very common in depression. The net result for both mania and depression typically is decreased sleep.
Distractibility (choice C) can be an attribute of both mania and depression. In manic individuals, their attention is often too easily drawn to unimportant or irrelevant external stimuli. In depressed individuals, they are usually unable to focus on completing any one task, since all tasks are often perceived as too difficult to complete. These people are often distracted by their own sad moods.
Impairment of functioning (choice E) is among the DSM-IV list of criteria for both a manic episode and a major depressive episode.
