TEST 3 PRACTICE Flashcards
1
Q
22 yr old present to ed with cc of “they are making me look toward heaven” Admits to a past diagnosis of schizophrenia, “but God cured me of it.” Review of the medical record reveals that he was discharged from the hospital the previous week on respiradone 4 mg at bedtime. His dose was increased to 6 mg by his outpatient psychiatrist 2 days prior to today’s visit. The patient believe that angels are forcing him to look up to heaven and he is unable to look “down to the devil in hell.” His mental status demonstrates a cooperative and appropriately dressed young man, alert, and oriented three times. Speech is not spontaneous, mood is worried, with flat afect. Thoughts are logical without looseness. He denies suicidal or homicidal ideation but has delusions. His insight is poor, but his judgement and impulse control are not currently impaired. Has upward gaze and his eyes are bilateral:
A
Medication induced dystonia (EPS); next step is benztropine
MOST COMMON IN YOUNG MEN!
antipsychotic medication can cause extrapyramidal symptoms (i.e. acute dystonia)
caused by dopamine antagonist needs to be treated with anticholinergic medication such as benztropin, or antihistamines such as diphenhydramine
2
Q
50 yo woman with schizoaffective disorder, bipolar type complains of nervous tics. Currently being treated with haloperidol 100 mg, denies significant affective symptoms but complains of chronic auditory hallucinations of whispers without commands. No suicidal or homicidal ideation, noted to be sticking tonuge in and out.
A
tardive dyskinesia, decrease dose, and switch to different atypical antipsychotic
3
Q
25 yo admitted with new onset of psychotic symptoms consisting of command hallucinations to harm others, paranoid delusions, and agitation. He begun olanzapine, After several days he is found lying in bed with eyes open but not responsive. Noted to be seating but is resistant to being moved. Vitals demonstrate 101.4F, bp 182/98, pulse 104, rep 22 breaths/min
A
NMS; acute mental status changes, diaporesis, rigidity, fluctuating vital signs
4
Q
43 yo with schizophrenia being followed in an outpatient community mental health clinic after being discharged from hospital. While hospitalized she was on risperidone. She has some paranoia, and ideas of reference, but denies auditory or visual hallucinations. Her mental status examination is significant for moderate psychomotor slowing, with little spontaneous speech, but coarse tremor of her hands. Her stated mood is “fine” and has blunted affect, with little expression, gait is wide based, and shuffling
A
Parkinsonism; bradykinesia, shuffling gait, masked faces, coarse tremor, increased risk factor is woman and older age
5
Q
32 yo admitted with the provisional diagnosis of psychotic disorder, rule-out dipolar. After 10 days, he is stabilized on valproate and aripiprazole. The nurses are concerned his medications need to be increased or switched as he has been recently sleeping less and is more agitated, often pacing the hallways. Upon examination, he admits to feeling “edgy,” but he denies racing thoughts increased energy, paranoia, delusions, stating “I just can’t stop walking; I feel like I’m going crazy!”
A
akathisia; treat with beta blocker or benzo
6
Q
You are caring for 22 y/o male on the trauma unit who becomes acutely agitated. You order haloperidol 5mg IV push. The pt is still agitated 20 minutes later so you order the dose to be repeated. Suddenly the pt’s head turns to one side (he can’t move it back) and his eyes are involuntarily looking upward
What is going on?
What are you going to do about it?
A
having an acute dystonic reaction: treat with: anti-cholinergic i.e. benzotropine, trihexyphenidyl, diphehydramine
7
Q
During your first clinic, you are seeing a 37 y/o male with schizoaffective disorder who was stared on olanzapine at his last visit by the previous resident. He complains that he gets dizzy whenever he stands up from a chair. Although his HR was 73 in the waiting room, it is now 93 after standing and walking back to the exam room.
What is going on?
What are you going to do about it?
A
alpha-1 blockade (CNS effect along with impotence, failure to ejaculate, etc), switch to a different drug; if olanzapine is the only thing that works, maybe work around it;
8
Q
You have been caring for a pt who was admitted to the hospital for a COPD exacerbation. She received clozapine at home and this was continued while she was in the hospital. The pt is now going home, and you want to write her a prescription for clozapine to take upon hospital discharge. You are told that you can’t!
What’s up with that? what Side effect?
A
You can’t write a prescription for clozapine bc you have to be a registered physician; responsible for causing agraunlar cytosis
9
Q
24 yr old woman is seen in ed after superficially cutting both her wrists. Her explanation is that she was upset because her bf of 3 weeks broke up with her. When asked, she says that she had numersoud sexual partners. Which therapy would she respond to?
A
dialectical behaioral therapy; this is a form of cognitive therapy and has been show to be effective at treating BPD. The therapy attempt to help the patient explore their own behavior, thoughts, feelings, in the present without delving into the patient’s childhood, which tends to be regressive for these patients, resulting in increased suicidal behavior and acting
10
Q
35 yr old has a history of being afrain to speak in public. He normally handles his fear by avoiding this activity or by keeping the size of the audience to a minimum. He is required to give a presentation in front of a large audience in 2 weeks and has been extremely anxious about it to the point where he cannot sleep. Although the public speaking event is new, he says he has had similar fears most of his life (>6 months). The clinician would also want to rule out substance use issue or other medical coniditions that may be related to anxiety. The patient is afraid he will somehow embarrass himself in in front of the audience.
A
SAD; treat with CBT: Relatxation training followed by progressive desensitization. Pharmacologic ineterventions include benzos beta blockers. Currently, the longer lasting drugs are SSRI (sertraline, fluxoxetine)
11
Q
15 yr old is hospitalized for suicide attempt. Made attempt after fight with bff after a party, and had several month history of irritability, worsening performance in school, poor sleep, anhedonia, anergia, and isolation from her family and friends. Diagnosed with depression and released. Comes back happy, says suicide was only for attention, and seems all good. Parents then say she thought there were camera’s in the doctors office recording her and that she is being stalked by several of the boys at her school:
A
schizoaffective: diagnosed with mdd with suicide attempt, treated and now has evidence of paranoia
12
Q
35 yr old has lived in a state psychiatric hospital for the past 10 years. She spends most of her day rocking, muttering solftly to herself, looking at her reflection in a small mirror. She needs helpwith dressing showering, and she often giggles and laughs for no apparent
A
schizophrenia: disorganized speech and behavior, flat or inappropriate affect, great functional impairment, and inability to perform basic activities such as showering or preparing meals. Grimacing along with silly and odd behaviorand mannerisms is common
13
Q
20 yr old woman brought to ed, after family can’t get her to eat or drink for 2 days. Patient is awake bu completely unresponsive both vocally and nonverbally. She actively resists any attempt to be moved. Her family reports that during the previous 7 months, she has become increasingly withdrawn, socially isolated, and bizarre; often speaking to people no one else could see:
A
catatonic schizophrenia, characterized by marked psychomotor disturbances including prolonged immobility, posturing, extreme negativism (the patient actively resists any attempts made to change his or her position). or waxy flexibility (patient maintains the position in which she is placed), mutism, echolalia (repitition of words said by another person), echopraxia (repetition of movements made by another person) Periods of immobility and nutism can alternate with periods of extreme agitation
14
Q
21 yr old brought ED by parents bc he has not slept, bathed or eaten for 3 days. The parents report that for 6 months their son has been acting strangly “not himself,” he has been locking himself in his room, talking to himself, writing on walls. 6 weeks prior to visit, their son became convinced that a fellow student was stealing his thoughts and making him unable to learn his school material. In the past 2 weeks they noticed that their son has become depressed and has stopped taking care of himself (no bathing, eating, getting dressed, etc). On exam, he appears dirty, disheveled, low energy, and suicidal:
A
schizoaffective disorder (only actively been not bathing, eating, been depressed, etc for 2 weeks at most if not 3 days).
15
Q
woman believes her childhood friend had a daughter that went to med school and that this was all so that she could become a psychiatrist and commit her (and the girl lives in california and has no contact with the woman whatsoever)
A
delusional disorder (other than this one delusion, the woman can function, work, etc)
16
Q
23 yr old graduate student presents with severe abdominal cramps, bloating, difficulty concentrating. BF says that she’s been extremely mean the past few days and anything he says sets her off. He does not recall any other changes in behavior:
A
Need SSRI (fluoxetine). Lithium has no known benefits in PMDD but would be gold standard for bipolar.
17
Q
Patient does not use drugs, symptoms appear episodically and otherwise normal functioning. Behavior seems strange, but no overt signs of psychosis. Reports having pms:
A
bipolar. Pms or pmdd does not account for manic symptoms. Need lithium
18
Q
33yr old writer is brought to ed by sister who voices concern that her sibling is acting “out of control.” The patinet laughs at sister’s accusation and rapidly retorts, “I feel great! She’s the one with something wrong.” The patient paces around the room, speaking rapidly. The ER MD attempts to redirect the interview several times, but the patient keeps talking. Her sister reports that the patient was like this several months ago, but otherwise has been normal. She remembers that both episodes seemed to occur around the time of her sister’s period. The patient responds by chanting, “yes, yes! I’ve got the PMS!” The patient has no known medical problems, substance abuse or fam history of psychiatric illlness.
A
bipolar: the patient presents in a manic state with elevated mood, irritability, psychomotor agitation, and rapid, pressured speech. Need lithium
19
Q
35 yo man is brought to office by his wife. He had previously suffered a major depressive episode 2 years prior and ceased medications 6 months ago. More recently, the patient had been working many overtime hours for several weeks to complete a project at work, and had slept much less than normal without apparent ill effect. When the project was completed, the patient continued to sleep little, shifted his activities to socializing and drinking with his colleagues. The patient admits he has not drunk this heavily since college. For the past few days the patient has crashed back into depression:
A
bipolar: pattern of decreased need for sleep, yet with no decrease in eergy level. Increased goal directed activity and excessive pleasure-seeking activity (drugs, alcohol), Need lithium
20
Q
27 yr old woman has been feeling lue fo the past 2 weeks. Has little energy and trouble concentrating. She states that 6 weeks ago she had been feeling very good, with lots of energy and no need for sleep. She says that this pattern has been occurring for at least the past 3 years though the episodes have never been so severe that she couldn’t work
A
cyclothymic disorder
21
Q
a 24 yr old with chronic schizophrenia is brought to the ed after his parents found him in his bed and were unable to communicate with him. On examination, the man is confused and disoriented. He has severe muscle rigidity, a temp of 39.4C his bp is elevated,, and he has a leucocytosis.
He is suffering from ____ and should be given ______
A
The patient has neuroleptic malignant syndrome NMS a life-threatening complication of antipsychotic treatment.
22
Q
a 54 yr old with a chronic mental illness seems to be constantly chewing, he does not wear dentures his tongue darts in and out, and grimaces, frowns, and blinks excessivley:
A
tardive dyskinesia; an extra pyramidal symptom assocaited with typical antipsychotics bc they work by blocking D2 dopamine receptors in the mesolimbic and mesocortical areas of the brain. However, these same medications also bind to dopamine receptors in other areas of the brain, such as the nigrostriatal pathway, thereby causing a variety of eps.
23
Q
32 yr old woman is brought to the ed by police after being found standing in the middle of a busy highway, naked, commanding traffic to stop. In the emergency room. she is agitated and restless, with pressured speech, and an affect that alternates between euphoric and irritable. Her father is contacted and states that this kind of behaviour runs in the family
A
bipolar, manic
24
Q
71 yr old woman with history of early AD is brought to hospital bc she “just isn’t acting like her normal self” On mental status exam, she is lethargic, easily distractable, and oriented only to peson. At baseline, she is oriented to person and place, but has difficulty recalling the date and time. Physical examination and diagnostic workup are suggestive of an uncomplicated urinary tract infection (UTI).
Which feature most distinguishes her delirium from AD?
decreased attention
disorientation
cognitive deficits
behavioral disturbances
A
decreased attention
both delirium and dementia can result in behavioral disturbances, cognitive deficits, and poor orientation. However, in all cases of delirium there is an alteration in level of attention. In early dementia, attention and concentration are typically maintained
25
71 yr old woman with history of early AD is brought to hospital bc she "just isn't acting like her normal self" On mental status exam, she is lethargic, easily distractable, and oriented only to peson. At baseline, she is oriented to person and place, but has difficulty recalling the date and time. Physical examination and diagnostic workup are suggestive of an uncomplicated urinary tract infection (UTI). What is the most important component of treating this patient's delirium?
treat her UTI with antibiotics
26
64 yr old with CAD and no prior psychiatric history who experienced visual hallucinations, paranoia, and fluctuation of attention and awareness on the evening of postoperative day number three following CABG. On examination later that night, the patient is oriented to person, place, and situation, but not to time. Otherwise, his mental status examination and physical examination are essentially unremarkable
delirium
next: find the CAUSE of the delirium by reviewing the medical record, performing focused history and physical examination, and obtaining clinically guided laboratory and imagine studies
27
A 40 year old male with Down's syndrome has symptoms of advanced dementia consistent with Alzheimer's disease. Why is early onset Alzheimer's disease common in Down's syndrome?
the amyloid precursor protein (APP) is located on chromosome 21
28
Patients with FTDP-17 have which of the following brain abnormalities?
Extensive deposition of intracellular hyperphosphorylated tau protein in neurons and glia
29
T/F: HIV encephalopathy is frequently treated with HAART therapy
How do they present on histo?
HIV associated dementia persists DESPITE HAART therapy:
Microglial nodules and
TEST: multinucleated giant cells near blood vessels
Involves white matter, diencephalon, and brainstem
30
OBESE requests antidepressent______ older person that has insomnia and is underweight:
buproprion bc it is an atypical with appetite suppression quality; mirtazepine bc it increases appetite and causes sedation
31
older patients with insomnia and continued weight loss requires an antidepressent. What do you prescribe and how does it work?
Mirtazepine: sedation (H1 receptor antagonism)
| increased appetite, weight gain (H1 receptor antagonism)
32
_______ is used in smoking cessation and DOES NOT CAUSE SEXUAL DYSFUNCTION BC IT LACKS THE SERATONERGIC COMPONENT
buproprion
33
87 y.o. male, 8 yrs of education, retired ironworker
progressive memory loss for 2-3 years:
repeating questions
word finding difficulties
difficulty with IADLs (e.g., finances, cooking, driving)
visual hallucinations for 5 months; animals, people invading home paranoia, irritability
relevant med hx: atrial fib, macular degeneration, cataracts,
hearing loss, freq dizziness + falls, recent CT: generalized atrophy
meds: warfarin, furosemide, zinc, risperidone for hallucinations
Prominent motor symptoms on exam: cogwheeling, rigidity
Lewy Body DM
34
Woman believes that a family of young children moved into the house, and so she cooks food for the kids to feed them, no idea that the hallucination isn't real; could be about small animals that come into the room, parkinsonism, COGWHEEL, sleep problems, bradykinesia.
lewy body dementia, adverse reaction to l/dopa (falls syncope, autonomic dysfunctino)
35
62 y/o man, right handed, w/ MA in Ed, retired teacher and realtor
5-6 year hx of memory problems, insidious onset, gradual progression. Word finding problems, forgetting events and conversations, getting lost in familiar areas, forgetting appointments. Retired because unable to perform his duties as realtor.
Early Stage AD:
Cardinal symptom: impaired learning of new information, reflecting earliest involvement of medial temporal region
Verbal memory tests – most sensitive
decreased delayed recall
decreased immediate but NORMAL delayed recall is NOT likely dementia
Impairment should be judged relative to estimated premorbid status
36
69 yr old retired engineer with history of ht and hyperlipidemia has been suffering from memory problems over the last several months. Previously, he functioned at a much higher level. Mild aphasia, memory impairment, and executive dysfunction are evident on mental status examination:
vascular dementia
37
75 yr old is brought by his daughter for psychiatric eval. He has become increasingly forgetful over the past year, missing engagements with his children and grandchildren. He has gotten lost several times driving in his own neighborhood. He has no psychiatric history, but he has felt lonely since the passing of his wife 14 months ago. His medical history is significant for poorly controlled hypertension. Which of the following additional features is necessary in order to accurately diagnose vascular dementia?
loss of independence in one or more independent activities of daily living. CT or MRI may show lacunar infarcts or microvascular changes in vascular dementia, wheras generalized cortical atrophy and ventricular enlargement are the changes seen in AD. Individuals with vascular Dementia usually remain alert, whereas those with delirium display a fluctuation in consciousness. While psychotic symptoms such as delusions and hallucinations can be seen, they are not necessary or specific for vascular dementia
38
75 yr old is brought by his daughter for psychiatric eval. He has become increasingly forgetful over the past year, missing engagements with his children and grandchildren. He has gotten lost several times driving in his own neighborhood. He has no psychiatric history, but he has felt lonely since the passing of his wife 14 months ago. His medical history is significant for poorly controlled hypertension.
how would this patient be predicted to perform on cognitive testing if he has vascular dementia as opposed to depressive illness?
better effort with poor insight (whereas depressed individuals typically make little effort)
39
73 yr old with vascular dementia becomes verbally aggressive at a nursing home. Geriatric psychiatrist is asked to evaluate for treatment. What is the initial step in managing the patient's behavior?
```
chlorpromazine
donepezil
lorazepam
physical restraints
verbal de-escalation
```
verbal de-escalation. antipsychotics like chlorpromazine should be avoided because the anticholinergic and orthostatic side effects, and benzos like lorazapam may cause disinhibition in patients, worsening their behavior and possibly causing a fall
40
24 yr old comes to ed with chief complaint of "my stomach is rotting out from the inside." States that 6 months of crying on a daily basis, decreased concentration, energy and interest in her usual hobbies. Lost 25 lbs during that time and connot get to sleep, and when she does wakes up early in the morning.
major depression: over 2 weeks of symptoms, anhedonia, crying, anergia, decreased concentration, 25 lb weight loss, and insomnia (early morning waking).
41
25 yr old with chief complaint of depressed mood for 1 month. Mother died 1 month ago, and since then has felt sad and been very tearful. Difficulty concentration, lost 3lbs, not sleeping soundly through the night:
uncomplicated bereavement (symptoms such as major depression, sadness, weepiness, insomnia, reduced appetitie, weight loss. Considered normal if less than 2 months. For this to be major depression, it would have to accompany marked functinal impairment, morbid preoccupations with unrealistic guilt or worthlessness, suicidal ideation, marked psychomotor retardaion, and psychotic symptoms in addition to the original symptoms described above).
42
45 yr old states "ever since my husband died suddenly of a hear attack 9 weeks ago, I can't sleep." Since then the patient has a very depressed mood, been crying, lost interest in activities, is fatigued, and has insomnia. Why is this major depression instead of bereavement?
the patient exhibits a marked functional impairment: guilt about things other than actions taken or not taken by the survivor at the time of loved one's death, thoughts of death other than the survivor feeling he/she would be better off dead without the loved one, a morbid preoccupation with worthlessness, maked psychomotor retardation, marked and prolonged function impariment, and hallucinations other than the survivor believeing he can hear the voice of the loved one
43
39 yr old married woman presents with 1 month of a gradually worsening depressed mood, with increased sleep, low energy, and difficulty concentrating, but no appetite or weight changes. Her medical history is significant for multiple sclerosis, but she is currently not taking medication. Her mental status exam is notable for psychomotor slowing and a depressed and blunted affect. Physical exam demonstrates several different sensory and motor deficits.
major depressive disorder du to another medical condition
44
52 yr old executive presents with the new onset of depression, early-morning awakening, decreased energy, distractibility, anhedonia, poor appetite, and weight loss for the past 3 months. His symptoms began shortly after he suffered a MI, and although he experienced significant sequelae, he felst less motivated and fulfilled in his life and work, believing that he is now "vulnerable." As a result, he does not push himself as he used to and his work output is beginning to decline. He feels "empty" but denies suicidal ideation
major depression disorder
45
14 yr old presents with 15 months of being irritable and depressed almost constantly. The boy has difficulty concentrating, and has lost 5 lbs during that time without trying. He states that he feels as if he has always been depressed, and he feels hopeless about ever feeling better. He denies suicidal ideation or hallucinations. He is sleeping well and doing well in school, though his teachers have noticed that he does not seem to be able to concentrate as well as he had previously.
dythymic disorder (for adults it is 2 years)
46
19 yr old woman has history of anger and irritability which occurs on monthly on an average. During this time, she reports feeling anxious and "about to explode," which notes during this time she can't concentrate and sleeps much more than she needs to. During the several days these symptoms last, she skips her classes because she can't function
premenstrual dysphoric disorder
47
55 yr old woman presents with psychiatrist with a depressed mood, decreased energy, and weight gain with a normal appetit. She never had these symptoms before and denies past psychiatric history. Her mental status examination is significant for a depressed-appearing female but is otherwise unremarkable. Physical exam is notable for diffusely enlarged thyroid gland and coarse, brittle hair:
depressive disorder due to another medical condition (hypothyroidism); obtain thyroid studies for this patient, including determinations of thyroid stimulating hormone, triiodothyronine, and thyroxine levels
48
34 yo suffered from major depression in the past and has at least a 10yr period of depressed mood with insomnia, fluctuating appetite, and decreased ability to concentrate. He also notes that his self-esteem is low and is experiencing no suicidal ideation, psychotic symptoms or weight loss (continues working)
persistant depressive disorder (dysthymia)
49
45 yr old man with history of schizophrenia and alcohol use disorder was brought by ambulance after he was found sleeping on the floor of a homeless shelter. He appears drowsy, but arousable, and mumbles, "the voices are killing me." He admits to taking a bottle of lorazepam because "I just couldn't take it anymore." Which of the following antipsychotics has been associated with decreased suicide attempts?
clozapine has been shown to reduce suicide attempts in patients suffering from schizophrenia and schizoaffective disorder
50
50 yr old with history of chronic treatment-resistant schizophrenia was admitted last night after reemergence of command auditory hallucinations telling him to "do bad things." He had been recently hospitalized and stabilized on clozapine. He denies missing any doses. What addition is the most common form of substance abuse in patients with schizophrenia and likely contributed to the patient's recent psychotic episode?
nicotine is the most frequent used substance by schizophrenics. Patients with schizophrenia are three times more likely to be addicted to nicotine compared to the general population. Smoking induces cytochrome P450 enzyme activity which results in significantly lower clozapine concentrations, and resulted in reemergence of psychotic symptoms.
51
26 yr old woman brought to ed by husband after she begins screaming that her children are calling to her and becomes hysterical. The husband states that 2 weeks previousl, the couples two children were killed in a car accident, and since that time the patient has been agitated, disorganized, and incoherent. He states that she wil not eat bc she believes he has been poisoning her food, and she has not slept for the past 2 days. The pateint believe that the nurses in the emergency room are going to cause her harm as well. The patient is sedated and later sent home. One week later, all her symptoms remit spontaneously. which of the following would be her most likely diagnosis?
```
delirium
schizophreniform disorder
mdd with psychotic features
brief psychotic disorder
PTSD
```
brief psychotic disorder is characterized by the sudden appearance of delusions, hallucinations, and disorganized speech or behavior, usually following a severe stressor. The episode lasts at least 1 day and less than 1 month, and is followed by full spontaneous remission. For the woman in the question, the psychotic episode was clearly precipitated by the death of the children. Schizophreniform disorder is differentiated from brief psychotic disorder by temporal factors (in schizophreniform disorder, symptoms are required to last more than 1 month) and lack of association of a stressor. PTSD has a more chronic course and is characterized by affective, dissociateive, and behavioral symptoms
52
a 75 yr old man is being cared for in a hospice setting. he has a widely spread prostatic carcinoma that is terminal. Which of the following psychiatric symptom is seen in 90% of terminal patients?
```
delusions
hallucinations
flighth of ideas
anxiety
depression
```
delusions are extremely common in terminally ill patients
53
```
22 yo man brought to ed after becoming exceedingly anxious in college dormroom, stating that the college administration was sending a hit squad to kill him. He also notest that he can see visions of men dressed in black who are carrying guns and stalking him. His thought process is relatively intact, without thought blocking or losse associations. His urine test is positive for;
barbiturates
heroin
benzodiazepine
amphetamines
MDMA (ecstasy)
```
amphetamine intoxication can result in a psychosis very closely resembling acute paranoid schizophrenia, with symptoms incuding paranoid delusions and visual hallucinations. Some investigators believe that prominent visual hallucinations and a relative absence of thought disorder are more charactersitc of amphetamine psychosis, but other investigators believe the symptoms are indistinguishable. Other drugs that produce psychosis similar to schizophrenia include PCP and LSD
54
72 yo woman is brought to ed by daughter after she was found rummaging in the garbage cans outside. Daugher states that the patient never had behavior like this. On interview, the patient states she sees martians hiding around her home and on occasion she hears them, too. She also demonstrates a constructional apraxia, with difficulty drawing a clock and intersecting pentagons. All of these symptoms point to a medical cause for this patients behavior except one.
Which symptom is common in patients with a psychiatric cause for their behavior instead of medical?
patients age
no previous history
visual hallucinations
auditory hallucinations
constructional apraxia
auditory hallucinations are quite common in psychiatrically caused psychoses, but the rest of the items point to a medical psychosis. Other signs that point to a medical cause could be altered mental status signs such as speech, movement or gait disorders, problems with alertness, memory, concentration, or orientation, and concurrent substance abuse history or medical problem
55
Children with ADHD have a deficit in ________, which are cognitive abilities to formulate a goal, plan the actions to achieve the goal, and maintain the plan in memory in order to execute it.
a. high-level cognition
b. intelligence quotient
c. affective functioning
d. executive functioning
d. executive functioning
56
What is the likelihood that a 42-year-old mother will give birth to an infant diagnosed with Down syndrome?
a. 1 out of 70
b. 1 out of 150
c. 1 out of 1000
d. 1 out of 30
a. 1 out of 70
57
The estimated hereditability of autism spectrum disorder is _______.
a. 40%
b. 90%
c. 20%
d. 70%
b. 90%
58
Behavior patterns of autism spectrum disorder include all of the following EXCEPT
a. adherence to routines.
b. preoccupation with a particular interest.
c. self-injurious behaviors.
d. ability to start but not end a conversation.
d. ability to start but not end a conversation.
59
________ uses shaping and positive reinforcement to improve the social, communicative, and behavioral skills of children with autistic disorder by intensively training and rewarding specific behaviors.
a. Behavioral family training
b. Multisystemic therapy
c. Applied behavior analysis
d. Social psychoanalysis
c. Applied behavior analysis
60
The most commonly inherited cause of mental retardation is ________, which occurs when a DNA series makes too many copies of itself and "turns off" a gene on the X chromosome.
a. cultural-familial
b. fragile X syndrome
c. Down syndrome
d. phenylketonuria
b. fragile X syndrome
61
As children with ADHD mature, about __________% will continue to have the disorder during adolescence.
a. 30
b. 65
c. 50
d. 25
c. 50
62
For every ________ girl(s) diagnosed with autistic disorder, about ________ boys are diagnosed.
a. one; two
b. three; four
c. one; four
d. two ; five
c. one; four
63
Which of the following is true of the two symptom clusters of ADHD has two symptom clusters (hyperactive-impulsive and inattentive)?
a. Hyperactive symptoms are always more severe than inattentive symptoms.
b. Children commonly have symptoms from each cluster.
c. Symptoms from one cluster always predominate clearly in cases of ADHD.
d. Hyperactive symptoms persist longer over the lifespan than do inattentive symptoms
b. Children commonly have symptoms from each cluster
64
________ is an indication of the neurodevelopmental basis of autistic disorder during the first few years of life.
a. Accelerated head and brain growth
b. Delayed development of fine motor skills
c. Rapid weight gain
d. Delayed skeletal development
a. Accelerated head and brain growth
65
For every ________ girl(s) diagnosed with autistic disorder, about ________ boys are diagnosed.
a. one; two
b. three; four
c. one; four
d. two ; five
c. one; four
66
Hand flapping, spinning, and ritualistic pacing are repetitive behaviors that serve no observable social functions. Collectively, these are called
a. compulsions.
b. disorder of verbal expression.
c. coping mechanisms.
d. stereotyped behaviors.
d. stereotyped behaviors.
67
In treating ADHD, ________ teaches parents how to reward positive behaviors and decrease negative behaviors.
a. medication monitoring
b. cognitive restructuring training
c. behavioral parent training
d. communication skills curriculum
c. behavioral parent training
68
Which of the following is one of the factors that likely contributes to the increased prevalence of autism spectrum disorder in recent years?
a. lack of special education programs
b. the measles virus
c. changes in diagnostic criteria
d. MMR vaccines
c. changes in diagnostic criteria
69
```
a 28 yr old is brought to the psychiatrist by her mother. The patient has been progressively isolating herself from everyone, is talking to people who aren't there, is having auditory hallucinations, and the delusional belief that her mother is going to kick her out of the house so it can be turned into a theme park. Which of the following is the lifetime prevalaence for this disorder?
1%
3%
5%
10%
15%
```
1
70
```
a 40 yr old woman is arrested by police after she is found crawling throught the window of a movie stars home. She states that the movie star invited her into his home because the two are secretly married and "it just wouldn't be good for his career if everyone know." The movie star denies the two have ever met, but notes that the woman has sent him hundreds of letters over the past 2 years. The woman has never been in trouble before and lives an otherwise isolated and unremarkable life.
delusional disorder
schizoaffective disorder
bipolar I disorder
cyclothymia
schizophreniform disorder
```
delusional disorder
This patient is suffering from an erotomanic delusion-the delusion of having a special relationship with another person, often someone famous
71
a 19 yr old is brought to the physician by his parents after he called them from college, terrified that the mafia was after him. He reports that he has eaten nothing for the past 6 weeks other than canned beans bc "they are into everything-I can't be too careful!." He is convinced that the mafia has put cameras in his dormitory room and that they are watching his every move. He occasionally hears the voices of two men talking about him when no one is around. his roommate states that for the past 2 months the patient has been increasingly withdrawn and suspic.
schizophreniform disorder and chronic schizophrenia differ only in the duration of the symptoms and the fact that the impaired social or occupational functioning assoiated with chronic schizophrenia is not required to diagnose schizophreniform. As with schizophrenia, schizophreniform disorder is characterized by the presence of delusions, hallucinations, disorganized thoughts and speech and negative symptoms.
72
19 yr old woman is brought to ed by her roomate after the patient told her that "the voices are telling me to kill the teacher." The roommate states the patient has always been isolative and "odd" but for the past 2 weeks she has been hoarding food, talking to herself, and appearing very paranoid. The patient becomes agitated in the ED and tries striking one of the nurses before being restrained. The patient was admitted and started on a daily dose of fluphenazine. After discharge from the hospital, she was kept on a low dose of the medication for 6 weeks and showed only a minimal response to the drug, even after it was raised to a moderate dosage level. Which is the next therapeutic step?
```
give a high dose of fluphenazine
give a low dose of clozaril
give a low dose of haloperidol
give fluphenazine decanoate IM
give a low dose of olanzapine
```
give a low dose of olanzapine
if patient doesn't respond to a conventional dopamine receptor antagonist (first generation- typical) then it is unlikely that the patient will respond well to another. It is better to switch to a low dose of serotonin dopamine antagonists (second-generation antipsychotic). It is too early in treatement to give up and go to clozapine
73
19 yr old woman is brought to ed by her roomate after the patient told her that "the voices are telling me to kill the teacher." The roommate states the patient has always been isolative and "odd" but for the past 2 weeks she has been hoarding food, talking to herself, and appearing very paranoid. The patient becomes agitated in the ED and tries striking one of the nurses before being restrained. Which of the following treatment options would be recommended?
```
haloperidol and lorazepam IM
clozapine PO
Fluphenazine decanoate IM
Mellarill IM
Lorazepam PO
```
haloperidol and lorazepam:
The use of a benzodiazepine and a high-potency antipsychotic has several advantages. While the antipsychotic treats the psychosis whithout a lot of anticholinergic side effects, the benzodiazepine reduces the amount of antipsychotic needed and protects the patient against dystonic reactions. Clozapine or fluphenazine decanoate would never be given in an acute setting
74
19 yr old woman is brought to ed by her roomate after the patient told her that "the voices are telling me to kill the teacher." The roommate states the patient has always been isolative and "odd" but for the past 2 weeks she has been hoarding food, talking to herself, and appearing very paranoid. Which of the following tests are likely to be abnormal in this patient?
CT (lateral and third ventricle enlargement will be seen)
75
47 yo woman is brought to ED after she jumped off an overpass in a suicide attempt. In the ED she states that she wanted to kill herself bc the dvil had been tormenting her for many years. After stabilization of her fractures, she is admitted to the psychiatric unit where she is treated with risperidone and sertraline. After 2 weeks she is no longer suicidal and her mood is euthymic. However, she still believes that the devil is recruiting people to try to persecute her. In the past 10 years, the patient has had three similar episodes prior to this one. Throughout this time, she has never stopped believing that the devil is persecuting her.
```
Delusional disorder
schizophreniform disorder
schizoaffective disorder
schizophrenia, paranoid type
major depression with psychotic features
```
schizoaffective disorder is diagnosed whenever the required criteria for schizophrenia are met (delusions, hallucinations, disorganized speech or behavior, and/or negative symptoms; durationg of the disturbance, including prodromal and residual period of at least 6 months, with at least 1 month of active symptoms) and the patient experiences at some point in the course of the illness a major depressive episode or a manic episode.
Delusional disorder is not accompanied by a decline in function (socially, etc)
76
a 45 yr old mother of 2 is convinced that she is HIV positive and has the AIDS virus. She is currently in good health, has had no changes in her health over the past 10 years, and has been tested for HIV 4 times, and has always tested negative
delusional disorder
77
a 22 yo business owner believes that he is infested with parasites. He otherwise is in good health, has had a recent physical, and is able to maintain good social contacts and relationships at work:
delusional disorder
78
36 yo woman is brought to the psychiatrist by her husband bc for the past 8 months she has refused to go out of the house, believing that the neighbors are trying to harm her. She is afraid that if they see her they will hurt her, and she finds many small bits of evidence to support this. This evidence includes the neighbors' leaving the garbage cans out on the street to try to trip her, and walking by her house to try to get a look into where she is hiding. She states that her mood is fine and would be "better if they would leave me alone." She denies hearing the neighbors or anyone else talking to her, but she is sure that they are out to "cause her death and mayhem."
```
Delusional disorder
schizophreniform disorder
schizoaffective disorder
schizophrenia
major depression with psychotic features
```
delusional disorder is the presence of one or more nonbizarre delusions without deterioration of psychosocial functioning and in the absence of bizarre or odd behavior. Auditory and visual hallucinations, if present are not prominent and are related to the delusional theme.
79
```
a 49 yo bank teller without a psychiatric history says that for the past 2 months, she has been increasingly convinced that a well-known pop music star is in love with her and they have an ongoing affair. She is well groomed, with no eveidence of thought disorder, and has been functioning well at work, and in social functions:
delusional disorder
acute reactive psychosis
prodomal schizophrenia
paranoid personality disorder
schizophreniform disorder
```
delusional disorder:
her high social and occupational functioning rules out any of the psychotic/schizophrenia spectrum diagnoses and possibilities and she is not paranoid. Her illness is clearly well circumscribed and is of delusional intensity only
80
```
62 yr old with chronic schizophrenia is brought to ed after wandering his halfway house confused and disoriented. His serum sodium was 123 meq/L and urine sodium was 5 meq/L. The patient has been treated with risperidone 4 mg/day for the past 3 years with good symptom control. His roomate reports that the patient often complains of feeling thirsty. Which of the following is the cause of the symptoms?
renal failure
inappropriate ADH secretion
addison disease
psychogenic polydipsia
nephrotic syndrome
this is made worse by?
```
schizophrenic drink excessive water and it is made worse by lithium and carbamazepine bc it causes water retention
81
72 yo woman is brought to ed by daughter after she was found rummaging in the garbage cans outside. Daugher states that the patient never had behavior like this. On interview, the patient states she sees martians hiding around her home and on occasion she hears them, too. She also demonstrates a constructional apraxia, with difficulty drawing a clock and intersecting pentagons. All of these symptoms point to a medical cause for this patients behavior except one.
Which symptom is common in patients with a psychiatric cause for their behavior instead of medical?
patients age
no previous history
visual hallucinations
auditory hallucinations
constructional apraxia
auditory hallucinations are quite common in psychiatrically caused psychoses, but the rest of the items point to a medical psychosis. Other signs that point to a medical cause could be altered mental status signs such as speech, movement or gait disorders, problems with alertness, memory, concentration, or orientation, and concurrent substance abuse history or medical problem
82
```
22 yo man brought to ed after becoming exceedingly anxious in college dormroom, stating that the college administration was sending a hit squad to kill him. He also notest that he can see visions of men dressed in black who are carrying guns and stalking him. His thought process is relatively intact, without thought blocking or losse associations. His urine test is positive for;
barbiturates
heroin
benzodiazepine
amphetamines
MDMA (ecstasy)
```
amphetamine intoxication can result in a psychosis very closely resembling acute paranoid schizophrenia, with symptoms incuding paranoid delusions and visual hallucinations. Some investigators believe that prominent visual hallucinations and a relative absence of thought disorder are more charactersitc of amphetamine psychosis, but other investigators believe the symptoms are indistinguishable. Other drugs that produce psychosis similar to schizophrenia include PCP and LSD
83
26 yr old woman brought to ed by husband after she begins screaming that her children are calling to her and becomes hysterical. The husband states that 2 weeks previousl, the couples two children were killed in a car accident, and since that time the patient has been agitated, disorganized, and incoherent. He states that she wil not eat bc she believes he has been poisoning her food, and she has not slept for the past 2 days. The pateint believe that the nurses in the emergency room are going to cause her harm as well. The patient is sedated and later sent home. One week later, all her symptoms remit spontaneously. which of the following would be her most likely diagnosis?
```
delirium
schizophreniform disorder
mdd with psychotic features
brief psychotic disorder
PTSD
```
brief psychotic disorder is characterized by the sudden appearance of delusions, hallucinations, and disorganized speech or behavior, usually following a severe stressor. The episode lasts at least 1 day and less than 1 month, and is followed by full spontaneous remission. For the woman in the question, the psychotic episode was clearly precipitated by the death of the children. Schizophreniform disorder is differentiated from brief psychotic disorder by temporal factors (in schizophreniform disorder, symptoms are required to last more than 1 month) and lack of association of a stressor. PTSD has a more chronic course and is characterized by affective, dissociateive, and behavioral symptoms
84
36 yo man with npd calls your office asking for an appointment with "the best therapist in the clinic." Theh patient states "they are not giving e the credit I deserve for my accomplishments at the law firm."
the patient begins seeing the therapist 2x a week for the last year. During one session, the therapist comes in 4 min late and apologizes to the patient stating that he had an emergency with another patient. During the session, the patient notes that the therapist "isn't as sharp as some of the therapists I hear on the talk shows," which defense mechanism is this?
denial
devaluation
isolation of affect
rationalization
splitting
devaluation
85
```
36 yo man with npd calls your office asking for an appointment with "the best therapist in the clinic." Theh patient states "they are not giving e the credit I deserve for my accomplishments at the law firm." What is most likely reason the patient is seeking treamtnet?
anger
anxiety
attempting to identify with others
grandiose thinking
seeking medication
```
anger
patients with npd rarely seek treatment and tend to have little insight into their grandiosity. When these individuald do present for treatment, it is usually due to underlying anger or depression from being belittled or not receiving the admiration to which they feel entitled.
86
22 yo single grduate student with narcissistic pd is admitted to a hospital after a car accidnet in which his right femur is fractured. A medical studetn has been assigned to follow the patient, but when she enters the room and introduces herself as a medical student, the patient states "oh, I wouldn't let a medical student touch me-I need someone with much more experience than you." Which of the following statements by the medical student is most likely to lead to a successful interview?
The patient wiill most likely become depressed after which of the following?
aging
graduation
job change
marriage
moving to a new city
aging
patient with NPD usually don't handle aging well because they value beauty, strength, and youth. Any blow to their fragile (but covert) self-esteem can raise their feelings of envy and anger, and subsequently lead to depression.
87
22 yo single grduate student with narcissistic pd is admitted to a hospital after a car accidnet in which his right femur is fractured. A medical studetn has been assigned to follow the patient, but when she enters the room and introduces herself as a medical student, the patient states "oh, I wouldn't let a medical student touch me-I need someone with much more experience than you." Which of the following statements by the medical student is most likely to lead to a successful interview?
I know this will be boring for you, but it's just one of the things you will have to put up with in the hospital
I know you must be scared to be in the hospital, but you will be safe here
I'm told that you are a avery articulate person, and I 'm hoping you'll teach me what I need to know
I understand that you think you deserve only the best, but I have been assigned to you
Please don't make this difficult, I hve to interview you as part of my job
C
Appealing to the patient's narissism by being admiring most often de-escalates the patient as well as improves the therapeutic alliance
88
45 yo man is admitted after a heart attack. 24 hours later he tries to leave the hospial against medical advice bc he is angry about the way the staff treated him. He as a grandiose sens of selfimportance and feels entitled. He is interpersonally exploitative with the psychiatrist who interviews him and is obviously envioius of a watch that he thinks is expensive. He shows no other abnormalities:
Narcissistic pd
89
```
a 25 yo with schizotypal comes to his psychiatrist with a complaint of a depressed mood. He notes that since losing hsi job as an astrologer, he has been depressed and unable to sleep. He says althrough his mood is usually fairly low (4 out of 10), it has lately been a constant 2. The patient also notes problems with concentration and energy level, and has crying spells. He reports he had premonitions that certain foods could heal him, so he has been mixing "magical potions" and eating "magical foods," A mental status exam reveals an ddly dressed man with constricted affect, ideas of reference, unusual believes and some mild paranoia. Which medication should he get?
zopidem (ambien for insomnia)
divalproex sodium for mood disturbance
escitalopram for depression
risperidone for paranoia
ziprasidone for ideas of reference
```
escitalopram
it is a ssri useful in treating depression. Patients with schizotypal pd who have either a depressive component to their illness or a secondary superimposed major depression (as in this case) should be treated with antidepressants. Ziprasidone and risperidone are atypical antipsychotics that would be effective if the patient was having transient psychotic episodes, and divalproex sodium would be good for treating mania
90
```
which of the following features must be present in a patients history to diagnose schizotypal
auditory hallucinations
cognitive and perceptual distortions
impulsive or manipulative behaviors
paranoid ideations
unstable and intesne relationships
```
cognitive and perceptual distortions
the odd quality with which patients perceive and think about the world is one of the diagnositc criteria
C and E are characteristics of boerderline personality disorder
91
45 yo married woman was admitted to the surgical service 2 days ago for appendectomy. The procedure went well, but she was found tearful saying "I wish I were dead." On obtaining further history, she is quite cooperative and talkative. She is questioned about the earlier comments, and she states the she "wanted attention." She was upset that her husband was not with her. She says she has never been away from him for that long since they started dating when the patient was 16 yo. She feels helpless and is having a diff time being active in her care. She feels overwhelmed regarding her postsurgical and discharge instruction, adn the nursing staff has become frustrated with her constant need for reassurance. Althought at times she is tearful during the interview, she denies prior or recent pervasive depressive or neurovegetative symptoms and is not actively suicidal:
encourage her to learn more about her surgery and become proactive in her care?
persuade her to become less dependent on her husband
insist her hhusband be present at all times while his wife is hopitalized
spend regular, short periods of time with her to discussdischarge planning and aftercare
transfer her to the psychiatric unit
spend regular, short periods of time with her to discussdischarge planning and aftercare
the patient discplays dependent personality disorder, and the most effective approach to dealing with her is to respect her need for attachment and schedule limited but regular appointments with her. Individuals with
92
30 yo is referred from pcp. He lives with mom and relies on her to make every day decisions. Has never worked and depends on her for financial support. Lacks self-confidence and is uncomfortable when left alone. Since his mother's diagnosis of cancer, the patient is preoccupied with the fear of his mother dying and being left aloe to care for himself.
```
what is the best/most useful treatment?
antianxiety meds
antidepressant meds
nothing bc research suggests he'll get better over time
individual psychotherapy
sociotherapies
```
sociotherapies
sociotherapies (group, family, milieu) have demonstrated to be moderately effective for patients who face the loss of their usual support systems. Medications for depression, anxiety, and or psychosis would be indicated if the patient had a comorbid psychiatric illness which is not evident (while it's true some personality disorders get better, some get worse, so treat!)
93
```
30 yo is referred from pcp. He lives with mom and relies on her to make every day decisions. Has never worked and depends on her for financial support. Lacks self-confidence and is uncomfortable when left alone. Since his mother's diagnosis of cancer, the patient is preoccupied with the fear of his mother dying and being left aloe to care for himself.
avoidant
borderline
dependent
histrionic
ocpd
```
dependent
avoidant: fear of humiliation
borderline: unstable and intense relationships
dependent: submissive reactive and clingy
histrionic: flamboyance with demanding personality
ocpd: pattern of preoccupation with order, perfection, and control
94
32 yo has been depressed since broke up with gf 2 weeks ago. Has no vegatative signs or symptoms of mdd. Overly reliant on his mother for major decisions and still lives at home. He has difficulty expressing disagreement with his mom bc he is afraid she will not support him. The patient does well at his job but has turned down any position that would require him to take responsibility for others. He seems to be very dependent on a few close friends as well:
Dependent personality disorder
95
```
which of the following personality traits is most likely seen in patients with histrionic pd
callousness
emotional lability
recklessness
cognitive dysregulation
grandiosity
```
histrionic pd usually demonstrate emotional lability (emotional lability is a sign or symptom typified by exaggerated changes in mood or affect in quick succession)
grandiosity is seen in antisocial and narcissistic
cognitive dysregulation is seen in borderline and schizotypal
recklessness in antisocial and borderline
callousness in antisocial personality
96
```
a 20 yr old woman comes to see a psychiatrist at the insistance of her mother who says her daughter "isn't herself." The patient is spending a great deal more time alone in her bedroom, she doesn't seem to care for her hygiene as well, and has been missing work a great deal more .She is very clingy and attention seeking with her mother:
histrionic
borderline
bipolar
mdd
delusional
```
mdd:
| she has a new onset of behavior unlike her usual personality which is common in mdd
97
a 23 yo woman with histrionic personality disorder comes to see her physician for frequent headaches. As the (male) physician is taking the patient's history, he notices that the patient is frequently reaching across the desk to touch his arm as he talks to her, as well as leaning far forward in her seat to be nearer to him. Which of the following responses is most appropriate?
tell the patient to stop touching him immediately
move his seat further from the patient so she cannot reach him
tell the patient that she will be referred to a female physician
tell the patient that he understand her concern about her headaches but touching him is not appropriate
tell the patient he understands her gratitude in this situation
tell the patient that he understand her concern about her headaches but touching him is not appropriate
this is best managed by being tactful and sympathetic to the patient, but firmly and clearly placing boundries on such behavior
98
35 yo woman with histrionic personality disorder has seen her psychotherapist once a week for the past year. She has come in the last few visits subtly different. She appears more distracted, she is late for appointments, she reports an increased amount of arguments with her famiy, and she appears flushed and even sweaty. You asked aabout use of illicit substances and she denies it. An important next step might be which of the following?
calling a family member about this change?
request a urine toxicology to screen for substances
no further workup is necessary, continue with the current framework of psychotherapy and treatment
ask her to go to her primary care physician
refer her to an alcoholics anonymous group
request a urine toxicology to screen for substances
substance use is a common feature of cluster B personality disorders. Significant changes in unusual behavior, alienation from loved ones, and physical signs are common features. Often patients are reluctant to admit use so a urine toxicology might be the most important step to help plan an appropriate intervention.
99
42 yo man comes with complaint of depressed mood and difficulty sleeping. He says his gf recently left him, and although he is upset about the loss, he cannot describe her in any specific detail, and they had not been going out together for very long. The patient's speech and manner appear somewhat theatrical and overblown. His affect appears euthymic and full range, and he appears to be trying to directly engage the female interviewer by touching her and asking her direct personal questions. In this manner, he appears to be trying to draw attention to himself by being somewhat seductive. He is shown to have normal thought processes and thought content on a mental status examination:
histrionic personality disorder
100
```
a patient with ocpd may also be categorized in a grouping of disorders named cluster C personality disorders. Which other personality disorders is part of Cluster C
antisocial
schizotypal
narcissistic
avoidant
borderline
```
avoidant
101
```
26 yo woman has been taking 6-7 hour long showers every day. She explains, "it all starts when I wake up, I am sure I am covered in germs and if I don't wash, I will get sick. If I don't wash, I get paralyzed with anxiety. Once I'm in the shower, I have no shower in a particular order. If I mess up, I have to start over, and this takes hours and hours. My skin is cracking and bleeding becaue I spend so much time in the water." Which of the following conditions does this patient is most likely have?
ocd
oc personality disorder
obsessive-compulssive traits
schizoid personality disorder
paranoid personality disorder
```
OCD: patient demonstrates classic obsessions and compulsions
102
```
23 yo med student makes lists of all the tasks that he must accomplish each day. He spends hours studing and refuses to go out with his colleagues even when there are no tests on the immediate horizon, preferring to spend his time looking at specimens in lab. He keeps meticulous notes during all his classes and prefers to attend every lecture, not trusting his colleagues to take notes for him. He is doing well in school and has a gf who is also a medical student:
ocd
oc personality disorder
obsessive-compulssive traits
schizoid personality disorder
paranoid personality disorder
```
obsessive compulsive traits bc his social and occupational functioning both are good, so that rules out personality disorder
103
```
24 yo is called into head office and told her chronic lateness in completing assignments will result in her dismissal if she does not change. The patient really loves her job, and the news comes as a major blow. She tells her bf in great detail about each and every step of the meeting and spends the entire night thinking about her job. The bf tells her she does not "look" particulatly upset. which defense mechanism is this?
undoing
displacement
intellectualization
rationalization
splitting
```
intellectualization
104
36 yo old has lifetime preoccupation with rules, work, order, and stinginess. Has trouble at work bc he keeps missing deadlines and has difficulty making decisions Patient does not realize he is the cause of the problems and blames others. Has a rigid and stubborn manner
OCD
105
```
35 yo woman is engaged in psychotherapy for avoidant personality disorder. SHe is distressed by her inability to maintain a romantic relationship with a man. During the course of treatment, the therapist learns that her father was an alcoholic and was physically abusive to the patient and her mother. Which defense mechanism is the patient using?
undoing
splitting
isolation of affect
idealization
displacement
```
This patient can be theorized to be using displacement to assume all men will act as punitively toward her as her father did. Displacement and pojection are the two defense mechanisms most commonly utilized by patients with avoidant personality disorders. Undoing is a defense mechnism in which a person tries to "undo" an unhealthy thought or action by engaging in its opposite. Spiltting is often used by patients with a personality disorder in which a person literally spilts apart the positive and negative qualities of the self and others. For example, an individual is either all bad or all good but never an integrated whole of both good and bad. Isolation of affect is a defense mechanism involving the creation of a gap between an unpleasant or threatiening cognition, and other thoruhgts and feelings. Idealization is the defense mechanism in which a person attributes exaggeratedly possitive qualities to the self and others
106
characterize the difference between patients with avoidant personality disorder and those with schizoid personality disorder
patients with avoidant would like to have friends more than patients with schizoid personality disorder
107
24 yo present to therapist. Which of the following is consistent with avoidant personality disorder?
i have a couple close friend but it is very hard to make friends. I m afraid most people wouldn't want me around
I'm usually fine around people. It's just when Im' around a lot of people I've never met before that I freak out
Im afraid that people are plotting against me
My mom thinks I have a problem with people. I can take them or leave them
My gf thinks I have a problem with people, like with her friends, what do you think?
i have a couple close friend but it is very hard to make friends. I m afraid most people wouldn't want me around
patient has some close relationships and seems to desire more but thinks people won't want him around
B is a social phobia
C is paranoid (psychotic disorder)
D is schizoid
E suggests dependent personality disorder
108
a patient is so nervous at work that he cannot think straight. He reports that his mood at home has been good, but that he knows he will fail at the new job bc, "I have always been such a dope when it comes to working with other people." After several sessions, the counselor diagnoses the patient with avoidant personality disorder. Which of the following would be the most helpful in assisting the patient to manage his anxiety regarding his new job?
tel the patient that he needs to be more confident and to "suck it up"
engage the ptient in cognitive therapy to help him deal with his distorted thinking
prescribe a benzo
tell the patient that he is probably not ready for this job if he is this anxious
engage the ptient in cognitive therapy to help him deal with his distorted thinking
goal is to help patients critically examine if their assumptions about themselves and other people are correct
109
21 yo comes to counselor after an embarassing interpersonal interaction in class. She has a long history of avoiding close interpersonal relationships bc of a fear of being rejected. She avoids new interpersonal situations bc she feels inadequate
avoidant personality disorder
treatment:
psychodynamic or CBT
110
which of the following is most consistent with antisocial personality traits?
13 yo living in an economically depressed area joins a gang to avoid being beaten up by competing gangs
38 yr old drug addict who has been arrested seven times for retail theft
67 yr old CEO who embezzles from his company, is unfaithful to his third wife, and has been involved in covering up corporate malfeasance from federal investigators
a 42 yo homeless female shizophrenic who has been arrested on misdemeanor trespassing charges 5 times in 2 years
a 28 yo woman who has a history of prostitution, drug abuse, and multiple suicide attempts with over 20 inpatient psychiatric admissions
67 yr old CEO who embezzles from his company, is unfaithful to his third wife, and has been involved in covering up corporate malfeasance from federal investigators
note, A is too young to be diagnosed with any personality disorder!
D is resorting to antisocial acts in order to survive
B the individual is stealing to support his drug habit
E is borderline personality disorder
C is displaying patterns of violating the rights of others across several settings
111
```
A 39 yo man with antisocial personality disorder incarcerated for life after murdering a man has a multitude of somatic complaints over the course of several years. Yearly physical exams never show anything physically wrong with him, yet he complains of a variety of aches and pains, neurologic symptoms, and GI distress. He does not enjoy the time he spends in the jail's infirmary. Which of the following is the most likely explanation for the complaints?
He is malingering
he has developed a psychotic disorder
he has developed a somatic disorder
he has an undiagnosed physical illness
he has an undiagnosed anxiety disorder
```
he has developed a somatic disorder
development of a somatic a mental disorder (characterized by recurring, multiple, and current, clinically significant complaints about somatic symptoms, although it is no longer considered a clinical diagnosis) is more common in patients with antisocial personality disorder as they grow older. There is no evidence of secondary gain here (which rules out malingering) nor is there evidence of psychotic thinking. Physical examinations have all been negative so physical illness is out, and the complaints are all around somatic symptoms, making a pure anxiety disorder unlikely
112
16 yo is incarcerated in a juv facility and is charged with theft, apparently to support her and her bf drug habit. She has had multiple invovlements with child and family services for running away from home, where she was sexually abused by her mother's bf. She has a diagnosis of ptsd. Prior to the onset of the abuse, she was doing extremely well in school, in an accelerated program. Which of the following speaks most strongly against a diagnosis of antisocial disorder?
her concurrent diagnosis of ptsd
her gender
her age
antisocial acts committed to support her drug habit
apparent high intelligence
AGE!
antisocial disorders cannot be diagnosed before 18 yr old. Antisocial personality disorder should not be overlooked in females, even though it is much more common in males. Antisocial actions committed solely during psychotic or manic episodes or to support a drug habit would not support a diagnosis of antisocial personality disorder
113
```
39 yo is evaluated in prison, and has a history of multiple arrests as both and adult and juvenile. After several interviews, he is diagnosed with antisocial personality disorder. He has a history of multiple psychiatric hospitalizations after suicide attempts and was in special ed programming as a child. What diagnosis is likely to have occurred comorbidly?
ADHD
Cocaine dependence
TBI
Major Depression
Conduct Disorder
```
Conduct Disorder
even though the others are frequently comorbid, evidene of a diagnosis of conduct disorder before age 15 i REQUIRED for a diagnosis of antisocial personality disorder.
114
```
39 yo is evaluated in prison, and has a history of multiple arrests as both and adult and juvenile. After several interviews, he is diagnosed with antisocial personality disorder. He has a history of multiple psychiatric hospitalizations after suicide attempts and was in special ed programming as a child. What diagnosis is likely to have occurred comorbidly?
ADHD
Cocaine dependence
TBI
Major Depression
Conduct Disorder
```
Conduct Disorder
even though the others are frequently comorbid, evidene of a diagnosis of conduct disorder before age 15 i REQUIRED for a diagnosis of antisocial personality disorder.
115
32 yo incarcerated man is seen by a psychiatrist after he gets into a fight with an inmate. He has a long history of incarceration and inability to conform to societal norms, which seems to have begun around age 13. He does not seem to be remorseful about his actions
antisocial personality disorder
116
```
a 20 yo man is brough to psychiatrist by his parents for odd thinking. He is dressed in clothes more consistent with a 1960's hippie, with long hair and marginal hygiene. He was reently fired for not showing up for his shifts and was forced to move back with parents. He has artistic aspirations and is very interested in philosophy, metaphysics, magic and occult. He talks about his desire for fame and wealth, given his special talents. He has recently gotten into some legal trouble as he prduced art work of fanciful paper currency, which he attempted to use at some local stores. Hower, he admits that he did not think that this was going to work and describes this as a performance art. Which of the following is most likely the diagnosis?
schizophrenia
schizoid personality disorder
schizotypal personality disorder
delusional disorder
bipolar disorder
```
schizotypal personality disorder
117
```
a woman with schizoid personality disorder was in a care accident and was rear-ended. The driver of the other car refused to take responsibility and hired a lawyer to provide his defense. The woman spends hours every day thinking about the specifics of the accident, including the colors of the cars involved, and what each party to the accident was wearing. Which of the following defense mechanisms is she using?
sublimation
undoing
projecting
intellectualization
introjection
```
intellectualization
| this is characterized by rehashing events over and over
118
a patient with schizoid pd comes to pcp with complaint of polyuria and polydipsia. He is found to have insulin-dependent diabetes. Which of the following interventions is likely to be most well received by the patient?
asking the patient to bring in a relative or close friend so that he can describe the treatment regimen to both of them at the same time
Referring the patient to a therapist for support in dealing with a chronic illness
Giving the patient detailed written information about the disease and telling him that the physician will be available to answer any questions
Referring the patient to a group that helps its members learn about diabetes
Scheduling frequent appointments with the patient so that all the treatment details cann be explained on a one-to-one basis
Giving the patient detailed written information about the disease and telling him that the physician will be available to answer any questions
They generally prefer to keep social interaction to a minimum .They do better with a more technical approach with as little human interaction as possible
119
48 yo woman presents to psychotherapist. She lives a very secluded life as a night time janitor at a department store and takes care of her elderly mother. She complains of feeling longely and is aware that she has a great deal of difficulty relating to othe people. What distinguishes her condition from someone with schizoid personality disorder?
A family history of a cousin with schizophrenia
a desire to engage in interpersonal relationships
lack of hallucinations or delusional thinking
her gender
a history of alcoholism
a desire to engage in interpersonal relationships
hallmark of schizoid personality disorder is detachment and disinterest in social relationships. This patient is clearly distressed by her lack of social relationships, which would clearly steer the diagnosis away from schizoid personality disorder. Men are more frequently, though not exclusively diagnosed with schizoid personality disorder
120
56 yo man presents to psychiatrist bc pcp concern of restricted affect and depression, who reports no complaints but gives a history of isolation and very limited interactions with others. The results of the patien'ts mental status examination are essentially normal, other than showing a restricted emotional range:
schizoid personality disorder
121
obsessive-compulsive personality disorder:
not impulsive! Total opposite, super rigid, not flexible, need to be in control, workaholic, may obsess about details to the point they miss the big picture
122
dependent personality disorder:
diff bc these people can only survive when they're in a relationship with someone else who says it's ok, what they're doing is ok, and if they ge
t out of one, they're right bac in another, and they'll stick in a relationship with an abusive person
123
which of the following statements is correct?
benzos directly open chloride channels
benzos show analgesic actions
clinical improvement of anxiety requires 2-4 weeks of treatment with benzos
all benzos have some sedative effects
benzos like other cns depressant readily produce general anesthesia
all benzos have some sedative effects
124
which of the followin is correct?
phenobarbital shows analgesic properties
diazepam and phenobarbital induce the p450 enzyme system
pheobarbital is useful in the treatment of acute intermittent porphyri
phenobarbital induces respiratory depression, which is enhanced by the consumption of ethanol
buspirone has actions similar to those of the benzos
d:
| barbiturates and ethanol are a potentially lethal combination
125
```
what drug should be administered to treat patient if he goes through alcohol withdrawl?
none
lorazepam
pentobarbital
phenytoin
buspirone
```
lorazepam
| it is important to treat the seizures associated with alcohol withdrawl.
126
30 yo woman with history of unstable interpersonal relationships, suicidal gestures, and marked impulsivity is referred to you for dialectical behavioral therapy (DBT)
which of the following is this patient most likely suffering from?
avoidant personality disorder
bipolar disorder
passive-aggressive personality disorder
borderline personality disorder
schizoid personality disorder
the foundations of DBT include which of the following
the patient is doign the best he/she can
the patient may fail therapy
the patient may not want to improve
the patient should not learn new behaviors
the patient is responsible for causing his/her problems
borderline personality disorder
DBT is a form of CBT and is used to treat Borderline personality disorder
A
The patient is presumed to be doing the best they can
The patients is encouraged to take responsibility for solving their own problems, and the may or may not have caused their problems. Either way, they are encouraged to take it upon themselves to solve their problems. They are also encouraged to learn new behaviors in a relative context and believe that they cannot fail in therapy
127
```
in controlled studies, which of the followiong medications is ineffective for use in childhood anxiety disorders
venlafaxine
SSRI
Buspirone
TCA
Bensodiazepines
```
benzodiazepines
128
```
when starting an ssri in an adolescent patient with separation anxiety disorder, the FDA recommends the clinician monior closely for?
hpovolemia
hypertension
anorexia
suicidal thoughts
delusions
```
suicidal thoughts
129
```
children with separation anxiety are at a higher risk for developing which pediatric disorder?
malingering
somatization disorder
bipolar disorder
learning disability
major depression
```
major depression
130
10 yr old with episodes of somatic complaints, anxiety, adn crying at school which resolves when he is sent home. He won't go anywhere without his mother. Best plan of treatment?
place on home bound tutoring to be provided by the school disrict
prescribe lorazepam for anxiety episodes
place the patient on fluoxetine in low dose
immediately restrict access to the mother until anxiety smptoms cease
reassure the mother that the patient is going through a phase and that this will pass with little impact on youth's subsequent life
C
ssri is first line
lorazepam (benzo) is habit forming and more likely to disinhibit the child.
Home tutoring will only reinforce the separatin anxiety
The disease is an indicator for future risk of depression illness
131
10 yr old exhibits anxiety when not in the presence of his mother. As a result, he stopped attending school although he was on cognitively on target. His anxiety began after his mother experience a serious, life-threatening illness. The patient believes that if he is separated from her, something terrible might happen to her. He also complains of several somatic complaints that have been difficult to diagnose_______
how do you treat?
separationg anxiety
ssri, relaxation technique
132
```
56 yo with long history of paranoid schizophrenia has been taking chloropromazine regularly for 27 years. About 5 years ago, he developed writhing movements of his wrists and fingers that disappear when he goes to sleep.
Which extrapyramidal syndrome is this?
akathisia
dystonia
nms
parkinsonism
tardive dyskinesia
```
tardive dyskinesia
usually affects perioral or limb musculature and causes choreiform movements. Its onset is usually several years after being on the medication, and it is more likely to affect older patients
akathisia is best descrbied as psychomotor restlessness that may have an onset of hours to days after beinning the neuroleptic
dystonia is an acute reaction to neuroleptics in which particular muscle groups (neck or occular muscles) comonly contract involuntarily. It can be painful and should be treated immediately with anticholinergics. NMS is a potentially lethal medical emergency in which patients may have global rigidity, mental status changes, fever, cardiovascular instability, elevated creatine phosphokinases, adn risk of rhabdomyolysis
Parkinsonism looks identical to parkinsonism with tremor and bradykinesia, and may have onset within weeks to months of beginning medication
133
56 yo with long history of paranoid schizophrenia has been taking chloropromazine regularly for 27 years. About 5 years ago, he developed writhing movements of his wrists and fingers that disappear when he goes to sleep.
Which anatomic structure in the brain is most likely implicated in the etiology of this movement disorder?
basal ganglia
cerebellum
frontal cortex
midbrain
motor cortex
the basal ganglia, implicated in the yoking of thought to motor action, and in controlling the initiation and quality of motor action, is theorized to be central to the pathophysiology of extrapyramidal syndromes, including dystonia, parkinsonism, akathisia, and tardive dyskinesia.
The cerebellum is important in controlling the coordination of motor movements and posture, as well as participating in procdural memory.
The frontal cortex is generally considered to be important in decision making, impulse control, short-term memory, and affect regulation. The midbrain contains nuclei that help to ensure the CNS homeostasis by regulating neurovegatative, autonomic, and arousal functions. The motor cortex servs as the last stage of cerebral processing of motor information before it descends into the spinal cord. An intact motor cortex is required for initiation of movement.
134
```
a 29 yr old present complaining of anxiety and depression. His social history reveals he is a janitor working 90 hours a week, and he reports stress arising from his marital relationship that is exacerbated by his occupational demands. You identify a central conflict in this patient of issues of intimacy versus self-absorption borrowing from the theoretical work of:
carl jung
karen horney
erik erikson
jean piaget
sigmund freud
```
erik erikson is perhaps bet known for his description of eight stages of human psychological experience spanning the life span, centered on stage-appropriate developmental conflicts:
basic trust versus mistrust (birth to 1 yr); autonomy versus shame and doubt (1-3) initiative versus guilt (3 to 5), industry versus inferiority (6 to 11), identity vs rold diffusion (11-to adulthood), intimacy vs isolation (21-40) generativity vs stagnation (40-65), and integrity vs despair (65-older)
Jean piaget is known for his work using observations of children and adolescents to build a framework describing cognitive stages of development beginning with the sensorimotor stage at birth and ending with the stage of formal operations
135
```
a 32 yo divorced woman is admitted for 2nd and 3rd degree burns to her right hand, which she attributes to accidentally spilling hot oil while she was cooking dinner. Upon evaluation, the surgeon recognizes the patient as someone he had treated for similar burns on the same hand 3 months ago. Further detail review of her medical records reveals that this is her sixth burn-related injury in 2 years. Which of the following is the most likely diagnosis?
body dysmorphic disorder
coversion disorder
factitious disorder
illness anxiety disorder
malingering
```
factitious disorder
patients with factitious disorders consciously produce symptoms to present as ill or impaired (maintain the "sick role")
136
```
42 yo returns to his internist for the fourth time in 5 months with the same complaints of intermittent numbness of his fingers and indigestion. Although his medical workup has been unremarkable, this has failed to reassure him. He remains anxius and is now concerned that he has celiac disease and requests a GI consultation. Which of the folllowing is the most likely diagnosis?
body dysmorphic disorder
coversion disorder
factitious disorder
illness anxiety disorder
malingering
```
illness anxiety disorder
137
17 yo boy presents with "legs giving out" for 1 week. During the episodes he experiences a generalized weakness and is unable to move his arms and legs. The episodes last a few minutes. He is currently in the 11th grade and earns Bs and Cs. Further questioning reveals that his parents have recently separated after a long period of verbal abuse toward each other. His physical examination and neurologic workup are unremarkable.
what is the most effective treatment?
confrontation about intentionally producing symptoms
explaining that the symptoms are not real
reassurance that a cause will be found
suggestion that symptoms will improve with time
suggetion that the family begins therapy
although the deficits often remeit spontaneously, education about the illness and suggesting the symptoms will improve can facilitate the process. These patients do not intentionally produce their symptoms (as in factitious disorder) and explaining that their deficits are not real may aggravate the situation and worsen their problems. Whereas reassurance about their likely improvement is appropriate, implying that their symptoms are caused by a neurologic illness (assuming that this has been ruled out) would be inaccurate and may serve to reinforce their use of phyical symptoms.
138
```
17 yo boy presents with "legs giving out" for 1 week. During the episodes he experiences a generalized weakness and is unable to move his arms and legs. The episodes last a few minutes. He is currently in the 11th grade and earns Bs and Cs. Further questioning reveals that his parents have recently separated after a long period of verbal abuse toward each other. His physical examination and neurologic workup are unremarkable.
body dysmorphic disorder
coversion disorder
factitious disorder
illness anxiety disorder
malingering
```
conversions disorder: evidenced by his altered sensory and motor functioning.
Patients with body dysmorphic disorder have a preoccupation with an imagined defect in appearance
Factitious disorder is intentionally producing the symptoms in order to assume the sick role as in factitious disorder
illness anxiety disorder is preoccupation with having a serious illness
139
24 yo presents with new-onset blindness for which there is no physicologic or anatomic explanation. The patient says that his mother died recently, and he was unable to send her money bc he lost it gambling. He does not seem to be bother by his blindness:
conversion disorder
| la belle indifference
140
26 yo is admitted for sepsis. Her roomate reports that she found the patient with a needle and syringe full of what the patient admitted was toilet water. The patient's physical examination reveals iv needlemarks not made by hospital staff. Records show she was admitted 1 year ago for drinking drain cleaner:
factitious disorder
141
2 yo is referred to you for evaluation due to suspicion that the child is the victim of physical abuse secondary to munchausen syndrome by proxy. Which of the following family members is usually the perpetrator who fabricates the presenting illness?
mother
mother is most commonly the perpetrator of intentionally producing physical or psychological symptoms in her child in order to assume the sick role by proxy the victim is usually a preschool child
142
```
a 49 yr old complains of HA, memory loss, disorientation and occasional paralysis that affects his arms and lasts several hours. During the MSE you notice that the patient is giving approximate answers to many questions (2+2=5, there are 6 toes on the foot):
amok
Ganswer syndrome
factitious disorder
illness anxiety disorder
```
Ganser Syndrome
| approximate answers and talking past the point, presenting with amnesia, disorientation, conversion symptoms, etc
143
```
you are asked to evaluate a 36 yo patient who reports depressed mood and suicidal ideation. During your examination you notice the prisoner responds to your questions with approximate answers
body dysmorphic disorder
ganser syndrome
munchausen syndrome
illness anxiety disorder
malingering
```
Ganser Syndrome: characterized by giving approximate or ridiculous answers to questions
144
```
a 32 yo divorced woman is admitted for 2nd and 3rd degree burns to her right hand, which she attributes to accidentally spilling hot oil while she was cooking dinner. Upon evaluation, the surgeon recognizes the patient as someone he had treated for similar burns on the same hand 3 months ago. Further detail review of her medical records reveals that this is her sixth burn-related injury in 2 years. Which of the following is the most likely diagnosis?
body dysmorphic disorder
coversion disorder
factitious disorder
illness anxiety disorder
malingering
```
factitious disorder
patients with factitious disorders consciously produce symptoms to present as ill or impaired (maintain the "sick role")
145
```
42 yo returns to his internist for the fourth time in 5 months with the same complaints of intermittent numbness of his fingers and indigestion. Although his medical workup has been unremarkable, this has failed to reassure him. He remains anxius and is now concerned that he has celiac disease and requests a GI consultation. Which of the folllowing is the most likely diagnosis?
body dysmorphic disorder
coversion disorder
factitious disorder
illness anxiety disorder
malingering
```
illness anxiety disorder
146
17 yo boy presents with "legs giving out" for 1 week. During the episodes he experiences a generalized weakness and is unable to move his arms and legs. The episodes last a few minutes. He is currently in the 11th grade and earns Bs and Cs. Further questioning reveals that his parents have recently separated after a long period of verbal abuse toward each other. His physical examination and neurologic workup are unremarkable.
what is the most effective treatment?
confrontation about intentionally producing symptoms
explaining that the symptoms are not real
reassurance that a cause will be found
suggestion that symptoms will improve with time
suggetion that the family begins therapy
although the deficits often remeit spontaneously, education about the illness and suggesting the symptoms will improve can facilitate the process. These patients do not intentionally produce their symptoms (as in factitious disorder) and explaining that their deficits are not real may aggravate the situation and worsen their problems. Whereas reassurance about their likely improvement is appropriate, implying that their symptoms are caused by a neurologic illness (assuming that this has been ruled out) would be inaccurate and may serve to reinforce their use of phyical symptoms.
147
```
17 yo boy presents with "legs giving out" for 1 week. During the episodes he experiences a generalized weakness and is unable to move his arms and legs. The episodes last a few minutes. He is currently in the 11th grade and earns Bs and Cs. Further questioning reveals that his parents have recently separated after a long period of verbal abuse toward each other. His physical examination and neurologic workup are unremarkable.
body dysmorphic disorder
coversion disorder
factitious disorder
illness anxiety disorder
malingering
```
conversions disorder: evidenced by his altered sensory and motor functioning.
Patients with body dysmorphic disorder have a preoccupation with an imagined defect in appearance
Factitious disorder is intentionally producing the symptoms in order to assume the sick role as in factitious disorder
illness anxiety disorder is preoccupation with having a serious illness
148
36 yo is referred by her gynecologist who reports a long history of sexual and other nonspecific complaints that have apparently shown no evidence of verifiable disease. The gynecologist further relates that she believees this patient has a long history of doctor shopping. On interview, the patient complains of physical pain in her back, belly, chest, excessive menstrual bleeding, constipation and lactose intolerance. She poitns out that "nobody's been able to figure out why I can't feel anything on the back side of my arm." She had multiple surgeries for abdominal complaints in the past, all with no significant findings or findings inconsistent with her complaints. She relates that "I've always been sickly, most of my life."
somatization disorder describes the condition suffered by individuals who have a long history of multiple somatic complaints (gastrointestinal, sexual, and neurologic) that despite exhaustive medical workups, have either no identifiable cause or are out of proprotion to the medical findings. These patients often describe themselves as having been "sickly their whole lives" and presumabley in their frustration with doctors' inability to find reasons for their problems, chronically "doctor shop."
149
26 yo is admitted for sepsis. Her roomate reports that she found the patient with a needle and syringe full of what the patient admitted was toilet water. The patient's physical examination reveals iv needlemarks not made by hospital staff. Records show she was admitted 1 year ago for drinking drain cleaner:
factitious disorder
munchausen's type: condition suffered by patients who intentionally produce signs or symptoms of medical illness. Commonly these patients are former healthcare workers or have such workers in their family
150
```
You are asked by the surgical service at your hospital to see a 34 yo woman well knowon to them from previous admissions with a number of vague complaints that have no obvious physical cause: abdominal pain, headache, and lower back pain. She appears tearful and says that although she does not think she has anything seirous, tells you she just wants to figure it all out so she can get home;
body dysmorphic disorder
coversion disorder
factitious disorder
somatization disorder
illness anxiety disorder
```
somatization disorder
caused by multiple physical complaints that cannot be explained by any objective physical finding. As in this case, patients' symptoms frequently date back many years and have prompted multiple doctor visits, even hospitalizations.
151
20 yo is brought to mental health center by his parents who are at their wit's end bc of son's drug problem. Son is sullen and completely uncommunicative. The parents are naive and have no idea what he's taking. How can you determine between the ause of cocaine vs amphetamine?
rhinorrhea
track marks on arm
severe smoker's cough and respiratory problems
extremely poor dentition
weight loss
coke and amphetamines are similar, both can be used by smoking, insufflation (rhinorrhea) or iv. However, "meth mouth" is commonly seen with prolonged abuse of methamphetamines, caused by grinding teeth, lowered saliva production, and too much sugar
152
19 yo is brought to ed after behaving abnormally. Friends say they are unsure what she was taking. What would be most like amphetamine intoxication?
urine toxcology confirms intoxication with amphetamines, which of the following withdrawal syndromes would you expect?
diarrhea, piloerection, yawning
delirium, autonomic hyperactivity, visual or tactile hallucinations
crash of mood into depression, lethargy, increased appetite
tremor, headache, hypertension
postural hypotension, psychomotor agitation, insomnia
crash of mood into depression, lethargy, increased appetite
A opiod withdrawl
B delirium tremens
D alcohol withdrawl
E sedative hypnotic withdrawl
153
19 yo is brought to ed after behaving abnormally. Friends say they are unsure what she was taking. What would be most like amphetamine intoxication?
flush face, slurred speech, unsteady gait
anorexia, diaphoresis, pupillary dilation
prominent hallucinations, pupillary dilation, incoordination
miosis, slurred speech drowsiness
hyperphagia, conjunctival injection, tachycardia
anorexia, diaphoresis, pupillary dilation, also could be: tachycardia, HT, pupillary dilation
a= alcohol intoxication
D=opiod intoxication
154
26 yo is brought to ed after becoming physically aggressive with bff. He is belligerent, angry, and mildly paranoid. The patient has not been eating or sleeping well, resulting in 10 lb weight loss. No medical history, is belligerent and uncooperative, is somewhat paranoid and seems angry. His physical exam is positive for hypertension tachycardi dilated pupils, diaphoresis, and a fine bilareral tremor in his hands
amphetamine intoxication
155
48 yo is brought to the ED. She is unresponsive to questions, stubles aroiund the room, is agitated, smells of alcohol, and is not cooperative. Upon questioning you find the patient has drank heavily for 30 years, has started preferring alcohol to meals, and has started losing weight.
which is most likely found on mental status exam?
confabulation
delusions
elevated affect
fluctuating consciousness
loose associations
confabulation:
the patient has a long history of heavy regular alcohol use and likely malnutrition. A common sequelae of this chronic thiamine deficiency resulting in korsakoff syndrome: anterograde amnesia, memory impairment, and confabulation
156
```
48 yo is brought to the ED. She is unresponsive to questions, stubles aroiund the room, is agitated, smells of alcohol, and is not cooperative. Administration of what mediine is most appropriate for initial treatment?
antipsychotic
benzodiazepine
disulfiram
glucose
thiamine
```
thiamine
patient has wernicke encephalopathy, characterized by the triad of delirium, ataxia, and ophthalmoplegia. Thiamine must be given first
157
```
a man enrolls in an outpatient rehabilitation program for which he is required to attend 3 metings per week. While he is interested in medication to minimize his risk of relapse, he admits to being "very forgetful" with medications. Which of the following medications would be most appropriate?
acamprosate
disulfiram
lorazempam
naltrexone
sertraline
```
naltrexone, an opiod antagonist that has been shown to help reduce craving, maintain abstinence aand reduce heavy drinking. Snother advantage is it is given in long-acting injectable form, beneficial for forgetful patients. Acamprosate has also demonstrated benefit in promoting abstinence, the evidence is not as strong as for naltrexone.
158
```
A patient says he simply cannot control his cravings to have too much alcohol. Which of the following agens has shown some success in decreasing cravings for alcohol?
fluoxetine
disulfiram
bupropion
diazepam
```
naltrexone (better than camprosate)
159
48 yo is drinking up to 6 beers a night and 12 on weekends. A year ago he had his liscense suspended for drunk driving, his marriage is failing, he was diagnosed with a gastric ulcer, he admits to having a problem, and has tried quitting on numerous occasions. He finds that he experiences insomnia if he does not drink for more than 2 days
why is thi sdependence rather than alcohol abuse?
the patient can't stop drinking despite knowledge of its harmful effect and his desire to quit
high quantity of alcohol consumed on a regular basis
the patients history of drunk driving
the fact that the patient cannot sleep if he doesn't drink
a medical complication due to drinking
the patient's inability to stop despite knowledge of its harmful effect and his desire to quit
his inability to quit drinking regardless of his desire to quit or knowledge of harm best differentiates dependence from abuse. Neither dependence nor abuse is determined based on quantity of alcohol consumed. The patient's statement that he cannot fall asleep when he tried to quit drinking does imply physiologic dependence, but the alcohol dependence criteria can be meet "WITHOUT PHYSIOLOGIC DEPENDENCE"
160
```
a 47 yo has a history of dependence upon alcohol. Which of the following signs is most characteristic of early alcohol withdrawl?
decreased bp
hypersomnia
persistent hallucinations
tremor
increased appetite
```
persistent tremor
vital signs are elevated in alcohol withdrawl bc of autonomic hyperactivity. patients will usually have insomnia as a result, not hypersomnia.
161
48 yo is brought to the ED. She is unresponsive to questions, stubles aroiund the room, is agitated, smells of alcohol, and is not cooperative. Upon questioning you find the patient has drank heavily for 30 years, has started preferring alcohol to meals, and has started losing weight.
which is most likely found on mental status exam?
confabulation
delusions
elevated affect
fluctuating consciousness
loose associations
confabulation:
the patient has a long history of heavy regular alcohol use and likely malnutrition. A common sequelae of this chronic thiamine deficiency resulting in korsakoff syndrome: anterograde amnesia, memory impairment, and confabulation
162
```
48 yo is brought to the ED. She is unresponsive to questions, stubles aroiund the room, is agitated, smells of alcohol, and is not cooperative. Administration of what mediine is most appropriate for initial treatment?
antipsychotic
benzodiazepine
disulfiram
glucose
thiamine
```
thiamine
patient has wernicke encephalopathy, characterized by the triad of delirium, ataxia, and ophthalmoplegia. Thiamine must be given first
163
```
a 52 yo man is admitted to the hospital 36 hrs earlier for an emergency appendectomy. The man is very agitated, and is talking nonsence to the nurse. You sujspect alcohol withdrawl. Which receptor is most closely associated witih these symptoms
D2
D4
GABAa
GABAb
5HT2
```
GABAa
in the cns, GABA is an inhibitory nt. At the postsynaptic GABAa receptor, GABA faciliatates chloride ion influx into a cell via a chloride channel, resulting in inhibition of that neuron. Alcohol and benzodiazepines both allosterically modulate the GABA-A receptor to facilitate GABAergic inhibition. Abrupt removal of alcohol or benzodiazepines after prolonged use results in a relative deficit of GABAergic inhibition, which can lead to anxiety, insomnia, delirium, and seizures
164
```
a 56yo man with a history of hep c and alcoholim tells you he wants to quit drinking and first detox. In a patient with alcoholism, in whom you suspect impaired liver functino, the most appropriate drug to treat withdrawl symptoms is:
phenobarbital
chlordiazepoxide
lorazepam
alprazolam
clonidine
```
lorazepam
| in cass of suspected liver impairment, it is advisable to use a benzo that minimally metabolized in the liver.
165
```
44 yo comes to ED and family member reports he has been living off alcohol and drugs and nothing else for weeks. The ED nurse is about to go in to draw blood from the patient and offer him food. How will the man's underlying condition be best treated in an acute medical setting
bensodiazepines
barbiturates
clonidine
phenytoin
disulfiram
```
benzodiazepines
This man is probably suffering from alcohol withdrawl and bc benzos and alcohol have a near-identical mode of action in their modulation of GABA receptors in the brain, it is the best choice
166
you have a patient in the ED that is overdosing, he has pinpoint pupils and tracks, he is overdosing on ______ and should be given_______
morphine, IV NALOXONE (aka narcan)
167
if you have a patient that has a TENS unit (low voltage electrical stimulus to the spinal cord and this overwhelms the sensory nerve fibers that usually carry back sensation of pain) or similar treatment for chronic pain. This is thought to work via the gate control theory of pain suggests that the nerve stimulous is reducing the chronic pain, so one of the mechanisms of action of the gate controlled theory of pain would be:
activation of alpha beta fibers, which reduces the ability of pain inputs in the spinal thalamic tract
168
if you have a patient on codeine (different than morphine bc it has to be metabolized to be effective) if you have a paitent that is not getting good pain relief on codeine. How is codeine matabolized?
its metabolized to morphine by deacetylating enzymes in the brain
169
if you have a patient with a spinal cord stimulator, one of the ways it's thought to reduce pain is by:
activating the body's endogenous peptides that are important in pain relief, and one of these is encephlin (an endogenous peptide releasd by the body as a response to injury and inflammation, enkephlin also binds to opiod receptors, and it inhibits further neurotransmitter release to reduce pain
170
if you have a heroin addict, and you're going to treat them with morphine replacement therapy (there are various substance abuse clinincs that give buponorfron as well, etc) which of the following is the first line treatment for this patient?
METHADONE (much better than narcan) is a long term replacement (or clonidine). Methadone is longer lasting and is much more controlled so it is ideal for helping with the withdrawl and weaning process. You still have constipation
171
patient has been taking opiods for a long time and has a high tolerance. Which of the following best characterises the tolerance in this patient?
tolerance has developed in the mu receptor in the brainstem, but he is still constipated.
172
patient has been taking opiods for a long time and has a high tolerance. Which of the following best characterises the tolerance in this patient?
tolerance has developed in the mu receptor in the brainstem, but he is still constipated.
173
opiods cause:
constipation, miosis, naseau vomitting, horners, etc
