Examination and Diagnosis of the Psychiatric Patient

Question 1

1.1.
Which of the following first steps is most appropriate in
conducting a psychiatric interview of a patient?

A. Obtain consent from the patient

B. Offer to meet with family and patient together

C. Identify elements of the process the patient wishes to alter

D. Perform a safety assessment

E. Review HIPAA laws and limits of confidentiality

Answer 1

1.1. A. Obtain consent from the patient
After introductions, consent to proceed with the interview should be
obtained. The nature of the interview and length of time should be
discussed and then the patient should be encouraged to give
feedback regarding altering elements in the process. While
discussion of limits of confidentiality and performing a safety
assessment should be included in all interviews, these are not the
initial steps that need to be done. If a family member wants to be
involved, it is typically best to have the patient present, though this is
often best suited for the end of the interview. (1)

Question 2

1.2.
Which of the following elements differentiates empathy from
identification?

A. Ability to maintain objectivity

B. Association with poor boundaries

C. Being able to experience the emotion

D. High association with physician burnout

E. True understanding of the situation

Answer 2

1.2. A. Ability to maintain objectivity
The ability to maintain objectivity is crucial in a therapeutic
relationship and can differentiate empathy from identification. With
identification, psychiatrists experience as well as understand the
emotion, which can lead to boundary problems along with physician
burnout. (2)

Question 3

1.3.
A person-centered approach, as opposed to a traditional medial
one, focuses on which of the following aspects during an
interview?

A. Deficits

B. Illness

C. Safety

D. Strengths

E. Transference

Answer 3

1.3. D. Strengths
A psychiatric interview should be person centered to best help
understand the patient and their goals. A person-centered approach
focuses on strengths and assets, as well as deficits, compared to a
traditional medical approach focusing only on illness and deficits.

Question 4

1.4.
Which question is a part of the the Rapid Alcohol Problem
Screen 4 (RAPS4) screening tool for substance use?

A. Have you ever been arrested for your drinking?

B. Have people annoyed you by criticizing your drinking?

C. Have you ever cut down on your drinking?

D. Have you ever driven drunk?

E. Have you ever failed to remember things after drinking?

Answer 4

1.4. E. Have you ever failed to remember things after
drinking?
The RAPS4 and CAGE are brief standardized questionnaires that
psychiatrists can use to assess substance abuse or dependence. There
is some overlap between the two. The RAPS4 includes the following
four questions: Have you ever felt guilty after drinking (Remorse),
could not remember things did or said (Amnesia), failed to do what
was normally expected after drinking (Perform), or had a morning
drink (Starter)? The CAGE also includes four questions: Have you
ever cut down on your drinking (Cut)? Have people annoyed you by
criticizing your drinking (Annoyed)? Have you ever felt bad about
your drinking (Guilty)? Have you ever needed a drink first thing in
the morning (Eye-opener)? Though driving drunk or getting arrested
for drinking can be a sign of abuse or dependence, it is not part of
these screening tools.

Question 5

1.5.
Which of the following medical conditions can resemble an
anxiety disorder?

A. Arthritis

B. Hyperthyroidism

C. Lupus

D. Malnutrition

E. Transient ischemic attacks

Answer 5

1.5. B. Hyperthyroidism
Obtaining a past medical history is a key part of all psychiatric
interviews. Some medical illness can contribute to or mimic
psychiatric disorders, or they might be caused by treatment of a
psychiatric disorder. A classic psychiatric disorder that can resemble
an anxiety disorder is hyperthyroidism. The other disorders listed
are more likely to mimic or cause depressive symptoms.

Question 6

1.6.
A family history of which illness might affect the choice of an
antipsychotic medication?

A. Diabetes

B. Cancer

C. Hyperkalemia

D. Hypothyroidism

E. Kidney stones

Answer 6

1.6. A. Diabetes
Obtaining a family history is essential in helping to define the
patient’s risk factors for psychiatric illness and can also be useful in
guiding medication choices. A family history of diabetes or
hyperlipidemia might make one utilize an atypical antipsychotic with
caution due to risk of worsening both conditions, along with causing
other metabolic side effects.

Question 7

1.7.
An increase in amount of speech noted on mental status
examination can be a sign of which of the following psychiatric
symptoms?

A. Depression

B. Disinterest

C. Mania

D. Paranoia

E. Thought blocking

Answer 7

1.7. C. Mania
An increase in the amount of speech on mental status examinations
could be a sign of mania or hypomania. A decrease in the amount of
speech can be from depression, anxiety, or disinterest. Decreased
speech could also be a sign of thought blocking or psychosis

Question 8

1.8.
A patient with manic symptoms replies in this manner when
asked what he did yesterday- “I hiked and biked with Mike and
Mat and ate rat that sat cat.” This is an example of which of the
following types of thought processes?

A. Clang association

B. Neologism

C. Perseveration

D. Tangentiality

E. Thought blocking

Answer 8

1.8. A. Clang associations
Thought process is the way in which thoughts are organized, formed,
or expressed. Clang associations are when words are put together by
the sound of the words rather than for the meaning (i.e., rhyming is
prominent). Neologisms are new words or combinations of a few
words that are not actually understandable or true words.
Perseveration is the repetition of words out of context. Tangential
thought process means never returning to the previous statement.
Thought blocking appears when a patient stops and the thought is
unable to come out, often leading to a stop midsentence.

Question 9

1.9.
Asking a patient a hypothetical example of what they would do
upon finding a stamped envelope on the street can help test for
which of the following cognitive functions?

A. Abstract reasoning

B. Impulse control

C. Fund of knowledge

D. Insight

E. Judgment

Answer 9

1.9. E. Judgment
Judgment refers to a person’s ability to make good decisions and act
on them. A classic example of a question to test judgment is, “What
would you do if you found a stamped envelope on the street?”
Abstract reasoning is the ability to shift between concepts and
examples, identifying similarities between like objects, for example.
Fund of knowledge can be tested by fact-based questions (i.e., “Who
is the president of the United States?”).
Insight refers to the patient’s
understanding of how they are functioning and potential
contributing factors to their illness.

Question 10

1.10.
Using empathy to convey understanding and noting the
patient’s strengths, along with exploring their ambivalence
and conflicts about change is a part of which of the following
techniques?

A. Acknowledgment of emotions

B. Minimizing patients’ concerns

C. Motivational interviewing

D. Premature interpretation

E. Summarizing

Answer 10

1.10. C. Motivational interviewing
Motivational interviewing is a technique used to motivate the patient
to change maladaptive behaviors. Relaying empathy and highlighting
ambivalence and conflicting feelings are key to motivating change.
Nonverbal actions, such as moving a tissue box, can sometimes be
used to help acknowledge emotions. Minimizing the patient’s
concerns might happen when attempting to reassure patients; thus,
concerns should be explored. Premature interpretations, even if
accurate, should be avoided as they can lead to the patient becoming
defensive and feeling misunderstood. Summarizing is a useful technique that should be done periodically to help clarify
understanding

Question 11

1.11.
Which of the following elements would constitute a passive
suicidal statement?

A. Being able to state many reasons to live

B. Denial of intent to act on the thoughts

C. Lack of having a plan

D. Not possessing the means to do it

E. Not taking preparatory steps toward the plan

Answer 11

1.11. B. Denial of intent to act on the thoughts
A suicide assessment should be performed for all patients during the
initial interview. The patient should be asked about any current
thoughts of suicide and if present, what the intent is. If a patient has
thoughts of suicide but denies intent to act on these thoughts or
denies a wish to be dead, that is referred to as passive suicidal
ideation. Higher-risk patients include those who have specific plans
to end their life and access to the means to complete the plan, along
with those who have taken preparatory steps to move forward with
the plan.

Question 12

1.12.
A patient presenting with anxiety has a mental status
examination notable for a tremor and pallor. Vital signs are
significant for an elevated heart rate. Which of the following
medical conditions should be ruled out?

A. Hypothyroidism

B. Normal pressure hydrocephalus

C. Pheochromocytoma

D. Temporal arteritis

E. Ulcerative colitis

Answer 12

1.12. C. Pheochromocytoma
Pheochromocytomas produce symptoms that mimic anxiety
including rapid heartbeat, tremors, and pallor. Increased urinary
catecholamines are diagnostic for a pheochromocytoma. Hyper, not
hypothyroidism can lead to anxiety. Normal pressure hydrocephalus
can be present with dementia, shuffling gait, and incontinence.
Temporal arteritis can cause unilateral throbbing headaches and can
lead to blindness. Ulcerative colitis can present as weight loss and
depressive symptoms.

Question 13

1.13.
What is an element that is included in a psychotherapy note,
but not a progress note?

A. A detailed assessment and plan

B. Comments on countertransference and dreams

C. Data that can be disclosed to the patient

D. Inclusion with the rest of the medical record

E. Information about third-party payer access

Answer 13

1.13. C. Data that can be disclosed to the patient
Psychotherapy notes include details of transference,
countertransference, fantasies, dreams, and personal information
about name of contacts of the patient, etc., which would not be
included in the actual progress notes in the medical record. Unlike
progress notes, psychotherapy notes should be kept separate from
the rest of the medical record and the data in them should not be
disclosed to any person, including the patient. Detailed assessments
and plans should be included in progress notes, not the
psychotherapy note.

Question 14

1.14.
Reliability data on the Structured Clinical Interview for the
DSM (SCID) suggests that it performs better on more severe
disorders for which of the following diagnoses?

A. Alcohol abuse

B. Bipolar disorder

C. Dysthymia

D. Social phobia

E. Unspecified eating disorder

Answer 14

1.14. B. Bipolar disorder
The SCID, Structured Clinical Interview for DSM, is designed to be
administered by an experienced clinician, requires training and is
primarily focused on research and is used to verify diagnoses in
clinical trials. Reliability data suggests that it performs better on
more severe disorders and alcohol dependence compared to milder
disorders, such as dysthymia

Question 15

1.15.
What rating scale was designed to assess change in psychotic
inpatients with significant impairment, and cover a broad
range of symptoms of depression and anxiety, with flaws
including needing a large amount of clinical training to achieve
good reliability?

A. Brief Psychiatric Rating Scale (BPRS)

B. Hamilton Anxiety Rating Scale (HAM-A)

C. Positive and Negative Syndrome Scale (PANSS)

D. Scale for the Assessment of Positive Symptoms (SAPS)

E. Structured Clinical Interview for DSM (SCID)

Answer 15

1.15. A. Brief Psychiatric Rating Scale (BPRS)
The BPRS was developed in the late 1960s as a short scale to
measure the severity of psychiatric symptomatology and is primarily
designed to assess changes in psychotic inpatients. However, good
reliability is difficult to achieve without extensive training and this
scale is often only suitable for patients with a fairly significant level
of clinical impairment. The HAM-A is often used to monitor
treatment response in clinical trials and in some clinical settings for
generalized anxiety disorders. The PANSS was designed to remedy
the deficits in the BPRS in the assessment of positive and negative
symptoms in schizophrenia and other psychotic disorders by adding
additional items and providing anchors for each. It is a highly
reliable tool which has become the standard for assessing clinical
outcomes in treatment studies for schizophrenia and other psychotic
disorders. The SAPS and the Scale for the Assessment of Negative
Symptoms (SANS) provide a detailed assessment of positive and
negative symptoms in schizophrenia, with the SAPS assessing for
hallucinations, delusions, thought disorders, etc., and the SANS
assessing for poverty of speech, apathy, anhedonia, etc. The SCID,
Structured Clinical Interview for DSM, is primarily used in research
and to verify a variety of diagnoses in clinical trials.

Question 16

1.16.
The Child Behavior Checklist (CBCL) is unable to assess which
of the following elements?

A. A clinical diagnosis

B. Cutoff scores for problems

C. Parent ratings

D. Symptoms within a clinical range

E. Teacher ratings

Answer 16

1.16. A. A clinical diagnosis
The CBCL includes different self-rated versions for parents, teachers,
and children to help assess preschoolers through adolescents. It does
not generate diagnoses, rather it suggests cut-off scores for problems
in the clinical range and provides a good overall view of
symptomatology and can be used to track changes over time.

Question 17

1.17.
The Connors Rating Scale is most commonly used in the
assessment of which psychiatric disorder?

A. Attention deficit hyperactivity

B. Bipolar

C. Major depressive

D. Obsessive compulsive

E. Substance use

Answer 17

1.17. A. Attention deficit hyperactivity
The Connors Rating Scale includes teacher-, parent-, and selfreported
measures and assesses a range of childhood and adolescent
psychopathology. The Connors Scale is most commonly used in
screening for ADHD in schools and in clinical populations, and can
be used to follow changes in symptom severity over time.

Question 18

1.18.
Finger agnosia, dyscalculia, dysgraphia, and right–left
disorientation are components of which of the following
syndromes?

A. Dressing apraxia

B. Gerstmann

C. Hurler

D. Neglect

E. Pickwickian

Answer 18

1.18. B. Gerstmann
Aside from language, the left hemisphere is responsible for limb
apraxia. Lesions in the left hemisphere can result in finger agnosia,
dyscalculia, dysgraphia, and right–left disorientation, referred to as
Gerstmann syndrome. Dressing apraxia is associated with special
deficits from right hemisphere damage and include right–left
confusion and difficulty putting limbs into clothing. Hurler
syndrome, an autosomal recessive condition, includes symptoms
such as hirsutism, corneal clouding, coarse facial features, and
moderate-to-severe intellectual disability. Neglect syndromes are
most commonly associated with right hemisphere damage in the
parietal region and include failure to detect visual or tactile stimuli,
or to move the limb in the contralateral hemispace. Pickwickian
syndrome is recognized by a puffy appearance, as seen in
hypothyroidism, obesity, and periodic respirations.

Question 19

1.19.
Impairment in which of the following features is unique to
Broca aphasia as opposed to other types of aphasias?

A. Awareness of deficit

B. Breakdown of syntactic structure

C. Comprehension

D. Fluency

E. Repetition

Answer 19

1.19. D. Fluency
Broca aphasia, or nonfluent or expressive aphasia, caused by a left
inferior frontal convolution lesion, is characterized by nonfluent
speech (i.e., telegraphic or agrammatism) with intact auditory
comprehension. This is in contrast to Wernicke aphasia, caused by a
superior temporal gyrus lesion, which has fluent speech but impaired
comprehension. Repetition can be somewhat impaired in both
aphasias. Unlike those with Broca aphasia, those with Wernicke are
not typically aware of their communication deficits

Question 20

1.20.
A patient is unable to bisect a line placed midline. This is
most commonly indicative of a lesion in which of the following
areas of the brain?

A. Cerebellum

B. Medulla

C. Parietal

D. Pons

E. Temporal

Answer 20

1.20. C. Parietal lobe
Failure to bisect a line placed midline is an example of a neglect
syndrome. It is characterized by failure to detect visual or tactile
stimuli or move the limb in the contralateral hemisphere. It is most
commonly associated with right hemisphere damage in the parietal
region, though other areas in the cortex and subcortical areas can
also cause it.

Question 21

1.21.
For older individuals, the technique of having them draw a
clock is a sensitive measure of which of the following
neuropsychological functions?

A. Attention and concentration

B. Planning and organization

C. Remote and recent memory

D. Sensory and motor

E. Speech and language

Answer 21

1.21. B. Planning and organization
The clock-drawing technique is widely used in elderly individuals at
risk for dementia as a test that is a sensitive measure of planning and
organization. More subtle difficulties can also be detected when
comparing performance to premorbid expectations such as
perseveration and neglect. Double simultaneous stimulation of visual
and auditory modalities can test for sensory and motor functions and
can also test for neglect. The WMS-III can measure attention,
memory, and new learning. Expressive language is often measured
by testing verbal fluency, via generating words within semantic and
phonetic categories. Conducting a digit span is a measure of
attention.

Question 22

1.22.
A high level of which of the following types of validity would
be shown if a test measuring hypochondria demonstrates the
patient with high scores had more doctor’s visits due to
symptoms of physical complaints?

A. Criterion validity

B. Discriminant

C. Face validity

D. Factor

E. Predictive validity

Answer 22

1.22. A. Criterion validity
Face validity refers to the content of the test items and if they
measure what they intend to measure. While it refers to the degree
the items on the surface measure what the instrument is supposed
to, criterion validity uses data outside the test to measure validity.
Discriminant validity tells whether the test can discriminate between
groups of patients at times (i.e., discriminate between mild,
moderate, vs. severe major depressive disorder). Factor validity
utilizes a multivariate statistical technique, factor analysis, to
determine if a group of items on a test empirically cluster together.

Question 23

1.23.
Which type of neuroimaging measures blood flow by using
heme molecules as an endogenous contrast agent?

A. fMRI (functional magnetic resonance imaging)

B. MRA (magnetic resonance angiography)

C. MRS (magnetic resonance spectroscopy)

D. PET (positron emission tomography)

E. SPECT (single-photon emission computed tomography)

Answer 23

1.23. A. fMRI (functional magnetic resonance imaging)
fMRIs measure regional cerebral blood flow by measuring heme
molecules as an endogenous contrast agent. MRA creates a 3-D map
of brain blood flow and is typically used by neurologists and
neurosurgeons. MRS is a research method used to measure brain
metabolism and is done in an MRI machine with additional software
to allow signals from protons to be suppressed and signals from
other compounds to be measured. PET scans involve the detection of
emitted positron radiation, typically by using FDG
(fluorodeoxyglucose) to measure regional brain glucose metabolism.
SPECT scans are not typically used to study the brain. They are more
commonly used to study other organs.

Question 24

1.24.
A young adult with chronic substance use has an MRI of the
brain which is significant for loss of gray-white matter and
atrophy. Mental status examination demonstrates
abnormalities in short-term memory, “scanning” speech, and a
notable tremor. Which of the following substances is most
likely being abused?

A. Alcohol

B. Amphetamines

C. Cannabis

D. MDMA (ecstasy)

E. Toluene

Answer 24

1.24. E. Toluene
Inhalants, such as toluene, as found in paints, glues, and cleaning
solutions, can cause significant brain damage, as well as damage to
other organs, such as the liver, kidneys, lung, bone marrow, etc. It
can
lead to hypoxia and can cause a loss of gray-white matter and
brain atrophy on MRIs. Chronic use can also be associated with
panic attacks and personality changes.

Question 25

1.25.
A patient recently started on valproate seems confused and
lethargic. Which of the following blood levels should be
checked urgently?

A. Ammonia

B. BUN

C. Platelets

D. Sodium

E. WBC

Answer 25

1.25. A. Ammonia
While valproate (valproic acid, Depakene; divalproex, Depakote) can
cause hematologic abnormalities including leukopenia and
thrombocytopenia, if a patient is presenting as lethargic or has a
change in mental status, ammonia levels should be checked urgently,
as valproate can increase ammonia levels. Elevated liver function
tests (LFTs) and acute pancreatitis are also risks of valproate
treatment.

Question 26

1.26.
Which of the following blood tests should be obtained at the
initiation of treatment with an MAOI (monoamine oxidase
inhibitor) and periodically after?

A. Basal metabolic panel

B. Complete blood count

C. Lipid panel

D. Liver function tests (LFTs)

E. Renal function panel

Answer 26

1.26. D. Liver function tests (LFTs)
Treatment with MAOIs can occasionally be associated with
hepatotoxicity. Thus, LFTs are usually obtained at the initiation of
treatment and periodically after. Blood pressure should also be
obtained before initiating treatment and monitored afterward.

Question 27

1.27.
Which vitamin or mineral level should be tested as part of a
standard workup for dementia?

A. Magnesium

B. Vitamin B12

C. Vitamin C

D. Vitamin D

E. Zinc

Answer 27

1.27. B. Vitamin B12
Vitamin B12 and folate deficiencies are associated with dementia,
delirium, psychosis, and paranoia and should be checked as part of a
workup. These deficiencies are especially common in patients who
abuse alcohol

Question 28

1.28.
Which of the following lab or vital sign abnormalities might
also contribute to prolongation of the QTc interval in a patient
on antipsychotic medications?

A. Hyperkalemia

B. Hypertension

C. Hypomagnesemia

D. Hyponatremia

E. Tachycardia

Answer 28

1.28. C. Hypomagnesemia
A QTc measurement on an EKG greater than 500 milliseconds is
considered prolonged and can increase the risk of a severe
arrhythmia. Factors that can prolong QTc include certain drugs, in
addition to bradycardia, hypokalemia, or hypomagnesemia.

Question 29

1.29.
Oral ziprasidone is contraindicated in patients with a history
of which of the following medical conditions?

A. A recent myocardial infarction

B. Hypoglycemia

C. Hyperprolactinemia

D. Leukocytosis

E. Renal failure

Answer 29

1.29. A. A recent myocardial infarction
Ziprasidone (Geodon) is associated with a dose-related prolongation
of the QTc interval and can lead to fatal arrhythmias. An EKG should
be checked before initiation. Ziprasidone is contraindicated in
patients with a history of known QTc prolongation, recent
myocardial infarctions, and uncompensated heart failure. It should
also be used with caution in those with bradycardia, hypokalemia,
hypomagnesemia, or those on other QTc prolonging drugs.

Question 30

1.30.
Which is the only abnormality of the brain that is better seen
on CT scans as compared to MRIs?

A. Atrophy

B. Calcifications

C. Inflammation

D. Strokes

E. Tumors

Answer 30

1.30. B. Calcifications
MRIs are typically preferred over CTs for most purposes due to a lack
of radiation exposure. CTs are primarily used in emergent situations.
The only component of the brain seen better on CT scans are
calcifications, which can be invisible on MRIs.

Question 31

1.31.
When using developmental tests on older infants and
preschoolers, which of the following areas should be the main
focus?

A. Language

B. Motor

C. Perceptual

D. Sensory

E. Social

Answer 31

1.31. A. Language
When using instruments such as the Gesell Infact Scale, the Bayley
Cales of Infant and Toddler Development, and the Denver
Developmental Screening Test with very young infants the tests focus
on sensorimotor and social responses to objects and interactions.
When used for older infants and preschoolers, the emphasis is on
language acquisition.

Question 32

1.32.
Which test measures communication, daily living skills,
socialization, and motor domains for typical children and
adolescents as well as those who are visual or hearing,
emotionally, or intellectually impaired?

A. Behavior Assessment System for Children (BASC)

B. Home Situations Questionnaire-Revised (HSQ-R)

C. Luria-Nebraska Neuropsychological Battery (LNNB:C)

D. Thematic Apperception Test (TAT)

E. Vineland Adaptive Behavior Scale

Answer 32

1.32. E. Vineland adaptive behavior scale
The Vineland Adaptive Behavior Scale is used for those 0 to 19 years
old to provide a standard score measuring adaptive behavior and
communication, skills of daily living, and socialization. There are
separate standardization groups for normal, visually handicapped,
hearing impaired, emotionally disturbed, and those with intellectual
disability. The BASC has teacher and parent rating scales as well as a child self-report of personality across various domains at home,
school, and the community in those ages 4 to 18 years. The HSQ-R is
a test of attentional capacity in which parents rate the child’s specific
problems with attention and concentration. The LNNB:C tests
sensory-motor, perceptual and cognitive functioning. The TAT is a
type of projective test that can assess interpersonal functioning.

Question 33

1.33.
An obese child with hypotonia and small hands and feet along
with hoarding, excessive daytime sleepiness, compulsive
behavior, and skin picking likely has a deletion in which of the
following chromosomes?

A. Elastin focus on 7q11-23

B. Microdeletion at 16q13.3

C. Paternal origin of 15q12

D. Paternal on 5p

E. Pregnancy-associated plasma protein-A (PAPPA)

Answer 33

1.33. C. Paternal origin of 15q12
Prader–Willi syndrome involves a deletion in 15q2 of paternal origin
and presents with hypotonia, failure to thrive in infancy, then
obesity, small hands and feet, and microorchidism. Compulsive
behavior, hyperphagia, hoarding, and anxiety/aggression, and skin
picking are also features of Prader–Willi syndrome. Rubinstein–
Taybi syndrome is sporadic or likely autosomal dominated, though
there have been microdeletions documented in some cases at
16q13.3. It presents with short stature, microcephaly, broad thumb,
big toes, etc., feeding difficulties, seizures, distractibility and
expressive language difficulties. Often these kids are loving and
responsive to music. Cri-du-chat syndrome is from a partial deletion
on 5p including the elastin locus on 7q11-23 and presents with a
round face, hypertelorism, epicanthal folds, slanting palpebral
fissures, a broad flat nose, etc. along with congenital heart disease,
severe intellectual disability, self-injury, and an infant-like cry.
Cornelia de Lange
syndrome is due to a lack of PAPPA linked to
chromosome 9q33 and presents with a continuous eyebrow, thin
downturning of the upper lip, microcephaly and short stature, etc.
along with failure to thrive, self-injury, language delays, profound
intellectual disability, etc.

Question 34

1.34.
A child is being evaluated for ADHD. Mental status
examination is noted for a long face with large ears. Medical
history is significant for mitral valve prolapse and intellectual
disability. Which of the following genetic mutations is most
likely present in this child?

A. Deletion on 7q11-23

B. Deletion on 15q12 of maternal origin

C. Inactivation of the FMR-1 gene

D. Partial deletion chromosome 5

E. Trisomy 21

Answer 34

1.34. C. Inactivation of the FMR-1 gene
The child depicted has fragile X syndrome, which is caused by an
inactivation of the FMR-1 gene at X q27.3. Features consist of a long
face, large ears, midface hypoplasia, a high-arched palate, short
stature, and macroorchidism. Mitral valve prolapse, joint laxity, and
strabismus are other features. ADHD symptoms of hyperactivity and inattention are often noted along with anxiety, speech and language
delays, and learning disorders. Deletion of 15q12 of maternal origin
causes Angelman syndrome. Fair hair and blue eyes are common
along with dysmorphic facial features of wide-smiling mouth, thin
upper lip, and pointed chin. The syndrome is notable for a happy
disposition and paroxysmal laughter and hand flapping. Deletions
that include the elastin locus on chromones 7q11-23 include features
such as short stature, broad forehead, depressed nasal bridge, and
elf-like features. It presents with anxiety and hyperactivity. Cri-du
chat involves a partial deletion on 5p and signs include an infantile
cry, severe intellectual disability, and a round face with
hypertelorism and epicanthal folds. Down syndrome features include
upward-slanted palpebral fissures, midface depression, and a flat,
wide nausea bridge, along with short stature. Hyperactivity and
increased depression and Alzheimer are notable in down syndrome
which is caused by trisomy 21.

Question 35

1.35.
What is the most common reason cited by elderly adults who
consider suicide?

A. Anxiety

B. Financial difficulties

C. Loneliness

D. Pain

E. Sickness

Answer 35

1.35. C. Loneliness
Suicide is a leading cause of death in the elderly, and loneliness is the
most common reason cited by older adults who consider suicide.
Feelings of loneliness, worthlessness, hopelessness, and helplessness
are all symptoms of depression, which is highly linked to suicide.
Approximately 75% of those who complete suicide suffer from
depression and/or alcohol abuse.

Question 36

1.36.
A pill-rolling tremor is most commonly associated with which
of the following classes of psychiatric medications?

A. Benzodiazepines

B. Phenothiazine

C. Selective serotonin reuptake inhibitors

D. Stimulants

E. Tricyclics

Answer 36

1.36. B. Phenothiazine
Mental status examination symptoms of adverse effects of
phenothiazine medication include a pill-rolling tremor, shuffling
gait, stooped posture, and body asymmetry, along with abnormal
movements of the mouth and tongue.

Question 37

1.37.
Which type of agnosia involves inability to recognize faces?

A. Anosognosia

B. Anosmia

C. Atopognosia

D. Prosopagnosia

E. Visual agnosia

Answer 37

1.37. D. Prosopagnosia
Prosopagnosia is the inability to recognize faces. A denial of illness is
called anosognosia. A denial of a body part is atopognosia and an
inability to recognize objects is called visual agnosia. Anosmia is the
loss of smell.

Question 38

1.38.
A fair skin, blue-eyed, blond-hair child presents with
language delays, hyperactivity, self-injury, and new-onset
seizures. She most likely has a genetic condition caused by the
buildup of which of the following substances?

A. Galactose

B. Iduronate 2-sulfatase

C. L-iduronidase

D. Phenylalanine

E. Uric acid

Answer 38

1.38. D. Phenylalanine
Phenylketonuria involves a defect in phenylalanine hydroxylase or
biopterin, resulting in accumulation of phenylalanine. It typically
presents in those with fair skin, blue eyes, blond hair, and rashes and
if untreated can lead to intellectual disability, language delays, selfinjury,
and hyperactivity. Generalized seizures can occur later in
development. Galactosemia is caused by a defect in galactose-1-
phosphate uridyltransferase or galactokinase and presents as
vomiting, jaundice, hepatosplenomegaly, cataracts, food refusal,
increased intracranial pressure, langue disorders, behavioral
problems, and anxiety. Hurler syndrome is caused by a deficiency in
alpha-L-iduronidase activity resulting in short stature,
hepatosplenomegaly, hirsutism, corneal clouding, dwarfism, coarse
facial features, and typically death before 10 years old. Hunter
syndrome is caused by a deficiency in iduronate sulfatase resulting in
a coarse face with flat nasal bridge, hearing loss, ataxia, enlarged
liver and spleen, recurrent infections, hyperactivity, sleep
abnormalities and intellectual disability. Uric acid builds up in
Lesch–Nyhan syndrome due to a defect in hypoxanthine guanine
phosphoribosyl-transferase, resulting in ataxia, chorea, kidney
failure, gout, along with aggression and self-biting.

Question 39

1.39.
A child presents with dysmorphic facial features consisting of
a broad forehead, a depressed nasal bridge, and widely spaced
teeth and is described as having elfin-like facies. The patient
has a medical history significant for cardiac and thyroid
abnormalities and a psychiatric history significant for
hyperactivity and anxiety though is very social and makes
friends easily. The child most likely has which of the following
genetic syndromes?

A. Cri-du-chat

B. Fragile X

C. Prader–Willi

D. Smith–Magenis

E. Williams

Answer 39

1.39. E. Williams
The symptoms are consistent with a diagnosis of Williams syndrome,
caused by a deletion that includes the elastin locus on chromosome
7q11-23 and is inherited in an autosomal dominant fashion. Cri-duchat
syndrome, caused by a partial deletion in 5p presents with a
round face with hypertelorism, epicanthal folds and slanting
palpebral fissures along with heart disease, GI abnormalities, severe
intellectual disability, self-injury, and cat-like cries. Fragile X is due
to inactivation of FMR-1 gene at Xq27.3 de ot CGG base repeats,
accounts for 10% to 12% of intellectual disability in males and
presents with a long face, large ears, midface hypoplasia, a higharched
palate, etc. Prader–Willi syndrome presents with a 15q12
deletion of paternal origin and symptoms include hypotonia, obesity,
small hands and feet, microorchidism, short stature,
almond-shaped
eyes, hyperphagia, hoarding, aggression and skin picking. Smith–
Magenis syndrome is caused by a complete or partial deletion of
17p11.2 and presents with a broad face and hands, small toes, a deep
voice, severe intellectual disability, hyperactivity, severe self-injury
including hand biting and head banging.

Question 40

1.40.
Which neuropsychological test measures sensory-motor,
perceptual, and cognitive functioning?

A. Luria-Nebraska

B. Millon Adolescent

C. Mullen

D. Rotter

E. Thematic Apperception

Answer 40

1.40. A. Luria-Nebraska
The Luria-Nebraska Neuropsychological Battery: Children’s Revision
(LNNB:C) provides standard measure for sensory–motor,
perceptual, and cognitive tests. The Millon Adolescent Personality
Inventory (MAPI) provides standard scores for personality styles,
expressed concerns, and behavioral correlates. The Mullen Scales of
Early Learning is a test of language and visual scales for receptive
and expressive ability in newborns to 5 year olds. The Rotter
Incomplete Sentences Blank Test is a qualitative projective test for
children and adolescents, with an adult version as well. The
Thematic Apperception Test (TAT) is also a projective test involving
generating stories for 6 year olds and up and can give data regarding
interpersonal functioning.

Question 41

1.41.
Suicidality falls under what category on the mental status
examination?

A. Judgment

B. Mood

C. Perception

D. Thought content

E. Thought Process

Answer 41

1.41. D. Thought content
Both suicidality and homicidality fall under the category of thought
content. Obsessional thoughts and compulsions also go under
thought content, along with delusions. Mood is what the patient
reports as their internal emotional state. Thought process does not
describe what the patient is thinking, rather how the thoughts are
formulated, organized, or expressed. Perceptual disturbances include
hallucinations, illusions, depersonalization, and derealization.
Judgment refers to the patient’s capacity to make good decision and
act on them

Question 42

1.42.
Which of the following respiratory symptoms is more
indicative of depression rather than an underlying pulmonary
disorder?

A. Breathlessness while active

B. Breathlessness with little changes with
exertion

C. Difficulty with expiration

D. Fluctuation in breathlessness over hours

E. Insidious onset of breathlessness

Answer 42

1.42. B. Breathlessness with little changes in exertion
In conducting a medical review of systems during a psychiatric
interview it is important to tease apart obstructive airway and other
organic pulmonary diseases from breathing problems due to
psychiatric conditions. In depression, breathlessness is experienced
at rest and shows little change with exertion and can fluctuate in
minutes. Often, a history can show the breathing problems coincided
with the depressive episode and is accompanied by panic attacks
including symptoms such as dizziness, sweating, palpitations, and
paresthesias. Often with depression, the emphasis is placed on
struggles with inspiration, whereas in true pulmonary disease the
difficulty is with expiration. In pulmonary obstructive airway
disease, the onset is typically insidious. Of course, when in doubt of
the origin of respiratory symptoms, a referral should be made to the
primary care doctor or pulmonologist.