Focus Flashcards
A clinician is considering combination therapy for
treatment-resistant depression. Which of the following
combinations has the most potential for serious
adverse reactions?
(A) Bupropion and fluoxetine
(B) Buspirone and nortriptyline
(C) Paroxetine and desipramine ,
(D) Phenelzine and lithium carbonate
(E) Venlafaxine and tranylcypromine
The correct response is option E: Venlafaxine and
tranylcypromine
Serious adverse reactions, sometimes fatal, with features
resembling serotonin syndrome and neuroleptic
malignant syndrome have been reported when venlafaxine
has been used with a monoamine oxidase
inhibitor. While some adverse interactions could
occur with the other combinations listed, none constitute_containdications.
Which of the following conditions is most commonly
comorbid with prepubertal bipolar disorder?
(A) Attention deficit hyperactivity disorder (ADHD)
(B) Autistic disorder
(C) Separation anxiety disorder
(D) Tourette’s disorder
The correct response is option A: Attention deficit
hyperactivity disorder (ADHD)
Studies of grep^jbejigJ^bipo[gr_disorder consistently find
that attention deficit hyperactivity disorder [ADHD] is a
common c^ D o j t i d ^ c p j T a j t b n . For example, Geller et
al. (1995) reported that about 90% of prepubertal
(and 30% of .adolescent) bipolar patients also had
ADHD. Other studies had similar findings, namely,
ADHD in 90% of children with mania and jn 57% of
adolescents with mania. These high proportions have
not been accepted universally, and further study has
been recommended (Reddy and Srinath, 2000). A
study in adults found a much earlier onset of bipolar
disorder in those with a history of childhood ADHD
(12.1 years vs. 20 years) than in those without ADHD.
A 39-year-old actuary for an insurance company is
offered a substantial promotion that will require her to
move to another city. Her new office will be on the
23rd floor of a high-rise building. She informs her psychiatrist
that she is “terrified” of riding in an elevator
and terrified of heights, but desperately wants the
new job. Which of the interventions listed below is
most likely to be successful for her?
(A) Cognitive therapy
(B) Hypnotherapy
(C) Insight-oriented psychotherapy
(D) Selective serotonin reuptake inhibitors
(E) Systematic desensitization
The correct response is option E: Systematic desensitization
This woman is suffering from a specific phobia.
Although all of the therapies listed have been found to
be at least of some use in the treatment of phobias, the
method that has been most studied and found most
effective is behavior therapy. The behavior therapy
techniques that have been employed with phobias
include systematic desensitization (serial exposure to a
predetermined list of anxiety-provoking stimuli graded
in a hierarchy from the least to the most frightening),
imaginal flooding (intensive exposure to the phobic
stimulus through imagery), and flooding (in vivo exposure
to the actual phobic stimulus).
During resettlement, a refugee takes on the values and
attitudes of the new culture and does not retain his
original cultural values. Which of the following best
describes this process?
(A) Integration
(B) Assimilation
(C) Separation
(D) Marginolizotion
The correct response is option B: Assimilation
Assimilation entails makmg_contactsjvjhjhe_new_cuIture
wjth.ojjtjetainina^one’s original cultural values.
During resettlement, there are a number of ways to
adapt to the new culture. Integration is_retaining one’s
own cultural identity while maintaining contact with
members of the newer culture. Separation is maintaining
the original cultural identity and not seeking
contact with the newer culture. Marginalization is
shedding_one’s originaljdentity and cultural values
but not seekingcpntact with other cultural groups
Parasomnias can be differentiated from dyssomnias
because parasomnias involve abnormalities in which
of the following aspects of sleep?
(A) Amount of sleep
(B) Initiationpfjleep
(C) Physiological systems that occur during sleep
(D) Quality of sleep
(E) Timing of sleep
The correct response is option C: Physiological systems
that occur during sleep
The factors listed in the other options are affected in
dyssomnias.
A 27-year-old male patient with an initial episode of
schizophrenia is treated with risperidone at an initial
dose of 2 mg daily, and after 1 week of treatment he
no longer experiences agitation. By the third week of
treatment, with gradual titration of risperidone to
6 mg daily, his delusions and halucinations are significantly
improved. At week 4, he describes some
trouble sleeping at night because of restlessness but
reports that he is much less fearful and no longer
hears voices. When seen for a scheduled appointment
at week 6, however, he is noticeably drooling
and is in constant motion, rocking back and forth and
fidgeting in his chair. The side effect of treatment that
he is most likely experiencing is:
(A) akathisia. -
(B) neuroleptic malignant syndrome.
(C) restless leg syndrome.
(D) serotonin syndrome.
(E) tardive dyskinesia.
The correct response is option A: Akathisia
Akathisia consists of a subjective .feeling crf restlessness
along with resjless movements, u^yajlyj^hejegs
or feet, which may be nTisjaJcenJpjjOjTaaJn
v_ihjgsja_ajea^ Akathisia is generaly seen
soon after the initiation of treatment, * but it may
become more prominent os the dose ofontipsycho’ic
medication is increased. In this vignette, the onset of
restlessness soon after the start of antipsychoticjreatment
makes akathisja more likely then restless leg
syndrome. Neuroleptic malignant syndrom.” and serotonin
syndrome would be unlikely causes of this presentation,
as they are associated with rigidity and
motcjMwtc^
A patient takes a medication for bipolar I disorder
throughout pregnancy and delivery..The newborn is
noted to be cyanotic and in’ respiratory distress. An
echocardiogram reveals significant displacement of
two leaflets of the tricuspid v a l / e into the ventricle and
o large atrial septal defect consistent with Ebstein’s
anomaly. Of the following medications, which was
the woman most likely taking during her pregnancy?
(A) Carbamazepine
(B) Gabapentin
(C) Lithium
(0) Topiramate
(E) Valproate
The correct response is option C: Lithium
Lithium is the on|y_pjycJToacjiye, noj>anti’convulsant
dnJaJhaMs^ fh q u g ht_ to_be_a ssoc^a^d_wltli_the s pec i f i c
birth defect r ^ ^ n ^ n o r n a l y . This defect is 2J)jimes
more common in children born to mothers taking lithium
than in the general population. Echocardiography and
fetal ultrasonography can be used after the 16th_week
qf_pregnancy to check for the presence, of_carajaC
abnormalities.
The general risk of major birth defect appears to be
two to three times greater with lithium than in the general
population. While initial information about the
teratogenic risk of lithium treatment was derived from
biased retrospective reports, more recent epidemiologic
data indicate that the tera^ogenic^xisk^ofJirstfrLinesfer
lithium exposure is [ower_jhg^previou_sly
suggesjed. The clinical management of women with
bipolar disorder who have childbearing potential
should be modified with this revised risk estimate.
V a J p n D a J e j s j^
tube defects in thgjetus, and caj^ani^z^pjne_with
craniofacial defects, f i n g j r n d M T y p o r j j ^ neural
tube_defects, anjdjJej/eJcjDn^ Qpi^pj?!^0
and topiramate have not been systematicqllysjudied
in pregnant women.
A forensic psychiatric evaluation differs from a general
psychiatric evaluation in that a forensic evaluation:
(A) typically includes a mental status examination.
(B) does not have a doctor-patient relationship.
(Q requires a completed written report.
(D) requires the presence of a lawyer during the evaluation
The correct response is option B: Does not have a
doctor-patient relationship
A forensic evaluation essentialy indya^_ajgeneral
psychiatric evaluatjoriwithm jts_co_r_text. Forensic evaluations
are done for third parties_and not for a
“patient,” and hence there is no doctor-patient relationship
(therapeutic alliance). There is no requirement
iri forensic evaluations for-the presence, ofanjgttorney
or for a report. Forensic evaluations are not confidential
in the same sense as a general evaluation in that
the information is typically transmitted to the thi.rd_pa.rty.
A 30-year-old man reports that he is unable to sleep
and hears noises and voices at night even though he
lives alone. The symptoms started abruptly on the d ay
preceding the, visit. During the interview, he repeatedly
brushes off his arms, muttering about bugs. The
information that would be most helpful in determining
initial interventions would be the history of:
(A) family disorders.
(B) medical problems.
(C) psychiatric hospitalization.
(D) recent stresses.
The correct response is option B: Medical problems
Psychotic symptoms may be due to a general medical
condition, may be medication induced, or may be
induced by substances of abuse. Medical reasons for
psychotic symptoms should be mledjwt, especially in
The practice of obtaining informed consent from an
individual prior to initiating any treatment fulfills
which of the following ethical principles?
(A) Nonmoleficence
(B) Autonomy
(C) Justice
(D) Competence
The correct response is option B: Autonomy
Autonomy refers tojhe notion in medical ethics_of_.individua[
sejffulg,or selfqovernanee to_ ma ke decisions.
Nonmoleficence embodies the ethical principle of
a void ing harm. Justice refers to fairness in jhe_d is tribut]
on__ p r_ _ a ppii ca t i o n _ _ o L psyc h lQ-tri?….lr^.c>iQl§ nt-
Competence is generally considered a legal determination
o fa. p_eis5n!sjab^ certain decisions,
including but not limited to treatment-related decisions
(e.g., competenc.e.to_execute,.a will is termea_^testar
n _ t a r y . c a p g c i t y “ ) . C o j p p j ^ e _ n c j^
capacity is a necessary requirementjpr informed_consent
but is_not sufficient for informed consent, which
has additional requirements (i.e., disclosure of relevant
informajion and v.ojujtfajiness)
Which of the following p^_hothergpies has the best
documented effectiveness in the treatment of major
depressive disorder?
(A) Supportive
(B) Psychodynamic
(C) Interpersonal
(D) Psychoeducational
(E) Family
The correct response is option C: lnjej£ej_onbl
I ntergerson a [_ond cognitive behaviortheropy are the
best documented psychotherapeutic treatments_for
major depressive disorder. Psychodynamic psychotherapy
is usually used with patients who also
have to work on some other life goals. Supportive and
psychoeducational techniques can also be useful,
depending on the severity of the depression
Which of the following antidepressants would be the
best choice for a patient concerned about erectile dysfunction?
(A) Bupropion
(B) Fluoxetine
(C) Nortriptyline
(0) Imipramine
(E) Venlafaxine
The correct response is option A: Bupropion
Most antidepressants other than bupropion have significant
rates of erectile dysfunction as well as other
aspects of sexual dysfunction. Mirjgzapine^ha.slower
rotes o M e x y a l dysfunction than, the SSRIs
The National Comorbidity Survey identified a number
of gender differences in exposure and in the development
of posttraumatic stress disorder (PTSD). Compared
with females, males have:
(A) higher trauma exposure, and higher prevalence of PTSD.
(B) lower trauma exposure, and lower prevalence of PTSD.
(C) higher trauma exposure, and lower prevalence of PTSD.
(D) lower trauma exposure, and higher prevalence of PTSD.
(E) the some trauma exposure, and the same prevalence of PTSD
The correct response is option C: Higher trauma exposure,
and lower prevalence of PTSD
The National Comorbidity Survey found that males
are more likely than females ..to_be exposed to traumatic
events (60% vs. 50%), while females a r e j n o re
likely than males to develop PTSD (12% vs. 6%). This
finding may represent a gender difference in susceptibJlity_
ib PTSD linked to biological, psychological, or
social factors, or it may be,a direct function of the differential
in types of traumatic events to which men and
women are exposed.
A cancer patient with significant nausea requires an
antidepressant. Which of the following medications
would be the best choice?
(A) Bupropion
(B) Duloxetine
(C) Mirtazopine
(D) Paroxetine
(E) Venlafaxine
Withjhe exception of mirtazapine, all of the drugs listed
have been shown in clinical trials to cause considerably
more nausea than placebo. The reason that nausea is
not a prominent side effect of mirtazapine is thought to
be its ^j^^^^^S_§Q_^?an effect shared with
antinausea drugs such as ondansetron and granisetron
When non-substance abusing men and women drink
the same amount of alcohol, the women are likely to
have higher alcohol blood levels than the men. The best
explanation for this is that compared with men, women:
(A) have a larger volume of distribution.
(B) have lower excretion rates.
(C) only metabolize by first-order kinetics.
(D) metabolize less alcohol in the gut.
(E) are deficient in acefaldehyde dehydrogenase.
The correct response is option D: IHa^lizeil^
9S§fioF_n35£§23
Alcohol metabolism, regardless of gender, is based on
zero-order kinetics. However, a number of factors contribute
to higher blood alcohol concentrations in women
than in men after consumption of the same amount of alcohol per unit of body weight. This includes a woman’s
lower body water contenhejgtiye tojnenjgjcghpl is distributed
in the total body .wafer, and women have Jess
water in^their body to dilute the alcohol); an.increased
ratio of jat-to-water content as women.age; lower quan-
Hh’es of alcohol dehydrogenasejn the gastric mucosa of
women compared with men; a tendency j o r women’s
bodies jo absorb more of the alcohol they drink than do
men’s bodies; and variation in blood alcohol concentration,
related to menstrual cycle.
Which of the following situations best describes when
weight considerations should determine hospitalization
for anorexia nervosa in children and young adolescents?
(A) Weight is less than 20% of recommended healthy body
weight.
(B) Weight is less than 25% of ideal body weight.
(C) Weight is being rapidly lost and outpatient efforts are ineffective,
regardless of actual weight.
(D) The family asks for hospitalization.
(E) Weight is fluctuating unpredictably over 2-3 months.
The correct response is option C: V^gJ]Ms_bj]ng_rap-
Idly lost and outpatient efforts are ineffective, regardl
e s s ^ actual weight
For patients whose initial weight falls 25% below
e x j D e d e ^ w e i g h t ^ j p j y i z a t i p n ]s often necessary to
ensure adequate intake and to limit physical activity.
Inj/ounqer children_aj}d^adpiesc_ents h ospita I i za f.ion
s j T p j ^ ^ _ _ c o n s i d e r e d . . e v e n .earlier whenever the
patient isJosing weight rapidly and before too much
weight is lost, since early intervention may avert rapid
physiological decline and loss of cortical white and
gray matter. Generally, specialized..eating disorder
un.its_yield better outcomes than general psychiatric
un.its.becau.se of nursing expertise and effectively conducted
protocols
Which of the following antipsychotic drugs is most
likely to be associated with hypejproloctinemia?
(A) Aripiprazole
(B) Clozapine
(C) Olanzapine
(D) Quetiapine
(E) Risperidone
The correct response is option E: Risperidone
Risperidone causes prolactin elevationsi t h a t a r e j i m i -
I q r to those caused by high-potencydopamine antagonist
antipsychotic medications. The other atypical
antipsychotics cause minimal or no increase in prolactin
levels.
Which of the following atypical ar ‘-psychotic drugs is
a D2 receptor partial agonist?
(A) Aripiprazole
. (B) Olanzapine
(C) Quetiapine
(D) Risperidone
(E) Ziprasidone
The correct response is option A: Aripiprazole
Aripiprazole is a partial agonist. A partial agonist is
an a^pjT]sjjhat_cannol; maximallyjsctivate a receptor
regajdless_of the concentration of drug present. While
this feature of aripiprazole suggests a mechanism of
action that differs from other atypical antipsychotics,
there is no evidence to date that aripiprazole is any
more or less effective then the other drugs.
A 33-year-old man started twice-weekly psychodynamic
psychotherapy 6 months ago with the goal of
exploring issues stemming from his distant relationship
with his father and his inability to form adequate mentoring
relationships in his work as a research chemist.
He reports an increasing preoccupation with his therapist’s
unwillingness to see him more frequently. The
patient has been speaking in therapy of his wish that
the therapist see him on Sunday. He believes that the
therapist refuses to have extra sessions because he
prefers other patients. Which of the following best
explains the patient’s behavior?
(A) Transference neurosis
(B) Delusional system
(C) Obsessional diathesis
(D) Erotomania
(E) Psychotic distortion
The correct response is option A: Transference neurosis
Over 6 months of intensive therapy, the patient has
developed a pervasive transference that reenacts
aspects of his childhood relationship with his father.
This is an example of a c | a j ^ J r a j ] s j e j ^^
at the core of traditional long-term psychodynamic
pjychothera pjes.
Which of the following disorders has the highest relative
risk for first-degree relatives?
(A) Alcoholism
(B) Anorexia
(C) Bipolar disorder
(D) Panic disorder
(E) Somatization disorder
The correct response is option C: Bipolar disorder
The relative risk for bjpolar disordensj^round 25. For
schizophrenia, it is 18; P J ^ i c j i s o r d e r , 10; anorexia,
5; alcoholism, around 7; and somatization, around 3.
g j r e l a n y e l r j s ^ is defined as
thejjrobability that a first^egree_£elative_of aj>atient
with qiLillnessjwJJLoLso developjhat illness.
A 68-yearold man has a grand mal seizure that is
attributed to an abrupt hyponatremia, with a serum
sodium concentration of 110 mmol/L. Which of the
following medications is the most likely cause?
(A) Gabapentin
(B) lithium
(C) Oxcarbazepine
(D) Topiramate \ .
(E) Valproate
The correct response is option C: Oxcarbazepine
According to the oxcarbazepine package insert, clinically
significant hyponatremia (serum sodium,
< 125 mmol/L) developed in 2.5% of patients in controlled
studies of epilepsy. Several possible mechanisms
have been proposed, but none are well
substantiated. Risk factors include ojdej^age, high
doses or blood levels, low pretreatment sodium levels,
other drugs that cquse__hypona(remia< and possibly
cigarette smoking.
Valproate can cause elevated liver function test results
and increased ammonia levels. There have been
some reports of hyponatremia with valproate, but this
occurs rarely. Topiramate can cause a hyperchloremic,
non-ion-gap metabolic acidosis (elevated chloride
level and reduced bicarbonate level). Lithium
may_ lead to_ djabetes insipidus^_ which _in turn can
causeJiypernqtremia. Gabapentin is not associated
with any alterations in serum electrolytes
Social, rhythm therapy, which is designed specifically
for bipolar disorder, is based on which of the following
models?
(A) Psychoeducation
(B) Object relations and self psychology theory
(C) Orcadian regulation and interpersonal psychotherapy
(D) Cognitive therapy techniques to address social dysfunction
(E) Supportive psychotherapy
The correct response is option C: G r ^ I g F r e g u I a t p i
alidjnterpersbQdj “^ychotherapy
Social rhythm therapy grew from a chronobiological
model of bipolar disorder. If modulates both biological
and psychosocial factors to mitigate a patient’s circadidn
and sleep-wake cycle vulnerabilities. Object
relations theory is psychodynamic theory based_on.
Melanie Klein’s metapsychology. Psychoeducation
entails offering the patient education about the
patient’s disorder. Cognitive thergpy is a treatment
designed to help people learn to identify and monitor
negative ways of thinking and then alter this tendency
and think in a more positive manner.
Rapid cycling in bipolar I or II disorder is associated
with:
(A) menopause.
(B) antidepressant use.
(C) cocaine abuse.
(D) early onset.
(E) alcohol abuse
The correct response is option B: Antidepressant use
Rapid cycling is associated with antidepressant use.
Rapid cycling in bipolar disorder is defined as four or
more mood episodes in the previous 1.2 months. Rapid
cycling is not related to any phase of the menstrual
cycle. It occurs in both pre- and postmenopausal
women. On the other hand, women constitute 70% to
90% ofjhe patients affected .by.copid_cycIi.ng. The syndrome
can appear or disappear at any time during the
course of bipolar I or II disorder. By definition, ful>j
j j a j j c e j i E ^
A 65-year-old woman has a history of a left frontal
lobe stroke. Which of the following psychiatric symptoms
is most commonly associated with a stroke in this
area of the brain?
(A) Panic
(B) Mania
{() Depression
(D) Obsessions
(E) Anxiety
The correct response is option C: Depression
Poststroke depression has been documented after
cerebrovascular accidents occurring in many areas in
the brain. However, anterior left hemisphere lesions,
particularly large Jesions and in the.early_reco,yejy
period, appear to carry ajiighexxj.skjsfpoststroke
depression. Other factors, such as history of depression
and degree of disability after stroke, are.also
associated with poststroke depression
Genetic studies of obsessive-compulsive disorder have
revealed linkages to which of the following disorders?
(A) Alcohol dependence
(B) Schizophrenia
(C) Shared psychotic disorder
(D) Somatoform disorder
(E) Tourette’s syndrome
The correct response is option E: Tourette’s syndrome
Genetic studies of patients with obsessive-compulsive
disorder have revealed h1glfemil0atesT6^aepril?
SioH and ^ ] e t ^ i j p r d e r ^ f a n d Jdurerteysyndronief.
A psychiatrist proposes to use an FDA-approved drug
not previously used for the treatment of mania
because it has biochemical properties similar to
known antimanic agents. The psychiatrist has also
read several articles describing open-label studies
suggesting efficacy of the drug. The patient in question
hcs not responded to any agent thus far. The psychiatrist
must do which of the following?
(A) Get an institutional review board approval, since what is
proposed is clinical research.
(B) Notify the FDA, since the drug is being used for o non-
FDA-approved purpose.
(C) Obtain informed consent from the patient or from an
appropriate proxy agent.
(D) Wait until there is higher-quality data Jo support this use of
the drug.
The correct response is option C: Obtain informed consent
from the patient or from an appropriate proxy agent
While obtaining explicit informed consent for any treatment
is important, it is especially important when the
treafmei]Lhas_noLbecome standard. When all available
treatments have failed, a nonstandard approach
basedjon. limited-evidence rnay_be all that j.s.ayajia.ble(
provided that proper precautions,_are taken. Unless the
psychiatrist’s intent is to demonstrate generalizable
knowledge; a nonstandard treatment is usually not considered
research. Physicians routinely and permissibly
use drugs for non-FDA-approved indications using their
best clinical judgment. W h i l e it is probably wise to wait
un*i] higher quality data” support the use of a nonstandard
treatment, it is not a “must.”
A 75-year-old retired physicist who is suffering from
metastatic cancer is referred to a psychiatrist by the
primary care physician because the patient wants to
die and has requested assistance in suicide. On evaluation,
the psychiatrist finds that the patient’s cognition
is intact. The most appropriate next step for the
psychiatrist is to:
(A) be as persuasive as possible so that the patient accepts the
cancer treatment.
(B) find out whether there are areas of suffering that can be
addressed by available palliative care measures.
(C) tell the referring physician that the patient can be given assistance
in suidde because the patient is a competent adult.
(D) tell the referring physidan that even though the patient’s
cognition appears intact, the patient is probably incapacitated
by virtue of the unreasonable choice that is being made
The correct response is option B: Find out whether
there gre_areqs of suffering _mat_cgn be addressed by
available palliative ^ e j n e c s u r e s
While sometimes direct persuasion to accept a medically
indicated treatment may be acceptable, the
main issue is to identify the sources of the patient’s suffering.
Most patients who request assisted suicide
eventually change their minds when the sources of
their suffering are better addressed. To recommend
assistance in suicide at this stage of the patient’s cancer
ignores the complexity of the situation. To use
incapacity as a reason for paternalism (option D) is
also unacceptable.
Of the following ethnic groups, which is at lowest risk
of completed suicide?
(A) African Americans
(B) Asian Americans
(C) Caucasian Americans
(D) Hispanic Americans
(E) Native Americans
The correct response is option B: Asian Americans
With regard to ethnicity, most studies have demonstrated
that Caucasjajis^re_ajjTJ
lowed in order by Native Americans, African
Americans, Hispanic Americans, and Asian Americans.
A 15-year-old boy is referred for psychiatric evaluation
after taking an overdose of an over-the-counter
cold medication. The patient denies that this was a
suicide attempt. The patient acknowledges that he has
been having difficulties for about a year, since the
separation of his parents. He often feels angry and
irritable, has difficulty sleeping, has little appetite, has
lost weight, has little interest in his usual activities, and
often wishes he was dead. His grades have dropped
to the point that he is failing his courses. Over the past
year, he has been smoking 1-2 packs of cigarettes a
day, drinking to the point of intoxication on the weekends,
and taking over-the-counter cold medication to
enhance the effects of the alcohol. His past psychiatric
history is significant for attention deficit hyperactivity
disorder (ADHD), for which he has a prescription for
a stimulant medication. He has not taken his medication
as prescribed. Instead, he hoards the medication
and then takes large quantifies to experience a
euphoric effect. Which of the following medications
would be the most efficacious in addressing this
patient’s symptom constellation?
(A) Bupropion
(B) Gtalopram
(C) Desipramine
(D) Trazodone
(E) Venlafaxine
The correct response is option A: Bupropion
Bupropion is effectiyejn,ji)ejregtmenj oj_mgnyJypes
oi_depressio.n. It is niejaj?pjjzed Jo^g_number__pf
amphetamine-like products, which are effective in the
treatment of_A_DHD. Bupropion has also been demonstrafed
to decrease nicotine use. In adolescents who
have depression, nicotine dependence, substance
abuse, and ADHD, bupropion might be the first-line
treatment, as it has been shown to be effective in
assisting with b o t h j m o j ^ j i e i ^
t h e _ £ o j ^ y r n p J o j n ^ ^ Citalopram and other
SSRIs as well as trazodone have not demonstrated
these added benefits. Venlafaxine and desipramine
have been found to be effective in both childhood and
adult ADHD, but they lack the pote_ntiglp.f_bupropjon
fq_asj|sh^jjTijDkjng cessotion.
A psychiatrist attends a dinner lecture sponsored by a
major pharmaceutical company, the maker of a newly
approved drug for major depression. The company’s
representative approaches the psychiatrist after the
lecture and says, “I hope we can count on you to prescribe
our medication. This is a great medication!”
The psychiatrist does not know what to say and later
feels troubled by this encounter. W h i c h of the following
statements reflects the psychiatrist’s ethical obligation
in this situation?
(A) The psychiatrist can accept dinners and “repay” the company
with favorable prescribing practices if the psychiatrist
chooses to do so.
(B) The psychiatrist should report the pharmaceutical representative’s
behavior to the local APA branch’s ethics committee.
(C) The psychiatrist should be aware that “strings attached”
industry-sponsored activities are unethical.
(D) The psychiatrist must repay the representative for the cost
of the dinner, since there are apparent, though unstated,
ethical conflicts.
The correct response is option C: The., psychiatrist
should be awqrejhat “strings attached” industry-sppnsored
activities a re u nethjca I
The American Medical Association Code of Mediccl
Ethics states that “ G i f t s _ j j } p u J d j o t _ b e _ a c ^ p J e j ^f
strings are attached.” In this question, the psychiatrist’s
attendance at a dinner whose purpose was educ
a t j o n a j j y i ^ if there are implicit or
explicit strings attached. Most psychiatrists would not
consider the psychiatrist’s behavior in this situation
unethical, although it would be unethical to promise to
prescribe a certain medication in return for drug company
favors, such as free dinners or concert tickets.
Clearly, the blurring of the boundaries between educational
activities and pharmaceutical company promotions
continues to be a d j f f i c j j ] H s j y j J g ^ g j he
psychigtric community, and eihjcaj„pjjcjiiajrists may
disagree about whether participation in any educational
activities provided by pharmaceutical companies
is ethical.
More severe and prolonged forms of conduct disorder
are most often associated with which of the following
comorbid disorders?
(A) Anxiety disorders
(B) Attention deficit hyperactivity disorder
(C) Depression
(D) Eoting disorder
(E) Tic disorder
The correct response is option B: Attention deficit
hyperactivity disorder
More_severe and prolonged conduct disorder js.associated[
with early onset, comorbid ADHD, and conduct
symptoms that are more frequent, numerous, and
varied.
A 62-year-old man Js taking desipramine for depression.
He presents with marked sedation, tachycardia,
and postural hypotension about 10 days after the
addition of a second antidepressant. Which of the following
medications is most likely responsible^-
(A) Venlafaxine
(B) Mirtazapine Vy*
(C) Citalopram ^V*0
(D) Sertraline
(E) Fluoxetine
The correct response is option E: Fluoxetine
Desipramine is a substrate for cytochrome P450 2D6.
Of the drugs listed, only fluoxetine is a potent inhibitor
of this enzyme. In this patient, taking fluoxetine resulted
in a marked increase in his blood levels of desipramine,
which accounted for his new physical symptoms
Which of the following diseases associated with
dementia characteristically has early changes in personality
and a late decline in memory?
(A) HIV infection
(B) Creurzfeldt-Jakob disease
(C) Parkinson’s disease
(D) Lewy body dementia ,
IE) Pick’s disease
The correct response is option E: Pick’s disease
Pick’s disease specifically affects the frontal and temporaljobes,
accounting for the early signs of personality
changes, loss of social skills, and emotional
blunting. Other features of dementia, such as memory
loss and apraxia, come later. Specific diagnosis of
Pick’s disease is usually made only on autopsy. The
medical illnesses Huntington’s disease, Parkinson’s
disease, and HIVjnfection precede those dementias.
Creutzfeldt-Jakob disease often has a clinical triad
associated with dementia, involuntary movement, and
periodic EEG activity. Lewy body dementia often presents
first with hallucinations_and psychosis
Which of the following features best distinguishes
anorexia nervosa from bulimia nervosa?
(A) Amenorrhea
(B) Decreased body weight
(C) Calluses on the dorsum of the hand
(D) Dental enamel erosion
(E) Enlarged parotid glands
The correct response is option B: Decreased body
weight
Decreased body weight is a defining feature of
cnorexia nervosa, whereas persons with bulimia nervosa
typically have normal body weight. All of the
other features listed may be present in both disorders.
Which of the following aspects of cognitive performance
is most likely to decline in the course of normal
aging?
(A) Short-term memory
(B) Speed of performance
(C) Store o’f knowledge
(D) Syntax
(E) Vocabulary
The correct’response is option B: Speed of performance
Speed of learning, p r o ^ ^ s m ^ j p e e d , ond speed of
performance of cognitive tasks tend to decline with
normal aging. The other functions listed do not
decline with normol gging, gnd g decline in any of
them may be an indication for a thorough or formal
assessment for cognitive impairment.
Disorders with significant psychiatric s ^ o t o m s that
can be linked to a single gene include:
(A) attention deficit hyperactivity disorder.
(B) bipolar disorder.
(C) fragile X syndrome.
(D) major depression.
(E) schizophrenia
The correct response is option C: Fragile X syndrome
All of these disorders have evidence of genetic transmission,
although only fragile X syndrome is due to a
single gene. I
The rule of confidentiality is waived in a psychiatristpatient
interaction when the treatment or evaluation
includes:
(A) o minor.
(B) o forensic consultation.
(C) on impaired physician.
(D) a patient who reveals a past felony.
The correct response is option B: A forensic consultation
Ethically, confidentiality is required in psychiatric treatment.
However, there are someinstgnces irrwhich confidentiality
is waived. When a psychiatrist is examining
a patient for forensic p_ujjpgs.es, the individual must be
informed that information collected during the examination
will be shared with the partyjhat engaged the psychiatrist,
such as the patientjJawyeior.Jhe_cp.urt. In
addition, common situations that require a waiver of the
confidentiality rule include mjej_ejDortingj^
and, in some states, elder abuse and spouse abuse.
Also, in most states, the psychiatrist evaluating a
potentjally violent patient is required t o w a r n a potential
victim of violence. However, in most states, a psychiatrist
treating an impaired physician, unlike the
physician’s colleagues, is not required to report the
physician if the phys’?’an is a private patient of the
psychiatrist. On the otfer hand, if the psychiatrist is
treating the patient under the auspices of a state diversion
program, the relationship becomes more complicated
and depends on the arrangement with the
specific state’s diversion program.
A patient who reveals p^sj^arjajejjOjjjness_buJJsj]ot
cJJrx§Djy^j^gerojJi^ou]cL notjikely. meet_ requiremjnjsjor
a b r e a c j W confidentiality. Finally, a minor’s
confidentiality woujd also be respected unlessjhere
^l_9£L?..rI16r9intsituation in which either the minor
or another person was likely to be harmed. In summary,
the rule of confidentiality is waived when there
is a threat of harmjo the patient or another person.
The highest percentage of persons with mental retardation
have an intelligence quotient of:
(A) <20.
(B) 20 to 35.
(C) 35 to 50.
(D) 50 to 70.
(E) 70 to 90.
The correct response is option D: 50 to 70
Up to 85% of persons with mental retardation have an
IQ between 50 and 70, which is mild mental retardation.
Patients with an IQ between 70 and 90 are
not considered mentally retarded.
A 4-year-old girl who has been cared for in seven different
foster homes since the age of 6 months, now
exhibits excessive familiarity with strangers. Her current
foster parents, with whom she has lived for the
past 5 months, state that she does not seem to be particularly
close to them. The girl’s biological mother is
reported to have used alcohol in a binge pattern during
her pregnancy. W h i c h of the following is the most
likely diagnosis?
(A) Attention deficit hyperactivity disorder
(B) Fetol alcohol syndrome
(C) Oppositional defiant disorder
(D) Pervasive developmental disorder
(E) Reactive attachment disorder
The correct response is option E: Reactive attachment
disorder
The girl’s indiscriminate sociability is behavior typical
of reactive attachment disorder, disinhibited type.
DSM-IV-TR also specifies an inhibited type of this disorder.
Often children with this disorder have experienced
a series of caregivers or prolonged separation from a
caregiver in early childhood. Symptoms of “markedly
disturbed and developmentally inappropriate social
relatedness” must be present before age 5 years
Which of the following diseases associated with
dementia characteristically has early changes in personality
and a late decline in memory?
(A) HIV infection
(B) Creirfzfelclt-Jcikob disease
(C) Parkinson’s disease
(D) Lewy body dementia ,
(E) Pick’s disease
The correct response is option E: Pick’s disease
Pick’s disease specifically affects the frontal and temporal
lobes, accounting for the early signs of personality
changes, loss of social skiljs, ond emotional
blunting. Other features of dementia, such as memory
loss and apraxia, come later. Specific diagnosis of
Pick’s disease is usually made only on autopsy. The
medical illnesses Huntington’s disease, Parkinson’s
disease, and HlV_.infec.tipn precede those dementias.
Creutzfeldt-Jakob disease often has a clinical triad
associated with dementia, involuntary movement, and
periodic EEG activity, l e w y body dementia often presents
first with hallucinations and psychosis.
An 8-year-old girl insists on keeping a rigid routine
when dressing, will wear only certain clothes, insists
on recopying her homework if there are any mistakes,
and has temper tantrums when the items on her desk
are moved. During a discussion of the diagnosis’and
treatment options, her parents express reluctance to
use medication and want to explore other options.
The first recommendation would be:
(A) cognitive behavior therapy.
(B) family therapy.
(C) interpersonal psychotherapy.
(D) parent training.
(E) supportive psychotherapy.
The correct response is option A: Cognitive behavior
therapy
Cognitive behavior therapy has been demonstrated to
benefit children with obsessive-compulsive disorder.
Uncontrolled trials of cognitive behavior therapy have
shown excellent response in up to three-fourths of
p_ajdej]]sjregted. Many experts recommend cognitive
behavior therapy as the first-line approach for the
majority of children and adolescents with pbsessivecompujsj_/
e dlisorder.
Which of the following are common hyperarousal
symptoms in posttraumatic stress disorder (PTSD)?
(A) Intense psychological distress at exposure to external cues
resembling the trauma
(B) Difficulty falling or staying asleep
(C) Intrusive images of the event
(D) Feelings of estrangement from others
The correct response is option B: Difficulty falling or
staying asleep
Difficultyjailing or staying asleep is a symptom of
hypej^arousal. In the DSM-IV-TR, posttraumatic stress
disorder symptoms are clustered into three categories:
reexperiencing, avoidance and numbing, and hyperarousal.
Options A and C are symptoms of reexperiencing
the event. Option D falls into category C of the
DSM-IV-TR criteria for PTSD, that is, “Persistent avoidance
of stimuli associated with the trauma and numbing
of general responsiveness.”
Which of the following medications is considered firstline
monotherapy for posttraumatic stress disorder?
(A) Clonazepam
(B) Sertraline
(C) Olanzapine
(D) Valproate
(E) Propranolol
The correct response is option B: Sertraline
S e j I r c i l i n e J s j D A ^ PTSD.
The other_ medications are less well established as
beneficial. Clonazepam, widely used as an anxiolytic,
has FDA approval p_nly for use as an anticonvulsant
and frecfment for panic disorder, for which it
is a second-line choice. Olanzapine has not been
reported as a treatment for PTSD. Propranolol has
been tried experimentally to diminish the autonomic
arousal associated with the trauma. The rationale for
its use is that it will curtail the body’s emotional/autonomic
response to the trauma by diminishing the
body’s “memory” of the heightened emotional state.
The beta-blockers, theoretically, will prevent or at least
minimize the PTSD syndrome.
A 50-yecr-old woman has a long history of difficulty
with driving because she worries that she might hit a
car or a person accidentally. She also worries excessively
about her son getting hurt or attacked when he
goes out. Her husband can often reassure her. Which
of the following diagnoses is most appropriate?
(A) Agoraphobia
[B] Delusional disorder
((] Generalized anxiety disorder
(D) Obsessive-compulsive disorder
(E) Panic disorder
The correct response is option C: Generalized anxiety
disorder
The worries that occur in generalized anxiety disorder
|urgncej. Obsessive-compulsive disorder involves
obsessions, which are intrusive unrealistic ideas that
may be rjej;ognjze.d_as.being absurd <but cannot be
resisted. Panic disorder involves anxiety episodes
without specific content. Ag^oxaphojblainvolves, bejng
i n^jh2ai]jDnji_fj^rn_j^ icji_esca pe_m ig ht_be.. d iff icu lt_or
embarrgssjng o j J o n v t a M i e l p may not be.available
in the event of panic
A 40-year-old woman with chronic headaches has
undergone trials with several narcotic and nonnarcotic
agents with variable success. Her’ physician
elects to try her on a newer antidepressant medication.
Which of the following medications is most likely
to be effective?
(A) Bupropion
(B) Mirtazapine
(C) Nefazodone
(D) Sertraline
(E) Venlafaxine
The correct response is option E: Venlafaxine
jdjLejpromisjnq^as^t^oaj^
qesicWarMefazodb’nel? /nirjazapine, or
Although the precise mechanism of action for analgesia
is unknown, itjs^beljeyed thajagents that increase
serojojjjrKmd norepinephrine are more effective than
those jhgt onjyjncrease serotonin
Echolalia and echopraxia are most likely manifestations
of which of the following disorders?
(A) Hypochondriasis
(B) Bipolar disorder, mixed episode
(C) Depression with catatonic features
(D) Lewy body dementia
(E) Frontotemporal dementia
The correct response is option C: Depression with
catatonic features
^£h°l_^ia_£Di?Sh?P^?^-?an characterize catatonic
depression. A mood disorder with catatonic features
must have two or more of the following features:
“^olo^lclirMoEp^,.. .e^eitTeiggitafiBn: extreme”negratmsrrf;
JSICOIK^ and
eTcfetqte?or ^^gra3_iGl>(APA Practice Guideline).
An adolescent female took an unknown drug at an allnight
dance party. She was brought to the emergency
department for evaluation of altered mental status and
marked hyperthermia. Which of the following was
most likely the drug that was ingested?
(A) Ketamine
(B) Methylenedioxymethamphetamine (MDMA)
(C) Flunitrazepam
(D) Gomma-hydroxybutyrate (GHB)
(E)Phencyclidine(PCP)
The correct response is option B: Methylenedioxymethamphetamine
{MDMA)
All of these drugs are commonly known as “club
drugs” and are frequently used at all-night dance parties.
MDMA has been reported in some instances to
cause severe adverse effects, including altered mental
status, convulsions, hypo- or hyperthermia, cardiovasc^
QrJDitability, he^LajpJoxicity, and death.
a dopamine enhancer that causes euphoria.
Higher doses j>[G_HB can make the user feel sleepy
and may cause_Y_o.mili.pg, muscle spasms, and loss of
consciousness. If mixed with alcohol, GHB can slow
breathing to a dangerously low..rate, which..has
caused a number of deaths. ‘
Bie^^Bm^SncSeTamm^are related substances.
They belong to a class of drugs called &i$scoafivfc
^anestherjci” vv^dTjiaye^^
c e p H o n J r o m j e j } ^ At lpwej^dose^k^ojpinej:auses
a j r e g j n y j e e i i n g j i r ^ ^ ajTajy^a^prpduce
numbness,in_rjie_exlreinities. Higher doses of ketamine
may produce a hallucinogenic effect.
lium’trdzepom? a | F i ^ _ _ i 3 n _ _ g n ^ T S g n j 6 , also
known a s j o h y p r j o f (a trade name) or |rjwfi&J,” has
been characterized as the l i ^ 2 a p e ^ r y § ‘ ‘ Flunitrazepam
is prescribed in Latin America and Europe
as a shorHean .treatment.for.insomnia arid as a preanesthetic
medication. Flunitrazepam can cause a
chemically induced amnesia and may cause
decreased blood pressure, drowsiness, visual disturbances,
dizziness, confusion, gastrointestinal disturbances,
and urinary retention.
A 23-year-old man who is hospitalized for psychosis
displays prominent, excessive, and purposeless motor
activity together with peculiar voluntary movements.
On one occasion, he stands in the middle of the ward
immobile and mute. He demonstrates w a x y flexibility.
The appropriate medical intervention is:
(A) benztropine.
[Bj clonidine.
(() lorazepam.
(D) propranolol.
(E) ziprasidone.
The correct response is option C: Loraze_pani
Lorazepam, by a variety of routes of administration,
imcjroves^atajonja^dramaticaIly, although temporarily.
ffijS-^depressi^ and scES^fiSS&I(catatonic
type) are the most frequently observed psychiatric disorders
that are associated with catatonia. Possible
medical causes include rca ana
eTc^h”al6^”a”thy] Catatonia may also appear as an
adverse drug effect of a neuroleptic medication or
phencyclidine^(PCPI7 Neurological causes of catato
A 49-year-old woman is referred for treatment of
chronic, severe majordepressipn. Which of the following
treatment approaches is most likely to be associated
with sustained improvement in her symptoms?
(A) Antidepressant medication plus psychotherapy
(B) Psychotherapy alone
(C) Antidepressant medication alone
(D) EG alone
(E) ECT plus psychotherapy
The correct response is option A: ‘ ^ d e p r e s s a n t medication
plus psychotherapy
Since the publication in 2000 of the APA Practice
Guideline for the Treatment of Patients With Major
Depression, additional studies now support combined
psychotherapy and antidepressant therapy for chronic
depression. The evidence for this approach in treating
mild or moderate depression is less compelling. W h i le
ECT is highly effective, ECT alone usually does not
produce sustained improvement. There have been few
controlled studies of ECT plus psychotherapy.
In people with typical left-brain dominance, the ability
to interpret the emotional tone of speech is a function
of the:
(A) left premotor cortex (Brora’s areo).
(B) right premotor cortex.
(C) left parietotemporal cortex (Wernicke’s area).
(D) right parietotemporal cortex.
(E) anterior cingulate gyrus.
The correct response is option D: Right parietotemporal
cortex
Just as Wernicke’s area in thedpminant hemisphere is
inyolv^d_in_understanding language, the correspond]
ncj_a_rea in the nondominant hemisphere interprets the
emotional tone of speech, or prosody. Analogous to
Broca’s area in the left hemisphere, the right premotor
cortex is involved in expressive language production,
providing the “music” for the semantic content.
W h i c h of the following psychotherapies has the greatest
body of evidence demonstrating efficacy for social
phobia?
(A) Insight-oriented psychotherapy
(B) Interpersonal psychotherapy
(C) Brief psychodynamic psychotherapy
(D) Cognitive behavior psychotherapy
(E) Supportive psychotherapy
The correct response is option D: Cognitive, behavior
psychotherapy
The most effective commonly used treatment for social
phobia is based on cognitive behavior therapy principles
and techniques. Other theoretical approaches
have been used, but little research has been done to
establish their usefulness. The major problem in social
phobia is njaj3tiye_ejfaJyjhlon. Mere exposure to the
social interaction does not produce anxiety reduction.
The individual with social phobia must alter dysfunctionaj^
belleis^arid,biased,perceptions. Therefore, cogn
iliy^Jnpjjtjpj;^ Olej^ejTtjpjvfor
treatment success.
A patient who is completely deaf arrives with an interpreter
at the outpatient clinic for an evaluation of
depressed mood. You wish to know about the
patient’s sleep quality. Of the following, which is the
most appropriate way to work with the interpreter and
the patient?
(A) Ask the interpreter, “How is she sleeping?”
(B) Ask the interpreter, “Please ask her how she is sleeping.”
(C) Look at the patient and ask, “How are you sleeping?”
(D) Loudly enunciate “How are you sleeping?” to the patient.
(E) Write out “How ore you sleeping?” and give it to the patient.
The correct response is option C: LooJc_ajJ}ej3atient
and_asJcjJ[Hoy/i^ ?”
One should always address the patient directly while
speaking in a regular manner. It is the job of the interpreter
to translate the words into sign language and vice
versa. The, interpreter is not jo be addressedjjjrecjly.
An internist consults a psychiatrist because of his frustration
with an elderly patient who has a diagnosis of
hypochondriasis. Medical tests are negative, but the
patient is unable to accept that he is not ill. The psychiatrist
confirms the diagnosis of hypochondriasis.
Which of the following is the best management strategy
for a patient with hypochondriasis?
(A) Refer the patient to a more psychologically minded internist
colleague.
(B) Have regularly scheduled appointments with limited reassurance.
(C) See the patient as needed, but for a limited time.
(D) Instruct the patient to call only for urgent matters.
(E) Refer the patient for psychotherapy.
The correct response is option B: Re^jyJgjy^chejMed
a pp^mt^ejTtsj^dW
The management of hypochondriasis is a challenge for
the internist. Regularly i scheduled appointments with
limited reassurance appears to be the _ management
strategy of choice. A more psychologically minded
internist might facilitate dependency, which might result
in more visits and greater preoccupation with the symptoms.
The other approaches do not provide enough
structure to help the patient contain his anxiety
A 29-year-old woman presents for an initial evaluation.
She describes periods of mood lability and
unstable interpersonal relationships, particularly with
men. During periods of stress, she reports feeling
angry and “empty” and sometimes scratches herself
with sharp items. Sleep is often a problem, and alprazolam
has been helpful. In developing a treatment
plan, which of the following principles would be most
appropriate?
(A) Restrict pharmacotherapy to antidepressants and mood stabilizers.
[BJ Treat with multiple classes of medications for potential
future symptoms.
{() Target specific symptoms that are currently causing disruption.
(D) Refuse to prescribe a benzodiazepine.
(E) Withhold medications if the patient engages in acting out
behavior.
The correct response is option C: TajgAej_sp^cjfic_symptoms
that are currently causing disruption
Of the options listed, C is the most germone to the
management of borderline personality disorder.
PajiejTJsj^ajjirjM^ taj3ejea[_a^p_roach. Many
patients will need mulHpJe_clqs_Ses-of^medications to
target_diffej^ent domajns_ofjJifficujty (affective, behavioral,
and cognitive). Due to the heterogeneity of presentation,
however, clinicians, must be flexible jn their
pharrnacotherapeutic approach.
A 45-year-old woman with bipolar disorder w h o has
been successfully maintained on lithium presents at
the clinic with the complaint of swelling in her ankles.
Examination reveals 2+ pitting edema. Her serum
lithium level is 0.8 mEq/L. The physician prescribes a
thiazide diuretic. Four days later the patient presents
at the emergency department with confusion, a
coarse tremor in her extremities, and ataxia. Her
serum lithium level is now 2.6 mEq/L. Urinalysis
reveals a *slightly elevated specific gravity and an
absence of blood, ketones, and protein. W h i c h of the
following best explains the patient’s lithium toxicity?
(A) Acute nephrogenic diabetes insipidus
(B) Increased reabsorption in the proximal tubules
(C) Decreased glomerular filtration rate
(D) Glomerulonephritis
(E) Tubulointerstitial nephropathy
The correct response is option B: I n c j ^ g s ^ r e a b s o r p -
t i o j i j n j h e j j r o x j ^
The patient has developed acjjtejjthjujj^^ after the
administration of a thiazide diuretic. Lithium is excreted
through the kidneys and is reabsorbed in the proximal
tubules with sodium,and water. When the body has a
sodium deficiency, such as occurs with the administration
of sodium-depleting diuretics, theJddneys_comp_ensgje_
byj^gbs^rbing_^ a0 ^ 3 ! ° J } 9 J ! y i ! h j f’
lithium. This,, and j he [oss of fluid volume, results in elevated
j e i um lithium levels and toxicity. Lithium may
induce nephrogenic diabetes insipidus. However, this
would cause production of large volumes of dilute urine.
Paradoxically, the administration of a hSjazjde^diuretic
re^dy^ejjjnne^ojjtp_ut. Cumulative exposure to lithium
may result in a tujpjjlojntej^ and_a
d e g e j p j e j n j f } ^ however, this
is an insidious rather than an acute process and is unrelated
to the introduction of a thiazide diuretic. Finally,
lithium may cause a glomerulonephritis, resulting in a
nephrotic syndrome. This is characterized by the presence
of large quantities of protein in the urine.
A random community sample contains 100 individuals
who meet diagnostic criteria for borderline personality
disorder. Which of the following is the best
estimate of the gender ratio of the sample?
(A) 50% men and 50% women
(B) 40% men and 60% women
(C) 25% men and 75% women
(D) 10% men and 90% women
The correct response is option C: 25% men and 75%
women
Borderline personality disorder isjhiejnosj^mmoj^persoj3gjity_
disojde^ It is present in 10%
o£jndividuj2|s^ i^^^^^^g^lnooM^ and 30%H50% of
cljmcaJjDQpuJarjons with a personality disorder. It occurs
i n an estimated 2% c j ^ j h e ^ e ^ ^ j ^
Borderline personality disorder is diagnosed predominajitjyjrrwomen,
with an estimated female-to-male ratio
of J3jJ_. The disorder is present in cultures around the
world. It is approximately five t[mes_mo£e_common
a n w i g ^ f i r s j ^ l ^
d i s p j d e j J } a n J n j T j e ^ There is also a
g r e a J e H a j T i j I i ^ ^ antisodgJ^
p^s^n^jityjjspjder, and mood disorders.
The Child Behavior Checklist is a commonly used
instrument completed by parents about their children’s
behaviors. In a study comparing the results from subject
groups obtained from multiple cultures, girls
scored higher than boys across all cultures on which
behavior scale?
(A) Aggression
(B) Anxious/depressed
(C) Attention problems
(D) Delinquency
(E) Thought problems
The correct response is option B: Anxious/depressed
A c j ^ s s ^ a J J j t u d i e ^ ^ 9ir j s _ s j ^ e j L J^
spjT^jc__compJa^
while boys were higher on attention problems, delinauejTt^
behavior, and ajjgjj5Sj>ive__be^^
Therej^/asjTo_signjficant differ_encej^jween boys and
girls on thought problems.
Characteristic cognitive processes in persons with
obsessive-compulsive disorder include:
(A) above average spatial recognition.
(B) better memory for pleasant events.
(C) decreased capacity for selective attention.
(D) impaired reality testing.
(E) normal confidence in one’s own memory.
The correct response is option C: Dja^ased^capacity
f?Xi§lectjve_aJtej^
In persons with obsessive-compulsive disorder, a
c]e£rej3$^a^cajDC^ is hypothesized
to be related to the difficulties in dismissing
obsessions. Persons with the disorder have negative
beliefs about responsibility, memory biases for disturbing
themes, and decreased confidence in their
memory, and they may show dejidj^Jrx_jpatial
rec^gj}itJon.
The Child Behavior Checklist is a commonly used
instrument completed by parents about their children’s
behaviors. In a study comparing the results from subject
groups obtained from multiple cultures, girls
scored higher than boys across all cultures on which
behavior scale?
(A) Aggression
(B) Anxious/depressed
(C) Attention problems
(D) Delinquency
(E) Thought problems
The correct response is option B: Anxious/depressed
A c j ^ s s ^ a J J j t u d i e ^ ^ 9ir j s _ s j ^ e j L J^
spjT^jc__compJa^
while boys were higher on attention problems, delinauejTt^
behavior, and ajjgjj5Sj>ive__be^^
Therej^/asjTo_signjficant differ_encej^jween boys and
girls on thought problems
In family studies of patients with schizophrenia, the
personality disorder that has been found to occur most
frequently in first-degree relatives is:
(A) borderline.
(B) histrionic.
(C) paranoid.
(D) schizoid.
(E) schizotypal.
The correct response is option E: Schizotypal
Although all cluster A personality disorders (paranoid,
schizoid, and schizotypal) are more common in the
biological relatives of patients with schizophrenia
than in control groups;,the greatest correlation has
bejnjojjndjDeJ^
a.!li5ShizoroJ}renia. There is increasing evidence, primarily
from twin studies, that genetJ£ja^tor^cont
r i b y j e t p p e r s o n a l i t y disorders. Other evidence to
support a genetic link is the relationship between certain
axis I disorders and personality disorders.
A 25-year-old woman presents to the emergency
department with the chief complaint, “I think I’m having
a heart attack.” She reports that while grocery
shopping she suddenly felt “scared to death.” Her
heart was racing, she felt short of breath and dizzy,
and she was nauseated and broke out in a sweat. Her
fingers and hands and the area around her mouth felt
numb. The episode lasted about 10 minutes and dissipated
on its own. She managed to drive herself to
the emergency department. Physical examination and
laboratory studies, including a chest X-ray, blood
chemistries, cardiac enzymes, and electrocardiogram,
are normal.
In the lab, which of the following substances would be
most likely to induce an episode with these symptoms?
(A) Carbon monoxide
(B) Sodium lactate
(C) Physostigmine
(D) Propranolol
(E) Sodium pyruvate
The correct response is option B: Sodium lactate
The patient is exhibiting the classic signs and symptoms
of panic disorder. Women are two to three times more
likely to be affected than men; the mean age at presentation
is about 25 years, and onset is typically
acute. A number of panic-inducing substances (panicogens)
have been identified. Respiratory panicogens
shift the acid-base balance. They include carbon dioxide,
sodium lactate, and bicarbonate. Neurochemical
panicogens act through specific neurotransmitter systems.
A 25-year-old woman presents to the emergency
department with the chief complaint, “I think I’m having
a heart attack.” She reports that while grocery
shopping she suddenly felt “scared to death.” Her
heart was racing, she felt short of breath and dizzy,
and she was nauseated and broke out in a sweat. Her
fingers and hands and the area around her mouth felt
numb. The episode lasted about 10 minutes and dissipated
on its own. She managed to drive herself to
the emergency department. Physical examination and
laboratory studies, including a chest X-ray, blood
chemistries, cardiac enzymes, and electrocardiogram,
are normal.
The medication that is most likely to be effective in the
long-term treatment of her condition with the best tolerance
of side effects is:
(A) alprazolam.
(B) buspirone.
(C) paroxetine.
(D) propranolol.
(E) imipramine.
The correct response is option C: Paroxetine
This patient is presenting with the classic symptoms of
panjc_dT|order. All of the medications listed have
been used in the treatment of this condition. In general,
experience is showing tfje^y^ejjpjity_oMhe
S J i R l s j D n d ^ d ^
monoamine bxidase inhibitors, and tricyclic and tetracylic
drugs in terms of effectiveness and tolerance of
adverse effects. The beta-adrenergic receptor antagonists
have not been found to be particularly useful for
panic disorder.
A 38-year-old man with migraine headaches had successfully
obtained relief by taking codeine. Recently
his physician started him on a trial of paroxetine for
suspected depression. The patient notes improvement
in his symptoms of depression and now has headaches
less frequently, but when he does have one, he
must take twice the amount of codeine for pain relief.
Which of the following best describes this drug interaction?
(A) Cytochrome P450 enzymes: inhibition
(B) Cytochrome P450 enzymes: induction ,
(C) Increased protein binding
(D) Decreased absorption
(E) Increased excretion
The correct response is option A: CyjpcJ¥qm_e_P450
enzymes: Inhibition
Codeine’s analgesic effect is a result of its metabolism
to morphine. This transformation is accomplished by a
cytochrome P450 enzyme, CYP2D6. If that enzyme is
inhibited—such as occurs with some drugs, including
paroxetine—thereby interfering with available substrate
(codeine) for transformation to the active
metabolite (morphine), the dose of codeine must be
increased above usual levels.
Which of the following antidepressants is most likely
to be associated with substantial weight gain?
(A) Bupropion
(B) Fluoxetine
(() Sertraline
(D) Venlafaxine
(E) Mirtazapine
The correct response is option E: Mirtazapine
^^ejih3jncj^ase and we]gh[_gain^iaye_beenjnore
consistently associated with mirtazapine than with the
other listed antidepressants, perhaps because of its
p_otent_H! antihistamine effect a_nd its. antagonism .of
thejerotonin 5-HT2 .receptor
Expert consensu suggests that tbeJength of timejor a
pharmacological trial in obsessive-compulsive .disorder
should be at least:
IA| 3 weeks.
(B) 6 weeks.
(C) 9 weeks.
(D) 12 weeks.
The correct response is option D: 12 weeks **
The latency for responses to medications is longer in
patients with obsessive-compulsive disorder than in
those with depression; response may take 10 to 1.2
weeks. There_isJ.ess.agreement.on what .is acceptable
qs an adequate,dose. Some fixed-dose trials suggest
that h i g j i e j j i o j e j j ^ ^ Trials of medications
used for obsessive-compulsive disorder indicate
that a daily dose for 1 Q_ ]2 w e e b is optimal ‘(e.g.,
clomipramine,..150 mg; fluvoxgmine, 150 mg; fluoxetln^
jiQjng; sertraline, 150 mg; paroxetine^40mg).
A 35-year-old man presents with a 4-week history of
low mood, crying spells, poor sleep with early morning
awakening, poor appetite with a 12-pound
weight loss, and d j f f i c ^ t y j n j : o n ^ At
age 27 he had been hospitalized with an episode of
mania, but shortly thereafter he decided not to continue
in outpatient follow-up treatment. He has no
medical problems and takes no medications. As initial
pharmacotherapeutic treatment, which of the following
is most appropriate?
(A) Lamotrigine
(B) Nortriptyline
(C) Sertraline
(D) Valproate
(E) Venlafaxine
The correct response is option A: Lamotngme
According to the APA Practice Guideline for the
Treatment of Patients With Bipolar Disorder (Revised),
t h e j i r s t j i n e . phqrmacological^ej]tment_ for_bjpolar
depression is the .initiation of either lithium or lamotrigine.
The treatment goals are the remission of the
symptoms of major depression and to avoidprecipitation_
of_a manic or hypomanic episode. Antidepressant
monotherapy is not recommended given the risk of
precipitating a switch into mania. Small studies have
suggested that intirp^rsona^jherapy and cognitive
behavior therapy may also be useful when added to
pharmacotherapy during depressive episodes in
patients with bipolar disorder.
A patient with borderline personality disorder is in
dialectical behavior therapy. She has left messages on
the therapist’s voice-mail while he is on vacation
despite an agreement that she would not call him at all
during his vacation and would go to the emergency
department if she became suicidal. The best approach
in dialectical behavior therapy is for the therapist to:
(A) explain that a treatment boundary has been violated and
therapy will have to end.
(B) wait for the patient to bring up the issue before discussing
the implications for therapy.
(C) explain to the patient that the treatment plan will have to
change if she cannot keep the agreement.
(D) make an exception since there is a history of serious
attempts and safety is an issue.
The correct response is option C: Explain jo the
patient that the treatment pjajv^ll^hayejo^change if
she cannot keep the agreement
Boundary issues are a significant aspect of treatment
of patients with borderline personality disorder.
Therapists should be alert to the occurrence of boundary
violations and proactive in dealing with them —
both in terms of ascertaining their meaning and in
terms of restoring the boundaries to maintain the
patient’s safety a n d the effectiveness of therapy
A patient being treated with interferon for hepatitis C
complains of depression, anxiety, and irritability. Which
of the following pharmacological agents has the most
evidence for efficacy in treating those symptoms?
(A) Trazodone
(B) Haloperidol
(C) Risperidone
(D) Nefazodone
(E) Sertraline
The correct response is option E: Sertraline
An II-year-old girl is referred for an evaluation of
school problems. Her teachers and parents describe
her as argumentative, hostile, disrespectful and difficult.
The girl often refuses jo listen, wjJ|_noLqbey instructions,
does not do her work, has temper tantrums, and
insists on having her own way. She has been this w a y
since preschool. The most likely diagnosis is:
(A) antisocial personality disorder.
(B) attention deficit hyperactivity disorder.
(C) conduct disorder.
(D) intermittent explosive disorder.
(E) oppositional defiant disorder.
The correct response is option E: Opposifiono! defiant
disorder
The features of oppositional defiant disorder include a
recurrent, pattern of.negativistic, defiant, disobedient,
and hostile behavior toward^ayfhqrity figures. Children
with conduct disorder demonstrate a repetitive
and persistent pattern of behavior in which the basic
rights of others and major age-appropriate societal
norms or rules are violated. Oppositional behavior js
notpartof. the criteria of A D H D . These behaviors do
not meet the criteria for antisocial personality disorder,
which, moreover, cannot be diagnosed in an 11-
year-old. These behaviors also do not fit the criteria of
intermittent explosive disorder.
Patients with end-stage renal disease who are on
hemodialysis are most likely to present with which of
the following psychiatric symptoms?
(A) Major depression
(B) Delirium
(C) Psychosis
(D) Panic attacks
(E) Generalized anxiety
The correct response is option A: Major depression
While various psychiatric symptoms can occur in
hemodialysis patients, depressioni is the most prevalent.
A 27-year-old woman has had five hospitalizations
over the 3-year period since she was initially diagnosed
with schizophrenia. On each occasion, recurrent
psychotic symptoms have been associated with
treatment nonadherence. Which of the following
strategies is supported by the greatest body of
research evidence as the most likely to improve medication
adherence for this patient?
(A) Ccrnitive-motivational interventions
. (B) Insight-oriented psychotherapy
(C) Psychoeducational interventions
(D) Family therapy
(E) Supportive group psychotherapy
The correct response is option A: Cp^njtiye-motivati
ojTdjntej^ve n t i on s
A review of 39 studies of psychosocial interventions
for improving medication adherence showed that p_ro-
QIoillijhsLi0^^!.?^ the qttitudinal and behavioral
9iJ2ecjs_oijaJ<i ng JJiedicatiojTS_ generally^ have__better
outcomes. Psychoeducation alone and family therapy
alone were ineffective. There is no evidence-based
data on insight-oriented psychotherapy.
Which of the following is the most likely symptom in
cocaine intoxication?
(A) Paranoid delusions
(B) Hypotension
(C) Bradycardia
(D) Depersonalization
The correct response is option A: Paranoid delusions
Cocaine intoxication can produce hypjjjension, tachycardia, seizures, paranoid delusions, and ^delirium.
Depersonalization is more commonly associated
with hallucinogen intoxication
A consultation-liaison psychiatrist, on arriving on the
internal medicine hospital unit, learns that the patient’s
nurse requested the consultation and that the attending
internist, does not want the consultation. Of thelollowing,
the best action for the psychiatrist would be to:
(A) talk briefly with the nurse about why he or she considered
the consultation important.
(B) apologize to the attending internist and leave the unit.
(C) talk with the nurse’s supervisor about the correct way to
request a consultation.
(D) proceed with the consultation and make treatment recommendations.
(E) ask to have a case conference about the patient with the
physician and nursing staff.
The correct response is option A: TaIkfjefly_wijhj_he
n urse a b o j j t j j y h y j i e ^ o j^
impjDrjant
The liaison process includes cajejinding and fosterinfl
the deyelopmentof greater psychiatric knowledge
inn_)j}pjyc_iatric_medicqlj:are^pipviders, as opposed
*2^!I!}R’y providing parient carejrecojmmendations
wh^n_asked. The_discrepancy between the internist’s
ond thejiurse’s perceptions suggests an opp^rtunity
fojMe^chmg.
Which of the following accurately describes the major
quality that fundamentally distinguishes brief dynamic
psychotherapy from long-term dynamic psychotherapy?
Brief therapy has:
(A) no more than five sessions.
(B) limited focus and goals. ,
(C) less demonstrated efficacy. ,
(D) no transference or countertransference phenomena.
(E) fewer demands on the therapist
The correct response is option B: Umjtep^jo^us_and
goals_
While brief therapy is intended to be shorter-term, it
can v a r y from one to 40 jessions, wjth^the_ayerage
dose to six. Brief therapy is not just a shorter version
of long-term therapy but is structured to address a specific,
limited focus with_the least-radical intervention
and generally does not aim J o r character change.
Outcome data have not demonstrated superior efficacy
for time-unlimited therapy. Trans|erence_and
countertransference occurjn all therapies, although
they may be less emphasized in brief therapy. The
therapist requires at least equal psychotherapeutic
skills as in classical long-term dynamic therapy and
must be muchmpreactive.
A 68-year-old man with bipolar I disorder has been
adequately maintained on lithium. His most recent
serum lithium level was 0.8 mEq/L. He has a variety
of medical problems for which he takes several medications.
He now presents with pressured speech, racing
thoughts, increased energy, and little sleep. His
serum lithium level is 0.3 mEq/L. His wife reports that
the patient has been adherent to his medication regimen,
but she began to notice a change 2 weeks after
his primary care physician started him on a new medication.
What was the most likely class of medication
added to his regimen?
(A) Angiolensin-converting enzyme inhibitors
(BJ Beta-blockers
(C) Nonsteroidal anti-inflammatory drugs
(D) Thiazide diuretics
(E) Xanthine bronchodilafors
The correct response is option E: Xanthine bronchodilafors
thine brojichpdilatgrs such as theophylline and aminophylline.
Because the kidney excretes lithium, any
medicationjhat^altersjenal funcjion_can^ajfecHih^m
levels. Thiazide diuretics reduce lithium clearance and
hence may increase lithium, levels. Certain nonsterojdd
qnWnflammatpry medications, such as
ibuprofen, may increase lithium levels. Beta-blockers
do not affect lithium levels. Angiotensin-converting
enzyme inhibitors may increaseJithium levels
A patient with an alcohol problem is ambivalent
about starting acamprosate. The psychiatrist explores
the patient’s thoughts about the advantages and disadvantages
of taking and not taking the medication,
attempting to tip the patient’s decisional balance in
f a y c ^ h a k i n g the medication. W h i c h of the following
techniques is the physician using?
(A) Cognitive reframing
(B) Contingency management
(C) Motivational enhancement
(D) Pessimistic anticipation
(E) Rational emotion
The correct response is option C: Motivational
ejihan^cement
Bo^Wtional”enhancenielfflthgapyyis a form of psychotherapy
that has been shown to be effective in the
treatment gfWqstance use disorders. I] uses directive,
em path ic, patienNcentered techniques fQ__address
ambivalence and denial
W h i c h of the following differentiates Lewy body
dementia from dementia of the Alzheimer’s type?
(A) Apraxia
(B) Choreiform movements
(C) Executive dysfunction
(D) Grodual progression of deficits
(E) Recurrent visual hallucinations
The correct response is option E: Recurrent visual hallucinations
Of the core criteria that are part of the consensus criteria
for the diagnosis of dementia with Lewy bodies,
visual hallucinations (usually well-formed) are a particularly
important finding in the differentiation. Other
core criteria are fluctuaHcmjnj^ and
spontaneous motor features of parkinsonism. In a
prospective study that aimed to validate these core criteria
using neuropathology at autopsy, the sensitivity
and specificity of these clinical criteria were 0 J J 3 a nd
respectively.
The symptom of “flashbacks” is a manifestation of
which of the following psychological states?
(A) Psychosis ,
(B) Fugue
(C) Hyperarousal
(D) Dissociation
The correct response is option D: Dissociation
Fla^hbadcexj^ as^ dissociative
states. Uncommonly, the individual suffering from
PTSD experiences flashbacks that can last from a few
seconds to h q u r s j ^ d a y s . During flashbacks, pdrts of
the traumatic event are reexperienced and the patient
behaves as though the event was occurring at .mat
moment. There is no evidence of psychosis during flashbacks
associated with PTSD. Flashbacks can also result
from the toxic effects of LSD and othe_hollucinogenic
apients. Flashbacks associated with hallucinogenic
. agents are. usually characterized by repeated psychedelic
experiences, usually visual, and occur after the
drug use has stopped. Fugue states include sudden
unexpected travel away from one’s home or customary activities, with amnesia for some or all of one’s past.
Hyperarousal is described by persistent,sympJojns_of
anxiety or increased arousal, including difficujryjalling
or_ staying asleep, irritability, difficulty concentrating,
hypervigilance, and exaggerated startle response.
Response prevention is a useful psychotherapeutic
technique for which of the following disorders?
(A) Generalized anxiety disorder
(B) Intermittent explosive disorder
(C) Obsessive-compulsive disorder
(D) Pedophilia
(E) Schizophrenia
The correct response is option C: Obsessive-compulsive
disorder
Resrjonse prevention^techniques that decrease the frequencyjsfjituals
have been shown in several controlled
clinical trials to be usefuljn the treatment of patients with
obessiveoompujsiye disorder. The patient is prevented
from engaging in compulsive acts, such as hand washing
after exposure to situations that the patient considers
contaminating. The pajienHs gra_duajly_exposed_to
fhe_fea,red_siruation and is helped, to. abstain from
engaging^in compulsive behavior after the exposure.
The patient begins with the easiest situation and gradually
_moves toward more difficult, tasks
A patient with alcoholism wants a psychiatrist to bill
the patient’s insurance company under another diagnosis
because the patient is afraid of the stigma
attached to the diagnosis.,The psychiatrist should:
(A) tell the patient that this would be lying and refuse to comply.
(B) comply with the request because stigmas are inherently
unfair to patients.
(C) comply with the request provided the patient’s fears are
adequately addressed.
(D) explore the reasons behind the request and explain why
this is something the psychiatrist is reluctant to do.
The correct response is option D: Explore the reasons
behind the request and explain wny this is something
the psychiatrist is rejuctant to> do
The issue of therapeutic benefit’to the patient must guide
the manner in which the psychiatrist works within the limits
of ethics and the law. M d o ^ a j a l s e i n s ^
is__bojJTjl[eg.q[^ndj^ thus options B and C are
not appropriate. Option A considers only the letter of the
law without an overall consideration of how to incorporate
one’s response into the therapeutic relationship
In a patient experiencing bereavement, which of the
following suggests the diagnosis of major depression?
(A) A poor appetite
(B) Initial insomnia
(C) A feeling of worthlessness
(0) Hallucinations of the deceased
(E) Sadness
The correct response is option C: A feeling of worthiessness
The symptoms that would prompt one to consider a
diagnosis of major depressive episode include feelings
of worthlessness and generalized guilt, not guilt about
“missed opportunities” with the deceased. The usual
signs of bereavement include feelings of sadness as
we]l_as insomnia, poor appetite, and weight loss. The
bereaved patient often believes_ that__the__depressed
nL°°^_is _ ri9r m aL Additional symptoms of major
depression include general_preqccupation with death
(not wishes to die to join the deceased), psychomotor
retardation, extended Junctional impairment, and hallucinatory
experience^other than about the deceased.
Which CNS structure is most responsible for arousal
and sleep-wake cycles?
(A) Amygdala
(B) Hippocampus
(C) Hypothalamus
(D) Reticular activating system
(E) Ventral striatum
The correct response is option D: Reticular activating
system
Tjiej^tjc^laj^a^^ is a collection of fibers
and nuclei that include the main monoammejiuclej,
extending from the r n ^ d y j j a _ p b l p n g a^
mus. Structures within the reticular acWwoWng system
moduJaje_ajgusal, sleep-y^J<:e_cycles, and conscious
activity. The amygdala is associated with fear, anxiety,
and aggression. The hippocampus is associated
with memory and anxiety. The_hypothalamus is
re\a\e6 to hormonal regulation, eajin^and_drinking.
The ventral striatum is associated with motivation.
A 38-year-old patient provides a 12-year history of
obsessive concerns about dirt, germs, and contamination
and spends more than 3 hours a day with washing
and cleaning rituals. Which of the following would
be preferred as an initial medication treatment?
(A) Desipramine
(B) Duloxetine
(C) Paroxetine
(D) Phenelzine
(E) Venlafaxine
The correct response is option C: Paroxetine
The patient’s history is consistent with a diagnosis of
obessjye<pfnpulsive disorder. Selective serotonin
reuptake inhibitors (SSRIs) a r e ] h e j W e j r e ^ ^
m ^ n j j o j ^ i s ^ o n d i t i o n , a n < ^ f l u o x e t i n e , f l u y o x a m j n e ,
paroxetine, and sertraline have FDA approval for this
indicajion. The_FrjAjias_also approved clomipramine
fpr_pbsessive-compu!sive disorder, but this agent has a
more^adverse side effect profile than the SSIlls
A 59-yeaj-ojd woman is seen for an initial outpatient
psychiatric assessment. Her husband says that
increasingly oyexjhe_p^sJ_2years she has seemed
Iessjjkejiej^usual_outgoingjelf. She has been increasingly
a pathetic and uninterested in her usual activities,
and more recently she has behaved Inappropriately in
social interactions, m a ^ g ^ u n j j s j j o j ^ o n im and
rejyjrujgJ}orne wjth items that, do notbelong to her.
Recently, her husband has had to be^injiejpjngjier
dre^ssjnjhe^morning, and he notes that she is occasionally
inconJ|n^nJ_.oLurine. On mental status examination,
her affect js. blunted and KeL speech js sparse,
although she does not report specific psychotic symptoms
or changes in mood. She kngw.sjhe ye.arandjhe
se_asan but.not.the month or.date, and she has particular
difficulty in namjnq objects. MRI shows prominent
f c c m i a j j a j i d ^ p m e j ^ ^ with relative sparing
of other cortical regions. Which of the following
diagnoses is most likely in this patient?
(A) Dementia of the Alzheimer’s type
(B) Creutzfeldt-Jokob disease
(C) Dementia associated with Huntington’s disease
(D) Dementia associated with Parkinson’s disease
(E) Pick’s d i s e a s e ‘
The correct response is option E: Pick’s disease
Of the diagnoses listed, o n | ) ^ j c k ^ j s e ^ s ^
t h e j r o n j d e j n ^ ^ It typically begins insidiousjy,
with oj}set.at an earlier, age .than, dementia, of
thj^Jzheimejis_type. Incontinence and.abnormalities
of_sp_eech gnd_la.nguage_pccur_relatively..eaHyjn the
illness course. Sympk)ms_of_iLo.ntaJ.|gbe_ dysjynctipn,
including apathy and soddly inappropriate behaviors,
qrecpmmon. Unlike dementia of the Alzheimer’s
type, which is generally associated with more diffuse
atrophy, changes seen on MRI and single photon
emission computed tomography in Pick’s disease.are
more localized Jo the frontotemporal_ regions. With
Huntington’s disease and Parkinson’sjjsease, chara
d e ^ t i c ^ n e u r o l o g ‘ i c a l . .findings are .prominent.
Neurological findings are also observed in
Creutzfeldt-Jakob disease, but the pJogressjon__pf
dementia is more fulminant.thani.with.Pick’sdisegse
and MRI may;SJTOW changesjnjba_sql ganglia j n a d d i -
^i°JU°^§Llbl9i9trophy.
A psychiatrist decides that a patient with alcohol
dependence would benefit from regular laboratory
monitoring. W h i c h of the following single tests would
best provide information about heavy alcohol use
o y e j j I i e j D r e c e d r ^^
(A) Aspartate aminotransferase (AST)
(B) Carbohydrate-deficient transferrin (CDT)
(C) Exhaled ethanol concentration (e.g., Breathalyzer)
(D) Mean corpuscular volume (MCV)
The correct response is option B: Carbohydrate-deficient
transferrin (CDT)
CDT is more sensitive and specific than the other tests
listed. However, better results may be obtained with
combined tests (e.g., CDT and ga_mjpa-g[ujajny|transferase—
GGT]. Because of interpatient variability in
the C D T test result, the individual patient is best used
as_his or her own baseline for CDT .levels.
A patient with major depression shows no improvement
after an adequate trial (in dose and duration) of
an antidepressant. The best next step is to:
(A) augment the antidepressant with thyroid hormone.
(B) augment with lithium.
(C) augment with both thyroid hormone ond lithium.
(D) switch to a different class of antidepressant.
(E) conduct a “washout” by stopping all medication for 4
weeks, and then reassess.
The correct response is option D: Switchjc^adferent
class_ of cntidep_res_s_gnt
If a patient shows not even a partial response despite
full therapeutic doses of a particular antidepressant,
ajjgjn^njajionjsjio^recom Switching to a different
drug, e.itheLwithin a class (if there has not been
another_trial withi_ajhe_same class) or in a different
class is warranted. The .addition of psychotherapy is
also an option. Washing out by suddenly stopping all
medications will probably precipitate discontinuation
symptoms that will worsen the patient’s status.
Of the following, which is the most common reason
psychiatrists are sued for malpractice?
(A) Sexual improprieties with patients
(B) Suicide
(C) Failure to obtain informed consent
(D) Tardive dyskinesia
(E) Unnecessary commitment
The correct response is option B: Suicide
Of the answer choices, suiadejsjhg most common reason
for malpractice,litigation against a psychiatrist.
Documentation of a proper assessment with consultation
helps to provide a reasonable defense. Sexual improprieties
are viewed most often as torts and are not usually
covered by malpractice, because a law has not been
broken. Failure to obtain informed consent, especially
when prescribing a conventional antipsychotic that could
produce tardive dyskinesia, can be a cause for litigation.
The best protection against malpractice is a documented
comparison of risks versus benefits in the decision about
treatment and an indication that this comparison has
been shared with the patient or, if the patient is incompetent,
wjth g member of the patient’s family.
Anorexia nervosa is most commonly comorbid with
which of the following personality disorders?
(A) Dependent
(B) Paranoid
(C) Schizotypal
(D) Obsessive-compulsive
(E) Histrionic
The correct response is option D: Obsessive-compulsive
The association between personality disorders and
other psychiatric disorders is important because of
impljcationsjor treatment. Anorexia nervosa has been
demonstrated to be associated with obsessive-compulsive
personality disorder. Anorexia nervosa has
not been associated with dependent, paranoid,
schizotypal, or histrionic personality disorders.
The use of wliich of the following has been associated
with hyperparathyroidism?
(A)’ Lamotrigine
(B) Divalproex
(C) lithium
(D) Topiramate
The correct response is option C: Lithium
Uthiy^rHnaj^ and r\X9^i9919^Y’
r o j a W ^ _ a j e _ j j n c o ^ buJ^/eJUsJgbjijheo^
effedsa^ociafed wjtJxJithiujTijherapy. Both hyperplasia
and-adenomas o f j h e parathyroid glands have
been described in association with lithium therapy
Narcolepsy is characterized by which of the following
signs and symptoms?
(A) Daytime nonrefreshing sleep episodes
(B) Bouts of urinary incontinence
(C) Early morning awakening
(D) Sleepwalking
(E) Sudden episodes of muscle tone loss
The correct response is option E: Syjiderj^epispdes of
muscle tone loss
Cgtapjexy_ or sudden joss of_myscle tone, is__often
broy^ht^orvby^.strong emotions^in-patients with narcolepsy.
The other three components of the classic tetrad
of narcolepsy are bouts of sleep attacks (that are refreshing),
sleep paralysis, and hypnagogic or hypnopompic
hallucinations that are abnormal intrusions of REM sleep.
The correct response is option E: Syjiderj^epispdes of
muscle tone loss
Cgtapjexy_ or sudden joss of_myscle tone, is__often
broy^ht^orvby^.strong emotions^in-patients with narcolepsy.
The other three components of the classic tetrad
of narcolepsy are bouts of sleep attacks (that are refreshing),
sleep paralysis, and hypnagogic or hypnopompic
hallucinations that are abnormal intrusions of REM sleep.
The correct response is option D: A specific constellation
of defense mechanisms
The psychodynamic clinician views personality disorders
as involving four major components: a_biologicajly
based temperament, a set of internalized object
relations, an enduring sense of self, and a specific
constellation of defense mechanisms.
The antidepressant duloxetine may simultaneously
improve mood and:
(A) panic attacks.
(B) Tronic pain.
(C) flashbacks.
(D) psychotic symptoms.
(E) night terrors.
”"”he correct response is option B: Chromc_pain
The antidepressant duloxetine is a serotonin/norepinephrine
reuptake blocker with ^dopamine. reuptake
effects as.well. It has been shown in several ‘studies to
have efficacy in major depression. Major depression
is frequently comorbid with chronic pain, often withouLorganic
cause. Duloxetine appears to improve
°othjjejDresjipn^ particularly
bgckqche and shpyjder pain. It is thought that
descending norepinephrine and serotonin fibers from
the brain via the spinal cord serve to dampen peripheral
pain signals. IncnejJsjdjTprepi^^^^ 5-HT
“tone”_may thus simultaneously improve mood and
comorbid pain. At this time, there are no studies to
support duloxetine’s use in treating panic attacks,
flashbacks, psychotic symptoms, or night terrors
A 48-year-old man with a medical history of gastroesophageal
reflux disease (GERD) is referred for a
psychiatric evaluation of his anxiety. For jhe_ past
month, since the patient’s initial evaluation and treatment
for GERD, he complains of an increasing sense
of unease, nervousness, restlessness, and inabjlity to
sji_gnd..read the paper. His medications include
20-mg/-day of esomeprazole, 10_mg_pf jnetoclopramide
q.i.d., and 0.5 mg of lorazepamJj.d.^oiaHy
or as needed. He is very concerned about his condition
because a sibling who had a similar problem
died from esophageal carcinoma. Other than being
noticeably fidgety, his mental status exam is unremarkable.
What is the most likely explanation?
(A) Development of generalized anxiety disorder
(B) Adjustment disorder with anxious features
(C) Somatoform disorder not otherwise specified (i.e., “sympathy
symptoms” with deceased sibling]
(D) Akathisia from metoclopramide
(E) Benzodiazepine withdrawal
The correct response is option D: Akathisia from metoclopramide
The description and observation of th_ejnai)il[tyJo_be
still—that is, .motor restlessness—suggests,_akqthjsia
rajherjhan a _simple anxiety or. adjustment disorder.
Metoclopramide, an aliphatic phenothtazme and a
cousin_of_chlorpromazine, is. the. mostJikely_culprit.
Benzodiazepine withdrawal would be a second possibility,
especially if the patient took lorazepam three
times a day for 1 month and then stopped sev<.rol
days before the evaluation.
A 30-year-old patient with no prior history of mental
R health treatment presents with a major depressive
episode. Which of the following elements would be the
most important in choosing a medication for treatment?
(A) Co-occurring diagnosis of alcohol dependence in full sustained
remission
(B) Good antidepressant response lo fluoxetine in a firstdegree
relative
(C) History of a hypomanic episode
(D) Inactive hepatitis C infection
[i\ Suicide attempt by aspirin overdose at age 16
The correct response is option C: History of a hypo-
4 manic episode
in deciding on pharmacotherapy of a major depressive
episode, it is most important to rule out a diaqnosis
of a bipolar disorder. Ini such patients, initiation
of either lithium or lamotrigine would be a reasonable
option. Particularly in more seriously depressed individuals,
some clinicians initiate simultaneous’ treatment
with lithium and anjintidepressgnt. In contrast to
treatment of major depressive disorder, qntidepressant
monotherapy is not recommended for treating
depression in patients with oipojar disorder
A 32-year-old woman with bipolar I disorder has
been adequately maintained on lamotrigine. Recently
she has experienced an exacerbation of her manic
symptoms, and her physician elects to add a second
mood stabilizer. Instead of improving, the patient’s
symptoms worsen. Her serum lamotrigine levels are
nearly undetectable. What was the most likely mood
stabilizer that was added?
(A) Olanzapine
(B) Carbamazepine
(C) Valproate
(D) Topiramate
(E) Lithium
The correct response is option B: Carbamazepine
Lamojrigine, vvhich_has been approved for the treatrpjnt
of^bip_olar depression, i sjjietg bo I i zed through .the
liver. Carbamazepine and oral contraceptives containing
ethynyl estradiol, which induce hepatic enzyme systems,
can rapidly decrease lamotrigine levels.
Valproate, which inhibits these enzymes, could
markedly increase lamotrigine levels. Olanzapine, topiramate,
and lithium do not affect the hepatic enzyme
system involved in the metabolism of lamotrigine
Obsessive-compulsive disorder is hypothesized to
involve* a neural circuit connecting the_cortex and
striatum with the:
(A) amygdala.
(B) hippocampus.
(C) hypothalamus.
(D) mammillary body.
(E) thalamus.
The correct response is option E: Thalamus
Brain imaging studies suggest that obsessive-compulsive
disorder involves abnormalities in a cortico-striatalthalamic
circuit. A complementary model of
obsessive-compulsive disorder has emphasized that
the orbifqfronfal cortex plays a major role in the
“worry circuit.” Data have indicated that hyperactivity
of the oj^itpjr^ntgUortex as well as the anterior cingujajejiorjex
a^mimshesjA’.ith Jreatment.
Which of the following psychiatric disorders occurs
most commonly as a comorbid disorder with anorexia
nervosa?
(A) Somatization disorder
(B) Generalized anxiety disorder
(C) Major depressive disorder
(D) Obsessive-compulsive disorder
(E) Social phobia
The correct Response is option C: Major_ depressive
disorder
Anorexia nervosa is associated with depression in
65%of cases, sqcial phobia in 34% of cases, and
obs^siy^compulsive disorder in 26% of cases.
W h i c h of the following is the LEAST problematic for
the psychiatrist according to ethical principles?
l^ju- (A) A psychiatrist in a metropolitan area agrees to treat her
financial adviser’s child.
(B) A psychiatrist in a remote area with no other psychiatrists is
involved in a romantic relationship with a patient’s adult
grandchild.
(C) A psychiatrist hires a current patient to perform clerical
work in the psychiatrist’s office.
(D) A psychiatrist convinces a patient who was sexually abused
by a former clinician to file a suit against that former clinician
and serves as the forensic expert for the patient
The correct response is option B: A psychiatrist in a
remote area with no other psychiatrists is involved in a
romantic relationship with a patient’s adult grandchild
^ Psychiatrists have an obligation in general to avoid
^f\9 roles that can compromise the primary fiduciary duty
;~jJLM they have to their patients as well as rojes that may
i ncrease the potential for exploitation of vulnerable
patients. In option B, although a romantic relationship
with a patient’s adult grandchild may create a problematic
dual role, the psychiatrist does not have the
option of referring the patient to another competent
clinician and thus lacks one possible w a y of avoiding
the dual role. In options A and^C, the psychiatrist is
entering into avoidable roles that involve interests of
the psychiatrist that could potentially conflict..with, the
interests of the patient. In option D, the psychiatrist
f e e d s to distinguish between treatment and advocacy,
the latter may not serve the patient while certainly
s j r y j n g j h e p j s r s p j a i o r j j r o f a s ^ or
convictions qfjh.e psychiatristjnjh is_case.
In the initial assessment, a psychiatrist is consulted by
a lesbian couple seeking help for some problems in
their long-standing committed relationship. Which of
the following is the best approach for the psychiatrist
to take in assessing the possibility of domestic violence
within the couple?
(A) Ask about it only when material is presented that suggests
the problem.
(B) Ask routine questions about battering while taking the history.
(C) Obtain information from collateral sources.
(D) The topic need not be raised because domestic violence is
low in lesbian couples.
(E) Wait until the therapy is well established before asking
about it.
The correct response is option B: Ask_r.Qutine_guestions
about battering while_ta|ting the history
Domestic violence in general is underestimated, and it
is particularly likely to.be overlooked, in lesbian couples
becguse_of j h e stereotype .that_batt^nng_|s_only
anjpjfense^of men.against women. Couples often do
nPli^D9JLu p_sppnta.neously
A patient is being treated for a cat phobia. The therapist
encourages the patient to pass by a pet store that
has cats in the window. From which of the following
psychotherapy approaches does this strategy derive?
(A) Cognitive behavior
(B) Insight oriented
(C) Interpersonal ,
(D) Short-term anxiety-regufoting
(E) Supportive
The correct response is option A: Cognitive behavior
5pecific_pjwbras_.qre.iearsjaf JP_eciric_objects, situations,
or activities. The treatment of choice for specific
phobias is exposure, a type of cognitive behavior
therapy. The patient is encouraged to discus_s_the irratjonajify
of the phobia and.encouraged to expose himor
herself to the reared_object. Interpersonal psychotherapy
focuses on current interpersonal problems
in depressed nonbipolar, nonpsychotic individuals.
Insight p s y c h o l h e r ^ y attemp]s.tp,make what is out of
awareness conscious, so that one can identify and
work through patterns of behavior derived from childhood.
Suppqrtiye_ psychotherapy emphasizes external
evejTts_ajTdJs^ directed toward helping patients return
to_their_preyjo^s bestJevel_ofJunctioning. Short-term
anxiety-regulating psychotherapy uses psychodynamic
principles and techniques to effect change
Which of the following cognitive functions is most
likely to remain stable with normal aging?
(A) Language syntax
(B) Recent memory
(C) Speed of information processing
(0) Topographic orientation
(E) Working memory
The correct response is option A: Language syntax_
Syntax, vocabulary, communication, and store of
knowledge fend_ to.remain. stable with normal aging,
but the other functions listed tend to decline with age.
consultation is requested for a 22-year-old man
because of a gradual onset of behavioral symptoms
that include irritability, aggression, and personality
change. Associated findings include mild jaundice,
dysarthria, and choreiform movements. The consultation-
liaisorvpsychiatrisf also notices a golden-brown discoloration
of the cornea. The most likely diagnosis is:
(A) Huntington’s disease.
(B) Wilson’s disease.
(Q Parkinson’s disease.
(D) progressive supranuclear palsy.
(E) adrenoleukodystrophy.
The correct response is option B: Wilson’s disease
W i l s o n ^ d isease, or h e j ^ o j e j ^ f i a ^ g ^ is
an autosomal recessive disorder.of. c^pgejMriefaholism
characterized by C N S and hepatic manifestations.
Copper deposition in the cornea results in the
telltale r_g.yser^le.ischerjjng.
According to DSM-IV-TR, a patient with recurrent hypomanic
episodes without intercurrent depressive features
would receive which of the following diagnoses?
(A) Bipolar I disorder
(B) Bipolar II disorder .
(C) Cyclothymic disorder
(D) Bipolar disorder, not otherwise specified
The correct response is option D: Bipolar disorder, not
otherwise specified
Recurrent hypomania in the absence of depressive
periods would be classified as bipolar disorder not
otherwise specified. According to DSM-IV-TR, a diagnosis
of bipolar I disorder requires at least one manic
or mixed episode; a diagnosis of bipolar II disorder
requires recurrent major depressive episodes with
hypomanic episodes; and a diagnosis of cyclothymic
disorder requires periods of hypomanic symptoms
and periods of depressive symptoms.
The ventral tegmentum, the nucleus accumbens, and
the prefrontal cortex are brain structures or regions
most involved in the neurobiology of:
(A) alcohol dependence.
(B) anorexia nervosa.
(C) bipolar disorder.
(D) panic disorder.
(E) schizophrenia
The correct response is option A: Alcohol dependence
Dopaminergic and glutaminergic circuits in the
tegmentum, accumbens, and prefrontal cortex are
necessary in producing pleasure from drug use, in the
development of addiction, and in the maintenance of
drug craving, salience, and impaired control over
use. The amygdala plays a more central role in anxiety
disorders. The cnterior cingulate gyrus, the thalamus,
the cerebellum, and the temporal lobe regions
are involved in schizophrenia. The hypothalamus has
been suggested as a site of dysfunction in anorexia.
A wide range of structures and regions have been
studied in the neurobiology of bipolar disorder
