Neuropsikiatri

Question 1

major depressive episode

Answer 1

major depressive episode is marked by symptoms in several
domains, including mood (typically depressed), sleep (there may
be insomnia or hypersomnia), appetite (either increases or
decreases in it), cognition, and energy level. Feelings of
worthlessness and recurrent thoughts of death or suicidal
ideation/planning are other core features that may be seen. In
order for a diagnosis of major depressive episode to be made,
significant functional impact must be present

Question 2

major depressive disorder

Answer 2

diagnosis of major depressive disorder is made after the
occurrence of at least two major depressive episodes that occurred
at least 2 months apart

Question 3

Depresi; patofisiologi dan struktur otak terkait

Answer 3

The dorsolateral prefrontal cortex has been shown to be
hypometabolic in patients with depression, whereas the
orbitofrontal cortex is hypermetabolic, and pharmacologic
therapies have been shown to reverse these changes. The
pathophysiology of depression is complex, and dysfunction of one
specific brain area does not account for the occurrence of
depression. Rather, depression results from alterations in neuronal
function in many brain areas and their connections. The subcallosal
cingulate gyrus is one of the potential targets for deep brain
stimulation for the treatment of depression; it is a central
component of the limbic system and the connections between
frontal and subcortical circuits, and is metabolically overactive in
depression. Other potential targets include the ventral portion of
the anterior limb of the internal capsule. While gross hippocampal
volume is likely preserved in depression, hippocampal
abnormalities have been demonstrated, and these at least in part
relate to abnormalities in the hypothalamic–pituitary–adrenal
(HPA) axis and the effects of glucocorticoids on the hippocampus.
Patients with depression have elevated levels of corticotropinreleasing hormone and other abnormalities of the HPA axis.
Malone DA Jr, Dougherty DD, Rezai AR, et al. Deep brain stimul

Question 4

Panic attack

Answer 4

Panic attacks are discrete episodes of symptoms that
include a sense of intense fear, associated with other physical
and/or psychiatric symptoms. Physical symptoms seen in panic
attacks include palpitations or chest discomfort, diaphoresis,
trembling, dyspnea, feeling of choking, nausea or abdominal pain,
paresthesias, chills or hot flashes, and dizziness. Psychiatric
symptoms include derealization (a feeling of unreality) or
depersonalization (a feeling of being detached from oneself), fear
of losing control, and fear of dying. Other types of panic attacks
are cued, being situationally bound: occurring in relation to a
specific internal or external trigger

Question 5

Panic disorder

Answer 5

Panic disorder is diagnosed
when recurrent panic attacks occur. Panic disorder may occur in
isolation or may be associated with agoraphobia. Agoraphobia is
characterized by a fear of being in places or situations where
escape would be difficult or embarrassing, or in which help would
be difficult to obtain,

Question 6

Dissociative amnesia

Answer 6

Dissociative amnesia is one of the dissociative disorders and is
characterized by extreme amnesia, far out of what would be
considered normal forgetfulness. There is typically a loss of
personal experiences. The information forgotten usually relates to
a stressful event. Some patients regain memory of the event,
whereas others remain chronically amnestic for it

Question 7

Depersonalization disorder

Answer 7

Depersonalization disorder is another dissociative disorder in
which there are intermittent or constant feelings of detachment
from oneself as if a person is viewing him- or herself as an outside
observer.

Question 8

dissociative identity disorder

Answer 8

dissociative identity disorder
(commonly known as “multiple personality disorder”), a person
exists in two or more distinct identities or states, with these
identities each unaware of the other and with each separately taking control of the person’s behavior over different time periods.

Question 9

dissociative fugue

Answer 9

Patients with dissociative fugue suddenly and unexpectedly
travel away from their environment and are then unable to recall
their past or their identity, and may assume a partial or completely
new identity.

Question 10

Manic episodes

Answer 10

Manic episodes are characterized by abnormally elevated or
irritable mood occurring along with several symptoms that are
extreme enough to impact the patient’s function. These symptoms
include grandiosity, pressured speech, racing thoughts, and
distractibility. Individuals experiencing a manic episode have or
perceive a reduced need for sleep, and often become involved in
several activities and projects. In situations where symptoms of
both an acute manic episode and an acute depressive episode occur,
with rapid shifts between or combinations of manic symptoms,
psychotic symptoms, and/or depressive symptoms, a mixed episode
may be specified

Question 11

Diagnosis Bipolar Disorders

Answer 11

A prior history of depression is not required for the diagnosis of
bipolar disorder; one manic or hypomanic episode is all that is
needed to diagnose bipolar I or II disorder respectively. However in a patient with a depressive episode, a diagnosis of bipolar
disorder is not made unless there is a history of symptoms meeting
diagnostic criteria for acute manic or hypomanic episode.
Bipolar disorder is equally common in males and females. The
first episode of either mania or depression typically occurs in
young adulthood.

Question 12

cyclothymic disorder

Answer 12

cyclothymic disorder. This
disorder can be thought of as a clinically attenuated form of
bipolar disorder with symptoms spanning over several years. It is a
disorder characterized by periods of hypomania and separate
periods of depressive symptoms (which do not meet criteria for
major depressive disorder) that have been occurring for at least 2
years. There are infrequent intervening periods of euthymia
(normal mood). These patients often have pervasive conflicts in
interpersonal relations

Question 13

Phobia, klinis, macam

Answer 13

phobias are types of anxiety disorders. A
phobia is an excessive fear of an object or situation with exposure invariably leading to
an anxiety response and/or panic attack, resulting in active
avoidance of the object or situation
Macam : agoraphobia, social phobia, and
specific phobia.

There are five types of specific phobias: (i) animal type (phobia
of animals in general or a specific animal, such as a dog, or spiders
[arachnophobia]); (ii) natural environmental type (phobia for
specific environmental or natural occurrences such as heights
[acrophobia], thunderstorms, or water [hydrophobia]); (iii) bloodinjury type (fear of blood [hemophobia] or of a bloody injury, or
fear of needles [such as fear of venipuncture]); (iv) situational type
(fear of specific situations or experiences such as fear of being in a
closed space [claustrophobia] or transportation on airplanes or
trains); and (v) other type (when the phobia does not fit into the
latter four categories).

Question 14

schizophreniform disorder

Answer 14

psychotic
disorder marked by both positive symptoms, such as hallucinations,
delusions, and disorganized thought, and negative symptoms, such
as emotional blunting, alogia (empty speech), apathy, and reduced
communicativeness.

Question 15

The main distinguishing feature between brief psychotic disorder
,schizophreniform disorder, and
schizophrenia

Answer 15

symptom
duration, being up to 1 month in brief psychotic disorder, more
than 1 month but less than 6 months in schizophreniform disorder,
and 6 or more months in schizophrenia. Patients with these three
disorders are typically managed similarly once the appropriate
diagnostic workup has been completed
Of patients with schizophreniform disorder, two-thirds
eventually meet diagnostic criteria for schizophrenia and one-third
recover within 6 months of symptom onset. Predictors of good
prognosis include occurrence of psychotic symptoms within 4
weeks of change in behavior or functioning, presence of prominent
positive symptoms, disorganization of thought, confusion, and
good premorbid function.

Question 16

Obsessive compulsive disorder

Answer 16

Obsessive-compulsive disorder (OCD) is one of the anxiety
disorders, and the main features of it are obsessions and
compulsions that are time consuming and affecting function.
Obsessions are persistent ideas, thoughts, or impulses that provoke
significant anxiety and distress. Compulsions are repetitive physical
or mental acts that are meant to counteract the distress caused by
an obsession. Adult patients with OCD recognize that their
obsessions or compulsions are unreasonable or excessive.

Question 17

Generalized anxiety disorder

Answer 17

generalized
anxiety disorder. This is a disorder characterized by chronic
excessive anxiety and worrying that are difficult for the patient to
control and negatively affect function. Symptoms of impaired
cognition, sleep, and energy may also occur.
Generalized anxiety disorder is more common in females as
compared to males, and usually begins in adolescence or young
adulthood. Unlike panic disorder, which often improves with age,
anxiety is significant during adulthood and older age.

Question 18

Posttraumatic stress Disorders

Answer 18

Posttraumatic stress disorder (PTSD) is an anxiety disorder
characterized by the occurrence of specific symptoms after
experiencing a traumatic event involving threat of death or injury
to oneself or others, resulting in intense fear or horror. These
symptoms include reexperiencing the traumatic event (such as
through nightmares or flashbacks), avoiding any stimuli associated
with the event, and experiencing symptoms of autonomic arousal
(such as increased startle reflex, insomnia, hypervigilance, and
irritability). A diagnosis of PTSD is made only after symptoms have
been occurring for more than 1 month; within a 1-month period of
symptom onset, a diagnosis of acute stress reaction is made. The
majority of patients with PTSD develop complete remission;
however, up to a fourth of patients develop a chronic disorder

Question 19

Somatic symptoms disorder

Answer 19

somatoform
disorder) and related conditions, including conversion disorder,
illness anxiety disorder, and body dysmorphic disorder, encompass
disorders in which psychological stresses manifest as physical
symptoms. characterized by
the occurrence of multiple recurrent symptoms, affecting various
systems, and cannot be fully explained by physical factors. In some
cases, pain is the predominant symptom. Patients fixate on
symptoms, and devote considerable thought, time, and energy to
them, recurrently seeking medical attention, often resulting in
excessive nondiagnostic testing and unnecessary medical
treatments. Age of onset is typically prior to age 30.
The key point distinguishing somatic symptom disorder and
related conditions from factitious disorder is that in the former,
symptoms are not intentionally feigned, whereas with factitious
disorder, symptoms are voluntarily feigned for secondary gain.

Question 20

body
dysmorphic disorder

Answer 20

body
dysmorphic disorder experience a chronic and intense
preoccupation with a perceived defect of appearance or overconcern with minor physical abnormalities. Such patients often
seek unnecessary and repeated surgical procedures to correct their
perceived deformity

Question 21

illness anxiety disorder

Answer 21

In illness anxiety disorder (which encompasses a disorder
previously known as hypochondriasis), there is chronic and
pervasive preoccupation with physical symptoms and fear of
having a serious disease, often resulting from misinterpretation of
physical symptoms, even after diagnostic testing and exclusion of
the condition of concern or any other identifiable medical
condition

Question 22

Conversion disorder

Answer 22

conversion disorder
is characterized by acute loss of motor or sensory function that
cannot be explained by a neurologic or other medical condition.
The symptoms often resemble neurologic syndromes, such as
hemiparesis, cerebellar ataxia, or seizures. Nonneurologic
symptoms such as blindness, deafness, or false pregnancy
(pseudocyesis) also occur. Conversion disorder is also classified as a dissociative disorder in some texts.

Question 23

conduct disorder

Answer 23

Termasuk Dalam disruptive behavior disorders.characterized by a chronic and pervasive violation of rules
(including deceit, theft, and destruction of property), of others’
rights (including physical aggression to people or animals), and
age-appropriate societal norms. Individuals with this disorder show
little empathy or remorse. Conduct disorder is more common in
males. Risk factors for conduct disorder include psychopathology in
parents, dysfunctional family environment and poor parenting
practices, exposure to physical, sexual, or emotional abuse or
neglect, and exposure to violence. the conduct disorder
remits and they are able to achieve adequate social and
occupational adjustment. Management of conduct disorder centers
primarily around institution of early multimodal psychosocial
interventions to prevent conduct disorder when there are early
signs of aggression or deviance in a child

Question 24

oppositional defiant disorder.

Answer 24

oppositional defiant disorder marked
by a dysfunctional pattern of hostile and defiant behavior that
cannot be explained by a mood or psychotic disorder. Oppositional
defiant disorder most frequently emerges between ages 6 and 8,
and is more common in males and those of lower socioeconomic
status and in urban dwellers

Question 25

Persistent depressive disorder (dysthymia)

Answer 25

Persistent depressive disorder (dysthymia) is a mood disorder
characterized by insidious and chronic symptoms of depression that
occur most of the day for more days than not. It is different from
major depressive episode and chronic depressive disorder. In the
former, there is a clear-cut episode of depression with a relatively
clear time of onset, and in the latter, there are persistent residual
symptoms of depression after onset of a clear-cut major depressive
episode. Rather, dysthymic patients often report they have
“always” been depressed and express significant symptoms of
depression, including hopelessness and anhedonia. Suicidal
ideation, however, is not a common occurrence in dysthymic
disorder, being much more common in severe depression.
Dysthymic disorder is chronic and often difficult to treat
pharmacologically

Question 26

Schizoaffective disorder

Answer 26

is a psychotic disorder with a concomitant
mood disorder. In this disorder, there are periods marked by the
co-occurrence of a depressive episode, manic episode, or mixed
episode, concurrent with psychotic symptoms, all within an
uninterrupted period of time. In addition, there are separate periods of delusions or hallucinations in the absence of prominent
mood symptoms. However, mood episodes should be present for
the majority of the duration of the active illness.
Schizoaffective disorder is distinguished from depression
or mania with psychotic features in that in schizoaffective
disorder, there must be at least a 2-week period during which
psychotic symptoms are present without prominent symptoms of a
mood disorder.

Question 27

brief psychotic disorder

Answer 27

symptoms started following a
significant stressor and consisted of hallucinations, delusions, and
disorganized speech, similar to the symptoms of schizophrenia.
However, symptoms lasted less than 1 month, and did not recur,
with a return to baseline. Brief psychotic disorder can also occur in
the absence of an acute stressor, and can also occur postpartum.

Question 28

delusional disorder, klinis Dan jenis

Answer 28

delusional disorder, patients typically are
able to function normally, apart from the ramifications the
delusion may have on the patient’s function and behavior.
Jenis:
- erotomanic type.
-Grandiose type, in which there are delusions of inflated worth,
power, knowledge, or identity.
-Jealous type, in which there are delusions that an individual’s
significant other is unfaithful.
-Persecutory type, in which the delusion is one of being persecuted
by someone.
-Somatic type, delusions of having a physical defect or medical
problem

Question 29

adjustment disorder, Bereavement

Answer 29

This is a constellation of emotional and
behavioral symptoms that occur in response to a recent stressor,
one that occurred within 3 months of symptom onset. The distress
exhibited is in excess to what would be expected from the stressor,
but symptoms are not as severe as they are in major depression
and symptoms do not persist
beyond 6 months of the stressor. Adjustment disorder may be
further qualified as being accompanied by depressed mood or by anxiety.
Bereavement is a diagnosis that is made when an expected
response occurs in reaction to the death of a loved one. Adjustment
disorder may subsequently be diagnosed if the bereavement
reaction is more prolonged than would be expected (longer than 2
months) or more excessive than would be expected

Question 30

intermittent explosive
disorder (IED)

Answer 30

intermittent explosive
disorder (IED), an impulse control disorder characterized by
several episodes of verbal or physical aggression that is out of
proportion to an instigating event. In between episodes, patients
may express remorse or regret for their actions. IED typically starts
in adolescence or early adulthood and is more common in men.
Treatment of IED includes psychotherapy, as well as
pharmacotherapy with mood stabilizers

Question 31

impulse control disorders , macam

Answer 31

• Intermittent impulsive disorders
• kleptomania : recurrent impulses to steal objects because of a sense of pleasure or
  gratification from the act of stealing, with the object being of little
  personal use or value.
• trichotillomania
  (recurrent pulling of one’s hair resulting in hair loss and a sense of
  pleasure or gratification), pyromania (deliberate setting of fires, a
  fascination with fire, and pleasure or gratification when setting
  fires or observing their aftermath), and pathologic gambling.

Question 32

Eating Disorders , macam

Answer 32

eating disorders include

• anorexia nervosa,
• bulimia nervosa,
• binge eating disorder,
• eating disorder not otherwise specified

Question 33

Anorexia nervosa

Answer 33

restricted energy intake relative to the
requirements and resulting in a significantly low body weight. In
an individual with anorexia nervosa there is disturbed perception
of one’s body weight/shape, an intense fear of gaining weight, and
an impaired self-perception of weight (such as denial of the
seriousness of low body weight). Anorexia nervosa is of two types:
The first is a restricting type, which occurs in approximately 50%
of patients, in which there is self-induced starvation and often
compulsive exercising without binge eating or purging behaviors.
The second type is a binge eating/purging type, in which the
patient regularly engages in binge eating followed by purging.
Anorexia nervosa is treated at least initially in the inpatient setting
to allow for medical stabilization and initiation of nutrition under
close supervision. Later, outpatient therapy revolves mainly around
psychotherapy, with pharmacologic management of comorbid
mood or anxiety disorders.

Question 34

Bulimia nervosa

Answer 34

patients binge and
subsequently partake in compensatory behaviors to prevent weight
gain such as excessive exercise, induction of emesis or misuse of
laxatives, diuretics, or other medications. In contrast to anorexia
nervosa, patients with bulimia nervosa typically maintain a normal
body weight. In patients with bulimia nervosa, self-assessment is
unduly influenced by body weight and shape. Treatment of bulimia
nervosa involves psychotherapy combined in some cases with
selective serotonin reuptake inhibitors

Question 35

Binge eating disorders

Answer 35

binge eating occurs over discrete
periods. During episodes of binge eating, there is a sense of lack of
control, embarrassment (by how much one is eating), and/or guilt.
Bulimia nervosa is distinguished from binge eating disorder in that
in the latter, inappropriate compensatory behaviors do not occur

Question 36

NMDA-receptor encephalitis

Answer 36

an
autoantibody mediated disorder that may be either paraneoplastic
or autoimmune.
there are usually prodromal psychiatric symptoms before
the frank acute psychosis occurs. Furthermore, and more
importantly, they are not typically associated with the cognitive
changes, seizures, and respiratory failure as described in this
patient. Standard of care dictates consideration of potential
secondary causes in patients presenting with primarily psychiatric
symptoms particularly when neurologic signs and/or symptoms
emerge. Neurologic disorders that may present initially with
psychiatric symptoms include (but are not limited to) infectious,
autoimmune and paraneoplastic encephalitides, and
neurometabolic and neurodegenerative disorders. Usually, other
signs and symptoms emerge to suggest one of these, so continued
examination and reassessment of patients presenting with acute
psychiatric symptoms is essential.

Question 37

specific learning disability

Answer 37

specific
learning disability. This is marked by difficulties learning and
acquiring academic skills out of proportion to any developmental,
mental, or neurologic disorders and despite interventions to target
those difficulties. Domains affected include reading, writing, or
math skills. Individuals affected with learning disability perform
below what would be expected for the individual’s chronologic
age.
In individuals with specific learning disability, capabilities in
other domains are typically average or may be above average,
though the various learning disabilities frequently co-occur

Question 38

Mental retardation

Answer 38

Mental
retardation is defined by significantly subaverage general
intellectual functioning, in more than one domain, as assessed by
standardized tests. Mild mental retardation is defined by an
intelligence quotient (IQ) of 55 to 70, moderate mental retardation
by an IQ of 35 to 55, severe mental retardation by an IQ of 20 to
35, and profound mental retardation by an IQ of less than 20.

Question 39

Personality Disorder

Answer 39

personality disorders consist of 10 distinct entities that share in
common a chronic and pervasive pattern of inner experiences,
thoughts, and behaviors. They affect the domains of cognition,
impulse control, affectivity, and interpersonal functioning. Features
are present in adolescence or early adulthood and persist over
time. They deviate from accepted societal culture and norms and
lead to distress or impairment. The caveat to the diagnosis of
personality disorders is that the features do not occur in the
context of signs or symptoms that are part of a mood, anxiety,
impulse control, or psychotic disorder, or any other psychiatric
disorder as the primary underlying illness. Personality traits are
patterns of behavior or thinking about oneself and the environment
that are relatively consistent over time, but they do not lead to a
diagnosis of personality disorder unless they are maladaptive or
cause functional impairment or distress. The personality disorders
are categorized into clusters A, B, and C. Different personality
disorders may co-occur in the same individual.
cluster A includes
paranoid, schizoid, and schizotypal personality disorders
cluster C includes avoidant, dependent,
and obsessive-compulsive personality disorders.
cluster B includes
narcissistic, antisocial, borderline, and histrionic personality
disorders

Question 40

paranoid personality disorders

Answer 40

Paranoid
personality disorder is marked by
pervasive distrust, paranoia, and suspiciousness of others. Persons
with paranoid personality disorders have an increased risk of
comorbid major depressive disorder, substance abuse, and agoraphobia
Paranoid personality disorder is more common in males and may
be an antecedent to paranoid type of delusional disorder

Question 41

Schizoid personality disorder

Answer 41

Schizoid personality disorder is marked
by blunted range of affect and emotions. There is a lack of interest
in or enjoyment of social relationships and intimacy. Individuals
with this disorder exhibit little pleasure in social activities, with a
preference for solitude, and lack close friends outside of the
immediate family. Schizoid personality disorder is more common
in males, and may appear as an antecedent to delusional disorder
or schizophrenia

Question 42

Schizotypal personality disorder

Answer 42

Schizotypal personality disorder is
marked by odd, peculiar, and eccentric ideas, beliefs, and/or
behaviors including magical thinking (such as superstitiousness or
belief in clairvoyance or telepathy), paranoid ideation, and
constricted affect. Individuals with this personality disorder have
social anxiety and are uncomfortable with close relationships; they
typically lack close friends outside of immediate family members.
Patients with schizotypal personality disorder have comorbid major
depression in 30% to 50% of cases.

Question 43

Munchausen’s syndrome

Answer 43

Munchausen’s syndrome is a chronic, severe form
of factitious disorder in which extensive deceptive means are often
employed in feigning physical signs, resulting in recurrent
hospitalizations in various geographic locations. In factitious
disorder imposed on other (previously, Munchausen’s syndrome [or
factitious disorder] by proxy), physical signs or symptoms are
intentionally produced in another individual who is under the
direct care of the perpetrator.
In malingering, the secondary gain is an external incentive (such
as money). In comparison, the secondary gain in factitious disorder
is assumption of the role of a patient.

Question 44

Avoidant personality disorder

Answer 44

hypersensitivity to criticism, feelings of inadequacy, and social
inhibition. Individuals with this disorder may avoid an occupation
or other activity that will involve contact with others because of
fear of criticism or rejection. They may show restraint in personal
relationships because of fear of being ridiculed, and are willing to
get involved with people only if certain of being liked. They often
view themselves as socially inept and inferior to others.
Unlike
persons with schizoid personality disorder , those with avoidant personality disorder want relationships
but avoid them because of fear of criticism, whereas those with
schizoid personality disorder prefer social isolation. Avoidant
personality disorder shares features with panic disorder with
agoraphobia but in the latter
condition, avoidance is of specific social situations that lead to
panic attacks. Avoidant personality disorder begins at an early age,
without clear precipitants, and is stable over time. Social phobia
and avoidant personality
disorder may co-occur.

Question 45

dependent personality disorder

Answer 45

have a chronic and excessive need to be taken care of.
They may be clingy and have fear of separation. They have
difficulty making day-to-day decisions without advice and
reassurance from others, and prefer for others to assume
responsibility for major areas of life. They are submissive and
avoid disagreement with others for fear of loss of approval. They
lack self-confidence and consequently avoid initiating projects or
doing things independently. Individuals with this disorder may feel
helpless when alone because of fear of being unable to care of
themselves, and may urgently seek a new relationship as a source
of care if another relationship ends. Dependent personality disorder
is equally common in males and females, and is one of the most
common personality disorders.

Question 46

Obsessive-compulsive personality disorder

Answer 46

is marked by a dysfunctional and unproductive preoccupation
with orderliness, perfection, and control at the expense of
flexibility and efficiency. Individuals with this disorder are
perfectionists without this necessarily being productive. They are
rigid and inflexible in various aspects of life including in work and in relationships. They often prioritize work at the expense of
leisure activities or friendship. Some individuals with this
personality disorder have difficulty parting with unneeded objects
(to the extent of hoarding in some cases). Although obsessive compulsive disorder may coexist with
obsessive-compulsive personality disorder, distinct and definable
obsessions and compulsions are absent in the latter, distinguishing
the two.

Question 47

Narcissistic personality disorder

Answer 47

is
marked by grandiosity and a sense of self-importance. These
individuals are arrogant and preoccupied by perceived positive
attributes such as success or beauty, believe that they are superior
to others, and have a sense of self-entitlement. On the other hand
they have fears of others seeing their flaws. They manipulate
others to achieve ends in their own self-interest, often at the
expense of the interest of others. Individuals with this disorder also
lack empathy. Narcissistic personality disorder is more common in
males, and major depression and
substance abuse are common comorbidities.

Question 48

Antisocial personality disorder

Answer 48

is
marked by disrespect of others and the law, starting since age 15.
Individuals with this disorder exhibit deceptiveness, impulsivity,
aggressiveness, recklessness, and irresponsibility (in the workplace,
financially, etc.). They lack remorse, with indifference to harming
others. Conduct disorder is a
prerequisite for the diagnosis of antisocial personality disorder;
antisocial personality disorder cannot be diagnosed in those
younger than 18. Impulse control disorder may occur in persons with antisocial personality
disorder, but the other features of antisocial personality disorder
discussed distinguish the two. Antisocial personality disorder is
three times more common in males as compared to females.

Question 49

Borderline personality disorder

Answer 49

is
marked by pervasive instability in various aspects including selfimage, relationships, and affect. In their interactions with and
perception of others, individuals with this disorder alternate
between idealization and devaluation (so-called splitting). They
have an intense fear of abandonment and go to extremes to avoid
this. They often engage in self-injurious behavior including suicidal
gesture or threats, or self-mutilation. The instability and extremism
extends to eating behaviors and sexuality. Borderline personality disorder is more common in females. Frequent comorbidities
include major depression, eating disorder, and substance abuse.

Question 50

Histrionic personality disorder

Answer 50

is
marked by attention-seeking behavior, including constant need to
be the center of attention and inappropriately seductive or
provocative behavior. Individuals with this disorder use their
physical appearance to draw attention to themselves, and may be
theatrical and dramatic. They also exhibit excessive emotionality
and have shallow and rapidly shifting emotions. Histrionic
personality disorder is more common in females, and common
comorbidities include major depression, conversion disorder, and
somatic symptom disorder.

Question 51

ADHD/attention-deficit/hyperactivity disorder

Answer 51

In
ADHD, symptoms start before age 12, are functionally impairing,
and are not consistent with developmental level. ADHD may
present with predominantly inattentive symptoms (such as
difficulty sustaining attention on a given task and are easily
distractible). ADHD may also present with
predominantly hyperactive symptoms (such as fidgetiness,
restlessness, and impatience). In some patients, a
combination of these occurs.
Although the etiology of ADHD is not clear, dysfunction in
frontal-subcortical circuits has been implicated. Genetic studies
have suggested involvement of genes related to dopamine action or
metabolism, though environmental factors play a role as well.
Children of parents with ADHD and siblings of children with ADHD
are more likely to be affected with ADHD than the general
population.
The first line of treatment for ADHD are psychostimulants
including amphetamines and methylphenidates, of which there are
various oral preparations. Common side effects include reduced
appetite, weight loss, insomnia, and headaches. An
electrocardiogram prior to initiation of stimulant medications is
recommended to exclude underlying structural or conduction
problems. Other medications used to treat ADHD include the
nonstimulant atomoxetine, tricyclic antidepressants, antipsychotics,
mood stabilizers, and the α2-agonist clonidine. Psychosocial
treatment is also an important part of managing ADHD

Question 52

folie à deux

Answer 52

folie à deux, a type of disorder in which a psychotic
belief develops in an individual that is similar to that held by a
close relation

Question 53

Serotonin, mekanisme aksi

Answer 53

Serotonin, or 5-hydroxytryptamine (5-HT), is synthesized from
tryptophan . Serotonin is metabolized by action of monoamine oxidase (MAO) into 5-hydroxyindoleacetaldehyde,
which by action of aldehyde dehydrogenase is transformed to 5-
hydroxyindoleacetic acid. MAO-A is the predominant isoform in the
metabolism of serotonin. In the CNS, the principle site of serotonergic neuronal cell bodies
is in the raphe nuclei of the brainstem, with diffuse projections to
the brain and spinal cord. Serotonin has various actions both in the
CNS and systemically. In the CNS, serotonin has a role to play in
the sleep-wake cycle; serotonin deficiency leads to insomnia, and
tryptophan (a serotonin precursor) promotes sleep. Serotonin has
also been implicated in violent behavior; low CSF levels of the
serotonin metabolite 5-hydroxyindole acetic acid (5-HIAA) have
been associated with aggressiveness and violent impulsivity.
Serotonin deficiency has also been implicated in both anxiety and
depression

Question 54

nonpsychotropic effects of serotonin

Answer 54

nonpsychotropic effects of serotonin, the
5-HT1B receptors elicit vasoconstriction and the 5-HT1D receptors
inhibit neuronal transmission and trigeminal neurogenic
inflammatory peptide release. Triptan medications such as
sumatriptan are agonists at these latter receptors. Action of
serotonin at 5-HT2A receptors leads to platelet aggregation.
Serotonin acts at 5-HT3 in the area postrema and the antiemetic
ondansetron is an antagonist at this receptor. Serotonin is released
by enterochromaffin cells in the intestines where it increases
intestinal motility. It also induces bronchoconstriction, and patients
with malignant carcinoid syndrome, in which there is excessive
production of serotonin, manifest many of the symptoms of a
hyperserotonergic state, including wheezing and diarrhea

Question 55

Serotonin syndrome

Answer 55

Serotonin syndrome results from overstimulation of
brainstem serotonin receptors. Symptoms include encephalopathy,
autonomic hyperactivity manifesting as hypertension, tachycardia,
and diaphoresis, as well as myoclonus, hyperreflexia, and tremor.
Serotonin syndrome can occur with any agent that increases
serotonin, and has even been reported with monotherapy, but is
more likely to occur with a combination of therapies that increase serotonin, and particularly with concomitant use of nonselective
monoamine oxidase inhibitors. Treatment generally includes
supportive care and withdrawal of the offending agent.
Serotonin withdrawal syndrome can occur with abrupt
discontinuation of serotonergic medications such as selective
serotonin reuptake inhibitors. Symptoms include dizziness,
paresthesias, dysphoria, and in some cases encephalopathy.
Therefore, gradual tapering of such medications is generally
recommended

Question 56

Tricyclic antidepressants (TCA)

Answer 56

tricyclic antidepressants (TCAs) are among the oldest
antidepressants and are still commonly used to treat depression.
The TCAs with a tertiary amine side chain such as amitriptyline,
doxepin, and imipramine inhibit reuptake of both serotonin and
norepinephrine, whereas some such as clomipramine
predominantly inhibit reuptake of serotonin. The TCAs do not
directly inhibit reuptake of dopamine, though they may indirectly
facilitate the effects of dopamine. All TCAs have some activity at
muscarinic, histaminergic, and α1-adrenergic receptors, though to
varying degrees. Because of these effects at noncatecholaminergic
receptors, they are used for various disorders not limited to
depression and anxiety, including urinary retention and
neuropathic pain.

Question 57

Tricyclic antidepressants, efek samping

Answer 57

Tricyclic antidepressants (TCAs) lead to urinary retention due to
inhibition of detrusor function, rather than bladder overactivity.
Because the TCAs all have, to varying degrees, activity at
muscarinic, histaminergic, and α1-adrenergic receptors, they have
various side effects. Antagonism at histamine receptors leads to
sedation, xerostomia, and weight gain. Antimuscarinic activity
leads to constipation, tachycardia, blurred vision (with increased
risk of glaucoma), and urinary retention, and hence imipramine is
used to treat overactive bladder and enuresis. α1-Adrenergic
antagonism can lead to postural hypotension, which can be
particularly detrimental in older adults. Of the commonly used
TCAs, amitriptyline has the highest antimuscarinic activity and α1-
adrenergic activity. Nortriptyline has the least α1-adrenergic
antagonism and is therefore less likely to cause orthostatic
hypotension. Doxepin has the highest antihistamine activity, and is
therefore the most sedating. At toxic doses, TCAs can cause
confusion, seizures, and arrhythmias. TCAs are metabolized
through oxidation by various cytochrome P450 isozymes and
subsequently undergo glucuronidation. Because their metabolism is
strongly dependent on cytochrome P450 enzymes, they have
various drug–drug interactions

Question 58

SSRI

Answer 58

The SSRIs include fluoxetine, fluvoxamine,
sertraline, paroxetine, citalopram, and escitalopram. They inhibit
reuptake of serotonin through inhibition of the serotonin
transporter, leading to increased availability of serotonin at the
postsynaptic membrane. The antidepressant and/or anxiolytic
effect of SSRIs may not become apparent for several days to weeks
because their mechanism of action involves pre- and postsynaptic
receptor changes that are not immediate
The SSRIs are metabolized by the
hepatic cytochrome P450 system and have various drug–drug
interactions, with the extent varying with each of the SSRIs.
Citalopram and escitalopram have the least potential for drug–drug
interactions

Question 59

Efek samping SSRi

Answer 59

Gastrointestinal side effects, including nausea, result in
part from action of serotonin at 5HT3 receptors in the area
postrema, but also from increased serotonin at the level of the
enteric nervous system. Tolerance to this side effect typically
develops after a few days of therapy. SSRIs cause sexual
dysfunction, particularly leading to erectile dysfunction in men.
They can lead to irritability and increased suicidal thoughts,
particularly in younger age groups. Some of the SSRIs can lead to
insomnia, whereas others are more sedating. Sertraline is one of
the least sedating SSRIs. Paroxetine has the highest anticholinergic
activity and therefore causes several anticholinergic side effects,
including xerostomia and urinary retention.

Question 60

Tipikal antipsikotik, mekanisme aksi

Answer 60

typical
antipsychotics exert their antipsychotic effect predominantly by
antagonism at D2 receptors.
The typical antipsychotics, first brought into clinical use in the
1950s, include chlorpromazine and thioridazine, which have low
potency at D2 (dopamine) receptors and higher antagonism at
muscarinic, adrenergic, and histaminergic receptors. They are
therefore more likely to cause side effects related to antagonism at
these receptors, such as dry mouth, orthostasis, and sedation,
respectively.
Those with higher potency at D2 receptors, such as haloperidol
and fluphenazine, have activity at muscarinic, adrenergic, and
histaminergic receptors as well and can lead to similar side effects,
but are less likely to do so. On the other hand, they are more likely
to lead to extrapyramidal side effects (EPS), which result from D2-
antagonism in the nigrostriatal pathway. The EPS can be divided
into acute reactions such as acute dystonia, which are in general
reversible with treatment with antimuscarinic agents such as
benztropine, and tardive dyskinesia (such as the orolingual
dyskinesias or tardive cervical dystonia),
which are in general irreversible but may be treatable with
botulinum toxin or deep brain stimulation to the globus pallidus
interna

Question 61

Atipikal antipsikotik, mekanisme aksi

Answer 61

The second generation of antipsychotics, so-called atypical
antipsychotics, includes clozapine, olanzapine, quetiapine,
risperidone, ziprasidone, and aripiprazole. These agents do have
antagonistic activity at D2 (dopamine) receptors, however, their
clinical antipsychotic effect results in large part from antagonism at
serotonergic 5-HT2A receptors. Studies to date have not shown
overall superior efficacy of the atypical antipsychotics over the
typical ones, though atypical antipsychotics may be more effective
at treating some of the negative symptoms of schizophrenia.
Because they have less antagonism at D2 receptors, they are less
likely to cause extrapyramidal side effects (EPS), but certainly can.
As a class, the atypical antipsychotics carry with them an
increased risk of weight gain, diabetes, and dyslipidemia. Patients
being treated with these medications should therefore periodically
be assessed for such side effects. Clozapine and olanzapine are
most likely to lead to weight gain. Ziprasidone and aripiprazole are
less likely to cause weight gain than the others.

Question 62

Efek samping antipsikotik

Answer 62

Some of the typical and atypical antipsychotics including
thioridazine, haloperidol, ziprasidone, and quetiapine have
negative ionotropic action on the heart and a quinidine-like effect,
leading to QT prolongation with the potential for arrhythmias.
Aripiprazole is least likely to do so. Other cardiac side effects
include myocarditis, which can rarely be seen with clozapine. The
atypical antipsychotics also have activity at muscarinic, adrenergic,
and histaminergic receptors, and several side effects result from
activity at these sites. Clozapine can lead to agranulocytosis in 1%
to 2% of patients, and patients being treated with this medication
are required to have periodic complete blood counts checked.
Clozapine also leads to a dose-dependent increased risk of seizures.
Clozapine is least likely of all the atypical antipsychotics to lead to
EPS. Because of the side effect profile of clozapine, its use is
usually limited to treatment of patients who have failed trials of
other typical and atypical antipsychotics. Among the atypical
antipsychotics, olanzapine has the highest antimuscarinic activity,
and side effects resulting from this include dry mouth, urinary retention, confusion, and constipation. Clozapine also has
significant antimuscarinic activity. Quetiapine has significant
antihistaminergic activity, and along with olanzapine, is the most
likely to lead to sedation.
Dopamine inhibits prolactin release, and treatment with both
typical and atypical antipsychotics can lead to hyperprolactinemia
and amenorrhea resulting from dopaminergic antagonism in the
tuberoinfundibular pathway

Question 63

Flumazenil

Answer 63

Flumazenil is an antagonist of benzodiazepines and other sedative–
hypnotic agents such as zolpidem and eszopiclone (the latter two
agents are used in the treatment of insomnia). Flumazenil does not
however antagonize the action of barbiturates.

Question 64

Antipsikotik yang meningkatkan resiko kejang

Answer 64

bupropion and clozapine have been associated with increased risk of
seizure at higher dosages. Olanzapine is less likely to cause seizures, but can do so; other atypical
antipsychotics rarely cause seizures. Amitriptyline, which is a
tricyclic antidepressant is also associated
with increased seizure risk with acute toxicity. Flumazenil, by
inducing a state of benzodiazepine withdrawal, can lead to
increased risk of seizures, particularly in patients with a prior
history of seizures.

Question 65

Mood-stabilizing agents

Answer 65

Mood-stabilizing agents used to treat bipolar disorder include
lithium carbonate, as well as the anticonvulsants including valproic
acid, carbamazepine, and lamotrigine

Question 66

Mekanisme aksi Lithium carbonate

Answer 66

mechanism of action of lithium carbonate is not clear, but
does include inhibition of the inositol and glycogen synthase kinase
3 signal pathways and downstream enzyme activity. Serum levels
of lithium should be monitored periodically. Common adverse
effects of lithium include tremor, thyroid dysfunction, acne, and
nephrogenic diabetes insipidus, which can lead to hypernatremia if
there is not adequate oral intake of fluids. Lithium is contraindicated in patients with sick sinus
syndrome because it has a negative chronotropic effect.

Question 67

Electroconvulsive therapy

Answer 67

Electroconvulsive therapy can be a highly effective therapy for
depression. It is most commonly used for major depression
refractory to medications but is also used acutely in depression
(without a prior drug trial) when necessary. Suicide is not a
contraindication for ECT. Other indications for ECT include
schizoaffective disorders, schizophrenia, and mania (particularly in
bipolar patients with a mixed episode [of both mania and
depression] or rapidly cycling bipolar disorder). In ECT, an electric
current is applied to the scalp in an anesthetized patient, with the
goal of inducing a nonconvulsive seizure. The mechanism of action
of the antidepressant effects of ECT is not well understood. Side effects include retrograde amnesia, which can be partially
irreversible.

Question 68

TMS

Answer 68

In TMS, a rapidly changing magnetic field is applied to the scalp
and is thought to affect the superficial layers of the cerebral cortex,
locally inducing small electric currents. Single-pulse TMS is
generally considered safe but seizures are nevertheless a potential
risk, even in individuals without a prior history of epilepsy.
Application of TMS to the left dorsolateral prefrontal cortex
improves symptoms in major depression. In VNS, intermittent
electrical stimulation is directly applied via an electrode to the left
cervical vagus nerve. The current is provided by a pulse generator,
a pacemaker-sized device that is implanted in the chest and is
connected to the electrode. Stimulation of the afferent vagus nerve
fibers leads to changes in several brainstem nuclei that are
involved in the pathophysiology of depression, such as the nucleus
of the tractus solitarius and raphe nuclei, leading to alterations in
serotonergic activity in cortical and limbic structures. VNS is used
as adjunctive therapy for chronic or recurrent depression in
individuals with either unipolar depression or bipolar disorder.

Question 69

Buspirone, mekanisme aksi

Answer 69

Buspirone is an anxiolytic agent without sedative–hypnotic
activity. Its mechanism of action involves partial agonism at
serotonergic (5-HT1A) receptors. It also has some activity at
dopaminergic D2 receptors.
The mechanism of action of bupropion is not well understood,
but animal studies have shown that it inhibits reuptake of
norepinephrine and dopamine and increases presynaptic release of
these neurotransmitters, without direct effects on the serotonin
system. At high doses, bupropion increases risk of seizures.
Bupropion, in addition to its use as an antidepressant, is used in
smoking cessation.

Question 70

Benzodiazepine

Answer 70

benzodiazepines belong to a class of medications known as
the sedative-hypnotics by nature of their ability to induce an
anxiolytic calming effect and sleep. They include alprazolam,
midazolam, chlordiazepoxide, temazepam, triazolam, flurazepam,
clorazepate, oxazepam, and diazepam. They act at GABAA
receptors, facilitating the action of GABA and increasing chloride
conductance.
The benzodiazepines may be used in the treatment of acute
anxiety, as is seen in generalized anxiety disorder, panic disorder, and agoraphobia. However, chronic use leads to tolerance
(decreased response to a specific dose after repeated exposure) as
well as physiologic dependence. Other adverse effects include
memory disturbance, sedation, and respiratory depression in
overdose (or even at therapeutic doses in those with pulmonary
disease). Chronic therapy for anxiety disorders therefore includes
medications such as the selective serotonin reuptake inhibitors,
tricyclic antidepressants, and serotonin–norepinephrine reuptake
inhibitors. The latter medications do not have acute effects on
anxiety, and in the initial weeks of therapy, benzodiazepines are
often used as adjuncts until the anxiolysis takes effect. Of the
benzodiazepines, flurazepam and clorazepate have the longest halflives. Triazolam has a rapid onset and short duration of action.
Besides the treatment of acute anxiety, benzodiazepines are also
used in the treatment of seizures, alcohol withdrawal, spasticity
and movement disorders, and insomnia.

Question 71

Hiponatremi pada SSRi

Answer 71

Hyponatremia is an established side effect of therapy with selective
serotonin reuptake inhibitors (SSRIs). Risk factors include older
age, female sex, and concomitant use of diuretics. Hyponatremia
resulting from SSRIs typically occurs within the first month of
therapy, but may not occur until several months after initiation of
therapy. Among the SSRIs, fluoxetine and paroxetine are more
likely to lead to hyponatremia. The pathophysiology of SSRIinduced hyponatremia is thought to be at least in part related to
the syndrome of inappropriate antidiuretic hormone, resulting
from excessive release of antidiuretic hormone mediated by
activation of serotonergic receptors. Although there are no
definitive data to support routine monitoring of serum sodium in
patients started on an SSRI, any change in mentation or other
symptoms potentially suggesting hyponatremia should prompt a
laboratory evaluation for this complication. In isovolemic
hyponatremia due to SSRIs, the treatment is discontinuation of the
SSRI along with fluid restriction. In more severe symptomatic
hyponatremia, treatment with intravenous sodium chloride may be
indicated. Rechallenge with SSRIs may not necessarily lead to
recurrent hyponatremia, though it can.

Question 72

GABA reseptor antipsikotik

Answer 72

GABA is an amino acid and is the major inhibitory neurotransmitter
in the CNS. Glycine is also an inhibitory amino acid
neurotransmitter and plays a prominent role in the brain and spinal
cord. GABA is synthesized from glutamic acid by action of the
enzyme glutamic acid decarboxylase. Disorders of this enzyme lead
to a deficiency in GABA and subsequently overactivation in the
CNS, as is seen in stiff person syndrome. The GABAA receptor is an
example of an ionotropic receptor, activation of which leads to
opening of chloride channels. The GABAB receptor is an example of
a metabotropic receptor, which is coupled to an inhibitory Gprotein, inhibiting adenylyl cyclase. Baclofen is an example of a
selective GABAB receptor agonist; benzodiazepines act at GABAA
receptors.

Question 73

serotonin–norepinephrine reuptake

inhibitors (SNRIs)

Answer 73

Duloxetine and venlafaxine are serotonin–norepinephrine reuptake
inhibitors (SNRIs): They inhibit reuptake of both serotonin and
norepinephrine by inhibiting serotonin and norepinephrine
transporters, respectively. The SNRIs and tricyclic antidepressants
(TCAs), because they increase both norepinephrine and serotonin,
are useful in the treatment of pain disorders. Unlike the TCAs, the
SNRIs are relatively selective and have little activity at muscarinic,
histaminergic, and α-adrenergic receptors

Question 74

Mirtazapine

Answer 74

Mirtazapine has complex pharmacology; it acts as an antagonist
at presynaptic α2-receptors, increasing release of norepinephrine
and serotonin, and also acts as an antagonist at 5-HT2 and 5-HT3
receptors. Its potent antagonism at histamine receptors accounts
for its sedating effects.

Question 75

antagonism 5-
HT2 receptor

Answer 75

Trazodone and nefazodone act primarily by antagonism at the 5-
HT2 receptor; trazodone was initially used as an antidepressant, but
its primary use today is as a hypnotic (sedative) because it is
highly sedating and little tolerance develops to its sedating effect
over time. An adverse effect that may occur with trazodone
therapy is priapism or prolonged painful erection

Question 76

nonselective monoamine
oxidase inhibitors (MAOIs)

Answer 76

Phenelzine and isocarboxazid are nonselective monoamine
oxidase inhibitors (MAOIs) and are among the oldest
antidepressants, rarely used in clinical practice today due to their
side effect profile. Because nonselective MAOIs block metabolism
of tyramine, found in certain foods such as cheese and wine, a
lethal reaction resulting from hyperadrenergic state can occur with
use of MAOIs, particularly when taken with other agents that
increase serotonin