ELEv ENTH EDITION

LA N G E q &A

PSYCHIATRY
Sean M. Blitzstein, MD
Staff Psychiatrist, Jesse Brow n VA Med ical Center
Director, Psychiatry Clerkship
Clinical Associate Professor of Psychiatry
University of Illinois at Chicago
Chicago, Illinois

N ew York Chicago San Francisco Athens Lond on Mad rid Mexico City
Milan N ew Delhi Singap ore Syd ney Toronto
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 Co nte nts

Contributors ............................................................................................................................................................v

Preface ................................................................................................................................................................. vii

Acknow ledgments ........................................................................................................................................... viii

1. Child and Adolescent Psychiatry ................................................................................................................. 1

Qu estions ........................................................................................................................................................... 1
Answ ers and Explanations ........................................................................................................................... 17

2. Adult Psychopathology ............................................................................................................................... 33

Qu estions ......................................................................................................................................................... 33
Answ ers and Exp lanations ........................................................................................................................... 58

3. Somatic Treatment and Psychopharmacology ........................................................................................ 81

Questions ......................................................................................................................................................... 81
Answ ers and Explanations ......................................................................................................................... 103

4. Psychological Treatment and Management .......................................................................................... 123

Qu estions ....................................................................................................................................................... 123
Answ ers and Exp lanations ......................................................................................................................... 132

5. Legal and Ethical Issues in Psychiatry and Medicine ......................................................................... 141

Qu estions ....................................................................................................................................................... 141
Answ ers and Exp lanations ......................................................................................................................... 154

6. D ifferential D iagnosis and Management ............................................................................................... 165

Qu estions ....................................................................................................................................................... 165
Answ ers and Explanations ......................................................................................................................... 185

7. Practice Test 1 .............................................................................................................................................. 205

Qu estions ....................................................................................................................................................... 205
Answ ers and Explanations ......................................................................................................................... 225

iii
iv Conte nts

8. Practice Test 2 ............................................................................................................................................... 247

Qu estions ....................................................................................................................................................... 247
Answ ers and Explanations ......................................................................................................................... 268

Bibliography ...................................................................................................................................................... 287

Index .................................................................................................................................................................... 291

 Co ntributo rs
Shetal M. Amin, MD
Legacy Com m u nity H ealth Services
Clinical Assistant Professor
Departm ent of Psychiatry and Behavioral
Sciences
Baylor College of Med icine
H ouston, Texas
Jennifer Sprague, MD
Psychiatry Resid ent
Departm ent of Psychiatry
University of Illinois at Chicago
Chicago, Illinois
Kelley A. Volpe, MD
Child and Ad olescent Psychiatry Fellow
Institu te for Ju venile Research
Departm ent of Psychiatry
University of Illinois at Chicago
Chicago, Illinois
Marika Inga Wrzosek, MD
Director, Med ical Stu d ent Ed u cation
Assistant Professor of Clinical Psychiatry
Departm ent of Psychiatry and Behavioral
Med icine
Med ical College of Wisconsin
Milw au kee, Wisconsin
Alexander K. Yuen, MD
Child and Ad olescent Psychiatry Chief Fellow
Institu te of Ju venile Research
Departm ent of Psychiatry
University of Illinois at Chicago
Chicago, Illinois
v
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 Pre fac e

Welcom e to Lange Q&A : Psychiatry, 11th ed ition. It is m y sincere p leasu re to p rovid e you w ith this ed ition
in su p p ort of you r ongoing ed u cation in p sychiatry. Psychiatric research and p ractice are at the forefront of
m ed icine, incorp orating p harm acology, p sychology, sociology, and neu rosciences; the resu lt is a genu ine
biop sychosocial ap p roach to p atient care. Su ch a sizeable integration yield s a broad field in w hich to stu d y
and test. Becau se of this, the 11th ed ition covers the gam u t of top ics, from ad u lt and child p sychiatry, to
psychopharm acology and ethics. All m ajor d iagnoses are covered , w ith the em phasis being on d ifferential
d iagnosis and treatm ent (w hether p sychological or som atic). In fact, this ed ition consists of eight chapters
w ith 810 qu estions, and it has been u pd ated to reflect the Am erican Psychiatric Associations Diagnostic and
Statistical M anual of M ental Disorders, Fifth Edition (DSM -5). As this book is geared tow ard m ed ical stu d ents
stu d ying for their Psychiatry clerkship exam inations, as w ell as for their United States Med ical Licensing
Exam ination (USMLE) Step 2 CK exam ination, each and every qu estion is clinically focu sed com p rising of
a p atient-centered vignette. Consistent w ith the USMLE form at, the answ ers are either m ultip le-choice or
extend ed m atching item s. In ord er to p rom ote self-assessm ent and form ative learning, all answ ers inclu d e
d etailed explanations regard ing why the incorrect choices are flaw ed . A list of references are also includ ed for
those stud ents w ho w ish to further research a particu lar issue.
Finally, a few su ggestions on how best to u se this book. This book shou ld be u sed as a su p p lem ent to
you r p rim ary learning. It neither rep laces read ing a basic text on Psychiatry, nor seeing live p atients d u ring
a rotation. Chap ters 1 throu gh 6 can be u sed to reinforce or com p lem ent certain areas. The final tw o chapters
(Chapters 7 and 8) are practice tests, each consisting of greater than 115 rand om ly ord ered qu estions that
sim u late an actu al board exam ination.

Sean M . Blitzstein, M D

vii
 Acknowle dg me nts

Thank you to m y p atient, su p p ortive, and organized ed itors at

McGraw -H ill. I also sincerely thank m y contributors, and m y prior
m entors and m entees, w ho have all given m e so m u ch. Finally, to
Jackie and Anika, w ho are m y hom e.

Sean M . Blitzstein, M D

viii
 CHAPTER 1
Child and Ado le s c e nt
Ps yc hiatry
Que s tions
DIRECTIONS (Questions 1 through 75): For each of
the multiple-choice questions in this section, select
the lettered answ er that is the one best response in
each case.
Questions 1 and 2
A 15-year-old girl w ith a history of m ajor d epressive
d isord er (MDD) com es to you r p rim ary care office
for a rou tine visit. When you w alk into the exam -
ining room , you notice that she is w ithd raw n w ith
her head bent d ow n. She d isplays p oor eye con-
tact and barely speaks d uring you r interview . She
ad m its that she u ses m arijuana ap proxim ately tw ice
per w eek and cu ts on her arm w hen stressed . H er
m other reveals that she is particu larly w orried as
the girls paternal u ncle com m itted su icid e 10 years
ago. You su spect that she is having a recu rrence of
d ep ressive sym ptom s and are concerned about her
risk for su icid e.
1. Which of the follow ing factors m ost increases
this patients risk of com m itting suicid e?
(A) Cu tting behavior
(B) Gend er
(C) Presence of d ep ression
(D) Relative w ho com m itted su icid e
(E) Su bstance u se
2. Fu rther history is obtained , and the p atient
reveals that she has, in fact, been feeling m ore
d ep ressed recently, w ith d ifficu lty sleep ing,
low ap p etite, fatigu e, and p roblem s con-
centrating. While she had su icid al id eation
d u ring her p reviou s m ajor d ep ressive ep i-
sod e, she d enies it at this visit. At this tim e,
she also d enies self-inju rious u rges. Which of
the follow ing w ou ld be the m ost ap propriate
p lan for treatm ent?
(A) Ad m it her to the hosp ital given her
history and potential risk.
(B) Ask you r p sychiatric colleagu e to assess
her at their next available intake.
(C) Prescribe antid ep ressant m ed ications
w ith a follow -u p ap p ointm ent in
2 w eeks.
(D) Refer her to a social w orker for
p sychotherapy.
(E) Tell the m other you w ill follow u p w ith
her at you r next rou tine visit.
Questions 3 and 4
A m other brings her 7-year-old son to you becau se
she is w orried that he sits u p in bed in the m id d le of
the night and scream s. She says that at those tim es
he is inconsolable but eventually falls back to sleep.
3. Which of the follow ing is the m ost likely
d iagnosis?
(A) Interm ittent exp losive d isord er
(B) N arcolep sy
(C) N ightm are d isord er
(D) N onrap id eye m ovem ent (N REM) sleep
arou sal d isord er, sleep terror typ e
(E) N REM sleep arou sal d isord er,
sleep w alking type
1
2 1: Child a nd Ad ole s c e nt P syc hia try

4. Du ring w hich stage of sleep d o these ep isod es Questions 7 and 8

m ost likely occur?
Parents bring their 6-year-old boy to the clinic at the
(A) Stage 1 requ est of the boys teachers. The teachers rep ort
(B) Stage 2 that he is quiet in class. When he d oes talk, he fre-
(C) Stages 3 to 4 quently m akes errors w ith verb tense. H is parents
(D) Rap id eye m ovem ent (REM) stage recall that his sp eech w as d elayed . On exam ination,
the boy is friend ly and cooperative. H is speech is
(E) Any stage
clear, but he u ses sim ple sentences w ith a lim ited
vocabulary. Otherw ise, his physical and laboratory
Questions 5 and 6
exam ination is norm al.
A 17-year-old girl w ith a history of asthm a p res-
ents for a p hysical exam ination p rior to entering 7. Which of the follow ing is the m ost likely
college. You note that she appears angry. Upon d iagnosis?
fu rther qu estioning, you learn that she has felt irri- (A) Child hood -onset flu ency d isord er
table for the past 6 m onths since breaking up w ith
(B) Langu age d isord er
her boyfriend of 2 years. She says she feels tired all
the tim e and com es hom e from school every d ay, (C) Social (p ragm atic) com m u nication
lies on the cou ch, and w atches You Tu be vid eos. H er d isord er
grad es have d rop p ed becau se she cannot concen- (D) Sp ecific learning d isability
trate. Despite her fatigue, she com plains of d ifficu lty (E) Sp eech sou nd d isord er
sleeping. She has lost 12 lb over the last 6 m onths.
She rep orts that she quit the senior celebration com - 8. By w hat age w ou ld failu re to sp eak 200 w ord s
m ittee, no longer hangs ou t w ith her friend s, can- be m ost consistent w ith a sp eech d elay in this
not im agine things w ill im p rove, and is consid ering patient?
not going to college. H er p hysical and laboratory
(A) 1 year
exam ination is norm al.
(B) 2 years
5. Which of the follow ing m ed ications w ou ld be (C) 3 years
the m ost app ropriate to treat this p atient? (D) 4 years
(A) Carbam azep ine (Tegretol) (E) 5 years
(B) Im ip ram ine (Tofranil)
Questions 9 and 10
(C) Lithiu m
(D) Olanzap ine (Zyp rexa) A 15-year-old boy w ithou t prior p sychiatric his-
(E) Sertraline (Zoloft) tory is on his school concert trip. H e is brought to a
local em ergency room becau se of the acu te onset of
6. Accord ing to the Diagnostic and Statisti- increased anger, agitation, and p aranoia. On inter-
cal M anual of M ental Disorders, Fifth Edition view , he reports feeling u nsafe because a govern-
(DSM -5), w hich of the follow ing sym p tom s m ent agency is spying on him .
in this p atient d ifferentiate her d isord er from
that in an ad u lt? 9. Which of the follow ing tests w ou ld be the
m ost im portant to ord er first?
(A) Anhed onia
(A) Electroencep halogram (EEG)
(B) Decreased concentration
(B) Glu cose tolerance test
(C) Insom nia
(C) Positron em ission tom ograp hy (PET)
(D) Irritable m ood
scan of his head
(E) Weight loss
(D) Thyroid fu nction tests
(E) Urine toxicology screen

10. All approp riate laboratory evaluations and
stu d ies com e back w ithin norm al lim its. Which
of the follow ing d iagnoses w ou ld be m ost
consistent w ith this patients presentation?
(A) Anorexia nervosa
(B) Bip olar d isord er, m anic
(C) Bord erline p ersonality d isord er
(D) Generalized anxiety d isord er
(E) Major d ep ressive d isord er
Questions 11 and 12
An 8-year-old boy is referred to you by a school
nu rse because he has been com p laining of stom ach-
aches every m orning in school. On interview ing the
boys m other, you learn that he d oes not like to go
to school, insists on com ing hom e im m ed iately after
school each d ay, and sleep s in his parents bed at
night. The m other d enies other com p laints.
11. Which of the follow ing is the m ost likely
d iagnosis?
(A) Post-trau m atic stress d isord er (PTSD)
(B) Reactive attachm ent d isord er
(C) Sep aration anxiety d isord er
(D) Social anxiety d isord er (social p hobia)
(E) Sp ecific p hobia
12. Which of the follow ing w ou ld you m ost likely
find in this p atients history?
(A) Low levels of p arental control
(B) Parent w ith an anxiety d isord er
(C) Parents w ith a w arm and accep ting style
(D) Secu re attachm ent
(E) Tem p eram ent characterized by
sociability and extroversion
Questions 13 and 14
A 16-year-old boy is brou ght to the p ed iatric em er-
gency d ep artm ent by his grand m other w ho rep orts
he is not acting like him self. H e rep orts that he
feels incred ibly great and d oes not need a d octor
becau se he has p ow ers to heal him self of all sickness.
H e sp eaks rapid ly and his grand m other rep orts he
has not slept m ore than 6 hou rs over the p ast 3 d ays.
Que s tions : 415 3
She rep orts that he ap pears extrem ely revved up
and hyp eractive.
13. Which of the follow ing is the m ost likely
d iagnosis?
(A) Attention-d eficit/ hyp eractivity d isord er
(ADH D)
(B) Bip olar d isord er, m ost recent ep isod e
m anic
(C) Major d ep ressive d isord er w ith
p sychotic featu res
(D) Panic d isord er
(E) Schizop hrenia
14. Ingestion of w hich of the follow ing su b-
stances w ou ld m ost likely bring abou t sim ilar
sym ptom s?
(A) Alcohol
(B) Cannabis
(C) Cocaine
(D) H eroin
(E) Phencyclid ine (PCP)
15. A 9-year-old boy w alks into you r office
accom panied w ith his mother. They are argu ing
abou t his w anting a new portable vid eo gam ing
system . H is m other, exasp erated w ith her sons
behavior, tells you that they w ere late becau se
it took him a long tim e to finally agree to get
into the car to come to the appointm ent w ith
you. Alone w ith you in you r office, he appears
irritated and refu ses to answ er your questions
or look up from his lap. After 10 minutes, he
tells you about the annoying kid s in his
class and how they mad e m e get in trouble.
Fu rther history from the m other reveals that,
d espite the above behavior, he has never been
violent or d estructive, and he has not had any
legal problems. Which of the follow ing is the
m ost likely d iagnosis?
(A) Agorap hobia
(B) Attention-d eficit/ hyp eractivity d isord er
(ADH D)
(C) Cond u ct d isord er
(D) Generalized anxiety d isord er (GAD)
(E) Op p ositional d efiant d isord er (ODD)
4 1: Child a nd Ad ole s c e nt P syc hia try
Questions 16 through 18
A 15-year-old girl w ho is a com p etitive figu re
skater presents w ith concerns about her w eight. She
believes that she w ou ld be a better skater if she cou ld
lose w eight and feels very u p set and fru strated that
she has failed in her attem pts. The girl relu ctantly
ad m its that she som etim es eats a w hole lot of food
at one tim e su ch as a qu art of ice cream , a large bag
of potato chips, and a jar of peanu t butter. You also
notice abrasions on the back of her right hand .
16. Which of the follow ing opening statem ents
w ou ld be the m ost ap p rop riate?
(A) Tell m e abou t the scratches on you r
hand .
(B) Ive noticed the cu ts on you r hand . Are
you trying to hu rt you rself?
(C) H ow d id the scratches hap p en?
(D) I see you have scratches on you r hand .
Do you have a cat?
(E) Som etim es I see girls w ho m ake
them selves throw up. H ave you ever
d one that?
17. Which of the follow ing laboratory abnorm ali-
ties w ould you m ost likely find in this patient?
(A) Elevated iron
(B) Elevated p rotein
(C) H yp erchlorem ia
(D) H yp okalem ia
(E) H yp onatrem ia
18. Which of the follow ing typ es of p sychother-
ap y w ould likely be the m ost effective for this
p articular p atient?
(A) Cognitive-behavioral therap y
(B) Fam ily therap y
(C) Grou p therap y
(D) Psychoanalysis
(E) Psychod ynam ic p sychotherap y
Questions 19 through 21
An 8-year-old boy w ith a history of major depressive
d isorder (MDD) treated w ith fluoxetine (Prozac) is
brought to the emergency department after running
into the street in front of a car on the w ay home from
school. H e is physically unharmed , but refused to
speak to the emergency room d octor. You are asked
to consult as you are on your psychiatry rotation. The
emergency room doctor is suspicious that the boys
behavior reflected und erlying suicid al impulses.
19. Which of the follow ing op ening statem ents
w ou ld be the m ost valu able in facilitating the
boys d iscu ssion of the situ ation?
(A) You su re w ere lu cky the car sw erved
at the last m inu te.
(B) You w erent trying to actu ally get hit
by the car, w ere you ?
(C) What were you thinking w hen you ran
into the street?
(D) It sou nd s like qu ite a d ay. Can you tell
m e abou t w hat hap pened after school
tod ay?
(E) Child ren w ho try to hu rt them selves
are very confu sed . Are you confu sed ?
20. Which of the follow ing sym p tom s of MDD
w ou ld be m ore likely in this p atient com p ared
to an ad olescent w ith MDD?
(A) Dru g u se
(B) H op elessness
(C) H yp ersom nia
(D) Psychom otor agitation
(E) Weight change
21. Which of the follow ing w ou ld be this child s
m ost likely m ethod of attem p ting suicid e?
(A) Firearm s
(B) H anging
(C) Ju m p ing from a significant height
(D) Stabbing
(E) Su bstance ingestion
22. An 11-year-old boy w ith enu resis presents
to the clinic for rou tine follow -up. H is bed -
w etting had not resp ond ed to behavioral
interventions, so you had p reviou sly initiated
treatm ent w ith intranasal d esm opressin
(Dd avp ) after com p letion of a fu ll p hysical
and laboratory exam ination. Which of the
 Que s tions : 1627 5

follow ing signs/ sym ptom s w ou ld be the m ost m ake od d , rep etitive m ovem ents w ith her hand s,
likely ad verse effect? and p refers to line her toys u p . She becom es acu tely
d istressed w hen rou tines are changed . The child s
(A) H ead ache
physical exam ination is u nrem arkable, bu t you note
(B) H ypotension that she d oes not seem to cry w hen she trip s over
(C) Liver toxicity you r exam ination stool, keep ing her attention on
(D) Sed ation aligning you r colored p encils.
(E) Trem or
25. Which of the follow ing is the m ost likely
Questions 23 and 24 d iagnosis?

A 9-year-old boy w ith a history of p anic d isord er (A) Au tism sp ectru m d isord er (ASD)
treated w ith cognitive-behavioral therapy is brought (B) Intellectu al d isability (ID)
to your office by his m other becau se he has been (C) Rett synd rom e
irritable and d ep ressed . On p hysical exam ination, (D) Selective m u tism
the boy appears d epressed bu t otherw ise norm al. (E) Social (p ragm atic) com m u nication
Laboratory exam ination is norm al. d isord er
23. What w ou ld be the likelihood of this p atient 26. The m other asks you abou t p rognosis for her
having a com orbid m ajor d ep ressive d isord er d au ghter s cond ition. Which of the follow ing
(MDD)? is the m ost p ositive p rognostic factor?
(A) 5% (A) Com orbid ep ilep sy
(B) 15% (B) Engagem ent in social skills training
(C) 25% (C) Fu nctional language by 5 years of age
(D) 50% (D) Intellectu al d isability
(E) 75% (E) Presence of catatonic sym ptom s
24. After a thorou gh history and m ental statu s Questions 27 and 28
exam ination, you d iagnose the boy w ith MDD
and d ecid e to initiate treatm ent w ith flu ox- A 12-year-old boy is referred by the cou rt for evalu -
etine. You inform the boy and his m other of ation. H e skip s school, stays ou t late at night, and
possible ad verse effects of flu oxetine. Which verbally abu ses his parents. H e has run aw ay from
of the follow ing w ou ld be the m ost likely sid e hom e on three sep arate occasions, p rom p ting his
effect? p arents to call the p olice. H e has been cau ght shop-
lifting and has been in nu m erou s p hysical fights
(A) H yp otension
w ith his p eers.
(B) Liver toxicity
(C) N au sea 27. Up on fu rther history, w hich of the follow ing
(D) Sed ation w ou ld m ost likely be fou nd in this p atient?
(E) Weight gain (A) Absence of a biological father
(B) Absence of a biological m other
Questions 25 and 26
(C) Mother w ith an anxiety d isord er
A 30-month-old girl is brou ght to the clinic by her (D) Patient being an only child
m other for a rou tine visit. The m other tells you that (E) Parents w ho d o not u se corp oral
the girl seem s to avoid affection, often d oes not look p u nishm ent
her in the eye, has stopp ed speaking in preschool,
and d oes not really engage w ith her p reschool peers
nor w ith her 5-year-old brother. She continu es to
6 1: Child a nd Ad ole s c e nt P syc hia try
28. Which of the follow ing p ersonality d isord ers
is this boy m ost likely to d evelop ?
(A) Antisocial p ersonality d isord er
(B) Avoid ant p ersonality d isord er
(C) Paranoid p ersonality d isord er
(D) Schizoid p ersonality d isord er
(E) Schizotyp al p ersonality d isord er
Questions 29 and 30
A 10-year-old girl w ho has recently been d iagnosed
w ith d iabetes m ellitu s typ e I is referred to you by
her ped iatrician for an evalu ation. You notice that
she seem s sad . H er parents are concerned about her
being d ep ressed . Consid eration is given for d iag-
nosing ad justm ent d isord er w ith d epressed m ood
versu s m ajor d epressive d isord er (MDD).
29. Which of the follow ing criteria for the d iagno-
sis of ad ju stm ent d isord er m ost d istinguishes
it from MDD?
(A) Sym p tom s cau se m arked d istress or
significant im pairm ent in fu nctioning.
(B) Sym p tom s d evelop follow ing an
id entifiable stressor.
(C) Sym p tom s d evelop w ithin 3 m onths of
the onset of the stressor.
(D) Sym p tom s d o not p ersist for m ore than
6 m onths follow ing term ination of the
stressor.
(E) Sym p tom s d o not rep resent norm al
bereavem ent.
30. Approxim ately w hat p ercentage of child ren
w ho are d iagnosed w ith d iabetes m ellitu s
typ e I d evelop ad justm ent d isord er follow ing
their m ed ical d iagnosis?
(A) 1%
(B) 5%
(C) 10%
(D) 33%
(E) 75%
Questions 31 and 32
A 9-year-old boy is referred to you for evaluation
because of repeated teasing at school related to his
inappropriate peer interactions. The teachers report
that at any time, w ithout w arning, the boy w ill make a
d isruptive sound or shout out in class. They d escribe
him as polite and neat but restless and jumpy.
31. Which of the follow ing is the m ost likely
d iagnosis?
(A) Cond u ct d isord er
(B) Op p ositional d efiant d isord er
(C) Panic d isord er
(D) Sep aration anxiety d isord er
(E) Tou rette d isord er
32. Which of the follow ing m ed ications w ou ld be
the m ost appropriate to prescribe initially?
(A) Bu p rop ion (Wellbu trin)
(B) Clonid ine (Catap res)
(C) H alop erid ol (H ald ol)
(D) Paroxetine (Paxil)
(E) Venlafaxine (Effexor)
Questions 33 and 34
A 7-year-old boy w ith leukem ia is referred to you
becau se of concerns abou t his m ood . H is p ar-
ents rep ort that he flu ctu ates betw een app earing
d epressed and acting angry. At tim es, he plays qui-
etly in his room , bu t at other tim es he d isp lays anger
outbu rsts, often hitting his 4-year-old brother. H is
m other ad m its that she has d ecreased her expecta-
tions of him , and feels that since he is ill he should
not receive any p u nishm ents.
33. Which of the follow ing m ethod s w ould be the
m ost effective w ay to engage his m other in a
d iscussion regard ing the role of her actions on
the boys behavior?
(A) Acknow led ge her gu ilt and anxiety
abou t her sons illness and explain the
im p ortance of p rovid ing lim its and
stru cture for his em otional w ell-being.
(B) Em p athize w ith the trau m a of having a
sick child .
(C) Refer her to a p arent su p p ort grou p .
(D) Sit qu ietly and m ake no com m ents
abou t her p arenting style.
(E) Tell her that treating her son like a baby
is hu rting him em otionally.

34. It is d eterm ined that the boy is su ffering from
m ajor d epressive d isord er. You d iscu ss both
p sychopharm acologic and psychotherapeu tic
treatm ent options, but she is concerned abou t
his ongoing leukem ia treatm ent. Which of
the follow ing approaches w ou ld be the m ost
ap propriate regard ing treating both his leu ke-
m ia and m ajor d epression?
(A) Treat the d ep ression p rior to the
leu kem ia.
(B) Treat the d ep ression after the leu kem ia.
(C) Treat the d ep ression concu rrently w ith
the leu kem ia.
(D) Treat the leu kem ia first and the
d epression w ill resolve.
(E) Treat the leu kem ia as treating the
d epression w ill not be effective in the
setting of a m alignancy.
Questions 35 and 36
An 8-year-old boy p resents to you r office for a rou -
tine visit. One m onth earlier, you d iagnosed him
w ith Tou rette d isord er and p rescribed m ed ication.
H e and his p arents rep ort that the m ed ication has
been help fu l.
35. Which of the follow ing d isord ers w ou ld this
p atient be m ost likely to d evelop ?
(A) Au tism sp ectru m d isord er
(B) Bip olar d isord er
(C) Langu age d isord er
(D) Obsessive-com p u lsive d isord er (OCD)
(E) Sep aration anxiety d isord er
36. Prior infection w ith w hich of the follow ing
w ou ld be m ost likely fou nd in the history of
this patient?
(A) Haemophilus influenzae
(B) Influ enza viru s
(C) Parainflu enza viru s
(D) Resp iratory syncytial viru s
(E) Streptococcus pyogenes
Que s tions : 2838 7
Questions 37 and 38
An 8-year-old boy w ith a family history of tic d isor-
d ers is referred to you for an evaluation of behav-
ioral d ifficulties in school. H is teachers report that he
is unable to sit still, constantly fid gets, and is unable
to complete class w ork becau se he is so easily d is-
tracted . When he com pletes his w ork, it is often d one
carelessly and is frequently not tu rned in. The teach-
ers also note that he blurts ou t replies and has a hard
tim e d u ring quiet tim e. The boys m other reports that
he has alw ays had a lot of energy. Preparing to leave
for school in the m orning is challenging because of
her sons d isorganization and forgetfulness. Other-
w ise, she has no complaints. She d enies that her son
prod uces any repetitive m ovem ents or sou nd s.
37. Which of the follow ing is the m ost likely
d iagnosis?
(A) Attention-d eficit/ hyp eractivity d isord er
(ADH D)
(B) Bip olar d isord er
(C) Cond u ct d isord er
(D) Op p ositional d efiant d isord er
(E) Unsp ecified d isru p tive behavior
d isord er
38. The p atient is su bsequ ently treated for the
above cond ition. H e retu rns to an app oint-
m ent after several w eeks, now w ith rep etitive
grim acing and blinking m ovem ents, w hich
have resu lted in his getting teased in school.
Which of the follow ing classes of m ed ications
is m ost likely to be resp onsible?
(A) Benzod iazep ines
(B) D 2 antagonists
(C) Monoam ine oxid ase inhibitors (MAOIs)
(D) Selective serotonin reu p take inhibitors
(SSRIs)
(E) Stim u lants
Questions 39 and 40
A 6-year-old boy is referred to you by his school to
evalu ate his d ifficu lty w ith keep ing u p w ith read ing
and m ath d esp ite his above average intelligence. It
is su sp ected that he su ffers from a learning d isord er,
so further testing and evaluation is ind icated .
8 1: Child a nd Ad ole s c e nt P syc hia try

39. Which of the follow ing find ings w ou ld be
required for a d iagnosis of sp ecific learning
d isord er w ith im p airm ent in read ing?
(A) The child has an above average IQ
(intelligence qu otient) bu t below
average read ing achievem ent.
(B) The child has an average IQ and below
average read ing achievem ent.
(C) The child s read ing achievem ent is
substantially below the child s IQ.
(D) The child s read ing achievem ent is
substantially above the child s IQ.
(E) The child s read ing achievem ent and IQ
are both below average.
40. What w ou ld be the ap p roxim ate risk of this
child having a com orbid psychiatric d isord er?
(A) 5%
(B) 10%
(C) 25%
(D) 50%
(E) 75%
Questions 41 and 42
(C) Methylp henid ate (Ritalin)
(D) Paroxetine (Paxil)
(E) Trazod one (Desyrel)
Questions 43 through 45
A 10-year-old boy is referred to you becau se his
ped iatrician su spects that he m ay have attention-
d eficit/ hyperactivity d isord er (ADH D). After a
thorou gh history, physical exam ination, and labora-
tory investigation you m ake the d iagnosis of ADH D.
After d iscu ssing the ad verse effects of m ed ications,
you p rescribe m ethylp henid ate to be taken in the
m orning and at lu nch on school d ays.
43. Which of the follow ing w ou ld be the m ost
likely sid e effect of m ethylp henid ate?
(A) H yp otension
(B) Insom nia
(C) Liver toxicity
(D) Trem or
(E) Weight gain
44. What is the likelihood that this patient w ill sig-
nificantly benefit from the m ethylp henid ate?

An 8-year-old child is referred to you for an evalu- (A) 10%

ation of bed -w etting. Several behavioral interven- (B) 25%
tions have been attem pted , inclu d ing eliminating (C) 33%
fluid intake in the evening, sched uled aw akenings at (D) 50%
night to use the bathroom, and a urine alarm (a bell (E) 70%
and pad ). These techniqu es have been u nsu ccessful,
and the child continues to u rinate in bed every night. 45. Despite education and reassurance, the mother
remains opposed to stimulant medications but
41. What is the likelihood of this p atient having a still w ishes her son to receive pharmacologic
com orbid m ental illness? treatment for his ADH D. Which of the follow -
(A) 5% ing med ications w ould be the most appropriate
(B) 10% to prescribe?
(C) 20% (A) Arip ip razole (Abilify)
(D) 50% (B) Atom oxetine (Strattera)
(E) 75% (C) Citalop ram (Celexa)
(D) Mixed am p hetam ine salts (Ad d erall)
42. Which of the follow ing m ed ications w ou ld be (E) Valp roic acid (Dep akote)
the m ost ap propriate to prescribe to treat this
p atient? Questions 46 and 47
(A) Benztrop ine (Cogentin)
Du ring a rou tine office visit, the m other of a
(B) Desm op ressin (Dd avp ) 37-m onth-old girl tells you that she is concerned
 Que s tions : 3951 9

abou t her d au ghters behavior. Since the birth of 48. In which of the following areas would you most
her son 4 m onths earlier, the m other states that her likely expect additional difficulties in this patient?
d aughter has been m ore irritable and angry. The
(A) Attention
child has told her m other that she d oes not w ant the
baby anym ore and to take him back. The m other is (B) Fine m otor skills
esp ecially concerned becau se her d au ghter tried to (C) Gross m otor skills
bite the baby the w eek before. (D) Im aginary p lay
(E) Potty training p rogress
46. Which of the follow ing statem ents w ou ld be
the m ost approp riate response to this m other? 49. Which of the follow ing qu alities w ou ld be
(A) If you sim p ly ignore you r d au ghters m ost associated w ith a m ore favorable p rog-
behavior, it w ill p ass. nosis in this child ?
(B) It is u nd erstand able that you r d au ghter (A) Easily toilet trained
is angry and exp eriences jealou sy w ith (B) Interested in m echanical toys
the new baby joining the fam ily. (C) Organized in p lay
(C) The next tim e she tries to bite him , you (D) Recip rocal conversation
should bite her back so she know s how
(E) Reciting songs and p oem s from m em ory
it feels.
(D) Tell you r d au ghter she is being a very Questions 50 and 51
bad girl and you w ont love her if she
bites the baby. A 17-year-old girl com es to you r office for a rou tine
(E) Tell you r d au ghter that she need s to visit. She states that she feels fine and offers no com -
love the baby and be a w ond erfu l big p laints. On p hysical exam ination, you find that her
sister. w eight is 92 lb and her height is 65 in. One year ear-
lier, her w eight w as 126 lb, and height 65 in. After
47. Which of the follow ing tasks w ou ld this girl fu rther d iscu ssion, you learn that she is terrified of
be able to p erform at her cu rrent age? gaining w eight and believes that she is fat and need s
to lose m ore w eight. She ad d itionally reports that
(A) Acknow led ge her angry and she has not m enstru ated in the past 6 m onths.
com petitive feelings tow ard her sibling.
(B) Be able to state her age and gend er. 50. Which of the follow ing laboratory abnorm a-
(C) Cou nt to 50. lities are you m ost likely to find in this p atient?
(D) Recognize that w ater p ou red from one (A) H yp ercholesterolem ia
glass into another of a d ifferent size is
(B) H yp erkalem ia
the sam e volu m e.
(C) H yp ocarotenem ia
(E) Rid e a bicycle.
(D) Increased thyroid -stim u lating horm one
(TSH )
Questions 48 and 49
(E) Leu kocytosis
A 4-year-old boy is referred to you for evalu ation
becau se he has p oor social related ness. Up on inter- 51. Which of the follow ing com p lications w ould
view , he appears healthy and w ell-kem pt. H e grabs be the m ost likely ind ication for ad m itting this
you r office key off you r d esk. At you r office d oor, p atient to the hosp ital?
he takes the key and locks and u nlocks you r d oor
rep eated ly. Desp ite attem p ts to red irect and d istract (A) Anem ia
him , he rem ains preoccu pied w ith this task. After (B) Arrhythm ia
abou t 10 m inu tes, you attem p t to take the key aw ay (C) Brad ycard ia
from him and he becom es extrem ely u p set, m aking (D) H yp otension
an insistent, p iercing cry. (E) Lanu go
10 1: Child a nd Ad ole s c e nt P syc hia try
Questions 52 and 53
An 8-m onth-old boy is brought to the clinic by his
m other. She com plains that her son has been expe-
riencing scream ing and crying fits w hen she leaves
him w ith a babysitter. She says that in the p ast he
d id not object to being left w ith a babysitter and asks
you w hy he becom es so u p set now , and w hat she
can d o about it.
52. Which of the follow ing statem ents w ou ld be
the m ost app ropriate response?
(A) This behavior is characteristic of
au tistic child ren.
(B) It is p ossible that you r son has
separation anxiety d isord er.
(C) This behavior su ggests that you re not
spend ing enou gh tim e w ith you r son.
(D) It sou nd s as thou gh you r son is overly
attached to you .
(E) This behavior is norm al at you r sons
age and w ill p ass w ith tim e.
53. Which of the follow ing d iagnoses w ou ld be
m ost ap prop riate if the boy in the p reviou s
qu estion (Qu estion 52) w ere an 8-year-old boy
w ith sim ilar behavior?
(A) Agorap hobia
(B) N orm al behavior
(C) Obsessive-com p u lsive d isord er
(D) Sep aration anxiety d isord er
(E) Social anxiety (social p hobia)
Questions 54 and 55
A 10-year-old boy is referred to you d u e to extrem e
d ifficulties in school. H e has been held back a grad e
and is still not p assing his classes. Du ring the cou rse
of your evalu ation, you learn that the boy hears
voices telling him that he is stupid and to leave the
classroom . Afraid to d isobey, he goes to the bath-
room frequ ently. H e also has d ifficu lty falling asleep
at night becau se the voices keep him aw ake. In ad d i-
tion, you learn that the boy believes others can read
his thou ghts. Physical and laboratory exam inations
are norm al. You su sp ect that the boy m ay be su ffer-
ing from schizop hrenia.
54. Which of the follow ing item s in his history
w ou ld be m ost consistent w ith you r p rovi-
sional d iagnosis?
(A) Alw ays social and ou tgoing
(B) Father w ith schizotyp al p ersonality
d isord er
(C) Parents getting d ivorced
(D) Recently transferred schools
(E) Recently u sed m ariju ana
55. Which of the follow ing featu res w ou ld ind i-
cate a poorer p rognosis in this patient?
(A) Acu te onset
(B) Affective sym p tom s
(C) Good p rem orbid ad ju stm ent
(D) Onset before the age of 13 years
(E) Well-d ifferentiated sym p tom s
Questions 56 through 58
A 9-year-old girl w ith a fam ily history of bipolar
d isord er is referred to you by her school because of
d isruptive behavior in class that has been w orsen-
ing over the past 3 m onths. H er teachers report that
her energy level is high, and she is m arked ly more
d istractible. She is also sleeping more poorly and is
increasingly m ore intrusive into her siblings per-
sonal space. Both attention-d eficit/ hyp eractivity d is-
ord er (ADH D) and a m anic episod e are consid ered .
56. Which of the follow ing sym p tom s w ou ld
be m ore consistent w ith ADH D rather than
m ania?
(A) Distractibility
(B) Im p u lsivity
(C) Low self-esteem
(D) Motoric hyp eractivity
(E) Pressu red sp eech
57. If this child s school is u nable to m anage her
behavior in her classroom d esp ite ou tp atient
treatm ent and m ed ication, w hich of the fol-
low ing long-term op tions w ou ld be the m ost
optim al school placem ent?
(A) H om e schooling
(B) Parochial school
 Que s tions : 5263 11

(C) School for child ren w ith learning Questions 61 and 62

d isabilities
A 12-year-old boy w ith Tou rette d isord er com es to
(D) Resid ential treatm ent
you r office for a rou tine visit. Tw o w eeks earlier,
(E) Therap eu tic d ay school you had p rescribed clonid ine for his illness. The
boy rep orts that his tics have su bsid ed slightly since
58. Further history and evaluation over time result starting the clonid ine, bu t he com plains abou t the
in the d iagnosis of bipolar d isord er, most m ed icine.
recent episod e manic. Which of the follow ing
med ications w ou ld be the m ost appropriate 61. Which of the follow ing ad verse effects is this
treatm ent? boy m ost likely exp eriencing?
(A) Bu p rop ion (Wellbu trin) (A) Dry m ou th
(B) Du loxetine (Cym balta) (B) H yp otension
(C) Methylp henid ate (Ritalin) (C) N au sea
(D) Mixed am p hetam ine salts (Ad d erall) (D) Sed ation
(E) Valp roic acid (Dep akote) (E) Trem or

Questions 59 and 60 62. The p arents bring in the boys 7-year-old

An 8-year-old boy is brou ght to you r office by his brother for evalu ation. After fu rther history
m other for evaluation of an u pp er resp iratory infec- is obtained , he is d iagnosed w ith attention-
tion. The m other m entions that her son has started deficit/ hyperactivity d isord er (ADHD). Which
w etting the bed again. In ad d ition, she m entions of the follow ing classes of med ications w ould
that the boys grand m other d ied recently and w on- be the most appropriate choice for the brother?
d ers if this is affecting him . (A) Antip sychotic
(B) Monoam ine oxid ase inhibitor (MAOI)
59. At w hich of the follow ing ages w ou ld a child
(C) Serotonin-sp ecific reu p take inhibitor
norm ally be able to ap preciate that d eath is
(SSRI)
irreversible?
(D) Stim ulant
(A) 2 years (E) Tricyclic antid epressant (TCA)
(B) 3 years
(C) 5 years 63. A 6-year-old boy is brou ght to the em ergency
(D) 7 years d ep artm ent by his m other, w ho reports that
(E) 12 years he w as p laying on som e step s in front of the
hou se w hen he slip p ed and fell. She tells
60. Which of the follow ing d efense m echanism s you that she is concerned that he m ight have
is the boy m ost likely em p loying w hen he is broken his arm . An x-ray of the boys arm
w etting the bed ? show s a fracture of the u lna, as w ell as signs of
several old fractures of varying ages. Which of
(A) Acting ou t the follow ing is the m ost app rop riate cou rse
(B) Denial of action?
(C) Regression (A) Recom m end calcium su pp lem ents and a
(D) Repression m ultivitam in d aily.
(E) Som atization (B) Refer the boy to an orthoped ist for
fu rther evalu ation.
(C) Set the cu rrent broken bone in a cast
and have the boy see his p ed iatrician for
follow -u p care.
12 1: Child a nd Ad ole s c e nt P syc hia try
(D) Tell the boy that you notice that he has
had m u ltip le broken bones and ask him
how each of these fractures happened .
(E) Tell the m other that you notice that
the boy has had m ultiple broken bones
and recom m end that she lim it the boys
sports activities.
64. Th e m oth er of a 6-year-old boy calls an d
asks you for ad vice. She says th at h er son
still su cks his th u m b, an d sh e is concerned
abou t th is beh avior. Wh ich of th e follow -
in g su ggestion s for h er to d o is th e m ost
ap p rop riate?
(A) Ask the d entist to construct a m outh
ap p liance that w ill d eter su cking.
(B) Coat her sons thum b in hot pepper
sauce.
(C) Give him gu m frequ ently.
(D) Ignore the behavior.
(E) Im p lem ent a behavioral system to
rew ard stop p ing.
Questions 65 and 66
A 14-year-old girl presents to her pediatrician com-
plaining that she has been freaking out. The girl
describes episodes of shaking, gasping for air, and
feeling like she is going to die. The feelings intensify
for a few minutes and resolve spontaneously. These
episodes have occurred at various times, in various sit-
uations, and the girl is worried that she is going crazy.
A complete history and physical examination does not
reveal any further relevant symptoms or signs.
65. Which of the follow ing is the m ost app rop riate
p harm acologic treatm ent?
(A) Arip ip razole
(B) Carbam azep ine
(C) Du loxetine
(D) Sertraline
(E) Valp roic acid
66. Prior to prescribing m ed ications, w hich of the
follow ing shou ld the p ed iatrician ord er next?
(A) Electrocard iogram (ECG)
(B) Electroencep halogram (EEG)
(C) N eu rology consu lt
(D) Pu lm onary function tests
(E) Routine laboratory stu d ies
67. A 5-year-old girl d iagnosed w ith lu pu s is seen
by her fem ale p ed iatrician for a rou tine visit.
After retu rning hom e from the clinic, the girl
asks her friend to p lay d octor. Which of the
follow ing d efense m echanism s best d escribes
this behavior?
(A) Displacem ent
(B) Dissociation
(C) Id entification
(D) Rationalization
(E) Reaction form ation
Questions 68 and 69
A 10-year-old girl w ith a history of asthm a is
brou ght to the clinic after a recent increase in her
asthm a sym p tom s. Du ring the visit, you learn that
she is being physically beaten by her m others boy-
friend on a regu lar basis.
68. Und er w hich of the follow ing circu m stances
d oes the law requ ire m and atory rep orting by
a p hysician of su sp ected child abu se?
(A) In all cases
(B) Only in cases in w hich the child show s
behavioral m anifestations of abu se.
(C) Only w hen consent of a p arent or
gu ard ian is obtained .
(D) Only w hen the p hysician believes it is in
a child s best interest.
(E) Only w hen the p hysician has exam ined
all child ren in the fam ily.
69. Which of the follow ing m anifestations w ou ld
be the m ost likely ou tcom e of the abu se?
(A) Aggression
(B) Dissociative d isord er
(C) Generalized anxiety d isord er
(D) Major d ep ressive d isord er
(E) Post-trau m atic stress d isord er

70. A 4-year-old boy is referred to you becau se he
w ill not sp eak in p reschool. Over the cou rse of
abou t 2 m onths, he grad u ally stop ped talking.
H is m other rep orts that he initially objected
to going to preschool, but now no longer
com plains. She states that at tim es her son is
qu iet and stays in his room , bu t that she has
not otherw ise noticed a significant change in
his sp eech or behavior. Which of the follow ing
is the m ost likely d iagnosis?
(A) Major d ep ressive d isord er (MDD)
(B) Persistent d ep ressive d isord er
(d ysthym ia)
(C) Selective m u tism
(D) Sep aration anxiety d isord er
(E) Social anxiety d isord er (social p hobia)
71. A 2-year-old boy is referred to you for evalu -
ation d u e to the su sp icion that the child is
the victim of abu se second ary to factitiou s
d isord er im posed by another. Which of the
follow ing fam ily m em bers is the m ost likely
p erp etrator fabricating the illness?
(A) Father
(B) Brother
(C) Mother
(D) Sister
(E) Uncle
72. A fru strated m other brings her 14-year-old son
to a child p sychiatrist after he is expelled from
three high schools in 1 year. She reports the
boy has tried tw ice to set his school on fire, has
slashed school bus tires, and has broken into
the principals office to steal athletic trophies.
In ad d ition, he has been su sp end ed nu m er-
ou s tim es for getting into fights w ith other
stu d ents. She shu d d ers and tearfully relates
that she recently caught him singeing one of
the fam ily cats w ith a cigarette butt. Which
of the follow ing p ersonality d isord ers is this
boy m ost at risk of d evelop ing in the fu tu re?
(A) Antisocial
(B) Bord erline
(C) H istrionic
(D) Obsessive-com p u lsive
(E) Schizotyp al
Que s tions : 6475 13
73. An 8-year-old boy is brou ght in by his m other
w ho com p lains that she cannot get her son to
listen to her. She is fru strated becau se he fre-
quently ignores her requ ests and instru ctions.
Consid eration is given tow ard the d iagnosis of
oppositional d efiant d isord er (ODD). Which
of the follow ing featu res w ou ld best sup port
the d iagnosis in this child ?
(A) Aggression to p eop le
(B) Dep ressive sym p tom s
(C) Disobed ience tow ard teachers
(D) Lack of p articip ation in tasks requ iring
attention
(E) Violation of ru les
74. A 13-year-old girl is seen by her p sychiatrist
1 year after an au tom obile accid ent. She d em -
onstrates intact langu age ability and com plex
m otor skills. She has no id entifiable abnor-
m alities in the perception of stim uli, bu t she
has lost the ability to read since the accid ent.
Which of the follow ing d eficits is she m ost
likely d em onstrating?
(A) Agnosia
(B) Alexia
(C) Anom ia
(D) Ap hasia
(E) Ap raxia
75. A 10-year-old girl w ithou t significant m ed ical
history is brou ght by her father to the p ed ia-
trician for evaluation. Over the past school
year, she has been having increasing d ifficu l-
ties going to sleep. Althou gh she has alw ays
had bed tim e ritu als, they have extend ed in
com plexity and length. Most of her tim e in
the evening is now spent going arou nd the
hou se nu m erou s tim es, locking and u nlock-
ing the d oors and w ind ow s. While she know s
the chances of a bu rglary are slim , she is
extrem ely anxiou s abou t her safety, and she
cant stop the u rges to perform these behav-
iors. As a resu lt, she only obtains 5 hou rs of
sleep, and she has been falling asleep in class
w ith d im inishing grad es. Which of the follow -
ing therap eu tic interventions is consid ered the
first-line treatm ent for this d isord er?
14 1: Child a nd Ad ole s c e nt P sychia try

(A) Cognitive-behavioral therapy (CBT) interp reting social cu es and u tilizes less com -
(B) Fam ily therapy p lex sp oken langu age, is able to retain basic
(C) Grou p therap y langu age for social com m u nication. H e can
care for his basic personal need s after exten-
(D) Short-term psychod ynam ic therapy
sive teaching, bu t w ou ld eventu ally requ ire
(E) Supp ortive therapy consid erable su pport from co-w orkers and
sup ervisors to m anage responsibilities in the
D IRECTION S (Questions 76 through 93): The fol- fu tu re.
low ing group of numbered items are preceded by
a list of lettered options. For each question, select
the one lettered option that is most closely asso- Questions 80 through 83
ciated w ith it. Each lettered option may be used Match the m ost likely d isord er w ith the appropriate
once, multiple times, or not at all. p atient.

Questions 76 through 79 (A) Anorexia nervosa

(B) Au tism sp ectru m d isord er
Match the severity level of intellectual d isability w ith
(C) Bu lim ia nervosa
the patients ad aptive functioning.
(D) Binge eating d isord er
(A) N o intellectu al d isability (E) Illness anxiety d isord er
(B) Mild intellectu al d isability (F) Interm ittent exp losive d isord er
(C) Mod erate intellectu al d isability (G) Obsessive-com p u lsive d isord er
(D) Severe intellectu al d isability (H ) Panic d isord er
(E) Profou nd intellectu al d isability (I) Pica
(J) Pyrom ania
76. A 14-year-old boy w ho has lim ited attainm ent
of conceptual skills, has sp oken language lim - (K) Tou rette d isord er
ited to single w ord s or p hrases, requ ires su p - (L) Trichotillom ania
p ort for all activities of d aily living, requ ires
sup ervision at all tim es, and w ho cannot m ake 80. A 14-year-old girl w ith ep isod es of palpita-
resp onsible d ecisions regard ing the w ell-being tions, chest p ain, shortness of breath, and
of others. d iaphoresis w ho has a norm al physical and
laboratory exam inations.
77. An 8-year-old girl w ho has no obviou s d eficits
in learning, is equ ally m atu re as her p eers, is 81. A 10-year-old overw eight girl feels a loss of
able to perform d aily living tasks w ithout su p - control w hen she qu ickly consum es large
p ort, and has sou nd ju d gm ent. am ou nts of food , d enies heavy exercise, vom -
iting or laxative u se afterw ard s, and feels
significant guilt and sham e regard ing her
78. An 11-year-old boy w ho has d ifficu lties in
behavior.
acad em ic skills of w riting, read ing, and m ath,
is im m atu re in social situ ations, and w ho
has d ifficulties w ith regu lating em otions and 82. An 8-year-old boy w ith erythem atou s,
behavior in age-ap p rop riate fashion. While he chapped hand s, and an otherw ise norm al
is able to p rovid e his ow n p ersonal care, he p hysical and laboratory exam ination.
requ ires su p p ort in m ore com p lex d aily living
tasks, ju d gm ent, and organization. 83. A 13-year-old girl w ith a bald p atch on the
back of her head and an otherw ise norm al
79. A 17-year-old boy w hose concep tu al skills p hysical and laboratory exam ination.
consistently lag behind those of his peers,
and , w hile he has d ifficu lties p erceiving or

Questions 84 through 87
Match the m ost likely d isord er w ith the appropriate
patient.
(A) Attention-d eficit/ hyp eractivity d isord er
(ADH D)
(B) Au tism sp ectru m d isord er
(C) Generalized anxiety d isord er
(D) Langu age d isord er
(E) Selective m u tism
(F) Social anxiety d isord er
(G) Social (p ragm atic) com m u nication
d isord er
84. A 6-year-old girl whose parents are going
through a divorce will not speak while at school.
85. A 9-year-old boy w ho frequ ently blu rts ou t
com m ents in class w ithou t w aiting his turn to
be called on.
86. A 7-year-old boy w ho p erform s w ell in school
althou gh seem s to talk as if reciting a m ono-
logu e rather than interacting in conversation
and generally avoid s other child ren, bu t d oes
not d isplay rep etitive or restricted interests.
87. An 8-year-old boy w ho is having d ifficu lty in
school and avoid s interactions w ith his class-
m ates and others for fear of em barrassm ent.
Questions 88 through 93
Match the age range w ith the corresp ond ing d evel-
opm ental m ilestone.
(A) Infant (018 m onths)
(B) Tod d ler (1836 m onths)
(C) Preschool age (36 years)
(D) School age (712 years)
(E) Ad olescence (1317 years)
88. Focu s on follow ing the ru les.
89. Establishing self as au tonom ou s, sep arate
from caregiver, by p racticing leaving and
retu rning to the caregiver.
Que s tions : 7694 15
90. Establishing tru st in the w orld throu gh
resp onsiveness and em p athy of a caregiver.
91. Preoccup ation w ith su perheroes w ho rep re-
sent id ealized caregivers as a resu lt of con-
flicted feelings tow ard caregivers.
92. The d evelop m ent of the ability to think abou t
and m anipu late id eas abstractly.
93. The d evelop m ent of the ability to ap p ly rea-
soning so that the child is not lim ited only by
p ercep tions.
DIRECTIONS (Questions 94 through 99): For each of
the multiple-choice questions in this section, select
the lettered answer that is the one best response in
each case.
94. A 16-year-old girl is brou ght to you by her
m other because of d ropping grad es, apathy,
and p oor m otivation. You learn that she has
recently started sm oking m ariju ana on a
regu lar basis. Which of the follow ing p atterns
w ou ld m ost su p p ort the d iagnosis of cannabis
u se d isord er, severe?
(A) Over 12 m onths, u sing m ore than
intend ed and being u nsu ccessfu l at
stopp ing, w ith a loss of her sum m er job
and legal consequ ences from her u se.
(B) Over 12 m onths, having cravings to
u se, spend ing significant tim e obtaining
m arijuana, and m issing school in ord er
to sm oke.
(C) Over 12 m onths, continu ing to use
d esp ite recu rrent argu m ents, being
high w hile d riving, u sing d espite
know ing it is affecting her m otivation,
need ing increased am ounts to get the
sam e high, and having ongoing
cravings w hen not u sing.
(D) Over 18 m onths, sm oking by herself bu t
need ing to sm oke m ore to achieve the
sam e effect.
(E) Over 18 m onths, sm oking m ost d ays
p er w eek, m ultip le tim es p er d ay, and
d eveloping w ithd raw al sym ptom s once
the m ariju ana is stopped .
16 1: Child a nd Ad ole s c e nt P sychia try
95. As the school p sychologist, you are asked to
see a fou rth grad er w ho has been consistently
acting out in class. H e often lies abou t things
he has d one in class, such as trying to cheat
on tests, and he physically bu llies you nger
child ren. You learn that at hom e he practices
shooting his BB gu n at squirrels as w ell as
at the fam ily d og. H e exp resses no concern
for these creatu res nor rem orse at his behav-
ior. Which of the follow ing is the m ost likely
d iagnosis?
(A) Au tism sp ectru m d isord er
(B) Bip olar d isord er
(C) Child hood onset schizop hrenia
(D) Cond u ct d isord er
(E) Op p ositional d efiant d isord er
96. An 8-year-old boy is brou ght to the p ed iatri-
cian for concerns that he has significant tan-
tru m s. The tantru m s occur at least three tim es
p er w eek (bu t frequ ently m ore) and inclu d e
p hysical aggression tow ard inanim ate objects
to the extent that he has d estroyed property.
H is parents note that the fam ily w alks on egg-
shells to p revent setting him off, and they are
starting to feel held hostage by his chroni-
cally irate m ood . They believe this change in
behavior started a year ago, bu t has m arked ly
w orsened in the p ast several w eeks. Which of
the follow ing is the m ost likely d iagnosis?
(A) Bip olar d isord er
(B) Disru p tive m ood d ysregu lation d isord er
(DMDD)
(C) Generalized anxiety d isord er
(D) Major d ep ressive d isord er (MDD)
(E) Op p ositional d efiant d isord er (ODD)
97. A healthy 16-year-old stu d ent, w ho started
school in the United States after fleeing a
w ar-engulfed region 1 year ago, is struggling
to keep up in her classes, m ore so w ith Eng-
lish than m ath. Which of the follow ing best
explains w hy her d ifficu lty is not d u e to a
learning d isability?
(A) H earing d eficit
(B) N eu rocognitive d isord er d u e to
traum atic brain injury
(C) N orm al variant in acad em ic attainm ent
(D) Post-trau m atic stress d isord er (PTSD)
(E) Vision d eficit
98. A 7-year-old girl is brou ght to the p ed iatri-
cian d u e to w eight loss. She has been grad u -
ally refu sing food s over the p ast several w eeks
to the point she is now barely even d rinking
su pplem ental shakes. This has resu lted in sig-
nificant w eight loss and fatigu e. The girls tells
you she is aw are she is losing w eight, that she
w ou ld like to fit into the ou tfits she has, bu t
that she is afraid of vom iting if she eats the
w rong thing. Physical exam ination reveals a
child in the 5th p ercentile of w eight, w hile her
baseline had p reviou sly been in the 30th per-
centile, and basic laboratory stu d ies reveal a
m ild m icrocytic anem ia. Which of the follow -
ing is the m ost likely d iagnosis in this case?
(A) Anorexia nervosa
(B) Avoid ant/ restrictive food intake
d isord er (ARFID)
(C) Binge eating d isord er
(D) Bu lim ia nervosa
(E) Sp ecific p hobia
99. A 7-year-old boy is brou ght to the p ed iatri-
cian becau se, for the p ast 6 m onths, he has
been telling his m other that he is a girl. Ini-
tially his parents felt this w as a p hase, bu t
the patient has becom e increasingly d istressed
and m ore insistent that he hop es his breasts
w ill grow d u ring p u berty. H e has been p u t-
ting on his old er sister s clothing, and prefers
p laying w ith her d olls rather than engaging in
rou ghhou sing w ith his p eers. H e has rep eat-
ed ly stated he d islikes his p enis and w ishes he
never had one. Physical exam ination reveals
norm al m ale genitalia of the app rop riate Tan-
ner stage. Based on this inform ation, w hich of
the follow ing is the m ost likely d iagnosis?
(A) Bod y d ysm orp hic d isord er
(B) Delu sional d isord er
(C) Gend er d ysp horia in child ren
(D) N onconform ity to gend er roles
(E) Transvestic d isord er
 Ans we rs a nd Expla na tions
1. (C) Su icid e is a consid erable risk in d ep ressed
ad olescents, and shou ld be sp ecifically
ad d ressed d u ring an interview w ith a p atient
w ho ap p ears d ep ressed or agitated , or has a
history of a su icid e attem pt. The ad olescent
su icid e rate has increased substantially d u r-
ing the p ast few d ecad es. Male gend er, a p rior
su icid e attem pt, history of psychiatric illness,
fam ily history, and su bstance u se are all risk
factors for a com p leted su icid e. A history of
a p rior su icid e attem p t is the largest risk fac-
tor for suicid e for both m ales and fem ales in
all age grou ps, and the m ajority of those w ho
com plete su icid e have attem pted su icid e in
the p ast. Greater than 90% of you th w ho com -
m it suicid e have com orbid psychiatric illness,
frequ ently m ajor d ep ression. Althou gh cu t-
ting behavior is concerning in ad olescents, it
is not necessarily associated w ith the intent
to kill oneself. More girls than boys d em on-
strate su icid al behavior and attem pts, bu t at
least three tim es m ore teenage boys com p lete
su icid e than d o teenage girls. This is becau se
boys m ore frequ ently u se gu ns and other
violent m ethod s to attem p t suicid e.
2. (C) Given the ad olescents history of d ep res-
sion and risk factors of su bstance use and
fam ily history, it is im p ortant to initiate
ap prop riate treatm ent for her qu ickly. Given
the severity of her d epression in the p ast, and
d ecline now , it is reasonable to initiate anti-
d ep ressant treatm ent at this visit w ith close
follow -u p . While it w ou ld be op tim al for a
p sychiatrist to evalu ate her as soon as possible
and a referral is ap propriate, the w ait in get-
ting to a specialist (psychiatrist) shou ld not
d elay care. She d oes not necessarily need to
be ad m itted to a hosp ital, since she d oes not
ap p ear at im m inent risk of self-harm . Cer-
tainly, w aiting m ore than that w ithou t any
intervention w ou ld be inad equ ate and inap -
p ropriate. She w ou ld likely benefit from m ed -
ication m anagem ent, so a p sychiatrist w ou ld
be p referable to a social w orker in this situ a-
tion, bu t therapy w ou ld also be appropriate
concurrent treatm ent.
3. (D ) The Diagnostic and Statistical M anual of
M ental Disorders, Fifth Edition (DSM -5) recog-
nizes N REM sleep arou sal d isord ers of tw o
types: sleep w alking typ e and sleep terror
type. Both are characterized by recu rrent epi-
sod es of incom plete aw akenings from sleep,
u su ally in the first third of the m ajor sleep
ep isod e, w ith am nesia for the ep isod es, no or
little recollection of d ream im agery, and resu l-
tant im pairm ent or d istress. Sleep terror type
involves rep eated ep isod es of su d d en aw ak-
ening from sleep accom p anied by p anic sym p -
tom s that begin w ith a scream ; it is associated
w ith u nresp onsiveness to com fort or attem p ts
to aw aken the child . Attacks typically last just
a few m inu tes and are often m ore d istressing
to the caregiver, as the patient d oes not recall
them in the m orning. N REM sleep arou sal
d isord er, sleep -w alking typ e, involves the
child sitting up or leaving the bed but is not
accom p anied by terror or au tonom ic arou sal.
N ightm are d isord ers occu r in the latter third
of the night and d u ring REM sleep , in con-
trast to sleep terrors. When aw akened , the
ind ivid u al qu ickly becom es oriented , u nlike
other parasom nias w here the ind ivid ual is
d isoriented , confu sed , and d ifficu lt to arou se.
Interm ittent exp losive d isord er d oes not occu r
17
18 1: Child a nd Ad ole s c e nt P sychia try
d uring sleep and involves outbursts of anger
and som etim es violent behavior. N arcolep sy
is characterized by the triad of sleep attacks,
cataplexy (sud d en loss of m uscle tone), and
hyp nopom pic/ hypnagogic hallu cinations or
sleep paralysis, as w ell as a hypocretin d efi-
ciency.
4. (C) Ep isod es of sleep terror, as w ell as of sleep -
w alking, occur d u ring d eep sleep (stages 34).
N ightm are d isord er occurs d uring REM sleep.
5. (E) This patient is su ffering from a m ajor
d ep ressive d isord er (MDD), single episod e. A
selective serotonin reu ptake inhibitor (SSRI)
such as sertraline is a first-line agent for MDD
in child ren and ad olescents. Tricyclic antid e-
p ressants (TCAs) su ch as im ip ram ine cau se
m ore ad verse effects than SSRIs typically d o,
and in overd ose are m u ch m ore likely to be
lethal. Mood stabilizers su ch as carbam aze-
p ine and lithiu m are u sed for bipolar d isor-
der and as adjuncts to the treatment of MDD
refractory to antidepressant medications alone.
Antipsychotics such as olanzapine are usually
reserved for use as adjuncts when psychosis
develops or in bipolar disorder.
6. (D ) In the DSM -5, m ajor d epressive d isord er
requ ires a d epressed m ood for at least 2 w eeks
for ad ults to receive the d iagnosis, but in the
case of child ren and ad olescents, an irritable
mood may substitute for having a d epressed
mood . The required symptoms that involve
sleep, appetite, anhed onia, concentration, and
psychomotor functioning are the same for
ad ults and ad olescents w hen diagnosing major
d epressive d isord er.
7. (B) This boy m ost likely su ffers from langu age
d isord er. Langu age d isord er is characterized
by p ersistent d ifficu lties in the acqu isition and
u se of langu age d u e to d eficits in com prehen-
sion (receptive) or prod u ction (expressive).
Typ ical sym p tom s inclu d e having a m ark-
ed ly lim ited vocabu lary, m aking errors in
tense, and having d ifficulty recalling w ord s
or prod u cing sentences w ith d evelopm entally
ap propriate length or com p lexity. In ad d i-
tion, the boys d ifficulties are interfering w ith
acad em ic fu nctioning. There is no ind ication
that this child has d ifficulties w ith speech
p rod u ction (i.e., he can clearly articu late pho-
nem es of sp eech), so d iagnosing sp eech sou nd
d isord er w ou ld be inappropriate. As there are
no d istu rbances in the flu ency and p attern of
speech, a d iagnosis of child hood -onset flu -
ency d isord er (stu ttering) is inap p rop riate.
Social (pragm atic) com m u nication d isord er is
characterized by persistent d ifficu lties in the
social use of verbal and nonverbal com m u-
nication, for instance im p airm ents in greet-
ings, inability to change com m u nication to
a given context, d ifficu lties follow ing ru les
for conversation or story-telling, or d ifficu l-
ties in u nd erstand ing w hat is inferred but not
overtly stated . This child is able to appropri-
ately m od u late verbal com m u nication, bu t his
d ifficu lty is in the expression of verbal cues.
There m ay be a com orbid learning d isord er,
but at this time, there is insufficient information
to m ake that d iagnosis.
8. (C) Sp eech d elay refers to exp ressive langu age
d evelop m ent and nu m ber of w ord s spoken.
The average nu m ber of w ord s a 2-year-old
sp eaks is 200 w ord s. Therefore, the inability
to sp eak 200 w ord s by age 3 w ould constitu te
a speech d elay.
9. (E) It is m ost likely that the boy u sed illicit
substances d u ring his trip that caused him
to experience the acute psychotic sym ptom s.
While it is im p ortant to ru le ou t other m ed i-
cal cau ses, su bstance use w ould be the m ost
likely. Seizu re d isord ers, head inju ries, d ia-
betes, and thyroid d isease often w ou ld be
accom p anied by other sym p tom s in ad d ition
to the new onset psychosis.
10. (B) While a su bstance-ind u ced state rem ains
p ossible d u e to the large nu m ber of su bstances
that cannot be confirm ed by u rine toxicology
screens, it is im portant to consid er that this
instance of p sychosis is a m anifestation of an
u nd erlying m ood d isord er, m ost likely bipolar
d isord er. In ad d ition to an elevated or irritable
m ood , the d iagnosis of bip olar d isord er neces-
sitates that ind ivid uals d isplay three of the
follow ing (four if irritable m ood ): grand iosity,

d ecreased need for sleep, increase in talkative-
ness, objective or su bjective flight of id eas,
d istractibility, increase in goal-d irected behav-
iors, and engagem ent in p otentially high-risk
behaviors. Mania in bip olar d isord er can often
p resent concu rrently w ith psychotic sym p -
tom s includ ing hallu cinations, d elu sions, and
d isorganized thinking. Anorexia nervosa (an
eating d isord er) and generalized anxiety d is-
ord ers d o not p resent w ith psychotic sym p-
tom s. Ind ivid u als w ith bord erline personality
d isord er m ay have p sychotic-like sym ptom s,
esp ecially w hen they are regressed , bu t they
are m u ch m ore likely to p resent w ith d ep res-
sion, suicid al thinking, and su bstance u se.
While p sychotic featu res can accom p any
m ajor d ep ressive d isord er, the d ep ressive
sym ptom s occu r first, and psychotic sym p-
tom s are m ore acu te and frequ ent in bipolar
d isord er
11. (C) This boys behavior and sym p tom s are
m ost consistent w ith sep aration anxiety d isor-
d er, characterized by d evelop m entally inap-
p rop riate and excessive anxiety concerning
separation from the hom e or from those to
w hom the ind ivid u al is attached . Consistent
w ith this d iagnosis, the boy d oes not like to
go to school, com es hom e im m ed iately after
school, sleeps in his parents bed at night,
and has repeated physical sym ptom s w hen
at school. The boy is not suffering from PTSD
becau se there is no evid ence of a trau m atic
event that is p ersistently re-exp erienced or
has cau sed sym ptom s of increased arou sal
and avoid ance of associated stim u li. For a
d iagnosis of reactive attachment d isord er,
the boy w ould need to have su ffered m ark-
ed ly d istu rbed social related ness, in m ost
contexts, beginning before the age of 5 years,
and display a pattern of inhibited , w ithd raw n
behavior toward caregivers. A related disorder,
d isinhibited social engagem ent d isord er, also
stem s from significant neglect or d eprivation
and results in child ren d isp laying a m ark-
ed ly overfam iliar ap p roach and com fort w ith
strangers. The boys sym p tom s are not con-
sistent w ith social anxiety d isord er (social
p hobia) becau se he d oes not have a m arked
and p ersistent fear of social or p erform ance
Answe rs : 415 19
situ ations, w ith exp osu re causing intense
anxiety. Finally, a d iagnosis of specific phobia
w ould require the display of marked and per-
sistent fear cued by the presence of anticipation
of a specific object or situation.
12. (B) Child ren w ith p arents w ho have a history
of an anxiety d isord er are at increased risk for
d evelop ing an anxiety d isord er them selves.
Other risk factors for d eveloping a child -
hood anxiety d isord er inclu d e p arents w ho
have an anxiou s, overly controlling, or reject-
ing style, an insecu re attachm ent w ith ones
p rim ary caregiver, and an inhibited and shy
tem peram ent.
13. (B) These sym p tom s are consistent w ith a
m anic ep isod e of bip olar d isord er. Attention-
d eficit/ hyperactivity d isord er is associated
w ith hyp eractivity and im p u lsivity bu t not
grand iosity and d elu sional thinking. Major
d ep ression m ay have psychotic sym ptom s
if severe, bu t it w ou ld not p resent w ith an
inflated m ood or increased energy. Panic
d isord er w ou ld present w ith recu rrent panic
attacks and significant anxiety. Although
schizophrenia can present w ith d elusional
sym ptom s, there are often other sym ptom s
such as grossly d isorganized speech and / or
behavior, or flat affect; in ad d ition, this p atient
has significant m ood sym ptom s.
14. (C) Cocaine is a stimu lant and can prod u ce
both manic and psychotic sym ptoms. Alco-
hol, cannabis, heroin, and PCP ingestion can
ind uce a psychotic state includ ing hallucina-
tions and paranoia, bu t it w ou ld not classically
be accompanied by manic symptom s.
15. (E) This boy likely has ODD. ODD is an exter-
nalizing behavior d isord er that involves a p at-
tern of hostile and d efiant behavior. Child ren
w ith ODD are often angry, argu m entative,
and easily annoyed by others. In ord er to con-
firm the d iagnosis, you w ou ld need to gather
ad d itional inform ation regard ing the length
of tim e the behavior has been present (at least
6 m onths is requ ired ), as w ell as rule ou t a
m ood , p sychotic, or su bstance u se d isord er.
Althou gh anxiety d isord ers can p resent w ith
20 1: Child a nd Ad ole s c e nt P syc hia try
tension, irritability, and even noncom pliance
w hen a child is p laced in a new situ ation (su ch
as a d octors office), this child d oes not ap p ear
to have anxiety in places w here escape m ay
be d ifficu lt in the event of a p anic attack (su ch
as in agorap hobia), nor excessive w orry abou t
a nu m ber of events (su ch as in generalized
anxiety d isord er). While the p atients p resent-
ing sym p tom s are not p rim arily involving
inattention, d istractibility, or hyp eractivity
consistent w ith ADH D, there is consid erable
com orbid ity betw een ADH D and ODD. H is
lack of violence or seriou s violation of ru les
is not consistent w ith cond u ct d isord er; how -
ever, ODD (esp ecially if u ntreated ) m ay lead
to cond uct d isord er over tim e.
16. (A) This patient appears to be suffering from
bulim ia nervous, an eating d isord er character-
ized by episod es of bingeing and compensa-
tory behaviors (e.g., purging). Signs of bulim ia
nervosa includ e erosion of tooth enamel
caused by acid ic vomitu s as w ell as abrasions
on the d orsu m of the hand d u e to scraping by
the u pper teeth as the ind ivid ual pushes the
hand to the back of the throat to ind u ce vom it-
ing. As it is not a secret that the abrasions are
there, but the patient has not mentioned them,
a d irect bu t open-end ed statement, such as,
Tell me about the scratches on your hand ,
is most likely to be helpful in this situation.
Usually, a patient appreciates a d irect ques-
tion rather than w ond ering if you ignored or
d id not notice something obvious. Questions
su ch as, Do you scratch you rself? or, Do
you have a cat? are not open-end ed ; they
require yes or no answ ers and are unlikely
to yield new information. Are you trying to
hurt you rself? or H ow d id the scratches
happen? m ay sound accu satory; patients are
more likely to offer information if you seem
nonjud gmental. If this girl d oes not volu nteer
inform ation that confirm s to you that she is
not ind ucing vom iting, you may need to u se a
more d irect bu t reassuring statement su ch as,
Som etimes I see girls w ho make them selves
throw up. H ave you ever d one that?
17. (D ) Med ical com p lications can arise for
bu lim ic p atients w ho engage in com p ensatory
behaviors su ch as ind u ced vom iting, laxative,
or d iu retic use. A hypokalem ic-hypochlore-
m ic alkalosis (d u e to vom iting) is a p ossible
seriou s find ing that can contribute to a card iac
arrhythm ia. Anem ia (as op p osed to increased
iron) can be seen, as w ell as d ecreased p rotein.
The red u ced chlorid e can lead to elevated
sod ium d u e to sod ium resorption. Becau se
of these changes, it is im portant to m onitor
bu lim ic p atients for electrolyte and acid base
im balances.
18. (A) Bulimia nervosa is most effectively treated
w ith cognitive-behavioral therapy. Family ther-
apy, group therapy, and longer-term, insight-
oriented therapies (such as psychoanalysis and
psychod ynamic psychotherapy) may be used
as adjuncts to cognitive-behavioral therapy,
but they have not been demonstrated to be as
effective in changing the behaviors associated
w ith bulimia nervosa.
19. (D ) When engaging a child in a clinical set-
ting, it is im portant to choose w ord s carefu lly
in ord er to establish an op en, tru sting connec-
tion, especially w ith a troubled and resistant
child . It is p referable to initiate the interview
w ith m ore op en-end ed rather than closed -
end ed qu estions. The qu estions shou ld op ti-
m ally reflect em p athy for the child and their
situ ation w ithout ap pearing too sentim ental
or jud gm ental. Also, it is im portant to avoid
assu m ptions abou t the p atients feelings w ith-
ou t checking w ith the patient first. The state-
m ent, You su re w ere lu cky the car sw erved
at the last m inute assu m es the boy w anted
to avoid being hit by the car, and also is a
com m ent that d oes not lead to any elabora-
tion from the p atient. Statem ents (B) and (C)
are both ju d gm ental and m ore likely to shut
d ow n conversation than facilitate it. Also, ask-
ing a child if they are confu sed is a close-end ed
qu estion that com es across as cond escend ing.
20. (D ) Psychom otor agitation is m ore com m only
seen in child ren w ith MDD com pared to ad o-
lescents w ith MDD. Child ren w ith MDD m ay
ap p ear m ore anxiou s and irritable than sad
and d ep ressed . H yp ersom nia, hop elessness,
w eight change, and illicit d ru g u se are m ore

com m only seen in ad olescents w ith MDD
com pared to child ren w ith MDD.
21. (B) Suffocation (e.g., hanging) is the most com-
mon m ethod for attem pting suicid e in ind ivid -
uals u nd er 15 years of age. Su bstance ingestion
is another comm on m ethod . While firearms
are used less frequently, they are more often
lethal. Other m ethod s of suicid e frequently
attempted by child ren inclu d e stabbing, cut-
ting, jum ping from build ings, ru nning in front
of vehicles, and gas inhalation. Some su icid e
attempts m ay be m istaken for accid ents, so
it is im portant to d irectly ask child ren if they
intend ed to hurt or kill themselves.
22. (A) H ead aches and nau sea are com m on
ad verse effects associated w ith the synthetic
antid iuretic horm one, Dd avp. H yp otension,
liver toxicity, sed ation, and trem or are not
typically associated w ith d esm opressin.
23. (B) Approxim ately 10% to 15% of child ren
w ith anxiety d isord ers d evelop MDD.
24. (C) The m ost com m on ad verse effects of flu ox-
etine inclu d e gastrointestinal sym p tom s (e.g.,
nausea, loose stools), insom nia, agitation, and
head aches. In general, hyp otension, liver tox-
icity, sed ation, and w eight gain are not sid e
effects associated w ith flu oxetine.
25. (A) This girls history and presentation are
consistent w ith ASD. ASD is characterized by
d eficits in social comm unication and social
interaction, as w ell as restricted , repetitive pat-
terns of behavior, interests, or activities (e.g.,
stereotyped or repetitive movements, inflex-
ible rigid ity to routines, fixated or restricted
interests, sensory input abnorm alities). Chil-
d ren w ith ASD have d ifficulties w ith social-
emotional reciprocity and have d ifficulty
engaging in prosocial behavior. Fu rther, they
often have imp aired eye contact and have d if-
ficulty und erstand ing nonverbal com munica-
tion or cues. They also have abnormal social
attachments, su ch as app earing to have no
interest in peers (as in this case). The DSM -5 sig-
nificantly revised the category of ASD, so that
verbal language abilities no longer represent
Answe rs : 1627 21
a separate criterion. While ASD is more com-
mon in males, it d oes exist in fem ales. ID m ay
be comorbid w ith ASD, but m ust be separately
assessed . ID is characterized by intellectu al and
functioning d eficits in conceptual, social, and
practical d omains. Rett synd rome is seen only
in fem ales and is characterized by normal pre-
natal and perinatal d evelop ment, normal head
circum ference at birth, and normal p sychom o-
tor d evelopment throu gh the first 5 m onths
of life. Betw een the ages of 5 and 48 months,
there is d eceleration of head grow th, loss of
hand skills w ith d evelop ment of stereotyped
hand m ovem ents su ch as hand w ringing,
loss of social interaction (w hich m ay improve
later), appearance of poorly coord inated gait
or tru nk m ovem ents, and severely im paired
exp ressive and recep tive language d evelop-
ment w ith severe psychomotor retard ation.
Consequ ently, child ren w ith Rett synd rom e,
d uring the period of regression, m ay appear
to meet criteria for ASD. In this case, there is
no evid ence of the typical physical examina-
tion abnormalities. Of note, Rett synd rome no
longer has its ow n d iagnostic criteria in the
DSM -5 bu t rem ains d escribed in the d ifferen-
tial d iagnoses for several d isord ers. Selective
m u tism is characterized by a failu re to sp eak,
d esp ite norm al ability to d o so, in social situ -
ations w here speaking is exp ected , su ch as at
school; ou tsid e of this social situation, they
d isplay norm al speech and interactions. Chil-
d ren w ith social (pragm atic) com m u nication
d isord er d isplay persistent d ifficu lties in how
they use verbal and nonverbal com m unica-
tion in social settings, bu t lack the restricted /
rep etitive p atterns of behaviors and interests
that are present in ASD.
26. (C) ASD is d iagnosed four times more in boys
than girls, and w hen it is present in girls, intel-
lectual d isability is often comorbid . The pres-
ence of functional language by age 5 is a positive
prognostic sign, and it also allow s child ren to
engage more effectively in social skills training.
The remaining listed factors negatively affect
the prognosis of patients w ith ASD.
27. (A) This patients presentation is consistent
w ith conduct disord er (CD). Factors associated
22 1: Child a nd Ad ole s c e nt P syc hia try
w ith an increased risk of a child d evelop ing
CD inclu d e a low IQ, low school achievem ent,
p oor parental su p ervision, p u nitive or erratic
p arental d iscip line, child hood physical abu se,
p arental conflict, the child s biological father
being absent, antisocial p arents, and having a
large fam ily.
28. (A) Child ren and ad olescents w ho are d iag-
nosed w ith cond u ct d isord er are at increased
risk for an tisocial p ersonality d isord er as
ad u lts. Antisocial p erson ality d isord er is
not d iagnosed u ntil after th e age of 18, and
on e of the criteria is evid ence of con d u ct
d isord er p rior to the age of 15. Earlier onset
of con d u ct d isord er is associated w ith an
increased risk of d evelop ing antisocial p er-
sonality d isord er. Cond u ct d isord er is not as
closely associated w ith avoid ant p erson al-
ity d isord er, p aranoid p ersonality d isord er,
schizoid p erson ality d isord er, or schizotyp al
p ersonality d isord er.
29. (D ) By d efinition, sym ptom s of ad ju stm ent
d isord er d o not last longer than 6 m onths
after a stressor or the term ination of its con-
sequences. If d epressive sym ptom s persist,
MDD m ay be d iagnosed . In both ad justm ent
d isord er and MDD, sym ptom s m ust cau se
m arked d istress or significant im pairm ent in
fu nctioning, m ay d evelop follow ing a stressor,
m ay d evelop w ithin 3 m onths of the onset of
a stressor, and m u st not represent norm al
bereavem ent. Ad ju stm ent d isord er m ay also
be given sp ecifiers d ep end ing on the p res-
ence of anxiety, d ep ressed m ood , and cond u ct
d istu rbances. Ad ju stm ent d isord er follow ing
bereavem ent m ay be given p rovid ed that
the ind ivid ual d oes not m eet criteria for fu ll
MDD, and the intensity of qu ality of the grief
reaction exceed s w hat is exp ected for cu ltu ral,
religiou s, or age-m atched norm s.
30. (D ) Follow ing a d iagnosis of d iabetes m ellitu s
type I, approxim ately 33% of child ren d evelop
sym ptom s of ad justm ent d isord er.
31. (E) Tou rette d isord er is the m ost likely
d iagnosis becau se the boys ou tbu rsts are
consistent w ith vocal tics, an d th e rep ort of
restless an d ju m p y beh avior is consistent
w ith m isinterp retation of m otor tics. Tou rette
d isord er m ost com m only d evelop s in grad e
school-aged boys, an d the involu ntary tics
m ay be m isinterp reted as p u rp osefu lly d is-
ru p tive behavior. It is not u n u su al for these
child ren to have d ifficu lty w ith social and
p eer interactions. Of note, there is frequ ent
com orbid ity w ith ADH D. Th is boy d oes
not su ffer from con d u ct d isord er or op p osi-
tion al d efian t d isord er becau se he is p olite
and d oes not d isp lay hostile, d estru ctive, or
angry behaviors. Th e ou tbu rsts are n ot typ i-
cal of p an ic d isord er, in w hich there are d is-
crete p an ic attacks, p eriod s of in tense fear,
or d iscom fort, w ith p hysical m anifestations
su ch as p alp itation s and su bjective d ifficu lty
breathing. There is no evid ence that this boy
exp eriences d istress an d w orry w h en sep a-
rated from an im p ortant attach m en t figu re
as in sep aration an xiety d isord er.
32. (B) Clonidine has become the first-line treat-
ment for Tourette disorder. It has a limited
side-effect profile and helps control symptoms
of a frequently associated comorbid disor-
der, attention-deficit/ hyperactivity disorder
(ADHD). Tricyclic antidepressants (TCAs) have
been shown to be effective in the treatment of
Tourette disorder, but other antidepressants
such as bupropion, paroxetine, and venlafax-
ine are not known to be effective. High-potency
antipsychotics such as haloperidol and pimo-
zid e were trad itionally the first-line agents for
Tourettes, but are more likely to cause signifi-
cant side effects. Recently, the newer atypical
(or second-generation) antipsychotics such as
risperid one and olanzapine have also been
used to treat the disorder.
33. (A) It is not u nu su al for p arents of a seriou sly
ill child to w ant to try to p rotect them from
any fu rther su ffering or d istress. H aving an ill
child is overw helm ing and anxiety-provok-
ing. Parents m ay end u p treating su ch chil-
d ren as if they w ere you nger than their actual
age and m ay be m ore reluctant to set ap pro-
p riate lim its. When calling a p arents attention
to the potential harm of su ch interaction, a cli-
nician m u st be tactfu l and em p athic. By gently

acknow led ging this m others d istress, she w ill
be m ore recep tive to hearing feed back abou t
her interactions w ith her child , inclu d ing that
her relu ctance to set lim its and stru ctu re m ay
inad vertently be d etrim ental. While it is essen-
tial, em p athizing alone w ill be insu fficient to
set the stage for a d iscussion of p arentchild
interactions. Referring her to a p arent su p p ort
grou p m ight be u sefu l follow ing you r initial
d iscu ssion w ith her. Telling her she is treat-
ing her son like a baby is overly harsh and
m ore likely to m ake her d efensive rather that
recep tive.
34. (C) A psychiatric illness in a child or ad oles-
cent w ith a m ed ical illness shou ld be treated
aggressively u sing the type of treatm ent m ost
effective for the sp ecific p sychiatric illness,
w hile keep ing in m ind p otential interactions
of treatm ents. Med ical illnesses can exacerbate
p sychiatric illness and vice versa. As su ch,
effective treatm ent of a m ental illness m ay
p ositively affect a m ed ical illness if im p rove-
m ent of psychiatric sym p tom s enables the
child to m ore fully participate in treatm ent of
the m ed ical cond ition. In ad d ition, em otional
state is related to im m u ne response. Althou gh
there is a specific stressor in this case, it is
u nclear w hether the d ep ressive sym p tom s
w ou ld resolve if the leu kem ia goes into rem is-
sion; in ad d ition, given the im p airm ent in this
boys fu nctioning and that it is u nclear if/
w hen the leu kem ia w ou ld rem it, not treat-
ing the d ep ression w ou ld be inap p rop riate.
Ap p rop riate p harm acologic treatm ent shou ld
be avoid ed only if there are sp ecific contrain-
d ications based on the m ed ical treatm ent the
child is receiving. In ad d ition, the effective-
ness of psychotherapy is related to the specific
m ental illness, not to the p resence or absence
of a m ed ical illness.
35. (D ) It is not u nu su al for child ren w ith Tou rette
d isord er to have com orbid p sychiatric d isor-
d ers. Obsessive-com pu lsive d isord er is a very
com m only associated d isord er, often present-
ing in ad olescence. Other anxiety d isord ers,
attentional d isord ers, and learning d isord ers
can be seen as w ell. Autism spectru m d isord ers
are not com m only associated w ith Tou rettes.
Answe rs : 2838 23
Mood lability can be an associated sym p tom ,
althou gh the incid ence of bip olar d isord er is
not p articularly increased . Langu age or sepa-
ration anxiety d isord ers are also not increased
in ind ivid u als w ith Tou rette d isord er.
36. (E) A su bset of child ren w ith prior grou p A
beta-hem olytic strep tococcal infections have
d evelop ed Tou rette d isord er after the infec-
tion. Other d isord ers associated w ith su ch an
infection inclu d e OCD and Syd enham chorea.
This grou p of d isord ers are referred to as p ed i-
atric au toim m u ne neu rop sychiatric d isord ers
associated w ith strep tococcal infections, or
PAN DAS. The other infectiou s agents listed
are not associated w ith Tou rette d isord er.
37. (A) This boys history is typical of ADH D,
com bined presentation. H e d oes not comp lete
tasks, is careless, loses necessary item s, is d is-
tracted and forgetful, is energetic, impu lsive,
and cannot tolerate playing quietly. Symptom s
are p resent before age 12 and are occu rring in at
least tw o settings, and are causing im pairment
and d istress. Increased energy and im pulsivity
can be a symptom of both ADH D and bipolar
d isord er, but to be an exacerbation of bipolar
d isord er, those symptom s m ust be associated
w ith energy and im pulsivity beyond base-
line, inflated mood , grand iosity, increase in
goal d irected activity, and a d ecreased need
for sleep. This boy d oes not d isplay excessive
aggression, d estru ction of prop erty, d eceitfu l-
ness, theft, or serious violations of rules, as
seen in cond u ct d isord er. H is behaviors are
not negativistic, hostile, or d efiant, so he d oes
not suffer from oppositional d efiant d isord er.
Therefore, he d oes not have characteristics of a
d isruptive behavior d isord er.
38. (E) Stim u lant m ed ications are the first-line
treatm ent for ADH D bu t have been associ-
ated w ith an increased risk of d eveloping
tics. In general, if a child suffers from tics or
has a fam ily history of tics, stim u lant m ed i-
cations shou ld be avoid ed , and an alternate
m ed ication shou ld be u sed to treat ADH D if
necessary. Benzod iazep ines, D 2 antagonists,
MAOIs, and SSRIs d o not com m only exacer-
bate tics and are not u sed to treat ADH D.
24 1: Child a nd Ad ole s c e nt P syc hia try
39. (C) To be d iagnosed w ith a learning d isor-
d er w ith im p airm ent in read ing, there m u st
be evid ence of an ind ivid u als p erform ance
in a given acad em ic area (in this case, read -
ing) falling below w hat is exp ected for age.
Psychom etric testing, su ch as IQ testing, is
one m easu re to assess the d isparity betw een
exp ected achievem ent and actu al achieve-
m ent. A learning d isord er can also be d iag-
nosed if the ind ivid ual is u sing significant
and excessive com p ensatory levels of effort or
su pp ort to sustain average achievem ent.
40. (D ) At least 50% of child ren w ith learning
d isord ers have a com orbid p sychiatric d is-
ord er. The m ost com m on com orbid cond i-
tions inclu d e ADH D, anxiety, and d epressive
d isord ers.
41. (C) Most child ren w ith enu resis are boys, and
overall anyw here betw een 20% and 40% have
a com orbid m ental d isord er.
42. (B) Of the choices p rovid ed , Dd avp is the treat-
m ent of choice for enu resis; it is a variation
of the antid iu retic horm one vasop ressin and
is given intranasally. Benztrop ine is u sed to
p revent extrap yram id al sym p tom s cau sed
by antip sychotic (neu rolep tic) u se. Meth-
ylp henid ate is a stim u lant com m only u sed
in the treatm ent of ADH D. Paroxetine is a
serotonin-sp ecific reu p take inhibitor u sed to
treat d ep ression and anxiety. Trazod one is an
antid ep ressant m ost often u sed for insom nia.
43. (B) The m ost com m on ad verse effects of m eth-
ylp henid ate and other stim u lant m ed ications
inclu d e insom nia, d ecreased ap p etite, w eight
loss, d ysp horia, and irritability. Trem or, hyp o-
tension, w eight gain, and liver toxicity are not
com m on sid e effects.
44. (E) Stim u lant m ed ications, su ch as m ethylp he-
nid ate, are effective in d im inishing sym ptom s
of ADH D in ap p roxim ately 70% of p atients.
45. (B) Atom oxetine is a nonstim u lant norepi-
nephrine reu ptake inhibitor, w hich has been
fou nd to be help fu l in treating both child hood
and ad ult ADH D. Mixed am p hetam ine salts
(Ad d erall) are u sed to treat ADH D, bu t they
are also stim u lants and w ill have sim ilar sid e
effects to the m ethylp henid ate-based m ed i-
cations. Aripip razole is a second -generation
(atyp ical) antip sychotic, citalop ram is an anti-
d ep ressant, and valp roic acid is a m ood stabi-
lizer u sed in bip olar d isord er; none are u sed to
treat ADH D.
46. (B) The clinician can be help fu l to p arents
by exp laining and norm alizing the child s
behavior. H ow ever, it is still im p ortant
for the p arent to resp ond to or correct this
behavior. In the case of this you ng girl, jeal-
ou sy of her you nger sibling is entirely nor-
m al and is m ore d ifficu lt for her, since as a
p reschooler her langu age skills m ay not be
d evelop ed su fficiently to articu late her d is-
tress. Once the m other accep ts this child s
behavior as u nd erstand able and in the nor-
m al range, she can resp ond in an em p athic
w ay w hile still setting lim its on her aggres-
sive behavior. Ignoring the behavior w ill not
ad d ress the aggression and is not em p athic.
Und er no circu m stances is biting the child
back help fu l. Threatening to w ithd raw
love is m anip u lative and anxiety-p rovoking
to the child . By telling the child that she m u st
love the baby, the m other is not tru ly em p a-
thizing w ith her and m ay elicit sham e and
fu rther resentm ent tow ard the baby.
47. (B) A 37-m onth-old girl is a you ng preschool
age child . At this stage, she shou ld be able
to state her age and gend er and be involved
in or have recently com p leted p otty train-
ing. Althou gh she has significant langu age,
it w ou ld be very u nu su al for her to u se her
langu age sp ontaneou sly to id entify and artic-
u late her feelings abou t her you nger sibling.
Althou gh a p recociou s 3-year-old m ay be able
to cou nt to 50, it w ou ld not necessarily be
exp ected of her u ntil she is 5 years. She is cu r-
rently consid ered to be in the p reop erational
stage of cognitive d evelopm ent and cannot
yet ap p ly concep ts of conservation of m atter
(concrete op erations). H er gross m otor skills
and balance are likely not d evelop ed enou gh
to rid e a bicycle. She shou ld be able to rid e a
tricycle, how ever.

48. (D ) This p atients p resentation is su sp iciou s
for au tism sp ectru m d isord er (ASD). ASD is
characterized by d eficits in social com m unica-
tion and social interaction as w ell as restricted ,
rep etitive p atterns of behaviors, interests, or
activities. Of the choices listed , the d ifficu lty
w ith im aginary p lay rep resents a d eficit in
u nd erstand ing relationships, w hich m ore
broad ly falls u nd er the d iagnostic criterion
of d eficits in social interaction. The langu age
im p airm ent criterion of the DSM -IV -TR w as
elim inated in the DSM -5. Attentional d ifficu l-
ties, im pairm ent in m otor skill d evelopm ent,
or d elay in potty training are not necessarily
featu res of ASD.
49. (D ) Child ren w ith au tism spectrum d isor-
d er (ASD) have m ore favorable p rognoses if
they are able to converse m eaningfu lly w ith
others; though no longer p art of the DSM -5
d iagnostic criteria, the acqu isition of fu nc-
tional language by the age of 5 years rem ains a
p ositive prognostic factor. It is not u nu su al for
child ren w ith ASD to be easily toilet trained ,
enjoy m echanical toys, be rigid ly organized in
their play, and be capable of m em orizing or
reciting p oem s, d ialogu e from a TV show or
m ovie. These latter characteristics are not nec-
essarily associated w ith a good prognosis.
50. (A) This girl likely has anorexia nervosa.
H yp ercholesterolem ia is com m on in anorexia
nervosa. Other find ings associated w ith the
starvation state are m ild norm ocytic norm o-
chrom ic anem ia and leu kop enia. If vom iting
is ind u ced , hyp okalem ia, hyp ochlorem ia, and
m etabolic alkalosis m ay be seen. H ypercaro-
tenem ia, cau sing yellow ing of the skin, m ay
be seen if m any carrots are eaten in an attem p t
to satisfy the appetite w ith a low -calorie food .
TSH is not typ ically altered .
51. (B) While all of the choices are complications
resulting from anorexia nervosa, a card iac
arrhythmia is consid ered a major com plica-
tion and therefore alone justifies an inpatient
ad mission. If the patient has mu ltip le minor
com plications (e.g., anem ia, brad ycard ia,
hypotension, lanu go), strong consid eration for
ad mission to the hospital shou ld also be given.
Answe rs : 3955 25
52. (E) Stranger anxiety occurs as part of nor-
m al child d evelopm ent and is evid ence of
the d evelopm ent of a secure attachm ent; it
d oes not su ggest that a p arent is inatten-
tive. Stranger anxiety u su ally ap p ears by 7 to
8 m onths and generally resolves w ith tim e.
Typ ically, stranger anxiety is stronger tow ard
com pletely u nknow n persons than tow ard
those w ho are m ore fam iliar. Becau se stranger
anxiety at this age is d evelop m entally app ro-
priate, this boy cannot be d iagnosed w ith sep -
aration anxiety d isord er, and he is not overly
attached to his m other. Child ren w ith au tism
spectrum d isord er, in fact, often lack this
d evelop m ental m arker.
53. (D ) This boy w ou ld be d iagnosed w ith sep a-
ration anxiety d isord er. While an 8-m onth-old
child w ou ld typically d isplay stranger anxi-
ety, an 8-year-old w ou ld not. This behavior
w ou ld have norm ally gone aw ay for m ost
child ren by age 3 or 4 years. School age chil-
d ren are exp ected to be able to sep arate from
the parent/ caregiver in ord er to attend school
and other activities. Ind ivid u als w ith agora-
phobia often refu se to leave their hom e d ue to
the fear of d eveloping a panic attack. Obses-
sive-com pu lsive d isord er is characterized by
obsessions and com pu lsions; the focu s is not
related to sep aration. Social anxiety d isord er
(social p hobia) involves anxiety in a social or
perform ance situ ation.
54. (B) Ind ivid uals w ho d evelop schizophrenia
are m ore likely to have a p arent w ith a p sy-
chotic or schizotyp al d isord er. Ind ivid uals
w ho d evelop schizop hrenia are m u ch m ore
likely to have a history of social w ithd raw al
and introversion rather than extroversion.
Recent stressors su ch as p arental d ivorce or
m oving m ay contribu te to the onset or exac-
erbation of som e p sychiatric d isord ers bu t
not sp ecifically schizophrenia. Finally, recent
d ru g u se w ou ld be m ore likely to su p p ort a
d iagnosis of su bstance-ind u ced p sychosis.
55. (D ) Early-onset schizop hrenia occu rs before
age 18 years, w hile child hood onset schizo-
phrenia has an onset before the age of 15 years.
Child hood onset of schizop hrenia is rare and
26 1: Child a nd Ad ole s c e nt P syc hia try
associated w ith a poorer ou tcom e. A better
p rognosis is associated w ith an acu te onset,
m ore affective sym ptom s, old er age at onset,
good p rem orbid fu nctioning, w ell-d ifferenti-
ated sym ptom s, and lack of a fam ily history of
schizophrenia.
56. (C) Child ren w ith ADH D often suffer from
low self-esteem , w hile child ren w ith m ania
are m ore likely to be eu phoric. Distractibility,
im p u lsivity, m otoric hyp eractivity, and p res-
sured sp eech m ay be seen in child ren w ith
both d isord ers.
57. (E) If a school is unable to manage a childs
behavioral or emotional difficulties despite
ad ded support and special placement in a sepa-
rate classroom, the most appropriate next step is
therapeutic d ay school placement. Therapeutic
schools are d esigned for stud ents w ith psychi-
atric disorders that are severe enough that their
home schools cannot keep the child or other
stud ents safe and manage the child in a learn-
ing environment. H ome schooling, a parochial
school, or a school for stud ents w ith learning
d isabilities are not therapeutic in nature and d o
not have teachers and staff w ho are trained to
w ork w ith students w ith emotional and behav-
ioral disord ers. Resid ential placement involves
the child resid ing at the school w hile receiving
therapeutic treatment and attend ing classes,
and is reserved for students w hose needs can-
not be met by therapeutic schools.
58. (E) Valp roic acid is an anticonvu lsant, w hich
is also a m ood stabilizer u sed to treat bip olar
d isord er. Du loxetine and bu propion are both
antid epressants and not ap propriate for treat-
ing m ania as they m ay w orsen the sym p tom s
or prom ote rapid -cycling. Methylphenid ate
and m ixed am phetam ine salts are stim u lants
u sed in attention-d eficit/ hyp eractivity d isor-
d er, and are contraind icated in m ania because
they m ay actu ally exacerbate m ania.
59. (D ) Typ ically, child ren are 7 or 8 years old
w hen they begin to und erstand the irrevers-
ibility of d eath. To und erstand that d eath is
irreversible, child ren m ust have com pleted the
cognitive stage of preoperational thou ght and
d eveloped the ability to have concrete think-
ing. Usually, this level of cognitive m aturity is
achieved betw een the ages of 6 and 10.
60. (C) This boy is displaying regression, a defense
mechanism in w hich there is an attempt to
return to an earlier d evelopmental phase to
avoid the tension and conflict at the present
level of development (e.g., d istress over the
grandmothers death). Acting out is a defense
mechanism in w hich an unconscious w ish or
impulse is expressed through action to avoid
an accompanying affect. Denial is a d efense
mechanism in w hich the aw areness of a painful
aspect of reality is avoided by negating sensory
d ata. Repression is a d efense mechanism in
w hich an idea or feeling is expelled or w ithheld
from consciousness. Somatization is the pres-
ence of physical symptoms that are a manifes-
tation of emotional or psychological d istress.
61. (D ) Sed ation is a frequ ent ad verse effect of
clonid ine u pon initiating treatm ent. With con-
tinu ed treatm ent, the sed ation usu ally sub-
sid es. Dry m outh is a less com m on ad verse
effect. H yp otension is a p ossible sid e effect as
clonid ine is also used as an anti-hypertensive
m ed ication. The red u ction in blood pressu re
u su ally d oes not resu lt in significant sym p -
tom s, how ever. In general, nausea and trem or
are not seen.
62. (D ) Stim u lants are the m ost com m only u sed
m ed ication in the treatm ent of ADH D, and
althou gh they can u nm ask tic d isord ers,
ADH D treatm ent gu id elines state that stim u -
lants can still be u sed in ind ivid u als w ith tics.
In fact, a recent stu d y fou nd that stim u lants
d id not w orsen tics in those w ith tic d isord ers.
Antip sychotics and MAOIs are not u sed for
ADH D. SSRIs are infrequ ently u sed to au g-
m ent treatm ent in som e cases and are not con-
sid ered a first-line treatm ent. Althou gh TCAs
m ay be as effective as stim u lants, their p oten-
tial for ind u cing a card iac arrhythm ia or, less
likely, su d d en d eath p reclu d es tricyclics from
being u sed as first line for ADH D.
63. (D ) The find ing of m u ltiple fractu res, espe-
cially w hen they are of d ifferent ages, is a

red flag for p hysical abu se. Even thou gh the
boy m ay be scared to rep ort w hat hap p ened
for fear of punishm ent, it is im portant to try
to talk w ith him alone and find out as m u ch
as possible. Recom m end ing extra vitam ins or
lim ited sp orts d oes not ad d ress the qu estion
of w hether the boy is safe at hom e. It is not
ap propriate to refer the boy to an orthop ed ist
or his ped iatrician prior to investigating the
p ossibility of p hysical abu se.
64. (E) In ad d ressing the d elicate task of helping a
child stop or alter their method of self-soothing,
sensitive and collaborative approaches are much
more preferable to abrupt and harsh interven-
tions. Encouraging a child to stop thumb suck-
ing with a more flexible reward system that is
enticing for the child engages the child in making
choices about their own body, rather than impos-
ing a harsh intervention. Both hot pepper sauce
and a mouth appliance are punitive in nature.
However, more passive approaches like ignoring
or offering gum are also not likely to be success-
ful. Because prolonged thumb sucking can result
in significant dental problems, helping a child
stop thumb sucking is eventually valuable.
65. (D ) This teenager is likely su ffering from p anic
d isord er. Serotonin-specific reu ptake inhibi-
tors (SSRIs) su ch as sertraline are effective in
the treatm ent of p anic d isord er. Antipsychot-
ics, su ch as arip ip razole, are not ind icated for
the treatm ent of panic d isord er. While d u lox-
etine, a serotonin-norep inep hrine reu p take
inhibitor, has an ind ication for the treatm ent
of generalized anxiety d isord er in child ren
over age 7 years, it has not been stu d ied exten-
sively in p anic d isord er. Mood stabilizers,
such as carbam azep ine and valproic acid , are
not as effective in p anic d isord er.
66. (E) Althou gh, the sym p tom s that the p atient
d escribes are consistent w ith p anic attacks,
it is im p ortant to ru le ou t any other m ed ical
causes that could be em u lating that p resen-
tation (e.g., m etabolic problem s such as thy-
roid d ysfu nction, electrolyte abnorm alities,
anem ia). An ECG w ou ld be help fu l if she
rep orted card iac sym p tom s as p art of her p re-
sentation. This optional test can be d one after
Answe rs : 5669 27
the blood w ork is com plete. An EEG and refer-
ral to a neu rologist is not necessary u nless one
has su sp icions of a seizu re d isord er. A p u lm o-
nary fu nction test is used to d iagnose asthm a,
w hich is a m u ch less likely etiology of this
p atients sym ptom s.
67. (C) Identification is the process of adopt-
ing other peoples characteristics. Identifica-
tion w ith a parent is important in personality
formation. This girls behavior may occur as
an attempt to imitate the doctor because she
ad mires her, or it may represent an effort to
cope w ith anxiety about the d octor because she
fears her. Displacement is a d efense mechanism
in w hich emotions are shifted from one idea or
object to another that resembles the original but
evokes less distress. Dissociation is a d efense
mechanism in w hich a persons character or
sense of id entity is temporarily but d rasti-
cally mod ified in ord er to avoid emotional d is-
tress. Rationalization is a d efense mechanism
in w hich rational explanations are offered in
an attempt to justify unacceptable attitudes,
beliefs, or behaviors. Reaction formation is a
d efense mechanism in w hich an unacceptable
impulse is transformed into its opposite.
68. (A) In all ju risd ictions in the United States, cli-
nicians are m an d ated rep orters of su sp ected
child abu se and are requ ired to rep ort all
cases. The law d oes not leave th e issu e to the
clin icians d iscretion or p arental/ gu ard ian
consent. Once the rep ort is m ad e, child p ro-
tective services (CPS) m ay screen th e in ci-
d ent ou t, if the incid ent d oes not m eet the
states d efinition of m altreatm ent or if insu f-
ficient inform ation is p rovid ed , CPS m ay
screen th e case in, w hich p rom p ts fu rther
investigation and p ossibly rem oving the
child from the hom e u ntil an investigation is
com p leted .
69. (D ) Although all of the listed choices are pos-
sible ou tcom es associated w ith child hood
abuse, d ep ression is the m ost com m on one. In
p articu lar, abu se of a chronic natu re can have
a significant effect on p ersonality d evelop -
m ent, and , in ad d ition, p red isp ose the child to
significant psychop athology as an ad u lt.
28 1: Child a nd Ad ole s c e nt P syc hia try
70. (C) This boys history is m ost consistent
w ith selective m u tism . H e d oes not sp eak at
school but continu es to talk at hom e. Consis-
tent failure to sp eak in a specific social situ -
ation d espite sp eaking in other situ ations is
not characteristic of MDD, persistent d epres-
sive d isord er (d ysthym ia), sep aration anxiety
d isord er, or social anxiety d isord er (social
p hobia). Social p hobia can be d iagnosed along
w ith selective m u tism .
71. (C) The m other is the m ost com m on perpetra-
tor of intentionally p rod u cing physical or psy-
chological sym ptom s in her child in ord er to
assu m e the sick role by p roxy (factitiou s d is-
7679. [76. (D ), 77. (A), 78. (B), 79. (C)] The DSM -5
ord er im posed on another). The victim is usu -
ally a preschool child , and im p osing an illness
on a child is consid ered to be physical abuse
w hich requ ires rep orting.
72. (A) The case represents a child w ith cond u ct
d isord er. Ind ivid u als w ith cond u ct d isord er
are at increased risk of later d evelop m ent of
antisocial p ersonality d isord er; in fact, DSM -5
criteria for antisocial personality d isord er
requ ire evid ence of a cond u ct d isord er before
the age of 15 years.
73. (C) Disobed ience tow ard authority figu res is a
characteristic of ODD. Aggression and violat-
ing ru les are sym p tom s consistent w ith con-
d u ct d isord er. If the hostile and negativistic
behavior consistent w ith ODD occu rs only in
the context of a m ood d isord er, the child can-
not be d iagnosed w ith ODD. Relu ctance to
p articip ate in tasks that requ ire ongoing m en-
tal attention is a com m on sym ptom of ADH D.
74. (B) Alexia is the inability to read . Agnosia is
the inability to recognize objects d espite intact
senses. Anom ia is the sp ecific inability to nam e
objects even though the object is recognizable
and can be d escribed by the p atient. Ap hasia
is m ore global than alexia and is an abnorm al-
ity in either the exp ression or the com p rehen-
sion of langu age. Apraxia is an inability to
p erform learned m otor skills d espite norm al
strength and coord ination.
75. (A) This p atients sym p tom s are consistent
w ith obsessive-com p u lsive d isord er (OCD).
CBT for OCD is the nonp harm acologic ther-
ap eu tic treatm ent of choice. The CBT often
involves exp osu re and resp onse p reven-
tion to help extinguish com pulsions. Fam ily
therapy can be help ful in ad d ressing fam ily-
related issu es contribu ting to the child s
sym ptom s. Grou p therapy can be p art of an
OCD treatm ent, particu larly CBT. Short-term
p sychod ynam ic and sup portive therap ies are
not consid ered ad equ ate treatm ents alone,
althou gh they m ay be help fu l in ad d ress-
ing related issu es su ch as self-esteem and
relationship s.
revised the intellectu al d isabilities (form erly
m ental retard ation, MR) severity scale to be
based on the d egree of d eficits in fu nctional
im p airm ent; su ch ad ap tive fu nctioning
involved ad ap tive reasoning in the follow ing
d om ains: concep tu al, social, and p ractical.
Ind ivid u als m ay fu nction at d ifferent levels
betw een each d om ain. Clinical assessm ent
(i.e., d egree of fu nctional ability) is necessary
to assess ad ap tive fu nctioning and therefore
severity of intellectu al d isability; p sychom et-
rics su ch as IQ testing shou ld be taken into
accou nt, bu t m ay not accu rately assess real-
life fu nctioning and attainm ent of p ractical,
d aily tasks. The d eficits in ad ap tive fu nc-
tioning m u st be related to the intellectu al
im p airm ents and occu r in the d evelop m ental
p eriod . The rep resentative abilities for m ild ,
m od erate, and severe intellectu al d isability
are listed in the qu estion stem . Ind ivid u als
w ith p rofou nd intellectu al d isability gen-
erally are lim ited to concep tu al skills that
involve the p hysical w orld , rather than sym -
bolic p rocesses (concep tu al d om ain), have
lim ited u nd erstand ing of sym bolic com -
m u nication in sp eech or gestu res bu t m ay
u nd erstand som e sim p le instru ctions (social
d om ain), and are d ep end ent on others of
all asp ect of d aily p hysical care, health, and
safety (p ractical d om ain). Of note, the range
of IQ for severe intellectu al d isability (for-
m erly MR) w as historically 25 to 39, for aver-
age (norm al) intelligence w as historically 90
to 110, for m ild intellectu al d isability w as
historically 55 to 70, for m od erate intellectu al

d isability w as 40 to 54, for p rofou nd intellec-
tu al d isability w as below 25, and bord erline
intellectu al fu nctioning w as consid ered an
IQ betw een 71 and 84.
8083. [80. (H), 81. (D ), 82. (G), 83. (L)] Palp itations,
chest pain, shortness of breath, and d iap horesis
com m only occu r d u ring p anic attacks, a com -
p onent of p anic d isord er (H). Binge eating
d isord er (D ) is characterized by sham e and
loss of control over eating large am ou nts of
food , w ithou t com p ensatory behaviors, and
w ithou t bod y im age d istortions. Chap p ed
hand s and other d erm atologic p roblem s are
often p resent in obsessive-com p u lsive d isor-
d er (G) d u e to excessive w ashing w ith w ater
or cau stic cleaning agents. Trichotillom ania
(hair-p u lling d isord er) (L) is m u ch m ore com -
m on in girls, w ith the onset frequ ently starting
w ith, or shortly after, p u berty. The rep eated
p u lling ou t of hair resu lts in d ecreased or
com p lete loss of hair in a sp ecific area. The
scalp , eyebrow s, and eyelashes are the sites
m ost com m only involved . Au tism sp ectru m
d isord er (B) is characterized by im p airm ents
in social interactions and the d evelop m ent of
stereotyp ed or rep etitive p atterns of behav-
iors, bu t w ithou t significant d elay in lan-
gu age skills or cognitive fu nction. Bu lim ia
nervosa (C), seen in 1% to 1.5% of ad olescent
girls and you ng w om en, is a bingeing and
p u rging typ e of eating d isord er; anorexia ner-
vosa (A) is an eating d isord er w ith significant
w eight loss and fear of w eight gain. Illness
anxiety d isord er (E), form erly hyp ochond ria-
sis, is the p reoccu p ation that one has a seriou s
d isease based on m isinterp retation of sym p -
tom s, d esp ite ap p rop riate m ed ical evalu a-
tion and reassu rance. Interm ittent exp losive
d isord er (F) is characterized by recu rrent
ou tbu rsts of behavior, m anifesting as either
verbal or behavioral aggression, that are ou t
of p rop ortion to p rovocation or p recip itating
stressors. Pica (I) is the eating of nonnu tri-
tional su bstances su ch as d irt or p aint. Pyro-
m ania (J) requ ires several criteria, inclu d ing
d eliberate and p u rp osefu l fire-setting and
tension or affective arou sal before the act,
w hich is not better accou nted for by con-
d u ct d isord er, a m anic ep isod e, or antisocial
Answe rs : 7093 29
p ersonality d isord er. Eye tics su ch as blinking
and eye rolling are the m ost com m on initial
sym p tom s in Tou rette d isord er (K). Facial tics
su ch as grim acing or licking m ovem ents and
vocal tics su ch as throat clearing or gru nting
are the next m ost com m on initial sym p tom s.
Whole-bod y tics, su ch as bod y rocking or
p elvic thru sting, and self-abu sive tics, su ch as
hitting, m ay d evelop later.
8487. [84. (E), 85. (A), 86. (G), 87. (F)] Selective m u t-
ism (E) is rare, and child ren w ho su ffer from
it are only m u te in certain situ ations (e.g.,
school). It often involves a stressful life event
such as parents d ivorce and the child ren
are m u te by choice. Blurting ou t in class is a
sym ptom of im pu lsivity that is often seen w ith
ADH D (A). N o langu age im pairm ent is seen
as p art of ADH D. Au tism sp ectru m d isord ers
(B) have both d ifficu lties in social interaction
as w ell as restricted / rep etitive interests, w hile
child ren w ith social (pragm atic) com m unica-
tion d isord er (G) stru ggle w ith the practical
ap p lications and nu ances of both verbal and
nonverbal com m u nication. Child ren w ith lan-
gu age d isord ers (D ) u nd erstand social con-
ventions, bu t stru ggle w ith the acqu iring and
u sing langu age d u e to problem s w ith com p re-
hension or p rod u ction. Child ren w ith gener-
alized anxiety d isord er (C) d isp lay excessive,
d ifficu lt to control w orry, abou t a m ultitu d e
of events; the anxiety or w orry also m anifests
w ith at least one (in child ren) p hysical sym p -
tom . Social anxiety d isord er (social phobia)
(F) is characterized by anxiety in situ ations
w here one is exp osed to be scru tinized ,
ju d ged , or observed .
8893. [88. (D ), 89. (B), 90. (A), 91. (C), 92. (E), 93. (D )]
As children grow , they pass through d ifferent
stages of d evelopment that represent emo-
tional and cognitive maturation. A vital task
of infancy (A) is to establish a secure sense of
trust that occurs in the relationship w ith ones
responsive caregiver. Tod dlers (B) struggle
w ith the increasing understanding that they
are a separate being from their caregiver, and
they practice separating and reuniting w ith
their caregiver as a w ay to consolid ate their
sense of separateness and autonomy. Preschool
30 1: Child a nd Ad ole s c e nt P syc hia try
(C) child rens identification w ith strong and
pow erful characters such as superheroes helps
them cope w ith their ow n feelings of smallness
and inadequacy (as compared to their parents).
This stage is also called the Oedipal phase; at
this time child ren typically experience long-
ings tow ard the parent of the opposite sex and
jealousy and hostility tow ard the same sex par-
ent. School age (D ) child ren d evelop the abil-
ity to think more logically and concretely and
thus can id entify that equal amounts of liquid
in tw o d ifferently shaped containers hold the
same amount; once they are able to grasp this
concept of conversation of liquid s, child ren
have progressed into the stage of concrete
operations, w here they can consistently hold
onto more than one d imension at a time. Ad o-
lescents (E) further advance in cognitive abili-
ties, finally d eveloping the ability to think in
an abstract fashion (reaching the stage Piaget
d escribed as formal operations).
94. (C) The DSM -5 rates the severity of su bstance
u se d isord ers on the basis of how m any cri-
teria are p resent, w ith m ild severity need -
ing tw o to three criteria, m od erate severity
need ing four to five criteria, and severe su b-
stance u se d isord er requ iring m ore than six
criteria. Substance u se criteria includ e trou ble-
som e behaviors and consequ ences associated
w ith the u se, inclu d ing a failu re to m eet w ork
or school expectations (su ch as failing grad es),
p utting oneself at risk (su ch as d riving w hile
u sing) or legal p roblem s. The criteria also
incorp orate evid ence of p hysical and / or p sy-
chological d epend ence on the su bstance; this
inclu d es tolerance, w ithd raw al, heavier u se
than intend ed , and d isp laying an ongoing
d esire or u nsu ccessful attem pts to cut back
on su bstance u se. N either u sing a su bstance
w hile alone nor the frequ ency of u se are
sym ptom s w hen d iagnosing a substance u se
d isord er; how ever, using a su bstance m ost
d ays per w eek and / or u sing alone ind icate
the persons use is m ore extensive and poten-
tially m ore concerning, w hich shou ld prom pt
fu rther qu estioning.
95. (D ) This child fu lfills criteria for cond u ct d is-
ord er, nam ely, three of the fou r follow ing
acts: aggression tow ard p eop le and anim als,
d estru ction of p rop erty, d eceitfu lness, and
seriou s violations of ru les. There is nothing
to su ggest an au tism sp ectru m d isord er, p ar-
ticu larly becau se it w ou ld have likely been
d iagnosed m u ch earlier; m ore im p ortantly,
his actions seem w illfu l and not rep etitive
or stereotyp ed . A child w ith bip olar d isor-
d er m ay d isp lay im p u lsivity and aggressive
behavior, how ever, the child m aintains an
overall sense of right and w rong and often
exp eriences regret for the ou t-of-control
behavior once sym p tom s are im p roved .
Also, bip olar child ren have significant m ood
sym p tom s that u nd erlie their behavior. Chil-
d ren w ith cond u ct d isord er m ay also have a
com orbid m ood d isord er, bu t m ood sym p -
tom s are not necessarily part of the cond uct
d isord er constellation. There is no evid ence of
psychotic symptom s, su ch as hallu cinations
or d elusions that w ou ld be characteristic of
child hood schizophrenia. Oppositional d efi-
ant d isord er requ ires 6 months of negativistic,
hostile, and d efiant behavior d irected mostly
at au thority figures. While it m ay be a p remor-
bid cond ition of cond uct d isord er, it is not as
severe.
96. (B) This child is exhibiting chronic irritability
that is im pairing to his fu nctioning, a hallm ark
of DMDD. The DSM -5 classifies DMDD, a new
d iagnosis, in the d epressive d isord ers seg-
m ent, and it is therefore im p ortant to d istin-
gu ish it from MDD. This p atient d oes not have
a p red om inantly d ep ressed m ood and neuro-
vegetative sym ptom s (e.g., insom nia, anergia,
change in ap petite, poor concentration) that
w ou ld be consistent w ith MDD. Criteria For
DMDD inclu d e that the sym p tom s have been
consistently p resent (3 or m ore per w eek) for
at least 12 m onths, w ithou t a sym ptom -free
p eriod m ore than 3 w eeks; sym p tom s m ust be
p resent by age 10 years, and no earlier than
age 6 years; sym p tom s m u st occu r in at least
tw o of three settings and m u st be severe in at
least one. There is no evid ence of m anic sym p -
tom s (e.g., d ecreased need for sleep, elevated
m ood , p ressu red sp eech, flight of id eas, and
grand iosity) consistent w ith bip olar d isord er.
H e d oes not ap pear to exhibit anxiety over

d ifferent areas of his life to ind icate general-
ized anxiety d isord er. While there is som e
overlap betw een DMDD and ODD (both m ay
be d iagnosed ), p atients w ith ODD d o not have
the pred om inate irritable m ood sym ptom s
intersp ersed w ith the anger ou tbu rsts in m u l-
tiple settings.
97. (C) This stu d ent is m ost likely struggling d ue
to variations in her acad em ic environm ent,
inclu d ing external factors su ch as learning in
English (not her native langu age), likely hav-
ing a gap w ith d isru p tion of her schooling
d ue to w ar, and possibly a lack of equ ivalent
ed u cational op p ortu nity in her hom e cou n-
try. Learning d ifficu lties d ue to neu rological
(e.g., stroke, traum atic brain injury) or sensory
(e.g., hearing or vision im pairm ent) cau ses are
d istinct from specific learning d isord ers. It is
im p erative that sensory d eficits are screened
and treated before giving a psychiatric d iag-
nosis; in this case, there is no ind ication of su ch
a d eficit, w hich, even if corrected , still w ou ld
not accou nt for the variance of this child s aca-
d em ic background . Learning d isord ers are
not m u tu ally exclu sive from PTSD, bu t there
is no evid ence of re-exp eriencing, arou sal, or
avoid ance sym p tom s seen in PTSD.
98. (B) This ch ild is exhibiting sym p tom s of
ARFID, w h ich is ch aracterized by avoid -
ing food or restricting food intake w ith-
ou t intentional efforts to lose w eight and
w ithou t bod y shap e concerns, that resu lt
in nu tritional d eficiencies and w eight loss.
Patien ts w ith ARFID d o not have the sam e
Answe rs : 9499 31
bod y im age concerns as in anorexia, and are
often aw are they are losin g w eigh t. Th ese
p atients tend n ot to binge eat as in bin ge
eatin g d isord er, n or engage in com p ensa-
tory m echanism s to lose w eight, su ch as in
bu lim ia nervosa. While this child d oes have
a fear of vom iting, w hich cou ld be a resu lt
of a sp ecific p h obia, the overarch ing clin ical
concern is her n u tritional statu s, w orsened
by the d istress of eating. For som e child ren,
th e avoid ance m ay be based on the food s
sen sory characteristics. Patients w ho lack an
interest in eating or have a low ap p etite m ay
also qu alify for a d iagnosis of ARFID.
99. (C) This child is struggling with gender d ys-
phoria of childhood. The core feature of gen-
der dysphoria (formerly called gender identity
disorder) is an experience of incongruence
between ones experienced gender and ones
assigned gender. Presentations of exhibited
behaviors differ pre- and post-puberty, but the
core features remain. In body dysmorphic dis-
order, the main feature is perception of a spe-
cific body part as abnormal, not the sense that
one is the wrong gender. In transvestic disor-
der, cross-dressing behavior generates sexual
excitement in heterosexual individuals (most
often) and does not challenge primary gender.
Insistence on being of some other gend er is not
considered delusional in the absence of other
psychotic symptoms. Nonconformity to gender
roles should be distinguished from gender dys-
phoria by the degree of distress and pervasive-
ness of gender-variant activities in the latter,
driven by the desire to be a different gender.
This page intentionally left blank
 CHAPTER 2

Adult Ps yc ho patho lo g y
Que s tions

DIRECTIONS (Questions 1 through 120): For each (D) 50%

of the multiple-choice questions in this section select (E) 100%
the lettered answer that is the one best response in
each case. Questions 3 and 4

A 40-year-old man w ith schizophrenia comes for his

Questions 1 and 2 regular outpatient med ication management appoint-
A 22-year-old single m an is referred to you for a ments. H e reports that over the last w eek his intestines
1-year history of strange behavior characterized and heart have been removed . H e has subsequently
by talking to the television, accu sing local p olice of w ithd raw n and been staying in his basement apart-
bu gging his room , and carrying on conversations ment, avoid ing friend s and family members. When
w ith him self. H is m other d escribes a 3-year history asked about his lack of getting out in the w orld , he
of progressive w ithd raw al from social activities, responds, What w orld? There is no w orld!
and reports the p atient d ropp ed ou t of college and
since has been living in his room at hom e. Attem pts 3. Which of the follow ing term s best d escribes
to hold a job as a bu sboy at a local restaurant have this sym p tom ?
abruptly end ed after d isp u tes w ith the em p loyers. (A) Cap gras synd rom e
(B) Cotard synd rom e
1. What is the p revalence of this patients likely
(C) Folie d eu x
illness in the general p op u lation?
(D) Fregoli d elu sion
(A) 0.1% (E) Major d ep ressive d isord er
(B) 1%
(C) 2% 4. Up on retu rning for a follow -u p visit 15 d ays
(D) 3% later, the p atient now claim s that cyborg
(E) 5% alien robots that look id entical to his p arents
have recently rep laced his m other and father.
2. The p atients m other inform s you that he has Which of the follow ing term s best d escribes
an id entical tw in brother. What is the likely this sym ptom ?
chance of the patients tw in also having the (A) Cap gras synd rom e
sam e illness? (B) Cotard synd rom e
(A) 1% (C) Delu sional d isord er
(B) 10% (D) Folie d eu x
(C) 20% (E) Fregoli d elu sion

33
34 2: Ad ult P sychop a thology
5. A 32-year-old w om an w ith a history of d ep res-
sion as a teenager, now 6 d ays p ostp artu m , is
brou ght into the em ergency room by her hu s-
band . She has not slep t for the p ast several
d ays, even w hile the new born is nap p ing.
She has been irritable, and has been pacing in
the m id d le of the night and w eeping, w hile
talking to no one in particular. Yesterd ay she
began to ignore the infant, bu t tod ay she vol-
u nteered that the child is the Antichrist and
m ust be d estroyed . She ad m its to you that
she w ants to sm other the infant in a hu m ane
w ay to p revent the ap ocalyp se. Which of the
follow ing d iagnoses is the m ost likely?
(A) Bip olar d isord er
(B) Delu sional d isord er
(C) Major d ep ressive d isord er (MDD) w ith
p sychotic featu res
(D) Schizoaffective d isord er
(E) Schizop hrenia
Questions 6 through 8
An 18-year-old college freshm an w ithou t p rior p sy-
chiatric history is brought to the em ergency room
after being fou nd on her d orm itory roof d ressed only
in her u nd erw ear, d esp ite freezing tem p eratu res.
Cam pu s p olice report she w as flapping her hand s
and clim bing the banister on the roof, stating to an
u nseen other, I w ill d o as you com m and soar to
m y d eath to fu lfill your p rophecy! She accu sed the
p olicem en of being Satans horsem en and cu rsed
as she w as being taken d ow n. H er room m ates con-
firm that for the p ast 5 w eeks the patient has been
acting bizarrely, and her speech has been increas-
ingly d isorganized . You p lan to obtain collateral
inform ation from her fam ily.
6. Which of the follow ing features w ou ld you be
m ost likely to find in her history?
(A) H ead trau m a
(B) Low intelligence
(C) N eglectfu l m other
(D) Physical or sexu al abu se
(E) Progressive social w ithd raw al
7. She is ad m itted to the psychiatric unit. H er
p hysical exam ination is unrem arkable, and
her blood alcohol is und etectable. H er urine
toxicology results com e back positive for can-
nabis, w hich she confirm s she started sm oking
abou t 3 m onths ago. Which of the follow ing
w ou ld be the m ost ap p rop riate p rovisional
d iagnosis?
(A) Brief p sychotic d isord er
(B) Schizop hreniform d isord er
(C) Schizop hrenia
(D) Su bstance-ind u ced m ood d isord er
(E) Su bstance-ind u ced p sychotic d isord er
8. She w as started on appropriate treatm ent. One
year later this w om an retu rns to you r office
w ith her m other for follow -u p . H er sym p tom s
rem itted w ithin a m onth. H ow ever, she has
not d one w ell in her freshm an year and for the
p ast several m onths has continu ed to exp eri-
ence w orsening social isolation and am otiva-
tion. While she has not u sed any su bstances
since she last saw you , she relu ctantly ad m its
to occasionally hearing the d evil com m u nicat-
ing w ith her. She tries to ignore the com m u ni-
cation, and has taken to arranging her books
in a certain m anner to p revent his controlling
her thoughts. On her m ental statu s exam ina-
tion she m akes poor eye contact and her affect
is blu nted . H er m other rep orts that the p atient
now rarely calls hom e, thou gh before shed d o
so tw ice w eekly. Which of the follow ing is the
m ost likely d iagnosis?
(A) Brief p sychotic d isord er
(B) Schizop hreniform d isord er
(C) Schizop hrenia
(D) Su bstance-ind u ced m ood d isord er
(E) Su bstance-ind u ced p sychotic d isord er
9. A 42-year-old w om an p resents to a therap ist
w ith a history of d ram atic m ood sw ings since
early ad olescence, w here she w ill qu ickly
becom e d eep ly d ep ressed for hou rs to d ays,
u su ally in resp onse to sep aration from a
loved one. She also ad m its to rage attacks,
w here she w ill break item s, scream , or scratch
herself su p erficially on her arm s. She inter-
m ittently binge d rinks and has frequ ently
engaged in u np rotected sexu al intercou rse
w ith new p artners. Others d escribe her as

reactive and intense. Which of the follow -
ing d efense m echanism s d oes this p atient
m ost likely em p loy?
(A) Altru ism
(B) Intellectu alization
(C) Sp litting
(D) Sublim ation
(E) Und oing
10. The fam ily of a 26-year-old patient w ith
schizophrenia brings him in for follow -u p.
H e w as initially d iagnosed at age 25 after a
psychotic break that, in retrosp ect, follow ed a
protracted cou rse of increasing isolation and
am otivation. Desp ite d ifficu lties, he w as able
to grad u ate from college and hold a fu ll-tim e
job by age 23. H e reports interm ittent hallu ci-
nations, bu t has been able to m aintain ind e-
pend ent living and p art-tim e em p loym ent.
On exam ination, he is a d isheveled m an w ho
articu lates a m u ltitu d e of d elu sional beliefs
w ith a sophisticated vocabu lary. Which of
the follow ing characteristics in this patient is
m ost strongly associated w ith a better overall
prognosis?
(A) Age at presentation
(B) Gend er of p atient
(C) Insid iou s sym p tom onset
(D) Pred om inantly p ositive sym p tom s
(E) Prem orbid fu nctioning
Questions 11 and 12
A 36-year-old patient w ith no previou s psychiatric
history is brou ght to the em ergency room by his
fam ily. For the p ast m onth he has not been eating
regu larly and has isolated him self in the ap artm ent
w here he lives alone. Tw o m onths ago he stop p ed
fishing, and rep orted feeling like a bu rd en on his
fiance. On m ental statu s exam ination, he d isp lays
p sychom otor retard ation and rarely blinks. H e
resp ond s in the negative to any qu estion asked .
On physical exam ination, he app ears in no acute
d istress, is afebrile, m arginally hypotensive, and
m ild ly tachycard ic. H e resists you r m otions w ith
strength proportional to w hat you exert and crud ely
m im ics your m ovem ents. H is laboratory stu d ies are
u nremarkable.
Que s tions : 513 35
11. Which of the follow ing d iagnoses is the m ost
likely?
(A) Catatonia associated w ith m ajor
d ep ressive d isord er
(B) Catatonia associated w ith schizop hrenia
(C) H yp othyroid ism
(D) N eu rolep tic m alignant synd rom e
(E) Unsp ecified catatonia
12. Recognizing the clinical situ ation in front of
you , you ad m it the p atient to the p sychiatric
w ard for inability to care for self. Which of the
follow ing treatm ents w ou ld be best started
im m ed iately?
(A) Am itriptyline
(B) Electroconvulsive therapy (ECT)
(C) Lithiu m
(D) Lorazep am
(E) Sertraline
13. A 49-year-old bank teller w ith no know n psy-
chiatric history is referred to your office by
her internist for an evaluation. For the p ast
2 m onths, she has been increasingly convinced
that a w ell-know n m usic star is in love w ith
her and that they have had an ongoing affair.
She is w ell-groom ed , and there is no evid ence
of thou ght d isord er or hallucinations. She has
been fu nctioning w ell at w ork and in other
social relationships. Which of the follow ing is
the m ost likely d iagnosis?
(A) Brief psychotic d isord er
(B) Delusional d isord er
(C) Paranoid p ersonality d isord er
(D) Schizop hrenia
(E) Schizop hreniform d isord er
Questions 14 and 15
A 46-year-old d ivorced w om an w ith a history of
m ajor d ep ressive d isord er is ad m itted to you r
inp atient p sychiatric u nit follow ing an intentional
acetam inop hen overd ose. She has had m u ltip le
psychiatric hospitalizations w ith similar presen-
tations. The patient reports a 3-w eek history of
insom nia, d ifficulty concentrating, low energy,
hop elessness, and a d ecreased app etite. She has been
36 2: Ad ult P sychop a thology
unable to w ork recently because of her d epression
and has lost interest in activities she once enjoyed .
She has no history of manic episod es. H er past psy-
chiatric history is significant for a prior episod e of
d epression after the birth of her second child . She
has u nd ergone treatment w ith several ad equ ate tri-
als of m ed ications, inclu d ing au gm entation w ith
lithium, yet she has continued to have resid ual
sym ptoms of d epression. She has never been treated
w ith psychotherapy. In the past she has experienced
au d itory hallucinations w hen her d epression w as
most severe. H er med ical history is significant for
hyp othyroid ism , w hich is ad equately m anaged w ith
levothyroxine. She also had prior surgery after a leg
fracture from a suicid e attem pt w here she jumped
ou t of a w ind ow .
14. Which of the following factors would be most
influ ential in you r recom m end ing electro-
convu lsive therapy (ECT) for this patient?
(A) Concu rrent thyroid d ysfu nction w ith
ad equate treatm ent
(B) H istory of associated p sychotic
sym ptom s w ith prior d epression
(C) H istory of p erip artu m d ep ression
(D) Severe d ep ression that has not
resp ond ed to several m ed ications
(E) Treatm ent-resistant d ep ression w ith
recu rrent su icid al id eation
15. The ind ications for ECT are d iscu ssed w ith
the patient, as w ell as the risks, benefits, and
sid e effects. She asks appropriate qu estions
and consents to ECT. Fu rther m ed ical history
is exp lored p rior to beginning the p roced u re.
Which of the follow ing cond itions w ou ld be a
relative contraind ication to p roceed ?
(A) Coronary artery d isease, w ith a
m yocard ial infarction 2 years ago
(B) Im p lanted p acem aker for p eriod ic
arrhythm ia
(C) Incid entally fou nd frontal m eningiom a
m easu ring 10 cm in d iam eter
(D) Second -trim ester p regnancy
(E) Trau m atic brain inju ry su stained in
teenage years
Questions 16 and 17
A 34-year-old w hite m ale is referred by his p rim ary
care physician for d epression. Upon initial inter-
view , he com plains of feeling blue. H is m ental
statu s exam ination reveals a d isheveled ap pearance,
d ep ressed m ood , p sychom otor retard ation, and su i-
cid al id eation w ithout plan. H is thought processes
are significant for thou ght blocking and som e slow -
ing. Deficits w ith rem ote and short-term m em ory
are noted . Ju d gm ent and insight are also im p aired .
You r provisional d iagnosis is m ajor d epressive
d isord er.
16. Which type of sleep d istu rbance you w ould
m ost exp ect to see in this patient?
(A) Decreased resp onse to sed ative d ru gs
(B) Early m orning aw akening
(C) Increased rap id eye m ovem ent (REM)
stage latency
(D) Sleep ing too d eep ly (d ifficu lty being
aw akened )
(E) Sleep ing too lightly (aw akened too
easily)
17. Which of the follow ing m etabolic changes
w ou ld be m ost likely fou nd in this p atient?
(A) Decreased m onoam ine oxid ase (MAO)
activity
(B) Increased catecholam ine activity
(C) Increased cortisol secretion
(D) Increased sex horm ones
(E) Increased im m u ne fu nctions
Questions 18 and 19
A 35-year-old m an is being treated for m ajor d ep res-
sive d isord er w ith paroxetine. H e has m issed his last
tw o appointm ents, leaving m essages telling you that
Ive been sp ectacular! H is w ife has since called
you to rep ort that her hu sband has been sp end ing
m oney on frivolou s item s and overd rew the cou -
p les bank account. She states that her hu sband now
quickly becom es agitated and angry. During the
interview in you r office, the p atient qu estions you r
cred entials and accu ses you of being m ore loyal to
his w ife than to him . Most of the interview is spent
interru p ting the p atient as you try to d ecip her his
 Que s tions : 1423 37

rap id sp eech. In his rant he threatens to cu t the brake 20. Which of the follow ing d iagnoses is m ost
lines on his m other-in-law s car becau se he feels she likely?
has been intru d ing in his m arriage.
(A) Bip olar I d isord er
18. Which of the follow ing is the next m ost (B) Bip olar II d isord er
ap propriate step ? (C) Cyclothym ic d isord er
(D) Dou ble d ep ression
(A) Discharge the p atient hom e as he
refu ses ad m ission, bu t see him (E) Persistent d ep ressive d isord er
tom orrow
21. The patient returns w ithin 4 w eeks, and he now
(B) Escort the p atient (w ith p olice assistance
d escribes w orsening d epression for the past
as need ed ) to the nearest em ergency
3 w eeks, w ith ongoing insomnia, poor appetite,
room
little energy, anhed onia, and poor concentra-
(C) Inform the m other-in-law that she is in tion. H e also ad mits to passive suicidal ideation
d anger w ithout plan. Which of the follow ing w ould be
(D) Inform the p olice that a threat has been the most likely d iagnosis?
m ad e against the m other-in-law
(A) Bip olar I d isord er
(E) Tell the w ife to have the m other-in-law
stay w ith her (B) Bip olar II d isord er
(C) Cyclothym ic d isord er
19. After ad d ressing the above situ ation, the (D) Dou ble d ep ression
p atient is su bsequently started on valp roic (E) Persistent d ep ressive d isord er
acid . Which of the follow ing ad d itional p har-
m acologic interventions w ould be the m ost Questions 22 and 23
ap prop riate?
A 26-year-old fem ale p resents to the psychiatric
(A) Check a seru m p aroxetine level em ergency d ep artm ent in an acu tely d istressed ,
(B) Cross tap er the p aroxetine to nervou s state. She com p lains of terrible anxiety,
nortrip tyline and the em ergency d ep artm ent staff is u nable to
(C) Discontinu e the p aroxetine calm her d ow n or gain an ad equ ate history from
(D) Initiate bu p rop ion the patient. On physical exam ination, she is slightly
(E) Initiate lorazep am d iaphoretic, tachycard ic, and her pup ils are m ild ly
d ilated . She is on no m ed ications.
Questions 20 and 21
22. Which of the follow ing tests w ould be the
A new patient com es to you r office for a p sychiat- m ost useful in d eterm ining the etiology of her
ric evalu ation. H e d escribes m any years w here he sym ptom s?
experiences episod es of 5 to 7 d ays of feeling very
(A) Blood glu cose
d epressed , w ith insom nia, low energy, and poor
concentration. H e d enies any suicid al id eation or (B) Catecholam ine m etabolites
prior attem p ts. Up on further history he reveals (C) Electrocard iogram (ECG)
ad d itional period s w here I feel the opp osite, w ith (D) Thyroid fu nction
d ecreased sleep, elevated energy, feeling on top of (E) Urine toxicology
the w orld , and increased sex d rive. These tim es last
1 to 2 w eeks, and he d enies any p aranoia, d elu sions, 23. Which of the follow ing su bstances w ou ld be
or hallu cinations. Desp ite these recu rrent ep isod es, m ost likely to app ear on her urine toxicology
he has alw ays been able to fu nction ad equ ately, resu lts?
although they rem ain d istressing to him . H e d enies
any d ru g or alcohol u se, and he has no significant (A) Caffeine
m ed ical p roblem s. (B) Cannabis
38 2: Ad ult P sychop a thology

(C) Cocaine the staff reports that she has becom e extremely d oc-
(D) Op iates ile and d isplays very little emotion. She has a large
(E) LSD appetite and compu lsively puts both food and non-
food item s in her mouth. She also d isplays sexual
Questions 24 through 26 d isinhibition, often w alking out of her room w ithout
her pants on.
A 46-year-old m an is ad m itted to the hospital for
elective cholecystectom y. On hosp ital d ay 4, he is 27. Which of the follow ing clinical cond itions best
noted to be afebrile, but acutely d iaphoretic, tachy- d escribes her behavior?
card ic, hypertensive, trem ulou s, and agitated . H e
(A) Arnold Chiari synd rom e
tears ou t his sutures and insists on leaving against
m ed ical ad vice (AMA). H e is ap parently hallu cinat- (B) Kl verBu cy synd rom e
ing, ju d ging from his insistence that he be allow ed (C) Mbiu s synd rom e
to squ ash those bu gs on the w all (there are none). (D) Pick d isease
(E) Pu nch-d ru nk synd rom e
24. Which of the follow ing d iagnoses is the m ost
likely? 28. N eu roim aging w ou ld m ost likely show d am -
(A) Brief psychotic d isord er age to w hich tem p oral lobe stru ctu re?
(B) Delirium (A) Am ygd ala
(C) Delu sional d isord er (B) H ip p ocam p u s
(D) Fu nctional neu rological sym p tom (C) Inferior horn of the lateral ventricle
d isord er (D) Insu la
(E) Postoperative sepsis (E) Su p erior tem p oral gyri

25. Which of the follow ing m ed ications w ou ld be Questions 29 and 30

m ost app rop riate to treat his cond ition?
A 22-year-old w oman presents w ith fatigue for 4
(A) Diazep am months. She also reports irritability and poor energy,
(B) Disulfiram w ith dismal sleep and poor concentration. She has
(C) Lorazep am maintained a rigorous exercise routine, as she states
(D) Phenobarbital it makes her feel good to run off her boyfriends cook-
(E) Phenytoin ing. Her oral intake has sharply d ropped and she has
lost a significant amount of w eight, but she explains
26. If u ntreated , w hat w ou ld be his m ost likely that she hasnt been as hungry d ue to increased
mortality rate? stress. H er thyroid stud ies are normal, her CBC
reveals anemia, and she is not pregnant, in fact stat-
(A) 5% ing that she hasnt had a period in several months.
(B) 10%
(C) 30% 29. Up on fu rther qu estioning, w hich of the
(D) 50% follow ing qu alities w ou ld you m ost exp ect to
find in her social history?
(E) 60%
(A) H er p arents likely p raise her su ccesses.
Questions 27 and 28 (B) She has a legal history significant for
A 62-year-old w om an presents to the nu rsing home reckless d riving.
w here you w ork as a consulting psychiatrist. She has (C) She has asp ired to be a m od el.
a history of a bilateral tem poral lobectomy for intrac- (D) She is of low socioeconom ic statu s.
table seizures. After a few w eeks at the new facility, (E) She is a scholastically gifted
in ad d ition to her short-term m em ory d ifficulties, perfectionist.

30. Which of the follow ing d iagnoses is the m ost
likely?
(A) Anorexia nervosa
(B) Avoid ant/ restrictive food intake
d isord er (ARFID)
(C) Bu lim ia nervosa
(D) Exercise-ind u ced am enorrhea
(E) Obsessive-com p u lsive d isord er (OCD)
31. A 23-year-old college stu d ent has been su f-
fering w ith frequ ent ep isod es of feeling
u tter d oom for the p ast 3 m onths. Du ring
these p eriod s, he also experiences trem u lou s-
ness, sw eating, d izziness, and tingling in his
extrem ities. H e rep orts having these attacks at
least once a w eek and is now becom ing fear-
fu l of attend ing classes lest he has an ep isod e.
Which of the follow ing m ed ications w ou ld be
the m ost appropriate for im m ed iate relief of
his sym ptom s?
(A) Alprazolam (Xanax)
(B) Chlord iazep oxid e (Libriu m )
(C) Divalp roex sod iu m (Dep akote)
(D) Fluoxetine (Prozac)
(E) Phenelzine (N ard il)
Questions 32 and 33
A 36-year-old grad u ate stu d ent com es to you r
office because of d ifficulty sleep ing since breaking
up w ith his fiance 5 m onths ago. H e is sp end ing
at least 2 hours in bed thinking abou t his ex-fiance
and w hat he cou ld have d one d ifferently. H is con-
centration is w orsening and hes having d ifficu lties
com pleting his coursew ork. While he feels d ow n, he
is not su icid al, and he is seeking su p p ort of friend s
in the p ost-breaku p p eriod . H e is attend ing m ost
classes. H e d escribes feeling tenser overall, espe-
cially w hen he is at a bar. H e is having m ore trouble
relaxing and has noted the new onset of low back
and should er pain.
32. Which of the follow ing is the m ost likely
d iagnosis?
(A) Acu te stress d isord er
(B) Ad ju stm ent d isord er
(C) Generalized anxiety d isord er
Que s tions : 2434 39
(D) Major d ep ressive d isord er
(E) N orm al reaction
33. Seven m onths later, your patients m ood has
w orsened , and he feels w orthless and hop e-
less that he w ill never find another girlfriend .
H e has lost a few p ou nd s and has not resu m ed
d ating, p referring to isolate him self in his
stu d io apartm ent. H e is still feed ing his d og,
bu t he has had to m iss increasing am ou nts of
w ork becau se he ju st cant get him self to get
read y for class. Which of the follow ing is the
m ost likely d iagnosis?
(A) Acu te stress d isord er
(B) Ad ju stm ent d isord er
(C) Generalized anxiety d isord er
(D) Major d ep ressive d isord er
(E) N orm al reaction
34. A 21-year-old college stu d ent is brou ght to
you r office by her p arents after com p leting
her spring sem ester w ith u ncharacteristically
low grad es. H er p arents rep ort that since
the sp ring session end ed 2 m onths ago their
d au ghter has been staying in her room , bu t
is irritable w hen they try to engage her in
conversation. She is not interested in fam ily
barbecu es or being a cou nselor for the p ark
d istrict soccer cam p . After her p arents leave
the exam ination room , your patient d iscloses
she has been feeling d epressed since a m onth
before final exam inations, and her concen-
tration and sleep have been horrible. She
had su icid al thoughts after she got her report
card back, but d enies them cu rrently. She also
ad m its to d rinking alcohol to m ake herself feel
better, and her intake ranges from 3 to 4 beers
or shots of liqu or m ost d ays of the w eek. Asid e
from likely alcohol u se d isord er, w hich of the
follow ing d iagnoses is the m ost ap p rop riate at
this tim e?
(A) Acu te stress d isord er
(B) Ad ju stm ent d isord er
(C) Am otivation synd rom e
(D) Major d ep ressive d isord er (MDD)
(E) Su bstance-ind u ced m ood d isord er
40 2: Ad ult P sychop a thology
35. A 37-year-old w om an, w ho w orks the night
shift at a local grocery store taking inventory,
reports that her child hood and college years
w ere u neventfu l bu t hap p y. She sp end s m ost
of her tim e alone w hen she is not at w ork.
She d oes not ventu re out of her house and
her social contacts are lim ited to w ork-related
interactions w ith cow orkers. She is an avid
p lant lover, and she spend s m ost of her free
tim e taking care of her ind oor nursery. She
reports that she is quite content w ith her life.
Which of the follow ing is the m ost likely d iag-
nosis for this p atient?
(A) Agorap hobia
(B) Au tism sp ectru m d isord er
(C) Avoid ant p ersonality d isord er
(D) Schizoid p ersonality d isord er
(E) Schizotyp al p ersonality d isord er
36. An 18-year-old , p regnant, hu m an im m u no-
d eficiency virus (H IV)p ositive w om an pres-
ents for the treatm ent of op iate u se d isord er.
She reports u sing heroin for the last 8 m onths
w ith su bstantial (bu t u nsu ccessfu l) efforts to
qu it for the last 4 m onths. She is now hom eless
and has recently been arrested for shop lifting.
Which of the follow ing pharm acological ther-
ap ies w ould be the m ost ap prop riate at this
tim e?
(A) Bu prenorphine
(B) Clonid ine
(C) H alop erid ol
(D) Methad one
(E) N aloxone
37. A 47-year-old w om an transfers care to you r
office. She has a long history of recu rrent
d epression. She also has a history since her
early tw enties that is significant for interm it-
tent com m and au d itory hallucinations and
p ersecu tory d elu sions that are often p res-
ent even w hen her affective sym p tom s are in
rem ission. She hold s a p art tim e job and lives
ind ep end ently. She has been com p liant w ith
m ed ications and has not been hosp italized
since a su icid e attem p t over 7 years ago. Which
of the follow ing is the m ost likely d iagnosis?
(A) Bipolar d isord er w ith psychotic features
(B) Major d ep ressive d isord er w ith
p sychotic featu res
(C) Schizoaffective d isord er
(D) Schizop hrenia
(E) Schizop hreniform d isord er
38. A 42-year-old bu siness execu tive p resents for
his first contact w ith a m ental health provid er.
H e rep orts that for the last 4 m onths he has
been feeling d ep ressed . H is low -energy level
and p oor m otivation are affecting his job
p erform ance and the CEO of his com p any
ad vised him to take a cou p le of w eeks off.
The p atient rep orts that he started feeling
d ow n w hen his w ife d iscovered that he w as
involved in his third extram arital affair. Since
then he has m oved into a sm all apartm ent by
him self. H e is sleep ing alm ost 12 hou rs every
night, has a p oor app etite, and is exp erienc-
ing financial d ifficu lty d u e to ind iscrim inate
p u rchases. H e lam ents the loss of his form er
self. H e reports that he u sed to have several
p eriod s of tim e p er year, lasting for u p to
1 w eek, w hen he only need ed 4 to 5 hou rs
of sleep, had large am ou nts of energy, spoke
qu ickly, and cou ld p arty all night and w ork
all d ay. Which of the follow ing d iagnoses is
m ost likely in this case?
(A) Bipolar I d isord er
(B) Bip olar II d isord er
(C) Bord erline p ersonality d isord er
(D) Major d ep ressive d isord er
(E) N arcissistic p ersonality d isord er
39. A 52-year-old w om an w ho has been treated
w ith m ed ication for 3 years for a chronic m ood
d isord er reports d ry m ou th, trou ble u rinating,
and occasional d izziness w hen she gets ou t
of bed . Which of the follow ing m ed ications is
she m ost likely being prescribed ?
(A) Divalp roex sod iu m
(B) Flu oxetine
(C) Im ip ram ine
(D) Lithiu m
(E) Phenelzine

Questions 40 and 41
A 72-year-old m an is brou ght in by his w ife to you r
geriatric p sychiatry clinic. The p atients w ife is con-
cerned abou t his progressive confu sion over the last
year. She is p articu larly d istressed that he rep eat-
ed ly asks the sam e qu estions throu ghou t the d ay.
H er hu sband has becom e increasingly u nstead y on
his feet and need s to u se a w alker w hen they go ou t.
She w ond ers if these sym ptom s m ay be related to
the m eningitis he su ffered from 3 years ago.
40. Which of the follow ing sym p tom s or signs
w ou ld m ost likely be fou nd in this p atient?
(A) Elevated opening p ressu re u p on lu m bar
p unctu re
(B) Frontal release signs
(C) H istory of incontinence
(D) Ocu lom otor d ifficu lties
(E) Perseveration
41. Which of the follow ing w ou ld m ost likely
be fou nd on neu roim aging w ith com p u ted
tom ography (CT) in this p atient?
(A) Cerebellar atrop hy
(B) Dilated lateral ventricles
(C) Focal su bcortical hyp ointensities
(D) Frontoparietal atrop hy
(E) Frontotem p oral atrop hy
Questions 42 through 44
A 69-year-old w om an is brou ght to you r geriatric
psychiatry clinic by her hu sband . She d enies any-
thing is w rong, but he is concerned that for the past
year or so she has been less able to recall things she
read s abou t in her m agazines. She u sed to be in
charge of grocery shopping, but over the past year
or so she has been leaving things off the list, and
her husband has taken over the job since the p atient
cant seem to organize it anym ore. She is no longer
able to keep track of the cou p les finances, and there
have been several occasions w hen her son fou nd
her w and ering ou tsid e, a nu m ber of hou ses aw ay.
She is otherw ise healthy, and takes a m ultivitam in
d aily. H er physical exam ination is unrem arkable.
Mental status exam ination reveals a healthy ap pear-
ing w om an w ho is coop erative w ith you r qu estions,
Que s tions : 3545 41
and lau ghs w hen she cannot recall any of the three
item s you ask her to rep eat. H er attention is intact.
She has som e d ifficulties nam ing objects. She states
her m ood as good and her affect is euthym ic and
fu ll range.
42. Which of the follow ing is the m ost ap propriate
p rovisional d iagnosis?
(A) Deliriu m
(B) Major d ep ressive d isord er
(C) Major neu rocognitive d isord er
(D) Mild neu rocognitive d isord er
(E) N orm al p ressu re hyd rocep halu s
43. A w orkup is p erform ed . H er laboratory val-
u es are u nrem arkable, and a CT scan of her
brain d em onstrates d iffu se cortical atrop hy
and norm al ventricles. Which of the follow ing
d iagnoses is m ost likely?
(A) Major neu rocognitive d isord er d u e to
Alzheim er d isease
(B) Major neu rocognitive d isord er d u e
to Lew y bod y d isease
(C) Major neu rocognitive d isord er d u e
to trau m atic brain inju ry
(D) Major neu rocognitive d isord er d u e to
vascular d isease
(E) Unsp ecified m ajor neu rocognitive
d isord er
44. If the p atients CT scan revealed a p rep ond er-
ance of atrophy in the frontal and tem p oral
regions, w hich of the follow ing behavioral
m anifestations w ou ld be m ost likely?
(A) Decline in object nam ing
(B) Mem ory p roblem s
(C) Poor organization
(D) Social d isinhibition
(E) Word find ing d ifficu lty
45. A 48-year-old m an has been d rinking u p to
6 beers p er night d u ring the w eek and u p to
12 beers a night on the w eekend . A year ago,
he had his d river s license su spend ed for
d ru nk d riving. H is m arriage is failing becau se
of these d ifficulties. Last m onth, he w as d iag-
nosed w ith a gastric u lcer as a result of alcohol
42 2: Ad ult P sychop a thology

consum ption. H e ad m its to an alcohol p rob- becom es ju m p y w henever she hears the
lem and has tried to stop on nu m erou s occa- train going by her hom e. Which of the follow -
sions. H e find s that he experiences insom nia if ing d iagnoses is the m ost ap p rop riate for this
he d oes not d rink for m ore than 2 d ays. Which p atient?
of the follow ing featu res of this case su ggests a
(A) Acu te stress d isord er
severe versus m od erate alcohol u se d isord er?
(B) Ad ju stm ent d isord er
(A) H igh qu antity of alcohol consu m ed on a (C) Generalized anxiety d isord er (GAD)
regu lar basis
(D) Posttrau m atic stress d isord er (PTSD)
(B) H istory of legal problem s
(E) Major d ep ressive d isord er (MDD)
(C) Inability to stop d rinking d esp ite
know ing the harm fu l effects Questions 48 and 49
(D) Marital conflict d u e to d rinking
(E) N u m ber of d ifficu lties he is A 40-year-old w om an w ith a 20-year history of
experiencing schizophrenia p resents to the p sychiatric em ergency
d ep artm ent after a su icid e attem p t by carbon m on-
46. A 26-year-old com pu ter p rogram m er w ithou t oxid e poisoning. She has ongoing com m and hal-
p reviou s p sychiatric history has been m ar- lu cinations to harm herself, and has acted on them
ried for 4 years. H is w ife is exp ecting their at least 10 tim es since her initial d iagnosis. She also
first child . She rep orts that 3 m onths ago the has p ersistent d elu sions that she is resp onsible for
p atient becam e p reoccup ied w ith the id ea w orld d isasters, w hich is w hy she m u st elim inate
that she becam e pregnant by another m an. herself as the sou rce of pain and su ffering in the
Du ring this tim e, he began m issing w ork and w orld . She has been tried on both typ ical and atyp i-
isolated him self in his bed room . H is affect has cal antipsychotics, thou gh none have been effective
p rogressively becom e m ore blu nted . Recently, in fu lly elim inating her p sychotic sym p tom s. H er
he believes that his w ife is carrying a child level of fu nctioning rem ains p oor, and she p resently
conceived by extraterrestrial forces. H e u rged lives in a grou p hom e.
her to have an abortion and she refu sed .
The p atient d enies any history of significant 48. Which of the follow ing is this p atients m ost
alcohol or illicit su bstance u se and his recent likely lifetim e risk of su icid e?
m ed ical evalu ation w as w ithin norm al lim its. (A) 1%
Which of the follow ing is the most app ropriate (B) 5%
d iagnosis?
(C) 10%
(A) Brief p sychotic d isord er (D) 30%
(B) Delu sional d isord er (E) 50%
(C) Major d ep ressive d isord er w ith
p sychotic featu res 49. Which of the follow ing m ed ications w ou ld
(D) Schizop hreniform d isord er be the m ost ap p rop riate to p rescribe for this
(E) Schizop hrenia p atient?
(A) Clozap ine
47. A 27-year-old w om an w as involved in a train (B) Flu p henazine
d erailm ent 2 w eeks ago. Since that event, she
(C) H alop erid ol
has felt d ow n, has not slept w ell, has exp e-
(D) Lithiu m
rienced rep eated and intru sive thou ghts of
the accid ent, and has recu rrent nightm ares. (E) Zip rasid one
Lately, she has changed her com m u te to avoid
the train, even thou gh this ad d s 3 hours to her 50. A 27-year-old internal m ed icine resid ent gen-
com m ute d aily. When on the train she has an erally d islikes w orking in an ou tp atient clinic.
acu te increase in her anxiety. She also often Tod ay, how ever, he is looking forw ard to his
 Que s tions : 4655 43

clinical w ork becau se one of his app ointm ents 53. In this p atient, w hich typ e of p sychotherap y
is a follow -u p visit for a single, attractive w ou ld be the m ost efficaciou s?
31-year-old w om an w ho is finishing her anti-
(A) Cognitive-behavioral therap y (CBT)
biotic regim en for treatm ent of p neu m onia.
Which of the follow ing term s bests d escribes (B) Dialectical behavioral therap y (DBT)
this d octor s resp onse to his patient? (C) Grou p therap y
(D) Psychoanalysis
(A) Cou ntertransference
(E) Psychod ynam ic therap y
(B) Em pathy
(C) Id entification Questions 54 and 55
(D) Projection
(E) Transference A 34-year-old w om an p resents for the treatm ent of
her severe, m ed ication-refractory, m ajor d epressive
Questions 51 through 53 d isord er. After review ing her p ast p sychiatric his-
tory and interview ing the patient, you conclu d e that
A 31-year-old w om an w as ad m itted to a p sychiatric she w ou ld be app ropriate for ECT.
u nit after attem pting suicid e by overd ose. She had
recently broken u p w ith her boyfriend of 4 m onths. 54. In d iscu ssing the effects of ECT w ith the
She also d escribes episod es of m ood lability, m arked patient, w hich of the follow ing should you tell
by feelings of d ep ression and anger d irected tow ard her is the m ost likely sid e effect?
the psychiatric resid ent w ho com pleted the rota-
(A) Am nesia
tion 5 d ays after her ad m ission. When the resid ent
left, she rep orted that she w as having u rges to cu t (B) Asp iration
her w rists. She has had nu m erou s ad m issions for (C) Card iac arrhythm ias
su icid al gestu res and a lifelong history of tu m u ltu - (D) Convu lsion fractu res
ou s rom antic relationships. As the patient nears her (E) Psychosis
d ischarge d ate, she rep orts that all the staff hates
m e except for Dr. Johnson. Dr. Johnson, a m ed ical 55. For the best p ossible ou tcom e, how m any
stu d ent, had a recent d ifference of opinion w ith the treatm ents is this patient likely to requ ire?
nursing staff regard ing the patients d ischarge.
(A) 2
51. Which of the follow ing d iagnoses is the m ost (B) 4
likely for this patient? (C) 10
(D) 15
(A) Bord erline personality d isord er
(E) 20
(B) Cyclothym ic d isord er
(C) H istrionic p ersonality d isord er
Questions 56 and 57
(D) Major d ep ressive d isord er (MDD)
(E) Schizoaffective d isord er A 38-year-old w om an p resents to your clinic telling
you that she has had d istu rbing, recu rrent thou ghts
52. Which of the follow ing w ou ld be the m ost abou t harm ing her 7-m onth-old infant. She im ag-
ap p rop riate ou tp atient treatm ent for this ines u sing a knife to stab her child , bu t she has no
p atient? d esire to hu rt her child . As a resu lt of having these
d istressing thou ghts, she has rem oved all sharp
(A) Antid epressants objects from her kitchen. Because of this, she has not
(B) Benzod iazepines been able to p rep are m eals at hom e and has chosen
(C) Grou p p sychotherap y to buy fast food or take ou t for the fam ily m eals. She
(D) Ind ivid u al psychotherap y feels very anxiou s regard ing these, althou gh she has
(E) Mood stabilizers not shared these thou ghts w ith her hu sband .
44 2: Ad ult P sychop a thology

56. Which of the follow ing d iagnoses w ou ld be 59. The p atient is su bsequ ently ad m itted , bu t tries
the m ost likely for this patient? to hit several staff as they tend to her; she also
rep eated ly tries to get ou t of bed and d em and s
(A) Delusional d isord er
to be let go. Which of the follow ing w ou ld be
(B) Obsessive-com p u lsive d isord er the m ost appropriate im m ed iate pharm aco-
(C) Obsessive-com p u lsive p ersonality logic m anagem ent for this p atient?
d isord er
(A) Dip henhyd ram ine
(D) Schizophrenia
(B) H alop erid ol
(E) Schizotyp al p ersonality d isord er
(C) Lorazep am
57. Which of the follow ing w ould be the m ost (D) Phenobarbital
ap propriate first-line p harm acotherap y for (E) Valp roic acid
this cond ition?
60. Which of the follow ing w ou ld be the m ost
(A) Lithium
ap p rop riate long-term treatm ent of this
(B) Lorazep am p atient?
(C) Flu voxam ine
(A) Antibiotic therap y
(D) H alop erid ol
(B) Chest x-ray every 6 m onths
(E) N ortrip tyline
(C) CT head every 6 m onths
Questions 58 through 61 (D) Ind w elling Foley catheter
(E) Intravenou s flu id s
A 72-year-old w om an is brou ght to the em ergency
d epartm ent from a nu rsing hom e for poor oral 61. Which of the follow ing is the m ost likely
intake. She is afebrile, has a pu lse of 95, and a blood 6-m onth m ortality of the d iagnosis in Qu es-
pressu re of 90/ 60. Mental statu s exam ination (MSE) tion 58?
reveals an aw ake and alert, bu t frail, m alnou rished
and d ehyd rated w om an w ho is oriented to p er- (A) 5%
son only. She rep orts that the p resid ent is George (B) 15%
Bu sh. She is easily d istracted and cannot recall any (C) 20%
of three item s after a few m inu tes. She is irritable (D) 35%
and sw ings at the staff w hen they try to insert an IV.
(E) 45%
The team starts IV flu id s as blood and u rine are sent
to the laboratory. A chest x-ray is u nrem arkable, as
Questions 62 and 63
is the head CT. One hou r later, she is calm er and
rep orts the correct d ay, tim e, and p lace; she is less You are a research psychiatrist cond u cting a d ou ble-
d istractible. blind , p lacebo-controlled trial of a new antid ep res-
sant. You have enrolled 200 p atients in the stud y, all
58. Labs are rem arkable for leu kocytosis and d irty of w hom m eet the criteria for u ncom plicated m ajor
u rinalysis. Asid e from cystitis, w hich of the d ep ression. You p lan to rand om ize 100 p atients to a
follow ing is the m ost ap p rop riate d iagnosis p lacebo m ed ication and the other 100 p atients to the
for the p atient? exp erim ental antid ep ressant.
(A) Deliriu m
62. Of the 100 p atients taking the placebo,
(B) Major d ep ressive d isord er
ap p roxim ately how m any p atients w ou ld be
(C) Major neu rocognitive d isord er d u e to exp ected to im p rove after 6 w eeks?
Alzheim er d isease
(D) Substance-ind u ced neu rocognitive (A) 5
d isord er (B) 10
(E) Unsp ecified neu rocognitive d isord er (C) 30
 Que s tions : 5668 45

(D) 50 66. A 32-year-old single su ccessfu l Wall Street

(E) 70 execu tive tells you that on w eekend s he likes
to visit a d om inatrix. H is regular, paid app oint-
63. Of the 100 p atients taking the exp erim ental m ent w ith this p erson is d escribed as hum ili-
antid ep ressant (assu m ing this d ru g is as effi- ating and som ew hat p ainfu l bu t also very
cacious as stand ard antid epressants), ap proxi- sexually arou sing. While he ad m its that this
m ately how m any p atients w ou ld be exp ected behavior m ay be w eird to som e p eop le, he
to im p rove after 6 w eeks? enjoys it, can afford it, and it d oesnt interfere
w ith his w ork or other hobbies. Which of the
(A) 10 follow ing d iagnoses is the m ost ap p rop riate?
(B) 30
(A) Fetishistic d isord er
(C) 50
(B) Frotteu ristic d isord er
(D) 60
(C) N o d iagnosis
(E) 80
(D) Sexu al m asochism d isord er
Questions 64 and 65 (E) Sexu al sad ism d isord er

You r p atient is a 38-year-old d ivorced Catholic Questions 67 and 68

m ale w ith a m onth long history of d ep ressed m ood ,
anhed onia, initial insom nia, low energy, and p oor A 28-year-old w om an com p lains of falling asleep
app etite. H e ad m its to su icid al id eation w ith a d u ring the d ay. This problem has been occu rring for
plan to overd ose for the past several d ays, and he 3 m onths and is now interfering w ith her w ork as a
has gathered p ills this m orning. Up on fu rther his- telephone operator as she falls asleep tw o or three
tory, he ad m its to sim ilar sym ptom s 5 years prior, tim es a d ay w hile speaking w ith cu stom ers. At tim es,
also w ith a p rior su icid e attem p t by overd osing. H e she find s herself falling asleep at her d esk, and she
d rinks 1 beer w eekly and d enies illicit d ru gs. H e is is aw akened w hen her head hits the com p u ter con-
on no other m ed ications except for a m u ltivitam in. sole in front of her. Od d ly enou gh, she reports, this
H e is su bsequ ently ad m itted after being m ed ically can happen w hen she becom es particularly stressed
cleared . ou t, for exam ple, if she is m anaging m any calls.
The p atient also states that this d istu rbance has not
64. What p ercentage of p atients w ith this illness im p roved d esp ite her sleep ing 8 hou rs each night.
eventu ally com m it su icid e?
67. Which of the follow ing is the m ost likely
(A) 1% d iagnosis?
(B) 5%
(A) Circad ian rhythm sleepw ake d isord er
(C) 10%
(B) H yp ersom nolence d isord er
(D) 20%
(C) Insom nia d isord er
(E) 30%
(D) N arcolep sy
65. Which of the follow ing characteristics of this (E) N ightm are d isord er
patient is the nu m ber one p red ictor of a fu tu re
com p leted su icid e? 68. Which of the follow ing is the m ost app rop ri-
ate p harm acotherap y for this cond ition?
(A) Age
(B) Gend er (A) Bu p rop ion (Wellbu trin)
(C) Previous attem pt (B) Flu oxetine
(D) Relationship statu s (C) Lorazep am
(E) Religion (D) Methylp henid ate (Ritalin)
(E) Phenelzine
46 2: Ad ult P sychop a thology
69. A 28-year-old w om an presents for her annu al
gynecology ap p ointm ent. She com p lains
that in the w eek before her period , she often
exp eriences m arked anger and irritability
and argu es m ore w ith her boyfriend . She also
reports d im inished energy and concentration,
and is sleep ing m ore than is u sual for her.
These sym p tom s, in ad d ition to breast tend er-
ness and head aches, alw ays rem it in the w eek
after her m enses is finished . Which of the
follow ing is the m ost likely d iagnosis?
(A) Major d ep ressive d isord er
(B) N o d iagnosis
(C) Persistent d ep ressive d isord er
(D) Prem enstru al d ysp horic d isord er
(PMDD)
(E) Prem enstru al synd rom e (PMS)
70. A 37-year-old accou ntant presents to the p ri-
m ary care clinic w ith com p laints of insom -
nia. H e ad m its to feeling blu e for 6 w eeks
since getting p assed over for prom otion.
Since that tim e, he has had poor sleep, often
aw akening early in the m orning. H e also has
had a d ecreased ap p etite w ith a 15-lb w eight
loss, p oor energy, gu ilt over not being good
enou gh, and he has been d istracted at w ork.
H e ad m its to passive su icid al thoughts w ith-
ou t a plan. Which of the follow ing w ou ld be
the likely cou rse of this patients illness if not
treated ?
(A) 3 to 6 m onths
(B) 3 to 7 m onths
(C) 6 to 13 m onths
(D) 9 to 15 m onths
(E) 12 to 18 m onths
Questions 71 and 72
A 36-year-old m an is brou ght to the em ergency
d epartm ent in respiratory arrest. On exam ination,
he is brad ycard ic and u nresponsive, w ith constricted
p u pils bilaterally. There are no other obviou s inju -
ries on the p atient, bu t no one is im m ed iately avail-
able to p rovid e collateral history. There is susp icion
that the patients cond ition m ay be the result of an
overd ose.
71. Which of the follow ing d ru gs is m ost likely to
cau se this p resentation?
(A) Alcohol
(B) Cocaine
(C) H eroin
(D) Inhalants
(E) Phencyclid ine (PCP)
72. Which of the follow ing w ould be m ost im por-
tant to ad m inister im m ed iately?
(A) Acetylcysteine
(B) Deferoxam ine
(C) Methad one
(D) Methylene blu e
(E) N aloxone
73. A 30-year-old male veteran from Operation
Iraqi Freed om / Operation End uring Freed om
presents to the m ental health clinic at the urg-
ing of his w ife. While stationed in Iraq on his
third d eployment, his u nit w as hit by a road sid e
bom b. H e saw a fellow Marine killed , w hile he
and several other members of the comm and
sustained nonlethal injuries. Since that time, he
has had chronic insom nia w ith ongoing night-
mares of the event as w ell as occasional flash-
backs. H e d escribes alw ays feeling on ed ge,
avoid ing crow d s, and becoming easily startled
w ith loud noises. H e ad m its to regular alcohol
use, especially w hen his sym ptoms are w orse.
H e feels d etached from events w ith his fam-
ily, preferring to isolate himself. Which of the
follow ing is the most appropriate treatment to
begin for this patient?
(A) Atyp ical antip sychotic
(B) Benzod iazep ine
(C) Lithiu m
(D) Serotonin-sp ecific reu p take inhibitor
(SSRI)
(E) Valp roic acid
74. A 40-year-old m arried w om an is referred by
her internist to a p sychologist for fu rther treat-
m ent. She p resents an 8-m onth history of recu r-
rent bou ts of terror, associated w ith chest
p ain, tachypnea, trem ors, flushing, nausea,
and fears of im p end ing d oom . These ep isod es

last for ap proxim ately 15 m inu tes and d o not
have a particu lar trigger. As a resu lt, she has
had increasing d ifficu lty traveling far from
her hom e d ue to concerns over having fu rther
attacks in p u blic. Despite ad equate treatm ent
w ith sertraline, she rem ains sym p tom atic and
in significant d istress. Which of the follow ing
psychotherapies would be the most appropriate
for her cond ition?
(A) Cognitive-behavioral therap y (CBT)
(B) Eye m ovem ent d esensitization and
rep rocessing (EMDR)
(C) Insight-oriented therap y
(D) Interpersonal p sychotherap y
(E) Su p p ortive p sychotherap y
Questions 75 and 76
You are treating a 48-year-old m arried fem ale on
the inpatient m ed ical u nit for pyelonephritis; she
has resp ond ed w ell to app ropriate antibiotic ther-
apy and has been afebrile for the last 24 hou rs. You
inform her of likely d ischarge if she continu es to
im p rove. The next m orning, how ever, she com -
p lains of feeling feverish and achy, and having d ys-
u ria again. The nu rsing staff reports that she has a
su d d en fever of 103F. You treat the fever w ith acet-
am inophen and p erform a physical exam ination,
ord er chest x-rays, d raw blood , and ord er a u ri-
nalysis w ith cu ltu re. While you are aw aiting these
resu lts, the nu rse inform s you that she w itnessed
the patient d ipping her therm om eter into a hot cup
of tea before her tem p erature w as taken.
75. Which of the follow ing d iagnoses m ost likely
accou nts for this w om ans behavior?
(A) Factitiou s d isord er
(B) Fu nctional neurological sym ptom
d isord er
(C) Illness anxiety d isord er
(D) Malingering
(E) Som atic sym p tom d isord er
76. Which of the follow ing is the m ost likely m oti-
vator of this patients behavior?
(A) Conscious d esire to assu m e sick role
(B) Consciou s d esire to avoid w ork
Que s tions : 6979 47
(C) Unconsciou s d esire to assu m e sick role
(D) Unconsciou s d esire to avoid w ork
(E) Unconsciou s conflict p rod u cing
sym p tom s
Questions 77 and 78
A 32-year-old m an is brou ght to the psychiatric
em ergency d epartm ent by the p olice after having
been arrested for p u blic nu d ity. On m ental statu s
exam ination, the p atient cannot sit d ow n and is
only partly cooperative. H e interrup ts the inter-
view several tim es d em and ing to contact his law -
yer, becau se m y rights given to m e by God and
ord ained by the Jeffersonians have been infringed .
H is sister ind icates that this p atient has been treated
for at least tw o ep isod es of m ajor d ep ression in the
p ast, one of w hich resu lted in a su icid e attem pt. H e
is cu rrently a com p u ter p rogram m er, bu t has been
increasingly stressed at w ork. One m onth ago, his
girlfriend broke u p w ith him , and since then he has
been increasingly irritable. Over the p ast 2 w eeks he
has m axed ou t his cred it card from online gam bling
sites, w hich he has continu ed to visit over the past
fou r consecu tive nights. Laboratory tests show a
negative d ru g screen and alcohol levels.
77. Which of the follow ing is the m ost likely
d iagnosis?
(A) Ad ju stm ent d isord er
(B) Bip olar d isord er
(C) Brief p sychotic d isord er
(D) Cyclothym ic d isord er
(E) Major d ep ressive d isord er (MDD)
78. Which of the follow ing w ould be the m ost
ap p rop riate pharm acologic treatm ent for this
p atient?
(A) Carbam azep ine
(B) H alop erid ol
(C) Lam otrigine
(D) Lithiu m
(E) Sertraline
79. A 68-year-old m an w ithou t p rior p sychiatric
history, bu t w ith a history of hypertension,
hyperlip id em ia, and arthritis is ad m itted for a
new left m id d le cerebral artery stroke. Which
48 2: Ad ult P sychop a thology
of the follow ing psychiatric sym ptom s w ou ld
be the m ost likely as a resu lt?
(A) Anxiety
(B) Depression
(C) Mania
(D) Obsessions
(E) Panic attacks
80. A 45-year-old w om an w ith no p reviou s p sy-
chiatric history is ad m itted to neu rology for
the treatm ent of an acu te m ultiple sclerosis
flare. She d oes not sm oke, d rink alcohol, or
u se other illicit d ru gs. She is started on ap p ro-
p riate therap y and by the third d ay her initial
low er extrem ity w eakness has resolved . H ow -
ever, she also begins to act strangely, and asks
you to change her room to p revent the nin-
jas ou tsid e from creeping in and stealing m y
sou l. She also tells you the nurses have been
p oisoning her m ed icine. Which of the follow -
ing d iagnoses w ou ld be the m ost likely?
(A) Ad ju stm ent d isord er
(B) Bipolar d isord er
(C) Psychotic d isord er d u e to m u ltip le
sclerosis
(D) Schizophrenia
(E) Substance-ind uced psychotic d isord er
81. A 42-year-old m an p resents w ith a history of
recu rrent ep isod es of m ajor d ep ression, w ith
one prior hospitalization. For the past several
m onths he has felt increasingly d ep ressed ,
w ith insom nia, low ap p etite, little energy, cry-
ing sp ells, and p oor concentration. H e is not
taking any current m ed ications. H e states that
he has been on fluoxetine, p aroxetine, sertra-
line, and venlafaxine in the p ast, and , w hile
theyve all been efficaciou s, he has stop ped
them d u e to significant erectile d ysfu nction.
Which of the follow ing m ed ications w ou ld be
the m ost ap propriate to prescribe?
(A) Aripip razole
(B) Bup ropion
(C) Citalop ram
(D) Lithium
(E) Sertraline
82. A 33-year-old male w ith a history of frequent
fighting, aggression, impulsivity, and sui-
cid e attempts is referred to a research facility.
H e receives multiple tests and studies. Upon
cerebrospinal fluid (CSF) analysis, d ecreased
metabolites of w hich of the follow ing neu-
rotransmitters w ould most likely be seen as
compared to ind ivid uals w ithout his problems?
(A) Dop am ine
(B) Gam m a-am inobu tyric acid (GABA)
(C) Glu tam ate
(D) N orep inephrine
(E) Serotonin
83. A 38-year-old w om an w ith m u ltip le sclerosis
of m od erate severity has had sym ptom s of
d ep ression and m em ory loss increasing over
the last year. On m ental statu s exam ination,
you notice a blu nted affect and d ecreased
sp eed of m ental processing. A m agnetic reso-
nance im aging (MRI) exam ination is m ost
likely to reveal w hich of the follow ing?
(A) Global cerebral atrop hy
(B) Mu ltip le p laqu es in frontal w hite m atter
(C) N orm al brain
(D) Periventricu lar lacu nar infarcts
(E) Ventricular enlargem ent
84. An 80-year-old w id ow ed w om an is ad m itted
to the hospital for confu sion. On exam ina-
tion she is som nolent, thou gh earlier in the
m orning she had been alert and aw are. She
is u ncoop erative, hostile, and hallu cinating.
H er insight and m em ory are p oor. The p ri-
m ary team w ishes to know if she is d eliriou s
or d em ented . Which of the follow ing signs/
sym ptom s in this p atient is the m ost sp ecific
for d eliriu m ?
(A) Com bativeness
(B) Flu ctu ating consciou sness
(C) Poor m em ory
(D) Psychosis
(E) Uncoop erativeness
85. A happily m arried grad uate stu d ent com es
to you r clinic w ith com p laints of insom nia.
She has been u nable to fall asleep because

she ru m inates abou t grad es, m oney, her rela-
tionship , and her you ng child ren. She has
alw ays been concerned abou t these, bu t lately
her w orries have gotten ou t of control. She is
u nable to relax and feels constant tension in
her m uscles. While she d enies sym p tom s of
p anic attacks, she has noticed an increase in
head aches and gastrointestinal d istu rbances
over the p ast few m onths. She d enies any
p roblem s w ith m ood . She d enies any recent
stressors, changes to her rou tine, or changes to
her hu sband s rou tine. Which of the follow ing
is the m ost likely d iagnosis?
(A) Ad ju stm ent d isord er
(B) Generalized anxiety d isord er
(C) Obsessive-com p u lsive d isord er
(D) Panic d isord er
(E) Social anxiety d isord er (social p hobia)
86. You are a research p sychiatrist w ho is stu d ying
signs and sym p tom s associated w ith certain
p sychiatric d isord ers, and notice a category
of patients w ho have sensory gating d eficits,
short-term m em ory d ifficulties, and abnor-
m alities in sm ooth-p u rsu it eye m ovem ents.
Which of the follow ing d iagnoses is m ost
likely to be fou nd in this p atient p op u lation?
(A) Attention-d eficit/ hyp eractivity d isord er
(ADH D)
(B) Major d ep ressive d isord er (MDD)
(C) Obsessive-com p u lsive d isord er (OCD)
(D) Posttrau m atic stress d isord er (PTSD)
(E) Schizop hrenia
87. A 23-year-old single m ed ical stu d ent com es
to you r office com p laining of d ifficu lty sleep-
ing, excessive w orry abou t his stu d ies, his
relationship w ith his p arents, and that his girl-
friend of 2 years is going to break u p w ith him
d espite being happ y w ith their relationship.
H e feels irritable at tim es, and has significant
m u scle tension. Because of these sym p tom s,
his grad es have su ffered . H e d oes not rep ort
a d epressed m ood . You d iagnose him w ith
generalized anxiety d isord er, and p rescribe a
com bination of psychotherapy and a selective-
serotonin reuptake inhibitor (SSRI). Three
m onths later, the patient com es back to you r
Que s tions : 8088 49
office reporting that his m ood has been d ow n
in the d u m p s, and he feels like he m ay never
feel better. Recently, he has been thinking that
life w as not w orth living anym ore and has
p assive thou ghts of su icid e. H e reports ongo-
ing thou ghts of overd osing on p ills. Which of
the follow ing w ould be the m ost appropriate
next step ?
(A) Call his p arents and arrange a fam ily
m eeting
(B) Discontinu e his SSRI and have him
retu rn in 1 w eek
(C) Refer the p atient to the p sychiatric
em ergency d ep artm ent
(D) Sched u le w eekly ou tp atient visits
(E) Sw itch the SSRI and have him follow -u p
w ith you in 1 m onth
88. A 36-year-old m arried w hite fem ale p resents
to the em ergency room w ith a 2-m onth his-
tory of d epression, term inal insom nia, fatigu e,
d ecreased ap p etite, anhed onia, and exces-
sive guilt. She feels hopeless and relu ctantly
ad m its to su icid al id eation for the p ast w eek,
w ith thou ghts of taking all of m y m ed icines.
After fu rther qu estioning, she states that I
w ou ld never d o it as she is a d evou t Catho-
lic w ho attend s chu rch regu larly. Which of the
follow ing characteristics m ost increases this
p articu lar patients risk of su icid e?
(A) Age
(B) Gend er
(C) H op elessness
(D) Marital statu s
(E) Religion
Questions 89 and 90
A 29-year-old m arried w hite w om an w ith a p ast
m ed ical history of recu rrent m igraines is brou ght to
the psychiatric em ergency d epartm ent by her hu s-
band w ho rep orts that, d esp ite feeling d ep ressed
2 m onths ago and being com p liant w ith p rescribed
treatm ent, she now has been acting bizarre for sev-
eral d ays. On initial interview , the p atient states, I
feel su p erbly su p rem e, and you have no id ea w hat
an am azing person I am ! The p atient is talking so
rap id ly that you cannot interru p t her. H er hu sband
50 2: Ad ult P sychop a thology

rep orts that the p atient has not slep t in over a w eek, (D) Retrograd e
and d u ring the sam e tim e p eriod , she has p u t a d ow n (E) Selective
p aym ent for a car, has p urchased a d iam ond tennis
bracelet, and has booked an extravagant vacation. Questions 93 and 94

89. Which of the follow ing is the m ost likely A 75-year-old man comes to you r office com plain-
d iagnosis? ing of poor sleep since his w ifes d eath 1 m onth ago.
Since that time, he has been unable to fall asleep,
(A) Anxiety d isord er and he has felt d ow n. H e is slightly more isolative
(B) Bip olar and related d isord er now , as many of the activities he enjoyed d oing w ere
(C) N eu rocognitive d isord er w ith his w ife. H is appetite is d ecreased , but he is still
(D) Psychotic d isord er bathing and cooking. H e sometim es feels guilty that
(E) Som atic sym p tom d isord er she d ied before him , and is angry w ith God that he
is alive w ith no soul mate anymore. H e sometim es
90. You suspect a medication is the cause for her hears the voice of his d eceased w ife encouraging
current condition, but neither she nor her hus- him to move on, and he d enies suicid al id eation.
band recall the medication prescribed 2 months
ago. Which of the following medications is the 93. Which of the follow ing is the m ost ap p rop riate
most likely etiology? d iagnosis at this tim e?

(A) Am itriptyline (A) Ad ju stm ent d isord er w ith d ep ressed

m ood
(B) Clonazep am
(B) Bereavem ent
(C) Flu oxetine
(C) Major d ep ressive d isord er
(D) Lithium
(D) Persistent com p lex bereavem ent
(E) Sertraline
d isord er
91. A 62-year-old m ale patient w ith schizop hrenia (E) Schizop hrenia
is brou ght into the em ergency d ep artm ent by
the police for trespassing. Up on interview, he 94. Which of the follow ing w ou ld be the m ost
tells the p hysician that over the past 3 w eeks app rop riate treatm ent for this p atient?
his television has been giving him cod ed (A) H osp italize the p atient im m ed iately
m essages. Which of the follow ing term s best (B) Prescribe an antid ep ressant
d escribes this p henom enon?
(C) Prescribe an antip sychotic
(A) H allu cination (D) Refer for brief su p portive therap y
(B) Id ea of reference (E) Refer for cognitive-behavioral therap y
(C) Illu sion
(D) Thou ght broad casting 95. When asked abou t his level of ed u cation, a
(E) Thou ght insertion 48-year-old m an w ith a history of schizoaf-
fective d isord er, d ep ressed typ e, sp end s the
92. A 45-year-old p atient tells her d octor that after next 5 m inutes d escribing his high school
hearing that her hu sband d ied , she cou ld not bu ild ing, friend s he had at the tim e, clu bs he
rem em ber leaving her office and going hom e. joined , and eventu ally his high school grad u a-
In every other resp ect, her m em ory is intact. tion cerem ony. H e conclud es by saying, And
Which of the follow ing types of am nesia is that w as the end of m y schooling. Which
this an exam ple of? of the follow ing term s d oes this response best
d em onstrate?
(A) Continuou s
(A) Circu m stantiality
(B) Generalized
(B) Loosening of associations
(C) Localized
 Que s tions : 89100 51

(C) Perseveration 99. A 21-year-old w om an com p lains of recu r-

(D) Pressured sp eech rent ep isod es w here she has extrem e anxiety,
(E) Tangentiality along w ith p alp itations, d izziness, nau sea,
abd om inal cram p s, d iarrhea, tingling of her
96. In her p sychiatrists office, a p atient su d d enly fingers, shortness of breath, and fearing she
low ers herself to the floor, begins flailing m ay d ie. These p eriod s last u nd er 30 m inu tes,
abou t w ild ly, then flings a garbage p ail against and theyve been increasing in frequency. She
the w all, and runs out of the office. Im m ed i- is u nable to p red ict w hen they w ill occu r, bu t,
ately afterw ard , she returns. She is alert and as a resu lt, she is often w orried abou t hav-
oriented , yet d oes not rem em ber the incid ent. ing another attack, and she has been u nw ill-
Which of the follow ing typ es of seizu res is the ing to leave her ap artm ent for several w eeks.
m ost likely? She d rinks 1 to 2 d rinks of alcohol p er m onth
and d enies illicit d ru g u se. She has no m ed i-
(A) Com p lex p artial seizu re cal problem s, is only on oral contraceptives,
(B) Jacksonian seizure and her physical and laboratory w orku p are
(C) N onep ilep tic seizu re negative. Which of the follow ing w ould be the
(D) Tem p oral lobe seizu re m ost app rop riate treatm ent?
(E) Tonicclonic seizu re (A) Bu sp irone
(B) Lithiu m
97. A 26-year-old m an new ly d iagnosed w ith (C) Lorazep am
narcolep sy exp lains that he has ep isod es of
(D) Valp roic acid
falling d ow n w ithou t any loss of consciou s-
ness, p recip itated by lau ghter or anger. Which (E) Venlafaxine
of the follow ing term s best d escribes this
sym p tom ? Questions 100 and 101

(A) Catalepsy A 46-year-old m an w ith a history of hyp ertension

(B) Catap lexy and hyperlip id em ia p resents to his p rim ary care d oc-
(C) H yp ersom nia tor w ith com plaints that Im d rinking too m u ch.
(D) H yp nagogic hallu cinations H e gives a long history of binges over 4 to 5 d ays
at a tim e, w here he w ill d rink 1 to 2 pints of gin per
(E) Sleep p aralysis
d ay. H e has had several DUIs and is at risk of losing
his job. In ad d ition, his d rinking has put a strain on
98. A 21-year-old m an w ith new ly d iagnosed
his m arriage. Unfortunately he has been u nable to
schizophrenia has been com p liant w ith his
maintain sobriety for any significant period of tim e.
med ications and is less p sychotic. At his next
H e is stressed out because of the consequences of
follow -u p appointm ent, he is noted to be rest-
his d rinking, and he ad mits to chronic, intermittent
less and constantly m oving. H e states that
insom nia. H e has a good appetite, how ever, and his
he feels as if he has to be m oving all the tim e
energy is ad equate u nless he is significantly hun-
and is u ncom fortable if he sits still. Which
gover. H e feels helpless but d enies suicid al id eation.
of the follow ing sid e effects is he m ost likely
exp eriencing?
100. Which of the follow ing m ed ications w ou ld be
(A) Akathisia m ost appropriate to prescribe for this patient?
(B) Akinesia
(A) Acam p rosate
(C) Dystonia
(B) Bu p rop ion
(D) Rabbit synd rom e
(C) Citalop ram
(E) Tard ive d yskinesia
(D) Lithiu m
(E) Olanzap ine
52 2: Ad ult P sychop a thology
101. Tw o w eeks later this sam e patient is seen
in the em ergency room after being p icked
u p by the police for d istu rbing the peace
and w and ering. On exam ination he app ears
confu sed , has nystagm us, and an unstead y
gait. Which of the follow ing shou ld be ad m in-
istered im m ed iately?
(A) Glucose
(B) H alop erid ol
(C) Lorazep am
(D) N altrexone
(E) Thiam ine
102. A 36-year-old man presents to the em ergency
d epartm ent after being found w ithout cloth-
ing in the street. H e has m ultiple excoriations
all over his bod y, is paranoid and agitated , and
states that bugs are craw ling all over him. H is
vitals are as follow s: T-99.1, BP-160/ 93, P-105,
R-20. Which of the follow ing substances w ould
be m ost likely found in his laboratory results?
(A) Alcohol
(B) Cannabis
(C) Cocaine
(D) Opiates
(E) PCP
Questions 103 and 104
A 72-year-old m arried m ale w ith a history of hyper-
tension, bord erline d iabetes, hyperlipid em ia, and
coronary artery d isease is brou ght in by his w ife.
Over the p ast year he has becom e increasingly for-
getfu l, m isp lacing his keys, getting lost w hile d riv-
ing, and starting to w and er. When confronted w ith
these situations he becom es d efensive, m aking up
excu ses for his behavior. H is sleep is erratic, bu t he is
eating w ell and enjoys w atching his favorite m ovies
on the television. H is w ife d escribes extrem e m ood
lability, w here he w ill be lau ghing and then crying.
H e d enies suicid al id eation. H e d oesnt d rink alco-
hol and d enies d ru g u se. H e w as a p rior sm oker bu t
qu it 20 years ago. H is p hysical exam ination and labs
are u nrem arkable.
103. As p art of his w orku p , an MRI of his brain
is ord ered . What w ou ld be the m ost likely
find ing?
(A) Atrop hy of brainstem and cerebellu m
(B) Atrop hy of frontal and tem p oral lobes
(C) Enlarged ventricles
(D) Global atrop hy
(E) Periventricu lar w hite-m atter lesions
104. Which of the follow ing w ou ld best d escribe
his clinical course?
(A) Continu ed im p rovem ent
(B) N o im p rovem ent or w orsening
(C) Rap id d ecline
(D) Stead y d ecline
(E) Step -w ise d eterioration
105. An 86-year-old w om an w ith m u ltip le m ed ical
problem s and a recent hip fractu re is ad m itted
to the intensive care u nit. While in the u nit, she
aw akens at night and m istakes her intrave-
nou s (IV) p ole for a fam ily m em ber com ing for
a visit. She then becom es agitated , attem p ting
to pu ll out her IV and get ou t of the hospital
bed . Which of the follow ing ap p roaches is the
m ost im p ortant in the u ltim ate m anagem ent
of this patient?
(A) Ad m inister d ip henhyd ram ine
(B) Ad m inister halop erid ol
(C) Ad m inister lorazep am
(D) App ly soft restraints
(E) Determ ine and correct the u nd erlying
cond ition
106. A 24-year-old grad u ate stu d ent in p hiloso-
p hy is referred by his stu d ent health center
for a p sychiatric evalu ation. Althou gh he
claim s to have had sim ilar bu t attenu ated
sym p tom s in ch ild hood , since beginn ing
his thesis, he d escribes an acu te w orsening
of fears that he w ill contract H IV. While he
u nd erstand s the m od es and risks of contrac-
tion and p ractices safe sex, he is u nable to get
rid of these thou ghts. As a resu lt, he feels
com p elled to w ash his hand s m any tim es p er
d ay, even to the p oint of their becom ing raw
an d bleed ing. Desp ite his insigh t that his
concerns are irrational, he is not able to stop
the behaviors. A p ositron em ission tom ogra-
p hy (PET) scan of this p atien ts brain w ou ld
 Que s tions : 101111 53

m ost likely d em on strate increased activity in easily agitated , striking at nu rsing staff and
w hich of the follow ing stru ctu res? his d au ghter. Which of the follow ing m ed ica-
tions w ou ld be m ost appropriate to prescribe
(A) Am ygd ala
in this case?
(B) Cau d ate nu cleus
(C) Cerebellu m (A) Am itriptyline
(D) H ip p ocam p u s (B) Clonazepam
(E) Parietal lobes (C) Dip henhyd ram ine
(D) Donep ezil
Questions 107 and 108 (E) H aloperid ol

A 70-year-old w id ow ed m an w ithou t significant 109. A 36-year-old w om an presents w ith com -

m ed ical history is brou ght in by his d au ghter d ue to p laints of a d epressed m ood for the p ast
concerns abou t his being able to ad equately care for m onth. She reports p oor sleep, little app etite
him self. H e has been fou nd lost in the d ow ntow n w ith w eight loss, low energy, d ecreased con-
area on several occasions, attem p ting to w alk into centration, and little libid o. She ad m its to feel-
strangers hou ses, as w ell. H e is unable to cook for ing hop eless and su icid al, althou gh she d enies
him self bu t is unable to calculate the correct am ou nt a sp ecific p lan or intent. She is su bsequently
for p u rchases. H is d au ghter has noticed that he begu n on p aroxetine 20 m g at bed tim e. Which
is d izzy w hen stand ing u p and has a w id e-based , of the follow ing sym p tom s w ou ld be m ost
slow w alk. Up on interview , he ap pears d isheveled likely to im p rove the earliest?
and smells of u rine. H e is friend ly and coop erative
(A) Decreased libid o
overall, althou gh easily d istracted and confu sed .
While he know s his nam e, he believes the year is (B) Dep ressed m ood
1989. When confronted abou t his m em ory d ifficu l- (C) H op elessness
ties, he states that there are sm all gnom es living in (D) Poor sleep
his furnitu re, w ho play tricks on him by m oving (E) Su icid al id eation
item s arou nd in his cond om iniu m . Accord ing to the
d au ghter, he rarely d rinks alcohol, d oes not sm oke 110. A 35-year-old m an com p lains to his therap ist
tobacco, and has never u sed illicit d ru gs. that his new p artner enjoys sexual activity
only w hen inflicting pain on him . This d is-
107. Which of the follow ing d iagnoses is m ost turbs and fru strates the patient. Which of the
likely? follow ing best d escribes the behavior exhib-
(A) Major frontotem p oral neu rocognitive ited by his p artner?
d isord er (A) Exhibitionistic d isord er
(B) Major neu rocognitive d isord er d u e to (B) Frotteu ristic d isord er
Alzheim er d isease (C) Sexu al m asochism d isord er
(C) Major neu rocognitive d isord er w ith (D) Sexu al sad ism d isord er
Lew y bod ies
(E) Transvestic d isord er
(D) Major vascu lar neu rocognitive d isord er
(E) Su bstance-ind u ced m ajor 111. An anxiou s 23-year-old Asian m ale u niver-
neu rocognitive d isord er sity stu d ent p resents to stu d ent health ser-
vices claim ing that his p enis is shrinking into
108. The above p atient is ap p rop riately d iagnosed his abd om en. Desp ite reassu rances from the
and then placed in an interm ed iate care facil- staff and the p hysician, he rem ains convinced
ity. Eight m onths later he is brou ght by the of this belief. Which of the follow ing syn-
d aughter becau se the nu rsing hom e is having d rom es is this p atient m ost likely su ffering
increasing d ifficu lty caring for him . H e is m ore from ?
confused , resp ond ing to internal stim uli, and
54 2: Ad ult P sychop a thology
(A) Cap gras synd rom e
(B) Koro
(C) Ku ru
(D) Taijin-kyofu sho
(E) Zar
112. A 21-year-old m ale college stu d ent is evalu -
ated by his college stu d ent health center after
being arrested for m astu rbating outsid e of a
sorority w ind ow late at night. H e ad m its to
having w atched a particu lar fem ale stu d ent
insid e the build ing over a period of several
m onths. Which of the follow ing is the m ost
likely d iagnosis?
(A) Exhibitionistic d isord er
(B) Frotteu ristic d isord er
(C) Gend er d ysp horia
(D) Transvestic d isord er
(E) Voyeuristic d isord er
113. A 45-year-old sep arated fem ale is brou ght by
her brother into the em ergency room w ith the
chief com p laint of strange behavior. She
has been living w ith her brother for the p ast
2 years, and she stop ped her m ed ications 12
m onths ago. The brother states that over the
past 6 m onths she has becom e increasingly
paranoid and d elu sional, believing that the
neighbors are sp ying on her. She insists that
the Chinese governm ent is using her as an
agent to com bat terrorism , and that they com -
m unicate their instru ctions via a w ireless sig-
nal transm itted d irectly to her brain. She is
often noticed to be talking w hen no one else is
in her room . In ad d ition, over the past m onth
she has been staying u p m ost of the night, p ac-
ing arou nd the hou se and attem p ting to con-
struct an anti-terrorism m achine, u sing p arts
of various household electronics. She states
that it is im portant that she alone com p letes
her m ission, that she is the m ost senior sp y
in the organization w ith a top-secret clear-
ance that only the Presid ent and I p ossess.
H er brother has had a hard tim e calm ing her
d ow n as she sp eaks too qu ickly to follow, goes
from one top ic to another, and w ont sit still.
Which of the follow ing d iagnoses w ou ld be
the m ost likely for this patient?
(A) Bip olar d isord er
(B) Delu sional d isord er
(C) Major d ep ressive d isord er w ith
psychotic featu res
(D) Schizoaffective d isord er
(E) Schizop hrenia
Questions 114 and 115
A 63-year-old Vietnam veteran w ith p osttrau m atic
stress d isord er (PTSD) p resents to the ou tpatient
m ental health clinic. H e has been prescribed nu m er-
ous m ed ications over the years, and he has recently
been taking citalop ram 40 m g d aily. H e d enies sid e
effects and strongly believes this has been the m ost
effective m ed ication he has taken. While he d enies
intru sive thou ghts or overt flashbacks, he continu es
to have severe nightm ares several tim es p er w eek
w hich significantly interfere in his sleep . H e rem ains
ju m p y at tim es, and becau se of this d oesnt attend
fu nctions w here there are large crow d s. H e has not
u sed alcohol or d rugs in 18 years, and he d enies any
su icid al id eation.
114. Which of the follow ing m ed ications w ou ld
be the m ost beneficial to p rescribe for
au gm entation?
(A) Alp razolam
(B) Bu p rop ion
(C) Prazosin
(D) Risp erid one
(E) Valp roic acid
115. In ad d ition to m ed ications, this p atient w ishes
to pursu e talk therapy. Which of the fol-
low ing form s of p sychotherap y w ou ld be the
m ost app rop riate to recom m end ?
(A) Behavior therap y
(B) Cognitive p rocessing therap y
(C) Cognitive therap y
(D) Dialectical behavioral therapy
(E) Psychod ynam ic p sychotherap y
116. A 23-year-old grad u ate stu d ent com es to the
psychiatric em ergency room com p laining of
anxiety. She has never been seen by a psychia-
trist before and is not taking any m ed ications.
 Que s tions : 112120 55

H er vital signs are notable for a heart rate of 119. A 26-year-old m an w ith schizophrenia is
110 beats/ m in. She is also slightly d iap horetic being d ischarged from his third ad m ission
and has m ild ly d ilated p u pils. Given her p res- to the p sychiatric u nit in 3 years. This m ost
ent state, w hich area of this p atients brain recent stay w as p rom p ted by acu te exacerba-
w ou ld m ost likely d em onstrate increased tion of com m and aud itory hallu cinations and
activity? paranoia that resulted in bizarre behaviors
su ch as lying in the m id d le of the road and
(A) Am ygd ala
berating cu stom ers that cost him his restau -
(B) Basal ganglia rant job. H is sym p tom s are im p roved w ith
(C) H ip p ocam p u s pharm acotherap y, w hich he is tolerating, w ith
(D) Locu s ceru leu s m ild sid e-effects of sed ation that are grad u ally
(E) Thalam u s im p roving. Which of the follow ing tim e p eri-
od s m ost accu rately d escribes w hen his risk of
117. You are asked to give a p sychiatric consu lta- su icid e is the highest?
tion on a 28-year-old w om an w ith system ic (A) At his first p sychotic break
lu pu s erythem atosu s w ho w as ad m itted to
(B) Du ring his first hosp italization
the m ed ical service. After you see her, one of
you r m ed ical colleagu es tells you that she w ill (C) In the w eek p reced ing this
no longer sp eak to any of them becau se she hosp italization
hates all of them and now insists on seeing (D) In the w eek w hile he is hosp italized
you becau se you are the best d octor in the (E) In the w eeks follow ing hosp italization
hospital. Which of the follow ing term s best
d escribes the patients behavior? 120. You are asked to review neu rop sychological
testing for a 19-year-old p atient w ho is fail-
(A) Acting out
ing classes at his local com m u nity college. H is
(B) Externalization resu lts ind icate an intelligence qu otient (IQ)
(C) Regression of 55. H e is has a grou p of p eers bu t is often
(D) Sp litting im m atu re, and his friend s often p revent him
(E) Su blim ation from being taken ad vantage of as he is very
gu llible. H e takes care of his p hysical need s
118. A 42-year-old w oman w ith recurrent episod es bu t p arents ensu re that he has enou gh grocer-
of major d epression is ad mitted to a med i- ies and need to rem ind him to check his bank
cal unit after a car accident that rend ered her accou nt balance. Which of the follow ing is the
unconscious. The patient regains conscious- m ost ap propriate d iagnosis?
ness after 3 days and corroborates that she w as, (A) Mild intellectu al d isability
ind eed , on an antid epressant, but she says she
(B) Mod erate intellectu al d isability
also cannot remember w hich one. She is started
on paroxetine (Paxil) for her d epression. Tw o (C) N o d iagnosis (norm al intellectu al
days after beginning this med ication, she fu nctioning)
develops tachycard ia, d iaphoresis, and myo- (D) Severe intellectu al d isability
clonic jerks. The neurotransmitter most likely (E) Profou nd intellectu al d isability
associated w ith the above reaction is synthe-
sized in w hich of the follow ing central nervous D IRECTION S (Questions 121 through 145): The
system structures? follow ing group of numbered items are preceded
by a list of lettered options. For each question,
(A) Cau d ate nu cleu s
select the one lettered option that is most closely
(B) Locu s ceru leus associated w ith it. Each lettered option may be
(C) N u cleu s accu m bens used once, multiple times, or not at all.
(D) Rap he nu cleu s
(E) Su bstantia nigra
56 2: Ad ult P sychop a thology

Questions 121 through 130: Match each scenario 125. A 27-year-old grad u ate stu d ent w oke u p late
w ith its most likely description. and skip p ed breakfast. She now has a m assive
head ache and is irritable w hen she w alks into
(A) Alcohol intoxication
her first m orning class. She feels like falling
(B) Alcohol w ithd raw al asleep and as if she has the flu by the end of
(C) Am p hetam ine intoxication the m orning.
(D) Am phetam ine w ithd raw al
(E) Caffeine intoxication 126. A veterinarian technician is brou ght to the
(F) Caffeine w ithd raw al em ergency d epartm ent after attacking w hat
(G) Cannabis intoxication he thought w as a cougar (it w as a hou secat).
(H ) Cannabis w ithd raw al In the em ergency room he is febrile, ap p ears
(I) Cocaine intoxication p anicked , has nystagm u s, and d em onstrates
u nexpected strength and rage.
(J) Cocaine w ithd raw al
(K) H allu cinogen intoxication
127. A 35-year-old p ilot is brou ght in for evalu ation
(L) Inhalant intoxication
becau se he has not slep t for d ays, and now he
(M) Opioid intoxication is anxiou s, tachycard ic, trem u lou s, and u nable
(N ) Opioid w ithd raw al to give coherent history. H is pu pils are d ilated
(O) Phencyclid ine intoxication and his blood p ressure is high, d esp ite norm al
valu es 2 w eeks ago on a flight physical.
121. A 32-year-old single, m ale w ith injected con-
ju nctiva cant concentrate at w ork, lau ghs 128. A 54-year-old w om an w ith arthritis com p lains
read ily at his cow orkers d ood les, feels of yaw ning, d iarrhea, abd om inal cram ps, and
relaxed , and sp eaks slow ly w hile seem ingly nausea. H er pup ils are d ilated and she has
focu sed on the air in front of him . notable piloerection.

122. A 45-year-old separated male ad mitted for 129. A 23-year-old m an is fou nd u nresponsive w ith
d epression and suicid al id eation is irritable, slow ed breathing. H e has m ultiple scars on his
asks for extra food , and spend s m ost of the first arm s and he has severe m iosis.
d ay sleeping. The chest pain he had on ad mis-
sion has subsid ed and he has no ECG changes.
130. On the third postop erative d ay you r 63-year-
old patient becom es agitated , d em and s you
123. After recess, a ju nior high school stu d ent rem ove the snakes from his room , and asks
sm ells fu nny, is stu m bling, feels d izzy and w hy it is so lou d at night (it is d aytim e). H e is
nauseated , yet rem ains sm iling and says she tachycard ic, hypertensive, and trem u lous.
feels su ch a ru sh. By the m id d le of her next
class she has a head ache but otherw ise feels
like she d id this m orning. Questions 131 through 136: Match each scenario
w ith the most likely receptor responsible from the
follow ing list.
124. A 17-year-old high school stu d ent attend s a
college fraternity party hosted by his eld er (A) 5-H T2 A recep tor
brother. After several hou rs, he feels m ore (B) Alp ha recep tor
courageou s and approaches lad ies he w ou ld (C) Beta recep tor
norm ally be too shy to engage, his w ord s are (D) Dop am ine recep tor
slightly slu rred , and he has d ifficulties m ov-
(E) H istam inergic recep tor
ing in a straight line. H e is slightly flu shed and
notes m ild m em ory problem s for events ear- (F) Mu scarinic recep tor
lier in the night.
 Que s tions : 121145 57

131. A 32-year-old m an on clozapine exp eriences
constipation.
132. A 29-year-old w om an on qu etiap ine experi-
ences d izziness on stand ing.
133. A 52-year-old m an on risperid one exp eriences
a m ilky d ischarge from his breasts.
134. A 41-year-old m an on haloperid ol experiences
resolu tion of his au d itory hallu cinations and
his d elu sions.
135. A 22-year-old w om an on olanzap ine exp eri-
ences significant sed ation and w eight gain.
138. You r p atient is angry w ith you and claim s you
are the w orst d octor ever, as op p osed to her
form er clinician, w ho actu ally listened to her.
139. You r bord erline p atient m isses seven ap p oint-
m ents in a row resu lting in you r term inating
her treatm ent contract.
140. After slip p ing in front of you r boss on a fro-
zen pu d d le, you exclaim that in a form er life
I w as actu ally an elite figu re skater!
141. You r 69-year-old p atient states he ju st has a
bad cold after being d iagnosed w ith m eta-
static lung cancer, and states all he need s is
som e hot tea and rest.

136. A 53-year-old m an on quetiap ine exp eriences

im p rovem ent and stabilization of m ood . 142. You argu e w ith the boss at w ork, and w hen
you com e hom e you harshly groom you r cat
so that she actu ally w riggles aw ay ou t of your
Questions 137 through 145: Match each scenario arm s.
w ith its most likely defense mechanism from the
follow ing list.
143. A 68-year-old w id ow volu nteers at the local
(A) Altru ism veterans nursing hom e.
(B) Denial
(C) Disp lacem ent 144. After rep eated ly failing to bring you r p or-
(D) H u m or tion of the grou p project to class, you accu se
(E) Projection the group lead er of forgetting to e-m ail you a
(F) Projective id entification rem ind er.
(G) Reaction form ation
(H ) Rationalization 145. After not m atching into you r chosen sp ecialty,
(I) Splitting you say that it w as fu ll of boring nerd s any-
w ay and that you really have w ay too m u ch
137. A 37-year-old married male is just told by his personality to be p art of them .
wife that she has been having an affair. He
immediately hugs her and tells her he loves her.
 Ans we rs a nd Expla na tions
1. (B) The patients 3- to 4-year history of bizarre
behavior, d elu sions, and d ecline in social fu nc-
tioning strongly su ggest that he has schizo-
p hrenia. The p revalence of schizophrenia in
the general p op u lation is ap p roxim ately 1%.
Schizophrenia is fou nd in all societies and
geograp hical areas arou nd the w orld , and
its p revalence is rou ghly equ al in m ales and
fem ales.
2. (D ) In tw in stu d ies, schizop hrenias m onozy-
gotic concord ance is 40% to 50%, suggesting
that there is a strong genetic com ponent to the
illness. The p revalence of schizop hrenia in the
follow ing p op u lations is: 10% to 15% in the
nontw in sibling of a patient w ith schizop hre-
nia, 12% in the child of one p arent w ith schizo-
p hrenia, and 40% in the child of tw o p arents
w ith schizop hrenia.
3. (B) Cotard synd rome d escribes nihilistic d elu -
sional content; in ad d ition to lost possessions,
patients m ay feel they have lost blood , heart,
intestines, as w ell as believe that the w orld
beyond them has been red uced to nothing-
ness. This psychotic/ d elusional theme can be
seen in m any psychotic illnesses. Capgras syn-
d rom e is a d elusion of d oubles characterized
by the belief that people have been replaced by
id entically appearing im posters. Folie d eux,
or shared psychotic d isord er, is w hen a sim ilar
d elusion is aroused in one person by the close
influence of another; both ind ivid uals are usu-
ally closely associated for a prolonged period
of tim e. The Fregoli d elusion is a variation of
the d elusion of d oubles, and is the belief that
fam iliar people assume the guise of strangers.
While m ajor d epressive d isord er can manifest
58
w ith psychotic featu res, the prominence of
psychosis w ith bizarre (not possible) d elusions
and w ithou t clear d epressed m ood m akes this
d iagnosis less likely. Further, though nihilis-
tic themes and negativism can be observed in
d epression, the d elusions are usually nonbi-
zarre (potentially feasible).
4. (A) Th e belief that p eop le h ave been rep laced
by im p osters is th e h allm ark of Cap gras
synd rom e. Delu sion al d isord er is ch aracter-
ized by th e p resen ce of (u su ally) n on bizarre
d elu sion s. See exp lan ation s to Qu estion 3
for fu rth er d efin ition s.
5. (A) This w om ans presentation is consistent
w ith p sychosis w ith p erip artu m onset, char-
acterized by d elu sions and hallu cinations d u r-
ing p regnancy or w ithin 4 w eeks of d elivery.
She fu rther exhibits insom nia, irritability, and
m ood lability. This, cou pled w ith previou s
early d ep ressive ep isod es, strongly su ggests
an ep isod ic m ood d isord er. Thou gh p ostpar-
tu m p sychosis can be d ue to d ifferent etiolo-
gies, m ost cases eventu ally m anifest as bip olar
d isord er. H ow ever, only a sm all fraction of
w om en w ith bip olar d isord er w ill m anifest
w ith p ostp artu m p sychosis. A less frequ ent
u nd erlying etiology of postpartu m psychosis
is MDD. Prim ary p sychotic illnesses, su ch as
d elu sional d isord er, schizoaffective d isord er,
and schizop hrenia, are even m ore rare.
6. (E) Progressive social w ithd raw al is com -
m only seen as part of the prod rom e of schizo-
p hrenia. All other choiceshead trau m a, low
intelligence, a neglectfu l m other, and abu se
have not been p roven in any conclu sive w ay

to be significantly linked to schizophrenia,
althou gh early theories held that a history of
one or m ore w as a pred isposing factor.
7. (E) While her history strongly su ggests a p ri-
m ary psychotic d isord er such as brief p sychotic
d isord er (lasting 1 d ay1 m onth), schizo-
p hreniform d isord er (lasting 16 m onths), or
schizophrenia, the presence of cannabis on her
toxicology screen preclud es su ch a d iagnosis
at this tim e, especially since the onset of her
cannabis u se pred ates the positive sym ptom s
by a few w eeks. Unless her sym p tom s p ersist
after sobriety from cannabis is attained , given
the prom inence of her psychotic (rather than
m ood ) sym ptom s, her m ost ap prop riate d iag-
nosis at this tim e is a su bstance-ind u ced (spe-
cifically cannabis-ind u ced ) p sychotic d isord er.
Fu rther, if her sym p tom severity rem ains ou t
of proportion, she m ay eventu ally m eet crite-
ria for a com orbid p rim ary p sychotic d isord er
as w ell as a cannabis u se d isord er.
8. (C) The p atient m eets criteria A for schizo-
p hrenia: for at least 1 m onth she has exhibited
hallu cinations, d elu sions, and d isorganized
sp eech. Fu rther her sym p tom s are occu r-
ring ou tsid e of an acu te m ood ep isod e and
are not d u e to another m ed ical cond ition.
They have p ersisted for over a year, d esp ite
sobriety from cannabis. Since her p sychotic
sym p tom s have lasted longer than 6 m onths,
her m ost ap p rop riate d iagnosis is schizo-
p hrenia. Brief p sychotic d isord er is charac-
terized by p sychotic sym p tom s lasting 1 d ay
to 1 m onth. Schizop hreniform d isord er refers
to sym p tom s lasting m ore than 1 m onth bu t
less than 6 in the absence of concu rrent m ood
d isord er, su bstance u se, or another m ed ical
cond ition.
9. (C) The patient meets the criteria for bord erline
personality d isord er characterized by rapid
mood sw ings, efforts to avoid aband onment,
chronic feelings of emptiness, intense anger
outbursts, impulsivity, fluctuations betw een
idealization and devaluation, and recurrent
self-mutilation or suicid ality. People w ith
this personality d isord er commonly employ
primitive d efense mechanisms, such as d enial,
Answe rs : 112 59
projective id entification, and splitting. Splitting
is d ividing external objects (ind ivid uals) into
all good or all bad categories. Altruism
(living vicariously by helping others) and sub-
limation (gratifying urges in socially acceptable
w ays) are mature d efenses, w hile intellectual-
ization (using intellectual processes to avoid
feelings) and und oing (acts performed to und o
obsessional thoughts) are consid ered neurotic
d efenses.
10. (E) Good p rem orbid fu nctioning p ortend s a
better p rognosis for this p atient. Other fea-
tu res of schizophrenia that pred ict a better
p rognosis inclu d e later age at p resentation,
fem ale gend er, acute and rap id onset of sym p-
tom s (as opposed to insid ious onset), and the
p resence of m ood sym p tom s. While pred om i-
nantly p ositive sym p tom s also p red ict a m ore
favorable prognosis, this patient has signifi-
cant negative sym p tom s, as evid enced by his
isolation and am otivation.
11. (A) This patient is presenting w ith several
catatonic featu res, includ ing negativism,
psychom otor slow ing, and echopraxia, w ith
slight vital sign flu ctuations. Catatonia is often
und erd iagnosed . While catatonia w as for-
merly consid ered a subtyp e of schizophrenia,
it is found more frequently in affective d isor-
d ers, especially m ajor d epressive d isord er.
This patients history of isolation, anhed onia,
psychom otor retard ation, d ecreased appetite,
and gu ilt (burd en on fiance) are m ore su g-
gestive of major d epressive d isord er. While
hyp othyroid ism shou ld be ru led ou t, catato-
nia is not a com mon presentation. There is no
evid ence to su ggest that he is faking symp-
toms for second ary gain, as in m alingering.
The lack of prior psychiatric history or psy-
chosis m akes a d iagnosis of catatonia associ-
ated w ith schizophrenia unlikely. There is no
evid ence of exposu re to antipsychotics nor
significant autonomic instability, so neuroleptic
malignant synd rom e is u nlikely.
12. (D ) The m ainstay of treatm ent for catatonia
is p harm acotherap y w ith benzod iazep ines
or electroconvu lsive therap y. In this case, it
is reasonable to attem p t a trial of lorazep am
60 2: Ad ult P sychop a thology
and assess for resp onse; if the patient begins
to becom e u nstable or requ ires high d oses of
lorazepam (>20 m g/ d ), or if his blood p res-
sure/ pu lse d o not tolerate the titration of
lorazep am , ECT w ou ld be the ap p rop riate
cou rse of action. Am itrip tyline, sertraline, or
lithium d ep end ing on w hether his d iagno-
sis is u nipolar or bip olar d ep ressionw ould
be ap p rop riate m aintenance therap y once the
catatonia is treated .
13. (B) This w om ans presentation is m ost con-
sistent w ith a d elusional d isord er. She has no
other psychotic sym p tom s, her fu nctioning is
still good , and the d elu sion is isolated to one
specific belief. In ad d ition, this patients d elu -
sion is nonbizarre (i.e., cou ld possibly occu r).
While d elu sional d isord er m ay consist of a
bizarre (cou ld not occu r) d elu sion, it is not as
com m on. She d oes not exhibit other psychotic
sym ptom s, m aking brief psychotic d isord er
u nlikely; fu rther, in brief p sychotic d isor-
d er, sym ptom s m u st resolve w ithin 1 m onth
w hereas hers have been occu rring for at least
2 m onths. There is no evid ence she has a p ara-
noid personality d isord er. Schizop hrenia and
schizophreniform d isord er are unlikely since
her sym p tom s are lim ited to one d elu sion,
and she has no hallu cinations, negative sym p -
tom s, nor im p airm ent in fu nctioning. In ad d i-
tion, the tim e cou rse is insufficient for these
d iagnoses.
14. (E) This w om an has a profou nd d epression
w ith m any lifetim e ep isod es, inclu d ing sev-
eral severe su icid e attem p ts. She has not
resp ond ed to several m ed ications or au gm en-
tation strategies. The p ersistence of su icid al-
ity in light of the treatm ent resistance is the
m ost pressing reason to p ursu e ECT. ECT can
ind u ce a rap id resp onse, and has excellent
rem ission rates (u p to 80%), m arked ly m ore
than for m ed ication alone. If her thyroid d ys-
fu nction w ere untreated , this w ould be a rea-
sonable place to initiate treatm ent, how ever
her thyroid abnorm ality has been stabilized .
H er prior history of psychotic sym ptom s d oes
not necessarily im p ly she w ou ld be a good
ECT cand id ate, bu t it is fu rther evid ence of the
severity of her illness. Perip artu m d epression
w ou ld sp u r the d ecision for ECT if she w ere
currently in the postpartu m state, acutely
suicid al, and / or a threat to her infant.
15. (C) There is no absolu te contraind ication to
ECT. H ow ever, a sp ace-occu p ying lesion can
cause d angerou s increases in intracranial pres-
sure. Since ECT cau ses a tem porary increase
in cerebral p erfu sion and the sku ll is a fixed
space (volum e), the increase in blood vol-
u m e cau ses increased intracranial p ressu re;
a sp ace-occu p ying lesion red u ces the p oten-
tial reserve the skull has to offset the increase
in p ressu re. Du e to the transient tachycard ia
that occu rs w ith seizures, a recent m yocar-
d ial infarction is also a relative contraind ica-
tion to ECT becau se of excess d em and s on the
m yocard iu m . After at least several m onths,
how ever, card iac risks of ECT are the sam e as
those for general anesthesia. Pacem akers and
a history of traum atic brain inju ry are not con-
traind ications. Pregnancy is also not a contra-
ind ication to ECT, and the risks are the sam e
as those of general anesthesia. With recent
ad vances in anesthesia, fractu res are u ncom-
mon since paralysis is attained for the d uration
of the ind uced seizu re.
16. (B) While m any sleep d istu rbances have
been noted in m ajor d ep ressive d isord er (as
d escribed by the other choices), early m orn-
ing aw akening has been the m ost consistently
linked w ith m ajor d ep ression. The d ecrease in
REM sleep latency and slow w ave sleep d eficits
often persist, even after treatment.
17. (C) Increased cortisol secretion in patients
w ith d epression w as one of the earliest obser-
vations in biological psychiatry, and has been
w ell borne out in subsequent stud ies. Levels of
MAOs are unknow n. Catecholamines, sex hor-
mones, and imm une function are d ecreased in
d epression.
18. (B) The m ost ap p rop riate next step is to ensure
the safety of the patient and others, and escort-
ing the p atient to the em ergency room w ith
p olice assistance gu arantees this is p reserved .
Discharge is inap p rop riate at this tim e as the
p atient has m ad e an active threat; w hile this

p atient is likely in a m anic episod e and the
hom icid al threat is related to the d elu sion of
his m other-in-law , the threat m u st be taken
seriously. States d iffer in the d u ty to w arn, bu t
at this tim e in ord er to m aintain safety, ad m is-
sion is necessary. If on d ischarge the threat
rem ains, the target and law enforcem ent m ay
need to be notified (there is a d u ty to w arn).
It w ou ld be inap p rop riate to have the w ife
stay w ith the m other-in-law as this w ould be
p utting her in harm s w ay.
19. (C) This patient is su ffering from a m anic
ep isod e, and given his anteced ent treatm ent
w ith an antid ep ressant, p aroxetine, it is likely
the antid ep ressant ind u ced the m anic sw itch.
In ad d ition to achieving m ood stabilization
through valp roate, it is critical to stop the
offend ing agent. While SSRIs are occasion-
ally u sed in bipolar p atients w ith d ep ressive
ep isod es, their u se is not recom m end ed as
m onotherapy d ue to this p otential to ind uce
m ania. Paroxetine levels are not u sed clinically.
N ortriptyline w ould be less appropriate than
paroxetine, as tricyclic antid ep ressants are
more likely than SSRIs to ind uce mania. Bupro-
pion is also an antid epressant and w ould not
be appropriate at this time. Lorazepam m ay
help w ith agitation, bu t the more imp ortant
step is to quickly stop the offend ing agent.
20. (C) This p atient gives a history consistent
w ith cyclothym ic d isord er, characterized by
ep isod es of hyp om ania and d ep ressive ep i-
sod es not m eeting criteria for MDD. Treat-
m ent is generally the sam e as for bip olar
d isord er. For a d iagnosis of bip olar I, only
a m anic ep isod e is necessary, thou gh m ost
p atients w ill su ffer from d ep ressive ep isod es
as w ell. Bip olar II d isord er is characterized
by m ajor d ep ressive ep isod es and hyp o-
m anic ep isod es. Persistent d ep ressive d isor-
d er (d ysthym ia) is a chronic d ep ression that
m ay also m eet severity for a m ajor d ep res-
sive ep isod e; sym p tom s p ersist for 2 years,
w ith no m ore than 2 m onths of sym p tom -
free p eriod s. Dou ble d ep ression is an old er
term referring to ind ivid u als w ith p ersistent
d ep ressive d isord er d evelop ing an MDD, as
w ell. Accord ing to the DSM -5, the d iagnosis
Answe rs : 1324 61
w ou ld be p ersistent d ep ressive d isord er w ith
interm ittent d ep ressive ep isod es.
21. (B) This patient is now experiencing a m ajor
d ep ressive episod e, w hich, cou pled w ith his
p rior hyp om anic ep isod es, w ould be consis-
tent w ith the d iagnosis of bipolar II d isord er.
See exp lanation for Qu estion 20 for rem aining
d efinitions.
22. (E) In this you ng p atient on no m ed ications,
a u rine toxicology screen is m ost likely to
d eterm ine the cau se of her current state, p rob-
ably d u e to d ru g intoxication. Blood glu cose
is im p ortant to test since hyp oglycem ia can
p resent w ith m ental status changes and d ia-
p horesis; how ever, it w ou ld be u nlikely in this
otherw ise healthy w om an. Catecholam ine
m etabolites w ou ld be p rem atu re at this tim e.
An ECG w ou ld be p art of a w orku p to ru le
ou t any arrhythm ias, bu t any abnorm alities
w ou ld not necessarily id entify a sp ecific etiol-
ogy or accou nt for her d ilated pu pils. Thyroid
fu nction tests are im portant, as thyrotoxicosis
can m anifest w ith panic-type sym p tom s, bu t
again, in a healthy w om an w ith an acute onset
of sym ptom s, the u rine d rug screen is m ore
likely to yield an etiology.
23. (C) This p atient is m anifesting signs and
sym ptom s of acute stim u lant (cocaine) intoxi-
cation, includ ing tachycard ia, d iap horesis,
and p u p illary d ilation. Caffeine is not rou -
tinely tested on urine toxicology screens and
w ou ld not cau se su ch a severe reaction. Can-
nabis intoxication m ay p resent w ith anxiety
and p aranoia, as w ell as conju nctival injection,
bu t it d oes not resu lt in d ilation of the p u p ils.
Intoxication w ith heroin and other op iates
w ill u su ally p resent w ith sed ation, resp iratory
d ep ression, and constricted (pinpoint) pu pils.
LSD w ill often cau se p rom inent hallu cinations
d uring intoxication.
24. (B) This p atient has acu te m ental statu s
changes, associated w ith vital sign abnor-
m alities and hallu cinations. This presentation
is su sp iciou s for acu te d eliriu m , sp ecifically
d elirium trem ens (DTs) d ue to alcohol w ith-
d raw al. Untreated , DTs can be lethal. The
62 2: Ad ult P sychop a thology
likelihood for onset is highest in the third to
fifth d ay after the last d rink. While postopera-
tive sep sis is another cause of d eliriu m , lack of
fever m akes this less likely than alcohol w ith-
d raw al. Brief psychotic d isord er, functional
neu rological sym ptom d isord er (conversion
d isord er), and d elu sional d isord er d o not fit
the acu te onset of sym ptom s w ith alterations
in the level of consciou sness and vital sign
abnorm alities. In ad d ition, fu nctional neu ro-
logical sym p tom d isord er d oes not m anifest
w ith hallu cinations.
25. (C) Benzod iazepines are the m ainstay of
treatm ent for d eliriu m trem ens (DTs). Of
the choices, only d iazepam and lorazepam
are benzod iazep ines; d iazep am is less id eal
than oxazepam becau se it has active m etabo-
lites and u nd ergoes extensive m etabolism in
the liver. Oxazepam and lorazepam are not
d ep end ent on liver function for their m etabo-
lism ; they are therefore id eal to treat DTs in
p atients w ith u nd erlying liver d isease. Disu l-
firam is not appropriate in the acute treat-
m ent of DTs, bu t m ay have a role in su stained
abstinence. Phenobarbital m ay be requ ired
to ind u ce sed ation in p atients w ho d evelop
seizu res d espite benzod iazepine treatm ent
or those w ho requ ire high d oses of benzod i-
azepines (e.g., enou gh to requ ire intu bation).
Phenytoin d oes not have a role in acu te DTs
treatm ent.
26. (C) Deliriu m trem ens, if untreated , has a m or-
tality rate of close to 30%. Becau se of early
recognition and im p roved treatm ents, the
m ortality rate of DTs is now app roxim ately
5%.
27. (B) Kl verBu cy synd rom e presents w ith
d ocility, lack of fear resp onse, anterograd e
am nesia, hyp erphagia, and hypersexu ality.
Arnold Chiari synd rom e d escribes a cond i-
tion w ith hyd rocephalu s and cerebellar ana-
tom ic and functional abnorm alities. Mbiu s
synd rom e is a congenital absence of the
facial nerves and nu clei w ith resu lting bilat-
eral facial p aralysis. Pick d isease is a form of
m ajor frontotem p oral neu rocognitive d isor-
d er (d em entia), often ind istinguishable from
m ajor neu rocognitive d isord er (d em entia) d u e
to Alzheim er d isease, in w hich the frontal and
tem poral lobes are preferentially atrophied .
Pu nch-d ru nk synd rom e d escribes an acquired
m ovem ent d isord er associated w ith trau m atic
d am age to the su bstantia nigra, for exam ple,
from boxing.
28. (A) Kl verBucy synd rom e is m ost closely
associated w ith severe d am age to, or d iscon-
nectivity of, the am ygd alae bilaterally. The
hipp ocam p u s, although im p ortant to short-
term m em ory, is not d irectly involved w ith
regu lating aggressive d rives, sexu al behav-
iors, or fear resp onses. The lateral ventricle
is a CSF-containing sp ace that has no d irect
neu rop sychiatric fu nctional role. The insu la,
fou nd d eep w ithin the central sulcus, is
m ed ial to the tem p oral lobe and not involved
in Kl verBu cy synd rom e. Su p erior tem poral
gyri are m ore generally involved w ith p ro-
cessing com plex aud itory inform ation su ch as
the u nd erstand ing of language.
29. (E) Th is p atien t is su fferin g from an eatin g
d isord er, p ossibly an orexia n ervosa. Man y
p atien ts w ith eatin g d isord ers h ave stron g
d rives for p erfection . Psych od yn am ically,
p atien ts often feel a lack of con trol an d seek
to con trol th e on e th in g th ey p erceive th ey
can , th at is, food . Fu rth er, p atien ts also lack
a sen se of valid ation from caregivers. Th ey
d on t ch aracteristically h ave legal p rob-
lem s, an d often are of a h igh socioecon om ic
statu s.
30. (A) This patients m ost likely d iagnosis is
anorexia nervosa. She exhibits intense food
restriction as w ell as com p ensatory behaviors
of over exercising to m ake u p for any caloric
intake she m ay have had . Anem ia is not u ncom -
m on in patients w ith anorexia, and fatigu e
is a frequ ent com p laint. The p resentation is
not consistent w ith avoid ant/ restrictive food
intake d isord er, w hich d escribes an eating d is-
tu rbance regard ing food s sensory characteris-
tics or the concern abou t ad verse consequences
of intake not related to bod y im age. In bu li-
m ia nervosa, p atients engage in food binges,
consum ing large qu antities of food and later

feeling intense guilt and sham e. Patients w ith
bu lim ia m ay also engage in com p ensatory
m echanism s, such as laxatives, ip ecac, self-
ind u ced vom iting, and over exercise to m ake
u p for the caloric intake. Exercise-ind u ced
amenorrhea is possible, but less likely given this
patients distorted necessity to compensate for
any food intake. Many patients with anorexia
also have obsessive-compulsive tendencies (per-
fectionism), but there is no indication that the
patient has OCD.
31. (A) Benzod iazep ines are effective in acu tely
stopping a p anic attack su ch as d escribed in
the vignette. Alp razolam has the shortest half-
life as w ell as the m ost rap id onset of action,
and is therefore the agent m ost likely to abort
the panic attack. H ow ever, because of these
sam e qu alities, it also has significant abu se
potential and should only be used for short-
term relief. Chlord iazepoxid e is a longer-acting
benzod iazep ine bu t d oes not have as rap id an
onset of action. Divalproate is not ind icated
for this p atient in the absence of m ood insta-
bility. Flu oxetine, an SSRI, and p henelzine,
an MAOI, both are ind icated for the long-
term treatm ent of panic d isord er, bu t onset
of sym ptom relief m ay take w eeks. As su ch,
m any clinicians w ill start an SSRI bu t w ill also
ad d an ad ju nctive benzod iazepine for the first
few w eeks of treatm ent, until the SSRI starts to
take effect.
32. (B) At this tim e his d iagnosis is m ost consis-
tent w ith an ad ju stm ent d isord er, specifically
w ith anxiety. Ad ju stm ent d isord er notes the
onset of m ood and behavioral changes fol-
low ing an acu te stressor. The sym p tom s rem it
w ithin 6 m onths after the stressor. Ad ju stm ent
d isord er can be sp ecified as occu rring w ith
d ep ressed m ood , w ith anxiety, w ith m ixed
anxiety and d ep ressed m ood , w ith d istu r-
bance of cond u ct, w ith m ixed d istu rbance of
em otions and cond u ct, and as w ell as rem ain-
ing u nsp ecified . In acu te stress d isord er, the
p atient is exp osed to a trau m atic event and
exp eriences reexp eriencing (e.g., flashbacks),
num bing, and increased arou sal sym p tom s
for u p to 1 m onth after the event. A breaku p is
not typically trau m atic in the sense that life
Answe rs : 2535 63
is not u su ally threatened . While this p atient
has an inability to relax an associated m uscle
tension, sym p tom s com m only associated w ith
generalized anxiety d isord er, his w orries are
lim ited to the recent relationship , and his
sym ptom s have not been long-stand ing. The
p atient d oes not m eet criteria for m ajor d epres-
sive d isord er at this tim e, bu t if his sym ptom s
p ersist or w orsen, this d iagnosis shou ld be
consid ered . This p atients sym ptom s are m ore
than w hat w ou ld be exp ected for a norm al
reactionhis sleep has been d isru p ted and it
is starting to affect his schoolw ork for the p ast
5 w eeks.
33. (D ) At this tim e the p atients cond ition has
w orsened , and he now has a p ervasive
d ep ressed m ood and d istu rbance in sleep,
ap p etite, concentration as w ell as associated
hop elessness and w orthlessness. In ad d ition
to w orsening self-care, his sym p tom s are now
significantly affecting his schoolw ork and
qu ality of life. H e therefore now m eets criteria
for m ajor d epressive d isord er, single episod e,
and w arrants ap p rop riate treatm ent, w hether
w ith m ed ication, therap y, or both.
34. (E) While this p atients sym p tom s are consis-
tent w ith MDD, her ongoing alcohol use pre-
clu d es the d iagnosis at this tim e; therefore,
substance-ind u ced m ood d isord er is the m ost
likely d iagnosis. If she rem ains sober for a
p eriod of tim e and her d epressive sym ptom s
continu e, she w ou ld then be d iagnosed w ith
MDD. Am otivation synd rom e is a controver-
sial synd rom e associated w ith cannabis u se,
and is not app rop riate in this case given the
lack of cannabis u se. In acu te stress d isord er,
the patient is exp osed to a trau m atic event and
exp eriences reexp eriencing (e.g., flashbacks),
nu m bing, and increased arou sal sym p tom s
for u p to 1 m onth after the event. Ad ju stm ent
d isord er is characterized by the onset of m ood
and behavioral changes follow ing an acu te
stressor that are out of proportion to a typical
resp onse.
35. (D ) Persons w ith schizoid p ersonality d is-
ord er are d etached , reclusive, d em onstrate a
restricted range of affect, and d o not m ind the
64 2: Ad ult P sychop a thology
lack of social interaction. Agorap hobia is tied
to the fear of having panic-type sym ptom s in
p ublic. Su ch sym p tom s are not m entioned in
this case. Autism spectru m d isord er is a d evel-
opm ental d isord er characterized by d eficits
in social com m u nication and w ith rep etitive,
restricted behaviors and interests. Persons
w ith avoid ant p ersonality d isord er are shy
and fearful of social rejection. H ow ever, their
lack of socialization is d istressing to them .
Schizotypal ind ivid uals can have schizoid fea-
tu res but they also have bizarre thinking and
an od d or eccentric m anner.
36. (D ) Methad one m aintenance is the m ost
ap p rop riate p harm acological therap y for the
treatm ent of op iate (heroin) u se d isord er,
even in p regnancy. Methad one m aintenance,
esp ecially w hen com bined w ith p sychoso-
cial services and obstetric m onitoring, sig-
nificantly im p roves neonatal ou tcom es and
obstetric ou tcom es for w om en ad d icted to
heroin. The low est effective d ose shou ld be
u sed d u ring p regnancy. There are no know n
teratogenic effects from m ethad one. Wom en
m ay requ ire higher d oses of m ethad one in
the third trim ester d u e to increased m etabo-
lism of the d ru g at that tim e. Bu p renorp hine
is a p artial op iate agonist that has a role in
m aintenance treatm ent, bu t its safety d u ring
p regnancy and breastfeed ing has not been
d efinitively established , and its u se in p reg-
nancy m ay lead to w ithd raw al sym p tom s in
op ioid -d ep end ent fetu ses. Clonid ine can be
u sed to treat hyp ertension and other sym p -
tom s d u ring acu te op iate w ithd raw al. While
halop erid ol (a first-generation antip sychotic)
m ay be u sed safely in p regnancy, it has no u se
for the treatm ent of severe op iate u se d isor-
d er, u nless agitation from acu te w ithd raw al
is p roblem atic. N aloxone is an op iate antago-
nist, u sed for op iate overd ose, not ap p rop ri-
ate in this case.
37. (C) This p atient exhibits ep isod ic m ood sym p -
tom s as w ell as chronic p sychotic sym p tom s
ou tsid e of those m ood ep isod es, m aking her
m ost likely d iagnosis schizoaffective d is-
ord er. There is no evid ence of p rior m anic
ep isod es, m aking bip olar d isord er u nlikely.
If the hallu cinations and d elu sions only
occu rred in the context of her d ep ressive
ep isod es, the m ost likely d iagnosis w ou ld
be m ajor d ep ression w ith p sychotic featu res.
While schizop hrenia w ou ld be on the d iffer-
ential, her affective (d ep ressive) sym p tom s
are p rom inent. Schizop hreniform d isord er
is characterized by sym p tom s of schizop hre-
nia, w hich last from 1 to 6 m onths, so it is
not ap p rop riate given the chronicity of her
sym p tom s.
38. (B) This p atients history is consistent w ith a
m ood p attern d efined by p eriod s of hyp om a-
nia (sym p tom s of m ania not severe enou gh
to cau se occu p ational d ysfu nction or p sychi-
atric hosp italization) and cu rrently a m ajor
d ep ressive ep isod e. H yp om ania w ith m ajor
d ep ression d efines bip olar II d isord er. In
bip olar I d isord er, the m ania is m ore severe,
cau sing notable occu p ational d ysfu nction,
p sychotic sym p tom s, or hosp italization.
While this p atient is in the m id st of a m ajor
d ep ressive ep isod e, his history of hyp o-
m ania ind icates a bip olar d iagnosis; this is
an im p ortant d istinction becau se im p rop er
treatm ent w ith antid ep ressants can p recip i-
tate a m anic ep isod e. Bord erline p ersonality
d isord er is characterized by a p ersistent p at-
tern of u nstable relationship s, m ood states,
and self-im age. N arcissistic p ersonality d is-
ord er is characterized by a p ervasive p attern
of grand iosity, need for ad m iration, and lack
of em p athy.
39. (C) Dry m ou th, d izziness (associated w ith
hypotension), and u rinary hesitancy are d u e
to anticholinergic and antiad renergic effects
of tricyclic antid ep ressants (TCAs) su ch as
im ip ram ine. Divalp roex sod iu m is a m ood
stabilizer that m ay cau se gastrointestinal
u p set and is com m only associated w ith sed a-
tion and trem or at higher d oses. Fluoxetine, a
serotonin-sp ecific reup take inhibitor (SSRI),
is m ost often associated w ith gastrointestinal
u p set, sexu al d ysfu nction, and activation/
agitation. Lithiu m is another m ood stabilizer
u sed in bip olar d isord er, m ost often caus-
ing p olyu ria, p olyd ip sia, trem or, and m en-
tal confusion at higher d oses. Phenelzine, a

m onoam ine oxid ase inhibitor (MAOI), can be
associated w ith hypotension bu t is less likely
to have anticholinergic effects.
40. (C) This patient likely has normal pressure
hydrocephalus (NPH), one of the few poten-
tially reversible causes of neurocognitive dis-
order (dementia). The classic triad of NPH is
confusion, gait apraxia, and incontinence. Ele-
vated opening pressure is not found in NPH
(thus the normal pressure part of the d iag-
nosis). Frontal release signs and perseveration
are nonspecific findings common in demented
patients but not specific to NPH. Oculomotor
difficulties are a part of the WernickeKorsakoff
syndrome.
41. (B) In N PH , CT scan com m only reveals d ilated
ventricles thought to be the resu lt of increased
p ressu re w aves im p inging w ithin the ventric-
u lar system . Cerebellar atrop hy is seen m ost
often in congenital d isord ers and alcoholism .
H ypointensities found in subcortical areas are
often ind icative of lacu nar strokes. Frontopa-
rietal atrop hy is seen in m ajor neu rocognitive
d isord er d ue to Alzheim er d isease. Fronto-
tem poral atrophy is fou nd in Pick d isease, an
u ncom m on type of frontotem p oral neu rocog-
nitive d isord er (d em entia).
42. (C) This p atient is m ost likely su ffering from
m ajor neu rocognitive d isord er (d em entia),
characterized by progressive im p airm ent of
cognitive fu nction in the absence of d eliriu m .
Mem ory im pairm ent and loss of fu nction in
at least one other cognitive d om ain are hall-
m arks. While som e loss of cognitive fu nction
is exp ected w ith age (m ild neu rocognitive
d isord er d oes not interfere w ith capacity for
ind ep end ence), it is too severe and this p atient
is no longer able to fu nction ind ep end ently.
Deliriu m is characterized by acu te m ental sta-
tu s change w ith d eficits in attention (i.e., fluc-
tu ating levels of consciousness). While m ajor
d ep ressive d isord er can present w ith neuro-
cognitive d eficits (pseu d od em entia), there
is no ind ication of d ep ression. This p atient
d oes not d em onstrate the gait apraxia and
u rinary incontinence characteristic of norm al
p ressu re hyd rocephalu s.
Answe rs : 3644 65
43. (A) The most common type of major neurocog-
nitive d isord er (d ementia) is d ue to Alzheimer
d isease, w hich demonstrates diffuse atrophy
on neuroimaging. Major neurocognitive d is-
ord er d ue to Lew y bod y d isease is clinically
similar to Alzheimers, but also includ es hallu-
cinations, parkinsonian features, and extrapy-
ramid al signs. Major neurocognitive disorder
d ue to traumatic brain injury is characterized
by emotional lability, dysarthria, and impulsiv-
ity. Major neurocognitive d isord er due to vas-
cular d isease (formerly multi-infarct d ementia)
is the second most common type of demen-
tia, and involves small w id espread lacunar
infarcts. It is seen in those w ith hypertension or
other card iovascular d isease; this patient d oes
not have either cond itions. Unspecified major
neurocognitive d isord er is reserved for patients
in w hom the precise etiology cannot be deter-
mined w ith sufficient certainly to make the
appropriate attribution. All the major neuro-
cognitive d isord ers must be d istinguishes from
major d epression; pseud od ementia refers
to a cond ition w here the patient demonstrates
symptoms consistent w ith memory d ifficulties,
but in the absence of a dementia; it is often seen
in d epression. Patients w ith pseud od emen-
tia usually have more d epressive symptoms,
have more insight into their symptoms than
d emented patients, and w ill often have a prior
history of d epression.
44. (D ) Major frontotem p oral neu rocognitive d is-
ord er (form erly Pick d isease) is characterized
by p referential atrop hy of the frontotem p oral
region, as op p osed to the p arietotem p oral d is-
tribu tion seen in Alzheim er d isease. Patients
m ay exhibit either a behavioral variant or lan-
gu age variant, bu t m any have featu res of both.
Patients w ith the behavioral variant m ust
show three or m ore behavioral sym ptom s
(behavioral d isinhibition, ap athy or inertia,
loss of sym p athy or em p athy, p erseverative/
stereotyped / ritualistic behaviors, or hypero-
rality and d ietary changes) or a p rom inent
d ecline in social cognition and / or execu te
abilities. Patients w ith the langu age variant
display a decline in language ability (difficulties
in speech production, naming, word finding,
comprehension).
66 2: Ad ult P sychop a thology
45. (E) The DSM -5 d istingu ishes the severity of
alcohol (and other substance) u se d isord ers
on the basis of how m any criteria are m et. Cri-
teria A includ e evid ence of a problem atic pat-
tern of alcohol u se that resu lts in im pairm ent
and / or d istress. Patients m eeting 2 to 3 sym p -
tom s m eet criteria for m ild alcohol u se d is-
ord er; those that have 4 to 5 sym ptom s m eet
criteria for m od erate alcohol u se d isord er;
those that m eet 6 or m ore of the possible listed
11 sym ptom s can be d iagnosed w ith severe
alcohol u se d isord er (form erly alcohol d ep en-
d ence). The DSM -5 d oes not d istingu ish abu se
from d ep end ence, and requ ires the nu m ber of
p roblem atic sym ptom s to d eterm ine severity.
This p atient d rinks alcohol in large am ou nts,
has had unsu ccessfu l efforts to cu t d ow n, has
cravings, has had persistent interpersonal
p roblem s d ue to d rinking, has had recu rrent
p hysical problem s d ue to d rinking, and has
had w ithd raw al sym p tom s; he m eets at least
six criteria and therefore can be d iagnosed
w ith alcohol u se d isord er, severe.
46. (D ) This p atient w ould m eet the criteria for
schizophrenia excep t that the d u ration of
his illness has been less than 6 m onths. Brief
p sychotic d isord er m ay present w ith psycho-
sis bu t the d uration of the d istu rbance m ust
be 1 m onth or less. This patients d elu sions
are too bizarre to typ ically be consistent w ith
d elu sional d isord er, and the age of onset for
d elu sional d isord er is u su ally m id d le age.
There is no evid ence of a d ep ressive d isord er
at this tim e.
47. (A) This patient has sym p tom s consistent w ith
PTSD or acute stress d isord er (i.e., trau m atic
event, intrusive m em ories of trau m a, avoid -
ance of rem ind ers, hypervigilance), bu t the
fact that the trau m a w as only 3 w eeks p rior
m eans that she w ou ld be d iagnosed w ith acu te
d istress d isord er. For PTSD, there m u st also be
evid ence of negative cognitions or m ood s. If
her sym ptom s d id p ersist after 4 w eeks, then
she w ou ld be d iagnosed w ith PTSD. Ad just-
m ent d isord er m ost often represents a change
in m ood , anxiety, or cond u ct that hap p ens
after a nontraum atic event. In GAD, there is
no associated trau m a, and the sym ptom s of
anxiety last for at least 6 m onths. The patient
has no evid ence of a primary d epressive illness
such as MDD.
48. (C) The lifetim e incid ence of su icid e in
p atients w ith schizop hrenia is ap p roxim ately
10%, compared w ith less than 1% in the general
population.
49. (A) Clozapine, the first atypical antipsy-
chotic, has been show n to d ecrease su icid -
ality in patients w ith schizop hrenia and is
p articu larly effective in treatm ent-refractory
p atients, such as the one in this exam p le. Clo-
zap ine requires regu lar blood m onitoring to
screen for the potentially seriou s sid e effect of
agranu locytosis. N one of the rem aining anti-
p sychotics, such as flu phenazine, haloperid ol,
or ziprasid one, have been show n to be effec-
tive in treatm ent-refractory schizophrenia or
to d ecrease su icid ality. While lithiu m has also
been show n to d ecrease su icid ality, its u se is
not ind icated in this case given the lack of any
affective sym p tom s.
50. (A) Feelings and attitudes originating from
the clinician, evoked by the patient, are called
countertransference. Transference d enotes feel-
ings and attitud es about the physician coming
from the patient. Empathy is the ability of the
clinician to psychologically put oneself in the
patients shoes and thereby und erstand the
patients thinking, feelings, or behavior. Id en-
tification is a d efense mechanism characterized
by the unconscious incorporation of some-
one elses traits into ones ow n mannerfor
example, ad olescents having hairstyles similar
to ad mired rock stars. Projection is a primi-
tive d efense mechanism w hereby one assigns
emotions to another person in an attempt to
psychologically d efend against (cover up) the
presence of those emotions w ithin oneself; for
example, the d octor in the case may tell his fel-
low resident that he believes that his female
patient is attracted to him, w hen in actuality he
is attracted to her.
51. (A) This patient d isplays symptom s of fear of
loss and aband onment, intense interpersonal
relationship s, recurrent suicid al behavior or

threats, affective instability, and d ifficulty
controlling intense anger, consistent w ith
bord erline personality d isord er. Patients
w ith cyclothymic d isord er often present w ith
similar sym ptoms of mood changes d u e to
hyp om anic ep isod es and m inor d epressive
episod es, bu t they are not u sually as frequent,
short-lived , or intense, and they are not asso-
ciated w ith the other symptom s of bord erline
personality d isord er above. Patients w ith his-
trionic personality d isord er, like those w ith
bord erline personality d isord er, m ay d isplay
excessive emotionality and attention seeking,
but their core symptoms center around super-
ficial sed uctiveness and theatricality. While
patients w ith bord erline personality d isord er
may have d ep ressive sym ptoms that d evelop
into MDD, this patients d epressive sym ptoms
are fleeting and in resp onse to stressors such as
perceived aband onment. Althou gh this patient
ap pears p aranoid that all the staff hates me,
there is no other evid ence for a primary psy-
chotic illness su ch as schizoaffective d isord er.
Of note, how ever, patients w ith bord erline
personality d isord er may experience tem po-
rary psychotic symptoms, such as paranoia, or
severe d issociation u nd er times of perceived
stress or substance u se.
52. (D ) Psychotherap y and stead y social su p p ort
rep resent the best long-term m ethod for the
m anagem ent of bord erline p ersonality d is-
ord er. Antid ep ressants, antip sychotics, and
m ood stabilizers d o have som e efficacy in
treating target sym p tom s in som e p atients
w ith bord erline p ersonality d isord er, bu t
the long-term m ainstay treatm ent is p sycho-
therap y. Med ication can be a u sefu l ad ju nct
in m anaging sym p tom s su fficiently so that
the p atient can later engage m ore effectively
in p sychotherap y. Benzod iazep ines m ay
treat anxiety in these p atients, bu t they have
p articu lar abu se liability in these im p u lsive
p atients.
53. (B) Psychotherapy is the mainstay of bord er-
line personality disord er treatment. Of the
available types of therapy, DBT has show n to
be particularly effective w ith borderline indi-
vid uals, especially w hen used in conjunction
Answe rs : 4556 67
w ith groups. DBT is an offshoot from CBT and
focuses on mind fulness and distress tolerance.
CBT is often a short course of therapy focused
on d ysfunctional thoughts w ith their result-
ing behavioral and emotional manifestations.
Group therapy is a component of DBT, but
should be used in conjunction w ith, not in place
of, ind ivid ual therapy. Psychoanalysis and
psychod ynamic therapies utilize psychoana-
lytic principles and focus on formative child -
hood experiences and the recurrent patterns of
behaviors in interpersonal relationships, unre-
solved feelings, and build ing of ego d efenses.
While these therapies may be of benefit, the
regression and intense emotions evoked may
be too d ifficult for the patient to handle.
54. (A) Amnesia is a comm on sid e effect of ECT,
presenting in the form of short-term memory
d eficits. Aspiration, fractures, and arrhyth-
mias are rare sid e effects. Psychosis can be
improved , rather than w orsened , w ith ECT; in
fact, ECT is a treatm ent of choice in patients
w ith m ajor d epressive d isord er w ith psychotic
features.
55. (C) For m ajor d ep ressive d isord er, 6 to 12
sessions are generally optim al for a good
riskbenefit ratio of p ositive treatm ent effects
versus m em ory im p airm ent (w hich is m ore
likely w ith greater than 20 treatm ents). For
catatonic cond itions, tw o or fou r ECT treat-
m ents m ay be effective. When ECT is u sed
for psychosis or m ania, a larger num ber of
treatm ents m ay be necessary.
56. (B) This p atient has d istressing recu rrent and
intru sive thou ghts (obsessions). She attem p ts
to ignore or su p p ress her sym p tom s by not
exp laining to her hu sband how she feels and
by getting rid of all the knives in her kitchen.
Obsessions are the m ental acts, w hereas com -
p u lsions are p hysical actions p erform ed to
d ecrease anxiety associated w ith the obses-
sions. Obsessive-com p u lsive p ersonality d is-
ord er is a p ervasive character style m arked by
a p attern of p reoccu p ation w ith ord erliness,
p erfectionism , and m ental and interp ersonal
control. These ind ivid u als are often d escribed
as control freaks by layp ersons and are
68 2: Ad ult P sychop a thology
noted to be p articu larly inflexible. Delu sional
d isord er or schizop hrenia are inap p rop ri-
ate d iagnoses becau se this p atient is not
p sychotic; her w orries are conceived of as a
p rod u ct of her m ind and not as im p lanted
m essages, as m ay occu r in schizop hrenia.
There is no m ention of a history of od d beliefs
or strangeness p rior to the birth of her child ,
w hich w ou ld be consistent w ith schizotyp al
p ersonality d isord er.
57. (C) Flu voxam ine and other serotonin-sp ecific
reu p take inhibitors (SSRIs) (e.g., p aroxetine,
flu oxetine, sertraline, citalop ram ) are know n
for their antiobsessional effects as w ell as for
their antid ep ressant and antianxiety effects.
Patients m ay requ ire higher d oses than those
need ed for d ep ression. Lithiu m is a m ood sta-
bilizer u sed for bip olar d isord er. Lorazep am ,
a benzod iazep ine, m ay d ecrease anxiety bu t
has no d irect antiobsessional effects. H alop er-
id ol is a typ ical high-p otency antip sychotic
(neu rolep tic) that m ay be u sefu l in severe
form s of OCD in w hich there is a p sychotic
com p onent. H ow ever, it d oes not am eliorate
p u rely obsessional thinking. Becau se of the
im p ortance of serotonin in the treatm ent of
obsessive-com p u lsive d isord er, of the tricy-
clic antid ep ressants (TCAs), clom ip ram ine
w ou ld be p referred if this class w ere selected .
H ow ever, TCAs are not first-line treatm ent
for OCD.
58. (A) This patients presentation and examina-
tion are m ost consistent w ith d eliriu m, as evi-
d enced by a fluctuating mental status w ith
attentional d eficits. Any num ber of m ed i-
cal cond itions can cau se d eliriu m, and the
eld erly are particularly p rone. This w oman is
eld erly, d ehyd rated , and w ith an active infec-
tion; any one of these can increase the risk of
d elirium. Urinary tract infections are a fre-
qu ent cau se of altered m ental statu s in the
eld erly. A chest x-ray can also elucid ate the
presence of infection, and a head CT can rule
ou t acute intracranial pathology, both of w hich
can cause d eliriu m. While major d epressive
d isord er can cause cognitive d eficits on
MSEs that are reversible w ith antid epressant
treatment, these pseud od ementias usu ally
present w ith a more stable MSE than is illu s-
trated in this case; in ad d ition, there is no evi-
d ence that this w om an is d epressed . Although
this p atient w ou ld be likely to have a neuro-
cognitive d isord er (d em entia) as she cam e
from a nu rsing hom e, her flu ctu ating m ental
statu s is ind icative of a d elirium . Dem entias
are d iagnosed in the context of a relatively sta-
ble set of d eficits on MSE, and the u nd erlying
causes are rarely associated w ith acu te m ed i-
cal insu lts. There is no evid ence of a su bstance
or other cause of a m ajor neurocognitive d is-
ord er (d em entia). Im portantly, how ever, the
p resence of a m ajor neu rocognitive d isord er
(d em entia) d oes p red ispose a patient to a
d elirium .
59. (B) Polypharm acy can w orsen d eliriu m . Anti-
p sychotics su ch as halop erid ol can be used
to calm an agitated patient w ith d eliriu m .
Anticholinergic agents like d ip henhyd ram ine
shou ld be avoid ed as they can w orsen or cause
d elirium , and sed ating m ed ications should
be u sed at low est p ossible d oses. Benzod iaz-
ep ines su ch as lorazep am shou ld be avoid ed
in m ost cases of d eliriu m (w ith the excep tion
of sed ative-hypnotic/ alcohol w ithd raw al) as
they can d isinhibit patients and w orsen the
behavioral p roblem s. In cases of d eliriu m
w ith very severe agitation, p henobarbital m ay
be u sed , bu t this w ou ld not be the ap p rop ri-
ate m anagem ent in this case. Valp roic acid ,
an anticonvu lsant and m ood stabilizer used
in bip olar d isord er, is not ind icated in this
p atient.
60. (A) The d efinitive treatm ent for d eliriu m is to
treat the und erlying cau se, in this case, treat-
m ent of the u rinary tract infection w ith anti-
biotics. Mental statu s need s to be m onitored
carefu lly as som e antibiotics can also w orsen
d elirium . Sched u led chest x-rays or CT scans
have no role in treatm ent of this patients con-
d ition and carry u nnecessary rad iation expo-
sure. An ind w elling Foley catheter w ould
increase the risk of d evelop ing a u rinary
tract infection, and unless there is ind ication,
shou ld be avoid ed . Any associated electrolyte
abnorm alities that m ay have resulted from the
p atients p oor oral intake need to be corrected ,

bu t intravenou s flu id s w ill not, by them selves,
treat the infection or the d eliriu m .
61. (C) Deliriu m carries a high-m ortality rate and
is a poor p rognostic sign. The 1-m onth m ortal-
ity rate of p atients w ho have had one ep isod e
of d eliriu m is u p to 14%, and the 6-m onth
m ortality rate is app roxim ately 22%.
62. (C) Abou t one-third of all p atients w ith
d ep ression respond to the su rp risingly pow -
erfu l p lacebo effect. H ow ever, this resp onse is
not as w ell su stained as in p atients placed on
antid epressant m ed ications.
63. (D ) Stand ard antid epressant therapies, inclu d -
ing SSRIs and TCAs, have a p ositive resp onse
in 55% to 65% of patients.
64. (C) This p atient likely has m ajor d ep ressive
d isord er. The rate of com pleted suicid e in
hosp italized p atients w ith m ajor d ep ression
is app roxim ately 10% to 15%. Most p atients
w ith m ajor d ep ression w ill have som e d egree
of su icid al id eation, and u p to 40% of p atients
w ith m ajor d ep ression w ill attem p t su icid e.
Screening for su icid e shou ld be perform ed
in any p atient w ith d ep ression, and stu d ies
have show n that asking abou t su icid e d oes not
p lant the thou ght in p atients; m ost p atients
w ho have attempted suicide have seen a doctor
w ithin 4 w eeks of the attempt.
65. (C) The nu m ber one p red ictor of a com p leted
suicid e is a previous attem pt. Old er single (or
d ivorced ) m ales are m ore likely to attem p t.
Religion, good su pport, and child ren can be
p rotective factors. Concu rrent su bstance u se
and anxiety d isord ers can increase the risk of
suicid e.
66. (C) There is no evid ence of occupational or
social d ysfu nction or marked d istress caused
by this patients activities. Virtually all DSM -5
d iagnoses are qualified by these criteria. If the
patient d id d escribe su ch concerns, the d iag-
nosis w ould m ost likely be sexu al masochism
d isord er, in w hich patients are aroused by psy-
chologically or p hysically pu nishing acts by
another person (or fantasies of pu nishm ent). In
Answe rs : 5769 69
sexu al sad ism d isord er, the p atient is aroused
by giving such punishment (or fantasies of giv-
ing it) to others. Fetishistic d isord er involves
sexu al arousal connected to nonliving objects.
In frotteuristic d isord er, the patient is sexually
arou sed by touching or ru bbing u p against a
nonconsenting person. All are examples of
parap hiliaspersistent sexual interest other
than sexual interest in genital stimu lation or
preparatory fond ling w ith norm al, m atu re,
consenting hu man partners.
67. (D ) N arcolepsy is a d isord er often affecting
p ersons in their teens or tw enties. It is a d is-
ord er of REM sleep m echanism s, character-
ized by catap lexy (su d d en loss of m u scle tone
follow ing intense em otion), hyp nopom pic or
hypnagogic hallu cinations, or sleep p aralysis
(an inability to p erform volu ntary m ovem ents
either at sleep onset or aw akening that can
be terrifying). Circad ian rhythm sleep w ake
d isord er is a d isord er cau sed m ost often by
sleep-sched u ling changes su ch as night-shift
w ork. H yp ersom nolence d isord er d escribes
self-reported excessive sleepiness d espite
m ain sleep p eriod of su fficient tim e. Insom nia
d isord er notes a com plaint of d issatisfaction
w ith sleep qu ality and qu antity. N ightm are
d isord er is d iagnosed in the absence of other
p red isp osing m ental illness (e.g., PTSD), in
w hich the p atient has rep eated nightm ares
causing significant d istress.
68. (D ) Methylphenidate, a stimulant, has been
shown to be useful in inhibiting the onset
of narcoleptic episodes, likely owing to the
capacity for the drug to enhance CNS arousal
mechanisms that inhibit REM-related mecha-
nisms. Antidepressant treatment with tricyclic
antidepressants has been found to be useful
in combination with methylphenidate in some
patients with narcolepsy. However, the efficacy
of bupropion, fluoxetine (a serotonin-specific
reuptake inhibitor), and phenelzine (a mono-
amine oxid ase inhibitor) has not been well stud-
ied in narcolepsy. Benzodiazepine regimens are
not particularly effective for narcolepsy.
69. (D ) This p atients sym p tom s fit DSM -5 crite-
ria for PMDD. The rem ittance of sym p tom s in
70 2: Ad ult P sychop a thology
the w eek after m enses is typical of PMDD. In
ad ults, persistent d epressive d isord er is char-
acterized by su bthreshold d epressive sym p -
tom s, for m ore d ays than not, over a 2-year
p eriod . H er sym p tom s are not severe enou gh
nor of sufficient d u ration (2 or m ore w eeks)
to d iagnose MDD, and her sym p tom s are
m ore d isru ptive and cau se m ore d istress than
p urely PMS.
70. (C) This p atient is d isp laying sym p tom s con-
sistent w ith m ajor d epressive d isord er, single
ep isod e. The average u ntreated d ep ressive
episod e lasts anyw here from 6 to 13 m onths;
w ith treatm ent, the d u ration d ecreases to
ap proxim ately 3 m onths. Treatm ent can also
d ecrease the risk of recu rrence in the future.
71. (C) H eroin overd ose is m ost likely to have
caused the clinical situ ation d escribed , inclu d -
ing the d ecreased level of consciou sness,
resp iratory d ep ression, and p inp oint (con-
stricted ) pu pils. Alcohol intoxication and PCP
m ay cause com a bu t both are associated w ith
nystagm u s rather than pu p illary size changes.
Cocaine u se causes pu pillary d ilatation, not
constriction, and is usu ally associated w ith
agitation in large am ou nts. Inhalants m ay
rarely cau se com a bu t are not classically asso-
ciated w ith pu pillary constriction.
72. (E) N aloxone is u sed to reverse the acu te effects
of opiate overd ose by blocking CN S opioid
recep tors. Acetylcysteine is ad m inistered in
acetam inop hen overd ose and d eferoxam ine is
u sed in iron overd ose. Methad one is u sed for
the long-term m aintenance of opiate ad d iction
and w ou ld only w orsen the sym p tom s of her-
oin overd ose. Methylene blue is u sed to treat
m ethem oglobinem ia.
73. (D ) This p atient is su ffering from sym p tom s
of posttrau m atic stress d isord er (PTSD),
m anifesting in som e p atients follow ing the
exp osu re to threatened or actu al d eath, severe
inju ry, or violence, and consisting of intru -
sion sym ptom s, avoid ance of related stim uli,
negative alterations in m ood and cognitions,
and increased au tonom ic arou sal. The best
stu d ied and m ost efficaciou s m ed ications are
consid ered to be the SSRIs. Antip sychotics,
inclu d ing the atyp icals, shou ld not be u sed
as m onotherap y, althou gh m ay be used in
conjunction, especially if there are associated
p sychotic sym p tom s. Benzod iazep ines shou ld
be avoid ed in this p atient p op u lation not only
becau se of the significant com orbid ity w ith
substance ad d iction bu t also as they have not
been fou nd to be p articu larly effective. Mood
stabilizers, su ch as lithium and valproic acid ,
are occasionally u sed in ad d ition to SSRIs in
ord er to target the m ood lability or aggression
som etim es seen in PTSD, althou gh they are
not as effective as SSRIs.
74. (A) Th is case is an exam p le of p an ic d isord er
and agorap hobia inad equ ately treated w ith
ap p rop riate m ed ication, n am ely sertraline.
Man y m ental illnesses, inclu d in g an xiety
d isord ers, are best treated w ith a com bina-
tion of p harm acology an d p sych oth erap y.
The best-stu d ied p sychotherap y for p anic
d isord er is CBT. Eye m ovem ent d esensitiza-
tion and rep rocessing (EMDR) is a sp ecific
th erap y that has been d evelop ed for PTSD.
Insight-oriented therap y is a long-term
d ynam ic therap y. Althou gh it m ay be u se-
fu l in som e cases of p anic d isord er, it has not
been as valid ated as CBT. Interp ersonal ther-
ap y ad d resses relation ship s as a contribu tor
of d ep ression and is u sed to treat ind ivid u -
als w ith m ajor d ep ression. The p u rp ose of
su p p ortive p sychoth erap y is to stren gthen
th e p atien ts d efen se m ech anism s in ord er to
retu rn them to a p reviou s level of fu n ction-
ing. It has not been ad equ ately stu d ied for
p anic d isord er.
75. (A) This case d ep icts a patient w ho is feign-
ing or p rod u cing sym p tom s of an illness to
gain gratification by assu m ing the sick role.
Factitiou s d isord er is som etim es referred to
as Mu nchau sen synd rom e; w hen caretakers
intentionally cau se illness in their charges,
such as child ren, the d isord er is called fac-
titiou s d isord er im posed on another. In
fu nctional neu rological sym ptom d isord er
(conversion d isord er), p atients present w ith
neu rologic sym p tom s that are not consistent
w ith know n anatom y or p hysiology, and the

concern is u sually w ith a specific sym ptom ,
not having a p articu lar d isease. In illness anxi-
ety d isord er, p atients have few som atic com -
p laints bu t are p rim arily concerned w ith the
id ea of being sick and having or acqu iring a
serious illness; the intensity is not so severe as
to w arrant a d iagnosis of d elu sional d isord er.
Som atic sym ptom d isord er is characterized by
m u ltip le, cu rrent, som atic sym p tom s that are
d istressing or result in significant d isruption.
There is no reason to believe this act cou ld
help her achieve financial or other m aterial
gain as in m alingering.
76. (C) Patients w ith factitious d isord er have an
u nconscious d esire to assu m e the sick role,
althou gh their sym p tom p rod u ction is fu lly
conscious. In m alingering, both sym ptom
p rod u ction and the d esire for second ary gain
(w ork avoid ance) are consciou s. In functional
neu rological sym ptom d isord er, the sym ptom
p rod u ction is believed to be d u e to u ncon-
scious conflicts.
77. (B) This patient m eets criteria for a current
m anic episod e w ith sym p tom s of p sychom o-
tor agitation, p ressu red speech, grand iose
d elusions, flight of id eas, and history of exces-
sive spend ing as evid enced by his cred it card
d ebt. H is history of good prem orbid function-
ing and a rem itted m ajor d ep ression are also
consistent w ith a d iagnosis of bipolar d isor-
d er. Ad justm ent d isord ers can p resent follow -
ing an id entifiable stressor and m ay m anifest
w ith m ild m ood , anxiety, or behavioral d istu r-
bances, bu t not overt m ania. Brief p sychotic
d isord er is characterized by psychotic sym p-
tom s lasting 1 d ay to 1 m onth, bu t w hich are
not better accou nted for by another m ood d is-
ord er w ith psychotic featu res (su ch as bipolar
d isord er) or psychotic d isord er. Cyclothym ic
d isord er is incorrect as this patient has had
both m anic and d ep ressive ep isod es, w hereas
in cyclothym ia the highs d o not exceed a hyp o-
m anic ep isod e, and the low s d o not extend to
a m ajor d epressive episod e. The patients cu r-
rent m anic ep isod e ru les ou t MDD; in fact,
althou gh he m ay have futu re m ajor d ep res-
sive episod es, he should never be d iagnosed
w ith MDD.
Answe rs : 7080 71
78. (D ) Lithium and valproic acid , along w ith
atyp ical or second -generation antip sychot-
ics (e.g., olanzap ine) are consid ered first-line
treatm ents for acute m ania, as w ell as preven-
tion of fu tu re m ood episod es. Carbam azepine
is also an effective m ood stabilizer, bu t d u e to
sid e effects is not u su ally first line. While halo-
p erid ol can be u sed to treat the acu te agitation
and p sychotic sym ptom s in bip olar d isord er,
it is not as effective for the m ood com p onent
or in preventing ep isod es of m ania, and its
sid e effects (e.g., extra-pyram id al sym p tom s,
tard ive d yskinesia) lim it its use as m onother-
ap y. Lam otrigine and lithiu m are both u sed in
the treatm ent of acu te d epressive episod es of
bip olar d isord er. Antid ep ressants su ch as ser-
traline should be avoid ed in this case as they
can w orsen m ania and likely prom ote rapid
cycling of m ood episod es.
79. (B) Classically, infarcts of the left frontal hemi-
spheres (part of left mid d le cerebral artery d is-
tribution) present w ith d epression, w hereas
those of the right frontal hem isphere present
w ith euphoria, inappropriate ind ifference, or
m ania (althou gh recent research tend s to refute
this). Obsessive-com pulsive behaviors pres-
ent occasionally after d iffu se bilateral frontal
injury. Anxiety and panic sym ptoms have not
been d escribed as having any particular asso-
ciation w ith left mid d le cerebral artery strokes,
although su ch comorbid cases m ay exist.
80. (E) This w om an has d eveloped psychosis
m arked by hallu cinations, d elusions, and
paranoia. She w as m ost likely given high-d ose
steroid s to treat her acute multip le sclerosis
flare, and the steroid s ind uced a psychotic
state. H igh-d ose steroid s can cause m ood d is-
turbance in many patients, and florid psycho-
sis in a sm aller subset. The symptom s u sually
entirely remit once steroid s are stopped or
tapered appropriately. While most symptom s
occur at high d oses, such as w ith IV steroid s,
steroid psychosis can occur in patients treated
w ith chronic low er level oral steroid s as w ell.
H er psychotic symptom s rule out an ad just-
m ent d isord er, and her age and lack of psychi-
atric history w ould not be consistent w ith a first
episod e of bipolar d isord er or schizophrenia.
72 2: Ad ult P sychop a thology
While m ultiple sclerosis can, by itself, prod u ce
d epression and affective lability, it d oes not
usu ally cau se psychotic sym ptoms.
81. (B) Sexu al d ysfu nction is a com m on sid e effect
of m any psychotropics, especially antid epres-
sants such as SSRIs. Wellbu trin, a non-SSRI
antid epressant, likely cau ses a low er incid ence
of sexu al d ysfu nction. Given his num erous tri-
als and incid ence of erectile d ysfu nction w ith
SSRIs, it is d oubtfu l that retrying sertraline or
sw itching to another SSRI (e.g., citalopram )
w ill be less likely to cau se sexu al d ysfu nc-
tion. Aripip razole (an atypical antip sychotic)
and lithium (a m ood stabilizer) can be u sed
in au gm enting p artially effective antid ep res-
sants, bu t w ould not be app ropriate first-line
m onotherapy in this case.
82. (E) The serotonin m etabolite d esignated
5-hyd roxyind ole acetic acid (5-H IAA) m ea-
sured in the CSF has been show n to be low er
in p ostm ortem analysis of victim s of su icid e
and patients w ith im pu lsivity and violence
or aggression w hen com pared w ith control
grou p s. N o su ch associations have been estab-
lished w ith the other neu rotransm itters listed .
83. (B) Depression is the m ost com m on present-
ing p sychiatric sym p tom in p atients w ith
m u ltiple sclerosis. It m ay present d u ring the
cou rse of m ild progressive cognitive d ecline
that is consistent w ith a subcortical neuro-
cognitive d isord er (d em entia) (i.e., slow ing of
m ental p rocessing, m otor d ifficu lties, blu nted
or inappropriate affect, w ith relative preser-
vation of langu age-d epend ent skills). N eu-
roim aging of these p atients u su ally show s
d iffuse w hite m atter plaqu es affecting the
frontal lobes. Cerebral atrophy and ventricu-
lar enlargem ent are associated w ith the m ost
com m on form of m ajor neu rocognitive d isor-
d er (d em entia), Alzheim er d isease. Periven-
tricu lar w hite-m atter changes are observed
in m ajor vascu lar neu rocognitive d isord er
(form ally m u lti-infarct d em entia).
84. (B) The patient appears to be suffering from
d elirium. Although aggressiveness or combat-
iveness, m emory d eficits, psychotic symptom s,
and u ncooperativeness m ay be seen in either
d elirium or major neurocognitive d isord ers
(d em entias), a fluctuation in the level of con-
sciou sness (i.e., from alertness to som nolence)
w ith d eficits in attention are the hallm arks for
d elirium. Attention is usually intact in neuro-
cognitive d isord ers (d em entias). Fu rther, the
acute onset of sym ptoms is more su ggestive
of d eliriu m. It is important to remember that
having a major neu rocognitive d isord er pre-
d isposes a patient to d elirium , so both m ay be
seen in the sam e patient.
85. (B) This p atient is su ffering from generalized
anxiety d isord er. H er sym ptom s inclu d e rum i-
nations abou t m any asp ects of her life, d espite
there not being any d isruption in those areas.
She also has physical sym ptom s associated
w ith anxiety. There is no p articu lar stressor
to qu alify for ad ju stm ent d isord er. H er ru m i-
nations m ay have an obsessional qu ality, bu t
they are not lim ited to a specific thou ght nor
associated w ith any com p ensatory com p u l-
sions, therefore m aking obsessive-com pu lsive
d isord er u nlikely. She d oes not have specific
p anic attacks or fears of fu tu re attacks con-
sistent w ith panic d isord er. H er anxiety is
not related to fears of hu m iliation or scru tiny
in a p erform ance situ ation, w hich w ou ld be
consistent w ith social anxiety d isord er (social
p hobia).
86. (E) There are a nu m ber of stigm ata associated
w ith schizop hrenia that are not inclu d ed in
DSM -5 d iagnostic criteria. These inclu d e soft
neu rologic signs su ch as short-term m em ory
d eficits, u nstable sm ooth-p ursu it eye m ove-
m ents, and d ecreased ability to habitu ate
to rep eated sensory stim u li (sensory gating
abnorm alities). In ad d ition, p atients w ith
schizophrenia have d ifficu lty in conceptual-
izing com p lex visu al com p ositions. Patients
w ith ADH D, MDD, OCD, and PTSD have also
d em onstrated short-term m em ory d ifficu lties,
bu t not the other signs m entioned .
87. (C) The m ost ap propriate next step is to send
the patient to the p sychiatric emergency
d epartment. This patient is experiencing an
acute episod e of major d epression and , becau se

of his suicid al id eation w ith active plan and
means to overd ose, he should be referred to
the emergency d epartment for further assess-
ment w hile ensu ring his safety. Stopping his
prescription w ill not ad d ress the im med i-
ate d anger to self, and having him follow u p
in 1 w eek or for w eekly outpatient visits are
also inappropriate given the imm ed iate safety
concerns. While his p arents may be called for
collateral information in the fu tu re, the more
pressing step is to ensu re the patients safety.
H e may not have respond ed to the SSRI or
have been in the minority of you ng ad u lts w ho
exp erience w orsening of su icid al thou ghts on
the SSRIs; either w ay, a sw itch in pharmaco-
therapy is likely necessary, bu t w ill not resolve
his acu te suicid ality, and is therefore inappro-
priate as the next imm ed iate step.
88. (C) The w om an p resents w ith a classic p resen-
tation for m ajor d ep ressive d isord er. H aving
a d epressive d isord er significantly increases
ones risk for suicid e, and feelings of hopeless-
ness have been fou nd to be a particu lar risk
factor. Many other factors also increase the
risk for com p leted su icid e su ch as w hite race,
m ale gend er, old er age, single/ d ivorced , and
having poor social su p p ort.
89. (B) The presentation exemplifies a manic epi-
sod e, w ith symptoms that includ e inflated
self-esteem and grand iosity, pressured speech,
a d ecreased need for sleep, and an impulsive
shopping excursion w ithout consid ering pos-
sible consequences. The most likely d iagnosis
is a type of bipolar d isord er, as this patient
has a history of d epression and now is manic.
How ever, before diagnosing bipolar d isord er
type I, the contribution of mania ind uced by
an antid epressant must be ruled out. If this
manic episod e occurred because of an antid e-
pressant, a more appropriate d iagnosis w ould
be substance-induced mood disorder. Anxiety
d isorders and neurocognitive d isord ers do not
present w ith the classic signs of mania. While
this patient has psychotic symptoms (grand i-
ose d elusions), a psychotic d isord er such as
schizophrenia cannot be d iagnosed as there is
no ind ication of prominent psychotic symp-
toms (hallucinations, d isorganized thought
Answe rs : 8192 73
processes and speech) in the absence of mood
symptoms. H er primary symptoms d o not
involve physical or somatic symptoms, w hich
w ould be seen in a somatic symptom disord er.
90. (A) This p atient w as m ost likely p rescribed
an antid ep ressant since her initial presenta-
tion w as for a d ep ressive ep isod e 2 m onths
ago. Since she also has m igraines, and tricyclic
antid ep ressants are often u sed in their treat-
m ent, this w as m ost likely the agent she has
been taking. While all antid ep ressants have
the potential to ind u ce a m anic sw itch in sus-
cep tible patients, the rate is slightly higher for
tricyclic antid epressants than for serotonin-
specific reu ptake inhibitors or serotonin-
norep inep hrine reup take inhibitors, such as
fluoxetine or sertraline, respectively. Benzo-
d iazepines (e.g., clonazepam ) are not know n
to cau se m ood sw itches into m ania, and m ood
stabilizers such as lithiu m are a treatm ent for
bip olar d isord er.
91. (B) The specific phenomenon described here is
an id ea of reference. The patient interprets an
event as relating to him, even though it clearly
d oes not. A hallucination is a perception in the
absence of a clearly defined stimulus, w hereas
an illusion is a misinterpretation of an evident
stimulus (for instance, IV tubing appearing like
snakes). Thought broad casting is a d elusional
belief that ones thoughts can be heard or some-
how know n by others w ithout d irect commu-
nication. Thought insertion is another d elusion
w here the patient believes thoughts from some
external entity are placed in his mind.
92. (C) The choices in this qu estion d escribe d if-
ferent patterns of am nesia. Localized am nesia
refers to m em ory loss su rrou nd ing a d iscrete
p eriod of tim e, typ ically occu rring after a trau -
m atic event; in this case, the patients am nesia
resu lts from learning of her hu sband s d eath.
Rarely, a patient m ay forget his or her entire
p reced ing life (generalized am nesia) or forget
all events follow ing a trau m a, excep t for the
im m ed iate p ast (continu ou s am nesia). Ret-
rograd e am nesia is any am nesia for events
that com e before a trau m atic event. Selective
am nesia involves the inability to recall certain
74 2: Ad ult P sychop a thology
asp ects of an event, thou gh other m em ories of
the event m ay be intact.
93. (B) This p atient is su ffering from bereavem ent.
H is w ife has d ied w ithin the last 2 m onths,
and his sym p tom s inclu d e an ap prop riately
d ep ressed m ood , althou gh he is still able to
fu nction and is taking care of his basic need s.
It is not u ncom m on to have au d itory or visu al
hallu cinations of the d eceased d u ring the griev-
ing p eriod . Also, m any ind ivid u als exp erience
survivors gu ilt as part of their grieving. While
this patient had a significant stressor (d eath of
w ife), his sym p tom s are better accou nted for
by bereavem ent rather than ad ju stm ent d is-
ord er, since the sym ptom s are not ou t of pro-
p ortion to w hat w ou ld be expected . If he had
suicid al id eation, severe loss of functioning,
significant d istressing au d itory hallu cinations
or other sym ptom s of psychosis, a d iagnosis
of m ajor d epression w ith or w ithou t p sychotic
featu res w ou ld be m ore appropriate. Persis-
tent com plex bereavem ent d isord er is pro-
p osed as a cond ition for fu rther stu d y, and
w ou ld d escribe severe bereavem ent p ersisting
over a year after d eath. Besid es the hallu cina-
tions relating to the d eceased w ife, there is no
other evid ence of a prim ary psychotic illness
such as schizop hrenia. It is im portant to note
that bereavem ent is not a psychiatric d isord er.
94. (D ) The m ost ap p rop riate treatm ent at this
stage is su pp ort. If sym ptom s persist, and he
begins to exp erience loss of fu nctioning or
significant d istress, an antid epressant m ay be
w arranted . H osp italization w ou ld be ind icated
if this p atient had active thou ghts of su icid e
and w as at risk of harm ing him self or oth-
ers. At this tim e, he is exp eriencing su rvivors
gu ilt bu t is not actively su icid al. There is no
ind ication for an antip sychotic, and cognitive-
behavioral therap y is not ind icated in this
case.
95. (A) Circum stantiality involves a circuitou s,
over-inclu sive answ er that only eventu ally
gets to the p oint as the p atient d em onstrates
in this exam p le. Loosening of associations is a
resp onse com p osed of a series of d isconnected
id eas. The p ointless rep etition of a w ord ,
p hrase, or id ea is perseveration. Pressured
speech is a continuou s, usu ally rap id , u ninter-
ru p tible stream of id eas that m ay m ake sense
bu t is often hard to follow . While this p atients
speech m ay be pressured , this is unable to be
d eterm ined by the vignette alone. Tangen-
tiality occu rs w hen the patient strays off the
p oint entirely, never retu rning to the original
intention of the answ er. Generally, the sp eech
or thou ght p rocesses of a schizophrenic or
schizoaffective patient m ay d em onstrate any
of these characteristics.
96. (C) A nonepileptic seizu re (formerly called
p seu d oseizu re) is a psychogenically ind u ced
behavior that resembles epileptic activity
externally, bu t the EEG is entirely norm al.
Althou gh the synd rom e may in some cases be
motivated by second ary gain (as in m alinger-
ing), it most often occurs in reaction to stress
and represents a type of functional neurologi-
cal sym ptom (conversion) d isord er. The other
choices, w hich each represents true epileptic
seizu res, rarely, if ever, includ e the purpose-
ful, com plex activity as is seen in this case.
N ot uncomm only, patients w ith conversion
d isord er (functional neurological symptom
d isord er) w ith seizures also have a concurrent
seizu re d isord er, and it is quite d ifficult to sort
ou t the epileptic seizu res from the nonepilep-
tic ones. Diagnosing a nonepileptic seizu re
often requ ires d emonstrating a norm al EEG at
the time of the event. The prognosis for non-
epileptic seizures is qu ite p oor, w ith frequent
exacerbations.
97. (B) N arcolep sy is a sleep d isord er character-
ized by the tetrad of hyp ersom nia (excessive
d aytim e som nolence), cataplexy (transient
loss of m otor tone associated w ith strong
em otions, as d em onstrated in this case), sleep
p aralysis (total or p artial p aralysis in sleep
w ake transition), and hyp nagogic or hyp -
nop om p ic hallu cinations (vivid d ream -like
hallu cinations occurring in the w ake/ sleep
transition). Catalepsy is a state of im m obility
som etim es seen in catatonic states.
98. (A) All of the choices are possible sid e effects,
either short term or long term, of antipsychotic

med ication. Akathisia is the su bjective sensa-
tion of motor and mental restlessness. Akinesia
is a d ysfunction of slow ed or absent m ovement
that can be associated w ith p seud op arkinson-
ism in the setting of antipsychotics (neurolep-
tics). A d ystonia, like akathisia and akinesia,
can occu r acutely and involves mu scle rigid ity
and spasticity. Rabbit synd rome is a late-onset
sid e effect that involves fine, rhythmic m ove-
ments of the lips. Tard ive d yskinesia is another
late-onset neurologic effect of antipsychotics
(neuroleptics) and can includ e choreoathetoid
movements of the trunk or limbs, as w ell as
other areas su ch as the tongue and lips.
99. (E) This p atient is likely su ffering from both
p anic d isord er and agorap hobia. The m ost
effective and tolerated m ed ications for p anic
d isord er are SSRIs (e.g., sertraline) or SN RIs
(e.g., venlafaxine). Busp irone, a 5-H T1 A
recep tor p artial antagonist, can be effective
in generalized anxiety d isord er bu t not p anic
d isord er. Lithiu m and valproic acid are m ood
stabilizers m ost often u sed in bipolar d isord er.
Lorazep am and other benzod iazep ines can be
help ful in treating anxiety, bu t should be m in-
im ized long-term d u e to the risk of ad d iction.
100. (A) This patient is suffering from alcohol u se
d isord er. While rehabilitation is the m ainstay
of treatm ent for ad d ictions, several m ed ica-
tions have been beneficial in red ucing alcohol
u se. Acam p rosate, a glu tam ate recep tor m od -
u lator, has show n efficiency in red u cing crav-
ing and alcohol u se. Antid ep ressants (e.g.,
bu p rop ion, citalop ram ), m ood stabilizers (e.g.,
lithiu m ), and antip sychotics (e.g., olanzap ine)
have not been d em onstrated to red u ce alcohol
u se and are not ind icated in the absence of a
com orbid m ood or psychotic d isord er.
101. (E) This p atient ap pears to be experiencing
Wernicke encephalop athy, a resu lt of chronic,
heavy, alcohol u se, cau sed by acu te thiam ine
d eficiency. It p resents classically w ith the
triad of confu sion, oculom otor abnorm alities
(e.g., nystagm u s), and ataxia. The treatm ent is
IV thiam ine. While glu cose is often given in
an em ergency setting, as w ell, it is im p erative
to give thiam ine first, as giving glucose before
Answe rs : 93103 75
thiam ine m ay w orsen the encep halopathy.
H aloperid ol, a typical antipsychotic, is not
ind icated as the p atient is neither p sychotic
nor agitated , and w ill not help the u nd erly-
ing cond ition. N either lorazep am , a benzo-
d iazepine u sed in acu te alcohol w ithd raw al,
nor naltrexone, an op iate antagonist u sed to
red u ce alcohol craving, w ill ap p rop riately
treat Wernicke encephalopathy.
102. (C) This p atient p resents w ith d isorganized
behavior, agitation, p aranoia, and form ication
(a particu lar type of tactile hallu cination in
w hich one has the sensation of bu gs craw ling
on or u nd er the skin), as w ell as elevated vital
signs and d ilated p upils. These are all consis-
tent w ith acute cocaine intoxication. Intoxi-
cation w ith alcohol p resents w ith d ecreased
level of consciou sness, d ecreased vital signs,
slurred speech, and poor coord ination. Can-
nabis intoxication can p resent w ith p aranoia
and tachycard ia, althou gh not u sually agita-
tion or form ication. Opiate use classically
p resents w ith a d ecreased level of consciou s-
ness, d im inished vitals, p inp oint p u pils, d ry
skin, and constipation. Patients w ho use PCP
m ay be qu ite agitated and p aranoid , as w ell
as have signs of sym p athetic stim u lation,
bu t they often p resent w ith ataxia, fever, and
nystagm u s (vertical, horizontal, or rotary).
103. (E) Given his card iovascu lar history, risk fac-
tors, and clinical presentation, this patient
m ost likely has m ajor vascu lar neu rocogni-
tive d isord er (d em entia), the second m ost
com m on cau se of d em entia after Alzheim er
d isease. Becau se the etiology is com m only
d ue to m u ltiple infarcts, periventricu lar w hite
m atter (lacu nar) infarcts m ay be seen on MRI.
Atrop hy of the brainstem and cerebellu m m ay
be seen in cases of Parkinson d isease. Fronto-
tem poral neu rocognitive d isord er (d em entia),
com m only referred to as Pick d isease, is a
com m on cause of d em entia in you nger ind ivid -
u als and d isp lays a p referential atrophy of the
frontal and tem p oral lobes on MRI. Enlarged
ventricles on MRI of the brain are consistent
w ith neu rocognitive d isord er (d em entia) d u e
to norm al p ressu re hyd rocephalu s, w hereas
cases of m ajor neurocognitive d isord er d ue
76 2: Ad ult P sychop a thology
to Alzheim er d isease m ay show general or
global atrop hy of the cerebru m .
104. (E) The cou rse of m ajor vascu lar neu rocogni-
tive d isord er (d em entia) is typically a step-
w ise d eterioration, corresp ond ing w ith the
continu ed infarcts occu rring to the patient.
Most, although not all, d em entias are irre-
versible, and so continued im p rovem ent is
u nu su al; how ever, m ajor neurocognitive
d isord er (d em entia) d ue to trau m atic brain
inju ry m ay not show im p rovem ent nor w ors-
ening over tim e (assu m ing no fu rther insu lts).
Rapid d ecline m ay be seen in cases of m ajor
neu rocognitive d isord ers d u e to p rion d isease
(e.g., Creu tzfeld tJakob d isease, ku ru ), w hile
stead y d ecline is typical for m ajor neurocog-
nitive d isord er (d em entia) d u e to Alzheim er
d isease.
105. (E) This p atient is exp eriencing d eliriu m .
Deliriu m is a synd rom e characterized by a
d istu rbance in attention and cognition. While
d elirium is a m ed ical em ergency and behav-
ioral control is im p ortant, the m ost im p or-
tant app roach is to id entify and correctly
the u nd erlying cau se(s). Com m on etiologies
inclu d e m etabolic, infectiou s, hyp oxia, organ
failure, and d rug intoxication/ w ithd raw al.
Behavioral control m ay be necessary w ith a
high-potency antip sychotic su ch as halop eri-
d ol or soft restraints. Dip henhyd ram ine and
other anticholinergic m ed ications shou ld be
avoid ed as they can w orsen d eliriu m . Benzo-
d iazepines shou ld also be avoid ed (excep t in
cases of alcohol or sed ative/ hypnotic w ith-
d raw al-ind uced d eliriu m ) as they can cau se
d isinhibition and w orsening agitation in m any
p atients.
106. (B) This p atient m ost likely su ffers from
obsessive-com pulsive d isord er (OCD), a d is-
ord er characterized by recu rrent obsessions
(e.g., fear of contracting H IV) and / or com -
p ulsions (e.g., frequent hand w ashing), w hich
cause significant d istress or im p airm ent in
fu nctioning. The neu rophysiologic nature of
this illness can be d em onstrated throu gh neu-
roim aging, w hich show s increased activity
(m etabolism ) in the cau d ate nu cleus, frontal
lobes, and cingu lu m . These d ifferences are can
be reversed after ad equ ate p harm acologic or
cognitive-behavioral therapy. The other areas
of the brain are not believed to be as involved
in OCD.
107. (C) This p atient likely has m ajor neu rocogni-
tive d isord er (d em entia) w ith Lew y bod ies, a
com m on cau se of d em entia that is sim ilar to
Alzheim er d isease. Com m on sym p tom s are
typical for and overlap w ith Alzheim ers, but
as in this case they have ad d itional sym ptom s
of urinary incontinence, orthostatic hypoten-
sion, visu al hallucinations, and parkinsonism .
Major frontotem poral neurocognitive d isor-
d er (d em entia) w as originally called Pick d is-
ease. While not rare, it is a com m on cau se of
early-onset d em entia, and often p resents first
w ith behavioral d ifficu lties, inclu d ing ap athy,
m ood lability, d isinhibition, and d epression.
As ind icative of the nam e, im aging d em on-
strates a p referential atrophy of the frontal
and tem p oral lobes. The above associated
sym ptom s (e.g., visu al hallucinations and
p arkinsonism ) are not u su ally seen. Patients
w ith m ajor vascu lar neu rocognitive d isord er
(form erly vascu lar d em entia) have a history of
card iovascular d isease, hypertension, strokes,
etc., and often have ad d itional neu rological
find ings not consistent w ith Lew y bod y d is-
ease. There is no evid ence in the history for
any su bstance-ind u ced m ajor neu rocognitive
d isord er (d em entia).
108. (D ) The pharm acologic behavioral m an-
agem ent of m ajor neu rocognitive d isord er
(d em entia) w ith Lew y bod ies is tricky. Anti-
cholinesterase inhibitors su ch as d onepezil
have d em onstrated efficacy in these p atients
and are w ell tolerated . While antip sychotics
are often u sed (d esp ite the increased risk of
m ortality) to treat agitation and / or p sychosis
in p atients w ith m ajor neu rocognitive d isor-
d ers, high-p otency agents like haloperid ol
are p articu larly concerning given the sensitiv-
ity and p otential for w orsening p arkinsonian
sid e effects. Med ications w ith anticholinergic
sid e effects, such as tricyclic antid epressants
(e.g., am itrip tyline) and antihistam ines (e.g.,
d iphenhyd ram ine) shou ld be avoid ed as they

m ay w orsen the d em entia. Clonazep am and
other benzod iazepines shou ld also be avoid ed
given the significant risk of d isinhibition.
109. (D ) While antid epressants su ch as parox-
etine help all the sym p tom s of d ep ression,
som e respond qu icker to m ed ications. Sleep,
energy, and ap p etite changes are u su ally
the first to resp ond , follow ed later by libid o,
hop elessness/ helplessness, and su icid al id e-
ation. Because of the d ifferential resp onse
tim es, it is im portant to m onitor a suicid al
p atient as their energy and m otivation m ay
im p rove before the d ep ression and su icid al-
ity, and thu s, the p atient m ay have the energy
to com m it su icid e.
110. (D ) Sexu al sad ism d isord er and sexu al m as-
ochism d isord er are, respectively, the d eri-
vation of sexu al pleasu re from causing or
receiving m ental/ p hysical abu se. Exhibition-
istic d isord er is exp osu re of the genitalia in
p ublic to an u nw illing p articip ant, and u su -
ally occu rs in m en. Frotteu ristic d isord er, the
ru bbing of genitals against another to achieve
arou sal, is also u su ally seen in m en and p er-
form ed in crow d ed places. Patients w ith trans-
vestic d isord er are arou sal by cross-d ressing.
111. (B) Koro, taijin-kyofu sho, and zar are all
exam p les of cu ltu re-bou nd d elu sions. Koro is
the w orry that the penis is shrinking into the
abd om en and is fou nd in South and East Asia.
Taijin-kyofu sho is the belief that ones bod y is
offensive to others, and zar is the d elu sional
belief of p ossession by a sp irit. Cap gras syn-
d rom e is the d elu sional id ea that im posters
have replaced once fam iliar p ersons. Ku ru is a
slow ly progressive neurologic d isease w hich
lead s to d eath, sim ilar to Creu tzfeld tJakob
d isease, cau sed by prions.
112. (E) Paraphilias encom p ass a w id e variety of
m alad ap tive sexu al behaviors and fantasies.
Voyeu ristic d isord er is d eriving sexu al plea-
sure from w atching another person or per-
sons involved in the act of und ressing or other
sexu ally oriented activity. Exhibitionistic d is-
ord er is a paraphilia involving exposing ones
genitalia to an u nsu sp ecting au d ience. Frot-
Answe rs : 104114 77
teuristic d isord er is the synd rom e of recu r-
rent, intense sexu al fantasies and behaviors
involving tou ching or ru bbing against a non-
consenting ad u lt. Gend er d ysphoria is a cond i-
tion w here there is incongru ence and d istress
betw een ones exp ressed gend er and assigned
gend er. Transvestic d isord er involves being
d ressed in clothing of the opposite sex for
sexual excitem ent; it is often present in hetero-
sexual m en and d iffers from gend er d ysphoria
(transsexu alism ) in that the person is u su-
ally com fortable and content w ith his gend er
id entity. It is, how ever, p ossible to see these
d isord ers concom itantly.
113. (D ) This p atients p resentation is m ost con-
sistent w ith schizoaffective d isord er, bip olar
type, characterized by the presence of psy-
chotic sym p tom s (e.g., paranoia, d elu sions,
hallu cinations) concu rrent w ith a m anic epi-
sod e (e.g., d ecreased need for sleep, increased
energy, grand iosity, increased goal-d irected
activity, flight of id eas). In this p atient, her p sy-
chotic sym ptom s occu rred in the absence of
m ood sym p tom s, as w ell, w hich d istinguishes
schizoaffective d isord er from a prim ary m ood
d isord er, su ch as bipolar or m ajor d epressive
d isord er. Patients w ith d elu sional d isord er
also have a d elu sion, althou gh the d elu sion is
u su ally m ore circu m scribed than in this case,
and they d ont have the au d itory hallucina-
tions or significant affective sym ptom s (i.e.,
m anic ep isod e) as seen in this case. Patients
w ith schizop hrenia obviou sly have sim ilar
sym ptom s su ch as paranoia, d elu sions, hal-
lu cinations, and d isorganized behavior, bu t
the m ood sym p tom s are not as prom inent or
enou gh to be d iagnosed w ith a m anic ep isod e.
114. (C) This p atient w ith PTSD continu es to be
sym p tom atic, sp ecifically w ith nightm ares,
insom nia, increased startle, and avoid ance.
Given the p artial efficacy and tolerability
of the citalop ram (an SSRI), au gm entation
w ith another agent m akes the m ost clinical
sense. Alp ha-ad renergic blockers like p ra-
zosin are p articu larly efficaciou s in treating
PTSD sym p tom s, p articu larly nightm ares
and insom nia. Benzod iazep ines, inclu d ing
alp razolam , have not d em onstrated efficacy
78 2: Ad ult P sychop a thology
in PTSD; in ad d ition, they shou ld be avoid ed
given the risk of d ep end ency, a p articu lar
concern in this case. Bu p rop ion, an antid e-
p ressant w ith norep inep hrine and d op a-
m ine reu p take blockad e activity, has not
been show n to be beneficial in treating PTSD.
Antip sychotics (e.g., risp erid one) and m ood
stabilizers (e.g., valp roic acid ) are often u sed
ad ju nctively in the treatm ent of PTSD, esp e-
cially for m ood lability, agitation, flashbacks,
and p sychotic sym p tom s, althou gh the evi-
d ence for their benefit is not as conclu sive as
for p razosin.
115. (B) Cognitive processing therapy is an evidence-
based form of cognitive-behavioral therap y
that has d em onstrated efficacy in the treat-
m ent of PTSD. It incorp orates both a cogni-
tive com ponent and exposu re to the trau m a
through rem em bering, d iscussion, and cues.
N either p ure behavior nor cognitive therapy
alone is as effective. Dialectical behavioral
therapy is another form of CBT, specifically
d evelop ed for treating bord erline personality
d isord er, and it u tilizes ind ivid ual therap y,
grou p s, safety-m anagem ent, and hom ew ork.
Psychod ynam ic p sychotherapy has not been
ad equately studied to recommend as a primary
treatment for PTSD.
116. (D ) The locu s ceruleu s is the alarm center of
the brain and is hyperactive in anxiety states.
It is the location of m ost of the norep inep hrine-
containing neurons in the brain. The am yg-
d ala and hippocam pu s, both part of the lim bic
system , are involved in fear/ anger responses
and m em ory form ation, resp ectively. The
basal ganglia coord inate m otor activity, w hile
the thalam u s is the brains relay center.
117. (D ) Sp litting is a prim itive d efense m echa-
nism , m anifested by view ing others as either
all good or all bad . It is com m on in p atients
w ith bord erline p ersonality d isord er althou gh
there is no other evid ence of bord erline
p athology in this case. Acting out refers to
p erform ing an action in contrast to bear-
ing and m anaging the im p u lse to p erform it.
Externalization rep resents the tend ency to
p roject ones ow n internal characteristics onto
others. Regression is a retu rn to patterns of
relating, thinking, or feeling that had com e
before ones cu rrent d evelop m ental stage; for
exam p le, m any m ed ical stu d ents w ho retu rn
hom e act as if they are teenagers w ith regard
to their parents or other hom etow n friend s.
Sublim ation is the channeling of d rives or con-
flicts into goals that are gratifying but socially
accep table (e.g., ind ivid u als afraid of blood
and hospitals w ho becom e hosp ital w orkers
or physicians).
118. (D ) This p atients reaction to p aroxetine is
consistent w ith serotonin synd rom e, a poten-
tially life-threatening cond ition caused by the
interaction of a serotonin-sp ecific reu p take
inhibitor (SSRI), su ch as p aroxetine, w ith a
m onoam ine oxid ase inhibitor (MAOI), w hich
resu lts in increased am ou nts of both catechol-
am ines and ind olam ines. Featu res of m ild
serotonin synd rom e includ e tachycard ia,
flushing, fever, hypertension, ocular oscilla-
tions, and m yoclonic jerks. Severe serotonin
synd rom e m ay result in severe hypertherm ia,
com a, au tonom ic instability, convu lsions, and
d eath; therefore, clinicians m u st w ait at least
14 d ays after d iscontinu ing an MAOI before
starting a serotonergic agent. Most serotonin
in the CN S is synthesized in the d orsal and
m ed ial raphe nu cleu s of the brain stem . The
caud ate nucleu s is located in the brain stem
and concerned w ith m em ory form ation. The
nu cleu s accu m bens is located in the striatu m
and thou ght to be involved w ith sensations
of rew ard and pleasu re, as w ell as ad d ictive
behaviors. The locu s ceru leu s synthesizes nor-
ep inep hrine, and the su bstantia nigra synthe-
sizes d opam ine.
119. (E) This m ans risk of suicid e is highest after
d ischarge from the hospital. Up to 10% of
p atients w ith schizop hrenia d ie by su icid e.
Up to 50% of su icid es am ong ind ivid u als w ith
schizophrenia occu rs shortly after d ischarge
from the hospital. Many sink into a d epres-
sive-like illness follow ing stabilization of their
p sychotic sym p tom s. Risk factors inclu d e
being m ale, u nm arried , u nem p loym ent, social
isolation, d ep ression, and p reviou s su icid e
attem p ts.

120. (A) This patient likely su ffers from m ild intel-
lectu al d isability (form erly m ental retard a-
tion). The DSM -5 specifies the level of severity
on the basis of intellectu al and ad aptive fu nc-
tion d eficits. Deficits occu r in the conceptu al
d om ain, the social d om ain, and the p racti-
cal d om ain. Psychom etric testing, su ch as
m easu rem ent of IQ, is no longer su fficient to
d eterm ine severity of im p airm ent, bu t is often
a com ponent to assess the concep tu al d om ain
d eficit. This p atient has d eficits in acad em ic
skills, has im m ature social jud gm ent that
p laces him at risk for being taken ad vantage
of, and need s help w ith com plex d aily living
tasks (m oney and groceries) even thou gh he
can care for his p hysical need s. In the past, an
IQ of 50 to 69 w ould be sufficient to d iagnose
m ild intellectual d isability; betw een 35 and 49
as m od erate; betw een 20 and 34 as severe; and
less than 20 as profound .
121130. [121 (G), 122 (J), 123 (L), 124 (A), 125 (F), 126
(O), 127 (C), 128 (N), 129 (M), 130 (B)] Cannabis
intoxication (G) inclu d es increased heart
rate for several hou rs, p ostu re-d ep end ent
changes in blood pressu re, injected conju ncti-
vae, a high w ith m ild eu phoria, feeling of
relaxation, p ercep tu al changes (tim e d istor-
tion, intensified ord inary experiences), and
increased sociability. Cocaine w ithd raw al
(J) is characterized by onset of d ysp horic m ood ,
hyp ersom nia, increased ap petite, and fatigue.
Inhalants have becom e increasingly com m on
d ru gs of abu se. Signs and sym p tom s of intoxi-
cation (L) are inhalant-sp ecific, bu t gener-
ally inclu d e rapid onset of effects, d izziness,
nausea, then slow ing, ataxia, slu rred speech,
and d isorientation. Bronchospasm m ay also
occur. Intoxication usu ally im p roves w ithin
an hou r of abstinence because the su bstances
are u su ally volatile hyd rocarbons. Treatm ent
of inhalant w ithd raw al is su pportive. In acu te
alcohol intoxication (A), as blood concentra-
tion of alcohol increases, there is w orsening
m otor p erform ance, incoord ination and jud g-
m ent errors, m ood lability, nystagm u s, slu rred
sp eech, potential blackou ts, altered vital signs,
and possibly d eath. Caffeine w ithd raw al
(F) can occu r w hen p eop le abru p tly stop
their accu stom ed intake. Sym p tom s inclu d e
Answe rs : 115130 79
head ache, sleepiness, irritability, concentra-
tion problem s, vom iting, and m u scle aches/
stiffness. Phencyclid ine (PCP) (O) and other
d issociative anesthetics can ind u ce vertical or
horizontal nystagm us (rotary w ith ketam ine),
hyp ertension (at least m ild , bu t hypertensive
crisis can occur), tachycard ia, ataxia, nu m b-
ness and high pain tolerance, ataxia, hyper-
acu sis, hypertherm ia, m u scle rigid ity, seizu res
inclu d ing statu s ep ilep ticu s, and d eath. The
p resence of nystagm u s helps to d istinguish
PCP intoxication from other form s of psycho-
sis. Behavioral m anifestations can be severe,
and severe agitation, rage, and p anic cou pled
w ith d isinhibition m ay cau se a d angerou s
clinical situ ation. Am phetam ine intoxication
(C) is characterized by both behavioral and
p hysiological changes. Patients m ay exp eri-
ence eu p horia, interp ersonal sensitivity, anxi-
ety, tension, or anger, im p aired ju d gm ent, and
im p aired social and occu p ational fu nctioning.
Fu rther, they m ay have tachycard ia or bra-
d ycard ia, p u p illary d ilation, insom nia, blood
p ressu re changes, sw eating or chills, nau sea
or vom iting. Chronic u se m ay resu lt in d ry
skin, acne-like lesions, or chronic nose bleed s.
Op iate w ithd raw al (N ) is characterized by
d ysp horia, nau sea, vom iting, m u scle aches,
lacrim ation, rhinorrhea, p iloerection, sw eat-
ing, d iarrhea, yaw ning, fever, and insom nia.
Op iates can be illegal or p rescrip tion, su ch as
narcotic analgesics. Sym p tom s of acu te intoxi-
cation (M) includ e pup illary constriction
(can be d ilation once anoxic brain inju ry has
occurred from respiratory d epression), d row s-
iness, slu rred sp eech, and p ossibly p u lm onary
ed em a. At higher d oses, com a or d eath w ith
resp iratory d ep ression m ay occu r. Alcohol
w ithd raw al (B) can start hou rs after the last
d rink, and is characterized by au tonom ic
instability (sw eating, tachycard ia), trem ors,
insom nia, nau sea/ em esis, transient hallu ci-
nations or illu sions, psychom otor agitation,
anxiety, and seizu res. Deliriu m trem ens can
d evelop , and can be d ead ly. Am p hetam ine
w ithd raw al (D ) is characterized by fatigue,
vivid d ream s, sleep d istu rbances, increased
ap p etite, and p sychom otor retard ation or
agitation. A caffeine intoxication synd rom e
(E) is possible, especially in ind ivid u als w ho
80 2: Ad ult P sychop a thology
consum e a large am ou nt or w ho are u nac-
custom ed to it. In stud ies, participants report
sym ptom s of jitteriness, d iuresis, irritability,
insom nia, p sychom otor agitation, and nau sea.
There is evid ence of a m ild cannabis w ith-
d raw al (H) synd rom e lasting several w eeks,
characterized by d ecreases in m ood and appe-
tite, w ith increases in irritability, anxiety, and
tension. Cocaine intoxication (I) is sim ilar to
am phetam ine intoxication. At higher d oses,
signs of toxicity m ay d evelop and includ e sei-
zu res, chest p ain, hyp erp yrexia, and d eath.
Susceptible u sers m ay also experience para-
noia, ranging from m ild hypervigilance to
frank paranoia and p ersecu tion. H allu cino-
gens inclu d e su bstances su ch as LSD, m es-
caline, and ecstasy. They prim arily affect
p erceptions and in intoxication (K) can result
in m ood changes, p aranoia, id eas of reference,
d ep ersonalization, hallucinations, and synes-
thesia. Au tonom ic sym ptom s m ay also occu r,
and inclu d e blu rry vision, tachycard ia, sw eat-
ing, trem ors, and p u p il d ilation.
131136. [131 (F), 132 (B), 133 (D ), 134 (D ), 135 (E),
136 (A)] Blockad e at the 5-H T2 A (serotonin)
recep tor (A) is thou ght to im p rove cognitive
and affective sym ptom s in schizophrenia and
other psychotic d isord ers. Blockad e at the
alp ha-1 ad renergic recep tor (B) is resp onsible
for the d izziness, sed ation, and orthostatic
hyp otension associated w ith m any of the low -
p otency typical and atyp ical antip sychotics.
The antip sychotics are not know n to affect
beta recep tors (C). Blockad e at the d op am i-
nergic D2 recep tors (D ) in the m esolim bic and
m esocortical areas of the brain are responsible
for red u cing the positive psychotic sym p -
tom s in schizop hrenia. Blockad e of the D2
recep tor in other p athw ays is resp onsible for
som e u nd esirable sid e effects: blockad e in
the nigrostriatal pathw ay is associated w ith
m ovem ent d isord ers su ch as extrapyram id al
sym ptom s, w hereas blockad e in the tubero-
infu nd ibu lar p athw ay is resp onsible for the
p rolactinem ia seen w ith som e antipsychot-
ics; d op am ine inhibits the release of p rolac-
tin, hence blockad e of the d opam ine receptor
resu lts in p rolactin release. Blockad e at the his-
tam ine-1 receptor (E) is believed to contribu te
to sed ation and cau se w eight gain. By block-
ing m uscarinic-1 receptors (F), antip sychotics
cause anticholinergic sid e effects of sed ation,
d ry m ou th, and constipation.
137145. [137 (G), 138 (I), 139 (F), 140 (D ), 141 (B),
142 (C), 143 (A), 144 (E), 145 (H)] Defense
mechanisms are conceptualized as the mind s
(m ostly unconscious) w ay of d ealing w ith d is-
tressing w ishes/ d rives/ thou ghts. They can be
subd ivid ed into im matu re, neu rotic, or mature
d efenses. The low er functioning d efense mech-
anisms are as follow s: Denial (B) is w hen an
ind ivid ual refuses to accept reality because it
is too d istressing; splitting (I) is also an imma-
ture d efense w here the person sees others or
other situ ations as all good or all bad and is
unable to tolerate positive and negative aspects
to be present w ithin one p erson; d isplacement
(C) is the channeling of ones unacceptable
w ishes or feelings into less anxiety prod uc-
ing onesfor instance, jerking the d ogs leash
harshly w hen one w as really u pset at having
been w oken up by a spouse (truly being angry
w ith the spouse); in projection (E) ones u nac-
ceptable id eas or thoughts are seen as com ing
from another (for instance, a cheating husband
accuses his w ife of being unfaithfu l); projec-
tive id entification (F) can be thou ght of as a
self-fulfilling prophecy, w herein the patients
unacceptable feelings are projected to another,
but the other (e.g., therapist) acts in such a w ay
that they become truefor instance, a patient
view s the w orld as fu ll of u nloving people (she
hates herself), then acts to push her therapist
to the breaking point w here he terminates her
care, therefore confirm ing her belief that the
w orld is full of unloving people. Examples of
neu rotic d efenses are as follow s: rationaliza-
tion (H) is the process of making excu ses
or cognitively reframing a situ ation to make
it less anxiety or d istress provoking; reaction
formation (G) d escribes the process of turn-
ing unacceptable d rives and d esires into their
opposite. The follow ing are m atu re d efense
mechanisms: altru ism (A) involves acceptable
actions that serve others and bring pleasure to
the ind ivid u al; hu mor (D ) involves expressing
unpleasant thoughts or feelings in a w ay that
brings enjoyment and pleasure to others.
 CHAPTER 3

S o matic Tre atme nt and

Ps yc ho pharmac o lo g y
Que s tions

D IRECTION S (Questions 1 through 73): For each (D) O isthotonos

of the multiple-choice questions in this section (E) Serotonin syn ro e
select the lettered answ er that is the one best
response in each case. Questions 3 and 4

A 24-ye r-o w o n resents to her ri ry c re

Questions 1 and 2 hysici n for regu r checku . During the ex in -
A 32-ye r-o n is itte to gener hos it tion, her octor notes 15- b w eight g in. The tient
fter ingesting n u nknow n qu ntity of hene zine co ins th t she w ys fee s tire uring the y
in su ici e tte t. After g stric v ge n in- es ite s ee ing fro 8 pm to 9 a m i y. On further
istr tion of ch rco s u rry, he is tr nsferre to the questioning, the hysici n e rns th t the tient
e ic intensive c re u nit for onitoring. Tw enty- fee s s n e ty, often thinks bout e th, c nnot
fou r hours ter, he begins to see horses running in concentr te t w ork, n cks the energy to c re for
the h n u s out his intr venous (IV) ines. her tw o chi ren. H ow ever, her oo icks u w hen
her hysici n questions her bout her chi ren.
1. Which of the fo ow ing tre t ents w ou be
the ost i ort nt t this ti e? 3. Which of the fo ow ing e ic tions w ou be
the ost ro ri te to tre t her i ness?
(A) Ch or ro zine
(A) F u oxetine
(B) Cy rohe t ine
(B) N ortri ty ine
(C) Lor ze
(C) P roxetine
(D) Me eri ine
(D) Phene zine
(E) Phenytoin
(E) Tr zo one
2. Tw e ve ys fter his su ici e tte t, he
receives ven f xine (Effexor) to tre t his 4. H er hysici n initi tes tre t ent w ith n nti-
e ression. One hour fter ingestion of the e ress nt t ther eu tic ose. Which of the
ven f xine, he beco es t chyc r ic n i - fo ow ing ti es w ou be consi ere ini-
horetic n eve o s yoc onic jerks. Which u equ te tri for the e ic tion?
of the fo ow ing con itions h s he ost ike y (A) 1 w eek
eve o e ? (B) 2 w eeks
(A) Acute ystoni (C) 6 w eeks
(B) Ak thisi (D) 3 onths
(C) N eu ro e tic ign nt syn ro e (E) 6 onths

81
82 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

Questions 5 and 6 bec u se she is w orrie th t her foo y be

oisone . U on interview, she is ys oor
Whi e on c in gener hos it , you re c e t eye cont ct, sycho otor ret r tion, n
4:30 a m to ev u te tient w ho w nts to be is- te rfu n constricte ffect. Which of the
ch rge . U on rriving on the f oor, the nurse te s fo ow ing w ou be the ost ro ri te
you he ju st u e ou t his thir IV of the y n e ic tion regi en for this tient?
st rte to sw ing the IV o e in the ir w hi e ye ing
rof nities. H e te s nu rses i e he u st c tu re (A) C oz ine
the tiger th t is oose in the rking ot. You qu ick y (B) F u oxetine n ris eri one
ook t his ch rt n see th t he is 55-ye r-o n (C) F u oxetine n c on ze
w ith history of coho u se isor er, itte 36 (D) F u oxetine onother y
hou rs e r ier for b o in in, n u se , n vo -
(E) Ris eri one onother y
iting. H is tr ns in ses w ere e ev te on is-
sion, bu t his he titis rofi e is sti en ing. H e is
8. A 40-ye r-o w o n w ith bi o r isor er
sche u e for u er en osco y in the orning.
resents to the e ergency roo 2 w eeks fter
st rting new e ic tion. She re orts th t
5. Which of the fo ow ing shou be the ost
she w s oing w e u nti she got vir
ro ri te e ic tion given t this ti e?
g stroenteritis n w s u n b e to e t for sev-
(A) Ch or i ze oxi e er ys. Whi e the vir sy to s reso ve ,
(B) Ch or ro zine she now co ins of n u se n vo iting,
(C) Disu fir t xi , n tre or. Which of the fo ow ing
stu ies shou be or ere first?
(D) H o eri o
(E) Ox ze (A) C rb ze ine eve
(B) De kote eve
6. You s e k brief y w ith this tient n re b e (C) H e CT
to sett e hi ow n. H is te er tu re is 102.1F, (D) Lithiu eve
u se is 130 be ts/ in, n b oo ressu re is
(E) Urine toxico ogy screen
220/ 120 H g. Which of the fo ow ing is
the ost ro ri te e ic tion n rou te of
9. A 25-ye r-o n resents to the e ergency
inistr tion to give?
e rt ent cco nie by his f i y w ho
(A) H o eri o intr u scu r y (IM) re ort th t the tient h s not eft his be -
(B) H o eri o intr venou s y (IV) roo in 3 w eeks. They re ort th t he s en s
(C) L bet o IV his y re ing science fiction nove s th t they
rovi e for hi . On ex in tion, you fin
(D) Lor ze IM
hi to be o orou s n isheve e . H e is
(E) Lor ze IV gu r e w hen you s e k w ith hi . H e oes
not ke eye cont ct n he voi s ooking
7. A 32-ye r-o sing e w o n resents to the t the te evision in the w iting roo bec u se,
e ergency e rt ent escorte by her f i y he s ys, he w nts to revent intru ers fro
fter she reve e to the her su ici e n to contro ing his thoughts. After co eting
t ke fu bott e of cet ino hen n rink the ex in tion, you it hi to the in -
bott e of w ine. She st tes th t she c nnot tient sychi tric u nit n begin ri i r zo e.
h n e w ork ny onger bec u se her boss is After 1 w eek, he is no onger fr i to ook t
trying to h ve her fire n her cow orkers re the te evision bu t he s en s uch of the y
he ing hi fin f u t in her w ork. She c i s cing the f oor, st ting th t he fee s rest ess.
they h ve even t e her hone n re h v- After re u cing the ri i r zo e to the ow est
ing her fo ow e . She re orts ifficu ty f ing ose you be ieve is ro ri te, he sti ces
s ee n oor concentr tion t w ork. She the h s. Which of the fo ow ing is the ost
h s ost 10 b over the st 2 onths, in rt ro ri te next ste ?
 Que s tions : 513 83

(A) A benztro ine 11. Which of the fo owing is the ost ike y serious
(B) A i henhy r ine co ic tion this tient y ex erience?
(C) A or ze (A) Diffu se intr v scu r co gu tion
(D) A ro r no o (B) Myoc r i inf rction
(E) Discontinu e ri i r zo e n try (C) Pu on ry e bo is
nother nti sychotic (D) Res ir tory f i u re
(E) Rh b o yo ysis
10. A 35-ye r-o w o n resents to the office
st ting th t she is e resse . She w s i
12. Which of the fo ow ing ong-ter si e effects
off fro her w ork 5 w eeks go, n is h v-
of high- ose thiori zine ost ike y e his
ing trou b e fin ing new job. She escribes
hysici n to sw itch to h o eri o ?
fee ing very ow, w ith fee ings of ho e essness
bout the fu tu re, n ifficu ty getting herse f (A) Agr nu ocytosis
u n resse in the orning. She h s ost (B) H y er ro ctine i
5 b n is s ee ing oor y. She re orts one re- (C) Pri is
vious e iso e of e ression. A ition y, she
(D) Retin ig ent tion
escribes erio bou t ye r go in w hich
she st ye u for sever ys in row n- (E) T r ive yskinesi
ning big rty for her hu sb n s birth y,
c e ning the hou se n st rting nu erou s Questions 13 and 14
other rojects; t th t ti e, others co ente A 45-ye r-o u ne oye invest ent b nker res-
th t she w s t king qu ick y n cting ike ents to you r office cco nie by his w ife. H e h s
the energizer bu nny. Which of the fo ow ing been ou t of w ork for 1 onth bec u se he is fr i
e ic tions w ou be the ost ro ri te to t ke the tr in into w ork. H e never h ifficu ty
tre t ent for her e ression? tr ve ing u nti 2 onths go, w hen on tr in ur-
(A) Bu ro ion ing f i y v c tion, he su ffere chest in, i-
t tions, shortness of bre th, n use , ting ing in his
(B) F u oxetine
extre ities, n fe r of ying. These sy to s
(C) L otrigine
ste bou t 15 inu tes. A w orku by c r io o-
(D) V roic ci gist w s neg tive. H ow ever, these sy to s h ve
(E) Ven f xine continu e , so cco nie by intense fe r n
fee ing of being et che fro hi se f. H e h s h
Questions 11 and 12 roxi te y tw o tt cks er w eek bu t so h s
severe nxiety w hen just thinking bout returning
A 33-ye r-o inte ectu y is b e e resi ent
to w ork s he is fr i he w i ie on the tr in. H e
of grou ho e resents to the e ergency e rt-
te s you th t he cou not h ve co e to see you
ent escorte by st ff e bers w ho be ieve he h s
w ithou t his w ifes he .
beco e confu se n isoriente over the st few
ys. H e h s been resi ent there for sever ye rs
13. Which of the fo ow ing e ic tions w ou
w ithou t inci ent, bu t st w eek his thiori zine w s
be the ost ro ri te first choice for this
ch nge to h o eri o bec use of concerns bout
tient?
the ong-ter u se of high oses of thiori zine.
On ex in tion, you fin hi to be isoriente to (A) Bu ro ion
ce n ti e; he is i horetic w ith te er tu re (B) Bu s irone
of 105.8F, h s he rt r te of 130 be ts/ in, n (C) F u oxetine
res ir tory r te of 20 bre ths/ in. H is extre ities
(D) Pro r no o
re stiff. Rou tine bor tories reve w hite b oo
ce (WBC) cou nt of 15,000/ L, b oo u re nitro- (E) Tr zo one
gen (BUN ) 75 g/ L, cre tinine 1.2 g/ L, n
cre tinine hos hokin se 2,300 I/ L.
84 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

14. The tient is nxiou s bou t w iting u nti the (A) Continu e ibu rofen t the rescribe
e ic tion t kes effect, n sks if you c n ose.
give hi so ething th t w i rovi e ore (B) Decre se the ose of ibu rofen.
i e i te re ief. You eci e to rescribe (C) Incre se the ose of ibu rofen.
benzo i ze ine in the interi . Which of the
(D) Sto the ithiu .
fo ow ing e ic tions w ou be the ost
otent? (E) Sw itch fro ibu rofen to s irin.

(A) A r zo Questions 17 and 18

(B) Ch or i ze oxi e
A 9-ye r-o boy is brou ght to the hysici n bec use
(C) Te ze
his rents h ve receive note fro his secon -
(D) Di ze gr e te cher co ining th t he is isru tive in
(E) Ox ze c ss. H is te cher be ieves he cou chieve better
gr es if he cou sit sti n y ttention. H is r-
Questions 15 and 16 ents re ort he h s w ys been n ctive chi bu t
oes h ve ifficu ty getting ong w ith other chi -
A 22-ye r-o sing e e co ege u sic stu ent
ren in the neighborhoo . In the ex in tion roo ,
re u ct nt y resents to you r office t the requ est of
the boy see s un b e to sit sti n h s ifficu ty
his rents. H is rents re w orrie bec u se he h s
co eting t sk you h ve ssigne . You eci e to
not been e ting, t ks const nt y, n never see s
rescribe hi ethy heni te.
to s ee . The tient st tes he h s never fe t bet-
ter, th t hes been co osing sever songs y,
17. Which of the fo ow ing is the ost co on
n requ ires on y few hou rs of s ee to fu nction.
si e effect of this tre t ent?
H e be ieves he w i be the next gre t rock st r n
w nts to finish the interview in or er to get b ck to (A) D yti e row siness
w riting, bu t he c nnot st y focu se ong enou gh to (B) Decre se in systo ic b oo ressu re
nsw er ny of you r qu estions. H e oes not h ve ny (C) Difficu ty f ing s ee
rior or f i y sychi tric history n enies u sing
(D) Incre se in etite
ny coho or i icit ru gs.
(E) S ow e grow th
15. You eci e to begin tri of ithiu . Before
initi ting tre t ent, w hich of the fo ow ing 18. Which of the fo ow ing sy to s w ou ost
w ou be the ini u bor tory infor tion ike y be ex cerb te by the e ic tion?
th t shou be obt ine ? (A) Be w etting
(A) Co ete b oo cou nt (CBC) (B) Myo i
(B) F sting g u cose n i i ne (C) Poor i u se contro
(C) Liver fu nction tests (D) Re ing ifficu ties
(D) Seru oni (E) Tics
(E) Seru cre tinine, BUN n e ectro ytes,
thyroi stu ies 19. An 8-ye r-o boy is brou ght to you r office
by his other bec u se of his h bits, w hich
16. One w eek fter st rting the ithiu , the tient h ve w orsene over the st ye r. She first
s r ins his nk e w hi e exercising. H is ri- notice the st ye r w hen sever ti es
ry c re octor ex ines hi n te s hi y he w ou re e te y b ink his eyes n
to use over-the-counter ibu rofen, w hich he frow n w hi e c e ring his thro t. H e continu es
w i h ve to t ke for ore th n 1 w eek. Which to o this es ite trying not to, n , in i-
of the fo owing wou be the ost ro ri te tion, he often sticks ou t his tongu e n s e s
course of ction? his shirt w hi e s e king w ith c ss tes.
These beh viors h ve resu te in his being
 Que s tions : 1424 85

te se n osing frien s t schoo . Which 22. Sw itching to w hich of the fo ow ing e ic -

of the fo ow ing gents w ou be the ost tions w ou be the ost ike y to i rove
effective to tre t his isor er? these sy to s?
(A) A r zo (A) Ari i r zo e
(B) A itri ty ine (B) C oz ine
(C) C oni ine (C) H o eri o
(D) P roxetine (D) O nz ine
(E) Ris eri one (E) Ris eri one

20. A 45-ye r-o n w ith history of hy er- 23. A 24-ye r-o rrie secret ry h s co -
tension, yoc r i inf rction, n chronic ine of izziness, it tions, n sw e ty
inso ni is referre to you by his ri ry s for the st 10 onths. She so occ -
c re hysici n for ev u tion of his jor sion y h s extre e u sc e tension in her
e ressive e iso e. H e h s been tre te for neck th t occu rs both t w ork n t ho e.
3 onths w ith f u oxetine 60 g i y, w ith She h s ifficu ty f ing s ee n fee s
no i rove ent. H e h s no history of rior e gy ost of the y. In ition, she h s
jor e ressive e iso es. Which of the fo - h ifficu ty concentr ting t w ork resu t-
ow ing w ou be the ost ro ri te next ing in her king ist kes. She h s gone to
ste in his tre t ent? oc e ergency roo three ti es bec u se of
the it tions bu t nothing w s foun . H er
(A) A ithiu .
f i y r ctitioner ce her on hy og yce-
(B) A thyroi hor one (T3). ic iet n referre her to neu ro ogist w ho
(C) Sw itch to cit o r . fou n no foc bnor ities. She te s you
(D) Sw itch to nortri ty ine. she h s ny w orries bout her f i y but
(E) Sw itch to ven f xine. oes not fee rticu r y e resse . Which of
the fo ow ing e ic tions w ou rovi e the
Questions 21 and 22 ost i e i te re ief of her sy to s?

You h ve been tre ting 55-ye r-o n w ith (A) Bu ro ion

schizo hreni for 20 ye rs w ith h o eri o n (B) Bu s irone
benztro ine. Gener y, he h s one w e n h s (C) C o i r ine
not requ ire jor e ic tion ch nges or hos i- (D) F u oxetine
t iz tions. Abou t 2 ye rs go, you notice so e (E) Lor ze
i s cking n tongu e rotru sions th t i not
bother the tient; how ever, now he so h s o , 24. A 22-ye r-o w o n is itte to sychi-
irregu r ove ents of his r s w hich ke it tric u nit fter seriou s su ici e tte t. She
ifficu t for hi to e t. h s h ny su ici e tte ts in the st
w ith v rying severity. H er r s re sc rre
21. Which of the fo ow ing con itions is ost fro rior tte ts t hu rting herse f. She
ike y the c u se of these sy to s? h been goo stu ent u nti high schoo ,
(A) Anticho inergic toxicity w hen she took u w ith f st crow , beg n
(B) H u ntington ise se bu sing coho n riju n , n r n w y
fro ho e sever ti es. She h s h sev-
(C) Meige syn ro e
er intense, stor y re tionshi s w ith en.
(D) Sy enh chore
Ou t tient tre t ent h s ost y consiste
(E) T r ive yskinesi (TD) of her co ints to her ther ist bou t her
f i y. She u su y c s her ther ist iy
bou t ifferent crises; how ever, her ther ist
w s on v c tion u ring her ost recent crisis.
86 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

She escribes fee ings of ho e essness n (C) N o e ic tion

he essness consistent y for the st sever (D) O nz ine
w eeks; in ition, she is s ee ing oor y, tire (E) To ir te
throu ghou t the y, istr cte , n h s ost
so e w eight ue to ck of etite. Which of 27. A 36-ye r-o n w ith his first e iso e
the fo ow ing e ic tions w ou be the ost of jor e ression h s been tre te for
he fu for this tient? 8 onths w ith roxetine n is cu rrent y in
(A) C on ze re ission. Bec u se of sexu ysfu nction, he
(B) F u oxetine eci e to sto t king the e ic tion 3 ys
go w ithou t first infor ing you . Yester y, he
(C) H o eri o
bec e cu te y irrit b e n even h crying
(D) Lithiu s e . H e so co ins of bo y ches, chi s,
(E) Zi r si one n gener eth rgy. Which of the fo ow ing
ste s w ou best evi te his sy to s?
25. A 30-ye r-o w o n, 10 w eeks regn nt w ith
her first chi , resents to you r office st ting (A) Rest rt roxetine.
th t she is e resse n is h ving oubts (B) St rt cet ino hen.
bou t beco ing other. She h s been ex e- (C) St rt bu ro ion.
riencing i y e esis n is h ving trou b e (D) St rt v roic ci .
fu nctioning t w ork. She re orts th t she w s (E) St rt ven f xine.
e resse throu ghou t her 20s, but iscontin-
u e her nti e ress nts w hen she bec e 28. A 20-ye r-o w o n is st rte on otrig-
regn nt bec u se of concerns bout h r ing ine for bi o r isor er, cu rrent y e resse .
her chi . She w ou ike you r he in ev u t- Tw o onths ter, she co es b ck re orting
ing risks n benefits of rest rting sertr ine, th t her sy to s re unch nge , es ite
w hich w orke w e for her in the st. Which her being co i nt w ith the e ic tion. You
of the fo ow ing risks w ou be the ost ike y review her e ic tion ist n iscover th t
to occu r? she w s recent y st rte on new e ic tion(s).
(A) Ebstein no y Which of the fo ow ing e ic tions w ou
(B) Gest tion i betes ost ike y be res onsib e for the ck of
effic cy?
(C) Inf nt eve o ent e y
(D) N eur tu be efects (A) Dros irenone n ethiny estr io
(E) Persistent u on ry hy ertension of (B) Ibu rofen
the new born (C) Lithiu
(D) V roic ci
26. A 19-ye r-o w o n is itte to n in - (E) Zi r si one
tient sychi tric f ci ity for her e ting isor-
er. She w eighs 82 b n st n s 5 ft 6 in t . Questions 29 and 30
She beg n ieting in high schoo to ose n
unw nte 5 b. Encour ge by co i ents A 68-ye r-o n resents to you r office on refer-
on her figu re, she continu e to ose nother r fro his ri ry c re hysici n for ev u tion
10 b. H er e ting h bits re ritu ize : She cuts of e ression. H e fee s e resse n ho e ess, n
her foo into s ieces n oves it rou n he h s ost his etite. H e no onger enjoys seeing
on her te. She h s n intense fe r of being his gr n chi ren. It t kes hi sever hours to f
overw eight. Which of the fo ow ing e ic - s ee t night, n he st ys s ee for on y bou t
tions w ou be the ost usefu for this tient? 3 hou rs. H e occ sion y oes not bu y foo bec u se
he is concerne bou t going broke; how ever, his
(A) Cy rohe t ine
f i y infor s you th t he is fin nci y w e -off.
(B) F uoxetine In ition, the tient fee s signific nt gu i t bou t
 Que s tions : 2534 87

beco ing bu r en on his f i y. H is height is 6 ft (A) As irin

w ith w eight of 155 b, ecre se fro his u su (B) Decre se f u i int ke
175 b. (C) H y roch orothi zi e
(D) N itrog ycerin
29. Which of the fo ow ing e ic tions w ou be
the ost ro ri te for tre ting his inso ni ? (E) Pro r no o

(A) Bu ro ion Questions 33 and 34

(B) Di ze
A 47-ye r-o e nove ist h s fe rs of cont in -
(C) Di henhy r ine
tion fro nything he be ieves is irty. In rest u -
(D) F uoxetine r nts, he u ses his ow n stic u tensi s th t he c rries
(E) Tr zo one w ith hi . E sew here, he w e rs g oves or u ses er
tow e s to voi tou ching irty objects. U on
30. Which of the fo ow ing si e effects of this retu rning ho e, he then rocee s to w sh his h n s
e ic tion w ou be the ost i ort nt to 10 ti es before going bou t his ctivities. If he cci-
e u c te the tient bou t? ent y tou ches nything rior to the co etion
(A) Anorg s i of w shing his h n s, he ex eriences nxiety n is
then u n b e to erfor his u su night y t sks. As
(B) Gyneco sti
resu t of these sy to s he re ins u n b e to h ve
(C) I otence e ningfu soci ife.
(D) Pre tu re ej cu tion
(E) Pri is 33. Which of the fo ow ing e ic tions w ou be
the ost effective tre t ent for his con ition?
Questions 31 and 32
(A) C o i r ine
A 57-ye r-o n w ith bi o r isor er, w ho (B) C on ze
you h ve tre te su ccessfu y for 20 ye rs w ith ith- (C) N ortri ty ine
iu 300 g ti , is itte to the gener hos it (D) O nz ine
w ith chest in.
(E) Phene zine
31. Which of the fo ow ing fin ings w ou be
34. After 12 w eeks of ther eu tic ose of the
ost ike y seen on his e ectroc r iogr
e ic tion, the tient no onger nee s to
(ECG)?
w sh his h n s qu ite so often bu t sti h s
(A) First- egree trioventricu r (AV) b ock signific nt istress w hen he touches irty
(B) PR interv ro ong tion things. Which of the fo ow ing tre t ents
(C) QT interv ro ong tion w ou be the ost ro ri te next ste ?
(D) Sino tri b ock (A) A bu s irone.
(E) T-w ve e ression (B) A ithiu .
(C) A ris eri one.
32. The tient is eter ine to h ve su ffere (D) Ch nge to ris eri one.
yoc r i inf rction (MI) n qu ick y u n er-
(E) Refer for cingu oto y.
goes ngio sty. H e is eventu y st bi ize
n isch rge fro the hos it on ro r n-
Questions 35 and 36
o o , to ic nitrog ycerin, hy roch orothi -
zi e, n s irin, in ition to his ithiu . A 21-ye r-o co ege stu ent h s been ex eriencing
Prior to his MI, his ithiu eve w s u su y u itory h u cin tions w ith co n s te ing hi
0.8 to 0.9 o / L. N ow it is 1.3 o / L on to hurt hi se f for ore th n ye r. H e h s h tri-
the s e ose. Which of the fo ow ing is the s w ith the fo ow ing gents since th t ti e: qu e-
ost ike y c u se for this ch nge? ti ine 400 g bi for 2 onths, then h o eri o
88 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

10 g bi for 6 w eeks, then o nz ine 30 g i y re ort th t she f i e sever c sses bec u se

for 2 onths. Des ite inor re u ction in the she h s not been going to c ss or tu rning in
voices, he re ins iso te fro f i y n frien s. ssign ents. She is not t king ny e ic -
tions n her toxico ogy screen is neg tive.
35. Which of the fo ow ing gents w ou be the On ent st tus ex in tion, her s eech is
ost ro ri te to begin? ressu re n her thou ght rocess is t ngen-
ti . You eci e to it her to the hos it .
(A) Ari i r zo e
Which of the fo ow ing e ic tions w ou be
(B) C oz ine the ost ro ri te to begin?
(C) Per hen zine
(A) Cit o r
(D) Ris eri one
(B) L otrigine
(E) Zi r si one
(C) O nz ine
36. Which of the fo ow ing rece tors is ost (D) To ir te
ike y res onsib e for the bove e ic tions (E) V roic ci
effic cy?
39. A 28-ye r-o w o n w ho you re tre t-
(A) D2
ing for bi o r isor er infor s you th t she
(B) D3 is 3 w eeks regn nt n is nxiou s bou t the
(C) D4 b bys he th. She is cu rrent y rescribe ith-
(D) 5-hy roxytry t ine-1 (5-H T1) iu 300 g bi , n she h s not h nic
(E) 5-hy roxytry t ine-3 (5-H T3) e iso e in 3 ye rs. Wh t w ou be best to
vise her reg r ing the u se of ithiu uring
37. A 65-ye r-o n w ith jor e ression regn ncy?
n hy ertension resents to the e ergency (A) Lithiu is highest risk u ring the thir
e rt ent bec u se he fe to the grou n fter tri ester of regn ncy.
rising fro ch ir. H e h s no signific nt c r-
(B) Lithiu incre ses the risk of neu r tu be
i c history n his ECG, e ectro ytes, n
efects.
neu ro ogic ex in tion re u nre rk b e.
H is f i y re orts th t his hysici n recent y (C) Lithiu c u ses eve o ent e y in
st rte new nti e ress nt bu t they o not ex ose inf nts.
know its n e. Which of the fo ow ing nti e- (D) Lithiu incre ses the risk of c r i c
ress nts w ou ost ike y be res onsib e for for tion.
his resent tion? (E) Lithiu incre ses the risk of c eft i
n te.
(A) Bu ro ion
(B) F u oxetine 40. You re c e to consu t on n 85-ye r-o
(C) I i r ine surgic tient w ho h s beco e co b tive,
(D) Mirt z ine ye ing, u nching st ff, n u ing ou t her
(E) N ortri ty ine IVs. She e n s to e ve bu t is too w e k
to get ou t of her hos it be . Which of the
38. A 21-ye r-o w o n w ith history of bu i- fo ow ing w ou be the ost ro ri te
i nervos resents to the e ergency intervention t this ti e?
e rt ent w ith her rents. She returne (A) Di henhy r ine
fro co ege st w eek, n since th t ti e,
(B) Done ezi
h s been st ying u very te, c ing frien s
roun the w or n t king nonsense (C) Lor ze
bout n internet st rt-u th t she is nning. (D) Orient tion to her su rrou n ings
She sks you to hu rry u w ith you r interview, (E) Ris eri one
since she h s w ork to get b ck to. H er rents
 Que s tions : 3546 89

Questions 41 and 42 43. Which of the fo owing gents wou be the

ost ro ri te to inister for his git tion?
A 67-ye r-o w o n resents to your office for
ev u tion of 20- b w eight oss over 4- onth (A) Ch or ro zine
erio n inso ni for the st 4 w eeks. H er (B) H o eri o
ughter infor s you th t her other no onger (C) Lor ze
enjoys ny of her hobbies n h s been s e king (D) Ris eri one
te y bou t ying. They h ve re y consu te
(E) Thiori zine
n internist w ho erfor e n extensive e ic
w orku , inc u ing che istries, b oo cou nt, thy-
44. Which of the fo ow ing gents w ou be the
roi stu ies, g strointestin i ging, n en os-
ost ro ri te to give in or er to ini ize
co y, of w hich w ere nor .
the tients risk of f ing?
41. You w ou ike to begin n nti e ress nt (A) H o eri o
e ic tion bu t w ou ike to ini ize (B) Per hen zine
verse si e effects w hi e ex oiting other (C) Qu eti ine
si e effects. Which of the fo ow ing gents
(D) Ris eri one
w ou be the ost ro ri te?
(E) Thiori zine
(A) Bu ro ion
(B) F u oxetine Questions 45 and 46
(C) Mirt z ine
A 32-ye r-o n resents to your c inic fter osing
(D) N ortri ty ine his job bec use he w s intoxic te w hi e w orking. H e
(E) Sertr ine h s been rinking i y since he w s 16 ye rs o . H e
w s b e to co ete co ege n w ent to w ork fu -
42. U on fu rther history, you e rn th t she h s ti e right fter gr u tion, but h s ost sever jobs
h sever f i e tri s of nti e ress nts since. H is w ife h s thre tene to e ve hi if he oes
n w ou ike to st rt tricyc ic nti e res- not get he .
s nt. Which of the fo ow ing con itions w ou
be the ost ike y to rec u e u sing su ch n 45. Which of the fo ow ing e ic tions w ou
gent? be the ost u sefu s beh vior o ifier to
ecre se his coho use?
(A) Estrogen re ce ent ther y
(B) L cu n r inf rcts (A) Ac ros te
(C) Left bu n e br nch b ock on ECG (B) Disu fir
(D) Tre t ent w ith o i ine (C) F u zeni
(E) Urin ry retention (D) N oxone
(E) N trexone
Questions 43 and 44
46. Further history reve s th t he oes not h ve
A 72-ye r-o n is itte to gener hos i-
oo isor er. He te s you th t often he si y
t s intensive c re u nit bec u se of tere ent
c nnot contro his cr ving to h ve nother rink.
st tu s. H is e ic w orku h s reve e neu o-
Which of the fo owing gents wou be the
ni n congestive he rt f i u re (CH F). On the sec-
ost ike y to ecre se his cr vings for coho ?
on hos it y, he is git te n u s out his
IV ccess. H e so h s been note to s e k ou t ou (A) Bu ro ion
w ith no one in the roo . H is eve of consciou sness (B) Disu fir
see s to w x n w ne. H e oes not h ve sychi- (C) F u zeni
tric history n is not ergic to ny e ic tions. (D) N oxone
Besi es his CH F n neu oni , he oes not h ve
(E) N trexone
other co orbi con itions.
90 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

Questions 47 and 48 bou t 1 onth go w hen he beg n h ving if-

ficu ty s ee ing. The st ff hysici n rescribe
A 36-ye r-o w o n is referre to you by her ri- or ze 2 g t be ti e; how ever, he w s
ry c re hysici n for n ge ent of nxiety sti u n b e to s ee . H e st rte w n ering
n fe r th t h s ersiste for sever onths. She u ring the y n h s since been restricte
re orts th t she w s r e n he host ge on to his roo . Bec u se he re ins git te u r-
bo t for sever ys by tw o r e en. Du ring ing the y, they h ve been giving hi or z-
this, she ex erience intense fe r for her ife. Since e 2 g every 6 hou rs for git tion. H is
then, she h s h intense stress w henever she is other e ic tions inc u e hy roch orothi -
ne r the w ter n h s frequ ent night res. She zi e 25 g/ , igoxin 0.125 g every other
c nnot rec et i s of the or e bu t tries to voi y, i ti ze 240 g su st ine re e se i y,
riving her c r w ithin sight of the oce n, w hich h s n tr ns er nitrog ycerin 0.4 g/ h s
been ifficu t bec u se of the oc tion of her ho e. nee e . H is e ectro ytes re nor exce t
She fee s et che fro her hu sb n n f iy for ot ssiu eve of 3.4 o / L. A recent
n h s b n one ns to u rsue her c reer s igoxin eve is not v i b e. Which of the
inter. She h s ifficu ty f ing s ee n is e si y fo ow ing interventions shou be consi ere
st rt e by hone c s. As resu t of her ex erience, first?
she no onger goes to u b ic ces one.
(A) Checking the hy roch orothi zi e eve .
47. Which of the fo ow ing e ic tions w ou be (B) Monitoring orthost tic vit s.
ost he fu in tre ting the sy to s she is (C) Re cing the ot ssiu .
ex eriencing? (D) Sto ing the roo sec u sion.
(A) A r zo (E) T ering the or ze .
(B) C rb ze ine
(C) F u oxetine Questions 50 and 51
(D) N trexone A 64-ye r-o n, cco nie by his w ife, res-
(E) Thiori zine ents to you r office co ining of e ory oss. H e
is retire stockbroker w ho c n no onger rec
48. She is tre te w ith the ro ri te e ic - stock qu otes ike he i sever ye rs go. H is w ife
tion n h s signific nt re u ction in ost h s beco e both concerne n nnoye bec u se
of her sy to s. H ow ever, she continu es he see s to i e i te y forget w h tever she te s
to ex eriences frequ ent, intense night res, hi . These e ory rob e s h ve s ow y ro-
resu ting in her h ving oor s ee n f tigu e gresse over sever ye rs. Recent y, he h iffi-
the next y. Which of the fo ow ing gents cu ty getting resse , n ore th n once, he u t
w ou be the ost benefici in re u cing these his u n erw e r on over his nts. H is w ife h s so
sy to s? note th t he s e ks u ch ess u ring inner th n
he once i . H e oes not h ve ny other signific nt
(A) Lor ze
e ic i nesses.
(B) N trexone
(C) O nz ine 50. Which of the fo ow ing e ic tions w ou be
(D) Per hen zine ost ike y to i rove his con ition?
(E) Pr zosin (A) A r zo
(B) Done ezi
49. You h ve been ske to ev u te n 80-ye r-
o e nu rsing ho e resi ent bec u se of (C) F u oxetine
ch nge in ent st tu s. The nu rsing st ff (D) Methy heni te
re orts th t he h s been tient there for (E) Tr zo one
bou t ye r w ithout ny rob e s, u nti
 Que s tions : 4756 91

51. U on fu rther questioning, his w ife re orts th t 54. A 48-ye r-o w o n resents to you r r ctice
he oes not s ee w e t night n w n ers w ith co ints of e ression. H er other
rou n the hou se i ess y. Su bsequ ent y, he sse w y 6 onths go fro u ng c ncer
s ee s for rge rt of the y. Which of n her f ther ie 4 ye rs go fro the s e
the fo ow ing e ic tions w ou be the ost ise se. She h s seen ther ists to he w ith
u sefu to contro this beh vior? her grief but she continu es to h ve ongoing
s ness, ter in inso ni , ow energy, oor
(A) H o eri o
etite, n ifficu ty concentr ting. She
(B) Lor ze h s ssive thou ghts of su ici bu t no n
(C) Tr zo one or intent. She enies rior su ici e tte ts.
(D) Tri zo In ition, es ite sever tte ts to qu it
(E) Qu eti ine s oking, she sti s okes tw o cks of cig -
rettes y n h s h w orsening sth s
Questions 52 and 53 resu t. She h s no ition e ic rob-
e s. Which of the fo ow ing e ic tions
A 25-ye r-o n is brou ght into the e ergency w ou be the ost ro ri te to u se in this
e rt ent eth rgic n stu orou s. H e res on s tient?
on y to infu sti u i, w kes u brief y n ye s, then
goes b ck to s ee . A bu nce ersonne re ort (A) Bu ro ion
th t they fou n hi ne r hou se know n for ru g (B) Bu s irone
tr fficking. There is no evi ence of hysic inju ry. (C) I i r ine
(D) Phene zine
52. Which of the fo ow ing e ic tions shou he (E) Tr zo one
receive first?
(A) Dextrose n f u zeni 55. A 52-ye r-o n w ho h s oor y contro e
(B) Dextrose, f u zeni , n n oxone i betes is referre to you for ev u tion of
e ic tion nonco i nce. You e rn th t he
(C) Dextrose, f u zeni , n oxone, n
c nnot f s ee t night n h s no energy
thi ine
u ring the y. H is etite is gone n he
(D) Dextrose n n oxone
oes not enjoy ctivities s he once i . Over-
(E) Dextrose, n oxone, n thi ine he fee s e resse . A ition y, he h s
been ex eriencing chronic in in his feet,
53. The tient is su bsequent y tre te n u rine ee e to be u e to neu ro thic in, w hich
toxico ogy screen is ositive for the resence of is not re ieve by n gesics. Which of the fo -
o ioi s. When he is ore ert, he infor s you ow ing e ic tions w ou be the ost u sefu
th t he h s been using intr venous (IV) heroin in tre ting this tients sy to s?
i y for sever w eeks. H is st use w s bout
8 hours go. H is heroin u se esc te fro (A) A r zo
snorting to IV use fter he no onger fe t goo (B) A itri ty ine
high fro snorting. H e h s never etoxifie (C) Bu ro ion
before. H e h s no co orbi e ic con i- (D) Cit o r
tions n he oes not use coho . Which of (E) Du oxetine
the fo ow ing e ic tions w ou be the ost
ro ri te to etoxify this tient? 56. A 47-ye r-o w o n resents to your office
(A) Bu renor hine for sychi tric c re bec u se she h s ju st re o-
(B) Ch or i ze oxi e c te to you r tow n. She h s history of bi o-
r isor er, bu t her rior sychi trist recent y
(C) C oni ine
sto e her ithiu bec u se she eve o e
(D) N oxone
thyroi uto ntibo ies. She co ins of being
(E) Pro r no o irrit b e n not b e to s ee for sever weeks.
92 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

She h s ots of energy bu t is king is- (D) Sw itch to o nz ine.

t kes t w ork s she is istr cte . She te s you (E) Sw itch to ris eri one ong- cting
th t her thou ghts re r cing n you h ve injection.
ifficu t ti e re irecting her nsw ers. H ow -
ever, she be ieves her biggest rob e is her Questions 59 and 60
f ci in, w hich w s i gnose s trige i-
n neur gi n h s not i rove w ith n - A 50-ye r-o n w ho h s fe t e resse for sev-
gesics. Which of the fo ow ing e ic tions er onths, resents to you r office for ev u tion.
w ou be the ost ro ri te in tre ting this He h s h oor s ee , ecre se etite w ith
tients sy to s? w eight oss, no interest in his hobbies, n c nnot
concentr te u ring you r cognitive ex in tion. H e
(A) A itri ty ine h s ssing thou ghts of ying bu t no ctive n or
(B) C rb ze ine intent. H e re u ct nt y its to frequ ent y he ring
(C) F u oxetine voices te ing hi th t he is going to ie soon. You
(D) G b entin su bsequ ent y eci e to st rt n nti e ress nt n
(E) Lithiu ris eri one t 0.5 g bi .

57. A 33-ye r-o w o n w ith history of schizo- 59. Which of the fo ow ing si e effects of ris eri-
hreni h s recent y st rte tre t ent w ith one w ou be the ost ike y?
o nz ine. She h s to er te the e ic tion (A) Agr nu ocytosis
w e n is iving in grou ho e, ntici t- (B) Anticho inergic si e effects
ing oving into her ow n rt ent. She no
(C) Leu kocytosis
onger he rs voices n no onger h s esire
to hurt herse f. Which of the fo ow ing si e (D) Orthost tic hy otension
effects w ou be ost ike y to interfere w ith (E) Weight oss
her co i nce?
60. As his ose of ris eri one is incre se , the
(A) Agr nu ocytosis risk of w hich of the fo ow ing si e effects w i
(B) Deve o ent of c t r cts so incre se?
(C) G ctorrhe
(A) Agr nu ocytosis
(D) Incre se excit bi ity
(B) Anticho inergic effects
(E) Weight g in
(C) Extr yr i sy to s
58. A 32-ye r-o e w ith schizo hreni is (D) Leu kocytosis
being tre te for n cu te ex cerb tion of his (E) Weight oss
u itory h u cin tions. As is his ttern, he
res on s very f vor b y to e ic tions w hi e 61. A 33-ye r-o rrie fe e w ith history
hos it ize , bu t w hen he is isch rge for- of bi o r isor er, w ith eri rtu onset,
gets to t ke the regu r y. This resu ts in h s been st b e since being int ine on ris-
cyc e of subsequent w orsening of his sy- eri one for the st sever ye rs. H er son is
chosis n rehos it iz tion. H e is current y oing w e , n the tient n hu sb n w ish
t king ris eri one 5 g/ or y, n he is to h ve nother chi . For the st ye r she
to er ting it w e w ith goo effic cy. Which of h s been tte ting to conceive w ithou t su c-
the fo ow ing w ou be the ost ro ri te cess. She is on no other e ic tions besi es
next ste in his tre t ent? the nti sychotic, n she h s not been u sing
birth contro . She h s no other e ic rob-
(A) Continu e the cu rrent regi en. e s, n she is current y sy to tic, w ith-
(B) Sw itch to c oz ine. ou t e ression or sychotic sy to s. She
(C) Sw itch to h o eri o . rinks 1 to 2 g sses of w ine er w eek, enies
i icit rugs, n oes not use tob cco ro ucts.
 Que s tions : 5766 93

Invo ve ent of w hich of the fo ow ing br in 64. A 45-ye r-o fe e execu tive w ho tr ve s
thw ys is ost ike y res onsib e for her often to Eu ro e fro the Unite St tes res-
inferti ity? ents to you r office co ining of signific nt
inso ni n yti e f tigu e fter tr ns t n-
(A) Locus ceru eu s
tic f ights. Which of the fo ow ing e ic tions
(B) Mesocortic tr ct w ou be the ost ro ri te tre t ent for
(C) Meso i bic tr ct her co ints?
(D) N igrostri t tr ct
(A) A itri ty ine
(E) Tu beroinfu n ibu r tr ct
(B) Di henhy r ine
Questions 62 and 63 (C) Me tonin
(D) Qu eti ine
A 19-ye r-o co ege stu ent resents to the office (E) Te ze
t the u rging of her frien s, w ho re concerne
bout her w e -being. For the st sever onths, Questions 65 and 66
she h s been incre sing y reoccu ie w ith her
w eight n bo y i ge, n h s been regu r y A 60-ye r-o n resents to you r office co in-
c nce ing ns w ith frien s bec u se she oes not ing of the su en onset of it tions, sw e ting,
w nt to e t w ith other eo e. She st tes th t she is sh king, shortness of bre th, choking, n fee ing
f t n w ou ike to ose 10 b. When qu erie fu r- th t he is going cr zy. These sy to s st 5 to
ther, she its th t she is bingeing n throw ing 10 inu tes n h ve occu rre sever ti es er
u ost every y. She enies ny x tive use, w eek for the st 3 onths. H e enies ny rtic-
n she h s not been restricting her e ting. She is u r stressor or event w hich rovokes the tt cks,
5 ft 4 in n w eighs 110 b. H er ot ssiu is 3.4; thou gh he is const nt y fr i of h ving futu re
other e ectro ytes re w ithin nor i its. You e iso es. H e h s recent y been seen by his c r io o-
re ete her ot ssiu n refer her to sychi trist gist w ho h s ru e ou t c r i c etio ogy.
for fu rther ev u tion.
65. Which of the fo ow ing w ou be the ost
62. Which of the fo ow ing w ou be the ost ro ri te e ic tion to tre t this tients
effective e ic tion for her con ition? isor er?
(A) Bu ro ion (A) Bu ro ion
(B) F u oxetine (B) I i r ine
(C) L otrigine (C) Phene zine
(D) Lithiu (D) Qu eti ine
(E) Mirt z ine (E) Sertr ine

63. You ter e rn th t she w s tre te in high 66. If the tients sy to s w ere u e to c r-
schoo for the s e sy to s w ith sertr ine i c etio ogy n he su bsequ ent y bec e
n cit o r , both t high oses for over e resse , w hich e ic tion w ou ose the
3 onths e ch, bu t w ith itt e i rove ent in highest risk?
her sy to s. Which of the fo ow ing e i-
(A) A itri ty ine
c tions w ou be the ost ro ri te next
ste ? (B) Bu ro ion
(C) Methy heni te
(A) Bu ro ion
(D) Sertr ine
(B) Lithiu
(E) Ven f xine
(C) P roxetine
(D) To ir te
(E) V roic ci
94 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

67. A 33-ye r-o w o n w ith i gnosis of of the fo ow ing si e effects o you infor hi
schizo hreni h s been int ine on h o- is the ost ike y?
eri o since she w s i gnose t ge 24. In
(A) He che
you r office, she s ys she h s not h her en-
stru erio in sever onths, h s i in- (B) H e ring oss
ishe sex rive, h s been isch rging i k (C) Me ory oss
fro her bre sts, n h s in u ring sexu (D) Seizures
intercou rse. Which of the fo ow ing w ou (E) Tooth in
ost ike y be incre se in this tient?
(A) A renocorticotro ic hor one (ACTH ) 70. You h ve been tre ting 33-ye r-o w o n
w ith bi o r isor er for 4 ye rs. In re r -
(B) Do ine
tion for nne regn ncy, you h ve gree
(C) N ore ine hrine to t er her e ic tions but see her fre-
(D) Pro ctin qu ent y in c se of nic e iso e. Six w eeks
(E) Serotonin into her regn ncy, she resents to you r office
w ith ressu re s eech n the be ief th t her
68. A 24-ye r-o n is hos it ize bec use b by is Jesu s Christ. H er hu sb n s ys he is
he h s been he ring voices for 6 onths te - concerne bec u se she h s sto e t king
ing hi to ki hi se f n now fe rs th t he her ren t vit ins n is cting biz rre y.
y ct on the . H e ost his job 2 onths go Which of the fo ow ing tre t ents w ou be
n on ent st tu s ex in tion e rs the s fest to tre t her isor er?
u nke t n isorg nize , w ith f t ffect.
(A) C rb ze ine
H e is begu n on ri i r zo e, n his sy -
to s eventu y ecre se enou gh for hi to (B) Di ze
be isch rge . On fo ow -u visit to you r (C) Div roex so iu
office, he re orts th t his h ucin tions h ve (D) E ectroconvu sive ther y (ECT)
i rove bu t th t he c nt sit sti n fee s (E) Lithiu c rbon te
ike he nee s to be const nt y in otion. The
tient inter ittent y st n s u n w ks 71. You re the consu t- i ison sychi trist on c
rou n you r office s you interview hi . for the tr u su rgery te . You re ske to
Which of the fo ow ing con itions ccount for ev u te 39-ye r o n w ho w s hit by
his new co ints? c r n severe y inju re . H e is un b e to give
(A) Acu te ystonic re ction history, bu t n cqu int nce w ho cco -
nie the tient to the hos it re orts th t he
(B) Ak thisi
is i y, he vy ru g u ser. On ex in tion,
(C) M nic e iso e the tient is note to h ve tr ck rks on his
(D) N eu ro e tic ign nt syn ro e r s. Which of the fo ow ing c sses of ru gs
(E) T r ive yskinesi o you te the surgeons is the ost ngerou s
if bru t y w ith r w n?
69. A 55-ye r-o n w ith ong history of jor
(A) C nn binoi s
e ression resents to your office fter u ti-
e f i e nti e ress nt tri s. Since the ge of (B) H u cinogens
20, he h s h equ te tri s of nortri ty ine, (C) O i tes
hene zine, f uoxetine, sertr ine, bu ro ion, (D) Se tive-hy notics
irt z ine, ven f xine, n u oxetine, w ith (E) Sti u nts
ini res onse. Other sychi trists h ve
suggeste ECT in the st, bu t he is concerne Questions 72 and 73
bout e ory oss. H e w ou ike to try tr n-
scr ni gnetic sti u tion (rTMS), n A 44-ye r-o n w ith history of chronic, severe
w nts to know ore bout si e effects. Which coho u se isor er is brou ght to the e ergency
 Que s tions : 6781 95

roo . You get re ort fro f i y e ber th t st rte on cit o r n h s n incre se of

he h s been iving off booze n ru gs n nothing 11 sec in his QTc v u e on ECG.
e se for w eeks. The e ergency e rt ent nu rse
is bou t to go in to r w b oo fro the tient n 75. A 51-ye r-o w o n being tre te for schizo-
offer hi foo . hreni eve o s i betes.

72. Which of the fo ow ing is the ost ro ri te

next ste in the tre t ent of this tient? 76. An 11-ye r-o gir being tre te for jor
e ressive isor er re orts frequ ent su ici
(A) A inister or ze . i e tion.
(B) A inister thi ine.
(C) Obt in co ete b oo cou nt. 77. A 34-ye r-o w o n being tre te for bi o-
(D) Obt in iver fu nction tests. r I isor er eve o s cu te in in her b o-
(E) Obt in vit in B12 eve . en n is i gnose w ith ncre titis.

73. After he is itte to the e icine service, 78. The WBC count of 27-ye r-o n being
w hich of the fo ow ing e ic tions w ou be tre te for the tre t ent refr ctory schizo-
the ost ro ri te to initi te? hreni ro s to 3,000/ L.
(A) Ac ros te
(B) C oni ine 79. A 42-ye r-o n sto s his nti e ress nt.
(C) Disu fir Tw o ys ter, he ex eriences fee ing of
(D) Lor ze ho e essness, h s ifficu ty s ee ing, n fee s
qu ite nxious.
(E) N trexone

D IRECTION S (Questions 74 through 83): The fol-
low ing group of numbered items are preceded by
a list of lettered options. For each vignette, select
the one lettered option that is most closely associ-
ated w ith it. Each lettered option may be used
once, multiple times, or not at all.
80. A 36-ye r-o wo n being tre te for bi o r
isor er fin s herse f urin ting very frequent y.
81. Sever onths fter st rting on new nti-
sychotic, 32-ye r-o tients tot cho es-
tero incre ses fro 200 to 250 g/ L.

Questions 74 through 81
Questions 82 and 83
For e ch vignette, choose the e ic tion ost ike y
For e ch vignette, choose the e ic tion ost
to be ssoci te w ith the si e effect.
ro ri te to rescribe.
(A) C rb ze ine
(A) A r zo
(B) C oz ine
(B) Cit o r
(C) Div roex so iu
(C) Div roex so iu
(D) H o eri o
(D) F u oxetine
(E) Lithiu
(E) H o eri o
(F) P roxetine
(F) Lithiu
(G) Per hen zine
(G) C oz ine
(H ) Pi ozi e
(H ) P roxetine
(I) Zi r si one
(I) Ris eri one
74. A 14-ye r-o boy being tre te h r co- (J) Sertr ine
ogic y for Tou rette isor er is ition y (K) Tr zo one
96 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

82. A 34-ye r-o n w ith schizo ffective isor- (C) C o i r ine

er h s been nonco i nt w ith e ic tions (D) F u oxetine
in the st. You w nt to be b e to give hi (E) F u vox ine
e ot injection of n nti sychotic.
Questions 86 and 87
83. You re tre ting 45-ye r-o veter n w ith
You re tre ting 28-ye r-o n w ith 6-ye r
history of coho use isor er for osttr u -
history of schizo hreni w ho ives w ith his rents.
tic stress isor er (PTSD), n he sks you
The tient h s h nu ber of ebi it ting si e
for so ething to he hi s ee .
effects, su ch s severe extr yr i sy to s,
fro tr ition nti sychotics inc u ing h o eri-
D IRECTION S (Questions 84 through 105): For o . H is f i y is w orrie bou t w eight g in, w hich
each of the multiple-choice questions in this sec- the tient ex erience on o nz ine. Des ite the
tion, select the lettered answ er that is the one best nu erous e ic tions, his sychotic sy to s
response in each case. continu e. You iscu ss c oz ine w ith the tient
n his f i y n they gree to try the e ic -
Questions 84 and 85 tion. You h ve initi te tre t ent s ow y n he h s
A 28-ye r-o sing e w o n resents w ith 8 w eeks show n signific nt i rove ent; how ever, he h s
of e ression, inso ni , ow energy n f tigu e, been ro u cing rge ou nt of s iv n roo
istr ctibi ity, n oor etite. She h s no rior so king his shirts.
sychi tric history n no f i y sychi tric his-
tory. After further history n bor tory ev u - 86. Which of the fo ow ing is the ost ro ri te
tions re co ete , she is begu n on sertr ine, next ste ?
w hich is eventu y incre se to 100 g/ . After (A) A nt ine.
2 onths on th t ose, the tient re orts th t she (B) A ro r no o .
fee s b ck to nor n sks w hen she c n sto
(C) A su b ingu tro ine.
the e ic tion.
(D) Discontinu e c oz ine.
84. H ow ong shou you reco en her to (E) Incre se the ose of c oz ine.
continu e the e ic tion?
87. In ition to the bove, the tient co ins
(A) 1 onth of it tions. An ECG reve s sinu s t chy-
(B) 2 onths c r i , w hich is consistent w ith rior ECGs
(C) 4 onths erfor e over the st onth. Which of the
(D) 10 onths fo ow ing is the ost ro ri te next ste ?
(E) 2 ye rs (A) A benztro ine.
(B) A bet o .
85. She returns for fo ow-u visit 1 onth ter.
(C) A or ze .
Her sy to s h ve continue to re in in
(D) A ro r no o .
re ission, though she escribes recent con-
f ict with her boyfrien ue to h ving itt e sex (E) Discontinu e c oz ine.
rive. The tient st tes th t it h s gotten to the
oint where she h s eci e to sto the e ic - 88. A 21-ye r-o sing e fe e co ege stu ent
tion un ess so ething c n be one. She is wi - is brou ght to the u niversity he th service by
ing to switch to nother e ic tion es ite the her roo tes. She kes it c e r to you th t
risk of re se. Which of the fo owing gents she oes not think theres nything w rong
wou be the ost ro ri te choice? w ith her, bu t her roo tes te you th t they
c nt e w ith her ny ore bec u se she
(A) Bu ro ion never s ee s n never shu ts u . The tient
(B) Cit o r insists this is bec u se she h s iscovere n
 Que s tions : 8293 97

i ort nt the tic roof th t she u st 91. The tient is 59-ye r-o fe e w ith schizo-
finish w riting. Shes convince th t the uni- hreni , s w e s oor y contro e i betes
versity w i i e i te y gr nt her tenure s e itu s, obesity, hy er i i e i , n hy er-
soon s they see the roof, thou gh she h s tension. She h s been tre te for over 35 ye rs
troub e st ying on to ic w hen you sk qu es- w ith v riou s first-gener tion nti sychotics,
tions bout it. She h s not seen sychi trist n thou gh she is on n equ te ose, she
before, n u rine toxico ogy screen, w hich sti h s resi u sychotic sy to s n h s
she consents to to rove I not cr zy, is now begu n to eve o invo u nt ry b inking
neg tive. Which of the fo ow ing is the ost n tongu e-ro ing ove ents. She is gree-
ro ri te gent for initi n inten nce b e to sw itching to n ty ic / secon -gen-
tre t ent of this tient? er tion nti sychotic. Which of the fo ow ing
e ic tions w ou be the ost ro ri te
(A) H o eri o
for this tient?
(B) L otrigine
(C) Lithiu (A) Ari i r zo e
(D) Lor ze (B) C oz ine
(E) O nz ine (C) O nz ine
(D) Qu eti ine
89. A 34-ye r-o e ectric engineer co ins to (E) Ris eri one
his octor th t he h s been fee ing e resse
for sever onths fter the bre ku of his 92. You ev u te 34-ye r-o ivorce , e, w ith
rri ge. Since th t ti e, he h s h signifi- history of coho use isor er w ho resents
c nt inso ni , ifficu ty concentr ting, h s w ith the chief co int of I c nt sto rink-
ost 25 b in the st 3 onths bec u se his ing, oc. He h s h sever reh bi it tion
etite isnt the s e, fee s f tigu e , h s sig- issions but is un b e to int in sobriety.
nific nt fee ings of gu i t reg r ing the se r - He is current y rinking one-fifth of vo k
tion, fee s ho e ess n he ess, n h s fe t ost i y. Whi e he is very iscour ge n
su ici w ithou t s ecific n. A i gnosis of gui ty bout his coho use, he is ho efu bout
jor e ressive isor er is e n he is getting better, n he enies erv sive e res-
begu n on n nti e ress nt. Which of the fo - sive sy to s or suici i e tion. H e h s
ow ing sy to s w ou be ex ecte to t ke rior history of signific nt coho w ith r w ,
the ost ti e to i rove? inc u ing one seizure n e iriu tre ens,
both requiring n ICU ission. Which of the
(A) Decre se etite
fo ow ing e ic tions w ou be ost ro-
(B) Decre se concentr tion ri te to rescribe for this tient?
(C) Decre se energy
(A) Disu fir
(D) Inso ni
(B) Meth one
(E) Su ici ity
(C) N trexone
90. A 58-ye r-o n w ith history of cirrho- (D) Sertr ine
sis, he titis C, n coho is w ishes to qu it (E) V roic ci
rinking bu t w nts to etox first. Which of
the fo ow ing e ic tions w ou be the ost 93. A 35-ye r-o sing e n resents to you r
ro ri te to rescribe in this tient? office co ining of inso ni . H e re orts
th t he is b e to f s ee t night, bu t st ys
(A) A r zo
s ee for on y 2 or 3 hou rs, then w kes u fre-
(B) Ch or i ze oxi e quent y throu ghout the night. H e is exh uste
(C) C on ze n w ou ike so ething to he hi s ee .
(D) Di ze Other th n fee ing fru str te n f tigue
(E) Lor ze u ring the y, he enies other e ressive
98 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

sy to s or ny st sychi tric history. e ic tions w ou be the ost ro ri te to

Which of the fo ow ing e ic tions w ou be rescribe?
the ost ro ri te for this tient?
(A) Bu s irone
(A) A itri ty ine (B) F u oxetine
(B) R e teon (C) F u vox ine
(C) Tr zo one (D) Lor ze
(D) Z e on (E) Pro r no o
(E) Zo i e
97. A 30-ye r-o e resents w ith 4 w eeks
94. A 40-ye r-o rrie , regn nt w o n w ith of ow energy, oor s ee , oor etite,
history of hy ertension, yoc r i inf rc- ecre se interest in e su r b e ctivities,
tion, egener tive isc ise se, n jor n ow oo . H e re orts being hos it -
e ressive isor er w ith sychotic fe tu res ize s you ng u t for 2-w eek erio of
is being consi ere for e ectroconvu sive gr n iosity, hy ersexu ity, ecre se nee
ther y (ECT) fter f i ing u ti e nti e- for s ee , n eng ging in risky beh viors. H e
ress nt n nti sychotic tri s. Which of w s st rte on ithiu bu t i not to er te the
the fo ow ing con itions w ou be re tive e ic tion u e to eve o ent of i betes
contr in ic tion to ECT? insi i u s n h s not t ken e ic tion since.
H e w orks s n ccou nt nt, his BMI is 35, n
(A) Degener tive isc ise se
his st A1c w s 5.2. Which of the fo ow ing
(B) H y ertension e ic tions w ou be the ost ro ri te to
(C) Pregn ncy rescribe for this tient?
(D) Psychotic e ression
(A) Lithiu
(E) Recent yoc r i inf rction
(B) Lu r si one
95. You re c e to consu t on 70-ye r-o (C) Qu eti ine
w o n, hos it ize in the ICU fter yo- (D) Sertr ine
c r i inf rction. The tient is ye ing t (E) V roic ci
st ff, u ing ou t her IV n trying to get out
of be . She refuses to t ke ny e ic tion by 98. A 29-ye r-o w o n w ith history of sei-
outh. H er ECG show s QTc of 480. Which zu res is i gnose w ith bi o r isor er,
of the fo ow ing e ic tions w ou be best to ost recent e iso e e resse , n st rte
he her git tion? on otrigine. Abou t w hich of the fo ow ing
si e effects w ou be the ost i ort nt to
(A) Ari i r zo e IM
e u c te the tient?
(B) Di ze IV
(C) H o eri o IV (A) Acu te ystoni
(D) Lor ze IV (B) Ak thisi
(E) Ris eri one Const IM (C) A stic ne i
(D) R sh
96. A 30-ye r-o w o n w ith no reviou s sy- (E) Ren f i u re
chi tric history resents to you r office sking
for he in n ging erfor nce nxiety. 99. A 19-ye r-o n w ith bi o r isor er is
She oves to ct n sing in her co unity brought in to the e ergency roo by the
the tre, but she beco es terrifie w hen get- o ice. H e is gr n iose n e usion , s w e
ting on st ge in front of crow s. As resu t, s git te n co b tive. H e is given n
her voice sh kes n she h s been un b e intr uscu r injection of h o eri o . After
to get goo rts. Which of the fo ow ing 30 inutes, the tient is fou n rching for-
w r . On hysic ex in tion, stiffness of the
 Que s tions : 94104 99

neck n b ck usc es re note . Which of the 102. A 58-ye r-o n w ith tri fibri tion,
fo ow ing ter s best escribes this si e effect? hy ercho estero e i , n hy ertension is
sent to you by his ri ry c re hysici n
(A) L ryngos s
for he in n ging his nxiety. H e re orts
(B) Ocu ogyric crisis th t for ny ye rs he h s w orrie bout
(C) O isthotonos everything, n th t he occ sion y h s to
(D) P eu rothotonos st y ho e fro w ork bec use he beco es so
(E) Tortico is fe rfu . H e often h s ifficu ty f ing s ee
n not u nco on y gets tension he ches
100. The tient is 59-ye r-o w o n w ith st w hen rticu r y stresse . H is e ic tions
e ic history of hy ercho estero e i , i - inc u e w rf rin, torv st tin, n hy ro-
betes, n i betic neu ro thy, w ho resents ch orothi zi e. H e oes not rink coho or
to her ri ry c re octor w ith the chief co - c ffeine. Which of the fo ow ing e ic tions
int of he ches. U on further interview, w ou be the ost ro ri te to tre t this
she st tes her sy to s beg n fter the e th tients sy to s?
of her hu sb n 5 onths go. Since th t ti e, (A) Bu ro ion
she h s fe t e ty, w ith oor s ee , f tigu e,
(B) Bu s irone
ecre se concentr tion, n w ishes th t she
w ou ie so I c n join hi . H er review of (C) Cit o r
syste s is re rk b e for ongoing sh r ins (D) C on ze
n nee es in her extre ities. H er hysic (E) Ven f xine
ex in tion is u nre rk b e, n her b oo
su g rs h ve been re tive y w e contro e . 103. A 40-ye r-o n is st rte on f u oxetine for
Which of the fo ow ing w ou be the ost jor e ressive isor er. H e notes i rove-
ro ri te tre t ent for her sy to s? ent in his oo , bu t h s ifficu ty s ee ing.
Tr zo one is su bsequ ent y e to his regi-
(A) Bu ro ion
en. Three ys ter, he c s co ining of
(B) Du oxetine infu erection th t h s not su bsi e fter
(C) F u oxetine sever hou rs. Which of the fo ow ing best
(D) Mirt z ine escribes this tients con ition?
(E) Re ssu r nce (A) Erecti e ysfu nction
(B) Ny ho ni
101. A 44-ye r-o rrie e tient w ith his-
tory of recurrent jor e ressive isor er (C) P r r xis
resents to sychi trist fter sto ing his ser- (D) Pri is
tr ine 1 onth go. A though it h s been effec- (E) S tyri sis
tive in the tre t ent of his e ression, he h s
h incre sing ifficu ty int ining n erec- 104. A 35-ye r-o rrie fe e is being fo -
tion, n this h s c use friction n conf icts ow e by sychi trist for her first e iso e
w ith his w ife. H e is concerne , how ever, th t of jor e ression. She is rescribe cit o-
he w i h ve re se of his e ressive sy - r 40 g i y n h s been in re ission
to s if not e ic te . Which of the fo ow ing for 3 onths. She now co ins of the new
w ou be the ost ro ri te h r co ogic onset of ecre se ibi o w hich is c u sing her
tre t ent for this in ivi u ? o er te ou nt of istress. Which of the
fo ow ing w ou be the ost ro ri te to
(A) Begin irt z ine.
to her cu rrent regi en?
(B) Begin roxetine.
(C) Begin ven f xine. (A) Bu ro ion
(D) N o e ic tion. (B) Desi r ine
(E) Rest rt sertr ine. (C) Lithiu
100 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

(D) Tr ny cy ro ine 107. A 16-ye r-o boy is brou ght to you by his
(E) Ven f xine other. She st tes th t, es ite h ving high
IQ, he oesnt co ete his ho ew ork, h s
105. A 41-ye r-o w o n resents to you r office been f i ing in schoo , n h s sto e going
sking for he in n ging her binge e t- out w ith frien s. H e its to s oking tw o to
ing. She e ts rge ou nts of ju nk foo three three joints of riju n i y.
or fou r ti es w eek, hi es foo , n su bse-
qu ent y fee s gu i ty bou t her ctions. H er 108. A 21-ye r-o n is brou ght into the e er-
BMI is 31. After erfor ing thorou gh his- gency e rt ent by the o ice fter getting
tory n hysic ex in tion, you eci e to rreste for ste ing g so ine. The tient fee s
rescribe to ir te. Which of the fo ow ing isconnecte fro re ity n frightene . On
si e effects o you te her is ost ike y? hysic ex in tion, he is note to h ve
(A) I rove ttention r sh rou n his ou th.
(B) P ncre titis
(C) Po yu ri 109. A 54-ye r-o n w ith o i te u se isor er
re se on heroin fter sever onths of
(D) Ren stones
sobriety. Whi e he beg n u sing $10 to $20 er
(E) Weight g in
y t first, he qu ick y incre se his u se to $50
to $60 er y bec u se I ont get high now
D IRECTION S (Questions 106 through 109): The
u n ess I u se ore.
follow ing group of questions are preceded by a
list of lettered options. For each question, select
the one lettered option that is most closely asso- D IRECTION S (Question 110): Select the lettered
ciated w ith it. Each lettered option may be used answ er that is the one best response in this case.
once, multiple times, or not at all.
110. A 27-ye r-o n w ith schizo hreni notices
Questions 106 through 109 the eve o ent of bre sts, ecre se ibi o,
n not ej cu ting w hen he h s n org s .
For the fo ow ing vignettes, choose the correct ter Which of the fo ow ing e ic tions is ost
fro the ist be ow . ike y res onsib e for these si e effects?
(A) A otiv tion syn ro e (A) Ari i r zo e
(B) C nn bis (B) C oz ine
(C) For ic tion (C) Qu eti ine
(D) H u cinogen ersisting erce tion (D) Ris eri one
isor er (E) Zi r si one
(E) Inh nts
(F) Intoxic tion D IRECTION S (Questions 111 through 121): The
(G) Psycho ogic e en ence follow ing group of questions are preceded by a
(H ) Su bst nce u se isor er list of lettered options. For each question, select
the one lettered option that is most closely asso-
(I) To er nce
ciated w ith it. Each lettered option may be used
(J) With r w once, multiple times, or not at all.

106. A 45-ye r-o n w ith chronic coc ine u se Questions 111 through 121
isor er resents to the e ergency e rt-
ent w ith co ints of bugs cr w ing on his For the fo ow ing vignettes, choose the correct si e
skin. effect fro the ist be ow .
(A) Agr nu ocytosis
(B) Ak thisi
 Que s tions : 105122 101

(C) B e h ros s gener ize rigi ity, i horesis, n tere

(D) Consti tion ent st tu s.
(E) G ctorrhe
(F) Gyneco sti 117. A 36-ye r-o n w ith schizo ffective is-
(G) N eu ro e tic ign nt syn ro e or er, e resse ty e h s been receiving f u -
hen zine ec no te 50 g intr u scu r y
(H ) Obstru ctive j u n ice
every 2 w eeks. Whi e his sy to s re w e
(I) O isthotonos
contro e , he h s recent y notice w hite
(J) Orthost tic hy otension isch rge fro his ni es, bi ter y.
(K) Pig ente retino thy
(L) Pseu o rkinsonis 118. A 26-ye r-o n being tre te w ith high-
(M) R bbit syn ro e ose thiori zine is fou n on o hth o ogic
(N ) Retrogr e ej cu tion ex in tion to h ve e ery ig ent tion
(O) T r ive yskinesi of the retin . Des ite iscontinu tion of the
(P) Tortico is e ic tion, the ig ent tion continu es n
the tient eventu y suffers tot b in ness.
111. A 35-ye r-o n w ith chronic schizo hreni
t king thiori zine notices th t, if he urin tes 119. A 22-ye r-o n co ins of severe rest-
fter sturb ting, his u rine e rs c ou y. essness n git tion fter st rting on ri i -
r zo e. H e co ins th t he c nnot sit sti
112. A 46-ye r-o C uc si n w o n w ith schizo f- n ces const nt y.
fective isor er, bi o r ty e h s been n-
ge for ny ye rs on ris eri one 3 g tw ice 120. A 26-ye r-o tient w ith schizo hreni is
i y or y. She enies ny co ints but on st rte on ch or ro zine. After 1 w eek, he
ent st tus ex in tion is note to h ve co ins of f u - ike sy to s. A CBC is
re etitive, r i ove ents of her ou th (bu t obt ine n is nor . After nother w eek,
not tongue) w ith s cking of her i s. the tient eve o s ye ow ish co or to his
skin n sc er .
113. A 22-ye r-o Afric n-A eric n n on c o-
z ine for 3 onths re orts sore thro t n 121. A 45-ye r-o tient w ith schizo hreni is
fever. A CBC is obt ine w ith WBC cou nt of st rte on high ose of ch or ro zine. The
3
1,000/ w ith 1% gr nu ocytes. next y, he co ins of being ight-he e
every ti e he st n s. On ex in tion, he is
114. A 43-ye r-o n w ith schizo hreni is note to h ve signific nt ecre se in b oo
on h o eri o . H e is note to h ve f exe ressu re n n incre se in he rt r te.
osture, festin ting g it, resting tre or, n
br ykinesi . D IRECTION S (Questions 122 and 123): For each of
the multiple-choice questions in this section, select
115. The s e 43-ye r-o n w s continu e the lettered answ er that is the one best response in
on h o eri o es ite his si e effects n each case.
fter sever ye rs eve o e choreo thetoi
ove ents of the trunk n i bs, ong w ith 122. You re c e in the i e of the night by the
i s cking n tongu e ove ents. su rgic service to see 52-ye r-o n w ho
w s itte to the hos it for n e ergency
en ecto y. Review of the ch rt ocu ents
116. A 21-ye r-o n w ith sychosis w s nu erou s st hos it iz tions for coho
st rte on h o eri o t high oses. Eight intoxic tion n w ith r w . The su rgic
ys into his tre t ent, he eve o e fever, te is concerne bout his w ith r w ing
102 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

w hi e in recovery. H ow ong fter this tients tri s of ithiu , v roic ci , n o nz -

st rink w ou you ost ike y ex ect to see ine, he is st rte on oxc rb ze ine. Three ys
serious w ith r w sy to s eve o ? ter, he co ins of n u se n w e kness;
he e rs confu se bou t w hy he is in the
(A) 6 hou rs
hos it . Which of the fo ow ing bor tory
(B) 12 hou rs stu ies w ou be the ost i gnostic in this
(C) 1 y c se?
(D) 3 ys
(A) BUN n cre tinine
(E) 7 ys
(B) CBC
123. A 33-ye r-o n w ith history of bi o r I (C) E ectro ytes
isor er is itte to the in tient u nit w ith (D) Liver fu nction tests
cu te ni . Bec u se he h s f i e reviou s (E) Oxc rb ze ine eve
 Ans we rs a nd Expla na tions
1. (C) Phene zine is ono ine oxi se inhibi-
tor, use (r re y now but frequent y in the st)
for the tre t ent of severe e ression. Phene -
zine, tr ny cy ro ine, n isoc rbox zi re
irreversib e b ockers of MAO-A ( ono ine
oxi se-A) n MAO-B ctivity; se egi ine,
given or y or in the for of skin tch, is
n MAO-B inhibitor th t w s eve o e for
the tre t ent of P rkinson ise se; t higher
oses, it is nonse ective MAO inhibitor n
is use in the tre t ent of e ression. These
e ic tions re extre e y ngerous in over-
ose, n , fter brief sy to tic erio
of 12 to 24 hours, y ro uce hy er yrexi
n utono ic excit bi ity sufficient enough to
c use rh b o yo ysis. Su ortive c re shou
be institute . If e iriu eve o s, s oses
of IV benzo i ze ines shou be use . Lor ze-
is referre bec use of its short e i in tion
h f- ife. N euro e tics, es eci y short- cting
gents such s ch or ro zine, shou be
voi e bec use of their ten ency to contrib-
ute to hy otension. If ventricu r rrhyth i s
eve o , they c n be tre te w ith i oc ine.
Cy rohe t ine is 5-HT2 nt gonist th t is
so eti es use in the tre t ent of the ost
severe c ses of serotonin syn ro e. Me eri-
ine shou be voi e bec use it y con-
tribute to the renergic crisis. Phenytoin y A thou gh ty ic fe tu res h ve tr ition y
be use if seizures eve o . Other e ic tions
th t re contr in ic te w ith MAOIs inc u e
sti u nts, econgest nts, ine recursors
such s l - o n l -try to h n, n the nti-
hy ertensives ethy o , gu nethi ine, n
reser ine.
2. (E) B ocking reu t ke of c techo ines n
in o ines in tients re y u sing n
MAOI c n resu t in otenti y ife-thre ten-
ing ru g inter ction know n s serotonin syn-
ro e. Me ic tions th t b ock su ch reu t ke
inc u e the SSRIs, TCAs, bu s irone, n other
nti e ress nts su ch s ven f xine. Fe tu res
of i serotonin syn ro e inc u e tri
of ent st tus ch nges, utono ic hy er-
ctivity, n neu ro u scu r bnor ities.
A ition sy to s inc u e t chyc r i ,
f ushing, fever, hy ertension, ocu r osci -
tions, n yoc onic jerks. Severe serotonin
syn ro e y resu t in seriou s hy erther i ,
co , u tono ic inst bi ity, convu sions, n
e th; therefore, one u st w it t e st 14 ys
fter iscontinu ing n MAOI before st rting
serotonergic gent. Acu te ystoni (inc u ing
o isthotonos) occurs w ith the u se of nti sy-
chotic e ic tions, not MAOIs. Ak thisi ,
or the inner fee ing of rest essness, is nother
extr yr i si e effect of neu ro e tic
rugs. N eu ro e tic ign nt syn ro e is
n i iosyncr tic re ction to neu ro e tic ru gs
rese b ing ign nt hy erther i .
3. (A) This tient is ike y su ffering fro
jor e ressive e iso e. Bec u se of her
w eight g in, hy erso ni , n oo re c-
tivity, her e ression h s ty ic fe tu res.
been thou ght to res on best to MAOIs su ch
s hene zine, these e ic tions re consi -
ere thir - ine gents bec u se of the otenti
risk of serotonin syn ro e n hy ertensive
crisis w hen e ting cert in tyr ine-cont ining
foo s. SSRIs such s f uoxetine n roxetine
y be s effic cious s MAOIs in tre ting ty -
ic e ression; how ever, roxetine shou
be voi e given this tients hy erso ni
103
104 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology
n w eight g in. Bec u se of their f vor b e
s fety rofi e, SSRIs h ve beco e first- ine
tre t ent in jor e ression. Tricyc ic nti-
e ress nts su ch s nortri ty ine re ess
effective th n MAOIs n SSRIs for ty ic
e ression. Tr zo one is n extre e y se t-
ing nti e ress nt th t is gener y u se for
ju nctive tre t ent of inso ni .
4. (C) Most tients w ho re going to h ve
res onse to n nti e ress nt o so w ithin
the first 6 w eeks. H ow ever, it c n t ke u to 12
w eeks to chieve fu res onse. Few er th n
50% of eo e w ith jor e ressive isor er
chieve fu re ission fro their first nti e-
ress nt tri .
5. (E) A coho w ith r w shou be strong y
consi ere in this tient. Benzo i ze ines
re the ru g of choice for contro of coho
w ith r w sy to s s w e s for ro hy-
xis g inst w ith r w seizu res n the
otenti y ife-thre tening e iriu tre ens.
Long- cting benzo i ze ines su ch s ch or-
i ze oxi e n i ze re ro ri te;
how ever, both re extensive y et bo ize
by the iver. Bec u se this tient h s e ev te
tr ns in ses, ox ze or or ze , w hich
on y u n ergo g u cu roni tion ( n re there-
fore not e en ent on iver fu nctioning) rior
to e i in tion, re refer b e. The ne onic
LOT (Lor ze , Ox ze , Te ze ) (requ iring i ysis) t eve s gre ter th n 2.0,
c n be he fu in re e bering w hich ben-
zo i ze ines re et bo ize in this w y. A
high- otency nti sychotic gent su ch s h -
o eri o y be necess ry to he contro this
tients git tion, how ever, n nti sychotic
w i not revent coho w ith r w , n ow -
otency nti sychotics, su ch s ch or ro -
zine, shou be voi e bec u se they
ctu y ow er the seizure thresho . Disu fi-
r is u se to tre t coho u se isor er, not
cu te coho w ith r w .
6. (E) This tient h s e iriu tre ens, w hich
is e ic e ergency. H e shou be tr ns-
ferre to n intensive c re setting w here IV
benzo i ze ines c n be inistere w ith
gre ter s fety. The IV rou te is referre in
this situ tion to ensu re equ te n r i
bsor tion. H o eri o c n be u se for its
se tive effect bu t it shou not t ke the ce
of benzo i ze ine. Si i r y, IV bet o
y be u sefu in the intensive c re unit bu t it
w i not n ge the u n er ying w ith r w
n shou not re ce benzo i ze ine.
7. (B) This tient is su ffering fro jor e res-
sion w ith sychotic fe tu res. Best r ctice
reco en s co bin tion of n nti e res-
s nt n n nti sychotic e ic tion, such s
f uoxetine n ris eri one. E ectroconvu sive
ther y, not iste ong the nsw er choices,
is nother effective tre t ent for sychotic
e ression. N either nti e ress nt ono-
ther y nor nti sychotic onother y is
s effective s the co bin tion. C oz ine,
secon -gener tion nti sychotic, is reserve
for the tre t ent of tients w ith schizo hre-
ni w ho h ve f i e tw o or ore nti sychotic
tri s. C on ze , benzo i ze ine, y
rovi e so e re ief fro nxiety, bu t w i not
tre t the u n er ying con ition.
8. (D ) This tient is ex eriencing sy to s of
ithiu toxicity, the severity of w hich is eter-
ine by checking ithiu eve . A ther eu -
tic ithiu eve is 0.8 to 1.2. At eve s rou n
1.2, tients ex erience tre or, n u se , i r-
rhe , n t xi ; this is fo ow e by seizu res
t eve s 1.5 to 2.0, then cu te ren f i u re
w ith su bsequ ent co n e th t eve s
bove 2.5. Bec u se ithiu h s su ch n rrow
ther eutic in ex, ehy r tion c n e to
toxicity. Whi e c rb ze ine n e kote
re both u se to tre t bi o r isor er, they
h ve u ch w i er ther eutic in exes. A he
CT is not in ic te in this c se, given th t the
y ost ike y c u se of the tients sy to s is
ithiu toxicity. Si i r y, there is nothing in
the vignette to su ggest subst nce intoxic tion
s c u se of her sy to s.
9. (D ) Ak thisi , ove ent isor er th t is
frequ ent si e effect of nti sychotic e i-
c tion, c n be ifficu t to istingu ish fro
nxiety in sychotic in ivi u ; how ever,
new -onset rest essness in tient recent y
st rte on nti sychotic e ic tion suggests
 Answe rs : 415 105

this i gnosis. A thou gh ore co on w ith
first-gener tion nti sychotics, it c n be seen
w ith secon -gener tion nti sychotics, s
w e , t r tes s high s 20%. Onset u su y
begins betw een 5 n 60 ys fter initi -
tion of tre t ent bu t c n occu r fter just one
ose. First, the nti sychotic (neu ro e tic)
ose shou be re u ce s u ch s ossib e.
If sy to s of k thisi continu e, in the
bsence of other extr yr i si e effects,
ny c inici ns w ou then st rt tre t ent
w ith bet b ocker su ch s ro r no o . In
gener , nticho inergic gents su ch s ben-
ztro ine re u se to tre t extr yr i
sy to s su ch s ystoni or rkinsonis .
Di henhy r ine is he fu in cu te ysto-
ni s bu t not in k thisi . Lor ze , ben-
zo i ze ine, is n ro ri te secon - ine
tre t ent for k thisi if sy to s re sti
not n ge or the tient c nnot to er te
bet b ocker. Given the tients i rove ent
of his sychotic sy to s, it is refer b e to
continu e tre t ent w ith ri i r zo e us
the bove junctive e ic tions r ther th n
sw itching to nother nti sychotic.
10. (C) This tient is su ffering fro bi o r II
e ression, w ith history ch r cterize by
current jor e ressive e iso e n his-
tory of hy o ni . The tre t ent of bi o r
e ression is controversi . Most tre t ent
gu i e ines reco en ithiu , otrigine,
u r si one, or qu eti ine s first- ine o tions.
V roic ci y be re son b e secon - ine
choice. Monother y with nti e ress nts (e.g.,
bu ro ion, f uoxetine, ven f xine) is not rec-
o en e ue to the risk of in ucing ni ,
n the use of nti e ress nts in conjunction
with oo st bi izers re ins eb t b e.
11. (E) This tient is ex eriencing neu ro e tic
ign nt syn ro e (N MS), r re bu t seri-
ou s si e effect of nti sychotic e ic tions.
Rh b o yo ysis is the ost co on nger-
ou s co ic tion of N MS, occurring in u to
25% of tients in one series. Di ysis y be
requ ire to rotect tients fro ren f i -
u re. The w hite b oo ce count n cre tinine
hos hokin se re often e ev te in N MS bu t
there re no s ecific bor tory fin ings. A
of the other iste co ic tions h ve been
re orte in N MS bu t w ith ess frequ ency.
12. (D ) Retin ig ent tion is know n to occu r
w hen thiori zine is u se in high oses
(>1,000 g/ ). It y not re it w hen thio-
ri zine is iscontinu e n c n eventu y
e to b in ness. The other choices c n occu r
w ith nti sychotics (neu ro e tics) n re
not s ecific to thiori zine.
13. (C) This tient is suffering fro nic isor-
er n gor hobi . There re ny e ic -
tions th t h ve e onstr te effic cy in nic
isor er, inc u ing TCAs, SSRIs, MAOIs, n
high- otency benzo i ze ines. Of the gents
iste , on y f u oxetine, n SSRI, is one of the .
Bu ro ion, n nti e ress nt w ith o -
ine ctivity, n bu s irone, rti 5-H T1
nt gonist w ith nti nxiety ro erties, re
not effective in nic isor er. Pro r no o ,
bet - renergic b ocker, y he to evi te
the hysic sy to s of nic su ch s t chy-
c r i , but it oes not revent the tt cks.
Tr zo one, n nti e ress nt w ith ixe
serotonergic effects, h s so shown conf icting
resu ts.
14. (A) A r zo is the ost otent benzo i-
ze ine iste . Using 1 g of or ze for
the equ iv ent ose in i igr s, the otency
re tionshi of so e co on benzo i ze-
ines is s fo ow s: r zo 0.5 g, i z-
e 10 g, ox ze 20 g, te ze
20 g, n ch or i ze oxi e 25 g.
15. (E) Bec u se ithiu is grou IA onov -
ent ion, the ki ney h n es it u ch s it
oes so iu . N inety-five ercent of ithiu
is excrete u nch nge throu gh the ki neys.
Therefore, e ectro ytes, cre tinine, n BUN
re requ ire to check b se ine ki ney func-
tion. Thyroi stu ies re so requ ire bec u se
ithiu inhibits the synthesis of thyroi hor-
one n its re e se fro the thyroi . A CBC
is o tion , thou gh ithiu y c u se
benign e ev tion in the WBC. F sting g u cose
n i i s shou be checke rior to initi t-
ing tre t ent w ith nti sychotic gents. Liver
fu nction tests shou be erfor e rior to
106 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

initi ting tre t ent w ith iv roex so iu ; 20. (C) Few er th n h f of tients chieve fu
r re c ses of f t he totoxicity h ve been re ission fro e ression fter tre t ent
re orte w ith iv roex so iu . In ition, w ith n SSRI. Best r ctice w ou be to sw itch
iv roex so iu y so e ev te seru to nother SSRI (cit o r ) or n SN RI (ven-
oni eve s in r re c ses. f xine); how ever, bec u se of his history of
hy ertension, ven f xine, w hich c rries w ith
16. (E) In so e in ivi u s, nonsteroi nti- it 5% to 7% r te of hy ertension, is not the
inf tory gents (NSAIDs) c use n incre se best choice. N ortri ty ine, tricyc ic nti e-
in ithiu eve s. Therefore, these gents shou ress nt, is otenti y ngerou s choice in
be use w ith c ution in tients t king ithiu , tient w ith history of yoc r i inf rc-
n voi e if ossib e. As irin n su in c, tion. Au g ent tion w ith ithiu n thyroi
how ever, o not ffect ithiu eve s n re hor one re re son b e choices for tient
therefore s fe for use w ith ithiu . Given his w ith partial res onse, bu t re not s ro-
bi o r isor er, the tients oo st bi izer ri te w hen tient h s no res onse to
shou not be iscontinue , n the other tre t ent.
choices re not ro ri te in this c se.
21. (E) The ost ike y syn ro e is TD, ove-
17. (C) Difficu ty f ing s ee n ecre se ent isor er th t y occu r fter ong-ter
etite re the tw o ost co on si e tre t ent w ith nti sychotic e ic tions
effects of ethy heni te. Sti u nts h ve (es eci y first gener tion) su ch s h o eri-
been re orte to s ow grow th; how ever, it is o . In tients on first-gener tion nti sy-
be ieve to be ess co on w ith ethy he- chotics, TD occu rs t n ver ge r te of bou t
ni te n ose re te . In ition, w hen 5% er ye r, w ith bou t 20% eve o ing TD
rug ho i ys re given (e.g., su erti e), w ithin 5 ye rs, n 40% eve o ing it w ithin
grow th reboun is seen. Methy heni te 20 ye rs. TD consists of nu ber of bnor-
y so c u se n incre se in systo ic b oo n invo unt ry ove ents su ch s i
ressu re. s cking, f ci gri cing, n choreo the-
toi ove ents of the i bs n trunk. Anti-
18. (E) Sti u nts h ve been frequ ent y re orte cho inergic toxicity, w hich u su y resents s
to ex cerb te the tics ssoci te w ith Tou rette e iriu , is not resent. In H u ntington is-
isor er, n so e stu ies h ve w rne th t e se, n u toso o in nt genetic isor er,
they shou not be given to chi ren w ith tics the invo u nt ry ove ents re cco nie
or f i y history of Tourette. H ow ever, this is by rogressive e enti . Meige syn ro e is
co ic te by the f ct th t so e stu ies h ve n or -f ci ystoni invo ving b inking n
i entifie frequ ent co orbi ity of ttention- chin thru sting, i u rsing or tongu e ove-
eficit hy er ctivity isor er (ADHD) n ents, n occ sion y shou er ove ent.
Tourette isor er. The other sy to s re not Sy enh chore , ssoci te w ith rheu tic
incre se by or ssoci te w ith sti u nt use. fever, occu rs in chi ren.

19. (E) This tient is su ffering fro Tou rette 22. (B) Whi e t r ive yskinesi y be rogres-
isor er. Ph r co ogic tre t ent is strict y sive, ost tients st bi ize n so e y
sy to tic n not cu r tive. Do ine (D 2) ctu y i rove, even if they continue t k-
rece tor nt gonis w ith nti sychotic e i- ing the nti sychotic. Whi e nti sychotics
c tion such s ris eri one rovi es the gre t- c use TD, secon -gener tion nti sychotics
est sy to re ief in chi ren su ffering fro re ess ike y th n first-gener tion nti sy-
Tou rette isor er. C oni ine, n h -2- chotics to c u se TD. H ow ever, c oz ine,
gonist, is refer b e in the tre t ent of i secon -/ thir - ine nti sychotic th t requ ires
Tou rettes s it oes not h ve the s e ong- regu r w hite b oo ce cou nt onitoring, is
ter si e effects s nti sychotics. The other the e st ike y to c u se TD n y, in f ct,
e ic tions iste re not u se for Tourettes. i rove sy to s.

23. (E) This tient ike y h s gener ize nxi-
ety isor er (GAD). Benzo i ze ines re the
ost effective e ic tions for qu ick y re u c-
ing sy to s of GAD. A benzo i ze ines
re effective n the choice shou be b se
on otency, h f- ife, n si e effects. Bu ro-
ion is n nti e ress nt w ith o iner-
gic n nor renergic ro erties, bu t is not
u sefu in the tre t ent of GAD. Bu s irone
is effective for re u cing sy to s of GAD
bu t requ ires sever w eeks for signific nt
i rove ent. The tricyc ic gent c o i -
r ine n SSRIs su ch s f u oxetine h ve
nxio ytic ro erties bu t so o not w ork s
qu ick y s benzo i ze ines.
24. (B) This tient ike y h s the i gnosis of bor-
er ine erson ity isor er (BPD) with co or-
bi jor e ressive isor er. Bor er ine
erson ity isor er is ri ri y tre te by sy-
chother y, rticu r y i ectic beh vior
ther y. However, e ic tion c n rovi e use-
fu junctive tre t ent. Given her co orbi
e ressive sy to s, f uoxetine wou be the
ost ro ri te tre t ent. However, recent
et - n ysis of h r cother y of BPD
showe th t oo st bi izers (e.g., v roic
ci , otrigine, to ir te) n secon -gen-
er tion nti sychotics (e.g., ri i r zo e, o n-
z ine, zi r si one) y be the ost effective
e ic tions for this con ition (es eci y ffec-
tive regu tion n i u sivity) in the bsence
of co orbi e ression.
25. (E) Decisions bou t w hether to continu e nti-
e ress nts u ring regn ncy re high y
in ivi u ize , b se on w eighing risks n
benefits for e ch in ivi u w o n. In one
stu y of regn nt w o en w ith histories of
jor e ression, 68% of those w ho iscon-
tinu e e ic tion re se , versu s 26% of
those w ho continu e e ic tion. One of the
ost seriou s otenti risks of SSRI ex osure
u ring regn ncy is ersistent u on ry
hy ertension of the new born (PPH N ), r re
con ition (12 er 1,000 ive births) in w hich
new borns eve o res ir tory f i ure u e to
ostn t ersistence of e ev te u on ry
v scu r resist nce. Whi e it is not c e r, there
is be ieve to be n incre se risk (23 ti es)
Answe rs : 1627 107
of PPH N in w o en ex ose to SSRIs te in
regn ncy. Ebstein no y, for tion
of the tricu s i v ve, is seen w ith ithiu
ex osu re. Gest tion i betes is not ssoci-
te w ith nti e ress nt u se. Inf nt eve -
o ent e y c n be seen w ith ex osu re
to v roic ci . N eu r tube efects re seen
w ith ex osu re to oo st bi izers su ch s c r-
b ze ine n v roic ci .
26. (C) Un ess there is co orbi sychi tric
isor er su ch s e ression or obsessive-
co u sive isor er, h r cother y gen-
er y h s i ite ro e in the tre t ent of
norexi nervos . Re orts on the usefu ness
of cy rohe t ine to sti u te etite h ve
been ixe . Gener y, these tients re y
h ve goo etite, bu t w ork h r not to
give in to their ow n hu nger. F u oxetine, n
SSRI, n to ir te, n nticonvu s nt, h ve
both show n to be effective in the tre t ent
of bu i i nervos , bu t not in the tre t ent
of norexi . The secon -gener tion nti sy-
chotic o nz ine c n in u ce w eight g in, but
bec u se of this, ost tients w ith norexi
w i not gree to t ke it.
27. (A) This tient ike y h s SSRI iscontinu -
tion syn ro e, w hich y occu r w ithin 1 to
3 ys of bru t y sto ing n SSRI. The ost
co on hysic sy to s re izziness,
n use n vo iting, f tigu e, eth rgy, n
f u - ike sy to s. Psycho ogic sy to s
of nxiety, irrit bi ity, n crying s e s re
so not u nu su . P roxetine y be ore
ike y to c u se this bec u se of its short h f-
ife n ck of n ctive et bo ite. F u ox-
etine h s ong h f- ife (24 ys) s w e s
n ctive et bo ite w ith very ong h f- ife
(715 ys), n therefore, oes not require
t ering. The iscontinu tion syn ro e is
not know n to be eth ; how ever, rest rting
the roxetine n then t ering it is re -
son b e choice. Acet ino hen is un ike y
to signific nt y he . Bu ro ion is n nti-
e ress nt w ithou t sexu si e effects, n
w ou be re son b e choice for the tre t-
ent of e ression, thou gh w ou not he
w ith the iscontinu tion sy to s. De k-
ote is tre t ent for bi o r isor er, w hich
108 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

this tient oes not h ve. Ven f xine is e ression or inversion, bu t the ch nges re
serotonin-nore ine hrine reu t ke inhibitor u su y not c inic y signific nt. First- egree
w ith si i r w ith r w si e effects. AV b ock n sinu s no e ysfu nction re r re.
Lithiu toxicity c n r re y c u se sino tri
28. (A) Concu rrent u se of otrigine n or b ock, AV b ock, AV issoci tion, br y r-
contr ce tives c n ffect eve s of both e i- rhyth i s, ventricu r t chyc r i , n ven-
c tions. The c e r nce of otrigine is sig- tricu r fibri tion, bu t these re usu y u e
nific nt y gre ter in w o en ex ose to or to u n er ying c r i c ise se.
contr ce tives; ow er eve s of the e ic -
tion w ou ccou nt for the tients ck of 32. (C) Thi zi e iu retics su ch s hy roch oro-
i rove ent. A ition y, otrigine y thi zi e c n incre se ithiu eve s ow ing to
in u ce the et bo is of or contr ce tives, ecre se ithiu c e r nce. Other e ic -
otenti y ren ering the ess effective. Ibu - tions th t c n incre se ithiu eve s re the
rofen, ithiu , n zi r si one o not ffect iu retics eth crynic ci , s irono ctone,
otrigine et bo is . H ow ever, v roic n tri terene; N SAIDs (exce t s irin n
ci decreases the c e r nce of otrigine, su in c); n the ntibiotics etroni zo e
necessit ting ow er otrigine oses w ith n tetr cyc ine. Nitrog ycerin n ro r no o
concurrent u se. o not interfere w ith ithiu c e r nce.

29. (E) Tr zo one is n nti e ress nt e ic tion 33. (A) C o i r ine, ixe serotonin n nor-
w hich ffects the serotonin syste by w e k e ine hrine reu t ke inhibitor (bu t c ssifie
reu t ke inhibition n nt gonist ctiv- s tricyc ic nti e ress nt) w s rove
ity t 5-H T1 , 5-H T1c, n 5-H T2 rece tors. It for the tre t ent of obsessive-co u sive is-
h s se tive effect, ike y ro uce by both or er (OCD) in the Unite St tes in 1989. Tri-
h - renergic n hist ine b ock e. It s co ring SSRIs to c o i r ine re ort
is extre e y se ting t nti e ress nt oses equ effectiveness; how ever, the si e effect
(300500 g), bu t is often u se t s er rofi e f vors the SSRIs, w hich re the ost
oses (50200 g) s n ju nct to other nti- co on first- ine tre t ent in c inic r c-
e ress nts to he w ith s ee . Both i ze tice. Other tricyc ic gents (su ch s nortri -
( benzo i ze ine) n i henhy r ine ( n ty ine) re not s effective s c o i r ine
ntihist ine) re u se s se tives, bu t nei- bec u se they re not s serotonergic. C on ze-
ther is n nti e ress nt, n both c n c u se y be he fu for the nxiety ssoci te
e iriu in the e er y. Both f uoxetine n w ith OCD, bu t it is not effective in tre ting the
bu ro ion re ore ctiv ting nti e res- u n er ying isor er (i.e., obsessions or co -
s nts n y initi y w orsen inso ni . u sions). O nz ine is secon -gener tion
nti sychotic w hich y be u se for u g en-
30. (E) Pri is , infu , ro onge erection, is t tion in severe c ses of OCD, bu t it is not rec-
r re si e effect of tr zo one. The nuf c- o en e s onother y. Phene zine is
tu rer h s re orte the inci ence of ny bnor- ono ine oxi se inhibitor (MAOI), use
erecti e fu nction to be bout 1 in 6,000 very r re y for e ression, bu t not u se in
en. This si e effect u su y occu rs w ithin OCD.
the first onth of tre t ent but c n occu r
t ny ti e. Any bnor erecti e fu nction 34. (C) Just ike in the tre t ent of refr ctory
shou ro ti e i te iscontinu tion of e ression, tre t ent of refr ctory OCD is
the e ic tion. The other sy to s re not rge y b se on c se re orts n c inic
co on or ngerous enou gh to w rr nt references. There re very few contro e
infor ing the tient. b in e tri s in refr ctory OCD. Pr ctice
gu i e ines reco en u g enting SSRIs
31. (E) Lithiu c uses ECG ch nges in bou t 20% w ith secon -gener tion nti sychotic (su ch
to 30% of tients, ost co on y T-w ve s ris eri one) for tients w ith o er te
 Answe rs : 2839 109

res onse to the SSRI. For tients w ith no inc u ing usc rinic, h -1- n h -2-
res onse, one shou consi er sw itching to renergic, o inergic, n hist inergic,
ifferent SSRI or to c o i r ine. In c ses, to v rying egrees. As c ss, their b ock e
sychother yin rticu r, ex osure ther- of h -1-rece tors is gener y be ieve to be
y w ith res onse reventionshou be rec- res onsib e for ny orthost tic hy otension th t
o en e . Bus irone n ithiu y h ve y occur, es eci y in the e er y. I i r -
so e u ti ity s u g enting gents, bu t their ine is terti ry ine which b ocks u ti e
evi ence b se is ess th n for nti sychot- rece tors n therefore h s ny si e effects;
ics. Anti sychotics re not gener y u se s nortri ty ine, secon ry ine, h s re tive y
onother y in OCD. Cingu oto y, surgi- ess h -1-b ocking otency n ten s to be
c roce u re, shou be reserve for severe, better to er te in gener . Bu ro ion, f uox-
refr ctory c ses. etine, n irt z ine re not ssoci te with
orthost tic hy otension.
35. (B) This tient is su ffering fro co n
u itory h u cin tions, w hich h ve not su f- 38. (E) This tient is resenting w ith bi o r is-
ficient y res on e to equ te tri s of or er, current y nic. First- ine tre t ent for
one first-gener tion nti sychotic e ic - ni inc u es v roic ci or ithiu , w ith
tion (h o eri o ) or tw o secon -gener tion or w ithou t concu rrent nti sychotic gent.
nti sychotics (qu eti ine n o nz ine). Anti e ress nts su ch s cit o r shou
Therefore, tri of c oz ine is w rr nte . not be u se in the setting of cu te ni , s
C oz ine w s the first secon -gener tion they y w orsen the con ition. L otrigine
nti sychotic n h s been fou n to be su e- is n nticonvu s nt, u se for bi o r e res-
rior to other nti sychotics in re u cing both sion n inten nce; it is not s n effective
ositive n neg tive sy to s. It y so nti nic gent. O nz ine is re son b e
i rove cognitive eficits in tients w ith tern tive to v roic ci , bu t ue to the
schizo hreni . It is not u se s first- ine tre t- risk of w eight g in, y not be the o ti
ent bec u se of 1% risk of gr nu ocytosis. choice for this tient w ith n e ting isor-
Ari i r zo e, ris eri one, n zi r si one er. To ir te is n nticonvu s nt use in
re secon -gener tion nti sychotics th t the tre t ent of bu i i nervos ; how ever it
re not s effective s c oz ine for tre t ent- is not consi ere effective for the tre t ent of
refr ctory schizo hreni . Per hen zine is bi o r isor er.
first-gener tion nti sychotic ike h o eri o .
39. (D) A of the co on y use oo -
36. (C) C oz ine cts t ny rece tors, inc u - st bi izing e ic tions c rry so e risk of fet
ing D 1, D 2, n D 4; hist ine-1; u sc rinic; for tions or otenti e eterious effect
h 1- renergic; n serotonin ty es 5-H T2, on ter cognitive eve o ent. Use of ithiu
5-H T2c, n 5-H T3. Efforts to i entify the ex ct uring the first tri ester incre ses the risk of
ech nis of the nti sychotic ction of c o- Ebstein no y, for tion of the tricus-
z ine h ve reve e t e st tw o ossibi i- i v ve, fro 1:20,000 to 1:1,000 tients. If
ties. Un ike first-gener tion nti sychotics, fetus h s been ex ose to ithiu , fet echo-
c oz ine h s uch ore otent nt gonis c r iogr shou be one between weeks 16
t the D 4 rece tor co re to the D 2 rece - n 18 of regn ncy. Lithiu y be use in
tor, es eci y in the i bic syste . This h s the secon n thir tri esters with c refu
e to s ecu tion th t the D 4 rece tor y ttention to equ te hy r tion. C rb ze-
e i te sychotic sy to s. C oz ine so ine c n c use cr niof ci efects (11%), finger-
h s ctivity t the 5-H T2 rece tor, ctivity th t n i hy o si (26%), neur tube efects, n
first-gener tion nti sychotics ck. eve o ent e y (20%). Div roex so iu
is ssoci te with neur tube efect r tes of
37. (C) Tricyc ic nti e ress nts, inc u ing i i r - roxi te y 2%, n y c use intr uterine
ine n nortri ty ine, b ock v rious rece tors, growth ret r tion. Benzo i ze ines such s
110 3: S oma tic Tre a tme nt a nd P sychop ha rma c ology
i ze y be ssoci te with c eft i n
te, though this re ins controversi .
40. (E) It is not u nu su for e iriou s tients to
beco e hosti e or co b tive, osing risk
to the se ves or to hos it st ff. Low - ose
ty ic n ti sych otics, su ch s ris eri one,
re very effective in re u cin g git tion in
e iriou s tients. Di henhy r ine shou
be voi e s the nticho inergic effects y w i en the QRS co
w orsen the e iriu n confu sion. Done e-
zi is n n ticho inester se inhibitor u se for
jor neu rocognitive isor ers ( e enti s).
A thou gh benzo i ze ines ike or ze
c n be u se for git tion in e iriu , th ey
shou be voi e in e er y tien ts u e to
the risk of w orsening e iriu n oten ti
isinhibition. Orient tion to su rrou n ings is
often ition y he fu in e iriu , bu t it
w i not i e i te y c the tient.
41. (C) Mirt z ine is n nti e ress nt w hose
h r co ogic rofi e is ifferent fro other
v i b e gents. It is centr h -2- ren-
ergic nt gonist n n nt gonist of 5-H T2
n 5-H T3 rece tors, s w e s H 1 rece tors.
B ock e of h -2-rece tor e s to enh nce
serotonin re e se; how ever b ock e of 5-H T2
n 5-H T3 e s to re tive enh nce ent of
5-H T1 ctivity giving irt z ine ifferent
si e effect rofi e th n SSRIs. For ex
irt z ine ten s to incre se etite n
c use w eight g in co re to cebo. In
ition, its H 1 nt gonis c u ses se tion.
H ow ever, t higher oses, h -2- rener-
gic b ock e so e s to incre se nore i-
ne hrine re e se, w hich y cou nter ct the
H 1- e i te se tion. In this tient, u se of
irt z ine (to ex oit its otenti incre se
etite n se tion si e effects) shou be
consi ere . Bu ro ion is n nti e ress nt
w hose si e effect rofi e inc u es inso -
ni n w eight oss, neither of w hich w ou
be benefici in this tient. F u oxetine n
sertr ine re SSRI nti e ress nts w hich,
w hi e effective, y initi y c u se ctiv tion.
N ortri ty ine is tricyc ic nti e ress nt th t
is eth in over ose n w hose nticho in-
ergic ro erties c n e to e iriu in the
e er y.
42. (C) Tricyc ic nti e ress nts (TCAs) ro u ce
sever c r iov scu r si e effects, the ost
signific nt being qu ini ine- ike effect s ow -
ing c r i c con uction. So e c inici ns voi
TCAs if there re ny ECG ch nges. Cert in y,
if there re ch nges in con uction, such s
ro onge QT interv , w i ening of the QRS
co ex, or AV con uction bnor ities,
TCAs shou be voi e . In over ose, they c n
ex, c use bun e br nch
b ock, n c use t chy rrhyth i s; how ever,
even t ther eu tic concentr tions, they y
h ve verse effects on c r i c con uction.
Estrogen re ce ent ther y n o i ine
re not contr in ic tions. TCAs c n be u se
in tients w ith rior cerebr inf rctions.
Whi e TCAs y ex cerb te urin ry retention
fro their nticho inergic effects, this is not
contr in ic tion to their use.
43. (B) This tient is ike y e iriou s n ro t
i entific tion n tre t ent of the u n er ying
c use is in ic te . To he contro the git -
tion th t y cco ny e iriu , ow - ose
h o eri o is frequ ent y u se . H o eri o
oes not tre t the e iriu , how ever. It is u se
ost frequent y bec u se it is the ost otent
of the ty ic nti sychotics, therefore requ ir-
ing ow er oses, w ith few er nticho inergic or
orthost tic si e effects. It so h s the v n-
e, t ge of being v i b e in or , IM, or IV for .
Low - otency gents (su ch s ch or ro zine
or thiori zine) re not on y ssoci te w ith
orthost tic hy otension n nticho inergic
si e effects, bu t so w ith ro ong tion of the
QT interv . Lor ze y he se te the
tient bu t it w i not he his sychosis n
cou c use isinhibition n w orsening of
his e iriu . Ris eri one is not v i b e in
renter for , n is therefore not s usefu
in n git te tient w ho requ ires IV or IM
e ic tion.
44. (A) Of the first-gener tion nti sychotics
iste (h o eri o , er hen zine, n thio-
ri zine), h o eri o is the ost otent n
h s the e st ctivity t h -1 rece tors.
Therefore, it is the e st ike y to c u se ortho-
st tic hy otension. The secon -gener tion
gents iste (ris eri one n queti ine)
 Answe rs : 4050 111

h ve ctivity t h -1 rece tors n re both re u sefu in re u cing the core sy to s of

ssoci te w ith orthost tic hy otension. PTSD (reex eriencing, voi nce, nu bing,
n hy er rou s ). Benzo i ze ines such
45. (B) The et bo is of ethy coho invo ves s r zo re not benefici in tre ting
tw o-ste enzy tic rocess. The first these sy to s. Anticonvu s nts re not
enzy e, coho ehy rogen se, et bo izes rou tine y u se ; o en- be stu ies of iv -
eth no to cet ehy e, w hich is qu ick y roex, c rb ze ine, n to ir te h ve
et bo ize by ehy e ehy rogen se. show e ixe resu ts. N trexone, n o ioi
Disu fir inhibits ehy e ehy rogen se, nt gonist, h s not been extensive y stu ie
resu ting in n ccu u tion of cet ehy e. in PTSD. Anti sychotics su ch s thiori zine
Acet ehy e c u ses f ci f u shing, t chy- h ve gener y not been u sefu , though the
c r i , hy otension, n u se n vo iting, secon -gener tion nti sychotics y be u se-
n hysic isco fort. Therefore, tient fu s ju nctive e ic tions, es eci y if the
on isu fir h s n incentive to re in tient h s co orbi sychotic sy to s.
bstinent. Obviou s y, isu fir w orks on y
if tients continu e to t ke it. Ac ros te, 48. (E) Pr zosin is n h -1- renergic rece tor
GABA-ergic gonist, n n trexone, n b ocker, tr ition y use to tre t hy ertension
o ioi nt gonist, re both u se to re u ce n benign rost tic hy ertro hy, w hich h s
cr vings for coho . F u zeni is benzo- e onstr te effic cy in tre ting night res
i ze ine nt gonist u se in benzo i ze ine n other sy to s in tients w ith PTSD.
over ose. N oxone is n o ioi nt gonist Se tive-hy notic gents, such s or ze ,
u se in e ergency n ge ent of o i te re not rticu r y he fu in tre ting PTSD
intoxic tion n over ose. n h ve rger otenti for hysio ogic
n sycho ogic e en ence. N trexone h s
46. (E) Mu ti e neu rotr ns itter syste s h ve not been extensive y stu ie in PTSD. O n-
been investig te in tte ts to contro co- z ine, secon -gener tion nti sychotic, n
ho cr vings. One syste th t ike y ys er hen zine, first-gener tion nti sychotic,
ro e in the rew r thw y is the o ioi sys- y be usefu in severe PTSD w ith sychotic
te . N trexone is n o ioi nt gonist th t sy to s, but they c rry risk of w eight g in
h s been show n to ecre se the nu ber of n et bo ic si e effects, s w e s t r ive
ys erson w ith coho use isor er rinks yskinesi over the ong ter .
n to incre se the ti e before re se of
he vy rinking. Tre t ent of e ression w ith 49. (E) This tient is ike y ex eriencing e ir-
n gent su ch s bu ro ion y he contro iu , s evi ence by his cu te ch nge in
rinking if co orbi e ression exists, bu t ent st tu s, w ith confu sion, isorient tion,
u se of nti e ress nts in the bsence of oo n git tion. E er y tients c n be rticu -
isor er h s not been effective in re u cing r y sensitive to the verse effects of ben-
cr vings. Disu fir is n coho -sensitizing zo i ze ines. This tient is t king 8 g/
gent w hich eters tients fro rinking. of or ze , w hich is rge ose. S ow y
F u zeni is benzo i ze ine nt gonist t ering the or ze , w hi e investig ting
u se in benzo i ze ine over ose. N oxone other otenti c u ses of e iriu , is re son-
is n o i te nt gonist th t is u se to cu te y b e first ste . H y roch orothi zi e eve s re
reverse the effects of o i te intoxic tion. not e sure , n the other choices w i not
ress or he to n ge his e iriu or the
47. (C) This tient is ike y su ffering fro ost- ike y u n er ying c u se.
tr u tic stress isor er (PTSD). First- ine
h r co ogic tre t ent for PTSD is the 50. (B) This tient is ike y su ffering fro jor
se ective serotonin reu t ke inhibitors (e.g., neu rocognitive isor er ( e enti ), ue to
f uoxetine, roxetine, sertr ine), w hich sev- A zhei er ise se. H e h s c e r cognitive
er r n o ize contro e tri s h ve show n ec ine, n , thou gh reversib e c uses of
112 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology

cognitive i ir ent shou be investig te , requ ire . Sever tre t ents th t shou be
there is no in ic tion th t ny reversib e c use i e i te y consi ere inc u e IV extrose,
is resent. There re five e ic tions cu r- u su y D 50, to tre t hy og yce i ; thi ine
rent y v i b e to tre t A zhei er ise se: to gu r g inst the eve o ent of Wer-
the nticho inester se inhibitors one ezi , nicke ence h o thy in n coho ic tient
g nt ine, riv stig ine n t crine, n w ith thi ine eficiency; n n oxone, n
the N - ethy -d - s rt te (N MDA) rece tor o ioi nt gonist, to reverse the effects of
nt gonist, e ntine. Of these e ic tions, o ioi intoxic tion. F u zeni is benzo i-
t crine is r re y u se u e to the risk of he tic ze ine nt gonist th t shou not be u se
f i ure. A r zo is short- cting benzo i- before obt ining fu rther history bec u se it
ze ine w hich y w orsen confu sion. There y cu te y ow er the seizu re thresho .
oes not e r to be n in ic tion for f u ox-
etine in this tient (su ch s e ressive 53. (A) Bu renor hine is one of the ost effective
isor er). Tr zo one is serotonergic nti e- e ic tions for o ioi etoxific tion. Given
ress nt often u se to tre t inso ni ; it w i in sub ingu for , it is ixe o ioi go-
not i rove cognitive bi ity. Methy heni- nist nt gonist w hich su resses o ioi w ith-
te is sti u nt th t oes not e r to be r w n b ocks the effects of other o ioi s.
in ic te in this c se. Benzo i ze ines such s ch or i ze oxi e y
be he fu s juncts to contro nxiety, but
51. (C) Tr zo one is serotonergic gent fre- they re not sufficient for o i te w ith r w .
quent y use in tients to he with s ee , n C oni ine, centr h -2- gonist, su -
in this tient y he w ith his w n ering resses the sy thetic res onse to the heroin
beh vior. It c n c u se orthost tic hy oten- w ith r w n he s to contro git tion n
sion n shou therefore be u se w ith c u - utono ic inst bi ity, such s e ev te b oo
tion in those w ith risk f ctors for f s. H o ressure n he rt r te; how ever, it w i not
n qu eti ine re nti sychotic e ic tions ress the heroin cr ving n is ess effective
th t shou both be u se c refu y in the in n ging w ith r w th n bu renor hine.
e er y. H o eri o is high- otency first- N oxone wou not be ro ri te beyon
gener tion nti sychotic th t is so eti es the initi resuscit tion efforts. Pro r no o is
u se to n ge severe git tion, bu t it y not use for heroin etoxific tion.
c u se extr yr i sy to s. Qu eti ine
is secon -gener tion nti sychotic; how - 54. (A) Bu ro ion ( rkete s Zyb n) is n nti-
ever, given the b ck box w rning bou t the e ress nt th t h s so been show n to be
risk of su en e th in e er y tients w ith effective s rt of s oking cess tion ro-
e enti -re te sychosis, nti sychotics gr . The ech nis of ction is u nc e r, bu t
shou be u se s ring y in the geri tric o - it is be ieve to h ve n effect on o iner-
u tion. Benzo i ze ines su ch s or ze gic tr ns ission. Giving u cig rettes y be
n tri zo shou so be u se w ith c u - extre e y ifficu t for tient w ho is so
tion in the e er y. They y ctu y w orsen suffering fro jor e ression; how ever,
the beh vior n c u se e iriu . If necess ry, st rting bu ro ion u ring the e ression
st rting oses shou be u ch ow er th n y he her qu it s oking in the fu tu re. The
st n r osing n s ow y t ere u . other nti e ress nts iste h ve no i ct
on s oking cess tion.
52. (E) P tients w ho resent w ith severe y tere
eve s of consciou sness nee to be e ic y 55. (E) Du oxetine is serotonin-nore ine hrine
ev u te n qu ick y tre te for sever reu t ke inhibitor (SN RI) th t is use in the
reversib e c u ses. These inc u e hy og yce- tre t ent of both jor e ression n in,
i , o ioi over ose, n coho intoxic - inc u ing neuro thic in n fibro y gi .
tion. Airw y rotection n onitoring of A r zo is benzo i ze ine not ro-
ir exch nge n c r iov scu r st tu s re ri te for tre ting either jor e ressive
 Answe rs : 5161 113

isor er or in. Whi e bu ro ion is use-
fu nti e ress nt, it so w i not he w ith
the tre t ent of in. Sever tricyc ic nti-
e ress nts, inc u ing itri ty ine n nor-
tri ty ine, re so u se to tre t chronic in.
H ow ever, tricyc ic nti e ress nts re ore
eth in over ose th n new er e ic tions ike
se ective serotonin reu t ke inhibitors (SSRIs)
n SN RIs, n they gener y h ve ore si e
effects, rticu r y nticho inergic n c r io-
v scu r ones. SSRIs su ch s cit o r y tions, w hich is not the c se in this tient, n
y ro e in chronic in n ge ent, bu t
the t re not s robust s w ith u oxetine.
56. (B) C rb ze ine is n nticonvu s nt th t
is u se to tre t both bi o r ni n tri-
ge in neu r gi . A itri ty ine n f u ox-
etine re both nti e ress nts, w hich re
not ro ri te in this tient w ho is in the
i e of nic e iso e. G b entin is n
nticonvu s nt th t h s e onstr te effic cy
in the tre t ent of trige in neu r gi ; how -
ever, it is not consi ere effective s n nti-
nic gent. Lithiu shou not be rest rte
ue to concerns bou t its rior effect on her
thyroi fu nctioning, n it so oes not tre t
trige in neur gi .
57. (E) As n nti sychotic w ith oo -st bi izing
ro erties, o nz ine is usefu for both sy-
chotic isor ers, ike schizo hreni , s w e s
bi o r isor er. Weight g in is si e effect of
ost nti sychotic e ic tions, both first n
secon gener tion; how ever, it is rticu r y
concerning w ith o nz ine. In one stu y of
nti sychotic u se in eo e w ith schizo hre-
ni , over 45% of tients on o nz ine g ine
ore th n 7% of their bo y w eight; o nz ine
ten s to in uce ore w eight g in th n other
nti sychotic gents. Agr nu ocytosis is r re
bu t otenti y f t si e effect of c oz ine.
O nz ine is not ssoci te w ith the eve -
o ent of c t r cts or incre se excit bi ity.
O nz ine is ike y to c use se tion n is
u su y inistere in the evening. E ev te
ro ctin n otenti g ctorrhe re si e
effects of first-gener tion nti sychotics n
ris eri one, but ess co on w ith o nz ine.
58. (E) Given th t the tient to er tes n
res on s to or ris eri one bu t su ffers ex c-
erb tions u e to oor co i nce, he is goo
c n i te for ong- cting e ic tion. Ris -
er Const (Ris eri one) is ong- cting for
of ris eri one given in bi onth y injections.
Continu ing his cu rrent regi en or sw itching
to nother or e ic tion su ch s o nz ine
w i ike y on y e to continu tion of the
viciou s cyc e of oor co i nce n re se.
C oz ine is ro ri te for tients w ho
h ve f i e tw o or ore nti sychotic e ic -
the regu r b oo onitoring so requ ires
co i nt tient. Whi e h o eri o is so
v i b e in e ot for , it is not s goo
choice for this tient, given his rior res onse
to ris eri one.
59. (D ) Ris eri one is n ty ic or secon -gen-
er tion nti sychotic gent th t h s otent
5-H T2 nt gonist ro erties s w e s b ock-
ing t D 2 n h -1-rece tors. Bec u se of the
h -1-b ocking ctivity, it y c use ortho-
st tic hy otension. Agr nu ocytosis is con-
cern w ith c oz ine, not ris eri one. A benign
eu kocytosis c n occu r w ith ithiu u se, bu t
not w ith ris eri one. Ris eri one y c use
w eight g in r ther th n w eight oss, n it oes
not c u se reci b e nticho inergic effects.
60. (C) Secon -gener tion nti sychotic gents, ike
c oz ine n ris eri one, re consi ere ty i-
c bec use of their ecre se ro ensity for
c using extr yr i si e effects (EPS) n
resu b y re uce (but not zero) risk of t r-
ive yskinesi . Unfortun te y, on y c oz ine
e rs to tru y obey this ru e. The other sec-
on -gener tion nti sychotic gents e r
to h ve so e egree of EPS, with ris eri one s
the e ing cu rit; t oses higher th n 6 g/ ,
ris eri one c uses EPS t r tes co r b e to
h o eri o . Agr nu ocytosis is concern with
c oz ine, not ris eri one. A benign eukocy-
tosis c n occur with ithiu use, but not with
ris eri one. Ris eri one oes not c use re-
ci b e nticho inergic effects, n usu y c uses
weight g in r ther th n weight oss.
61. (E) Anti sychotic gents b ock o ine
rece tors in sever thw ys in the br in.
B ock e of o ine rece tors in the
114 3: S oma tic Tre a tme nt a nd P sychop ha rma c ology

tu beroinfu n ibu r tr ct resu ts in incre se rhyth s ee w ke isor ers, e ye s ee

ro ctin re e se ( o ine cts s n inhibi- h se ty e. Me tonin is gener y benign
tor of ro ctin re e se), w hich y c use intervention w ithou t risks of bu se, e en-
inferti ity, enorrhe , g ctorrhe , n ence, or res ir tory su ression. A itri -
gyneco sti . Ris eri one c u ses ore ro- ty ine n qu eti ine re se ting but h ve
ctin incre se th n other nti sychotic e i- seriou s si e effects n shou not be u se for
c tionsin f ct, it y r ise ro ctin eve s ri ry inso ni . Di henhy r ine is u se
u to 100-fo . Do ine nt gonis in the for inso ni bu t c n e ve tients fee ing
esocortic n eso i bic tr cts is res onsi- row sy the next y. Short- cting benzo i z-
b e (in rt) for the nti sychotic effect. B ock- e ines su ch s te ze c n be u sefu in the
ing o ine rece tors in the nigrostri t tre t ent of inso ni ; how ever, these e i-
syste c uses the extr yr i sy to s. c tions c rry w ith the risk of e en ence
The ocu s ceru eu s, oc te in the br in ste , is n rebou n inso ni .
the ost i ort nt nor renergic nuc eu s in
the br in. 65. (E) This tient ike y h s nic isor er.
Sertr ine is se ective serotonin reu t ke
62. (B) This tient is su ffering fro bu i i ner- inhibitor (SSRI) rove for the tre t ent of
vos . First- ine h r co ogic tre t ent is nic isor er. A thou gh other e ic tions
n SSRI su ch s f u oxetine, w hich ecre ses re effective, SSRIs re the s fest in over ose
sy to s of bingeing n u rging in e en- n h ve few er si e effects. Bu ro ion, n
ent of ny oo isor er. Bu ro ion is con- nti e ress nt w ith o inergic ech -
tr in ic te in tients w ith e ting isor ers nis , is not effective in the tre t ent of nic
ue to n incre se risk of seizure. L otrig- isor er. I i r ine is tricyc ic nti e res-
ine is n nticonvu s nt u se in the tre t- s nt n hene zine is ono ine oxi se
ent of bi o r e ression n inten nce. inhibitor; w hi e both re effective in tre ting
Lithiu is so u se to tre t bi o r isor er. nic isor er, SSRIs re f r better to er te
Mirt z ine is n nti e ress nt w hich fre- n s fer. Qu eti ine is n nti sychotic e -
qu ent y c u ses w eight g in, n is therefore ic tion th t w ou not be ro ri te for this
oor choice for tient w ith bo y-i ge tient.
issu es.
66. (A) The tricyc ic nti e ress nts, such s
63. (D ) To ir te is n nticonvu s nt u se in itri ty ine, h ve been show n to incre se
the tre t ent of bu i i n binge-e ting is- ort ity in c r i c tients bec u se of their
or er. In sever contro e tri s, to ir te qu ini ine- ike effects n ten ency to both
ecre se the frequency of binge e iso es n incre se he rt r te n ecre se b oo res-
e to w eight oss. Lithiu n v roic ci sure. Bu ro ion is n nti e ress nt th t is
re both use to tre t bi o r isor er n not s fe in c r i c tients. As c ss, het-
ro ri te for bu i i . Bu ro ion is n nti- ines, su ch s ethy heni te, h ve been
e ress nt but is contr in ic te in tients fou n to be s fe in tients w ith c r i c is-
w ith e ting isor ers u e to n incre se risk e se, thou gh re not ro ri te for tre t-
of seizure. P roxetine is n SSRI th t c n be ing jor e ression in this tient. As there
u se in the tre t ent of bu i i ; how ever, y be inor ch nges in b oo ressu re n
this tient h s re y f i e tw o SSRI tri s, u se, tients shou be onitore c ose y.
n is u n ike y to benefit fro thir ; in i- Sertr ine is so s fe for tients w ith c r i c
tion, it ten s to incre se w eight g in w hich ise se n ossesses few ru g rug inter-
w ou ke it oor choice in this tient. ctions. Ven f xine c n incre se the b oo
ressu re n ver ge of 8 to 10 H g bu t
64. (C) Me tonin, hor one invo ve in cir- this effect is ose re te . At oses ess th n
c i n rhyth , h s been show n to be effec- 150 g/ , c inic y signific nt ch nges re
tive in the tre t ent of jet g n circ i n re tive y r re.
 Answe rs : 6271 115

67. (D ) The sy to s the tient is ex erienc- (ECT), w hich requires gener nesthesi ,
ing re co on effects of e ev te ro ctin rTMS c n be erfor e in the office, w ithou t
eve s. H o eri o s ech nis of ction is ny nesthesi . The ost co on si e effect
o ine rece tor b ock e (D 2). Do ine is he che t the site of the ic tion. The
nor y inhibits ro ctin secretion in the tre t ent is very ou n tients re ske
tuberoinfun ibu r thw y, but bec use h - to w e r e r u gs; how ever, he ring oss h s
o eri o b ocks o ine, ro ctin secretion not been re orte . A so, u n ike w ith ECT,
is u no ose . H o eri o oes not signifi- there is no e ory oss ssoci te w ith the
c nt y incre se ACTH , o ine, nore ine h- roce u re. Seizu res n tooth in re r re
rine, or serotonin. co ic tions.

68. (B) This tient ost ike y h s k thisi , w hich 70. (D ) Decisions bout e ic tions u ring reg-
is n nti sychotic(neu ro e tic)-in uce si e n ncy re high y in ivi u ize , b se on
effect. P tients gener y ex erience su bjective w eighing risks n benefits for rticu r
fee ings of rest essness n c n be seen sw ing- in ivi u . ECT h s been u se in regn ncy
ing their egs, rocking b ck n forth w hi e sit- for ore th n 50 ye rs n its s fety n effi-
ting, cing, n r i y tern ting betw een c cy is w e ocu ente . V roic ci n
sitting n st n ing. Acute ystoni s re ch r- ithiu (in ition to secon -gener tion nti-
cterize by infu contr ction of usc es sychotics) re in ic te s first- ine gents
resu ting in bnor ove ents or ostu res, for the tre t ent of nic e iso es, w ith c r-
such s s s s of the j w , bnor osi- b ze ine s goo tern tive; how ever,
tioning of the he , or ifficu ty sw ow ing. three re ssoci te w ith n incre se
The onset of cu te ystoni u su y eve o s risk of congenit bnor ities w hen t ken
w ithin the first w eek of initi ting or incre sing uring the first tri ester. Benzo i ze ine
neuro e tic e ic tion. Ak thisi c n so e- such s i ze re not first- ine tre t ent
ti es be ist ken for nxiety or ni , but in for ni , n y be ssoci te w ith n
this c se there re no other signs (such s e u- incre se risk of or c efts w ith first-tri ester
sions of gr n eur, ecre se nee for s ee , ex osu re.
incre se energy, or hy ersexu ity) to in i-
c te nic e iso e. N euro e tic ign nt 71. (D ) Cess tion or re u ction in se tive, hy -
syn ro e is ife-thre tening co ic tion notic, or nxio ytic e ic tions th t h ve
invo ving u sc e rigi ity n ystoni , s w e been u se he vi y or for ro onge erio
s u tono ic sy to s su ch s e ev te te - of ti e y resu t in w ith r w syn ro e
er ture, incre se he rt r te, n incre se ch r cterize by sy to s th t eve o
b oo ressu re. T r ive yskinesi is ong- w ithin hou rs to few ys fter cess tion or
ter consequence of nti sychotic use, n re u ction. Au tono ic hy er ctivity, ortho-
it is ch r cterize by invo u nt ry, choreo th- st tic hy otension, usc e w e kness, tre or,
etoi ove ents of the bo y, es eci y in the inso ni , n u se , vo iting, u itory/ visu /
extre ities. It is not infu , thou gh y be t cti e h ucin tions, git tion, or nxiety y
so ew h t is b ing, n is often irreversib e. occur. By f r, the ost serious seque e re
gr n seizu res or e iriu . De en ing on
69. (A) Tr nscr ni gnetic sti u tion is new the otency, ou nt, frequ ency, n ength
tre t ent for e ression, rove in 2008 of u se, u to 75% of tients c n ex erience
by the FDA for tre t ent of jor e res- gr n seizu res on the secon or thir y
sion th t h s f i e t e st one nti e ress nt of w ith r w , n ny h ve ore th n one
tri . The tre t ent invo ves ying series seizu re. De iriu y eve o betw een the
of e ectro gnetic u ses to the eft orbit thir n eighth y of w ith r w . Minor
refront cortex; fu tre t ent consists of sy to s y ersist for u to 4 w eeks.
t e st 20 i y sessions, e ch sting bou t With r w fro other e ic tions iste is
40 inu tes. Un ike e ectroconvu sive ther y u n e s nt, bu t is not ife thre tening.
116 3: S oma tic Tre a tme nt a nd P sychop ha rma c ology

72. (B) Chronic coho ics often t ke in c ories bi o r isor er, on y v roic ci c rries
fro itt e e se besi es coho n re thu s w rning of n incre se risk of ncre titis.
t risk for thi ine eficiency. If thi ine- A thou gh c rb ze ine n c oz ine c n
eficient tient is given foo (g u cose), he both c u se gr nu ocytosis, c oz ine is ore
or she c n eve o Wernicke ence h o - ike y to be u se ( n is FDA rove ) for
thy ( e iriu ) fro the bo ys tte ts to the tre t ent of refr ctory schizo hreni .
et bo ize g u cose in the bsence of thi ine P roxetine is the on y nti e ress nt iste
yro hos h te. A though the other choices n h s very short h f- ife su ch th t it ro-
re i ort nt concerns, none re of the s e u ces signific nt w ith r w syn ro e fter
cu ity s thi ine eficiency. ju st 2 ys. Whi e c rb ze ine, iv roex
so iu , n ithiu ( s w e s nti sychot-
73. (D ) This n wi rob b y su ffer fro co- ics) y be u se to tre t bi o r isor er,
ho w ith r w . Benzo i ze ines n coho on y ithiu c uses both o yu ri ( benign
h ve si i r o es of ction in their o u - si e effect) n ne hrogenic i betes insi i-
tion of GABA rece tors in the br in. This u s, resu ting in frequ ent u rin tion. Whi e
si i rity kes benzo i ze ine su ch s nti sychotics h ve the risk of incre sing cho-
or ze sensib e n co on choice for estero , of those iste , c oz ine h s the ost
the tre t ent of coho w ith r w . Ac - signific nt effect.
ros te, isu fir , n n trexone re use
for re se revention in tients w ith coho 82. (I) H o eri o , c oz ine, n ris eri one
u se isor er, bu t not for n ging coho re u sefu in the tre t ent of schizo hre-
w ith r w . C oni ine, n h -2- gonist ni , bu t on y h o eri o n ris eri one re
th t o u tes utono ic inst bi ity, is u se v i b e in e ot injection. Ris eri one
to n ge sy to s of o i te w ith r w , w ou be refer b e bec u se it is secon -
n ctu y y b ock ( sk) the u tono ic gener tion nti sychotic w ith better si e
w rning signs of coho w ith r w . effect rofi e.

7481. [74 (H), 75 (B), 76 (F), 77 (C), 78 (B), 79 (F), 80 83. (K) Tr zo one, serotonergic nti e res-
(E), 81 (B)] Psychi tric ru gs c n h ve seriou s s nt, is n effective s ee ing i th t is not
si e effects, so e of w hich re the subjects of h bit for ing. Whi e benzo i ze ines such s
b ck box w rnings on rescribing infor- r zo y he w ith inso ni , it is w ise
tion ckets. Pi ozi e, first-gener tion to voi rescribing the in tient w ith
nti sychotic, inter cts w ith nu ber of history of coho use isor er bec u se of their
e ic tions, inc u ing cit o r ; the co bi- cross-re ctivity w ith coho .
n tion of these tw o e ic tions c n ro ong
the QTc. A thou gh c oz ine, h o eri o , 84. (D ) The reco en e ength of tre t ent
er hen zine, i ozi e, n zi r si one re of first e iso e of u ni o r e ression is t
nti sychotics u se to tre t schizo hreni , e st 6 onths n u su y on the sc e of 9 to
c oz ine is the ost ike y to c u se hy er- 12 onths, n ossib y onger, e en ing on
g yce i n e to the eve o ent of i - tient f ctors such s f i y history of oo
betes. After controversi set of he rings on isor er, severity n u r tion of the e res-
the subject of chi ren n nti e ress nts sive e iso e, n co orbi sychi tric sy -
in the Unite King o n Unite St tes in to s such s nxiety n subst nce buse.
2003 n 2004, regu tors eci e there w s Discontinu tion w ithin the first 16 w eeks of
enou gh evi ence to show th t so e of the tre t ent is ssoci te w ith high risk of
SSRIs, inc u ing roxetine, y incre se re se.
the risk of su ici thoughts in chi ren. This
w rning is now exten e to you ng u ts, u 85. (A) Bu ro ion is the one nti e ress nt iste
to ge 24. A thou gh c rb ze ine, iv - th t oes not c use sexu ysfu nction, n
roex so iu , n ithiu re use to tre t is so eti es e to SSRIs in or er to he
 Answe rs : 7291 117

w ith sexu ysfu nction. Cit o r , f u ox- in conju nction w ith ithiu or iv roex
etine, n f u vox ine re SSRIs th t h ve so iu initi y; how ever, u e to their si e
been re orte to c u se v rying egrees of effects n risk of t r ive yskinesi , they re
sexu ysfunction. C o i r ine is tricy- not rou tine y u se s inten nce tre t ent.
c ic nti e ress nt th t h s gre ter inci ence L otrigine is n nticonvu s nt th t is u se
of sexu ysfunction th n other TCAs, ike y for the tre t ent of bi o r e ression n
ue to its otent serotonin reu t ke inhibiting inten nce tre t ent; it is not u sefu u r-
ro erties. ing n cu te nic e iso e. Lor ze c n
be u se initi y for se tion n s ee , bu t
86. (C) Si orrhe is co on si e effect of it is not effective for tre ting or int ining
tre t ent w ith c oz ine (u to 30% of tients w ith bi o r isor er.
tients). It c n be extre e y botherso e to
the tien t n oth ers bu t oes n ot u su y 89. (E) The neu roveget tive sy to s (ch nges
requ ire iscontin u tion of tre t en t. Often , in etite, oor concentr tion, nergi , n
beh vior e su res re su fficient, su ch s s ee isturb nces) ten to res on first w ith
the u se of ozenges or cin g tow e on nti e ress nt tre t ent, often rior to sig-
the tien ts i ow t n ight. Anticho in er- nific nt oo ch nges or re u ction in su i-
gic gents su ch s tro ine ro s often he ci ity. This is w hy it is co on w is o in
to re u ce the vo u e of s iv . A n t in e sychi try th t tients w ho begin to recover
y be h e fu in th e tre t ent of rkin - fro e ression y be t gre ter risk for
soni n sy to s n ro r n o o is u sefu suici e th n w hen they re t the height of
in the tre t ent of k thisi . Incre sing the e ression. As they st rt to function better
ose w ou not n ro ri te ro ch in hysio ogic y (w ith i rove s ee , energy,
this situ tion . n otiv tion), they y be ore c b e of
c rrying out suici i u se.
87. (D ) P tients on c oz ine often eve o er-
sistent sinus t chyc r i th t oes not requ ire 90. (E) In c ses of su s ecte iver i ir ent, it is
cess tion of tre t ent. Often, the t chyc r i vis b e to u se benzo i ze ine ini y
reso ves w ithou t necessit ting fu rther inter- et bo ize by the iver (e.g., or ze n
vention; how ever, shou it ersist, it y be ox ze ). These benzo i ze ines o not go
tre te w ith the bet - nt gonist ro r no- through oxi tion, bu t r ther on y throu gh
o . Benztro ine is n nticho inergic gent g u cu roni tion. The other benzo i ze ines
th t w i not he the t chyc r i , n y, iste re et bo ize ost y by the iver
in f ct, w orsen it. C oz ine h s signific nt n cou qu ick y bu i to toxic eve s in
h -rece tor b ock e, w hich often c u ses cirrhotic tient.
orthost tic hy otension, requ iring gr u
titr tion of the ose; bec use of this, bet o 91. (A) The tient h s ike y eve o e t r ive
w ou not be ro ri te s it y ex cerb te yskinesi (TD). A of the secon -gener tion
this si e effect. Lor ze is benzo i z- nti sychotics h ve ow er r tes of TD co -
e ine th t yc the tient, bu t w i not re to the first-gener tion nti sychotics.
irect y ffect he rt r te. Sto ing the c oz - A thou gh they h ve w rnings reg r ing
ine w ou not be necess ry or ro ri te in the incre se risk of i betes n hy er i -
this c se. i e i ( et bo ic syn ro e), they c u se it t
ifferent r tes, so this is often f ctor in choos-
88. (C) This tient resents w ith signs n ing rticu r nti sychotic e ic tion. The
sy to s su ggestive of first nic e iso e. e st ike y to c u se et bo ic syn ro e re
Lithiu n iv roex so iu re in the ri i r zo e n zi r si one, fo ow e by
inst y of initi n inten nce tre t ent ris eri one n queti ine. C oz ine n o n-
of bi o r I isor er. Anti sychotics, such z ine h ve the highest r tes of weight g in,
s h o eri o n o nz ine y be u se hy er i i e i , n insu in resist nce.
118 3: S oma tic Tre a tme nt a nd P sychop ha rma c ology

92. (C) N trexone, u-o ioi rece tor b ocker, rob e s reso ve, so e y ersist in efi-
exerts its h r co ogic effect through o - nite y.
u ting coho s reinforcing effects. It h s
been show n to signific nt y re u ce the risk of 95. (A) This tient h s e iriu , co on co -
he vy rinking in tients. Another v n- ic tion in the ICU. Low - ose nti sychot-
t ge is th t it c n be converte to onth y ics su ch s ri i r zo e c n be very he fu if
intr u scu r injection, w hich c n incre se u se ju icious y. H o eri o is often use in
co i nce. Whi e isu fir , n versive c inic r ctice; how ever, IV h o eri o c n
gent th t inhibits ehy e ehy rogen se, engthen the QTc n therefore shou not be
c n so be use , ore recent stu ies h ve re - u se for this rticu r tient. Benzo i z-
eg te it to secon - ine e ic tion. N one of e ines su ch s i ze n or ze c n
the other e ic tions iste re effective for w orsen e iriu in the e er y n shou
coho use isor er: Meth one is ong- be voi e . Ris eri one (Ris er Const )
cting o ioi gonist u se in o i te u se isor- is the ong- cting for of ris eri one, n
er. N either sertr ine ( n nti e ress nt) nor w ou not be ro ri te in this setting.
v roic ci ( oo st bi izer) tre ts coho
u se isor er in the bsence of n u n er ying 96. (E) The tient ike y suffers fro erfor nce
oo isor er. nxiety, for of soci nxiety isor er
(soci hobi ). Pro r no o , bet b ocker,
93. (D ) A of the e ic tions iste re s ee i s; is very he fu in n ging erfor nce
how ever, on y z e on, nonbenzo i ze ine nxiety. T ken i e i te y before the fe re
hy notic w ith h f- ife of on y 4 hou rs, is event, it ecre ses he rt r te, b oo ressu re,
ro ri te for i e inso ni (f ing n tre or, n consequent y ecre ses nxi-
s ee bu t frequ ent y w kening u ring the ety. Bu s irone is n nxio ytic gent th t is
night). A of the tern tives iste re ore he fu in the tre t ent of gener ize nxi-
u sefu for eo e w ho h ve initi inso ni ety isor er. F uoxetine n f u vox ine
( ifficu ty f ing s ee ) n requ ire e ic - re nti e ress nts u se in the tre t ent of
tion t be ti e. A itri ty ine n tr zo one gener ize nxiety isor er n nic isor-
re both se ting nti e ress nts. R e teon er. Lor ze is benzo i ze ine th t c n
is e tonin-rece tor gonist. Zo i e is be he fu in n ging cu te nxiety, bu t its
nother nonbenzo i ze ine hy notic w ith cco nying se tion y be rob e tic
onger h f- ife th n z e on. in erfor nce context.

94. (E) ECT h s re tive y few con tr in ic tions 97. (B) The tient resents w ith history of bi o-
n in so e c ses is referre for its r i r isor er n is cu rrent y e resse . Tre t-
onset of ction. H ow ever, bec u se of the ent for bi o r e ression is co ic te ;
c r iov scu r effects of ECT, history of how ever, the cu rrent best r ctice ro ches
recen t yoc r i inf rction (w ithin the inc u e u r si one, qu eti ine, n ithiu s
st 6 onths) is re tive con tr in ic - onother ies. The tient h s re y f i e
tion. Another re tive contr in ic tion is the ithiu n w ou be better serve by iffer-
resence of c inic y sign ific nt in tr cr - ent tre t ent. Lu r si one is w eight neu tr
ni s ce-occu ying esion u e to the risk ty ic nti sychotic th t h s been show n to
of br in ste herni tion. ECT y be er- be effective for the tre t ent of bi o r e res-
for e in tients w ith egener tive isc sion. Queti ine is so n effective tre t ent,
ise se or hy ertension, n u ring reg- how ever it is ssoci te w ith w eight g in n
n ncy. ECT is s fe n effective tre t ent the tient is re y overw eight. Sertr ine
for sychotic e ression. The ost co on n other SSRIs h ve ixe evi ence for bi o-
co ints tients h ve fo ow ing ECT re r e ression, n they shou never be re-
i ir en ts in both nterogr e n ret- scribe s onother y s they incre se the
rogr e e ory. A th ou gh ost e ory r te of fu tu re nic e iso es. V roic ci
 Answe rs : 92109 119

is secon - ine tre t ent for bi o r e res- his jor e ression. Rest rting sertr ine
sion; it is ore effective for cu te ni th n w ou be ike y to c u se the s e rob e s
cute e ression. n e to non herence.

98. (D ) A thou gh there re v riou s si e effects 102. (D ) This tient h s sy to s of gener ize
of otrigine, the ost ngerou s is th t nxiety isor er. A of the e ic tions iste ,
of severe r sh, w hich c n eve o into exce t c on ze , benzo i ze ine, c n
StevensJohnson syn ro e, otenti y ife- inter ct neg tive y w ith w rf rin. Bu ro ion
thre tening co ic tion. Beginning t ow is so ike y to w orsen nxiety. Bu s irone n
ose n s ow y incre sing re u ces the risk cit o r re re son b e choices for his nxi-
signific nt y. Acu te ystoni n k thisi re ety, bu t his PT/ PTT n IN R w ou h ve to
both si e effects of nti sychotic e ic tions. be onitore c refu y. Ven f xine y so
A stic ne i is r re si e effect of c rb - e ev te b oo ressu re.
ze ine. Ren f i u re c n occur w ith ithiu .
103. (D ) Pri is , infu , ro onge erection,
99. (C) A of these re ty es of ystonic re ctions is r re bu t seriou s si e effect of tr zo one.
th t re in u ce by the u se of nti sychotics Erecti e ysfu nction refers to ifficu ty obt in-
(neu ro e tics). O isthotonos, so know n s ing or int ining n erection, co on
arc de cercle, is s s of the neck n b ck si e effect of SSRIs. N y ho ni is ins ti -
th t c uses the tient to rch forw r . The b e sexu esire in w o n w hi e s tyri sis
ost r ing of these ystoni s is ryn- is its cou nter rt in en. A r r xis, or s i
gos s , w hich is the s s of the u sc es of the tongu e, is so know n s Freu i n
contro ing the tongue n the thro t; this c n s i .
e to res ir tory istress. Ocu ogyric cri-
sis is s s of the extr ocu r u sc es, often 104. (A) Sexu ysfunction (e.g., ecre se ibi o,
resu ting in the tient ooking u n u n b e erecti e ysfunction, norg s i ) is not unco -
to ook ow n. P eu rothotonos, so know n s on y seen w ith SSRIs n other nti e res-
Pis syn ro e, is e ning ostu re in u ce s nts (such s those iste ). Bu ro ion is one of
by the s s of the torso u sc es. Tortico - the few nti e ress nts w hich c uses itt e to
is is s s of the neck u sc es th t u su y no sexu ysfunction, n , in f ct, y reverse
brings the neck to one si e or nother bu t y the si e effect w hen e to tre t ent. In
so u forw r or b ckw r . ition, ny other sychotro ic e ic -
tions inc u ing ithiu n nti sychotics c n
100. (B) A thou gh ny of the iste nti e res- so c use sexu ysfunction.
s nts w i tre t her e ression equ te y,
on y u oxetine, co bine serotonin- 105. (D ) To ir te is n nticonvu s nt u se
nore ine hrine reu t ke inhibitor, h s been in the tre t ent of bu i i n binge e t-
rove in the tre t ent of both e ression ing isor er. It c rries w ith tw o to fou r
n neu ro thic in. Given her ike y jor ti es incre se risk of ren stones. To i-
e ressive isor er, re ssur nce w ou not r te often c u ses cognitive i ir ent,
be ro ri te or effic ciou s. rticu r y w or -fin ing ifficu ty, short-
ter e ory rob e s, n rob e s w ith
101. (A) With the exce tion of irt z ine, bu ro- ttention. P ncre titis is r re si e effect of
ion, n nef zo one (now off the rket v roic ci , n o yu ri is seen w ith ith-
ue to risk of he tic f i ure), nti e res- iu u se. To ir te c u ses w eight oss, not
s nts c n c u se signific nt sexu ysfu nction, w eight g in.
inc u ing ecre se ibi o, erecti e ysfu nc-
tion, n norg s i . Given the recurrent 106109. [106 (C), 107 (A), 108 (E), 109 (I)] For ic -
n tu re of his i ness, e ving hi w ithou t tion is the fee ing of bu gs cr w ing on the skin,
e ic tion w ou ike y e to re se of u su y ssoci te w ith coho w ith r w ,
120 3: S oma tic Tre a tme nt a nd P syc hop ha rma c ology
bu t so w ith ru g intoxic tion, rticu r y
w ith coc ine. A otiv tion syn ro e is
ck of rive or otiv tion u su y ssoci-
te w ith chronic ru g u se, es eci y c nn -
bis. Inh nts, inc u ing g so ine, re vo ti e
subst nces th t h ve r i -onset intoxic ting
effects. To er nce is the nee for higher oses
of ru g in or er to chieve the s e effect.
M riju n is c ssifie s c nn bis. H u ci-
nogen ersisting erce tion isor er is so
know n s f shb ck. It is ch r cterize by
istressing retu rn of erce tu ch nges
w ithou t the ingestion of h u cinogens, su ch
s LSD. Intoxic tion is re resente by beh v-
ior , cognitive, or erce tu ch nges t ken
in re tionshi to ru g ingestion. Psycho ogi-
c e en ence is cr ving or nee to con-
tinu e t king rug, frequent in those tients
w ith su bst nce u se isor ers. Su bst nce u se
isor er enco sses revious i gnoses of
buse n e en ence n w ys inc u es
continu e u se of su bst nce (e.g., coho or
i icit ru gs) in s ite of verse consequ ences
re te to the su bst nce (fu nction i ir-
ent). With r w is set of signs n sy
to s, hysic n sycho ogic , th t re
ssoci te w ith coho or ru g cess tion.
110. (D ) Anti sychotic gents, in ition to b ock-
ing o ine rece tors in the nigrostri t
thw y (c u sing extr yr i sy to s)
n the eso i bic thw y ( ecre sing h -
u cin tions), so b ock o ine in the tu ber-
oinfu n ibu r syste . Do ine nor y this occu rs, the ru g u st be sto e i
inhibits ro ctin re e se in this thw y,
n therefore o ine b ock e incre ses
ro ctin eve s, c u sing sexu ysfu nction,
gyneco sti in en, n g ctorrhe in
w o en. The ost ike y e ic tions to c u se
these si e effects re first-gener tion nti sy-
chotics n ris eri one.
111121. [111 (N ), 112 (M), 113 (A), 114 (L), 115 (O),
116 (G), 117 (E), 118 (K), 119 (B), 120 (H), 121
(J)] Anti sychotics, so know n s neu ro e -
tics, c n c u se w i e v riety of si e effects.
These si e effects c n be broken ow n into
so e of the fo ow ing c tegories for n e s-
ier ro ch. The o inergic si e effects
inc u e those th t re u e to the b ock e of
the n tu r o ine inhibition of ro ctin
re e se fro the nterior itu it ry c u sing
g ctorrhe (E) n gyneco sti (F). The
si e effects th t rise fro o ine b ock-
e in the b s g ng i c u se v riou s ys-
toni s, inc u ing b e h ros s (s s of
the eye i s) (C), o isthotonos (s s of the
neck n b ck c u sing n rche ostu re)
(I), n tortico is (s s of the sternoc ei o-
stoi ) (P). The b ock e of D 2 rece tors in
the nigrostri t thw y c n so c u se other
extr yr i syn ro es su ch s k thisi
(su bjective fee ing of rest essness) (B), seu -
o rkinsonis (L) w hich rese b es P rkin-
son ise se, ch r cterize by u sc e rigi ity
n short festin ting g it, r bbit syn ro e
(M) ( r re si e effect of ong-ter nti sy-
chotic u se ch r cterize by invo u nt ry, fine,
rhyth ic otions of the ou th n i s), n
t r ive yskinesi (O), isor er of bnor-
invo u nt ry ove ents c use by ro-
onge u se of nti sychotics. An i iosyncr tic
bu t r re co ic tion of nti sychotics (neu -
ro e tics) is neu ro e tic ign nt syn ro e
- (G). This is ch r cterize by hy erther i ,
ch nge in ent st tu s, n incre se u s-
c e tone. It c n e to rise in u sc e bre k-
ow n ro u cts (cre tine kin se eve s re
ty ic y e ev te ), ren f i u re fo ow ing
ehy r tion, u on ry co ic tions, n
e th. C oz ine c n c u se gr nu ocytosis
(A), ngerou s si e effect th t so eti es
c n resent w ith sore thro t n fever; if
e-
i te y. Consti tion (D ) is co ic ting
si e effect of so e nti sychotics, rticu -
r y those w ith nticho inergic effects. This
c n often be re ieve w ith u se of x tive.
Obstru ctive j u n ice (H) is r re n occu rs
in y w ith ch or ro zine. Sy to s
inc u e fever, n u se , ise, n ru ritu s.
Orthost tic hy otension (J), su en ro in
b oo ressu re u on st n ing, is u e to h -
1- renergic b ock e. It is es eci y trou b e-
so e w ith ch or ro zine n c oz ine
n best h n e by r ising oses s ow y.
Pig ente retino thy (K) is observe w ith
high oses of thiori zine n best etecte
w ith goo o hth o ogic ex in tion. An
ition si e effect of so e nti sychotic
 Answe rs : 110123 121

e ic tions th t y ecre se co i nce zu res re r re y foc n u su y occu r w ithin

is retrogr e ej cu tion (N ); org s y be 48 hou rs fter coho consu tion ce ses.
chieve bu t ej cu tion is bnor , w ith De iriu tre ens ost often occu rs w ithin
retrogr e ro u sion of the se en, resu ting 72 hou rs of cess tion of rinking, thou gh
in c ou y e r nce of the u rine. y e k for sever ys fu rther.

122. (D ) A coho w ith r w c n t ke the for of 123. (C) This tient is exhibiting sy to s of
inor w ith r w sy to s su ch s sw e t- hy on tre i , re tive y co on si e effect
ing, f u shing, n tre u ou sness, or ore of oxc rb ze ine, so obt ining seru e ectro-
serious consequ ences inc u ing w ith r w ytes w ou be critic . The other tests w ou
seizu res or w ith r w e iriu , so know n not he in i gnosing hy on tre i , n
s e iriu tre ens. Minor w ith r w sy - oxc rb ze ine eve s re not rou tine y checke
to s c n st for sever ys. With r w sei- (un ike eve s of c rb ze ine).
This page intentionally left blank
 CHAPTER 4

Ps yc ho lo g ic al Tre atme nt and

Manag e me nt
Que s tions

DIRECTIONS (Questions 1 through 42): For each of (C) Ego strengths

the multiple-choice questions in this section, select (D) Projections
the lettered answ er that is the one best response in (E) Unconsciou s thou ghts
each case.
3. A 43-year-old m an is chastised at w ork. When
Questions 1 and 2 he com es hom e, his friend asks him how his
d ay w ent. H e respond s angrily saying that a
A 38-year-old m ale thinks that he is a failu re and real friend w ou ld nt be so nosy. Which of
w ill never find a p artner w henever he feels rejected . the follow ing d efense m echanism s m ost likely
H e often find s him self getting d epressed and isolat- characterizes this reaction?
ing him self w hen he thinks like this. H is therap ist
thinks that it w ould be a good id ea for him to m ake (A) Denial
a log of the situ ations, his im m ed iate thou ghts, his (B) Disp lacem ent
im m ed iate feelings, alternate resp onses to those (C) H u m or
thoughts and feelings, and re-rate his feelings after (D) Intellectu alization
com pleting the exercise so they can be exam ined (E) Isolation of affect
d uring their sessions.
4. A 20-year-old w om an d iagnosed w ith bord er-
1. Which of the follow ing types of therapeu tic line p ersonality d isord er thinks of her thera-
ap proaches is the therapist m ost likely u sing? p ist as the best person Ive ever know n. The
(A) Cognitivebehavioral next w eek, the therapist announces that he
(B) Exp ressive w ill be going on vacation. The patient becomes
enraged and states that he is the cru elest
(C) H yp notherap y
d octor in the w orld ! Which of the follow ing
(D) Psychoanalysis d efense mechanism s best characterizes this
(E) Psychod ynam ic reaction?

2. Which of the follow ing term s refers to the (A) Devalu ation
im m ed iate thou ghts (e.g., I am a failu re) (B) Id ealization
that the p atient exp eriences and record s in this (C) Intellectu alization
type of therapy? (D) Repression
(A) Au tom atic thou ghts (E) Sp litting
(B) Core beliefs

123
124 4: P syc holog ica l Tre a tme nt a nd Ma nag e me nt

5. A 16-year-old boy has just lost his mother and m ind . Which of the follow ing analytic tech-
father in a car accident. In your office, he talks niques d oes this best rep resent?
philosophically about death and its implica-
(A) Free association
tions. When asked how he feels about his par-
ents death, he responds by saying that it is the (B) H yp nosis
nature of things to pass away. Which of the fol- (C) Rep ression
lowing defense mechanisms best d emonstrates (D) Thou ght record s
this patients inability to talk directly about his (E) Transference
emotional experience concerning personal loss?
(A) Denial 9. A psychotherapist has been m eeting regu larly
w ith a 10-year-old boy for 18 months. During
(B) Intellectu alization
one of the therapy sessions, she find s herself
(C) Projection feeling very angry at the patient after he reports
(D) Su ppression beating up his little brother. Which of the
(E) Und oing follow ing phenomena is the psychotherapist
most likely exhibiting?
Questions 6 and 7
(A) Countertransference
A 44-year-old w om an w ith schizop hrenia is stru g- (B) Extinction
gling w ith p aranoia, au d itory hallu cinations, and (C) Interp retation
d elu sions. She lives w ith her m other but has a poor (D) Resistance
relationship w ith her. She tells you that everyone
(E) Transference
w ants her to sp end a lot of m oney and bu y d ru gs.
10. In an acu te inp atient p sychiatric u nit, the
6. Which of the follow ing resp onses w ou ld be
resid ent p sychiatrist is in charge of lead ing a
the m ost usefu l?
grou p consisting of p atients new ly ad m itted
(A) Well, d ecid ing for you rself is best. to the w ard . Du ring group d iscu ssion she asks
(B) If you bu y d ru gs, Ill call the p olice. tw o participants to act out a scenario, d escribe
(C) Perhap s w e shou ld look at w hat you r their feelings abou t the situ ation, and then
m other w ou ld think abou t that. exp lore the ind ivid u al conflicts w hich arose.
Which of the follow ing techniques of p sycho-
(D) Why d o you think everyone w ants you
therapy d oes this m ost represent?
to d o that?
(E) N o, they d ont. (A) Feed back
(B) Free association
7. You d ecid e that su p p ortive therap y w ou ld be (C) Go-arou nd
helpfu l to this patient. Which of the follow ing (D) Psychod ram a
w ou ld be the m ost ap p rop riate goal of su p -
(E) Resistance
p ortive therap y for this p atient?
(A) Correcting fau lty id eas Questions 11 and 12
(B) Exp loring the feeling of m eaninglessness
A 28-year-old fem ale p atient w ho is ad d icted to opi-
in life
oid analgesics states that she has been up set w ith
(C) Investigating the freed om of ind ivid u als fam ily for not continu ing to su p p ort her financially
(D) Personality change and allow ing her to stay w ith them . She has been
(E) Strengthening of d efenses u nem ployed for m any years since leaving college.
They recently told her that she shou ld be m ore ind e-
8. A 32-year-old p sychiatry resid ent is in p sycho- p end ent; they w ant her to start w orking and find a
analysis 4 d ays p er w eek. H e is encouraged to p lace to live. In her next therap y session, she tells
lie on the cou ch and say w hatever com es to her therapist that she u nd erstand s w hy they w ou ld
 Que s tions : 516 125

say that, bu t then goes on to d escribe a fight w ith her 14. A 34-year-old male is referred by his job because
boyfriend , stating she w ants to break u p w ith him of ongoing interpersonal conflicts. During
becau se he is not su p p ortive of her. H er therap ist the interview, he appears very focused on his
asks if it is p ossible she is u pset at her parents for health, his attractiveness to others, and his suc-
w anting her to be m ore ind ep end ent bu t exp ressing cess at work. When confronted with his diffi-
this anger tow ard her boyfriend instead . culties, he becomes defensive, blaming others,
and accusing them of being jealous of me. He
11. Which of the follow ing therapeu tic techniqu es describes himself as better than his friends
best d escribes the therap ists resp onse? and colleagues and admits to taking advantage
of others in order to get what I deserve. Which
(A) Cou ntertransference
of the following treatment modalities would be
(B) Em p athy the most appropriate for this patient?
(C) Interp retation
(A) Anger m anagem ent
(D) Parad oxical intervention
(B) Com bined ind ivid u al and grou p
(E) Working throu gh
therapy
12. The p atients fam ily m em bers and close (C) Psychoanalysis
friend s w ork w ith the therap ist and join the (D) Psychopharm acotherap y
p atient in a session. Du ring the m eeting, they (E) Social skills training
tell her about her m alad aptive behaviors and
how they have affected her and her fam ily 15. A 29-year-old w om an has been d epressed for
negatively. They then give her an u ltim atu m , 2 months prior to seeking med ical attention.
w hereby if she d oes not get treatm ent for her She believes that nobod y likes her even though
ad d iction they w ill not continu e to su pp ort she is alw ays cord ial, and that there is noth-
her. Which of the follow ing techniqu es best ing she can d o to change the w ay other people
d escribes this scenario? perceive her. Therefore, w hen she is around
peop le she feels tense and u ncomfortable and
(A) Behavioral therap y
has started avoid ing leaving the hou se. Which
(B) Fam ily therap y of the follow ing cognitivebehavioral therapy
(C) Grou p therap y (CBT) interventions w ould most d irectly target
(D) Intervention the physical feelings she has around people?
(E) Relap se p revention (A) Cognitive restru cturing
(B) Exp osu res
13. A 24-year-old female patient with a history of
generalized anxiety disorder presents for therapy. (C) Keep ing a m ood d iary
In a previous session she reluctantly discussed (D) Keep ing a thou ght record
how much she did not like her new step-mother (E) Progressive m u scle relaxation
and didnt approve of her father marrying her.
This session she reports that her step-mother is 16. After several weeks, a 40-year-old female patient
in the hospital and she has been spending most who is in psychodynamic psychotherapy begins
of the past few days at the hospital caring for her, to show up late and miss appointments; each
buying many get-well gifts and inserting herself time this happens she has a reason for doing
in her step-mother s care. Which of the following so. However, the therapist begins to feel that
concepts best describes this behavior? her behavior is interfering with her treatment.
The therapist is not sure if the patient under-
(A) Abreaction
stands that her behavior is inappropriate and
(B) Dep end ency potentially damaging to her therapy. Which of
(C) Projection the following topics would be the most impor-
(D) Reaction form ation tant to review with the patient before making
(E) Sp litting an interpretation of her behavior?
126 4: P syc holog ica l Tre a tme nt a nd Ma nag e me nt

(A) Bou nd aries and ru les d efining the w ay (D) Interp retation
in w hich therap y is cond u cted (E) Refram ing
(B) Focu s on the therapeu tic goals
(C) Method u sed to change the p atients Questions 19 and 20
m alad aptive thou ghts
An 18-year-old , single m an p resents to you r office
(D) Patients need for attention com plaining that he cannot pass a m ovie theater
(E) Reasons the p atient is late to the w ithou t stop p ing, going insid e, and bu ying cand y.
ap pointm ents This behavior is trou blesom e to him and interferes
w ith his d aily activities, resu lting in his being con-
17. A 45-year-old m an p resents to you r ou tp atient stantly late to other app ointm ents. You d ecid e to
clinic hand icap ped by a fear of parking lots help the p atient w ith behavior therap y.
and field s. The fear started 4 m onths p rior to
this visit. At the beginning of cognitive ther- 19. Which of the follow ing w ould be the m ost
ap y, he tells you that his behavior is constantly ap p rop riate focu s of the therapy?
being scru tinized and criticized by other
p eop le. H e claim s that he cannot change his (A) Analyzing the p atients relationship s
behavior, becau se if he d oes, others w ill think (B) Decreasing the m alad ap tive behavior of
he is a fool. Which of the follow ing w ou ld be stopping by m ovie theaters
the m ost appropriate response? (C) Exam ining the p atients negative eating
habits
(A) Thats silly. People w ill not think you
are a fool. (D) Exp loring the p atients child hood
trau m as
(B) Yes, I can see that.
(E) Working on resolving the p atients
(C) What m akes you think th at others
u nconsciou s conflicts
are con stantly scru tinizing you r
beh avior?
20. Which of the follow ing behavioral interven-
(D) H ow can you possibly think other tions w ould be the m ost help fu l in this case?
p eople care enou gh abou t you to
constantly scru tinize your behavior? (A) Aversion therap y
(E) Well, m aybe you are a fool. H ave you (B) Environm ental m od ification
ever thou ght of that? (C) Exp osu re and resp onse training
(D) Mod eling
18. A 32-year-old fem ale in therap y d escribes (E) Relaxation training
how she feels that she should have a life p art-
ner; and since she is not currently d ating, she 21. A 39-year-old m an p resents to you r office
is u nlikely to ever get m arried and is therefore com plaining of chronic stress, anxiety, and
u nlovable. H er therapist points ou t to her that p oor sleep. H e also ad m its to interm ittent
she has had a few m eaningful long-term rela- head aches, w hich you d iagnose as tension
tionships in the past and that she has d ated as head aches. You recom m end behavioral ther-
recently as a cou p le of m onths ago. The thera- ap y for red u ction of his head aches. Which of
p ist also explains that m any p eople m ay not the follow ing behavioral techniqu es w ould be
d ate, bu t this d oes not m ean they are u nlov- m ost appropriate for this patient?
able or w ill never get m arried . Which of the
follow ing term s best d escribes the therap eu tic (A) Aversive stim u li
intervention d escribed above? (B) Biofeed back
(C) N egative reinforcem ent
(A) Clarification
(D) Stim u lu s control
(B) Confrontation
(E) System atic d esensitization
(C) Em p athy

Questions 22 and 23
A 32-year-old m ale com p lains of ongoing d epression
for the past m onth w hich he attribu tes to the break-
up w ith his fiance. H e has been having insom nia,
d ecreased appetite, and low energy, althou gh he
d enies anhed onia or problem s concentrating. H e
also d enies any su icid al id eation. H e has ju st started
to d ate som eone else w ithin the last w eek. After d is-
cussion w ith the patient, it is d ecid ed to u tilize both
m ed ication and interp ersonal psychotherap y for his
d ep ression.
22. Which of the follow ing goals w ou ld be the
m ost likely focu s of his p sychotherapy?
(A) Character change
(B) Clarifying com m u nication p atterns
(C) Strengthening d efenses
(D) Interpreting transference
(E) Pointing ou t resistance
23. Which of the follow ing techniqu es w ou ld
be m ost likely u tilized d u ring this p atients
therapy?
(A) Dream interp retation
(B) Defense analysis
(C) Free association
(D) H ypnosis
(E) Role p laying
Questions 24 and 25
A 22-year-old college stud ent presents com plaining
of having no goals in his life, not d oing as w ell as he
could in school, and d esiring but having no serious
long-term romantic relationships. H e has not chosen
a m ajor and states that his ind ecision is paralyzing
him from m oving on w ith the rest of m y life. After
d iscussing various form s of psychotherapy w ith the
patient, you recomm end psychoanalysis fou r times
per w eek.
24. Which of the follow ing is the m ost im p ortant
reason for the frequ ency of p sychoanalysis?
(A) Allow the p atient to get enou gh su p p ort
d u ring the course of their treatm ent.
(B) Allow transference to bu ild betw een
p atient and therapist.
Que s tions : 1726 127
(C) Com p lete hom ew ork frequ ently to
better learn abou t their issu es.
(D) Prevent conflicts from arising betw een
the therapist and p atient.
(E) Requ ire m ore intensive treatm ent d u e to
severity of m ental illness.
25. Which of the follow ing w ou ld be the m ost
im p ortant tool in his p sychoanalysis?
(A) Altering cognitive d istortions
(B) Altering m alad ap tive behaviors
(C) Interp retation of transference
(D) Interp reting d ream s
(E) Solving interp ersonal p roblem s
26. A m ale th erap ist h as been w orkin g w ith a
fem ale p atient for over 3 years, enabling her
to im p rove her self-esteem and confid ence,
and to eventu ally d ivorce her em otion ally
abu sive h u sban d 1 year ago. The p atient con-
tinu ally thanks the therap ist and exp lains
that she is sexu ally attracted to the therap ist.
H e is initially taken aback and then som e-
w hat flattered by her sexu al interest. H ow -
ever, he also realizes that he feels a strong
attraction to her and feels the n eed to care
for her. Which of the follow ing w ou ld be the
m ost ap p rop riate n ext step for the th erap ist
to take?
(A) Act cold , show less em p athy, and set
m ore rigid bou nd aries d u ring sessions.
(B) Exp lore the p atients feeling in ord er to
increase her erotic transference.
(C) Ignore the p atients d isclosu re of her
sexu al attraction.
(D) Seek su p ervision w ith a m entor or
colleague.
(E) Term inate or fire the p atient from his
care.
Questions 27 and 28
You are seeing a 25-year-old man in cognitivebehav-
ioral therapy w ho suffers from generalized anxiety
d isorder, as w ell as epilepsy. H e often talks about
the many dreams he has w hile in his sessions, and
he is having a hard time w ith the restructuring of
128 4: P syc holog ica l Tre a tme nt a nd Ma nag e me nt

malad aptive thoughts. You d ecid e that hypnosis may relationships. He blames the problem on his
be helpful as an adjunctive therapy for this patient, sabotaging things when the women start to
as he has been hypnotized before w ith good results get serious. He is clearly ambivalent about his
and you have a skillful hypnotist in your clinic. The desire to settle down with someone. Accord-
patient is hopeful that hypnosis w ill be beneficial for ing to Erik Erikson, which of the following stages
him again. of development is the patient most likely in?
(A) Tru st versu s m istru st
27. Which of the follow ing characteristics is the
best p red ictor of resp onse to hyp nosis in this (B) Au tonom y versu s sham e
p atient? (C) Initiative versu s gu ilt
(D) Intim acy versu s isolation
(A) Patient has a lot of d ream s.
(E) Id entity versu s role confu sion
(B) Patient is resp onsive to su ggestion.
(C) Patients d iagnosis. 31. A 9-year-old boy w ith attention-d eficit/
(D) Patient w ith low seizu re threshold . hyperactivity disorder (ADHD), predominantly
(E) Trained hyp notist w ill be d oing his hyp eractive/ im p u lsive presentation, presents
treatm ent. to you r office accom panied by his m other. H e
is cu rrently on m ethylp henid ate (Ritalin) and
28. The p atient is started in hyp nosis, bu t there they both w ond er if there is som ething else
is a concern as to w hether he is in a trance that can be d one to help the patient. Despite
d u ring the sessions. Which of the follow ing som e benefit and tolerability, the child contin-
ind icators w ou ld be m ost likely increased in a u es to have d ifficulty w ith com pleting hom e-
trance state? w ork and follow ing instru ctions at school
and at hom e. H e has also recently gotten
(A) Am nesia
into a m inor p hysical fight w ith a p eer. Par-
(B) Pain p ercep tion ent m anagem ent training is recom m end ed for
(C) Pu lse the parents. Which of the follow ing aim s best
(D) Reflexes illu strates how p arent m anagem ent training
(E) Resp irations w ill help the fam ily?
(A) Focu sing on m alad ap tive
29. You are treating an 11-year-old boy for op p osi- com m unication in the fam ily
tional d efiant d isord er and have heard from
(B) Focu sing on the fam ilys interp ersonal
the p arents that his d isord er has had a sig-
relationship s
nificant im p act on the fam ily d ynam ics. They
have tw o old er child ren w ho often feel left (C) Increasing p arental u se of p ositive
ou t and feel d istanced from the fam ily u nit. reinforcem ent to increase d esired
You recom m end a trial of fam ily therap y. behaviors
In this case, w hich of the follow ing w ou ld (D) Interp reting p arents negative cognitions
be the m ost ap p rop riate focu s of the fam ily abou t the p atient
therap y? (E) Teaching parents to p ositively refram e a
negative exp erience
(A) Assigning roles in a hou sehold
(B) Early child hood exp eriences 32. A 14-year-old boy w ith attention-d eficit/ hyper-
(C) Im p u lsive behavior activity d isorder (ADH D) is frequently late for
(D) Relationship p atterns school and forgets to d o his chores around the
(E) Unconsciou s conflicts house d ue to his d isorganization. H is parents
are fed up w ith him and ask you w hat they can
30. A 32-year-old man presents for psychother- d o to help change his behavior. Which of the
apy. He denies pervasive depression or anxi- follow ing represents the most helpful behav-
ety symptoms, but he has had a string of failed ioral tool for patients w ith ADH D?

(A) A chart of behaviors to be rew ard ed by
p arents
(B) Aversion therapy
(C) Interp retation of m alad ap tive behaviors
(D) Positively refram ing a negative
exp erience
(E) Pu nishm ent
Questions 33 and 34
A 25-year-old u nm arried m an in his fou rth year of
m ed ical school presents to you r office com p laining
of not being able to rem ain in a relationship w ith
a girlfriend for longer than 3 m onths. H e says that
he w ould like an insight-oriented therap y, and you
agree that this form of therapy w ou ld help him . You
decide to treat this patient with brief psychod ynamic
p sychotherap y.
33. Which of the following factors would best predict
a positive outcome with brief psychodynamic
psychotherapy in this particular patient?
(A) Age
(B) Gend er
(C) Marital statu s
(D) Motivation for change
(E) Socioeconom ic statu s
34. Which of the follow ing asp ects best d istin-
gu ishes his sp ecific typ e of p sychotherap y
from other form s of therap y?
(A) Correcting cognitive errors
(B) Id entification of a focal conflict
(C) Interp reting d ream s
(D) Interp reting resistance
(E) Mod ifying m alad ap tive behaviors
35. A 20-year-old m an is cu rrently in college and
has com p leted the first sem ester of his sop ho-
m ore year. H alfw ay into the second sem ester,
his grad es d rop from As to Fs over a 3-m onth
p eriod . H e becom es increasingly isolated
and p aranoid , believing that the governm ent
is after him becau se he has solved all theo-
logical p roblem s throu gh d irect com m u ni-
cation w ith God . H e is started on olanzap ine
10 m g by m ou th (PO) d aily and is tentatively
Que s tions : 2737 129
d iagnosed w ith schizop hreniform d isord er.
H e recovers after 4 m onths bu t has another
relap se 6 m onths later in the absence of an
elevated , irritable, or d ep ressed m ood . H e is
then given a d iagnosis of schizop hrenia and
referred for m ed ication m anagem ent and
therap y. After a few w eeks of therap y, the
p atient exp eriences a w orsening of his p sy-
chotic sym p tom s. Which typ e of therap y w as
he m ost likely referred to?
(A) Behavioral therap y
(B) Fam ily therap y
(C) Grou p p sychotherap y
(D) Psychoanalytic p sychotherap y
(E) Su p p ortive p sychotherap y
36. A 50-year-old m an is in p sychoanalysis
becau se he feels stagnant in his p ersonal
life. H e notes he is not having any p roblem s
w ith his w ork or relationship w ith his w ife,
althou gh he feels that he has never had m ore
than a p latonic relationship w ith her. While he
feels cap able and confid ent in m ost sp heres
of his life, inclu d ing his relationship s, he feels
like he is at a road block in therap y and d oes
not know how to p roceed . H e has, how ever,
m entioned a reoccu rring d ream about his
w ife tu rning into his m other and taking care
of him . The therapist thinks that interpreting
his d ream m ay be a good tool to u se in ther-
ap y. Which of the follow ing u ses of his d ream
w ou ld be the m ost ap p rop riate in this case?
(A) Interp reted by the analyst to
su blim inally influ ence the m ind of the
p atient.
(B) Provid e inform ation abou t p sychic
conflicts.
(C) Rep resent the consciou s fram ew ork for
behavior.
(D) Used to alter cognitive errors.
(E) Used to change behavior.
37. You have been assigned to lead a d ialectical
behavioral therap y grou p for p atients w ith
bord erline p ersonality d isord er. Du ring the
grou p one of the p atients relates a story abou t
getting into a fight w ith her m other. Afterw ard
she w as so d espond ent she had thou ghts
130 4: P syc holog ica l Tre a tme nt a nd Ma nag e me nt

abou t cu tting herself. Instead of resp ond - Which of the follow ing stages of grou p form a-
ing, she w atched her favorite com ed y m ovie. tion is this grou p m ost likely in at this tim e?
Which of the follow ing skills d id the p atient
(A) Form ing
m ost likely em p loy?
(B) Storm ing
(A) Cognitive restructu ring (C) N orm ing
(B) Distress tolerance (D) Perform ing
(C) Em otion regu lation (E) Ad jou rning
(D) Interpersonal effectiveness
(E) Mind fu lness 41. A 38-year-old law yer is referred for behavioral
therapy because of extrem e social anxiety
Questions 38 and 39 w hich is interfering in his ability to litigate. In
his early therap y sessions, he is told to m ake
A 33-year-old w om an p resents to the em ergency a hierarchy of situ ations that m ake him anx-
d epartm ent saying that she w ants to kill herself. She iou s. The therap ist then begins w orking w ith
has felt increasingly d epressed for m any m onths, him by first exposing him to the least anxiety-
w ith late insom nia, p oor ap p etite, w eight loss, d is- p rovoking item s on the list and then grad u ally
tractibility, and fatigu e. She cu rrently feels hopeless increasing the severity. Which of the follow ing
and help less, and has a p lan to overd ose on p ills therapeu tic techniques is the therapist m ost
that she has stockpiled at hom e. likely u tilizing?

38. Other than her feelings of helplessness and (A) Aversion

hopelessness, w hich of the follow ing cognitive (B) Flood ing
d ifficulties w ou ld she m ost likely also exhibit? (C) Mod eling
(A) Begging the question (D) Su ggestion
(B) Circu lar reasoning (E) System atic d esensitization
(C) Personalization
42. A 47-year-old , d ivorced m ale has been
(D) Rigid , black-or-w hite thinking
attend ing p sychotherap y for 8 m onths d u e to
(E) Selective abstraction ongoing stress and conflicts at w ork. Du r-
ing m ost of his therap y sessions, the p sychia-
39. After hospitalization, w hich of the follow ing trist resp ond s to his com m ents w ith em p athic
form s of p sychotherap y w ou ld be the m ost resp onses. Which typ e of p sychotherap y is
ap p rop riate to help m inim ize this patients the p sychiatrist m ost likely u tilizing in this
su icid ality? case?
(A) Behavioral therapy (A) Behavioral
(B) Cognitive therap y (B) Cognitive
(C) H yp nosis (C) Dynam ic
(D) Interpersonal p sychotherap y (D) Existential
(E) Parad oxical therap y (E) Su p p ortive

40. In the context of a w om ens grou p , one m em -
ber has been frequ ently sid e talking. As
th e facilitator, you bring this u p d u ring the
grou p . Th e m em ber states she only d oes this
becau se you d ont give enou gh tim e for each
m em ber to talk. The other grou p m em bers
agree w ith h er.
D IRECTION S (Questions 43 through 47): The fol-
low ing group of questions is preceded by a list of
lettered options. For each patient scenario, select
the one lettered option that is most closely asso-
ciated w ith it. Each lettered option may be used
once, multiple times, or not at all.
 Que s tions : 3850 131

(A) Biofeed back 46. To train a 4-year-old boy to say thank you,
(B) Cou ntertransference his m other gives him a sw eet w henever he
(C) Flood ing d oes.
(D) H ypnosis
(E) N egative reinforcem ent 47. To train a 4-year-old boy not to bite his class-
m ates, his m other p uts soap in his m ou th
(F) Positive reinforcem ent
w henever he d oes.
(G) Projection
(H ) Projective id entification
D IRECTION S (Questions 48 through 50): The fol-
(I) Punishm ent
low ing group of questions is preceded by a list
(J) Real relationship of lettered options. For each question, select the
(K) Schem a one lettered option that is most closely associated
(L) Sp litting w ith it.
(M) Therap eu tic alliance (A) Josef Breu er
(N ) Transference (B) Jean-Martin Charcot
(O) Und oing (C) Erik Erikson
(D) Sigm u nd Freu d
43. You are seeing a 26-year-old w om an w ho com -
plains of m igraines. She is otherw ise healthy. (E) H einz Kohu t
You exp lain to her that you w ou ld like to try a (F) Franz Anton Mesm er
techniqu e in w hich you give her inform ation
on m u scle tension and tem peratu re. 48. Mad e m any contributions to p sychiatry and
neu rology w ith a sp ecial interest in d escribing
hysteria.
44. You are seeing a 45-year-old m an in p sycho-
analysis fou r tim es p er w eek. Du ring one ses-
sion he appears less com fortable talking. H e 49. Know n as the inventor of the cathartic treat-
eventu ally tells you that you r new glasses m ent or talking therap y.
rem ind him of his au nt w ho cared for him as a
child bu t w as cru el to him . 50. Know n as the d evelop er of self-p sychology.

45. A p atient w ho is afraid of clow ns is taken to

the circus in the beginning of her therapy in
ord er to get over her fear.
 Ans we rs a nd Expla na tions
1. (A) Cognitivebehavioral therap y refers to a
variety of techniqu es that focus on the construc-
tion and reconstruction of peoples cognitions,
emotions, and behaviors. Cognitivebehavioral
therapists use a range of m od alities to help
p atients assess, recognize, and d eal w ith prob-
lem atic and d ysfu nctional w ays of thinking,
em oting, and behaving. In this case, a thou ght
record is being u sed to exam ine the p atients
feelings and beliefs. Exp ressive therap y u ses
d ifferent form s of exp ression (e.g, art, m ove-
m ent, m usic, or w riting) to have a patient
exp ress his or her feelings and w ork throu gh
them . H ypnotherapy uses hypnosis to u ncover
u nd erlying conflicts and hypnotic su ggestion
in ord er to change behaviors. Psychoanaly-
sis encou rages patients to verbalize all their
thoughts, includ ing free associations, fanta-
sies, and d ream s. The analyst u ses these to
u nd erstand the u nconsciou s conflicts causing
the patients sym ptom s or character problem s.
Psychod ynam ic therap y attem pts to d iscover
the unconscious content of a patients psyche
and then w ork on the issu es in therap y; it has
its root in p sychoanalysis.
2. (A) Au tom atic thou ghts are the im m ed iate
thoughts that com e to m ind in any situation
that are based on underlying core beliefs; these
are d eep ly held id eas regard ing the w orld
and oneself that d rive a patients em otional
resp onses and behavior. Ego strength is the
ability of the ego to cope w ith com p eting
conflicts betw een the id , ego, and su perego
w hich help one m anage stress and m aintain
stability. Projections are d efense m echanism s,
w hereby an ind ivid u al u nconsciou sly attri-
bu tes u nd esirable asp ects of oneself onto
132
others. Unconscious thoughts are instinctual
thoughts, d rives, and need s that are ou t of
ones aw areness.
3. (B) Disp lacem ent is a d efense that transfers
a feeling abou t, or a resp onse to, one object
(p erson) onto another object (p erson). Denial
is a d efense that keep s ou t of consciou s aw are-
ness an asp ect of external reality or subjective
d istress that is too u ncom fortable for the p er-
son to accept. H u m or is consid ered a m atu re
d efense m echanism that em p hasizes the am u s-
ing or ironic asp ects of a stressor. Intellectu -
alization is a d efense in w hich the ind ivid u al
favors abstract thinking over d ealing w ith the
d istu rbing feelings of an id ea or exp erience.
Isolation of affect involves d etachm ent of
feelings from a p articu lar id ea or exp erience.
4. (E) Splitting occu rs w hen an ind ivid u al is
u nable to see others m od erately, w ith both
p ositive and negative qualities (i.e., peoples
actions are either all good or all bad ). Devalu -
ation is a d efense that attribu tes excessive
negative qu alities to another. Id ealization attri-
bu tes excessive p ositive qu alities to another.
Intellectu alization is a d efense that u tilizes
excessive abstract thinking or generalizations
to m anage threatening em otions. Rep res-
sion expels d isturbing w ishes, thoughts, or
exp eriences from consciou s aw areness.
5. (B) This is an exam p le of intellectu alization, a
d efense that u tilizes excessive abstract think-
ing or generalizations to m anage threatening
em otions. Denial is a d efense that keep s out
of consciou s aw areness an aspect of exter-
nal reality or subjective d istress that is too

u ncom fortable for the person to accep t. Pro-
jection is a d efense w hereby a thou ght, feel-
ing, or id ea that is u naccep table to the p erson
is falsely attribu ted to another. Su p p ression
is w here one intentionally avoid s thinking of
d istressing thou ghts, feelings, id eas, or experi-
ences. Und oing is a ritu alistic act com p leted
in ord er to red u ce gu ilt abou t an event that
occurred in the past.
6. (D ) The best strategy in any com m u nication is
to try to gain clarity. Asking this patient w hy
she believes w hat she d oes m ay lead now here
bu t it m ay help to u nd erstand the p atients
concerns. Choice (A) m ay be helpful in som e
situ ations and certainly has a positive ring
to it. H ow ever, this patients com m ent is an
im p licit qu estion. She is asking for help and
genu inely d oes not know w hat to d o. H id ing
behind p ithy m axim s is not u su ally help fu l.
Choices (B) and (C) are coercive and block
com m u nication. Giving supp ortive guid ance
is ap p rop riate in this situ ation, bu t coercion
is never ap p rop riate in a therap eu tic rela-
tionship. Choice (E) is not coercive but also
blocks com m u nication. While the p atient m ay
requ ire reality testing, the resp onse m ay sacri-
fice a m ore insightfu l, em p ow ering rep ly.
7. (E) The goal of su p p ortive therap y is the
strengthening of current d efense m echanism s.
Throu gh su p p ortive care, the p atient can learn
to cope w ith d ifficu lt problem s u sing alread y
established abilities. Correcting fau lty id eas
is the exp ressed goal of cognitive therap y.
Exp loring the feeling of m eaninglessness in
life and investigating the freed om of ind ivid u -
als are goals of existential p sychotherap y. Per-
sonality change is a goal of psychod ynam ic
p sychotherap y, w here d efenses are exam ined
grad u ally in ord er to achieve a m ore op tim al
level of fu nctioning.
8. (A) This is an exam p le of free association.
Freu d believed that all m ental activity is cau s-
ally related , m eaning that free associations are
not truly rand om . They follow logically, bu t
the m issing connection is being held d ow n or
rep ressed u nconsciou sly by d efenses. H yp no-
sis is w here a p atient is placed in a trance and
Answe rs : 110 133
their unconscious is explored . Rep ression is
a d efense m echanism that exp els d isturbing
w ishes, thou ghts, or exp eriences from con-
scious aw areness. Thou ght record s refer to a
p atient record ing situ ations, feelings, au to-
m atic thou ghts and alternative responses then
re-rating the initial feelings; this techniqu e
is com m only u sed in cognitivebehavioral
therapy. Transference, in strict term s, is the
re-exp eriencing of p ast exp eriences w ith the
analyst in the setting of p sychoanalytic psy-
chotherapy. Cou ntertransference is the ana-
lysts resp onse to this. H ow ever, these term s
have com e to m ean the transferring of em o-
tions and feelings that one has from ones past
to the physician or care provid er in the case
of transference and the p hysician tow ard the
p atient in countertransference.
9. (A) Cou ntertransference is the consciou s or
u nconsciou s em otional reaction of the thera-
p ist to the p atient. Transference is the con-
scious or u nconsciou s em otional reaction of
the p atient to the therapist based on a past
relationship the p atient had w ith a signifi-
cant other person (e.g., a p arent). Extinction
is a term frequ ently u sed in learning theory,
w hich refers to the red u ction in frequ ency of a
learned resp onse as a resu lt of the cessation of
reinforcem ent. Interp retation is insight offered
by the therap ist regard ing p atterns of thou ght
or behavior. Resistance is the patients u ncon-
scious opposition to full d isclosure of feelings
or id eas.
10. (D ) Psychod ram a is a techniqu e in w hich
grou p m em bers are u sed as the au d ience
and the cast in reenactm ents of scenarios and
conflict. The content of the d ram a is u sed to
exp lore ind ivid u al p roblem s in a grou p setting.
Feed back, a card inal featu re of grou p p sycho-
therapy, com es from peers as w ell as from the
lead er. Feed back from p eers in the grou p can
be a p ow erfu l stim u lu s for insight and change.
Free association is u sed in p sychoanalytically
oriented grou ps. These grou ps are largely
ou tpatient grou ps w hose m em bers can toler-
ate and effectively u se this techniqu e. Mem -
bers are encou raged to be sp ontaneou s w ith
their thou ghts and feelings, and the therap ist
134 4: P syc holog ica l Tre a tme nt a nd Ma nag e me nt
assists in p ointing ou t com m on them es and
p ossible connections. Go-arou nd is a com m on
techniqu e w here each grou p m em ber is asked
to introd u ce them selves, state how they are
feeling, or otherw ise specifically respond ; this
gives each ind ivid u al a chance to p articip ate.
Resistance is the u nconsciou s op position to
fu ll d isclosu re of thou ghts or feelings.
11. (C) Interp retation is u sing a hyp othesis to
exp lain the p sychological m eaning of a behav-
ior or sym p tom s. Cou ntertransference is w hen
the therap ists feelings and em otions are
d irected tow ard a p atient. Em p athy is w hen
a therap ist id entifies and u nd erstand s a
p atients situ ation or feelings. Parad oxi-
cal intervention is a therap eu tic techniqu e
w here a therap ist instru cts a p atient to hold
onto a sym p tom in ord er to get the p atient
to u nd erstand that the sym p tom is not help -
fu l. Working throu gh refers to thinking abou t
and d iscu ssing a p roblem in ord er to lessen
its intensity or im p act.
12. (D ) Intervention is an orchestrated attem p t
by one or m any to get an ind ivid u al to accep t
p rofessional help or treatm ent, u su ally for an
ad d iction or crisis. Behavioral therap y focu ses
on changing a patients m alad aptive behaviors
or actions; its pu rpose is not to get a patient to
com m it to treatm ent. Fam ily therap y involves
an entire fam ily in therapy together w ork-
ing to change the d ynam ics, d evelop m ent,
and system s of interaction; fam ily therap y
d oes not usu ally focu s on the problem s of
one m em ber. Grou p therapy is w hen a group
of ind ivid uals w ork on issu es in conju nction
w ith each other; it can be help fu l becau se the
d ifferent backgrou nd s and problem s can be
looked at together in ord er to help each p er-
son w ith their ow n d ifficu lties. Relapse pre-
vention is u sed in ad d ictions treatm ent, w here
ind ivid u als are tau ght self-control and how to
m aintain changes in behavior, as w ell as how
to anticipate and cope w ith relap se.
13. (D ) This p atient is d em onstrating the concep t
of reaction form ation, w hich is w hen u nac-
ceptable or anxiety-provoking em otions are
d ealt w ith by acting in the opposite m anner.
Abreaction is w hen a p atient relives an em o-
tional or traum atic experience to get rid of or
p u rge negative em otions and m ove forw ard .
Dep end ency is w here one need s another p er-
son or ad d ictive su bstance in ord er to m aintain
a level of em otional or p hysical fu nctioning.
Projection is a prim itive d efense consisting of
attribu ting ones ow n und esirable thou ghts,
d esires, or em otions onto som eone or som e-
thing else. Sp litting is a d efense m echanism
w here one view s them selves and / or others as
all good or all bad . It is com m only seen in
p atients w ith bord erline personality d isord er.
14. (B) This ind ivid u al has featu res of narcissistic
p ersonality d isord er. Althou gh p atients w ith
narcissistic p ersonality d isord er have d iffi-
culty w ith confrontation, it is necessary to help
them w ork tow ard change; therefore, group
therapy is a good setting for this to take p lace.
In ad d ition, in ind ivid u al therap y p atients
can process these situ ations and exam ine how
p ossible insu lts to the ego can be d ealt w ith, as
w ell as ad d ressing the other ind ivid u al issu es.
Anger m anagem ent as w ell as social skills
training can be helpfu l, but are not enough
to exam ine the d eep u nd erlying issu es and
d efenses that patients w ith narcissistic p erson-
ality d isord er have. Sim ilarly, p sychoanalysis
alone w ou ld not be enou gh to help patients in
w hich m any of their relationship s and social
interactions are affected by their p ersonality
d isord er. Pharm acotherapy is often not help -
fu l w ith personality d isord ers unless severe
im p u lsivity or p sychosis is p resent, or u nless
a p atient has a com orbid p sychiatric d isord er
(e.g., m ajor d ep ressive d isord er).
15. (E) Progressive m u scle relaxation is a relax-
ation technique u sed in CBT to control and
m inim ize m u scle tension. Of the op tions, it is
the only one d irectly targeted at the p atients
u ncom fortable feelings w hile arou nd other
p eop le. Cognitive restru ctu ring and keep ing
a thou ght record are techniqu es w hich m ay
im p rove the sym p tom s by id entifying and
m inim izing au tom atic thou ghts. Exp osu re
therapy is a techniqu e used to d ecrease the
avoid ance behaviors by exp osing p atients to
the feared stim u li in ord er to show they can

tolerate it. It is com m only u sed in treating
anxiety d isord ers. A m ood d iary is a techniqu e
u sed for m onitoring ones m ood to d eterm ine
triggers, au tom atic thou ghts, and treatm ent
p rogression.
16. (A) In this case, it w ou ld be im p ortant for
the therap ist to review the fram e for ther-
ap y. In p sychod ynam ic p sychotherap y the
fram e refers to the bou nd aries and ru les
d efining the w ay the therap ist and p atient
interact (e.g., the m eeting tim e, p lace, length,
other d etails d ow n to w here the therap ist and
p atient u su ally sit, how fees for service are
collected , w hat hap p ens w hen a p atient starts
m issing ap p ointm ents). The fram e is im p or-
tant as it gives p sychotherap y a stru ctu re
and sets u p a sp ecific d ynam ic betw een the
p atient and therap ist. Therefore, if bou nd ar-
ies or ru les are challenged the therap ist can
u se this to better u nd erstand the reasons as
w ell as d eterm ine any transference issu es at
p lay. In this case the therap ist su sp ects the
p atient m ay not u nd erstand the fram e u sed
for her therap y sessions and w hy it is im p or-
tant. Review ing the therap eu tic goals and
the typ e of therap y p rovid ed m ay both be
reasonable top ics for the therap ist to d iscu ss;
how ever, it w ou ld not ad d ress her reasons for
being late and not show ing u p for ap p oint-
m ents. Interp reting the p atients behavior as a
need for attention m ay not only be incorrect,
bu t it m ay be exp erienced by the p atient as an
attack or hu rtfu l, p articu larly if she d oes not
u nd erstand the therap eu tic fram e correctly.
Sim ilarly, looking at the ind ivid u al reasons
w hy she is late avoid s the su bject of w hy this
p attern of behavior is p resent.
17. (C) One reason this is the best resp onse is that
it is a qu estion. Patients w ith cognitive d istor-
tions often take their view of the w orld as a
given. They d o not qu estion their p ersp ectives.
Asking a qu estion invites p atients to exam ine
their perspectives and thereby becom e open
to the p ossibility that their thoughts m ay be
inaccu rate. Again, gaining clarity is alw ays a
good first step in com m u nication. Choices (D )
and (E) are also qu estions bu t are au thoritar-
ian and p u nitive, not to m ention insu lting; to
Answe rs : 1119 135
have the best ou tcom e in any form of therap y,
there m u st be a good relationship or alliance
betw een the p atient and therap ist. Choice (A)
m ay also be harm fu l as a p atient shou ld not
be called silly. Choice (B) is am biguou sto
w hich p art of the qu estion are you resp ond -
ing? The p atient m ay believe that you are
insu lting him rather than attem p ting to be
sup portive.
18. (E) Refram ing is a techniqu e com m only u sed
in cognitivebehavioral therap y. First, a ther-
ap ist w ill exam ine how p atients thou ghts or
beliefs abou t them selves or the w orld m ay
be skew ed . Then the thou ghts or beliefs are
refram ed by com p aring them to a m ore nor-
m alized p ersp ective. Clarification is w hen
a therap ist asks for fu rther d etails abou t a
p atients exp erience or situ ation they are
d escribing. Confrontation is w hen a thera-
p ist d irectly asks p atients abou t their m al-
ad ap tive behaviors or sym p tom s. Em p athy
is w hen a therap ist show s u nd erstand ing or
agrees w ith p atients, show ing them that they
are able to p u t them selves in the p atients
shoes or see their p ersp ective. Interp retation
is w hen a therap ist p resents the p atient w ith
a hyp othesis regard ing the reason(s) (often
u nconsciou s) a p atient has certain behaviors
or sym p tom s.
19. (B) Behavior therap y is focu sed on behaviors,
not on p ossible und erlying factors that cause
the behaviors. In this case, ad d ressing the
negative or m alad ap tive behavior (e.g., stop -
p ing by m ovie theaters to bu y cand y) w ould
be ad d ressed . Behavior therap y is a here-
and -now ap p roach to m alad ap tive behaviors.
It m ay u tilize inform ation su rrou nd ing the
em ergence of a p articu lar m alad ap tive behav-
ior in ord er to constru ct a behavior m od ifi-
cation p lan. Althou gh behavior therapy can
and d oes change neu robiology, this is not
its exp ressed goal. It d oes not focu s on the
p atients relationship s or seeking the sou rces
for the p atients negative eating habits. This
is also w hy child hood issu es su ch as trau m a
are not typ ically ad d ressed in behavioral
therapy. Resolving und erlying conflicts in an
attem p t to change behavior is a d escrip tion of
136 4: P syc holog ica l Tre a tme nt a nd Ma nag e me nt
the goals of psychod ynam ic p sychotherapy or
p sychoanalysis.
20. (C) In this case, exp osu re and resp onse train -
ing w ou ld be the m ost help fu l in d ecreas-
ing the p atients m alad ap tive behavior of
stop p ing at m ovie th eaters. It w ou ld teach
m ore ad ap tive behaviors throu gh exp osin g
him to situ ations w h ere h e cou ld p ass by a
m ovie th eater an d en gage in an alternative
behavior. Aversion therap y is w hen a nega-
tive (p ainfu l) stim u lu s is p aired w ith a m al-
ad ap tive behavior in ord er to extin gu ish the
behavior; it is not com m only u sed and often
the beh avior retu rn s over tim e. In this case,
en vironm en tal m od ification w ou ld be less
help fu l as the p atient w ill likely encou n ter
situ ation s w here he m ay p ass m ovie the-
aters in th e fu tu re; in ad d ition , changing th e
en vironm en t d oes n ot ad d ress the behav-
ior. Mod eling is w here ad ap tive behaviors
are tau ght by d em onstration, w hich w ou ld
be d ifficu lt to teach in this p articu lar case.
Relaxation train ing is u sed to help a p atient
to han d le an xiety-p rovoking situ ations, not
chan ge an u nh ealthy beh avior.
21. (B) Biofeed back and stress red u ction are u sed
to red u ce the frequency and severity of ten-
sion head aches. They are equ ally effective in
accom plishing this goal. Su bstance w ithd raw al
synd rom es are exam ples of aversive stim uli,
and the resu ltant negative reinforcem ent theo-
retically lead s to a d ecrease in su bstance u se.
Stim u lus control is u sed in the treatm ent of
insom nia: The negative association betw een
m u ltip le failed attem p ts at falling asleep and
the specific environm ent w here they occurred
is elim inated by red u cing d istractions and
creating an environm ent m ore cond ucive to
sleep (e.g., taking televisions and com pu ters
ou t of the bed room ), as w ell as teaching good
sleep hygiene. System atic d esensitization is a
behavioral techniqu e w hich can be u sed in
asthma, where the patient is exposed to provok-
ing stimuli in a progressive manner.
22. (B) The m ajor focus of interpersonal psycho-
therapy is comm unication analysis. Ind irect,
unclear interpersonal commu nication patterns
are id entified in the cou rse of therapy. These
com m u nication p atterns are then altered ,
for instance, by role playing or asking the
p atient to try ou t d ifferent form s of com m u -
nication d u ring the session. Character change,
interp reting transference, and p ointing ou t
resistance are m ore the focu s of p sychod y-
nam ically oriented p sychotherap y. Strength-
ening of d efenses is the goal of su p p ortive
p sychotherap y.
23. (E) Interp ersonal p sychotherap y focu ses on
the patients role and com m unication style
w ithin im p ortant relationship s and how his
or her position m ay be cau sing or com p li-
cating the illness (e.g., d epression). If one or
tw o specific w ays of com m u nicating can be
altered so that a relationship im p roves, the
d ep ressive illness also im proves. This ther-
ap y also has the ad d ed benefit of d u rability;
once a com m unication pattern is im p roved
and the p atient better u nd erstand s how his or
her role in a relationship m ay create d istress,
the d epressive illness is not as likely to recu r.
Variou s techniqu es u sed in interpersonal
p sychotherap y are role p laying, su p portive
listening, clarification, and com m u nication
analysis. Interpreting d ream s, analyzing p sy-
chic d efenses, and free association are used
in m ore p sychod ynam ically based therap ies,
such as psychoanalysis. H ypnosis is a sleep-
like state ind u ced by a therap ist, w hich has
been of som e u se in behavioral m od ification
such as sm oking cessation. It is not a goal or
com ponent of interpersonal p sychotherapy.
24. (B) Psychoanalysis tend s to be am ong the lon-
gest of therap ies and involves the p rocess of
free association, in w hich the patient lies on
a couch, facing aw ay from the therap ist, and
says w hatever com es to m ind . It takes four to
five sessions a w eek to su ccessfully com p lete
an analysis becau se it is d ifficu lt for patients
to bu ild , su stain, and w ork through their
transference and d efensive stru ctu re; less fre-
qu ent sessions d ecrease the form ation of a
transference neurosis and increase d efenses.
Psychoanalysis is based on an exp ressive or
exp loratory m od el of therap y, as op p osed to
a su p portive m od el aim ed at stabilizing crisis

and reestablishing a baseline level of fu nction.
H om ew ork is a m ethod u sed on cognitive-
behavioral therap y and not p sychoanalysis.
In p sychoanalysis, conflicts betw een therap ist
and patient are analyzed and d iscussed as they
often represent a recreation of child hood con-
flicts and relationship s. There is no correlation
betw een severity of m ental illness and length
of therapy. Patients w ho are in psychoanalysis
are not m ore likely to be severely ill and w ill
need a certain level of insight and com petence
to gain the benefits of p sychoanalysis w ithout
encou ntering severe p roblem s.
25. (C) The m ajor tool of p sychoanalysis is the
carefu l interp retations of the transference
neu rosis. Altering cognitive d istortions is
the m ain goal of cognitive therap y. While
psychoanalysis m ay accom p lish m any tasks,
inclu d ing changing m alad aptive thou ghts
and behaviors and solving interp ersonal
problem s, these are the consequ ences of anal-
ysis, not the instru m ents of change. Althou gh
interpreting d ream s can lead to insights into a
patients u nconsciou s thou ghts and feelings, it
is an ad ju nctive tool.
26. (D ) In this case, the therap ist is having an inap -
p rop riate attraction to his p atient and shou ld
seek su pervision in ord er to u nd erstand the
reasons for his (and the p atients) sexu al feel-
ings. In ad d ition, a su p ervisor can help to
m ake sure that the transference or counter-
transference is not significantly interfering in
the therapy. N ot ad d ressing the situ ation, or
acting less em pathic or cold w ould be evasive
and confu sing to the p atient, m aking it d iffi-
cult for the patient to m ove forw ard in ther-
ap y. The therap ist shou ld not try to elicit m ore
behaviors or continu e to d eep en any erotic
transference that cou ld lead to a greater pow er
d ifferential or m ore sed uctive behavior; this
cou ld p ut the relationship in jeopard y or cross
bou nd aries inap p rop riately. Althou gh the
therapist can fire or term inate the patient, the
situ ation m ay not be seriou s enou gh to w ar-
rant su ch severe actions; it m ay also send the
m essage to the p atient that her sexu al feelings
are d angerous and that the therap y w as not a
safe place to d iscuss them .
Answe rs : 2030 137
27. (B) While a skilled hyp notist is very im por-
tant, far and aw ay the m ost im portant factor in
hyp nosis is a p atient w ho is highly resp onsive
to suggestion, as ind icated by the patients
prior p ositive exp erience w ith hyp nosis and
belief that it w ill be help fu l. Som e ind ivid u als
are able to alter their su bjective experience in
resp onse to su ggestion m ore than others; som e
patients can be tau ght self-hypnosis. N one of
the other characteristics is as im p ortant in the
su ccess of hypnosis.
28. (A) There are nu m erou s ind icators of a trance
state, su ch as am nesia, anesthesia, and red u ced
p ulse, reflexes, and respiration. Other changes
inclu d e changed voice qu ality, eye closu re,
lack of bod y m ovem ent, p u p illary changes,
red u ced blinking, and tim e d istortion.
29. (D ) Fam ily therap y focu ses on the relation-
ships betw een m em bers and how to m ake
them m ore ad aptive to the situations. In this
case, fam ily therapy w ill help the p arents
and child ren u nd erstand w hy there are con-
flicts betw een them and w ork w ith the fam ily
as a u nit; the p u rp ose is neither to blam e nor
change the brothers behavior. Fam ily therapy
d oes not stress assigning roles to each m em -
ber. Unlike p sychoanalysis or p sychod ynam ic
therapy, fam ily therapy d oes not focu s on any
ind ivid u als early child hood exp eriences or
traum a, u nconsciou s conflicts, or im pu lses
that led to the fam ily m em bers pathology.
30. (D ) This p atient is in the Erikson stage of inti-
m acy versus isolation w hich occu rs in you ng
ad u lts from the ap p roxim ate age of 20 to
40 years. This is the p eriod w hen ad u lts are
struggling w ith becom ing em otionally close
and physically intim ate w ith another versu s
feelings of loneliness. Tru st versu s m istru st
occu rs from birth to 1 year w hen infants learn
w hether or not p rim ary caregivers can satisfy
basic need s. The au tonom y versu s sham e/
d ou bt stage occu rs in tod d lers from ages 1 to
3 years w hen child ren attem pt to m aster tasks
on their ow n (as w ell as their ow n im pu lses),
and , if su p p orted (as op p osed to p u nished ),
grow confid ent and secu re in their ability to
su rvive. Initiative versus gu ilt occu rs from age
138 4: P syc holog ica l Tre a tme nt a nd Ma nag e me nt
3 to 5 years w here p reschool child ren gain a
sense of w ell-being from d isplaying initiative
w ithou t feeling gu ilty. The id entity versu s
role confu sion stage occu rs d u ring ad oles-
cence from ages 11 to 19 years w hen teenagers
attem p t to d eterm ine w ho they are and w hat
they w ish to accom plish in life.
31. (C) Parent m anagem ent training is a type of
therapy that focu ses on giving parents tools to
m anage p roblem behaviors in child ren w ith
d isrup tive behaviors. The goal is to increase
the u se of positive reinforcem ent to increase
d esired behaviors at hom e and school. This is
typically d one w ith behavior charts and earn-
ing p rivileges. The other choices apply m ore
to other types of fam ily therapy.
32. (A) A behavioral tool th at is u sed qu ite effec-
tively is a beh avior ch art. It can serve as a
p ositive incen tive to good beh avior w h en
th e rep ort is p ositive and is then rew ard ed .
Th e rew ard s can be ad ju sted for th e d egree
of p ositive beh avior obtain ed . N either aver-
sion therap y nor p u n ish m en t is help fu l for
teachin g p atien ts w ith ADH D n ew , m ore
constru ctive behaviors. In terp retive strate-
gies su ch as a w ell-tim ed in terp retation of
m alad ap tive beh aviors or p ositively refram -
in g a n egative exp erien ce are n ot beh avioral
tools.
33. (D ) Motivation for change goes beyond a
d esire for rem oval of sym ptom s and inclu d es
a w illingness to tolerate d iscom fort and to
take risks in a search for u nd erstand ing. The
other d em ographics d o not play as significant
a role.
34. (B) In brief p sychod ynam ic therap y a single,
focal area of conflict is id entified , and d u ring
the therapy the tim e is sp ent actively interpret-
ing transferences as they p ertain to this id en-
tified focal conflict. Many types of therapy
correct cognitive errors and mod ify malad ap-
tive behaviors, although cognitivebehavioral
therapies are specifically concerned w ith these
ou tcom es. Interpretations of d ream s and resis-
tance m ay certainly take place in brief psy-
chod ynam ic therapy; how ever, they are only
interp reted in so far as they relate to the id en-
tified focal conflict.
35. (D ) Psychoanalytic p sychotherap y or psy-
choanalysis is not generally ind icated in
p atients w ho have d ifficu lty w ith reality
testing, such as those w ith schizophrenia.
The inevitable regression, introsp ection, and
self-exam ination required in these intense,
insight-orientated p sychotherap ists are u su -
ally overw helm ing to p sychotic p atients and
actu ally m ay cau se m ore harm than good ,
w ith a resu ltant w orsening of p sychosis. All
of the other types of psychotherapies can be
helpfu l in the treatm ent of schizophrenia or
other psychotic d isord ers.
36. (B) Dream s p rovid e inform ation abou t p sychic
conflicts. In this case, d ream interpretation
m ay help the p atient learn m ore abou t his cu r-
rent u nhap p iness and conflict in his m arried
life. Dream s are u sed to u ncover p sychic con-
flicts, w hich, w hen interp reted app ropriately
and consciou sly (not su blim inally), can lead to
a p rod u ctive change in behavior. Accord ing to
p sychoanalytic theory, d ream s rep resent the
u nconsciou s w orkings of the m ind , not the
conscious ones, and may be symbolic in con-
tent. Interpreting d reams may eventually lead
to an alteration in a patients cond uct, but
reducing cognitive errors or changing behavior
is not its primary purpose.
37. (B) Dialectical behavioral therap y (DBT) w as
d evelop ed to treat bord erline personality d is-
ord er. It is often p erform ed in both grou p and
ind ivid u al settings to m inim ize the intense
transferences often d eveloped by patients
w ith bord erline p ersonality d isord er in ind i-
vid ual therapy. The focu s is on teaching skills
to m inimize m ood d ysregulation and self-
harm. Distress tolerance focuses on d istracting
from and tolerating negative em otions. Cog-
nitive restru cturing is a concept from cogni-
tive therap y that is som etim es em ployed in
DBT. It refers to recognizing and changing
m alad ap tive thou ghts. Em otion regu lation
focu ses on recognizing and regulating m ood
changes. Interp ersonal effectiveness relates to
interp ersonal skills and assertiveness training.

Mind fulness is based on trad itional Bu d d hist
p ractice of being in the m om ent w ithou t
ju d gem ents.
38. (D ) Patients w ho are su icid al characteristi-
cally have severe hopelessness and think
abou t events in rigid , black-and -w hite w ays.
They see very few op tions and becom e over-
w helm ed w ith their feelings of hop elessness
w hich are exacerbated by seeing no w ay
ou t. Begging the qu estion and circu lar rea-
soning are both logical fallacies. They occur
w hen an id ea is p roven to be tru e w hen
assu m ed im p licitly or exp licitly in the p rem -
ise (e.g., only w eak p eop le p u t them selves in
m y position, therefore I am a w eak p erson).
Personalization is ones tend ency to relate
events to oneself w ithou t any reason for d oing
so. Selective abstraction is term from cognitive
therapy w here d etails of a scenario are taken
ou t of context and believed w hile everything
else contrary abou t the scenario is ignored .
39. (B) Cognitive therap y is the p sychotherap y
that w ould be m ost ap prop riate to help this
p articu lar p atient solve problem s m ore p ro-
d uctively. Behavioral therapy is focu sed on
behaviors, not on the p ossible u nd erlying
factors that cause behaviors. H ypnosis is a
sleep-like state ind uced by a therapist, w hich
has been of som e u se in u ncovering psychod y-
nam ic processes and in behavioral m od ifica-
tion such as stopp ing sm oking. Interp ersonal
therapy is aim ed at und erstand ing com m uni-
cation patterns and roles in relationship s. In
p arad oxical therap y, d evelop ed by Bateson,
the therapist su ggests that the patient engage
in the behavior w ith negative connotations
(e.g., a phobia or com pulsion).
40. (B) Storm ing is the second stage of Tu ckm an
stages of group d evelopm ent w hich includ es
p ow er stru ggle and bou nd ary testing; grou p
m em bers m ay have internal conflict w ith each
other or rebel against the facilitator. Form -
ing is the first stage in w hich grou p m em -
bers are oriented to the grou p and roles are
form ed . N orm ing is the third stage in w hich
grou p m em bers get to know each other bet-
ter and resolve their d ifferences. Perform ing
Answe rs : 3143 139
is the next stage w here m em bers w ork hard
to achieve goals. Ad journing is the final stage
w here the w ork is com p lete and / or the grou p
end s.
41. (E) System atic d esensitization is the process
of exposing a patient to feared objects or situ -
ations and teaching them to d ecrease their
anxiety and fear in ord er to overcom e them .
System atic d esensitization is som etim es called
grad u ated exp osu re therap y and can be u sed
w ith m any typ es of anxiety d isord ers, inclu d -
ing social anxiety d isord er (p hobia) and sp e-
cific phobias. Aversion therapy is w hen a
stim ulu s is paired w ith som ething negative
or d iscom forting in ord er to get a patient to
avoid or stop a certain m alad aptive behavior.
Flood ing is w hen a p atient is exp osed to the
m ost feared situ ation all at once. Mod eling is
w hen observed behaviors are im itated . Su g-
gestion is w hen an id ea or behavioral change
is consciou sly su ggested to a p atient in ord er
to change the behavior.
42. (E) Su pportive psychotherap y attem p ts to
fortify p sychological d efenses by provid ing
em p athic reassu rance as op p osed to p rob-
ing into a p atients p sychological conflicts.
Behavioral therap ies u tilize op erant cond i-
tioning, relaxation training, and exposure
techniqu es (am ong others) in ord er to change
d ysfunctional behavior, m ostly in the treat-
m ent of anxiety d isord ers. Cognitive therapy
is often com bined w ith behavioral therap y; it
w as d evelop ed by Aaron Beck and is u sed for
d ep ressive and anxiety d isord ers. It is based
on the belief that the w ay that p atients think
and act are d ue to cognitive schem as w hich
d erive from child hood exp eriences and tem -
p eram ental factors. Dynam ic psychotherapy
d elves into cu rrent and p ast conflicts in ord er
to bring unconscious m aterial into conscious-
ness. Existential psychotherap y is based on
existential p hilosop hy and em p hasizes p er-
sonal feeling and exp erience over rational
thinking.
43. (A) Biofeed back is the p rocess w hereby a
p atient receives inform ation on physiologic
variables in ord er to alter those variables and
140 4: P sycholog ica l Tre a tme nt a nd Ma nag e me nt
u ltim ately the corresp ond ing behavior. For
exam p le, p atients w ith m igraine head aches
obtain inform ation on m u scle tension or tem -
p erature. They w ill then use this inform ation
to d ecrease the intensity of the head aches by
d irectly trying to relax and alter the know n
p aram eters.
44. (N ) Transference (and transference neu ro-
sis) can be und erstood as a general phenom -
enon in w hich the p atient d isp laces onto
others (inclu d ing the therapist) the feelings,
thoughts, and conflicts from the patients past
(p articu larly early child hood ).
45. (C) Flood ing is a techniqu e u sed in behavior
therapy w here a patient is exp osed to a feared
or anxiety-provoking stim u lus all at once to
help him or her overcom e the fear or anxiety.
It is u sed m ost frequ ently in sp ecific p hobias
as in this case.
46. (F) Positive reinforcement is a behavioral tech-
nique w here a rew ard (a sw eet) is given after a
specific behavior (saying thank you) in ord er
to increase the frequency of that behavior.
47. (I) Punishm ent is presenting an aversive
stim ulu s (soap in the m ou th) after a behavior
(biting) in ord er to d ecrease the frequency of
that behavior. Countertransference (B) is the
com pilation of a therapists feelings tow ard
a patient. H ypnosis (D ) is a sleep -like state
ind u ced by a therap ist, w hich has been of
som e u se in u ncovering u nconsciou s pro-
cesses and in behavioral m od ification su ch as
sm oking cessation. N egative reinforcem ent
(E) is an operant cond itioning techniqu e w here
an aversive stim u lu s is rem oved in ord er to
increase the frequ ency of a d esired behavior.
For exam p le, p u tting on you r seat belt so the
car w arning stops beeping. Projection (G) is a
d efense m echanism w here u nw anted feelings,
attitu d es, and thou ghts are u nconsciou sly
attribu ted to others. Projective id entification
(H) is sim ilar to p rojection, bu t w ith the ad d i-
tion that the other ind ivid ual is ind u ced to
behave in su ch a w ay as to confirm the p rojec-
tions. The real relationship (J) is consid ered to
be the relationship betw een a p sychoanalyst
and p atient w hich is not influ enced by trans-
ference. A schem a (K) refers to an organized
p attern of thou ghts or behaviors relating to
oneself, others, and the environm ent arou nd .
Splitting (L) is another d efense m echanism
characterized by view ing feelings, others,
and situ ations in all good or all bad term s.
Therap eu tic alliance (M) refers to the healthy
relationship betw een a p hysician/ therap ist
and p atient. Und oing (O) is a d efense m echa-
nism w here a p atient attem pts to u nd o an
u nw anted thou ght or action (e.g., an obses-
sion) by engaging in contrary behavior (e.g., a
com pu lsion).
48. (B) Jean-Martin Charcot is known for his contri-
butions to neurology, including the description
of many medical diseases including Charcot
Marie tooth disease, amyotrophic lateral scle-
rosis (ALS), Charcot joint, Charcot aneurysms,
and Charcot triad. He was also known for his
descriptive work on hysteria and other neuroses.
49. (A) Josef Breu er is know n for his u se of the
cathartic treatm ent or talking therap y in the
fam ous case of Anna O, w hich w as su bse-
qu ently follow ed closely by Sigm u nd Freu d .
50. (E) H einz Kohu t is m ost w ell-know n for his
d evelop m ent of self-psychology. It w as a
very influ ential school of thou ght w ithin
p sychoanalysis and help ed d irect m od ern
ap p roaches to therap y, p articu larly concern-
ing the treatm ent of narcissism . Erik Erikson
(C) w as a p sychoanalyst w ho p osited eight
stages of d evelopm ent, from infancy to old
age. Sigm u nd Freu d (D ) w as the fou nd er of
p sychoanalysis, best know n for his theories of
the u nconsciou s m ind . Franz Anton Mesm er
(F) is consid ered the father of m od ern hyp no-
sis; the w ord m esm erism is d erived from his
nam e.
 CHAPTER 5
Le g al and Ethic al Is s ue s in
Ps yc hiatry and Me dic ine
Que s tions
DIRECTIONS (Questions 1 through 51): For each of
the multiple-choice questions in this section, select
the lettered answ er that is the one best response in
each case.
Questions 1 and 2
The case m anager for a 35-year-old m an that you are
treating contacts you to d iscuss concerns regard ing
a change in your p atients behaviors. You learn from
the case m anager that the patient has been m ak-
ing p rovocative sexu al com m ents tow ard her over
the past m onth. Du ring your session, the p atient
exp resses concern that his case m anager is som ehow
conspiring against him and he plans to d o som e-
thing abou t it. On fu rther qu estioning, he becom es
increasingly irritable and abru p tly storm s ou t of
you r office. You hear him in the hallw ay exclaim ing,
That w om an, Im going to stab her and she w ont
bother m e anym ore!
1. You r first cou rse of action shou ld be w hich of
the follow ing?
(A) Attem p t to contact the p atient over the
next several hou rs to d iscu ss the intent
of his threat tow ard his case m anager.
(B) Contact the p atients fam ily and let
them know abou t his threats tow ard the
case m anager.
(C) Inform the p olice of the content of you r
p reviou s sessions and his recent threat
tow ard the case m anager.
(D) N otify the case m anager of the p otential
d anger.
(E) Resp ect the p atients confid entiality
and w ait u ntil you r next sched u led
ap p ointm ent w ith him to d iscuss his
feelings.
2. The legal p reced ent that gu id es the ap p rop ri-
ate cou rse of action in this case is w hich of the
follow ing?
(A) Durham v. United States
(B) OConnor v. Donaldson
(C) Rogers v. Commissioner of the Department
of M ental Health
(D) Rouse v. Cameron
(E) Tarasoff v. Regents of University of California
Questions 3 through 5
Tw o years ago, you w ere the anesthesiologist
involved in a cesarean d elivery of a baby born w ith
cerebral palsy. You had heard from your obstetrical
colleagu e that the fam ily w as planning to sue, and
tod ay a process server d elivers papers notifying you
that the fam ily has brought an action against the
p hysicians involved in the su rgery, inclu d ing you.
3. In m ed ical m alp ractice cases, the p laintiff
m ust establish w hich of the follow ing?
(A) Burd en of p roof beyond a reasonable
d ou bt
(B) Clear and convincing evid ence of
w rongd oing
(C) Crim inal intent
(D) Crim inal m ischief
(E) H arm or d am age
141
142 5: Le ga l a nd Ethica l Is s ue s in P sychia try a nd Me d ic ine

4. Which of the follow ing behaviors best p rotects 7. The p atients fam ily hires an attorney to chal-
a p hysician against a m alp ractice su it? lenge the valid ity of her w ill. Which of the
follow ing item s, if p resent, w ou ld u nd erm ine
(A) H aving the patient sign a no harm
this patients com petence to m ake a w ill?
contract.
(B) H iring a m alp ractice attorney to (A) Inability to read and w rite.
exam ine the p hysicians treatm ent (B) Paranoid d elu sions regard ing the
p ractices. p atients fam ily.
(C) Maintaining a good therap eu tic alliance (C) Patients nond elu sional exp lanation of
w ith the p atient. w hy she w ants to d onate her estate to
(D) Refusing to prescribe m ed ications that the local hum ane society.
m ay have ad verse effects. (D) Presence of a d iagnosable p sychiatric
(E) Seeing the p atient in clinic on a w eekly d isord er.
basis. (E) Refu sal to u nd ergo treatm ent
recom m end ed by her p rim ary care
5. When d eterm ining m ed ical m alpractice, the p hysician.
term stand ard of care refers to the use of
m ed ical and p sychiatric treatm ents that are: Questions 8 and 9
(A) End orsed by the Am erican Med ical A 23-year-old m an w ith no p rior p sychiatric history
Association is charged w ith m u rd ering his next-d oor neighbor.
(B) Evid ence based H is friend s note that he becam e increasingly iso-
(C) Safe and free from any p otential lative and su sp iciou s of others in the w eeks p rior
negative sid e effects to the crim e. The exam ining psychiatrist reported
(D) The m ost cu rrent treatm ents available that the m an harbored paranoid d elu sions regard -
ing his neighbor and noted that his thou ght p rocess
(E) Used by average, reasonable
w as too d isorganized to com p lete the exam ination.
p ractitioners in sim ilar circu m stances
8. Which of the follow ing legal stand ard s is
Questions 6 and 7
the cu rrent basis for establishing an insanity
An 80-year-old w id ow w ith a h istory sign ificant d efense?
for schizop hrenia w as recently d iagnosed w ith (A) Am erican Law Institu te test (Mod el
end -stage hep atic cancer. She is concerned abou t Penal Cod e)
the d isp osition of her estate and d oes not w ant
(B) Du rham ru le
her fam ily to receive any of h er m on ey. Sh e p lans
to d onate her entire estate to the local hu m ane (C) Irresistible im p u lse ru le
society. (D) MN aghten ru le
(E) Prod u ct ru le
6. Which of the follow ing is m ost im p ortant in
establishing a legally valid w ill? 9. Crim inal resp onsibility requ ires d em onstra-
tion of the crim inal act along w ith w hich of the
(A) Conservatorship of estate
follow ing elem ents?
(B) Inform ed consent
(C) Lack of m ental illness (A) Dim inished m ental cap acity
(D) Testam entary cap acity (B) Mens rea
(E) Witnesses at the signing of a w ill (C) Mod u s op erand i
(D) Psychiatric d isord er
(E) Witness to the act

Questions 10 and 11
An obese 54-year-old w oman presents via ambu-
lance to the emergency d epartment complaining of
severe substernal chest pain lasting 40 minutes, pro-
fuse sw eating, and nausea. Her vital signs are blood
pressure 195/ 96 mm H g, heart rate 63 beats/ min,
respiratory rate 18 breaths/ min, temperature 98.8F.
An electrocardiogram reveals 3-mm ST-segment ele-
vations in lead s V4, V5, and V6. Cardiac enzymes and
laboratory w orkup are pend ing. You suspect a lateral
w all myocardial infarction and recommend imme-
d iate thrombolytic therapy. The patient exclaims,
Youre crazy if you think Im going let some intern
care for me! My family w ill d rive me across tow n to
the private hospital! The patient then jumps from
the gurney and begins w alking tow ard the exit.
10. Which of the follow ing is the m ost ap prop riate
next step?
(A) Ad m it the patient to the card iology
service on a physician em ergency
certificate.
(B) Allow the p atient to leave against
m ed ical ad vice.
(C) Detain the p atient u ntil the resu lts of the
card iac enzym es are available.
(D) Detain the p atient u ntil you can assess
her ability to p rovid e inform ed consent.
(E) Sed ate the p atient and begin
throm bolytic therapy.
11. On further evalu ation, the patient d em on-
strates a thorou gh u nd erstand ing of the infor-
m ation you have given to her and ap p reciates
the consequences of not being treated im m e-
d iately. The ap propriate next step is w hich of
the follow ing?
(A) Ad m it the p atient to the card iology
service on a physician em ergency
certificate.
(B) Allow the p atient to leave against
m ed ical ad vice.
(C) Detain the p atient u ntil the resu lts of the
card iac enzym es are available.
(D) Detain the p atient so that her fam ily can
m ake d ecisions on her behalf.
(E) Sed ate the p atient and begin
throm bolytic therap y.
Que s tions : 413 143
12. A 19-year-old m an w ith a history significant
for bip olar I d isord er is charged w ith assau lt-
ing a p olice officer. This is the m ans fifth arrest
in the p ast 4 m onths for aggression tow ard an
au thority figu re. The assigned attorney has
inform ed the forensic p sychiatrist involved
in the case that the p atient has been nonco-
operative and belligerent w hile attem p ting
to prepare for his d efense. The attorney also
questions w hether the patient has an und er-
stand ing of the severity of his crim e given his
acu te m ental state and lack of form al ed uca-
tion. Which of the follow ing item s w ou ld be
consistent w ith the assertion that the patient is
incom p etent to stand trial?
(A) Failu re to com p rehend the crim inal
charges.
(B) H istory of p rior assau lt charges.
(C) Inability to p rovid e inform ed consent.
(D) Inability to read and w rite.
(E) Presence of a d iagnosable m ental
illness.
13. A 35-year-old m an is brou ght to the em er-
gency room by his fam ily for threatening to
shoot his m other in the chest. Urine toxicology
is negative for cocaine, p hencyclid ine (PCP),
or op ioid s, and his blood alcohol level is 0.04.
You learn from the p atients fam ily that for
several d ays he has been threatening to kill his
m other and has even w ritten notes about how
he w ou ld execu te his p lan. On m ental statu s
exam ination (MSE), the p atients sp eech is
lou d , p ressu red , and threatening tow ard the
em ergency d ep artm ent staff. Fam ily history
is significant for a bip olar sp ectru m d isor-
d er. The patient states that he has not d one
anything w rong and d em and s to be released
im m ed iately. Which of the follow ing next
steps w ou ld be the m ost appropriate?
(A) Arrange for a p olice hold given the
p atients p otential for violence.
(B) Involu ntarily ad m it the p atient to an
inp atient p sychiatric w ard .
(C) Med icate the p atient w ith a m ood
stabilizer and arrange for outpatient
follow -u p .
144 5: Le ga l a nd Ethica l Is s ue s in P sychia try a nd Me d ic ine
(D) N otify the police abou t the patients
hom icid al threats.
(E) Warn the patients m other about the
p atients threats.
Questions 14 and 15
You are the psychiatrist on d uty w hen a man, arrested
by the police for assaulting his w ife, is brought into
the emergency room for an evaluation. The mans
behavior is w ild and unpredictable. H e refuses to
answ er your questions and accuses you of having
an affair w ith his w ife. At one point he picks up a
chair and looks menacingly at a nurse before being
subd ued by police officers. Detectives tell you that
the man has been arrested in the past for aggression
tow ard family members, and that the only chance of
his avoid ing jail time that night is to be ad mitted to
the psychiatric unit. H ow ever, the man makes it clear
that he d oes not w ant to stay in the hospital.
14. Which of the follow ing shou ld ju stify the
p hysicians d ecision to involu ntarily ad m it
the patient?
(A) H istory of prior p sychiatric
hosp italization.
(B) Im m inent threat to others.
(C) Med ication noncom p liance.
(D) Presence of a d iagnosable m ental
d isord er.
(E) Refu sal to follow -u p w ith p sychiatric
ou tpatient services.
After being ad m itted to the psychiatric unit, the
patient becom es increasingly aggressive tow ard
staff. H e ad am antly refu ses all m ed ications offered
to help calm his agitated behaviors. The patient at
one point accu ses a staff m em ber of stealing m oney
from his w allet and attem p ts to p u nch him . You
place a stat ord er for a H ald ol 5 m g intram u scu lar
(IM) injection to sed ate the p atient and p revent fu r-
ther escalation of his com bative behaviors.
15. Ad m inistering the H ald ol w ithou t the
p atients consent d irectly challenges w hich of
the follow ing ethical principles?
(A) Au tonom y
(B) Beneficence
(C) Confid entiality
(D) Ju stice
(E) N onm aleficence
16. A 36-year-old woman with delusional disord er
is brou ght to the em ergency room by p olice
after she w as fou nd tresp assing on the Gov-
ernor s p rivate estate. She claim s she has
been having an affair w ith the Governor and
d em and s that he acknow led ge he is the father
of her 5-year-old son. This is the third tim e the
p atient has been caught stalking the Gover-
nor. The patient is su bsequ ently ad m itted to
the inp atient unit and d ischarged several d ays
later to her p arents w ith w hom she lives. The
Governor u ltim ately d ecid es to pu rsue charges
against the w om an. The w om ans attorney
em p loys a forensic p sychiatrist to evalu ate the
w om an and rend er an op inion abou t her m en-
tal status at the tim e of the crim e. Which of
the follow ing statem ents regard ing her incar-
ceration is m ost accu rate if fou nd not guilty by
reason of insanity?
(A) She w ill not serve any tim e and w ill
be released w ith close p sychiatric
follow -u p .
(B) She w ill serve half her crim inal sentence
incarcerated and the other half in a
locked p sychiatric facility.
(C) She w ill serve her original crim inal
sentence once she is d eem ed sane.
(D) She w ill serve less tim e than if fou nd
gu ilty.
(E) She w ill serve m ore tim e in a locked
p sychiatric u nit than she w ou ld in
p rison if she w ere fou nd gu ilty.
Questions 17 and 18
A 9-year-old girl is brou ght to the p ed iatric em er-
gency d ep artm ent by her p arents for evalu ation of
a p ersistent cough. She is w ithd raw n and com plains
of a scratchy throat. Vital signs are stable and the
p atient is afebrile. On exam ination, the lungs are
clear to auscultation bilaterally and the posterior
oropharynx is clear. There are m ultiple bruises on
her bu ttocks and back. A chest x-ray d em onstrates
several rib fractu res in d ifferent stages of healing.
H er p arents rep ort that their d au ghter is qu ite active

w ith her you nger siblings and often gets into fights
w ith them . The p atient agrees w ith her p arents.
17. Which of the follow ing is the m ost likely
d iagnosis?
(A) Age-app ropriate rou gh p lay
(B) Major d ep ressive d isord er
20. At the p atients next follow -u p visit, she
(C) Physical abu se
(D) Sexu al abu se
(E) Som atic sym p tom d isord er
18. Which of the follow ing is the m ost ap p rop ri-
ate next step ?
(A) Confront the siblings abou t their
behavior.
(B) Discharge the p atient w ith follow -u p in
1 w eek to reevalu ate her bru ises.
(C) N otify Child Protective Services.
(D) Refer for fam ily therapy to ad d ress the
issu e of rou gh p lay.
(E) Treat the p atient w ith p enicillin.
Questions 19 and 20
A 17-year-old girl p resents to you r office com plain-
ing of a bu rning vaginal d ischarge. She inform s you
21. A 44-year-old m an w ith insu lin-d ep end ent d ia-
that she has been involved in a consensual sexu al
relationship w ith her boyfriend and is w orried that
she has contracted a sexu ally transm itted d isease
(STD). You start the p atient on antibiotics. Three
days later, you discover that the culture of her vaginal
d ischarge grew N eisseria gonorrhoeae.
19. A few d ays later, you receive a call from the
p atients p arents d em and ing to know w hy
their d au ghter w as seen in you r office. Which
of the follow ing is the m ost appropriate next
step?
(A) Alert the parents that their d au ghter is
at risk for hu m an im m u nod eficiency
virus (H IV) and shou ld be tested .
(B) Ask the p arents abou t their d au ghters
sexu al history.
(C) Exp lain to the p arents that their
d au ghter has contracted an STD and
requ ires im m ed iate antibiotic treatm ent.
Que s tions : 1421 145
(D) Find ou t the boyfriend s nam e and
telephone num ber to confirm the
history.
(E) Maintain confidentiality by disclosing no
information, but encourage the patient to
d iscuss this issue w ith her parents.
requ ests to be tested for H IV. She rep orts that
her boyfriend recently tested negative, bu t
given her ad m itted p rom iscu ity, she w ond ers
if she has contracted H IV. Which of the follow -
ing shou ld be d one p rior to ad m inistering the
H IV test?
(A) Directly inform the p atients boyfriend
that he is at risk for H IV.
(B) Exp lain to the p atient how the test is
p erform ed and interp reted , along w ith
inform ation on confid entiality and how
you w ill p roceed if the resu lt is p ositive.
(C) Inform the d ep artm ent of p u blic health
of you r intent to ad m inister an H IV test.
(D) N otify her p arents abou t the patients
requ est for an H IV test.
(E) Perform a p regnancy test.
betes m ellitu s and end -stage renal failu re has
been on d ialysis for several years w hile aw ait-
ing a kid ney transp lant. H e feels as thou gh he
has w aited long enough and d oes not w ant
to continu e living tied to a m achine. After
several fam ily m eetings and consultations
w ith other p hysicians, he inform s you that he
no longer w ishes to be d ialyzed . You obtain a
p sychiatric consu lt that conclu d es no evid ence
of a m ood or thou ght d isord er. The fam ily is
u p set w ith the p atients d ecision and d em and s
that you continue to ad minister d ialysis u ntil a
transplant is available. Which of the follow ing
is the m ost ap p rop riate next step ?
(A) Coerce the p atient into continu ing
treatm ent.
(B) Continu e d ialysis u ntil you convince the
ethics com m ittee to su p p ort the fam ilys
d ecision.
(C) Encou rage the fam ily to d issu ad e the
p atient from w ithhold ing treatm ent.
146 5: Le ga l a nd Ethica l Is s ue s in P sychia try a nd Me d ic ine
(D) Resp ect the patients w ishes and
d iscontinu e d ialysis.
(E) Tell the patient that a transplant w ill
arrive soon and encou rage him to
rem ain in treatm ent.
22. A 40-year-old su rgical attend ing is ad m itted to
the m ed ical u nit after d eveloping severe right
flank pain. Fu rther w orkup confirm s a d iag-
nosis of nep hrolithiasis. One of the su rgical
resid ents asks you abou t the attend ings con-
d ition in ord er that ad equ ate coverage can be
arranged . Which of the follow ing is the m ost
ap prop riate next step?
(A) Arrange a conference betw een you r
m ed ical attend ing and the su rgical
hou se staff.
(B) Inform the su rgical resid ent of the
attend ings cond ition and length of stay.
(C) Reveal only the estim ated length of stay.
(D) Tell the su rgical resid ent that you w ill
not say anything, bu t she cou ld take a
look in the attend ings chart.
(E) Tell the su rgical resid ent to ad d ress all
concerns d irectly to the attend ing.
23. A 43-year-old m an is referred to you for
continued treatm ent of d epression after his
release from jail. The cou rt m and ated p sychi-
atric treatm ent w hile he is on p robation. The
p atients probation officer calls you for infor-
m ation regard ing his cond ition, p rogress, and
treatm ent com pliance. Which of the follow ing
is the m ost ap p rop riate resp onse?
(A) Corresp ond w ith the p robation officer
only through w ritten d ocum ents.
(B) Discuss the case with the probation officer
because the treatment is court mandated.
(C) Ignore the requ est altogether becau se
p sychiatric treatm ent bears no relation
to law enforcem ent.
(D) Lim it you r d iscussion w ith the
p robation officer to only treatm ent
com pliance because the rest of the
inform ation is confid ential.
(E) Obtain a confid entiality w aiver from the
p atient before speaking to the probation
officer.
24. A 23-year-old w om an w ith a know n history
of heroin u se is ad m itted for intravenou s (IV)
antibiotic treatm ent for infective end ocard itis.
The nu rse inform s you that the p atient w as
accid entally given the w rong antibiotic bu t
has su ffered no ad verse reaction. Which of the
follow ing is the m ost ap p rop riate next step ?
(A) Encourage the p atient to seek legal
action becau se a critical m istake has
occu rred .
(B) Enforce the no harm , no d isclosu re
ru le.
(C) First rep ort the m istake to the hosp ital
ad visory com m ittee.
(D) Inform the p atient that she w as given
the w rong m ed ication.
(E) Notify the patients family of the mistake.
25. A 38-year-old w om an is ad m itted to the oncol-
ogy u nit w ith severe aplastic anem ia. She
ap p ears p ale and w eak. Vital signs ind icate a
blood p ressu re of 110/ 75 m m H g and a p u lse
of 110/ m in. H em atocrit is 18%. On MSE, cog-
nition is intact and there is no evid ence of a
m ood or p sychotic d istu rbance. The p atient
states that she is a Jehovahs Witness and
refu ses any blood transfu sion on the basis of
her religiou s beliefs. Which of the follow ing is
the most appropriate next step in the treatment
of this patient?
(A) Ad m inister p acked red blood cells.
(B) Exp lain the im p lications of no treatm ent
bu t resp ect the p atients refu sal for
treatm ent.
(C) Persu ad e the p atient that she m u st
accep t the transfu sion.
(D) Refer the case to the hosp itals ethics
com m ittee.
(E) Refer the p atient for involu ntary
p sychiatric treatm ent based on her
life-threatening d ecision.
26. The p arents of a new born w ith Dow n syn-
d rom e find their d au ghter to be lethargic
and m inim ally resp onsive. Med ical evalu a-
tion is significant for the follow ing cerebro-
spinal flu id find ings: opening pressu re of
100 m m H g, w hite blood cell cou nt of 5,000/ L

(p red om inantly neu trop hils), protein m ore
than 40 m g/ d L, glu cose content m ore than
40 m g/ d L, and Gram stain p ositive for bac-
teria. You suspect grou p B streptococcal m en-
ingitis and recom m end IV antibiotic therap y.
The p arents feel as thou gh their child w ill u lti-
m ately have a p oor quality of life and requ est
that treatm ent be w ithheld . Which of the
follow ing is the m ost app rop riate next step ?
(A) Refer the case to the ethics com m ittee
for review at their next sched u led
m eeting.
(B) Rep eat the lum bar punctu re to verify
the d iagnosis.
(C) Resp ect the p arents w ishes becau se
they are the prim ary d ecision m akers.
(D) Start intravenous antibiotics against the
p arents w ishes.
(E) Threaten to rep ort the p arents to child
p rotective services unless they change
their d ecision.
27. You are a p sychiatrist w ho hosts a m orning
rad io show d ed icated to ed u cating the general
p u blic abou t m ental illness. Du ring a qu es-
tion and answ er segm ent, a caller p hones in
to ask abou t you r op inion regard ing a prom i-
nent politician w hose recent erratic behaviors
have gained significant m ed ia attention. The
caller asks you d irectly w hether you believe
the p olitician has a bipolar sp ectru m d isord er.
Which of the follow ing resp onses is the m ost
ap prop riate?
(A) Com m ent in w ritten form only.
(B) Offering a p sychiatric d iagnosis in su ch
instances is u nethical.
(C) Provid e an off-the-record or
anonym ou s opinion.
(D) State you r d iagnosis bu t ind icate that
other problem s m ay account for the
sym p tom s.
(E) Stating you r op inion p u blicly is
legitim ate as long as the p olitician is not
you r p atient.
28. An 84-year-old w id ow ed m an w ith severe
m ajor neu rocognitive d isord er (d em entia),
for w hom you have been the p rim ary care
Que s tions : 2229 147
p hysician for years, is d iagnosed w ith hepato-
cellu lar carcinom a. The patient d oes not have
an ad vance d irective and never d esignated a
p ow er of attorney. Psychiatric consultation
conclud es that the patient is unable to m ake
an inform ed d ecision regard ing treatm ent
options, and you tu rn to his fam ily for gu id -
ance. The p atients old est son is ad am ant that
his father receive chem otherapy, w hile the
tw o you nger d au ghters feel that he shou ld
not su ffer the ad verse effects of chem otherapy
especially becau se hes so d em ented . Which
of the follow ing is the next appropriate step?
(A) Abid e by the d aughters w ishes becau se
the patients quality of life is already poor.
(B) Abid e by the sons w ishes becau se he is
the old est.
(C) Ask the p atient w hich fam ily m em ber
he w ou ld like to d esignate p ow er of
attorney.
(D) Consu lt the hosp itals ethics com m ittee.
(E) Let the p atient d ecid e w hether or not to
p roceed w ith treatm ent.
29. A 27-year-old w om an w ho is 3 m onths post-
p artu m is brou ght to the em ergency room by
her hu sband and m other w ith concerns that
the patient is not acting like herself. The
hu sband inform s the consu lting p sychiatrist
that for the past few w eeks the p atient has
been increasingly irritable, w ithd raw n, and
crying alm ost d aily. H e d oesnt u nd erstand
w hy the p atient is behaving like this given
that the p regnancy w as planned and the
p atient w as looking forw ard to having a fam -
ily. The p atient tearfu lly ad m its that this is her
first child and that she is overw helm ed w ith
the responsibilities of being a new m other.
On fu rther qu estioning, she hesitantly con-
fesses to intru sive thou ghts of su ffocating
her child and som etim es w orries abou t being
alone w ith the baby. She d enies su icid al id e-
ation or aud itory/ visu al hallu cinations. The
p atient is w illing to seek ou tp atient treatm ent
bu t ad am antly refu ses volu ntary ad m ission.
H er m other states that the p atient is ju st
exhau sted and that everything w ill be fine
after she gets som e rest. Which of the follow -
ing is the m ost ap p rop riate next step ?
148 5: Le ga l a nd Ethica l Is s ue s in P sychia try a nd Me d ic ine
(A) Ad m inister a stat d ose of lorazep am
2 m g IM and reevalu ate w hen the
p atient is m ore calm .
(B) Ad m it the patient involuntarily.
(C) Call Child Protective Services becau se
the infant is at risk of harm .
(D) Discharge the p atient and inform
the hu sband and m other to bring
the patient back to the hosp ital if her
sym ptom s d o not im prove in the next
few w eeks.
(E) Give the p atient a 2-w eek sup ply of
flu oxetine to treat her d ep ression and
then arrange ou tpatient follow -up.
30. A physician is at a comm unity fair w ith her
spouse w hen a patient approaches the p sychi-
atrist to say hello. The spou se d oes not recog-
nize the patient. The patient d oes not introd u ce
him self to the sp ou se, nor d oes the physician
acquaint the tw o. After a brief conversation,
the patient politely excu ses him self and leaves.
On the w ay hom e, the spouse asks, Who w as
that man you w ere talking to earlier? The
physician should d o w hich of the follow ing?
(A) Answ er the sp ou ses qu estion tru thfu lly.
(B) Ask the sp ou se to gu ess the id entity of
the person.
(C) Inform the sp ou se that he m u st first
p rom ise not to reveal the id entity of the
p atient before answ ering the qu estion.
(D) Inform the sp ou se that revealing
su ch inform ation w ou ld com prom ise
confid entiality.
(E) Lie to the sp ou se to p rotect the id entity
of the patient.
Questions 31 and 32
You have been treating a fem ale patient w ho has
been seeing you for p sychod ynam ic p sychotherap y
for app roxim ately 6 m onths. N ear the end of the
su ggested cou rse of treatm ent, the p atient reports
that she feels m arked ly better abou t her progress
and attributes her im p rovem ent to you r exp ertise.
Prior to the last session, she confesses that she has
alw ays found you attractive and that she w ou ld like
begin an intim ate relationship w ith you . You feel
flattered by the p atients sexu al interest and are su r-
p rised by you r ow n interest in the patient.
31. Which of the follow ing is the most appropriate
cou rse of action?
(A) Decline p articip ation in the relationship
becau se sex w ith a form er p sychiatric
p atient is u nethical.
(B) Engage in sexu al relations becau se sex
w ith a cu rrent or form er p sychiatric
p atient is ethical.
(C) Engage in sexu al relations becau se sex
w ith a form er p sychiatric p atient is
p erm issible only if you d o not exp loit
you r p ast p osition of au thority.
(D) Engage in sexu al relations becau se there
is no established p rofessional cod e of
ethics regard ing sex w ith p sychiatric
p atients.
(E) Inform the p atient that the p rofessional
cod e of ethics requ ires that you w ait
1 year after term ination before you can
ethically engage in sexu al relations.
32. Which of the follow ing w ou ld be the m ost
ap p rop riate cou rse of action if the above
p atient w ere you r m ed ical or su rgical p atient?
(A) Decline particip ation in the relationship
becau se sex w ith a cu rrent p atient is
u nethical.
(B) Engage in sexu al relations becau se sex
w ith a cu rrent nonp sychiatric p atient is
ethical.
(C) Engage in sexu al relations becau se sex
w ith a cu rrent nonp sychiatric p atient is
p erm issible only if you d o not exp loit
you r p ast p osition of au thority.
(D) Engage in sexu al relations becau se there
is no established p rofessional cod e of
ethics regard ing sex w ith nonp sychiatric
p atients.
(E) Inform the p atient that the p rofessional
cod e of ethics requires that you w ait
1 year after term ination before you can
ethically engage in sexu al relations.
33. A 52-year-old man, for w hom you have been
the primary care physician for the last 20 years,

w as recently diagnosed w ith amyotrophic
lateral sclerosis. The disease has rapid ly pro-
gressed and he has experienced multiple respi-
ratory complications that likely w ill require a
tracheotomy. Severe muscle w eakness and atro-
phy are apparent in all limbs. The patient states
that there is no meaning in continuing w ithout
his physical capacities. H e asks for your help
in ending his life in a humane and d ignified
manner. H is MSE is unremarkable and there
is no evidence of any psychiatric d isorder. You
d iscuss the patients request w ith his family and
they unanimously support his d esire to end
the suffering. Which of the follow ing w ould
be the most appropriate course of action?
(A) Ignore the p atients requ est.
(B) Provid e the p atient w ith inform ation
regard ing how to effectively end his
life.
(C) Provid e the p atient w ith enou gh
m ed ication refills to p rovid e a lethal
d ose.
(D) Refu se to p articip ate in assisting the
p atient w ith su icid e and focu s on
resp ond ing to the p atients end -of-life
issu es.
(E) Resp ect the p atients w ishes by help ing
him end his life in a p ainless and
resp ectfu l m anner.
34. You are an inp atient p sychiatrist treating a
p atient w ith bip olar I d isord er. The p atient
has a long history of m ed ication noncom p li-
ance resu lting in severe, persecu tory d elu -
sions d u ring his m anic ep isod es. After 1 w eek
of treatm ent, you receive a p hone call from
hospital ad m inistration inform ing you that
the p atients insu rance w ill not cover the cost
of an ad d itional inpatient stay. You are encou r-
aged to d ischarge the p atient so that the hosp i-
tal w ill not have to incu r these costs. You feel,
how ever, that the p atient requ ires m ore tim e
on the inpatient u nit because of safety con-
cerns. Which of the follow ing actions w ou ld
be the m ost ap p rop riate?
(A) Contact the insu rance com pany w ithou t
the patients perm ission and request
coverage for ad d itional d ays.
Que s tions : 3036 149
(B) Ensu re that the p atient is established
w ith a casew orker to su p ervise the
p atient in the com m unity before
d ischarge.
(C) Establish follow -u p at the p atients
outpatient com m u nity m ental health
facility p rior to d ischarge.
(D) Keep the p atient on the u nit as long as it
is m ed ically necessary.
(E) Sp eak w ith the inp atient social w orker
to d eterm ine w hether the patient is
eligible for a loan.
Questions 35 and 36
You receive a subp oena from an attorney rep resent-
ing a p arty that has filed a law su it against one of
you r p atients. The su bp oena p ertains to releasing
the m ed ical record s of you r patient.
35. Which of the follow ing is the m ost ap p rop riate
next step ?
(A) Contact the attorney w ho obtained
the su bpoena to d iscu ss the p rocess of
releasing the m ed ical inform ation.
(B) Do not release the inform ation and
contact your patient regard ing the
su bpoena.
(C) Release the m ed ical record s d irectly to
the presid ing jud ge.
(D) Release the m ed ical record s u p on
receiving the su bp oena.
(E) Requ est that the p atient sign a release
of inform ation form and tu rn over the
record s.
36. A cou rt hearing has been organized by you r
p atients attorney to qu ash the su bpoena you
have been issu ed . At the hearing, the ju d ge
rules that you should release the entire m ed i-
cal record even thou gh your patient has not
consented to the release of information. Which
of the follow ing w ould be the most appropriate
next step?
(A) Ap p eal to the states Sup rem e Cou rt to
block the release of the m ed ical record .
(B) Refu se to d isclose the p atients m ed ical
record regard less of the cou rt ord ers.
150 5: Le ga l a nd Ethica l Is s ue s in P sychia try a nd Me d ic ine
(C) Release only inform ation that w ill not
incrim inate you r p atient.
(D) Release the com p lete m ed ical record to
the jud ge.
(E) Work ou t a p lan of legal action w ith
you r p atient.
37. A cou rt-ap pointed forensic psychiatrist is
evalu ating a m an charged w ith arm ed robbery
to d eterm ine w hether he is com petent to stand
trial. Du ring the interview, the d efend ant con-
fesses to m u rd ering a w om an 3 years ago
and hid ing her bod y in an u nd isclosed area.
Which of the follow ing actions w ou ld be the
m ost appropriate?
(A) Avoid d etails of the d efend ants prior
crim inal history in the report.
(B) Encou rage the d efend ant to sp eak w ith
his attorney about the m u rd er.
(C) Im m ed iately notify au thorities of the
d efend ants confession.
(D) Inclu d e this d etail in the final rep ort.
(E) Withd raw from the case.
38. A 28-year-old w om an w ith m ajor d ep ressive
d isord er has been seeing you for w eekly psy-
chotherap y and has failed to p ay her bill for
2 m onths. Which of the follow ing is the m ost
ap p rop riate next step ?
(A) Contact the patients family to d etermine
if the patient is financially stable.
(B) Contract w ith a billing collector to
d em and im m ed iate p aym ent.
(C) Inform the p atient that you w ill not see
her if she d oesnt pay for her treatm ent.
(D) Inqu ire as to the reasons she has been
avoid ing p aym ent at the p atients next
visit.
(E) Term inate the treatm ent.
39. A wealthy 46-year-old male banker is in psy-
chotherapy with you for treatment of a single
episode of major depression. After significant
improvement in his symptoms, he offers you the
opportunity to take part in one of his financial
ventures. The investment appears to be sound
and fairly lucrative. Which of the following is
the most appropriate response to the banker?
(A) Becau se you r d ep ression is im p roved ,
it w ou ld be ap p rop riate for u s to be
bu siness p artners.
(B) I can invest w ith you only w hen ou r
treatm ent is nearing its end .
(C) I have to d ecline; it p otentially
m ay interfere w ith ou r treatm ent
relationship .
(D) It is p robably a bad id ea; Im alread y
com m itted in other investm ents.
(E) Thank you for thinking abou t m e. Id
be honored to invest w ith you .
Questions 40 and 41
A 23-year-old Cau casian Catholic w om an w ith a
history of m ajor d epressive d isord er and m u ltiple
m ed ical illnesses p resents to your office after argu -
ing w ith her hu sband . She is a stay-at-hom e m other
of fou r child ren and ad m its that she is u nable to
w ork becau se of her m ed ical lim itations. She rep orts
that her hu sband d oes not allow her to visit w ith
friend s or fam ily w ithou t his consent and generally
d oes not help w ith child care or other household
d u ties and obligations. As a result, she is becom -
ing increasingly resentfu l, d ep ressed , and isolative.
Du ring the session, she ad m its to thou ghts of killing
herself. Of note, she has a p ast history of an over-
d ose attem pt w ith aspirin.
40. Which of the follow ing is her strongest risk
factor for su icid e?
(A) Age
(B) Gend er
(C) Marital statu s
(D) Past history of su icid e attem p t
(E) Term inal m ed ical illness
41. Which one of the follow ing, if d ocu m ented ,
w ould mostly likely legally protect a physician
in the event of a patient suicid e?
(A) A w ritten no self-harm contract
signed by the p atient.
(B) An assessm ent of su icid e risk and
p rotective factors.
(C) The p atients m issed ap p ointm ents.
(D) The p atients refu sal to consid er
p harm acological treatm ents.

(E) The patients verbal p rom ise to seek
m ed ical attention if feeling su icid al.
42. A 36-year-old m an w ith a history of bip olar I
d isord er is brought to the em ergency d epart-
m ent by p olice after stabbing a patron in a
bar room braw l. H is blood alcohol level w as
0.320 u pon arrival, and the p atient requ ired
intram u scu lar (IM) H ald ol for agitation. The
p atient has no recollection of the event, and
the victim d ied 2 hours later. The p atient has a
history of assau lt w hile being m anic. H e cu r-
rently p articip ates in w eekly p sychotherap y
sessions and attend s his m ed ication m anage-
m ent ap pointm ents every m onth. H is law yer
has chosen to assert an insanity p lea in d efense
of the patient. Which of the follow ing factors
is m ost likely to u nd erm ine his assertion of the
insanity d efense?
(A) Inability to recall the event.
(B) Mental d isease or d efect.
(C) Prior history of assau lt.
(D) Voluntary intoxication.
(E) Violent nature of the crim e.
43. You are a forensic p sychiatrist hired as an
exp ert w itness by the d efense attorney of a
m entally ill p atient charged w ith crim inal m is-
cond u ct. The attorney is seeking you r help in
convincing the ju ry that the patient w as m en-
tally ill at the tim e of the crim e. Which of the
follow ing is your prim ary resp onsibility as an
exp ert w itness?
(A) Cou ntering evid ence of crim inal
resp onsibility.
(B) Establishing reasonable d ou bt.
(C) Evalu ation, d iagnosis, and initiation of
treatm ent of the accu sed .
(D) Obtaining a not guilty by reason of
insanity verd ict.
(E) Rend ering an opinion based on
reasonable m ed ical certainty.
Questions 44 and 45
A 48-year-old m an is involu ntarily ad m itted to the
hosp ital after an acute m anic episod e. The patient
is hyperactive, d em and ing, and increasingly talk-
Que s tions : 3745 151
ative on the u nit. H e becom es intru sive, not able to
be red irected , and d em and s im m ed iate release. You
exp lain to him that you feel he is gravely d isabled
and u nable to care for him self. H e d isagrees w ith
you and d em and s d u e p rocess.
44. On w hich of the follow ing legal princip les is
the patients request for a hearing based ?
(A) Actu s reu s
(B) H abeas corp us
(C) Mens rea
(D) Parens p atriae
(E) Rights u nd er the Fou rth Am end m ent
45. The cou rt agrees that the p atient is severely
d isabled and in need of acu te m ed ical m anage-
m ent. You initiate treatm ent w ith qu etiapine
and his sym ptom s of m ania m arked ly d im in-
ish. The p atient requ ests im m ed iate d ischarge
and agrees to follow u p w ith a p artial hospi-
talization program . You feel that he w ou ld
benefit from fu rther inp atient treatm ent bu t is
no longer gravely d isabled or a threat for self-
harm . Which of the follow ing is the next m ost
ap p rop riate step ?
(A) Ap pease the patient by increasing
sm oking privileges.
(B) File for another cou rt hearing to d etain
the patient fu rther.
(C) Ignore the p atients requ est becau se he
has been com m itted by the court.
(D) Persu ad e the patient to stay for a few
m ore d ays.
(E) Release the patient to the partial
hosp italization p rogram .
Questions 46 and 47
You are consu lted by the m ed ical team to evalu -
ate a w om an on the m ed ical u nit w ho su ffers from
a m ajor neurocognitive d isord er (d em entia). The
internist believes that she requ ires a central line for
flu id s and m ed ication, bu t is u nsu re if she is able to
fu lly com p rehend the risks and benefits of the p ro-
ced ure. The team is requ esting help in d eterm ining
her capacity to give inform ed consent.
152 5: Le ga l a nd Ethica l Is s ue s in P sychia try a nd Me d ic ine
46. Which of the follow ing com ponents is the
m ost im portant in obtaining inform ed consent
in this case?
(A) Ability to read and w rite.
(B) Absence of m ental illness.
(C) Involving fam ily m em bers in this
d iscu ssion.
(D) Petitioning a court to establish the
p atients com petence.
(E) Raising alternative treatm ent op tions.
47. The fam ily is su bsequ ently contacted abou t
her cond ition, and they requ est a m eeting
w ith the treatm ent team . Du ring the m eeting,
the patients eld est son notifies you that the
p atient d id create a living w ill ap proxim ately
1 year ago, but they are unsure whether it would
be useful. Which of the follow ing w ould you
tell them best d escribes the pu rpose of a living
w ill?
(A) Absolves personal resp onsibility.
(B) Arranges for fu neral services and
d istribu ting her estate.
(C) Establishes p ersonal p references
regard ing end -of-life issu es.
(D) Prevents the p atient from changing her
m ind about life su pport if she becom es
term inally ill.
(E) Requ ests p hysician-assisted su icid e if
she becom es term inally ill.
48. A 28-year-old m an involved in a m otor vehicle
accid ent brings a law su it against the d river.
Em ergency d ep artm ent record s d o not show
any p hysical inju ries, but the p atient is claim -
ing to su ffer from p osttrau m atic stress d is-
ord er (PTSD). You are asked to evalu ate the
p atients sym p tom s. H e com p lains of d istress-
ing d ream s of the accid ent, having flashbacks
w hile aw ake, and avoid ing the intersection
w here the accid ent occu rred . H is sym p tom s
have lasted for 3 m onths. Past psychiatric his-
tory is significant for m ajor d epressive d isor-
d er, im p u lsivity, and violent behavior. H e has
been incarcerated nu m erou s tim es, show ing
a blatant d isregard for the law. On MSE, the
p atient is likable and coop erative. H is m ood is
rep orted as being d ep ressed and he cu rrently
d enies any hallu cinations or d elu sions. Which
of the following items from your evaluation of
the patient most raises your suspicion regarding
a d iagnosis of m alingering?
(A) Du ration of sym p tom s.
(B) Flashbacks w hile aw ake.
(C) H istory of m ajor d ep ressive d isord er.
(D) Lack of physical inju ries.
(E) Prior incarcerations.
49. One of you r p atients consistently m isses
ap p ointm ents w ithou t giving you ad vance
notice. After num erou s failed attem p ts at
resolving this issu e w ith the patient, you real-
ize that the p atients behavior is not changing
and you d ecid e to d ischarge the p atient from
you r care. Which of the follow ing m ost ap p ro-
p riately d escribes w hat you shou ld d o?
(A) Contact the patients fam ily/ friend s
to requ est their help in im p roving the
p atients attend ance.
(B) N otify the p atients insu rance com p any
that she is d ischarged from you r care.
(C) N otify you r staff that the p atient is not
to be given fu rther appointm ents.
(D) Write a letter to the p atient notifying her
that she has been d ischarged effective
im m ed iately d u e to her failu re to
com ply w ith treatm ent.
(E) Write a letter to the p atient stating that
she w ill be d ischarged in 60 d ays d ue to
her failu re to com p ly w ith treatm ent.
50. You are asked by the cou rt to p rovid e a foren-
sic evaluation for a child cu stod y case. The
child had been living w ith his biological
m other and stepfather since birth. Recently,
the child s stepfather passed aw ay from lu ng
cancer leaving the u nem ployed m other alone
to raise the child . The child s biological father,
w ho is a renow ned orthop ed ic su rgeon in the
com m unity, is requ esting full cu stod y becau se
he asserts that he is better able to financially
su pport the child . The child s m other refu ses
to relinquish cu stod y d u e to concerns that
leaving her hou sehold w ill em otionally im p act
the child . She also im p lies that the father has
anger p roblem s and voices su sp icion as to

w hether he is, in fact, the biological father.
Which of the follow ing factors w ou ld be the
m ost im p ortant in d eterm ining w hich p arent
shou ld get custod y?
(A) Who can p rovid e for the best interests
of the child ?
(B) Who has the highest level of ed u cation?
(C) Who is in the best m ental and p hysical
health?
(D) Who is the m ost financially stable?
(E) Who is the biological p arent?
51. You are an internal m ed icine resid ent w ho has
been assigned to rotate throu gh the inp atient
m ed ical service for the next 2 m onths. Shortly
after you begin, you notice that one of you r
colleagu es consistently com es to w ork late and
sm ells of alcohol. Som etim e later, you notice
Que s tions : 4651 153
that your colleagu e has been m aking increas-
ingly careless m istakes and m issing im p ortant
m eetings and d iscu ssions. Occasionally, you
observe that his hand s shake w hen he is d ocu -
m enting his notes or hold ing his charts. You
are concerned that he m ay have an alcohol use
d isord er. Which of the follow ing is the m ost
ap p rop riate cou rse of action?
(A) Confront the colleagu e and d em and that
he seek ad d iction cou nseling services.
(B) Contact the Dru g Enforcem ent
Ad m inistration to rescind his license.
(C) Do nothing so as to avoid p ersonal
liability.
(D) N otify the hosp itals com m ittee for
im p aired p hysicians.
(E) N otify the local p olice.
 Ans we rs a nd Expla na tions
1. (D ) A physician or therap ist has a d uty to
p rotect id entifiable victim s from im m inent
d anger. This obligation m ay be fu lfilled by
d irectly contacting the p arty at risk, notify-
ing the p olice, or taking other ap p rop riate
m easu res to p rotect the victim . Contacting the
p atients fam ily fails to protect the intend ed
victim . Although notification of the police is an
accep table intervention in this case, d isclosing
u nrelated confid ential inform ation abou t the
p atient is inap prop riate. When notifying third
p arties, care should be taken to release only
inform ation necessary to p rotect the p otential
victim . The rem aining choices fail to protect
the potential victim .
2. (E) Tarasoff v. Regents of University of California
is the land m ark legal p reced ent establishing
liability to third p arties. It ru led that m ental
health p rofessionals have the d uty to p rotect
id entifiable, end angered third p arties from
im m inent threats of seriou s harm m ad e by
their ou tpatients. Therefore, the physician m ay
ethically break confid entiality in cases involv-
ing im m inent harm to others. In the Tarasoff
case, a stud ent at the University of California
(Prosenjit Pod d ar) exp ressed intentions to
kill a fellow stu d ent (Tatiana Tarasoff) to his
therapist. Pod d ar tragically follow ed throu gh
on his threat and m u rd ered the you ng w om an
at her hom e. Tarasoff v. Regents of University
of California hold s legal preced ent only in the
state of California; how ever, the case has been
ad op ted by p hysicians/ therapists as the stan-
d ard of care and has led to nationw id e legis-
lative changes. There have been tw o ru lings
regard ing the Tarasoff case. The original d eci-
sion, Tarasoff I (1976), established a d u ty to
154
w arn. The California Su p rem e Cou rt revised
its p reviou s hold ing in Tarasoff II (1982) w ith
a d u ty to p rotect. Durham v. United States
held that an ind ivid u al is not crim inally
resp onsible if the u nlaw fu l act w as the p rod -
u ct of m ental d isease or m ental d efect. The
d ecision resu lted in the p rod u ct ru le of crim i-
nal responsibility (insanity d efense) and u lti-
m ately w as rep laced by the Am erican Law
Institu te stand ard . In Rogers v. Commissioner
of the Department of M ental Health, the court
exp ou nd ed op inions regard ing the treatm ent
of involu ntarily com m itted patients. OConnor
v. Donaldson and Rouse v. Cameron relate to
involu ntary hosp italization.
3. (E) The fou r Ds of establishing m ed ical m al-
p ractice cases involve proving that a deviation
of du ty directly cau sed a dam age. The plaintiff
m ust establish the presence of a fid u ciary or
d octorpatient relationship (a d u ty), negli-
gence (d eviation from stand ard of care), and
d am ages d irectly cau sed by that negligence.
Typ ically, the bu rd en of p roof in m ed ical m al-
practice cases (civil cases) is by a p rep ond er-
ance of evid ence (greater than 50%). Proof
beyond a reasonable d ou bt refers to crim i-
nal cases. Clear and convincing evid ence is
reserved for sp ecial cases d ecid ed by the cou rt.
N either crim inal intent nor crim inal m ischief
is requ ired to p rove m ed ical m alp ractice.
4. (C) As a broad generalization, a good p atient
d octor relationship is key for a p hysician to
potentially avoid or d eflect a law su it. It is the
physicians d u ty as a health care p rovid er to
facilitate op en com m u nication regard ing the
patients illness, treatm ent recom m end ations,

risks versu s benefits of su ch treatm ents, and
to acknow led ge any errors that the physician
m ay have m ad e. Requ iring that a p atient sign
a no harm contract is not reasonable nor
d oes it stand u p as a legal d ocum ent in a court
of law . H iring a m alpractice attorney, seeing
the p atient on a m ore frequ ent interval, or
avoid ing prescribing m ed ications w ith p oten-
tially ad verse sid e effects d o not d ecrease a
p hysicians risk for m alp ractice su its.
5. (E) The standard of care for determining medi-
cal malpractice is based on how a similarly qual-
ified practitioner w ould have performed und er
the same or similar situation. Usually the testi-
mony of an expert w itness (a physician quali-
fied by evidence of his/ her expertise, training,
and special know ledge to provid e an opinion
about the case) is necessary to d emonstrate the
stand ard of care in med ical malpractice suits.
Treatments that are endorsed by the American
Med ical Association, evid ence based , free from
ad verse effects, or the most current are not suf-
ficient to establish the stand ard of care.
6. (D ) Testam entary capacity refers to ind ivid u als
com p etence to m ake a legally valid w ill. Case
law and statu tes d iffer across states. H ow -
ever, the central elem ents of testam entary
cap acity inclu d e: (1) com p rehension of the
act of w riting or signing a w ill, (2) know led ge
of p otential heirs, and (3) u nd erstand ing
the extent of ones assets or p rop erty. Con-
servatorship of estate refers to an ind ivid -
u als ability to m anage his or her finances.
Inform ed consent is the p rocess of obtaining
p erm ission for m ed ical treatm ent. Im p ortant
elem ents inclu d e the ability to m ake a vol-
u ntary d ecision regard ing treatm ent, exp la-
nation of risks and benefits, and cap acity to
m ake an inform ed d ecision. The p resence or
absence of a m ental illness d oes not neces-
sarily im p air an ind ivid u als com p etency to
m ake a w ill. Althou gh w itnesses are neces-
sary at the signing of a w ill in ord er for the
w ill to be enforceable in a cou rt of law , the
w itness m u st first ensu re that the ind ivid u al
has testam entary cap acity in the event the
w ill is challenged and the w itness is asked to
attest to the ind ivid u als com p etence.
Answe rs : 18 155
7. (B) Com p etence is d eterm ined by an ind ivid -
u als ability to m ake d ecisions in accord ance
w ith ones ow n goals, concerns, and valu es.
Althou gh p hysicians often rend er opinions
on an ind ivid uals com petence, only a ju d ges
ru ling d eterm ines w hether an ind ivid u al is
com petent or incom petent. The p resence of
p aranoid d elu sions regard ing the p atients
fam ily qu estions her ability to m ake rational
d ecisions, and significantly u nd erm ines her
assertion that she w as com p etent to m ake a
w ill. The inability to read and w rite, the p res-
ence of a d iagnosable psychiatric d isord er,
and the refu sal to u nd ergo treatm ent recom -
m end ed by her prim ary care physician d o not
au tom atically u nd erm ine a p atients com p e-
tence to m ake a w ill as long as the criteria for
testam entary cap acity are m et. An exp lana-
tion of w hy the p atient w ants to d onate her
estate to the local hu m ane society d oes not
u nd erm ine the p atients com p etence to m ake
a w ill u nless su ch an exp lanation d em on-
strates that the p atient is u nable to m eet any
of the sp ecified criteria.
8. (A) The Am erican Law Institu te test is the
m od ern stand ard for the insanity d efense. It
hold s that a person w ith a m ental d isease or
d efect shou ld not be held crim inally resp onsi-
ble for an act if the p erson (1) cou ld not app re-
ciate the w rongfu lness of the cond uct and (2)
cou ld not conform the cond uct to the require-
m ents of the law . The Am erican Law Institu te
test expand ed u p on the 1843 MN aghten rule,
w hich held that an ind ivid u al w as not gu ilty
by reason of insanity if, as a resu lt of a m ental
d efect, the p erson w as u naw are of the natu re,
qu ality, and consequence of his or her act or
d id not know that the act w as w rong (right-
w rong test). The Du rham ru le arose from a
1954 District of Colu m bia case in w hich the
cou rt held that an accu sed is not crim inally
resp onsible if his u nlaw fu l act w as the p rod -
u ct of a m ental d isease or m ental d efect. This
is also know n as the p rod u ct ru le of crim inal
resp onsibility. The irresistible im p u lse ru le is
an antiqu ated stand ard for p roving an insan-
ity d efense. Established in England in 1922,
the irresistible im p ulse rule states that an ind i-
vid u al is not resp onsible for a crim inal act if
156 5: Le ga l a nd Ethica l Is s ue s in P sychia try a nd Me d ic ine
he w as unable to resist that act d u e to a m ental
illness.
9. (B) Crim inal resp onsibility requires (1) crim i-
nal intent (m ens rea) and (2) a crim inal act
(actu s reu s). H aving either d im inished m ental
capacity or a know n psychiatric d isord er can
serve to avoid crim inal responsibility, bu t are
not required to p rove crim inal resp onsibility.
Mod u s operand i is the pattern in w hich an
action or crim e is execu ted by a p erson. A w it-
ness to the crim e also is not requ ired to p rove
crim inal responsibility.
10. (D ) Before discharging or transferring the
patient, it is important to determine whether she
can make an informed decision regarding her
care. Informed consent requires that the patient
(1) comprehend the issues and/ or choices pro-
vided by the physician, (2) appreciate the con-
sequences of making a certain decision, and (3)
arrive at a voluntary decision after weighing the
facts. At this point in the vignette, there is not
enough information to establish the patients
ability to make an informed decision regard -
ing her care. Exceptions to informed consent
include incompetence, emergency situations
(e.g., comatose or unresponsive patient), a com-
petent patients waiver of informed consent,
and therapeutic privilege. The other choices are
incorrect because this patients ability to make
an informed decision has not been assessed.
11. (B) A com p etent patient has the right to refu se
treatm ent, even if the consequ ences are life
threatening. In the extension of this vignette,
the patient has ad equately d em onstrated the
elem ents of an inform ed d ecision. The other
choices are incorrect becau se they w ould
p revent a com petent patient from m aking an
inform ed d ecision in her treatm ent.
12. (A) In Dusky v. United States (1960), the Su p rem e
Cou rt ru led that com petency to stand trial
requ ires the crim inal d efend ant to be able to
(1) rationally consu lt w ith ones attorney and
(2) rationally and factu ally u nd erstand the
p roceed ings against him . A history of p rior
assau lt charges or illiteracy d oes not constitu te
grou nd s for incom p etency. Inform ed consent
is im p ortant in m aking d ecisions related to
m ed ical treatm ents bu t has little bearing on
ones com petency to stand trial. A person can
suffer from a m ental illness and be com petent
to stand trial.
13. (B) In volu n tary h osp italization is u sed w h en
a p h ysician believes th at an in d ivid u al is an
im m in en t th reat to th em selves or oth ers, or
is oth erw ise u n able to ap p rop riately care
for th em selves. Arran gin g a p olice h old is
in correct as p olice h old s are issu ed w h en
an in d ivid u al w h o is arrested requ ires a
p sych iatric evalu ation . If th e arrested in d i-
vid u al d id n ot requ ire in p atien t p sych iatric
care, h e w ou ld be released back in to th e
cu stod y of th e p olice. Arran gin g for ou tp a-
tien t treatm en t w h en th e p atien t is actively
h om icid al is an im p rop er cou rse of action .
N otification of th e p olice or w arn in g th e
p atien ts m oth er is n ot im m ed iately n ec-
essary if th e p atien t is w ell con tain ed in a
closed p sych iatric u n it.
14. (B) Involu ntary ad m ission to the hosp ital is
ju stified w hen the p atient is d eterm ined to
be (1) an im m inent d anger to self or others or
(2) gravely d isabled or unable to care for self.
The criteria for involu ntary hosp italization
is d erived from the d octrine of parens patriae
w hich allow s the state to intervene and act as
a su rrogate parent for those w ho are unable to
care for them selves or m ay harm them selves.
State law s d iffer on the length of tim e a person
can be com m itted to the hospital on the basis
of either criterion. A history of prior psychi-
atric hosp italization, m ed ication noncom p li-
ance, presence of a p sychiatric d isord er, or
refu sal to follow -u p w ith ou tp atient services
are all im p ortant factors w hen d eterm ining
w hether an ind ivid u al shou ld be hosp italized ,
bu t are not requ isite elem ents for involu ntary
hosp italization.
15. (A) Forcing treatm ent on a patient d irectly
challenges his au tonom y. In general, an ad u lt
w ith d ecisional cap acity has the legal right
to d eterm ine w hat m ay be d one to his bod y.
H ow ever, a physician m ay m ed icate a patient
against his w ill and w ithou t a cou rt hearing

if it is d one to p revent a p atient from cau sing
im m inent harm to him self or others. In the
vignette, the patient is grossly im paired and
p oses an im m ed iate threat to others. Benefi-
cence refers to a physicians d uty to d o good
for the p atient. Confid entiality, or physician
p atient privilege, is a legal concep t that p ro-
tects com m u nications betw een a p atient and
his or her d octor from being d isclosed to a third
p arty. Justice refers to the concep t of rew ard
and pu nishm ent and the im p artial d istribu -
tion of social benefits (e.g., w hether resou rces
shou ld be d istributed equ ally to those in need
vs. w hether they shou ld go w here they w ou ld
have the greatest im pact on the ind ivid u al or
society). N onm aleficence refers to a physi-
cians intention to not harm or bring harm to
the patient.
16. (E) N ot gu ilty by reason of insanity (or gu ilty
but m entally ill in som e state) is a verd ict ren-
d ered in a crim inal case w hich find s that the
d efend ant w as insane at the tim e of com m itting
the crim e. This is d eterm ined by the applica-
tion of the test for insanity used in the particu-
lar jurisd iction. Contrary to popular belief, the
insanity d efense (1) is seld om asserted , (2) is
u su ally u nsu ccessfu l, and (3) typically lead s
to a greater num ber of years that the d efen-
d ant spend s in a m ental hospital. Ind ivid uals
found not gu ilty by reason of insanity are usu-
ally com m itted to a m ental facility rather than
serving tim e incarcerated . Typ ically, the com -
m itm ent is not for a set am ount of tim e bu t
rather u ntil the ind ivid u al is d eem ed not to
be a threat to society. Releasing an ind ivid ual
found not guilty by reason of insanity w ithou t
ap p rop riate psychiatric treatm ent is u nethical
and fails to p rotect society.
17. (C) Typical signs of physical abuse inclu d e
bu rns w ith p ecu liar p atterns (e.g., cigarette
m arks, geom etric d esigns, bilateral im m er-
sion patterns), bruises in low -trau m a areas
(e.g., bu ttocks, genital areas, or back), reti-
nal hem orrhages, and m ultiple fractu res at
d ifferent stages of healing. Child abu se can
occur in all socioeconom ic levels, and physi-
cally abu sed child ren can d isplay a range
of p sychop athology inclu d ing d ep ression,
Answe rs : 920 157
PTSD, ADH D, and op p ositional d efiant d is-
ord er. Age-appropriate rou gh play is not a
likely cau se for this child s inju ries. The his-
tory and physical exam ination d o not provid e
sufficient evid ence to d iagnose either a m ajor
d ep ressive d isord er or som atic sym ptom d is-
ord er. There is not enou gh evid ence to su g-
gest sexu al abu se in this p articu lar case.
18. (C) Every state requ ires m and atory rep orting
of abu se or neglect to Child Protective Ser-
vices. In cases in w hich there is a reasonable
suspicion of abu se, a report should be filed
even if the p atient and fam ily d eny the alle-
gations. In cases of su sp ected abu se, step s to
ensu re the safety of the m inor shou ld be taken
im m ed iately. Referring the fam ily to therap y
or d ischarging the patient w ith follow -u p to
reevaluate her bruises d isregard s the child s
safety and p otentially subjects the minor to
continu ed abuse. Consid ering the extent of the
physical injuries, it is u nlikely that the patients
younger siblings inflicted them ; consequently,
neither confronting the siblings about their
behavior nor treatm ent w ith penicillin serves
any pu rp ose.
19. (E) Accord ing to the Am erican Med ical Asso-
ciation (AMA) Cod e of Med ical Ethics, confi-
d entiality in the treatm ent of m inors shou ld
be m aintained u nless sp ecifically p rohibited
by state law (e.g., in cases of abortion) or w hen
the parents involvem ent is necessary to m ake
complicated or life-threatening treatment d eci-
sions. The other choices all constitute violations
of confid entiality to your patient.
20. (B) Inform ed consent for H IV testing involves
a thorou gh exp lanation of the tests interp re-
tation, inform ation regard ing confid ential-
ity, and fu rther evalu ation need ed if the test
is p ositive. The p atient shou ld be aw are of
the risk of false positives and negatives, and
the need for confirm atory testing if the test
resu lt is p ositive. Choices (A) and (D ) are
incorrect becau se they violate p atient confi-
d entiality. When a patient tests positive for
H IV, state law s m ay requ ire notification of the
sexual partner (this is u sually d one w ithou t
revealing the p atients id entity) in ad d ition to
158 5: Le ga l a nd Ethica l Is s ue s in P sychia try a nd Me d ic ine
the d epartm ent of p ublic health. There is no
reason to notify the states health d ep artm ent
or perform a p regnancy test before ad m inis-
tering an H IV test.
21. (D ) The American Medical Association (AMA)
Cod e of Ethics states that the principle of patient
autonomy requires that physicians respect the
d ecision to forego life-sustaining treatment of a
patient w ho possesses d ecision-making capac-
ity. In this case, the patients d esire to stop
d ialysis should be respected because adults
w ith d ecisional capacity are able to determine
w hich treatment they should accept or deny.
The remaining choices und ermine the patients
right to make an informed decision.
22. (E) Physicianpatient confidentiality should be
maintained except in certain cases (e.g., d uty to
protect others, m and atory rep orting, or em er-
gencies). Thus, the physician should not reveal
confid ential information w ithout the express
consent of the patient. The remaining choices
violate physicianpatient confid entiality.
23. (E) Confid entiality betw een patient and phy-
sician should be respected even in cases of
cou rt-mand ated treatm ent. Obtaining a confi-
d entiality w aiver from the patient is essential
before releasing any inform ation to the proba-
tion officer. Ignoring the probation officers
request is inappropriate in such circumstances.
The other choices are incorrect because they
violate physicianpatient confid entiality.
24. (D ) The patient shou ld im m ed iately be
inform ed that she w as accid entally given the
im p rop er m ed ication. Evalu ating the p atient
for any ad verse reaction and exp laining the
m istake is the ap p rop riate first step . Encou r-
aging the p atient to seek legal action is both
alarm ist and inap p ropriate in su ch a case. The
fact that the patient d id not suffer harm is
not a reason to conceal the m ed ication error.
Althou gh m any hosp itals requ ire d ocu m en-
tation or reporting of su ch to a p articu lar
p erson or com m ittee, this shou ld not be the
first course of action. N otifying the patients
fam ily of the m istake is a breach of confid enti-
ality and inap propriate.
25. (B) Exp laining the im p lications of no treat-
m ent bu t resp ecting the p atients refu sal for
treatm ent is the m ost ap p rop riate cou rse of
action. This allow s the p atient to m ake an
inform ed d ecision w ith regard to her treat-
m ent. The elem ents integral to inform ed con-
sent inclu d e (1) cap acity to m ake a d ecision;
(2) an ad equ ate exp lanation of the risks, ben-
efits, rationale for treatm ent, and alternative
treatm ents (inclu d ing no treatm ent at all);
and (3) a volu ntary d ecision. In this vignette,
there is no evid ence that the p atient su ffers
from a cond ition that m ight im p air her d eci-
sional cap acity. Fu rther, her stated religiou s
belief is consistent w ith a Jehovahs Witnesss
refu sal of hu m an blood p rod u cts. Ad m in-
istering p acked red blood cells infringes on
the p atients right to refu se a blood transfu -
sion and consequ ently is incorrect. Strongly
p ersu ad ing the p atient to arrive at a d ecision
for treatm ent is coercive and cou ld p revent
the p atient from m aking a volu ntary d eci-
sion. It is inap p rop riate to refer the case to
the hosp itals ethics com m ittee if the p atient
has d ecisional cap acity and d ecid es to refu se
treatm ent. It is also inap p rop riate to invol-
u ntarily hosp italize this p atient if she has
arrived at her d ecision in com p liance w ith the
elem ents of inform ed consent.
26. (D ) Accord ing to the AMA Cod e of Med i-
cal Ethics, treatm ent d ecisions m u st be m ad e
in the best interest of the child or neonate
regard less of the d esires of the p arents. Treat-
m ent can be w ithheld or w ithd raw n only
in cases in w hich the risks far ou tw eigh the
benefits, there is low p otential for su ccess, or
w hen treatm ent extend s the child s su ffering
w ithou t p otential for a m eaningfu l existence.
In this p articu lar case, the neonate su ffers
from a seriou s, bu t treatable, central nervou s
system infection and treatm ent shou ld not
be w ithheld . The lu m bar p u nctu re resu lts
u nequ ivocally d em onstrate bacterial m enin-
gitis. Withhold ing treatm ent u ntil the next
regu larly sched u led ethics m eeting w ou ld
likely resu lt in the neonates d em ise. Threat-
ening to rep ort the p arents to child p rotective
cu stod y u nless they revoke their d ecision is
coercive and inap p rop riate.

27. (B) It is u nethical to offer sp ecific p sychiatric
d iagnoses for ind ivid u als that you have not
p ersonally exam ined . Moreover, com m ent-
ing on an ind ivid u al that you have evalu ated
w ou ld be a breach of confid entiality.
28. (D ) Consu ltation w ith the ethics com m ittee
shou ld be sought w hen the p atients prior
w ishes are u nclear or if fam ily m em bers are
u nable to agree on treatm ent options. Com -
p etent ad u lts m ay form ulate p references
(ad vance d irectives) regard ing their m ed i-
cal treatm ent in the event that an inju ry or
illness cau ses severe im p airm ent or loss of
d ecisional cap acity. Ad vance d irectives can
be established by d ocu m enting the ad u lts
m ed ical preferences and goals in a living w ill
or by d esignating a health care proxy (d u rable
p ow er of attorney for health care) to m ake
treatm ent d ecisions on the patients behalf.
Fam ily and / or close associates shou ld be con-
su lted to aid in reaching treatm ent d ecisions
if there is no ad vance d irective or d esignated
p ow er of attorney. Ethics com m ittee consulta-
tions are also u seful w hen the pow er of attor-
neys d ecision is unreasonable or contrary to
the patients prior w ishes. It w ou ld be inap-
p ropriate to allow a severely incapacitated
p atient to d esignate a pow er of attorney or
m ake treatm ent d ecisions. Choosing sid es in
a fam ily conflict w ou ld be arbitrary; consu lta-
tion w ith the hosp ital ethics com m ittee w ou ld
help clarify issu es in a com p licated case such
as this.
29. (B) The most appropriate course of action is to
involuntarily ad mit the patient. Major d epres-
sive d isord er with peripartum onset is a form of
clinical d epression that d evelops in 3% to 6% of
w omen during pregnancy or the weeks follow-
ing d elivery. Approximately 50% of postpar-
tum d epressive episod es actually begin prior to
delivery, thus episod es are collectively referred
to as peripartum episod es. Postpartum depres-
sion usually refers to episod es that start w ithin
4 w eeks after d elivery. Symptoms can last
from several months to a year. It is imperative
that examining physicians inquire about the
mothers thoughts tow ard her child when con-
cerns for peripartum d epression are present.
Answe rs : 2132 159
Peripartum mood episod es can present either
w ith or w ithout psychotic features. Infanticide
is most often associated with psychotic epi-
sod es (e.g., command hallucinations to harm
the infant, d elusions that the infant is evil, etc.).
Although the patient in the vignette denied
overt psychotic symptoms, she d emonstrated
a significant clinical d ecline and acknow l-
edged that she had thoughts of harming her
infant. Discharging the patient und er any cir-
cumstances is inappropriate because the infant
remains at risk of harm. Child Protective Ser-
vices should be notified in cases of suspected or
known child abuse or neglect. Administering
lorazepam and reassessing the patient do not
ad d ress the issue of the babys safety.
30. (D ) Most physicians w ill somed ay find them -
selves in situations w here they encounter their
patients in the com mu nity. Patientphysician
confid entiality d oes not cease once a physician
leaves the hospital and m ust be maintained
regard less of w ho is making the inquiry. Confi-
dentiality can only be broken when the physician
has a d uty to protect others, in cases of m and a-
tory reporting, or in med ical em ergencies. The
remaining choices violate physicianpatient
confid entiality.
31. (A) Sexu al or rom antic relationship s w ith cu r-
rent or form er p sychiatric p atients (regard -
less of the tim e elap sed since treatm ent) are
alw ays consid ered u nethical, m aking the
other choices incorrect. Ad d itionally, p sychi-
atrists shou ld avoid situ ations in w hich their
interactions w ith cu rrent or form er p atients
cou ld be m isinterp reted as an intim ate rela-
tionship .
32. (A) Sexu al relations w ith cu rrent patients are
u nethical and constitute sexual m iscond u ct.
The AMA Cod e of Med ical Ethics states that
sexu al and / or rom antic relations w ith form er
p atients are u nethical if the physician u ses or
exp loits tru st, know led ge, em otions, or influ -
ence d erived from the p reviou s p rofessional
relationship . At the very least, the p hysician
has an ethical d u ty to term inate the physician
p atient relationship prior to initiating any
rom antic or sexu al relationship s.
160 5: Le ga l a nd Ethica l Is s ue s in P sychia try a nd Me d ic ine
33. (D ) Accord ing to the AMA Cod e of Med ical
Ethics, p hysician-assisted su icid e is fu nd a-
m entally incom patible w ith the physicians
role as healer, and the p hysician shou ld
aggressively respond to a p atients end -of-
life need s rather than assist in su icid e. Phy-
sician-assisted su icid e is d efined as the act of
facilitating a p atients d eath by p rovid ing
the necessary m eans and / or inform ation to
enable the p atient to perform the life-end ing
act. Sim p ly ignoring the p atients requ est is
inap p rop riate becau se it fails to recognize and
ad d ress p otential end -of-life issu es. End -of-
life issu es that shou ld be ad d ressed w ith the
p atient includ e ad equ ate pain control, em o-
tional/ fam ily su pport, com fort care, respect
of patient autonom y, and appropriate m u l-
tid isciplinary referrals (hospice, cou nseling,
religiou s issu es, etc.). The rem aining choices
are consistent w ith the d efinition of p hysician-
assisted su icid e and are therefore u nethical.
34. (D ) The treating p hysician is u ltim ately legally
resp onsible for d eterm ining w hether a p atient
is ap p rop riate for d ischarge. Discharging a
m ed ically unstable or u nsafe patient is con-
sid ered negligence and can potentially lead
to a law suit if there is an ad verse outcom e. A
p sychiatric patient can be consid ered for d is-
charged as long as he/ she d oes not m eet the
criteria for involu ntary ad m ission (i.e., im m i-
nent risk to self or others or grossly u nable to
care for self). The patient in the vignette is not
consid ered safe to leave the hospital, w hich
m akes the other answ er choices incorrect.
Contacting the insu rance com p any w ithou t
p erm ission violates patient confid entiality.
Regard less of w hether the p atient has insu r-
ance or qualifies for a loan, the p hysician
shou ld continu e to treat the patient as long as
it is m ed ically necessary.
35. (B) When a physician is served a subpoena to
release m ed ical information, the appropriate
first step is to contact the patient to find out
if he or she consents to the release. Discussing
the implications of the law suit w ith your
patient and clarifying w hether the patient
has the proper legal cou nsel for the law su it
are also important. Contacting the attorney of
the party requesting the subpoena and releas-
ing the med ical record s w ithout consent from
the patient constitute unethical breaches of
physicianpatient confidentiality. Releasing the
m ed ical information d irectly to the jud ge at
this stage makes no sense and w ould likew ise
be a breach of confid entiality. Requesting that
you r patient sign a release of information is
inappropriate w ithout first d iscussing w hether
the patient consents to releasing the record s.
36. (D ) Turning over m ed ical record s to com ply
w ith a d irect cou rt ord er is ethical and legal.
To d efy a ju d ges ord er can p otentially p lace a
p hysician in contem p t of court. When the d is-
closu re of confid ential inform ation is required
by law or cou rt ord er, p hysicians shou ld d is-
close the m inim al inform ation requ ired by
law . H ow ever, in this case releasing p artial
record s violates the cou rt ord er. Working ou t
a p lan of legal action or ap p ealing to the states
Sup rem e Cou rt is not the role of the physician,
bu t rather the p atients attorney.
37. (A) In the United States crim inal ju stice sys-
tem , a com petency evaluation is an assess-
m ent of the d efend ants ability to u nd erstand
and rationally p articip ate in a cou rt process
(Dusky v. United States, 1960). The p sychia-
trists goal in assessing for com petency to
stand trial involves evaluating w hether the
d efend ant has a rational und erstand ing of the
crim inal cou rt proceed ings, the capacity to
u nd erstand the d ifferent potential outcom es of
the cou rt proceed ings (e.g., plead ing gu ilty vs.
not guilty), and has a su fficient ability to com -
m u nicate w ith and assist the attorney in the
d efense. The exam iner should d ocu m ent that
he or she has fu lly inform ed the d efend ant of
the purpose and nature of the evaluation pro-
ced u re and the extent of nonconfid entiality. In
situations such as this w here confid entiality is
lim ited the p sychiatrist m u st m ake every effort
to m aintain confid entiality w ith regard to any
inform ation that d oes not bear d irectly u p on
the legal purpose of the evaluation. There is no
need for the exam iner to w ithd raw from the
case in the event of a crim inal confession, nor
it is app rop riate for the exam iner to p ersu ad e
the d efend ant to act in any particular m anner.

38. (D ) Inquiring abou t possible reasons the
patient m ay be avoid ing or d eferring payment
m ay help u ncover important treatment issues.
Such inquiry often lead s to how the patient
feels about the therapy and / or the therapist.
These feelings can be u tilized to ad d ress fac-
tors related to her symptoms. Ad d itionally,
concerns may arise regard ing the financial sit-
uation of the patient that otherw ise w ou ld not
have been d iscussed in the sessions. Exploring
such issues should be d one in a sensitive m an-
ner to avoid alienating the p atient. Contacting
the patients family violates physicianpatient
confid entiality. Requesting that a billing collec-
tor d em and s im med iate payment and term i-
nating treatment w ould be far too aggressive at
this point. Inform ing the patient that you w ill
not see her if she d oes not im med iately pay her
bill may be perceived as confrontational and
threatens the therapeutic alliance.
39. (C) Becom ing involved in the business ventu re
of a psychotherapy patient could have signifi-
cant ad verse effects on the patients transfer-
ence (feelings and m em ories exp erienced by
the patient that are aroused by the therap ist)
as w ell as on the p hysicians cou ntertrans-
ference (feelings arou sed in the p hysician
w hile w orking w ith the p atient). Therefore,
it shou ld be avoid ed . Bu siness relationship s
w ith form er p atients are often p erceived as
p roblem atic, and business relationships w ith
current patients are consid ered u nethical.
Anger, d istru st, and gu ilt are som e of the feel-
ings that m ay occu r if a bu siness ventu re su ch
as the one d escribed w ere to fail. Fu rtherm ore,
a physicians bu siness involvem ent w ith a
p atient m ight affect the neu tral stance essen-
tial to effective psychotherapy. The central
concern that involvem ent in a business ven-
tu re m ight interfere w ith treatm ent shou ld be
exp lained to the p atient honestly.
40. (D ) The m ost significant pred ictor of su icid e
is a p ast history of su icid e attem p t. Other
su icid e risk factors includ e: ad vancing age
(>45), gend er (M > F), m arital status (sep a-
rated or d ivorced > m arried ), alcohol u se d is-
ord er (su icid e rate is 50% higher in those w ith
alcohol u se d isord er vs. those w ith no sub-
Answe rs : 3343 161
stance use), em ploym ent status (unem ployed
or retired > em ployed ), su pport system (living
alone > living w ith others), and health statu s
(seriou s m ed ical cond ition or term inal illness
> good health).
41. (B) Suicidal behavior is among the most stressful
emergencies encountered by mental health pro-
fessionals. There is no algorithm or scoring tool
that is able to consistently identify a patients
risk for suicide. If a malpractice claim is brought
up against a psychiatrist, adequate documenta-
tion of the patients suicide risk and protective
factors assist the court in determining the scope
and complexities of the patients treatment. Fail-
ure to document these assessments and inter-
ventions potentially gives the court a reason
to believe they were not done. No self-harm
contracts do not hold up as legal documents in a
court of law. The remaining choices are not suf-
ficient enough to legally protect a psychiatrist in
the event of a patient suicide.
42. (D ) An ind ivid u al w ho com m its a crim e w hile
voluntarily intoxicated cannot assert an insan-
ity d efense becau se the basis of su ch behavior
stem s from a rational d ecision to d rink. Invol-
u ntary intoxication m ay be u sed effectively as
an insanity d efense if the ind ivid u al had no
choice in becom ing intoxicated (e.g., the per-
son w as unknow ingly d rugged ). A m ental
d isease or d efect or inability to recall the event
m ight be used to enhance an insanity d efense,
not u nd erm ine it. Prior history of assau lt or
the natu re of the crim e shou ld have no bear-
ing on an insanity d efense. H ow ever, if p rior
violent behavior has been associated w ith a
m ental illness and the inability to appreciate
the crim inality of ones cond uct or conform to
the law , this cou ld be u sed to strengthen an
insanity d efense.
43. (E) Med ical expert w itnesses are called to
p resent their professional opinions based
on reasonable m ed ical certainty. An expert
w itness shou ld have cu rrent and su bstan-
tial experience and know led ge in the area in
w hich they testify, and m ay be called to testify
in both civil and crim inal trials. A p hysician
w ho p rovid es exp ert testim ony is exp ected to
162 5: Le ga l a nd Ethica l Is s ue s in P sychia try a nd Me d ic ine
p erform an im p artial evaluation and p rovid e
an ind epend ent op inion. Exp ert testim ony
shou ld be based upon current scientific d ata
and a stand ard of care that is accep ted am ong
those w ho p ractice in the respective field . It is
not the responsibility of the exp ert to ensu re a
p articu lar ou tcom e for either sid e. Unlike the
trad itional p hysicianpatient relationship , the
exp ert w itness d oes not initiate treatm ent of
p atients and has lim its on confid entiality.
44. (B) H abeas corp u s refers to the U.S. Constitu -
tions clau se that the state shall not d eprive
any person of life, liberty, or prop erty, w ithou t
d ue process of law . Und er habeas corp us, cit-
izens have the right to p etition the cou rt w hen
d etained to d ecid e w hether they are being held
law fu lly. Establishing crim inal resp onsibility
requ ires the p resence of both actu s reu s and
m ens rea. Actu s reu s refers to the volu ntary
act of com m itting a crim e, and m ens rea refers
to crim inal intent. Both choices are incorrect
as they have nothing to d o w ith the patients
right to d u e p rocess. Parens p atriae refers to
the states fu nction as parent for those unable
to care for them selves. This is often u sed for
ju stification of involu ntary com m itm ent. The
Fou rth Am end m ent p rotects citizens from
u nreasonable searches and seizu res.
45. (E) It w ou ld be u nethical to involuntarily
d etain a patient in treatment if he or she is
no longer d eemed to be gravely d isabled or a
threat to self or others. In this case, the patient
shou ld be p rom ptly d ischarged to the partial
hospital program . Appeasing the p atient by
increasing sm oking privileges fails to ad d ress
the key issue in this question. Filing for another
cou rt hearing is approp riate only if the patient
is still gravely d isabled or a d anger to self or
others. Althou gh the patient w as initially com-
mitted by the court, it w ould be unlaw ful to
ignore the patients request for d ischarge if he
no longer meets criteria for involuntary hospi-
talization. Persu ad ing the patient to stay a few
more d ays even thou gh he w ishes to leave the
hospital and no longer m eets criteria for invol-
untary com mitment is inapp ropriate.
46. (E) The key elem ents to inform ed consent
inclu d e the cap acity to m ake a d ecision, a
volu ntary choice w ithout coercion or d u ress,
and an ad equ ate u nd erstand ing of the ratio-
nale, risks, benefits, and alternative treat-
m ent op tions. The rem aining choices are not
requ ired for inform ed consent.
47. (C) Living w ills, also know n as ad vance d irec-
tives, preserve patient autonom y by establish-
ing p ersonal p references regard ing end -of-life
issu es. If p atients lose their d ecisional cap acity
in the fu tu re, ad vance d irectives ou tline w hat
p roced u res they d o or d o not d esire w ithou t
relying on p hysician or fam ily m em ber op in-
ions. Patients are able to change their living
w ills if d esired . Physician-assisted su icid e is
not consid ered ethical. The rem aining choices
are not characteristics of a living w ill.
48. (E) Malingering is characterized by intentional
feigning of sym ptom s for second ary gain (i.e.,
financial com p ensation, d isability benefits,
avoid ing crim inal p rosecu tion or m ilitary
d uty, etc.). A d iagnosis of m alingering shou ld
be su sp ected w hen there is the p resence of
one or m ore of the follow ing factors: (1) liti-
gation (esp ecially w hen the p atient is referred
by a law yer), (2) d iscrep ancy betw een objec-
tive find ings and the p atients com p laints, (3)
a d iagnosis of antisocial p ersonality d isord er
(w hich his history su p p orts), and (4) a failu re
to com ply w ith the evaluation and recom -
m end ed treatm ents. The d u ration of sym p-
tom s in this case has no bearing on a d iagnosis
of m alingering. The lack of physical inju ries or
the presence of flashbacks in a claim of PTSD
is not su fficient to raise su sp icions of m alin-
gering. PTSD occu rs in ind ivid u als exp osed to
actu al or threatened d eath or inju ry and con-
sequently m ay not involve p hysical injuries. A
p ast history of m ajor d epression d oes not raise
a su sp icion of m alingering.
49. (E) Accord ing to the AMA Cod e of Med ical
Ethics, p hysicians are obligated to p rovid e
continu ity of care for their patients. When
d ischarging a patient from you r care, ad vance
notice of the p end ing d ischarge m u st be given
to allow the patient su fficient tim e to obtain
another p hysician. Contacting the p atients
fam ily breaches confid entiality and is not the

ap propriate proced ure for d ischarging the
p atient. N otifying the insu rance com p any fails
to inform the patient of her d ischarge and d oes
not provid e her tim e to obtain a new p hysi-
cian. The rem aining choices fail to provid e the
p atient w ith su fficient notice to obtain prop er
m ed ical follow -u p .
50. (A) The prevailing concep t in d eterm ining
child custod y is based on ind ivid u al(s) w ho
can provid e for the best interests of the child .
Factors that can be used to determine the best
interests of the child includ e assessing the ind i-
vid uals biologic relation, financial stability,
level of ed u cation, and health. H ow ever, it is
the aggregate rather than any single factor
w hich d eterm ines w hat is in the best interest
of the child .
Answe rs : 4451 163
51. (D ) Physicians are ethically obliged to rep ort
colleagues w ho are im paired , incom petent,
or engaging in unethical cond uct. The d u ty
to report stem s from physicians obligation
to protect patients against harm . Reporting
p roced u res vary from state to state; how ever,
the AMA Cod e of Med ical Ethics suggests ini-
tial reporting to a hosp itals im p aired physi-
cian p rogram . If no su ch program exists, the
chief of staff or clinical service d irector shou ld
be notified . For p hysicians w ithou t hosp ital
p rivileges, an im p aired physicians p rogram
ru n by a m ed ical society or the state board
licensing com m ittee shou ld be m ad e aw are of
the im paired physician. The other choices d o
not m eet the AMA gu id elines and fail to ini-
tiate proper treatm ent and sup ervision of the
im p aired p hysician.
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 CHAPTER 6
Diffe re ntial Diag no s is and
Manag e me nt
Que s tions
D IRECTION S (Questions 1 through 60): For each of
the multiple-choice questions in this section, select
the lettered answ er that is the one best response in
each case.
Questions 1 and 2
A 43-ye r-old w o n p resents to you r office tell-
ing you th t recently she h s been exp eriencing n
incre se in the volu e of voice th t she h s been
he ring for ye rs. It const ntly criticizes her beh v-
iors reg rd less of her ood . She lso notes th t for
ost of the p st ye r, her ood h s been very low .
She is no longer ble to get ny ple su re fro w tch-
ing television. H er sleep is p oor nd her energy is
low . In d d ition, she d escribes 20-lb w eight loss in
the p st ye r bec u se she no longer feels the need to
e t. She d enies the u se of ny d ru gs or lcohol.
1. Which of the follow ing d i gnoses best
ccou nts for this p tients sy p to s?
(A) Bip ol r II d isord er
(B) M jor d epression w ith psychotic fe tures
(C) Schizo ffective d isord er
(D) Schizop hreni
(E) Schizoid p erson lity d isord er
2. Which of the follow ing ed ic tion co bin -
tions w ou ld best tre t this p tients sy pto s?
(A) Div lp roex sod iu nd lor zep
(Ativ n)
(B) Flu oxetine (Proz c) nd d i zep
(V liu )
(C) H lop erid ol (H ld ol) nd p erp hen zine
(Tril fon)
(D) Mirt z p ine (Re eron) nd cit lop r
(Celex )
(E) Zip r sid one (Geod on) nd sertr line
(Zoloft)
Questions 3 and 4
A 29-ye r-old w o n w ho ju st d elivered 3 w eeks
go is referred bec u se her obstetrici n noticed th t
she ppe red to be d isheveled . Upon initi l inter-
view , the p tient tells you th t she h s been feel-
ing d ow n since d elivering her son. She tells you
th t w hile she continu es to c re for her son, she is
grow ing incre singly d ep ressed bec u se she d oes
not get ny p le sure fro t king c re of hi . She is
u n ble to sleep nd h s not been e ting uch either.
She feels tired ll the ti e. She lso tells you th t t
ti es, she w ill he r b by in the b ckground cry-
ing, bu t w hen she checks on her son, he is sleep ing
sound ly. She d enies ny thoughts of w nting to hu rt
her son or herself.
3. Which of the follow ing d i gnoses is the ost
likely?
(A) Ad ju st ent d isord er
(B) Brief p sychotic d isord er
(C) M jor d ep ressive d isord er w ith
p erip rtu onset nd p sychotic fe tu res
(D) Postp rtu obsessive-co p u lsive
d isord er
(E) Schizo ffective d isord er, d ep ressed typ e
165
166 6: Diffe re ntia l Diag nos is a nd Ma na g e me nt
4. Which of the follow ing is the
te first step in her tre t ent?
(A) Flu oxetine (Proz c) nd qu eti p ine
(Seroqu el)
(B) H lop erid ol (H ld ol)
(C) H osp it lize the p tient
(D) Lithiu
(E) Su p p ortive ther p y
Questions 5 and 6
A 64-ye r-old w o n is brou ght to the e ergency
d ep rt ent by her neighbor, w ho s ys y friend
isnt cting right. The p tient requ ires the su p p ort
of nurse w hile w lking to n ex in tion t ble.
Ex in tion reve ls th t she c nnot correctly id en-
tify the se son or the tow n she is in. She d oes not
recognize her neighbor. She is in ttentive nd see -
ingly p thetic to the ctivity rou nd her. She d ozes
off repe ted ly d uring the interview , bu t e ch ti e
is rou s ble nd resu es nsw ering qu estions. H er
nsw ers re illogic l nd inconsistent.
Vit l signs re w ithin nor l li its nd she
is neither tre u lou s nor d i p horetic. N eu rologic
ex in tion find s bil ter l sixth nerve p lsy nd
horizont l nyst g u s. Urine toxicology screen nd
blood lcohol level re neg tive.
5. Which of the follow ing is the
d i gnosis?
(A) Acu te su bd u r l he to
(B) Alcohol w ithd r w l
(C) Folic cid d eficiency
(D) N or l p ressu re hyd rocep h lu s (N PH )
(E) Wernicke encep h lop thy
6. Which of the follow ing is the ost i p ort nt
first step in n ging this p tient?
(A) Ad inistr tion of benzod i zep ine
(B) Ad inistr tion of folic cid
(C) Ad inistr tion of thi ine
(D) Co p u ted to ogr p hy (CT) sc n of the
he d
(E) Intr venou s (IV) flu id s nd observ tion
ost pp rop ri- Questions 7 and 8
A 62-ye r-old w o n p resents to you r office long
w ith her d u ghter. H er d u ghter exp l ins to you
th t l tely, her other h s been extre ely con-
cerned bout her bod y od or. Despite ultiple re s-
su r nces fro her d ughter th t she d oes not s ell,
she continues to be concerned th t other people find
her bod y od or extre ely offensive. The p tient tells
you th t she know s th t she s ells bec u se she c n
s ell her ow n bod y od or ll the ti e d espite t king
u ltip le show ers throu ghou t the d y. Despite being
concerned bout her od or, she continues to w ork
fro ho e s she h s d one for the p st 30 ye rs
nd she continu es to sp e k w ith friend s on the tele-
p hone. She p ys her onthly bills w ithou t the help
of her f ily. H er thinking otherw ise see s logic l
nd pp rop ri te.
7. Which of the follow ing is the ost likely
d i gnosis?
(A) Delu sion l d isord er
(B) M jor d ep ressive d isord er w ith
p sychotic fe tu res
(C) Obsessive-co p u lsive d isord er
(D) P r noid p erson lity d isord er
(E) Schizop hreni
ost likely 8. Which of the follow ing w ou ld be the ost
p p rop ri te tre t ent?
(A) C rb zep ine (Tegretol)
(B) Electroconvu lsive ther p y (ECT)
(C) Flu oxetine (Proz c)
(D) Lithiu (Esk lith)
(E) Ol nz p ine (Zyp rex )
Questions 9 and 10
A 29-ye r-old n w ith history of chronic schizo-
p hreni co es to the e ergency d ep rt ent w ith
te p er tu re of 102.9F, l bile blood p ressu re rising
to 210/ 110 H g, p u lse of 110/ in, nd resp i-
r tory r te of 22 bre ths/ in. This p tients ed ic -
tions includ e h lop erid ol, benztrop ine (Cogentin),
nd clon zep (Klonop in). H e c nnot correctly
id entify the d y, d te, or ye r, nd believes hi self
to be in city fro w hich he oved 10 ye rs go.
A f ily e ber ind ic tes th t 3 d ys go he w s

he lthy nd co pletely oriented nd th t he h s no
signific nt ed ic l or surgic l history.
Physic l ex in tion reve ls th t he is in cute
d istress w ith hypertonicity. L bor tory ex in tion
reve ls cre tinine phosphokin se (CPK) of 45,000
IU/ L, w hite blood cell cou nt of 15,000/ L nd no
left shift, sod iu of 145 Eq/ L, nd cre tinine of
2.5 g/ d L. Lu b r p u nctu re prod u ces cle r fluid
w ith slightly elev ted p rotein cou nt.
9. Which of the follow ing is the ost likely
d i gnosis?
(A) Anticholinergic synd ro e
(B) Centr l nervou s syste (CN S) infection
(C) M lign nt hyp erther i
(D) N eu rolep tic lign nt synd ro e (N MS)
(E) Prolonged i obiliz tion
10. With ppropri te tre t ent, the p tient recov-
ers co pletely nd returns ho e. In onths
ti e, he co es to the e ergency dep rt ent
st ting th t the voices in the w lls re telling
hi to kill hi self. He h s t ken no edic tions
since he left the hospit l. His vit l signs re st -
ble nd edic l workup is neg tive. Which of
the following ther pies should be initi ted first?
(A) ECT
(B) H lop erid ol d ep ot injections
(C) Ol nz p ine
(D) Physic l restr ints
(E) S fety onitoring only
Questions 11 and 12
A 39-ye r-old w o n co es to the e ergency
d ep rt ent nd co pl ins th t since her boyfriend
broke u p w ith her 3 onths go, she h s been sleep -
ing nd e ting p oorly, h s lost ll interest in her
w ork, nd feels gu ilty th t she d rove her boyfriend
w y. In the p st onth, she h s begu n to feel hop e-
less, help less, nd th t life y not be w orth it. In
the p st 2 w eeks, she h s d eveloped belief th t
r re d ise se is rotting her he rt, nd over the p st
w eek, voice h s been telling her she is no good nd
should t ke n overd ose of he rt ed ic tion she is
prescribed . At first she w s ble to ignore the voice,
how ever, she is now t the point th t she believes
she shou ld ct on it.
Que s tions : 413 167
11. Which of the follow ing shou ld be the ost
i ed i te n ge ent?
(A) Ad ission to ed ic l u nit
(B) Ad ission to p sychi tric u nit
(C) Med ic tion nd d isch rge to close
f ily e ber
(D) Referr l to n ou tp tient p sychi trist
(E) Restr ints nd ed ic tion in the
e ergency d ep rt ent
12. Which of the follow ing ed ic tion(s) w ou ld
be the ost p p rop ri te?
(A) Benzod i zep ine only
(B) Lithiu nd selective serotonin
reu p t ke inhibitor (SSRI)
(C) Lithiu only
(D) SSRI nd n ntip sychotic
(E) Tricyclic ntid ep ress nt (TCA) only
Questions 13 and 14
A 22-ye r-old n is brou ght to the e ergency
d ep rt ent by p olice fter n ep isod e in w hich he
r ns cked the office w here he w orks looking for
evid ence. H e st rted this job 2 onths go fter
gr d u ting fro college. H e lives w ith fou r roo -
tes, nd he believes they re je lous of hi
bec u se of his job nd h ve therefore been p oison-
ing his food . H is f ily reve ls th t once before
w hen he beg n college he w ent throu gh p eriod
of cting cr zy but got better w ithout tre t ent
nd h s d one w ell since. In the e ergency d ep rt-
ent, he is shou ting th t he h s been u p for w eek
w riting cl ssic book bou t ccou nting bu t th t
so eone t the office stole it fro hi . H e need s
to be p hysic lly restr ined by e ergency d ep rt-
ent secu rity. Physic l ex in tion nd co plete
l bor tory w orku p nd toxicology screen p rove to
be neg tive.
13. Which of the follow ing ed ic tion(s) w ould
be the ost p p rop ri te to initi te?
(A) Antip sychotic nd benzod i zep ine
(B) Bu sp irone (Bu Sp r)
(C) C rb zep ine (Tegretol)
(D) Lithiu
(E) SSRI
168 6: Diffe re ntia l Diag nos is a nd Ma na g e me nt

14. Three onths l ter, the p tient sees his d octor (A) Acu te stress d isord er
for follow -u p . H e is t king lithiu nd h lo- (B) Ad ju st ent d isord er
p erid ol. H e is d oing w ell, except he co pl ins (C) MDD
of p inful u scle cr p ing. H is lithiu level
(D) P nic d isord er
is 0.8 Eq/ L. Which of the follow ing w ou ld
be the ost p p rop ri te next step in his (E) PTSD
n ge ent?
17. A p tient w ith history of bip ol r d isord er is
(A) Decre se the h lop erid ol d ose. d itted to p sychi tric hosp it l in n cute
(B) Decre se the lithiu d ose. nic ep isod e. H er ed ic tions inclu d e n
(C) Incre se the h lop erid ol d ose. SSRI nd benzod i zepine, w hich re both
(D) Incre se the lithiu d ose. d iscontinu ed on d ission. An ntipsychotic
nd ood st bilizer re st rted . Tw o d ys
(E) St rt b clofen (Liores l).
fter d ission, she c lls the nu rsing st ff to
her bed . She is extre ely frightened nd co -
Questions 15 and 16
p l ins excited ly th t she c nnot stop looking
A 29-ye r-old w o n tells her d octor th t bou t u p . On ex in tion, her eyes re noted to be
3 w eeks go she w s c rin g for ch ild w ho r n d evi ted up w rd , bil ter lly. Which of the fol-
into the street nd w s killed by bu s. Since then, low ing sid e effects is ost consistent w ith her
she c nn ot get th e i ge of the ccid ent ou t of h er p resent tion?
ind . Even in sleep , she d re s bou t it nd it p re- (A) N MS
vents her fro sleep ing ore th n few hou rs t
(B) Ocu logyric crisis
nigh t. She u sed to t ke bu s to w ork, bu t she n ow
d rives bec u se she c nnot be r to be ne r bu ses s (C) Retrocollis
this c u ses her to think bou t the ccid ent. In the (D) Torticollis
p st w eek, sh e h s begu n issin g w ork bec u se (E) Tris u s
she is u n co fort ble le ving her h ou se. Sh e feels
extre ely gu ilty, believing the ccid ent w s h er Questions 18 and 19
f u lt.
A 59-ye r-old w o n w ith long history of gener-
15. Which of the follow ing is the ost likely lized nxiety d isord er (GAD) tells her p ri ry c re
d i gnosis? d octor th t 2 d ys go w hile in crow d ed su p er-
rket she felt d izzy, long w ith ssoci ted he rt
(A) Acu te stress d isord er p lp it tions, p ressu re on her chest, nd fright-
(B) Ad ju st ent d isord er ening sense of d oo . Shortly there fter, she fell
(C) M jor d ep ressive d isord er (MDD) u nconsciou s nd w oke u p inu tes l ter to crow d
(D) P nic d isord er nd gor p hobi rou nd her. She felt so ew h t better nd rejected
others d vice th t n bu l nce be c lled . She
(E) Posttr u tic stress d isord er (PTSD)
qu ickly d e her w y ho e.
16. The p tient d ecid es g inst ny ed ic tion
18. Which of the follow ing w ou ld be the ost
bu t follow s u p w ith p sychother p y. A ye r
p p rop ri te next step in her n ge ent?
l ter, lthou gh she is no longer h ving d is-
tressfu l sy pto s rel ting to the ccid ent, she (A) Cognitive-beh vior l ther p y
feels s d nd te rfu l ost of the ti e, is h ving (B) Electroc rd iogr (ECG)
trou ble e ting, h s lost interest in g rd ening, (C) Re ssu r nce th t her cond ition is benign
nd w kes u p t 4 a m every orning, u n ble
(D) Short- cting benzod i zep ines
to get b ck to sleep. She const ntly feels tired
throughout the d y. Which of the follow ing is (E) SSRI
the ost likely d i gnosis?
 Que s tions : 1424 169

19. Which of the follow ing d i gnoses is the ost to feel d epressed , helpless, nd hopeless, nd
i p ort nt to ru le ou t first? he su bsequ ently overd oses on his ed ic tion.
H is w ife find s hi u nconsciou s nd p roceed s
(A) Acu te stress d isord er
to c ll 911. Which of the follow ing w ou ld be
(B) C rd iov scu l r d ise se the ost likely c u se of d e th?
(C) GAD
(A) C rd i c rrhyth i
(D) Illness nxiety d isord er
(B) Resp ir tory f ilu re
(E) P nic tt ck
(C) Seizu re
20. A 28-ye r-old le p resents to you r office (D) Shock
bec u se he w nts to stop p rticu l rly d is- (E) Stroke
turbing beh vior. H e tells you th t he often
goes on p u blic tr ins w ith the intention of try- Questions 23 and 24
ing to ru b his genit ls on other p eop le w ithou t
their consent. H e continu es to h ve f nt sies A 19-ye r-old n w ith no p reviou s psychi tric his-
bou t this, bu t he w ishes to stop bec u se he tory is noted by his college roo te to be cting
is fr id of getting into trou ble. Which of the biz rrely for the p st onth nd h lf, h ving con-
follow ing is his ost likely d i gnosis? vers tions w ith people w ho re not there, w lking
rou nd the d or itory roo n ked , nd ccusing the
(A) Exhibitionistic d isord er roo te of c lling the Dep rt ent of H o el nd
(B) Frotteu ristic d isord er Secu rity to h ve hi onitored . The p tients vit l
(C) Sexu l sochis d isord er signs re ll w ithin nor l li its nd his neurologic
(D) Sexu l s d is d isord er ex in tion show s no d eficits or bnor lities.
(E) Voyeu ristic d isord er
23. Which of the follow ing tests w ou ld be ost
usefu l in the initi l d i gnosis of this p tient?
Questions 21 and 22
(A) Co p lete blood cou nt (CBC)
A 53-ye r-old n presents to your office co pl in-
(B) Erythrocyte sed i ent tion r te (ESR)
ing of w orsening d epression. H e st tes th t he no lon-
ger enjoys spend ing ti e w ith his f ily, he is only (C) Liver fu nction tests
getting few hours of sleep t night, nd his ppetite (D) N oncontr st CT sc n of the br in
is uch low er th n it used to be. H e feels tired ll d y (E) Toxicology screen
long. You d ecid e to initi te n SSRI.
24. If the bove test w ere neg tive, w hich of the
21. Which of the follow ing sid e effects is he follow ing w ou ld be the ost likely d i gnosis?
ost likely to exp erience fter 3 onths of
(A) Delu sion l d isord er
tre t ent?
(B) M jor d ep ression w ith p sychotic
(A) Di rrhe fe tu res
(B) H e d ches (C) Schizop hreni
(C) N u se (D) Schizop hrenifor d isord er
(D) Sed tion (E) Su bst nce-ind u ced p sychosis
(E) Sexu l d ysfu nction
Questions 25 and 26
22. The p tient retu rns few ore ti es, nd
d u ring e ch visit, you incre se the d os ge of You h ve been sked by the su rgery te to ev lu -
the SSRI. H ow ever, he d oes not report ny te 35-ye r-old n w ho h d surgery to rep ir his
d ecre se in his d epressive sy pto s. Bec use fr ctu red right w rist 24 hou rs go nd is now co -
of his l ck of response to n SSRI, you d ecid e to pl ining of nxiety. The p tient h s been in the hos-
initi te tricyclic ntid ep ress nt. H e continu es pit l for 2 d ys. H is he rt r te is 120 be ts/ in, nd
170 6: Diffe re ntia l Dia g nos is a nd Ma na g e me nt

his blood pressure is 160/ 106 H g. H e is febrile 28. Which of the follow ing w ou ld be the ost
nd reports th t he h s never su ffered nything like pp rop ri te tre t ent for this p tient?
this before. H e is not in ny p in nd h s no pre-
(A) A low -sti u lu s environ ent
viou s psychi tric history. H is ed ic tion inclu d es
only cet inophen for p in control. You note th t (B) Benztrop ine
he is d i phoretic, flu shed , nd tre u lou s. (C) Methylp henid te (Rit lin)
(D) Phenytoin (Dil ntin)
25. Which of the follow ing is the ost p p rop ri te (E) Prop r nolol (Ind er l)
ed ic tion to tre t this p tient?
(A) C rb zep ine 29. A 40-ye r-old d ivorced w o n is brought
in to the e ergency d ep rt ent fter being
(B) Clonid ine (C t p res)
fou nd sleep ing in p ile of le ves. Initi lly, she
(C) Lor zep is d ifficu lt to rou se nd h s trou ble nsw er-
(D) Meth d one ing you r qu estions d u e to u bling. She
(E) N ltrexone (ReVi ) d oes not ppe r to be in respir tory d istress,
bu t her p u p ils re noted to be p inp oint. After
26. Withou t the bove tre t ent, w hich of the few hou rs, she beco es ore inter ctive nd
follow ing co p lic tions is he ost t risk for is co p l ining of d iffu se, cr p y bd o in l
d evelop ing? p in nd sy p to s of the flu . H er pu p ils
re now slightly d il ted , nd she is y w ning.
(A) Abd o in l p in
H er vit l signs re te p er tu re of 99.3F,
(B) Cirrhosis he rt r te of 99 be ts/ in, nd blood pressu re
(C) F tty liver of 142/ 90 H g. Cu rrently, w hich of the
(D) Mu scle cr p s follow ing is the ost likely d i gnosis?
(E) Seizu res (A) C nn bis bu se
(B) Coc ine intoxic tion
Questions 27 and 28
(C) Coc ine w ithd r w l
You re w orking in the psychi tric e ergency (D) Op i te intoxic tion
d ep rt ent of l rge etropolit n hospit l. A (E) Op i te w ithd r w l
20-ye r-old n w ith unknow n p sychi tric his-
tory is brou ght in by the p olice fter being fou nd Questions 30 and 31
stu bling n ked rou nd loc l college c p u s.
H e is rked ly git ted , p cing, nd pp e rs to be A 70-ye r-old w id ow is d itted for n ev lu tion
resp ond ing to intern l sti u li. On ex in tion, you of d epression nd nxiety. She tells you th t for
note th t he is t chyc rd ic w ith he rt r te in the the p st 15 ye rs her f ily d octor h s prescribed
110s, he h s tics or sp s s in his f ce, nd he h s so e p ills th t h ve help ed her sleep nd feel less
vertic l nyst g u s. nervou s. She s ys th t she r n ou t of the yesterd y
nd since th t ti e h s felt incre singly nxiou s nd
27. Which of the follow ing tests w ou ld be ost jittery. She lso notes th t shes now h ving tre ors
helpfu l in the d i gnosis? in her h nd s th t h ve not been there before.
(A) CBC
30. Which of the follow ing ed ic tions w ou ld be
(B) Electroencep h logr (EEG) the ost d ngerou s to su d d enly d iscontinue?
(C) M gnetic reson nce i ge (MRI) of the
br in (A) Flu p hen zine (Prolixin)
(D) N oncontr st he d CT (B) I ip r ine (Tofr nil)
(E) Toxicology screen (C) N ortrip tyline (P elor)
(D) Thiorid zine (Mell ril)
(E) Tri zol (H lcion)
 Que s tions : 2535 171

31. Which of the follow ing w ould be the ost Questions 34 and 35
d ngerou s sid e effect of bru p tly stop p ing the
bove ed ic tion? A 34-ye r-old fe le p resents to you r office s she
h s been feeling d epressed nd ngry for the p st
(A) Au tono ic hyp er ctivity cou ple of d ys bec u se she believes th t her boy-
(B) Seizu res friend is going to le ve her. As resu lt, she h s been
(C) H llu cin tions c lling hi every hour ju st to confir th t he is not
(D) Worsening nxiety le ving her. She tells you th t she h s h d ny rel -
tionships in the p st w hich h ve lw ys been very
(E) Vo iting
rocky, c u sing her e otions to const ntly go u p nd
d ow n. When ny of these rel tionships end ed ,
Questions 32 and 33
she cu t on her r s sup erfici lly to relieve stress.
A 73-ye r-old n is d itted to the hosp it l for At this ti e, she tells you th t she d oes h ve so e
co u nity- cqu ired pneu oni nd d ehyd r - thou ghts of w nting to cut herself, bu t no thoughts
tion. On d y 2 of his hosp it liz tion, you re sked of w nting to end her life.
to ev lu te the p tient for d ep ression; the st ff h s
noted th t he see s very w ithd r w n. H e is not e t- 34. Which of the follow ing is the ost likely
ing or sleeping w ell. The nu rsing st ff reports th t d i gnosis?
l st night he w s ngry nd requ ested to le ve the (A) Bip ol r d isord er
hospit l. You t lk w ith the p tients f ily nd find
(B) Bord erline p erson lity d isord er (PD)
th t the p tient h s no previou s psychi tric history.
Prior to the onset of this illness 5 d ys go, he h d (C) H istrionic PD
no d ep ressive sy pto s nd no d ifficu lties w ith (D) M jor d ep ressive d isord er
cognition. On ex in tion, his vit l signs re te - (E) N rcissistic p erson lity d isord er
per tu re of 98.2F, he rt r te of 87 be ts/ in,
blood pressure of 130/ 86 H g, nd p erip her l 35. Which of the follow ing is the ost pp rop ri-
oxygen s tur tion of 95% on roo ir. H e is d row sy te tre t ent for this d i gnosis?
nd oriented only to p erson. H is Mini-Ment l St te
(A) Arip ip r zole (Abilify)
Ex in tion (MMSE) score is 23/ 30.
(B) Cit lop r (Celex )
32. Which of the follow ing is the ost likely (C) Cognitive-beh vior l ther p y
d i gnosis? (D) Di lectic l beh vior l ther p y
(E) Psycho n lysis
(A) Anxiety d isord er
(B) Deliriu Questions 36 and 37
(C) F ctitiou s d isord er
(D) M jor d ep ressive d isord er (MDD) A 65-ye r-old w o n w ith p st ed ic l history
of noninsu lin-d ep end ent d i betes ellitu s nd
(E) M jor neu rocognitive d isord er
d epression is d itted w ith incre singly d epressed
(d e enti )
ood over the l st onth. She is u n ble to co -
plete her crossw ord pu zzles bec use of d ifficu lty
33. The ed ic l te sks for ed ic tion reco -
concentr ting. She h s trouble f lling sleep nd
end tions if the p tient beco es git ted .
lso w kes u p in the id d le of the night. She d enies
Which of the follow ing w ou ld be the ost
su icid l id e tion, but d oes feel gu ilty th t she is
pp rop ri te ed ic tion to reco end ?
d epressed . Prior to this episod e, she w s d oing w ell
(A) Benztrop ine nd w s ctively eng ged in co u nity volunteer
(B) Dip henhyd r ine grou p s. In the l st onth, she h s lost 13 lb d ue to
(C) Lor zep poor int ke. When sked w hy she is not e ting, she
st tes she is w orried th t she w ill beco e infected
(D) H lop erid ol
w ith b cteri . She h s been to her p ri ry p hysici n
(E) Thiorid zine
for n ev lu tion, bu t she cl i s everything w s
172 6: Diffe re ntia l Dia g nos is a nd Ma na g e me nt

nor l. H er hu sb nd confir s th t the p tient h s looks frightened nd sks, Wh t is h p p ening to

been very w orried bou t getting d ise se to the e? H is ood is OK nd his ffect is fl t. H e is
p oint w here she w ill e t only food in se led con- fu lly oriented . H e s ys th t he he rs nu ber of
t iners. H e lso confid es in you th t she h s been p eople t lking to hi , ybe in y he d , s ying
w orried th t she ight h ve c ncer, nd , d esp ite b d things bou t hi .
re ssu r nces fro her p ri ry c re p hysici n, she
continu es to voice her concerns to her hu sb nd th t 38. Which of the follow ing d i gnoses is ost
y intestines re not w orking. likely?
(A) Brief p sychotic d isord er
36. Which of the follow ing is the ost likely
d i gnosis? (B) Delu sion l d isord er
(C) Schizop hreni
(A) M jor d ep ressive d isord er (MDD)
(D) Schizop hrenifor d isord er
w ithou t p sychotic fe tu res
(E) Su bst nce-ind u ced p sychotic d isord er
(B) MDD w ith p sychotic fe tu res
(C) Obsessive-co p u lsive d isord er (OCD) 39. Which of the follow ing l bor tory tests or pro-
(D) Persistent d ep ressive d isord er ced u res w ould be the ost helpfu l in n rrow -
(d ysthy i d isord er) ing the bove d ifferenti l?
(E) So tic sy p to d isord er
(A) CBC
37. Which of the follow ing ed ic tion(s) w ou ld (B) EEG
be the ost p p rop ri te tre t ent for this (C) Electrolytes
p tient? (D) N oncontr st he d CT
(A) Div lp roex sod iu (E) Toxicology screen
(B) Lithiu nd sertr line
Questions 40 and 41
(C) N ortrip tyline nd lor zep
(D) Sertr line A 35-ye r-old w o n w ith no previous person l or
(E) Sertr line nd risp erid one f ily psychi tric history is brought to the e er-
gency d ep rt ent by her husb nd, w ho reports th t
Questions 38 and 39 his w ife w s tte pting to kill herself by cutting her
w rists. H er husb nd tells you th t 6 onths go the
An 18-ye r-old n is brou ght to the p sychi tric p tients gr nd other d ied . Since th t ti e, her hus-
e ergency d ep rt ent by his p rents for ev lu tion b nd believes th t the p tient h s been beco ing
of his beh vior. Three onths go, the p tient st rted ore d epressed . She h s d ifficulty f lling sleep nd
cl sses t the st te university loc ted in d ifferent h s lost 15 lb in 2 onths. She w s recently fired fro
city, lthough he w ou ld co e ho e e ch w eekend her job s p r leg l bec use she w s un ble to con-
to visit. H is p rents h ve noticed th t over the p st centr te nd d e frequent ist kes. She feels guilty
3 w eeks he h s beco e incre singly w ithd r w n nd th t she is un ble to feel better, nd she end orses feel-
d oes not see to be t king c re of hi self. The p r- ings of hopelessness nd w orthlessness. She believes
ents w ere recently c lled by the p tients roo te th t her only w y out of this is to kill herself.
w ho infor ed the th t the p tient h s not been
going to cl sses for the l st w eek, h s not been e ting 40. Which of the follow ing w ou ld be the ost
or b thing, nd h s been spe king bout how peo- p p rop ri te tre t ent?
p le in his cl sses re trying to kill hi . The p tient
(A) Flu zenil (Ro zicon)
d enies ny d ru g u se nd is not on ny ed ic tion.
On ex in tion, the p tients vit l signs re w ithin (B) Flu oxetine
nor l p r eters. H is physic l (inclu d ing neu ro- (C) Flu p hen zine
logic ex in tion) is u nre rk ble. H e is p cing (D) Lor zep (Ativ n)
nd ppe rs to be resp ond ing to intern l sti uli. H e (E) Phenelzine (N rd il)
 Que s tions : 3645 173

41. After being begu n on the p p rop ri te ed ic - the d e n of her college is concerned bout her nd
tion, w hich of the follow ing sid e effects y w orried th t she y be d ep ressed . The p tient tells
i ic w orsening sy pto of her illness? you th t d esp ite being f r w y fro her ho e for
the first ti e, she w s enjoying school nd her new
(A) Ak thisi
friend s u ntil 2 onths go, w hen she le rned th t
(B) Constip tion her p rents w ere getting d ivorced . Since th t ti e,
(C) Di rrhe her gr d es h ve gone fro As nd Bs, to Bs nd Cs
(D) Inso ni bec u se she is concerned bou t her p rents nd her
(E) N u se sister t ho e. She feels bu ed ou t ost of the
ti e, nd her friend s note th t she see s unh ppy
Questions 42 and 43 nd occ sion lly beco es te rfu l w hen t lking
bou t her f ily. She d enies d ifficu lty sleep ing or
A 46-ye r-old n w ith no previou s p sychi tric his- ch nges in ppetite or w eight, nd she continu es to
tory p resents w ith co pl ints of feeling d epressed enjoy d ily trip s to the gy to exercise. She d enies
since his w ife d ied 2 w eeks go fro p ncre tic c n- ny suicid l id e tion.
cer. H e sh res th t lthough he know s she is d e d ,
he so eti es he rs her c lling his n e. This h s 44. Which of the follow ing is the ost likely
occu rred sever l ti es nd usu lly h pp ens ore d i gnosis?
often t night w hen he is f lling sleep. H e d enies
ny visu l h llu cin tions, p r noi , or d elu sion l (A) Acu te stress d isord er
beliefs. H e expresses gu ilt bou t not sp end ing ore (B) Ad ju st ent d isord er w ith d ep ressed
ti e w ith his w ife w hen she w s live bu t d enies ood
ny thou ghts of w nting to end his life. H e is now (C) GAD
sleeping only bou t 3 to 4 hou rs t night nd h s (D) MDD
h d slightly d ecre sed pp etite since her d e th.
(E) N or l grief
Desp ite the bove, he h s still been ble to go to
w ork nd focu s on his job.
45. Which of the follow ing tre t ents w ou ld be
ost p propri te?
42. Which of the follow ing is the ost likely
d i gnosis? (A) Di lectic l beh vior l ther p y
(A) Ad ju st ent d isord er (B) Flu oxetine (Proz c)
(B) M jor d ep ressive ep isod e (C) N ortrip tyline
(C) N or l grief (D) Psychother p y
(D) Persistent d ep ressive d isord er (E) Risp erid one (Risp erd l)
(d ysthy ic d isord er)
Questions 46 and 47
(E) Schizop hreni
A 26-ye r-old w o n w ith no p reviou s psychi tric
43. Which of the follow ing w ou ld be the ost history is referred to you by her p ri ry c re p hysi-
pp rop ri te tre t ent for this p tient? ci n for ev lu tion of nxiety tt cks. She tells you
(A) A itrip tyline (El vil) th t p p roxi tely 2 onths go she beg n h ving
period s l sting 10 or 15 inu tes d u ring w hich, she
(B) Flu oxetine (Proz c)
s ys, I feel like I going to d ie. Du ring these epi-
(C) H lop erid ol (H ld ol) sod es, her he rt r ces, she feels s thou gh she c nnot
(D) Lithiu c tch her bre th, she is d izzy nd fr id she y p ss
(E) N o intervention t this ti e out, nd she h s tingling nd tre ors in her h nd s.
She is concerned bec use she is now h ving d iffi-
Questions 44 and 45 cu lty le ving her hou se d ue to w orry th t these ep i-
sod es w ill occu r, king it i p ossible for her to get
You re sked to see n 18-ye r-old w o n w ith
ho e. She is u n ble to id entify ny triggers le d ing
no p reviou s psychi tric or ed ic l history bec u se
174 6: Diffe re ntia l Dia g nos is a nd Ma nag e me nt
to the episod es. She is not on ny
h s no ed ic l proble s.
46. Which of the follow ing is her
d i gnosis?
(A) GAD
(B) P nic d isord er nd gor p hobi
(C) Sep r tion nxiety d isord er
(D) Soci l nxiety d isord er (soci l p hobi )
(E) Sp ecific p hobi
47. Which of the follow ing w ou ld be the
p propri te tre t ent to initi te?
(A) Alp r zol
(B) Lithiu
(C) Prop r nolol
(D) Sertr line (Zoloft)
(E) Tr nylcyp ro ine (P rn te)
Questions 48 and 49
A 36-ye r-old w o n w ith no for er p sychi t-
ric history is referred to you by d er tologist
for ev lu tion of her chronic lly ch pped h nd s.
She s ys she h s been seeing her d er tologist for
p proxi tely 5 ye rs for this proble nd tre ted
w ith v riety of top ic l gents w ith li ited su c-
cess. Over the p st 3 w eeks, her h nd s h ve beco e
w orse, to the p oint w here they re lw ys cr cked
nd bleed ing. Relu ct ntly, she confid es in you th t
she h s h d longst nd ing fe r of ger s, bu t since
her colle gu e t w ork h s been sick, she h s been
w shing her h nd s t le st 40 ti es p er d y bec u se
she is fr id of contr cting the d ise se. She lso
refu ses to tou ch nything th t ight infect her w ith-
ou t u sing h nd kerchief. She d its to being very
tid y t ho e, s w ell. She spend s bou t 2 hou rs
in the orning getting show ered . She re lizes her
fe rs of cont in tion re irr tion l, but every ti e
she tries to stop w shing her h nd s she beco es
incre singly nxiou s.
48. Which of the follow ing d i gnoses w ou ld be
ost likely?
(A) GAD
(B) Obsessive-co p u lsive d isord er (OCD)
ed ic tion nd (C) Obsessive-co p u lsive p erson lity
d isord er (OCPD)
(D) P nic d isord er
ost likely (E) So tic sy p to d isord er
49. Which of the follow ing tre t ents w ould be
ost ppropri te for this p tient?
(A) Cognitive-beh vior l ther p y
(B) ECT
(C) Lithiu
(D) Psychod yn ic p sychother p y
ost (E) Risp erid one
50. A 47-ye r-old secret ry co es to your office
co pl ining, I lw ys w orried . She s ys
th t she w orries bout her job, her kid s, her
hou sew ork, nd her hu sb nd . She is seeking
help now bec u se she h s been h ving n
incre singly d ifficu lt ti e concentr ting t
w ork nd h s been ore irrit ble w ith p eo-
ple rou nd her. H er sleep h s been ok y,
bu t she d oes not feel rested w hen she gets u p
in the orning. She h s been ore w re of
these feelings over the l st 2 ye rs nd they
occu r l ost every d y. She d enies ny d is-
crete p nic tt cks. Which of the follow ing
d i gnoses is the ost likely in this p tient?
(A) GAD
(B) OCD
(C) Soci l nxiety d isord er (soci l p hobi )
(D) P nic d isord er
(E) Schizop hreni
51. A 28-ye r-old w o n w ith no p revious psy-
chi tric or ed ic l history is d itted to the
neu rology service for ev lu tion of cu te onset
of nu bness nd w e kness of the right sid e of
her f ce nd right r nd leg. Physic l ex -
in tion show s sy etric l 2/ 4 reflexes in
ll d istribu tions, d ow ngoing p l nt r reflexes
bil ter lly, nd 2/ 5 strength in the right u p per
nd low er extre ity in ll u scle group s. N o
trop hy or f scicul tions re noted . H er g it
is t xic nd st ggering w ith extre e ex g-
ger ted ove ents of her r s; how ever, she
d oes not f ll w hen bu l ting w ithou t ssis-
t nce. Given the severity of her d eficits, she

see s u nconcerned by her level of d is bility.
Which of the follow ing d i gnoses w ou ld be
the ost p propri te?
(A) Conversion d isord er
(B) F ctitiou s d isord er
(C) M lingering
(D) So tic sy pto d isord er
(E) Und i gnosed neurologic d ise se
52. A 54-ye r-old w o n w ith p st ed ic l
history of hypothyroid is is d itted w ith
septic right knee. The surgery te sks you
to ev lu te the p tient bec use they fou nd
th t the flu id sp ir te fro the knee w s
grow ing p thogen fou nd p ri rily in the
hu n ou th. They su sp ect the p tient w s
injecting s liv into her knee. You ev lu te the
p tient nd find her to be p le s nt nd coop -
er tive. She tells you th t she h s h d very
tough ti e l tely bec use her husb nd h s
recently been sick. Fortu n tely, she is nu rse
nd h s been ble to c re for hi t ho e.
L tely, she d its to feeling overw hel ed
nd not pp reci ted . She h s no id e w h t h s
c used the proble w ith her knee. You t lk to
the f ily nd they tell you the p tient is in
no fin nci l d ifficu lty nd continu es to enjoy
w ork s nu rse. After w orking closely w ith
you for sever l w eeks, she eventu lly d its
to injecting her knee lthou gh c nnot u nd er-
st nd w hy she d id it. Which of the follow ing
is the ost p p rop ri te d i gnosis?
(A) Conversion d isord er
(B) F ctitiou s d isord er
(C) Illness nxiety d isord er
(D) M lingering
(E) So tic sy p to d isord er
Questions 53 and 54
An 18-ye r-old w o n in her first ye r of college
co es to see you for ev lu tion of d epression, fter
her roo tes encour ged her to seek help . She
rep orts d ifficu lty f lling sleep nd e rly orning
w kenings, poor concentr tion, f tigue, nd nxi-
ety over the p st onth since rriving for the f ll
se ester. She tells you th t her p rents re very strict
nd she is w orried th t she w ill not get str ight
Que s tions : 4655 175
As. On ex in tion, she is c l , thin w o n
d ressed in very b ggy jogging suit. You co -
ent on her thinness, nd she tells you she p rid es
herself on her pp e r nce nd tries to st y sli by
exercising bou t 4 hou rs d y long w ith good
d iet. She d enies proble s w ith e ting too u ch or
too little, nd cl i s th t only d iet nd exercise help
her to control her w eight. Desp ite you r concerns,
she d its th t she w ou ld like to lose few ore
p ou nd s. Up on fu rther qu estioning, she infor s you
she h s not h d regu l r enstru l period for over
ye r.
53. Which of the follow ing w ou ld be the ost
likely w orking d i gnosis?
(A) Anorexi nervos
(B) Anxiety d isord er
(C) Bod y d ys orp hic d isord er
(D) Bu li i nervos
(E) MDD
54. Which of the following tests would be ost help-
ful in supporting your provision l di gnosis?
(A) ECG
(B) Seru yl se
(C) Seru gnesiu level
(D) Seru p ot ssiu level
(E) Weight nd height
55. A 5-ye r-old boy is referred to you by his ped i-
trici n for ev lu tion of ggressive beh vior.
H is ed ic l nd extensive neu rologic w orku p
w s neg tive. An interview w ith the p tient
reve ls restless boy w ho is ble to eng ge in
convers tion. H e tells you he gets ngry nd
fru str ted in school s he thinks its boring.
H is p rents rep ort th t he is cu rrently rep e t-
ing kind erg rten d u e to p oor p erfor nce
nd d ifficu lty soci lizing w ith other child ren.
H is ggressive ou tbu rsts t school see to
occu r t ti es w hen he d oes not und erst nd
the schoolw ork. H is other tells you th t she
still h s to help hi pick ou t his clothes for
school nd get d ressed . H is f ily history is
p ositive for tw o p tern l u ncles w ith le rn-
ing d is bilities. Which of the follow ing tests
w ou ld be ost help fu l in the ev lu tion of
this p tient?
176 6: Diffe re ntia l Dia g nos is a nd Ma na g e me nt
(A) Good enough-H rris Dr w -A-Person
Test
(B) Kohs Block Test
(C) Minnesot Mu ltip h sic Person lity
Inventory-2 (MMPI-2)
(D) Pe bod y Voc bu l ry Test
(E) Wechsler Intelligence Sc le for Child ren
(WISC)
Questions 56 and 57
An 8-ye r-old boy is brou gh t in to you r office
by h is oth er bec u se sh e is con cern ed th t h e
c nnot stop blinking his eyes nd shru ggin g his
sh ou ld ers. Sh e tells you th t this occu rs l ost
every d y n d h s been th is w y for the p st ye r
nd h lf. Sh e tells h er son to stop d oin g this
w h ile h e is in you r office, n d h e d oes stop . You
notice, h ow ever, th t h e st rts b rkin g n d cou gh-
in g rep e ted ly.
56. Which of the follow ing ed ic tions w ou ld be
the ost ppropri te in tre ting the p tients
cond ition?
(A) Ato oxetine
(B) Clonid ine
(C) L otrigine
(D) Lor zep
(E) V lp roic cid
57. You begin the p p rop ri te ed ic tion nd
2 onths l ter the boy nd his other retu rn
for follow -u p visit. She tells you th t w hile
the eye blinking nd should er shrugging h ve
gotten better, he is now f lling sleep in his
cl sses t school. Wh t is the next ost p pro-
p ri te step in the n ge ent?
(A) Ad d nother ed ic tion to keep the boy
w ke.
(B) Ed u c te the other bou t p rop er sleep
hygiene.
(C) Discontinu e the ed ic tion.
(D) Red u ce the d os ge.
(E) Sw itch to nother ed ic tion.
58. A 17-ye r-old boy w ith h istory of tten -
tion-d eficit/ h yp er ctivity d isord er (ADH D)
p resents w ith od d beh vior, confu sion,
blood p ressure of 128/ 85 H g, nd he rt
r te of 68 be ts/ in. H is p rents rep ort th t
t ti es they h ve observed hi repetitively
tou ching his sto ch nd r pid ly blinking his
eyes. On ex in tion, he p p e rs d zed nd
u n ble to concentr te. Which of the follow ing
is the ost likely d i gnosis?
(A) A p het ine toxicosis
(B) Ep ilep sy
(C) H yp oglyce i
(D) MDD
(E) So tic sy p to d isord er
59. A 50-ye r-old n w ith long history of IV
d rug u se is brought to the hosp it l by p olice
fter loc l ho eless shelter w orker noted
hi to be confu sed nd w lking funny.
While t the shelter, he bec e very su spiciou s
of the w orkers nd ccu sed the of t king his
belongings. On ex in tion, you observe th t
he h s left p u p il th t cco od tes but d oes
not re ct, d epressed d eep tend on reflexes in
ll d istribu tions, nd loss of p osition sense t
the gre t toes bil ter lly. Althou gh the p tient
w s tre ted w ith ntip sychotic ed ic tions in
the p st, he d enies cu rrently t king ny ed i-
c tion. Which of the follow ing d i gnoses best
ccou nts for this p tients sy p to s?
(A) Antip sychotic-ind u ced d yskinesi
(B) Kors koff p sychosis
(C) N eu rolep tic lign nt synd ro e
(D) N eu rosyp hilis
(E) Wernicke encep h lop thy
60. A 57-ye r-old w o n w ith no p revious p sy-
chi tric history co pl ins of incre sing nxi-
ety over the l st 2 onths. Tod y she reports
th t it bec e very b d . She lso notes th t
w ith these p eriod s of nxiety she gets p ou nd -
ing he d che nd once f inted . She continu es
to feel sh ky. When you check her vit l
signs, her he rt r te is 170 be ts/ in nd her
blood p ressu re is 230/ 130 H g. She is d i -
p horetic nd tre u lou s. Given this p tients
sy p to s, w hich of the follow ing cond itions
is ost likely?

(A) Acu te lcohol intoxic tion
(B) H yperc lce i
(C) H yp othyroid is
(D) Pheochro ocyto
(E) Posterior circu l tion stroke
D IRECTION S (Questions 61 through 66): For each
patient vignette, select the one lettered option
that is most closely associated w ith it. Each let-
tered option may be used once, multiple times, or
not at all.
(A) Conversion (fu nction l neu rologic l
sy pto ) d isord er
(B) H ep tic enceph lop thy
(C) H u n i u nod eficiency viru s (H IV)
(D) H yp erthyroid is
(E) H yp oglyce i
(F) Pheochro ocyto
(G) So tic sy p to d isord er
(H ) Syste ic lu p u s erythe tosu s (SLE)
61. A 55-ye r-old n is d itted to the hosp it l.
H is w ife reports th t hes ch nged over the
l st ye r, h s beco e very forgetfu l, nd
h s period s w hen he beco es very u p set.
On ex in tion, he h s signific nt e ory
i p ir ent, sterixis, p l r erythe , nd
l rge ecchy otic re on his right sc p u l .
H e w s initi lly cooper tive, bu t now is very
git ted nd d e nd s to le ve.
62. A 52-ye r-old n w ith history of IV d ru g
u se is brou ght to the e ergency d ep rt ent
by his soci l w orker fro ho eless shelter.
She h s know n the p tient for 10 ye rs bu t h s
seen d r stic ch nge in hi over the l st ye r.
While previou sly jovi l nd inter ctive, he is
now d iseng ged nd subd u ed . H e h s been
incre singly forgetfu l, tod y h ving d ifficu lty
u sing his e ting u tensils. H e h s lost t le st
40 lb in the l st 6 onths nd co pl ined
bou t feeling w e k nd losing his b l nce. H e
scores 20/ 30 on the MMSE.
63. A 33-ye r-old w o n is brou ght to the e er-
gency d ep rt ent by her hu sb nd , w ho tells
you th t over the l st few onths she h s been
Que s tions : 5666 177
incre singly te rfu l, irrit ble, restless, s w ell
s h ving d ifficu lty p ying bills nd b l nc-
ing her checkbook. She h s occ sion l hot
fl shes. On ex in tion, she continuou sly
ch nges position in her se t. She h s d ifficulty
w ith si p le rith etic nd short-ter e -
ory. H er d eep tend on reflexes re brisk sy -
etric lly throu ghou t. She h s fine resting
tre or of her h nd s nd d ifficu lty rising fro
se ted p osition.
64. A 33-ye r-old w o n p resents w ith 1-ye r
history of tension he d ches, recently w ors-
ening nd now ssoci ted w ith blu rry vision.
So f r, n extensive neu rologic ev lu tion h s
been u nreve ling. She volu nteers th t she h s
been sick ost of her life, beginning t ge 16
w hen she h d su rgery for p resu ed end o-
etriosis, w hich h s left her u n ble to h ve
sexu l rel tions. Since the su rgery, she h s
h d inter ittent bd o in l cr ping, blo t-
ing, nd d i rrhe . Review of her ch rt show s
th t 3 onths go, she s w rheu tologist
for knee, b ck, nd eye p in.
65. A 30-ye r-old w o n is brou ght to the hos-
p it l by her fi nc. H e s ys th t over the l st
2 w eeks, she h s been tot lly d ifferent p er-
son. She h s not been e ting or sleeping, nd
h s been irrit ble nd ngry. E rlier in the
onth, she co pl ined of he d ches, p in in
her h nd s nd feet, nd fever. On ex in -
tion, she looks tired ; she is fully oriented bu t
h s d ifficu lty rel ting the events of the l st
onth. Occ sion lly, she see s to beco e
confused .
66. A 42-ye r-old w o n in the e ergency d ep rt-
ent pp e rs confu sed nd w ill not llow
blood to be d r w n. She is not oriented to ti e
or pl ce. She t kes ed ic tions for cond i-
tion, bu t c nnot el bor te fu rther. The only
vit l signs th t w ere t ken show he rt r te
of 140 be ts/ in nd blood p ressure of 172/
98 H g. Physic l ex in tion is re rk-
ble for fine tre or of her h nd s bil ter-
lly, nd d i phoresis. Five inu tes l ter, the
p tient h s seizu re.
178 6: Diffe re ntia l Dia g nos is a nd Ma na g e me nt
DIRECTIONS (Questions 67 through 72): For each
patient vignette, select the one lettered option that is
most closely associated w ith it. Each lettered option
may be used once, multiple times, or not at all.
(A) Deliriu
(B) MDD (p seu d od e enti )
(C) M jor neu rocognitive d isord er d u e to
Alzhei er d ise se
(D) M jor neu rocognitive d isord er d u e to
frontote por l lob r d egener tion
(Pick d ise se)
(E) M jor neu rocognitive d isord er d u e
to H u ntington d ise se
(F) M jor neu rocognitive d isord er d ue to
Lew y bod y d ise se
(G) M jor neu rocognitive d isord er d u e
to Prion (Creutzfeld tJ cob) d ise se
(H ) M jor v scu l r neu rocognitive d isord er
67. A 71-ye r-old fe le is brou ght to the ER by
her hu sb nd . Over the p st few ye rs, he h s
noticed th t she h s been h ving e ory
p roble s. She often forgets w here she p u t
her keys or pu rse. H e no longer lets her d rive
bec u se she gets lost e sily. On MMSE, she h s
p rticul r p roble s w ith the d y of the w eek,
d te, three-ite rec ll, nd n ing pencil.
68. A 68-ye r-old le w ith no p sychi tric history
is brou ght by his d u ghter bec u se, d esp ite
u ltiple re ssu r nces, he continu es to insist
so eone else is in the house. The p tient st tes
he sees s ll n every d y ju st insid e of
the d oor. H is d ughter h s lso noticed th t
he h s proble s w ith his e ory. On ex i-
n tion, he h s shu ffling g it nd blu nted
ffect, w hich the d ughter st tes beg n t the
s e ti e s the visu l h llu cin tions.
69. A 55-ye r-old le is brou ght by his w ife
bec u se she h s noticed ch nges in his beh v-
ior. L tely, his food p references h ve ch nged
nd he is now cu rsing lou d ly in pu blic. On
ex in tion, he is e sily git ted . N eu rologic
ex in tion d e onstr tes p ositive B binski
resp onse nd snou t reflex. An MRI show s
trophy in the front l nd te p or l lobes.
70. An 86-ye r-old fe le is brou gh t to th e ED
fter the nu rsing ho e st ff noticed su d d en
ch nge in h er beh vior over the l st sever l
d ys. On history nd p hysic l ex in tion, it
is d ifficu lt to elicit infor tion s the p tient
keep s f lling sleep . H er vit l signs show
te p er tu re of 101.2F n d he rt r te of
101 be ts/ in. Urin lysis is p ositive for
ketones.
71. A 59-ye r-old fe le is brou ght in by her son
w ith w ho she lives. H e st tes th t over the
p st cou p le of onths his other h s been
isol tive, no longer sp end s her ti e re d -
ing w hich she u sed to enjoy. She w ill re in
w ke l te t night nd e rly in the orning,
nd her p p etite h s d ecre sed . H e is lso con-
cerned bec use she w ill so eti es re e ber
inor d et ils fro the d y before, bu t other
ti es w ill not rec ll w h t she h d for bre k-
f st. Ment l st tu s ex in tion is signific nt
for incre sed sp eech l tency, d ep ressed ood
nd ffect, nd trou ble rec lling 2/ 3 ite s
fter sever l inu tes.
72. A 39-ye r-old le w ith no p reviou s p sychi-
tric history p resents w ith co p l ints of feel-
ing very d ep ressed l tely. H is f ily notes
th t he h s been u ch ore irrit ble recently,
often yellin g w ith little p rovoc tion nd
see ingly t lking to hi self. On MSE, he is
noted to h ve qu ick, su d d en, bu t involu nt ry,
jerking ove ents of his r s.
D IRECTION S (Questions 73 through 98): For each
of the multiple-choice questions in this section,
select the lettered answ er that is the one best
response in each case.
73. A 56-ye r-old n p resents to you r office t
the requ est of his w ife, w ho s ys th t he d rinks
too uch. Wh t w ould be the ost i port nt
str tegy in ev lu ting this p tient for lcohol
u se d isord er?
(A) Ascert in how often he d rinks.
(B) Ask hi how frequ ently he gets d ru nk.
(C) Ask hi w h t his f ily nd friend s
s y bou t his d rinking.
 Que s tions : 6778 179

(D) Perfor co plete l bor tory Questions 77 and 78

investig tion.
A 55-ye r-old le w ith history of lcohol u se
(E) Qu ntify the ver ge ou nt he d rinks.
d isord er presents to you r office bec use he w ould
like to stop d rinking lcohol. H e believes he d rinks
74. A 42-ye r-old d ivorced le p resents to you r
bec u se he is d ep ressed nd w ishes to lso get tre t-
office st ting th t for the p st 7 onths he
ent for his d epression. After fu rther history is
h s been w orrying bout fin nci l nd w ork-
obt ined , it is reco end ed th t the first step is to
rel ted p roble s. H e st tes th t ore often
bst in fro ll lcohol s it c n c u se d ep ression.
th n not, he is w orrying bou t these issues
H e grees to this pl n.
throu ghou t the d y. H e h s d ifficu lt ti e
st ying sleep, he feels tired ll d y long,
77. Wh t is the likelihood of his re ining
nd he c n no longer concentr te d equ tely
d ep ressed if he is ble to refr in fro u sing
t w ork d u e to the w orrying. H e lso tells
lcohol for 1 onth?
you th t he feels very tense in his shou ld er
nd b ck. Which of the follow ing is the ost (A) 5%
p propri te d i gnosis? (B) 15%
(A) Depend ent person lity d isord er (C) 25%
(B) Gener lized nxiety d isord er (GAD) (D) 33%
(C) M jor d ep ressive d isord er (MDD) (E) 50%
(D) P nic d isord er
78. The bove p tient retu rns fter 6 w eeks of
(E) Soci l nxiety d isord er
int ining sobriety fro lcohol. H e tells
you th t he h s continu ed to feel d ep ressed .
Questions 75 and 76
H e h s p roble s sleep ing t night, feels tired
You re interview ing 54-ye r-old rried w o n throughou t the d y, h s poor pp etite, nd he
w ho h s been u rged to see shrink by her f - no longer d erives ple su re fro pl ying w ith
ily. She d escribes sy p to s of feeling ineffectu l, his d ogs? Which of the follow ing ed ic tions
believing th t the w orld is lw ys hostile to her, nd w ou ld be the ost p p rop ri te to begin t this
know ing th t things w ill never ch nge. ti e?
(A) A itrip tyline (El vil)
75. This tri d of sy p to s is ost ssoci ted
(B) Bu sp irone (Bu Sp r)
w ith w hich of the follow ing d isord ers?
(C) Lithiu (Esk lith)
(A) Dep ressive d isord ers (D) Lor zep (Ativ n)
(B) Dissoci tive d isord er (E) Sertr line (Zoloft)
(C) GAD
(D) P nic d isord er Questions 79 and 80
(E) Schizop hreni
A 52-ye r-old le w ith longst nd ing history of
lcohol use d isord er is brought into the ED intoxi-
76. Which of the follow ing tre t ents w ou ld
c ted w ith lcohol. B sic l bs re d r w n nd he is
ost likely t rget these sy p to s?
found to be d ehyd r ted , so he is given IV fluid s
(A) Beh vior l ther p y long w ith glu cose. Abou t n hou r l ter, the physi-
(B) Cognitive ther p y ci n reev lu tes the p tient nd find s th t his speech
(C) Cou p les ther p y is ore slurred , he is very confused , nd he now h s
nyst g us.
(D) Interp erson l ther p y
(E) P r d oxic l ther p y
180 6: Diffe re ntia l Diag nos is a nd Ma na g e me nt

79. Which of the follow ing is the next ost (A) Ad ju st ent d isord er
p propri te step in the n ge ent of this (B) Bip ol r d isord er
p tient? (C) MDD
(A) Ad inister ntibiotics. (D) Persistent d ep ressive d isord er
(B) Ad inister benzod i zep ine. (E) Schizop hreni
(C) Ad inister hep rin.
(D) Ad inister thi ine. 83. A 45-ye r-old n is in the e ergency dep rt-
ent bec use of di betic foot ulcer. In g ther-
(E) Ad inister tissu e p l s inogen
ing history, the physici n le rns th t this n
ctiv tor.
lives lone nd works nights s security gu rd.
He s ys he h s no friends but th t this does not
80. After d in istr tion of th e correct ed ic -
bother hi . He h s never been hospit lized
tion the p tien t i p roves signific ntly. H is
or received ny psychi tric help. On MSE, his
f ily rrives th e n ext orn in g n d th ey
ffect is fl t. Although he nswers questions
tell you th t he h s recen tly been st rting
nd see s to trust the judg ent of the doctors,
to ke u p f cts bou t h is life. You ord er
he h s little interest in the interview. He exhibits
n MRI of his br in nd d iscover lesion s in
no signs or sy pto s of psychosis or depres-
h is ill ry bod ies. Wh ich of th e fol-
sion. Wh t is the ost likely di gnosis?
low in g d i gn oses w ou ld best exp l in th ese
sy p to s? (A) MDD
(A) Alcohol-ind u ced jor neu rocognitive (B) P r noid p erson lity d isord er
d isord er (Kors koff synd ro e) (C) Schizoid p erson lity d isord er
(B) Conversion d isord er (D) Schizop hreni
(C) F ctitiou s d isord er (E) Schizotyp l p erson lity d isord er
(D) M jor neu rocognitive d isord er d u e to
Alzhei er d ise se 84. The id entified p tient is 30-ye r-old sep -
r ted fe le brou ght into the e ergency roo
(E) Wernicke encep h lop thy
by her id entic l tw in sister. The p tients his-
tory is not ble for prior episod e of d epres-
Questions 81 and 82
sion 5 ye rs go su ccessfu lly tre ted w ith
A 27-ye r-old n co p l ins th t he h s felt d ow n venl f xine. The p tient h s been st ying
in the d u ps for onths nd is feeling gu ilty w ith her sister since her sep r tion 1 onth
bec u se he h s been h ving n extr rit l ff ir. go. For the p st 2 w eeks, she h s been p cing
In recent w eeks, he h s st rted to believe th t his rou nd the hou se, not sleep ing ore th n 2 to
w ife is p oisoning his food nd the rest of his f ily 3 hou rs per night. Desp ite her feeling s d
is involved in n el bor te plot to d rive hi fro i ed i tely fter the sep r tion, the p tient
the hou se. now feels w ond erfu l, like I c n cco p lish
nything! In f ct, she h s been tte p ting to
81. Assu ing his thinking is d elu sion l, how re od el her sister s b throo , even thou gh
w ou ld his d elu sions be best ch r cterized ? she h s no tr ining or experience. H er sister
h s been extre ely concerned bou t her, bu t
(A) Biz rre she h s been u n ble to t lk to her bout it s,
(B) Ego-syntonic I c nt get w ord in ed gew ise, nd she
(C) Mood congru ent d oesnt lw ys ke sense. The p tient is
(D) Mood incongru ent only t king or l contr ceptives nd o epr -
(E) So tic zole for cid reflux. H er sister is concerned
th t she, herself, y eventu lly d evelop this
82. Which of the follow ing d i gnoses w ou ld ost illness. Wh t is her p p roxi te risk of d evel-
likely be resp onsible for the bove d elu sions? oping this d ise se?
 Que s tions : 7989 181

(A) 0% to 10% ed ic tions w ou ld be the best choice for this

(B) 10% to 20% p tient?
(C) 20% to 30% (A) Alp r zol (X n x)
(D) 50% to 70% (B) Cod eine (Brontex)
(E) 80% to 90% (C) Dip henhyd r ine (Ben d ryl)
(D) Qu eti p ine (Seroqu el)
85. A 33-ye r-old w o n w ith history of
(E) Zolp id e (A bien)
schizop h reni tells you she h s been h e ring
voices for the p st 5 ye rs. Sh e h s b se-
88. An 8-ye r-old girl p resents to her p ed i tri-
line u d itory h llu cin tion th t she c nnot
ci n w ith her p rents second ry to incre sed
u nd erst n d ost of the ti e. Du ring p eri-
p roble s t school. She recently entered the
od s w here the voices beco e w orse, she
third gr d e nd h s been h ving d ifficu lties
typ ic lly he rs co nd u d itory h llu ci-
w ith beh vior in cl ss. At ho e, her p r-
n tions. Fro s fety st n d p oint, w hich of
ents d escribe her s ctive nd lw ys ov-
the follow ing is the ost i p ort nt infor-
ing fro one ctivity to the next. At school,
tion to obt in reg rd ing her u d itory
the child is u n ble to sit still in her ch ir nd
h llu cin tions?
frequ ently interru p ts the lessons. On ex i-
(A) H ow long she h s been he ring voices. n tion, you notice th t she is fid gety nd
(B) H ow lou d the voices re. const ntly p l ying w ith her h nd s. When
(C) Wh t the voices re s ying. she tte p ts to co p lete t sk she is e sily
d istr cted . Which of the follow ing w ou ld be
(D) Whether she recognizes the voices.
the ost effective p h r cother p y for this
(E) Whether the voices co e fro insid e or p tient?
ou tsid e her he d .
(A) Clonid ine
86. A 38-ye r-old n co p l ins th t for the (B) I ip r ine
p st 2 ye rs he h s requ ired sever l n p s (C) Methylp henid te
over the cou rse of the d y; he find s the n ps (D) Risp erid one
qu ite refreshing, but sees his d octor bec use
(E) Sertr line
l tely, s he is w king u p , he feels o en-
t rily p r lyzed . H e is cu rrently not on ny
89. A 30-ye r-old le co es to n urgent c re
ed ic tions. H e d enies the u se of ny illicit
f cility 8 hou rs fter the onset of u scle ches,
su bst nces. Which of the follow ing is the ost
ru nny nose, runny eyes, d ifficu lty sleeping,
likely d i gnosis?
nd loose stools th t he ttribu tes to flu
(A) Circ d i n rhyth sleep w ke d isord er, viru s. H e lives in d ifferent city nd is visit-
d v nced sleep -ph se type ing for conference. H e rep orts th t he forgot
(B) Circ d i n rhyth sleep w ke d isord er, his ed ic tions t ho e. H e t kes orphine
d el yed sleep -p h se typ e IR every 6 hou rs for chronic low b ck p in,
(C) H yp erso nolence d isord er d ip henhyd r ine occ sion lly to help w ith
sleep , venl f xine 150 g d ily for d ep res-
(D) N rcolepsy
sion nd Lisinopril for blood pressu re control.
(E) P r so ni On ex in tion, he is sw e ting, y w ning, h s
d il ted pu pils nd is ss ging his u scles.
87. A 45-ye r-old le w ith history of op i te H is blood p ressu re is 160/ 95 H g, pu lse
u se d isord er p resents to you r office co p l in- of 102 bp , nd he is febrile. When sked to
ing of p roble s w ith sleep . H e cl i s th t cont ct his pri ry c re p hysici n he beco es
he h s been sober fro heroin for the p st incre singly git ted , st ting they w ou ld not
10 ye rs. H e sks to be st rted on ed ic - contribute ny infor tion to this visit. L b
tion for his inso ni . Which of the follow ing v lues re ll w ith in nor l li its. Which
182 6: Diffe re ntia l Diag nos is a nd Ma na g e me nt

of the follow ing ost likely exp l ins his etfor in, u ltivit in, n OTC herb l su pp le-
sy pto tology? ent, tr d ol for chronic b ck p in, nd recent
ntibiotic prescription for linezolid . H is vit l signs
(A) Anticholinergic toxicity
re: BP of 160/ 92, he rt r te of 110 bp , nd te -
(B) H ypertensive crisis p er tu re of 101.2F. On ex in tion, he d i p horetic
(C) Influ enz nd h s clonu s in his bil ter l low er extre ities.
(D) Op i te w ithd r w l
(E) Serotonin synd ro e 92. Which of the follow ing is his ost likely
d i gnosis?
Questions 90 and 91
(A) Bipol r d isord er
A 28-ye r-old fe le w ith p st ed ic l history (B) H ypertensive crisis
of hypothyroid is nd syste ic lu pu s erythe - (C) Migr ine w ith u r
tosus (SLE) is hospit lized for lupu s fl re requ ir- (D) N eu rolep tic lign nt synd ro e (N MS)
ing IV steroid s. You re consu lted for the p tient
(E) Serotonin synd ro e
s she is co pl ining of ud itory h llu cin tions
nd h s been beco ing incre singly git ted . H er
93. Which of the follow ing is the best next step in
ed ic tions inclu d e IV ethylp red nisone, u lti-
the n ge ent of this p tient?
vit in, nd levothyroxine. On ex in tion, the
p tients ood is l bile nd she end orse u d itory (A) Continu e ll ho e ed ic tions.
h llucin tions. H er vit l signs re st ble. H er TSH is (B) Discontinu e linezolid , tr d ol,
0.7 IU/ L nd her T4 is 7.2 u g/ d L. p henelzine.
(C) Discontinu e etfor in.
90. Which of the follow ing is the ost likely
(D) Discontinu e over the cou nter herb l
d i gnosis?
sup ple ent.
(A) Bipol r d isord er d u e to hyperthyroid is (E) Incre se risp erid one.
(B) Brief psychotic d isord er
(C) MDD w ith p sychotic fe tu res 94. A 58-ye r-old le w ith no p st ed ic l his-
(D) Schizop hreni tory is brou ght to the d octor s office by friend .
(E) Steroid -ind u ced p sychotic d isord er The friend rep orts the p tient h s ccu u -
l ted too u ch stu ff in his one-story ho e
91. Which of the follow ing is the best next step in nd h s not been ble to le ve his ho e. The
the n ge ent of this p tient? p tient cl i s th t he y need these ite s t
so e point in the futu re nd refu ses to throw
(A) Decre se steroid d os ge nything w y. When sked if he h s ever
(B) Incre se levothyroxine tried to cle n out his hou se he gets d efensive,
(C) Initi te ECT fid gety nd st tes he cou ld bsolutely never
(D) Initi te lithiu throw nything ou t! H is friend brings in p ic-
tu res of the p tients ho e show ing ound s
(E) Initi te sertr line
of ite s in every roo . The p tient h s been
u ne p loyed for 1 ye r, expl ining th t he
Questions 92 and 93
need s the ti e to t ke c re of his ho e. Which
A 38-ye r-old n w ith p st ed ic l history of of the follow ing is the ost likely d i gnosis?
chronic low er b ck p in nd hypertension presents (A) GAD
w ith friend to the e ergency roo co p l ining of
(B) H o rd ing d isord er
git tion nd he d che for 2 d ys. Upon fu rther
qu estioning, he d its to p st p sychi tric history (C) OCD
of MDD w ith psychotic fe tures. Soon fter p resen- (D) Obsessive-co pu lsive person lity
t tion he beco es confu sed nd nonresponsive. H is d isord er (OCPD)
ed ic tion list inclu d es p henelzine, risp erid one, (E) P nic d isord er
 Que s tions : 90100 183

95. A 31-ye r-old fe le is fou nd in D ll s, Tex s 98. A 35-ye r-old le is u rged to go to psy-
sitting in coffee shop for n entire d y. When chi trist by cow orker bec u se of frequent
sked to le ve the coffee shop u p on closing, nger ou tbu rsts. H e rep orts th t s long s
the p tient c nnot rec ll ny id entifying infor- he c n re e ber he h s h d hot te p ter.
tion or w here she is fro . The p olice re L tely, he h s been getting into to trou ble t
c lled , w ho escort her to n e ergency d ep rt- w ork d u e to u ltip le verb l confront tions
ent. When se rched , her ID c rd is fou nd w ith cow orkers, w hich occ sion lly esc l te
in her p u rse, d ocu enting th t the p tient is to the p tient throw ing v rious office objects
fro Michig n. Fu rther investig tion reve ls cross the roo . H e feels very gu ilty fter, but
her f ily rep orted her issing 2 w eeks go. he is u n ble to p revent his beh vior. H e h s no
Of note the p tient w s d op ted t you ng signific nt leg l proble s otherw ise. Which of
ge second ry to child bu se. Wh ich of the the follow ing is the ost likely d i gnosis?
follow ing is the ost likely d i gnosis?
(A) Antisoci l p erson lity d isord er
(A) Bord erline p erson lity d isord er (B) Bip ol r II d isord er
(B) Dep erson liz tion d isord er (C) Bord erline p erson lity d isord er
(C) Dissoci tive nesi (D) Cond u ct d isord er
(D) Dissoci tive id entity d isord er (E) Inter ittent exp losive d isord er
(E) M jor neu rocognitive d isord er d u e to
Alzhei er d ise se D IRECTION S (Questions 99 through 108): For
each of the follow ing patients, choose the most
Questions 96 and 97 appropriate diagnosis. Each lettered option may
be used once, multiple times, or not at all.
A 26-ye r-old fe le p resents to her pri ry c re
physici n w ith d ifficu lty sleep ing. She co pl ins (A) Antisoci l p erson lity d isord er
of const ntly fid geting in bed w ith const nt urge
(B) Avoid nt p erson lity d isord er
to ove her legs. She gets u p nd w lks rou nd in
ord er to help relieve it. This occu rs ost nights of (C) Bord erline p erson lity d isord er
the w eek nd h s gre tly interfered w ith her bil- (D) Dep end ent p erson lity d isord er
ity to sleep . Physic l ex in tion is neg tive for ny (E) H istrionic p erson lity d isord er
bnor lities. H er l b w ork show s low MCV, low (F) N rcissistic p erson lity d isord er
ferritin, nd he oglobin of 9.0 g/ d L. (G) Obsessive-co p u lsive p erson lity
d isord er
96. Which of the follow ing is the ost likely
(H ) P r noid p erson lity d isord er
d i gnosis for this p tient?
(I) Schizoid person lity d isord er
(A) GAD (J) Schizotyp l person lity d isord er
(B) Inso ni d isord er
(C) N on-REM sleep rou s l d isord er 99. A 45-ye r-old w o n recently is rele sed fro
(D) Obstru ctive sleep p ne p rison for r ed robbery. She h s nu erous
(E) Restless legs synd ro e j il sentences for ste ling, bribery, nd rson.
She end orses th t she s w p sychi trist s
97. Which of the follow ing is the ost p p rop ri- child for beh vior l proble s, getting into
te step in the tre t ent of this p tient? trou ble t school nd t ho e. Upon further
questioning, she rec lls p eriod of ti e
(A) Initi te hyd rocod one. torturing her f ilys p et c t s child .
(B) Initi te iron rep l ce ent.
(C) Initi te lor zep . 100. A 57-ye r-old n presents to his pri ry
(D) Initi te el tonin. p hysici n w ith co p l ints of bd o in l p in.
(E) Initi te risp erid one. H e is cco p nied by his other, w ith w ho
184 6: Diffe re ntia l Diag nos is a nd Ma na g e me nt
he lives. The p tient ppe rs to d efer to his
other to nsw er ny of the qu estions d u r-
ing the interview. The p tient t lks bou t how
he c lls his other throughou t the w orkd y
to sk her trivi l qu estions nd so she c n help
hi ke ny, everyd y d ecisions. H e h s
recently been ore nxiou s s he fe rs th t she
is old er nd y d ie soon, w hich w ou ld
le ve e lone, help less, nd u n ble to cop e.
101. A 30-ye r-old n w orks in lighthou se d u r-
ing the overnight shift by hi self. H e h s
no friend s, prefers to be lone in his sp re
ti e, nd d oes not d esire to ke person l
or inti te rel tionships. H e presents d ue to
incre sed stress now th t he h s cow orker t
his job.
102. A 34-ye r-old w o n h s just gone throu gh
her second d ivorce nd is cu rrently in
tu u ltu ous rel tionship w ith n she et
1 onth go. H er ex in tion reve ls sc rs
on her w rist, w hich she expl ins re fro cut-
ting herself w hen I get ngry or up set. She
often feels e pty insid e bu t d its to intense
ch nges of ood , qu ickly beco ing d espon-
d ent or ngry. She reports it is ll her f u lt she
feels this w y.
103. A 45-ye r-old w o n presents to her p ri ry
c re ppoint ent p rovoc tively d ressed for
rou tine ex in tion. She exu ber ntly exp l ins
her cu rrent rel tionship w ith so eone she h s
et only online nd not in person. She goes
into gre t d et il reg rd ing his erits, cl i ing
th t he is the one. H ow ever, t the end of the
interview she sks the p hysici n if he is single.
104. A 32-ye r-old n p resents to the e ergency
d ep rt ent fter suffering l cer tion to his
left ind ex finger. When ed ic l stu d ent
tte p ts to ev lu te hi he rebu kes hi ,
excl i ing I only t lk to ttend ing p hysi-
ci ns. H e is noted to be t lking lou d ly on his
telephone bout how su ccessful he h s been
in the fin nci l rket, how he is su re he w ill
see the Chief of the d ep rt ent, nd how he
c nnot be bothered by low -level e ployees.
105. A 46-ye r-old n is reco end ed to see
e p loyee he lth s he continu ou sly believes
his colle gu es t w ork re ou t to s bot ge
his e p loy ent. As resu lt, he h s w ritten
thre tening e ils to his peers nd su pervi-
sors. When confronted w ith the f ct th t he
h s been invited to t ke p rt in soci l ctivi-
ties w ith others, he st tes th t he is being
tricked into co p l cency nd pl ns to sue
the org niz tion.
106. A 21-ye r-old w o n w ho is in her third ye r
of college p resents to ther p ist u p set th t
she is u n ble to ke friend s. She exp resses
th t she w ou ld like to join school clu b to
eet new p eop le nd ke friend s bu t she is
too shy. She d oesnt go ou t to p rties d esp ite
being sked , bu t they w ou ld nt like e
nyw y.
107. A 34-ye r-old w o n is new ly d i gnosed w ith
hyp ertension. Upon interview, she d its
th t she st ys l te t her job on regul r b sis
bec use she spend s n excessive ount of
ti e on e ch project, ensuring everything is
in ex ct ord er nd properly for tted . She
triple-checks not only her ow n but ll of her
colle gues w ork. She d oesnt believe th t oth-
ers re c rrying their lo d but believes she is
the only one w ho excels t her job. She is d is-
ppointed , how ever, bec use her fellow col-
le gues re ll ble to le ve t the ppropri te
ti e.
108. A 32-ye r-old w o n p resents to her OB/
GYN for routine c re. She is noted to be
d ressed w ith ulticolored sc rves, b ngles,
nd l rge nu ber of cryst l jew elry. She
st tes she is p l re d er s profession,
believing she h s the tools to u nlock p er-
sons fu tu re. She c e to her p point ent
fter re d ing her strologic l forec st, bu t w s
concerned bec u se of the color of y ur .
 Ans we rs a nd Expla na tions
1. (C) The ost likely d i gnosis in this c se is
schizo ffective d isord er. The p tient h s pro -
inent psychotic sy pto s, includ ing ud itory
h llu cin tions, w hich re ru nning co en-
t ry of her beh viors, bu t lso concu rrent
ood sy p to s, includ ing d epressed ood ,
d ecre sed sleep, nhed oni , nd poor ppetite.
Also i p ort nt, the p tients h llu cin tions
h ve occurred in the bsence of ood sy p-
to s, nd her ood sy pto s ppe r to h ve
been present for jority of the tot l d ur -
tion of her illness. The presence of pro inent
psychotic sy p to s in the bsence of ood
sy pto s kes jor d epression w ith psy-
chotic fe tures unlikely. A d i gnosis of schizo-
phreni lone w ou ld not d equ tely ccou nt
for this p tients ood sy pto s. Bipol r II
d isord er is not v lid choice since there is no
cle r history of hypo nic episod e. Schizoid
person lity d isord er is unlikely bec u se th t
d i gnosis w ould not ccount for the p tients
overt psychotic nd ood sy pto s.
2. (E) In schizo ffective d isord er, it is i p ort nt
to tre t both the ood nd psychotic sy p-
to s. Bec u se the p tients sy pto s inly
consist of d ep ression nd p sychosis, co bi-
n tion of n ntip sychotic nd ntid epress nt
ed ic tion w ould be re son ble ppro ch.
Mirt z pine, cit lopr , flu oxetine, nd ser-
tr line re ntid epress nt ed ic tions, w hile
zipr sid one, h lop erid ol, nd p erp hen zine
re ntipsychotic ed ic tions. Lor zep
nd d i zep re benzod i zepines. Div l-
p roex sod iu is ood st bilizer nd is u sed
for bip ol r d isord er.
3. (C) The p tient ost likely h s d i gnosis
of jor d ep ressive d isord er, w ith p erip r-
tu onset nd p sychotic fe tu res, since the
d ep ression st rted w ithin 4 w eeks of giving
birth to her son. H e ring child crying is
co on p sychotic sy p to of p ostp rtu
d ep ression. Althou gh the p tient h s been
h ving p sychotic sy p to s, d i gnosing her
w ith brief p sychotic d isord er w ou ld not
fu lly ccou nt for her ood sy p to s. In
ord er to eet the d i gnosis of schizo ffec-
tive d isord er, p tient u st h ve p sychotic
sy p to s d u ring p eriod w hen there re no
ood sy p to s p resent. Ad ju st ent d is-
ord er w ou ld not ccou nt for her signific nt
ood or p sychotic sy p to s. Postp rtu
obsessive-co p u lsive d isord er w ou ld u su -
lly p resent s other w ith signific nt
ou nt of nxiety d u e to ego d ystonic, obses-
sive thou ghts.
4. (A) The p tient w ou ld best be tre ted by initi-
ting n ntid epress nt (su ch s n SSRI) nd
n ntip sychotic (to d d ress her h llu cin -
tions). H osp it lizing this p tient w ou ld be pre-
tu re bec use the other is still t king c re
of her child nd is not h ving ny thou ghts of
w nting to hu rt the child or herself. Lithiu
is ind ic ted s ood st bilizer for so eone
w ho h s d i gnosis of bip ol r d isord er. H lo-
perid ol lone w ou ld help tre t her p sychosis,
bu t w ou ld d o nothing to d d ress her d ep res-
sion. Provid ing su pportive ther py could help
the p tient, how ever, consid ering the severity
of her illness, ed ic tions w ould need to be
initi ted .
185
186 6: Diffe re ntia l Diag nos is a nd Ma na g e me nt
5. (E) This p tient presents with the sy pto s
nd signs of Wernicke enceph lop thy, which
results fro thi ine (vit in B1) deficiency.
It is ch r cterized by bil ter l bducens nerve
p lsy, horizont l nyst g us, t xi , nd
glob l confusion cco p nied by p thy. E ch
of the other choices is possible nd should be
ctively ruled out. An cute subdur l he -
to would typic lly present fter tr u
to the he d. Depending on the loc tion of the
he to , p tients c n h ve proble s with
speech, ltered ent l st tus, he iplegi , nd/
or nonre ctive pupil. Alcohol withdr w l
usu lly presents with unst ble vit l signs, tre -
ulousness, nd git tion. Folic cid deficiency
presents with di rrhe , cheilosis, nd glossi-
tis; neurologic bnor lities re usu lly not
seen. NPH is ssoci ted with the cl ssic tri d of
de enti , incontinence, nd g it disturb nce.
6. (C) If Wernicke encep h lop thy is su sp ected ,
e ergent d inistr tion of IV thi ine is
essenti l, bec u se ny sequ el e of thi ine
d eficiency re reversible w ith this tre t ent;
ist ken d inistr tion of thi ine is r rely
h r ful. A CT sc n of the he d should be
ord ered i ed i tely in this c se; opti lly,
the IV thi ine w ould be st rted s the CT w s
being rr nged. The re ining choices do not
d dress the urgent need to replete thi ine. It
should lso be noted th t giving this p tient ny
glucose prior to d inistering thi ine c n
result in w orsening of the Wernicke enceph -
lop thy (the et bolic conversion of glucose to
pyruv te requires thi ine s cof ctor).
7. (A) Delu sion l d isord ers p resent w ith d elu -
sion (typic lly not biz rre) for t le st 1 onth.
These p tients otherw ise h ve n org nized
thou ght p rocess nd function w ell in other
spects of their life. This p tient d oes not
h ve ny ch r cteristics of bip ol r d isord er or
d ep ression nd therefore w ould not be given
d i gnosis of schizo ffective d isord er. P tients
w ith obsessive-co p u lsive d isord er h ve
nxiety over p rticu l r thou ghts th t they
know re not r tion l (obsessions), nd they
p erfor ritu lized beh viors to relieve their
nxiety (co p u lsions). P r noid p erson lity
d isord er cou ld be d i gnosed if the p r noi
w ere longst nd ing p roble th t ffected
u ltip le sp ects of the p tients life but never
re ched p sychotic (d elu sion l) level. In this
c se, the only psychotic sy pto d escribed is
bod y od or. In ord er to eet criteri for d i g-
nosis of schizop hreni , the sy p to s w ou ld
l st for t le st 6 onths, the d elu sion w ou ld
likely be biz rre, nd she w ou ld h ve other
p sychotic sy p to s su ch s u d itory h llu -
cin tions, d isorg nized speech, d isorg nized
beh vior, nd / or fl t ffect.
8. (E) Delu sion l d isord ers re typ ic lly tre ted
w ith n ntip sychotic. Of the choices listed ,
the only ntipsychotic is ol nz pine. C rb -
zep ine is n ntiepilep tic th t is lso u sed
to tre t bipol r d isord er. ECT c n be used for
the n ge ent of cu te psychosis, but h s
not been show n to be benefici l in the tre t-
ent of d elu sion l d isord er. Flu oxetine is n
SSRI nd is ost co only used for d epres-
sive nd nxiety d isord ers. Lithiu is ood
st bilizer nd is not used s tre t ent for
d elusion l d isord er.
9. (D ) N MS is ch r cterized by severe (le d
p ip e) rigid ity, ch nge in ent l st tus, uto-
no ic inst bility, elev ted CPK, nd elev ted
w hite blood cou nt; slight elev tion in cere-
brosp in l flu id p rotein cou nt is p ossible. N MS
y be ind u ced by ny ntipsychotic ed i-
c tions (neuroleptics), inclu d ing the typic l
ntip sychotics. N o one sy p to is necess ry
for the d i gnosis; inste d , constell tion of
sy pto s nd their severity, in setting of
ntip sychotic exp osure, ke the d i gnosis
ore or less likely. Anticholinergic synd ro e,
resu lting fro overd osing on nticholinergic
ed ic tions, d oes not p rod u ce rigid ity nd n
elev ted CPK. A CN S infection w ou ld be bet-
ter su pported by ch r cteristic find ings on the
lu b r p u nctu re nd CT or MRI sc n; n ele-
v ted CPK w ou ld be possible if the CN S infec-
tion c u sed seizu res. M lign nt hyp erther i ,
n cute uscu l r p thologic p rocess, rese -
bles N MS, bu t follow s the d inistr tion of
inh led nesthetic gents, s in gener l su r-
gery. Prolonged i obiliz tion cou ld resu lt
in n elev ted CPK, bu t w ou ld not ccou nt for
the other find ings.

10. (C) Co nd u d itory h llucin tions re
p sychi tric e ergency nd ost clini-
ci ns w ou ld gree th t this p tient should
be rest rted on n ntip sychotic ed ic tion.
ECT h s so e effic cy in tre t ent-resist nt
schizophreni bu t is not first-line ther py.
Bec u se they re long cting (i.e., w ith long
h lf-life) nd given his risk of fu ture N MS,
d ep ot injections of neu rolep tic re not first
choice. As this p tient is not violent, p hysic l
restr ints shou ld be void ed .
11. (B) This w o n likely su ffers fro jor
d ep ressive d isord er w ith p sychotic fe tu res.
Co nd u d itory h llu cin tions to co -
it suicid e, such s overd osing on ed ic -
tions, re psychi tric e ergency nd u su lly
requ ire psychi tric d ission. Therefore, d is-
ch rging to n outp tient setting w ould not be
reco end ed . While she w ill need co plete
ed ic l w orku p to rule out ed ic l c uses of
d epression, there is no ind ic tion for d itting
her to ed ic l unit t this ti e; the w orku p
c n usu lly be cco plished on psychi t-
ric unit. There is no ind ic tion, su ch s vio-
lent beh vior, th t w ould necessit te physic l
restr ints.
12. (D ) This p tient requ ires n ntid epress nt
nd ntip sychotic ed ic tion. In f ct, nei-
ther n ntid ep ress nt nor n ntip sychotic
lone tre ts jor d ep ressive d isord er w ith
p sychotic fe tu res s w ell s both together.
Althou gh benzod i zep ine y help this
p tients irrit bility, s sole gent it is p oor
choice for tre ting her d ep ressive nd p sy-
chotic sy p to s. Lithiu d oes h ve so e
ntid ep ress nt effects, bu t in the bsence of
convincing evid ence th t this p tient h s
bip ol r d isord er, lithiu is not the p p rop ri-
te choice (If this p tient h s only p rti l
resp onse to the SSRI, lithiu y t so e
p oint in the fu tu re be d d ed for u g ent -
tion.). A TCA w ou ld not be the first choice.
First, there is su ggestion th t this p tient
h s so e c rd i c history nd the tricyclics c n
h ve p ro rrhyth i effect. Second , u nlike
SSRIs, tricyclics c n be leth l in overd ose
nd this p tient h s risk f ctors for su icid e
tte p t, su ch s recent bre ku p w ith her
Answe rs : 515 187
boyfriend , co nd u d itory h llu cin tions,
nd feelings of help lessness.
13. (A) The p tient p resents w ith p sychotic sy p -
to s nd git tion, long w ith qu estion ble
nic sy p to s (e.g., d ecre sed sleep , gr n-
d iosity, incre sed p rod u ctivity). The d iffer-
enti l d i gnosis inclu d es bip ol r d isord er,
schizo ffective d isord er, nd schizop hreni
( ong others). Initi l ed ic tions in this c se
re i ed t the t rget sy p to s of git tion,
d elu sion l thinking, nd d isru p tive beh vior
nd w ou ld re son bly inclu d e n ntip sy-
chotic nd benzod i zep ine. Bu sp irone is n
nxiolytic u sed ostly in gener lized nxi-
ety d isord er. It is not ind ic ted for bip ol r
d isord er nd w ou ld not d equ tely d d ress
the t rget sy p to s seen in this c se. While
ood st bilizers su ch s c rb zep ine nd
lithiu w ou ld tre t bip ol r d isord er, they
w ou ld not r p id ly tre t his p sychosis nd gi-
t tion. SSRIs u st be u sed w ith extre e c u -
tion in bip ol r illness bec u se they c n incite
or ex cerb te ni .
14. (A) When the p tient retu rns for his first
follow -u p visit, his lithiu level is ther p eu tic
t 0.8 Eq/ L nd is not in need of d ju st ent.
H ow ever, his u scle stiffness is likely n
extr -p yr id l sy p to (EPS) of h lop eri-
d ol, n ely cu te d ystoni . Other EPS inclu d e
p rkinsoni n sy pto s (e.g., br d ykinesi ,
cogw heel rigid ity, pill-rolling tre or, sk-
like f ce). EPS is nor lly tre ted by low ering
the d ose of the ntipsychotic or st rting nti-
cholinergic ed ic tions su ch s benztropine
(Cogentin), not w ith u scle rel x nt su ch
s b clofen. The p tient w ould h ve to be fol-
low ed closely for ree ergence of p sychotic
sy pto s.
15. (A) Acu te stress d isord er is re ction th t y
occur in p tient w ho w itnesses or experiences
tr u tic event. The event ust involve
d e th, thre tened d e th, serious injury, or sex-
u l viol tion. The typic l sy pto s includ e
hyper rou s l st tes, d issoci tive st tes, void -
nce beh viors, nd intrusive reexperiencing
of the event (e.g., fl shb cks, night res).
PTSD is si il r in ost respects to cu te
188 6: Diffe re ntia l Diag nos is a nd Ma na g e me nt
d istress d isord er, but in PTSD the sy pto s
persist for t le st 4 w eeks follow ing the
tr u ; shorter d ur tion suggests d i g-
nosis of cu te d istress d isord er. The p tient
d oes not ppe r to be suffering fro ny of
the typic l criteri for d just ent d isord er or
MDD, except for gu ilt. Althou gh she h s nxi-
ety nd void nce sy pto s si il r to gor -
phobi , there is no evid ence of p nic tt cks or
p nic d isord er, nd her sy pto s re better
ccounted for by her cute stress d isord er.
16. (C) While the p tient initi lly h d sy p to s
consistent w ith cu te stress d isord er, ll of
these sy p to s resolved w ith p sychother-
p y. H d these sy p to s p ersisted over
1 onth, she w ou ld h ve et criteri for
PTSD. When she p resents g in ye r l ter,
she d isp l ys sy p to s consistent w ith MDD
su ch s d ep ressed ood , nhed oni , p oor
sleep nd p p etite, nd feeling tired ll d y
long. Ad ju st ent d isord er shou ld not be
d i gnosed w hen d i gnosis of MDD c n be
d e. The p tient d oes not p p e r to h ve
ny p nic tt cks nd she d oes not d escribe
fe rs of h ving nother p nic tt ck w hich
w ou ld be consistent w ith d i gnosis of p nic
d isord er.
17. (B) Ocu logyric crisis is sp ecific ex p le of
n cu te d ystonic re ction in w hich there is
sp s of the u scles of extr ocu l r otion.
N MS, lso re ction to ntip sychotic ed i-
c tions, is ch r cterized by rigid ity, fever,
leu kocytosis, u tono ic inst bility, nd
d eliriu . Torticollis nd retrocollis re d d i-
tion l d ystonic re ctions th t refer to u scle
sp s s th t c u se bnor l p ositioning of
the he d , w hile tris u s is sp s of the j w
u scles.
18. (B) Benzod i zep ines, SSRIs, nd cognitive-
beh vior l ther p y e ch h ve p l ce in tre t-
ent of the nxiety d isord ers. In this c se,
w hile the p tient d oes h ve history of GAD,
she d oes not h ve history of p nic tt cks.
It w ou ld be u nco on for 59-ye r-old
w o n to su d d enly d evelop p nic tt cks.
Therefore, fu rther ed ic l w orku p is neces-
s ry. A short d ifferenti l d i gnosis list w ould
inclu d e rrhyth i , hyp oglyce i , ngin ,
seizu re, nd orthost tic hypotension.
19. (B) Reg rd less of p tients p st p sychi tric
d i gnosis, ed ic l c u ses of physic l signs
nd sy p to s u st lw ys be ru led ou t. The
nxiety d isord ers, lthou gh intensely d istress-
ing nd u nco fort ble to p tients, r rely, if
ever, resu lt in u nconsciou sness. M ny sp ects
of the p tients story see to be rel ted to nx-
iety nd cou ld , in f ct, occu r d u ring p nic
tt ck; how ever, this p tients p resent tion
is ore consistent w ith ische ic he rt d is-
e se w hich shou ld p ro p t c rd i c w orku p .
Illness nxiety d isord er is the w orry of h ving
or obt ining serious illness d espite re ssur-
nce by ed ic l p rovid ers.
20. (B) P r p hilic d isord ers d enote ny intense
nd p ersistent sexu l interest other th n
genit l sti u l tion or fond ling w ith nor l,
tu re, or consenting hu n p rtners. P r -
p hili s re fu rther d ifferenti ted b sed on
w h t beh vior p rovid es the u rges or f nt sies.
Frotteu ristic d isord er is obt ining rou s l
fro tou ching or ru bbing g inst noncon-
senting p erson. Exhibitionistic d isord er is the
d esire to exp ose ones genit ls to noncon-
senting p erson. Sexu l sochis d isord er is
the d esire to be hu ili ted by nother p erson,
w hile sexu l s d is d isord er is the d esire to
inflict p hysic l or p sychologic l su ffering
on nother p erson. Voyeu ristic d isord er is
rou s l fro w tching u nsu sp ecting p eop le
u nd ressing, n ked , or h ving sex. A few other
p r p hili s inclu d e: p ed op hilic d isord er, sex-
u l f nt sies, u rges, or cts involving sex w ith
p rep u bescent child ren; tr nsvestic d isor-
d er, sexu l rou s l fro cross-d ressing; nd
fetishistic d isord er, w hich is sexu l rou s l
fro the u se of nonliving objects or nongeni-
t l bod y p rts.
21. (E) While ny of the sid e effects listed y
occu r w ith the u se of SSRIs, ost of the
w ill d i inish or resolve over ti e. Sexu l
d ysfu nction, either nifesting s d el yed
org s or d ecre sed libid o, c n re in
sid e effect in 25% to 80% of p tients fter
3 onths of tre t ent.

22. (A) The ost co on c use of d e th w ith
tricyclic ntid epress nt overd ose is c rd i c
rrhyth i . The rrhyth i is d u e to the
d ru gs block d e of sod iu ch nnels in the
yoc rd iu le d ing to c rd i c cond u ction
slow ing. Seizu res, shock, resp ir tory f ilure,
nd co c n lso occu r, bu t re not the ost
co on c u ses of d e th. Strokes re typ ic lly
not c used by overd osing on tricyclic ntid e-
p ress nts.
23. (E) The key p oints in this c se p resent tion re
the bsence of previou s psychi tric history
nd the d u r tion of sy pto s. Before d i g-
nosing pri ry ent l illness, it is necess ry
to ru le ou t the effects of su bst nce. A u rine
toxicology screen usu lly includ es opi tes,
coc ine, c nn binoid s, p het ines ( nd
so eti es PCP). A phet ines, coc ine,
nd PCP intoxic tion c n i ic sy p to s
of schizophreni . CBC, ESR, nd liver fu nc-
tion tests re u nlikely to id in the d i gnosis.
Althou gh CT sc n is help fu l to ru le ou t
ss lesion or bleed ing, these re not likely
given his ge nd the nonfoc l neu rologic
ex in tion.
24. (D ) Delu sions, h llu cin tions, nd d isor-
g nized beh vior re so e of the h ll rk
sy pto s of schizophreni . Bec use the
sy pto s h ve been present for ore th n
1 onth bu t less th n 6 onths ( nd there
is no p reviou s p sychi tric history), the ost
p p rop ri te d i gnosis is schizop hrenifor
d isord er. Delu sion l d isord er u su lly ni-
fests in id d le- ged ind ivid u l w ho, w hile
fu nction l in society, exp eriences circu -
scribed d elusion of the je lou s, eroto nic,
gr nd iose, p ersecu tory, or so tic typ e. As
this p tient is lso su ffering fro pro inent
u d itory h llu cin tions, this w ou ld exclu d e
the d i gnosis of d elusion l d isord er. There is
no history su ggestive of ood d isord er nd
thu s jor d epression w ith psychotic fe tu res
is not s likely. Since the toxicology screen is
neg tive, the d i gnosis of su bst nce-ind u ced
p sychotic d isord er is less likely.
25. (C) The p tient is ost likely exp eriencing
lcohol w ithd r w l s d e onstr ted by the
Answe rs : 1627 189
f ct th t since being hospit lized 2 d ys go
(his l st d rink) he h s h d n incre se in his
blood p ressu re, he rt r te, nd h s incre sed
nxiety, s w ell s d i p horesis nd tre ors.
Oftenti es, p tients c n lso beco e febrile.
Benzod i zep ines re the tre t ent of choice
for lcohol w ithd r w l. Any benzod i zep ine
c n be u sed the choice d ep end s on the
d esired rou te of d elivery or the p resence of
liver d ysfu nction. With d ecre sed liver fu nc-
tion, lor zep (Ativ n) or ox zep (Ser x)
is p refer ble bec u se they re p ri rily
et bolized nd eli in ted ren lly inste d
of throu gh the liver ( s re the other benzo-
d i zep ines). Ad d ition lly, lor zep y be
chosen bec use it c n be given IV, intr u scu -
l rly (IM), or by ou th (PO). C rb zep ine
nd / or p ropr nolol h ve been u sed in so e
settings for lcohol w ithd r w l, but neither
re reco end ed for severe lcohol w ith-
d r w l, d eliriu tre ens, or seizu res. Cloni-
d ine nd / or eth d one re u sed for op i te
w ithd r w l. N ltrexone h s been u sed to help
int in bstinence fro lcohol bu t h s no
effic cy in w ithd r w l.
26. (E) Alcohol w ithdr w l c n be life thre tening.
Tre ors begin bout 6 to 8 hours fter cess -
tion, follow ed by perceptu l bnor lities
(h llucinosis) w ithin 8 to 12 hours. Seizures
y occur nyw here fro 12 to 72 hours fter
cess tion of lcohol. Deliriu tre ens (DTs)
y occur ny ti e in the first w eek of bsti-
nence. In the p st, before i proved d i gnosis
nd n ge ent, untre ted DTs h d ort l-
ity r te of pproxi tely 15%. Abd o in l p in
nd uscle cr ps re co on sy pto s of
opi te w ithd r w l. Cirrhosis nd f tty liver re
long-ter consequences of lcohol use.
27. (E) This p tient is exp eriencing cu te intoxic -
tion w ith PCP s illu str ted by his git tion,
p sychosis, vit l sign inst bility, nd tics. A
toxicology screen is the best w y to d i gnose
this cond ition. Urine toxicology screens co -
only includ e op i tes, coc ine, c nn bis nd
PCP, but this v ries d epend ing on ind ivid u l
institu tions. A CBC w ou ld not id in the d i g-
nosis of this p tients su bst nce-ind u ced psy-
chotic d isord er. There is no ind ic tion for n
190 6: Diffe re ntia l Diag nos is a nd Ma na g e me nt
EEG t this ti e bec u se no seizu re history
is elicited nd the p tient d oes not p p e r
p ostict l. Althou gh structu r l br in lesions
c n c u se psychotic sy pto s, subst nce-
ind u ced sy p to s re ore co on in this
ge grou p. As in this c se, nonfoc l neu ro-
logic ex in tion w ou ld d ecre se the likeli-
hood th t i ging stu d ies w ou ld lter the
d i gnosis or tre t ent pl n.
28. (A) Unless the p tient is extre ely git ted
nd t risk for hurting hi self or others, the
best choice for tre t ent w ou ld be to p l ce
hi in qu iet, d rk (low sti u l tion) roo .
If the p tient is violent nd / or p sychotic,
co bin tion of ntipsychotics (neu rolep tics)
nd benzod i zepines cou ld be u sed to keep
the p tient s fe. Methylphenid te is sti u-
l nt, w hich w ou ld likely w orsen his git tion.
Benztrop ine, u sed to p revent extr p yr id l
sy pto s ssoci ted w ith ntipsychotic use,
ight w orsen the p tients d eliriu . Bec u se
the p tient is not su ffering fro seizures, p he-
nytoin is not ind ic ted . Bet blockers su ch s
p rop r nolol re u sed for blood pressure n-
ge ent s w ell s k thisi c u sed by nti-
p sychotics. There is no ind ic tion for its u se in
this p tient.
29. (E) The first p rt of the vignette illu str tes so e
of the fe tures of op i te intoxic tion, n ely
p up ill ry constriction, d row siness, i p ired
ttention nd e ory, nd slu rred sp eech.
In the second inter ction, the p tient show s
signs nd sy pto s of opi te w ithd r w l.
Y w ning, u scle ches, d i rrhe , l cri tion
or rhinorrhe , nd fever re ll typic l of opi-
te w ithd r w l. Ad d ition lly, ild ly elev ted
vit l signs y occu r; how ever, signific nt
t chyc rd i nd hypertension shou ld lw ys
sign l possible lcohol w ithd r w l. Ph r -
cologic n ge ent of opi te w ithd r w l c n
inclu d e clonid ine, centr lly cting lp h -
2- gonist, nd eth d one, synthetic long-
cting opi te. Lor zep c n be u sed to tre t
elev ted vit l signs nd lop er id e c n be
u sed to tre t d i rrhe .
30. (E) Tri zol is short- cting benzod i ze-
p ine. Su d d en d iscontinu tion of ny sed tive,
hyp notic, or nxiolytic gent, su ch s benzo-
d i zepines, c n c use signific nt w ithd r w l
sy pto s, includ ing seizu res. Flu phen zine
nd thiorid zine re ntipsychotics, nd i ip-
r ine nd nortriptyline re TCAs. N either
ntipsychotics nor TCAs c use life-thre tening
w ithd r w l sy p to s.
31. (B) As with the sudden discontinu tion of
lcohol, benzodi zepine or b rbitur te with-
dr w l c n be life thre tening. The ost con-
cerning discontinu tion side effect is seizures.
Other withdr w l sy pto s include tre ors,
nxiety, uditory, visu l, nd t ctile h llucin -
tions, nd utono ic hyper ctivity. The onset
of sy pto s depends on the h lf-life of the
edic tion, the dose, nd dur tion of use. Vo -
iting is not co on side effect of sed tive-
hypnotic withdr w l.
32. (B) The p tient is exhibiting typ ic l signs
of d eliriu , includ ing n i p ired level of
consciousness nd d ifficu lty w ith cognition,
nifested s d row siness, p oor ttention,
nd d isorient tion. Cl ssic lly, these sy p-
to s y fluctu te d u ring the d y. P tients
w ho eet criteri for d eliriu y ppe r
d ep ressed w ith d ecre sed level of rou s l
or y p pe r overly ctive nd energetic,
w ith the d ep ressed typ e occu rring ore
co only. P tients lso show cognitive nd
e ory i p ir ents, w hich y be ni-
fested s d isorient tion or d ecre sed c p city
to register, ret in, nd rec ll infor tion. An
MMSE y lso be low d u e to n und erly-
ing jor neu rocognitive d isord er (d e en-
ti ) or d epressive illness. In this setting, it
w ou ld be i p ort nt to g ther infor tion
fro f ily or other ind ivid u ls w ho know
the p tient in ord er to ev lu te for p os-
sible coexisting d e enti or jor d epres-
sion. Risk f ctors for d eliriu re extre es
of ge, prior history of d eliriu , lcohol use
d isord er, sensory i p ir ent ( u d itory or
visu l), nd pre-existing br in d ge. There
is bro d etiologic d ifferenti l for d eliriu . In
this c se, c us tive f ctors y be infection,
hypoxi , et bolic bnor lities, nd cu rrent
ed ic tions. It is d ifficu lt to d i gnose n
u nd erlying d e enti or MDD in d eliriou s

p tient. There is no ind ic tion of n nxi-
ety d isord er or p tient p u rp osely ind u cing
sy pto s s in f ctitious d isord er.
33. (D ) A high-potency ntipsychotic such s h lo-
perid ol is the d rug of choice for n ging the
git ted or confused p tient w ith deliriu .
Benztropine, d iphenhyd r ine, nd thiorid -
zine ll h ve nticholinergic properties th t
y ctu lly w orsen the d eliriu . Lor zep ,
especi lly in older p tients, y h ve p r -
d oxic l d isinhibiting effect nd ex cerb te gi-
t tion nd confusion. H loperid ol in low d oses,
such s 0.5 g every 8 hours, helps to n ge
the git ted p tient. It lso h s the d v nt ge
of IM, IV, or PO d inistr tion. It is gener lly
reco ended to obt in n EKG to ev lu te for
QTc prolong tion prior to initi tion.
34. (B) The cluster B person lity d isord ers re
ch r cterized s the d r tic nd e otion l
p erson lity grou p. Bord erline PD p tients d is-
p l y longst nd ing p ttern of inst bility in
ny sp ects of their lives. They see things in
either bl ck or w hite, w hich contribu tes to
gre t d e l of ffect d ysregu l tion. Self- u ti-
l tion su ch s su p erfici l cu tting or bu rning is
co on. H istrionic PD p tients typic lly d is-
pl y dr tic bu t su p erfici l e otions, w ith
over-sexu lized beh viors. N rcissistic PD
p tients d isp l y n overv lued sense of self,
entitle ent, nd r ge. Bip ol r d isord er nd
jor d epression re ffective d isord ers th t
p resent s h ving p eriod s of good fu nctioning
long w ith p eriod s of i p ir ent or d istress
d uring the cu te episod es (e.g., d u ring nic
or d epressed ph ses).
35. (D ) Di lectic l beh vior l ther p y is con-
sid ered the tre t ent of choice for p tients
w ith bord erline p erson lity d isord er. Cogni-
tive beh vior l ther p y is p roble -solving
p sychother p y specific lly u sed for d istorted
ssu ptions nd neg tive feelings th t c n
ex cerb te p sychi tric sy p to s like d ep res-
sion nd nxiety. Psycho n lysis c n be used
for d ifferent psychi tric illnesses; how ever,
it is not consid ered first-line tre t ent for
bord erline p erson lity d isord er. Med ic tions,
inclu d ing ntip sychotics su ch s rip ip r zole,
Answe rs : 2838 191
nd SSRIs su ch s cit lop r , c n be effective
in tre ting bord erline p erson lity d isord er;
how ever, ed ic tions tend to be ore use-
fu l in conjunction w ith psychother py nd
shou ld be t ilored to specific sy pto s.
36. (B) This p tient is exhibiting signs nd sy p-
to s consistent w ith MDD w ith p sychotic fe -
tu res. For ore th n 2 w eeks, the p tient h s
d ispl yed d ep ressed ood , loss of interest in
p le su r ble ctivities, w eight loss, in bility to
concentr te, poor sleep, nd guilt bou t her
current d epressive st te. She is lso su ffering
d elusion l concerns bout bod ily fu nctioning
nd infection. If the p tient were co pl ining of
nond elu sion l cont in tion fe rs (obses-
sions) nd perfor ing ultiple co pu lsive
t sks to rid herself of the p thogens, d i g-
nosis of OCD cou ld be consid ered . Persistent
d ep ressive d isord er (for erly d ysthy ic d is-
ord er) presents w ith chronic od er te level
of d ep ressive sy p to s for t le st 2 ye rs;
how ever, this p tient is d escribing n cu te,
severe, ep isod ic d eco pens tion over the l st
onth. A p tient w ith so tic sy p to d is-
ord er presents w ith t le st one physic l sy p-
to th t c uses signific nt d istress, resu lting
in soci l or occu p tion l d ysfu nction.
37. (E) Bec use of the d elu sion l qu lity to her
p resent tion, the tre t ent of choice is both
n ntid ep ress nt nd n ntip sychotic, or
electroconvu lsive ther p y (ECT). Antid ep res-
s nts lone w ith or w ithout benzod i zepines
w ou ld not help w ith her p sychotic sy p to s.
Div lp roex sod iu nd lithiu re u sed s
ood st bilizers in bip ol r d ep ression or
ni , bu t not co only in the tre t ent of
u nip ol r d ep ression.
38. (A) Brief psychotic d isord er is d i gnosed w hen
sy pto s h ve been persistent for ore th n
1 d y bu t less th n 1 onth. Schizop hreni
w ou ld be d i gnosed if the p tients sy p to s
occu rred for longer th n 6 onths, nd schizo-
p hrenifor d isord er w ou ld be d i gnosed if
these sy pto s persisted for gre ter th n
1 onth bu t few er th n 6 onths. Delu sion l
d isord er is cond ition usu lly beginning in
id d le ge in w hich the p ri ry sy p to is
192 6: Diffe re ntia l Diag nos is a nd Ma na g e me nt
gener lly nonbiz rre d elu sion. Delu sion l
d isord er is further cl ssified into subtypes,
inclu d ing gr nd iose, je lou s, p ersecu tory,
so tic, nd eroto nic. There is no cle r his-
tory or evid ence on physic l ex in tion of
d rug use consistent w ith su bst nce-ind u ced
p sychotic d isord er.
39. (E) The ost helpful test would be urine toxi-
cology screen, since intoxic tion with v riety
of subst nces, including coc ine, PCP, c nn bis,
or phet ines y i ic the sy pto s of
schizophreni . It is necess ry to first rule out
these intoxic tion syndro es prior to offici lly
king di gnosis of pri ry psychotic ill-
ness, such s schizophreni . There is no specific
d i gnostic u tility for CBC or electrolytes
for ny of the p ri ry p sychotic d isord ers.
Bec u se the p tient d oes not p resent w ith
signs or sy p to s of seizu re d isord er, n
EEG is u nlikely to p rovid e infor tion th t
w ill i p ct the d i gnosis. A CT sc n y d ju st ent d isord er. A d i gnosis of p ersistent
help to ru le ou t ss lesion or bleed , bu t
his ge nd nonfoc l neu rologic ex in -
tion ke this n u nlikely contribu tion to his
p resent tion.
40. (B) The p tient h s d i gnosis of MDD s
ch r cterized by the d ep ressed ood , p oor
concentr tion, p oor sleep , p oor p p etite, nd
gu ilty feelings. Althou gh it p p e rs th t the
p tients d ep ression w s triggered by d e th
in the f ily, she nevertheless eets criteri
for MDD. There re tw o choices for ntid e-
p ress nts in this grou p . Flu oxetine, n SSRI,
is the best choice t this ti e. Phenelzine, n
MAOI, is not the first choice of ntid ep res-
s nt s the SSRIs h ve ore f vor ble sid e
effect p rofile, re s fer in overd ose, nd h ve
si il r effic cy in the tre t ent of MDD. Flu -
zenil is benzod i zep ine nt gonist u sed
for the tre t ent of benzod i zep ine over-
d ose, flu p hen zine is n ntip sychotic, nd
lor zep is benzod i zep ine. N one re
p p rop ri te first-line tre t ents for MDD.
41. (D ) SSRIs h ve nu ber of sid e effects,
inclu d ing d i rrhe , constip tion, n u se ,
he d che, sexu l d ysfunction, nd git tion.
A frequ ent, initi l sid e effect is inso ni ,
w hich is lso co on sy p to of d ep res-
sion. Most of the bove sid e effects i prove
fter sever l d ys. Ak thisi (inner sense of
restlessness) nd constip tion re co on
sid e effects of ntipsychotics.
42. (C) N or l grief c n ppe r si il r to jor
d ep ressive ep isod e (MDE), bu t there re
w ys to d istingu ish betw een the tw o. While
bere ve ent is not p sychi tric d i gno-
sis, it is psychosoci l stressor th t c n pre-
cipit te n MDE in vu lner ble ind ivid u l.
Nonbere ve ent-rel ted depression responds
to the s e ed ic tions nd tre t ents s
bere ve ent-rel ted d ep ression. MDE shou ld
be consid ered if the d ep ressive sy p to s l st
for longer th n 2 w eeks, nd ssoci ted w ith
p sycho otor ret rd tion, ch nge in pp etite/
w eight, d ecre sed energy nd concentr tion,
nd thou ghts of su icid e. The resp onse to nor-
l bere ve ent exclu d es the d i gnosis of
d ep ressive d isord er shou ld be consid ered for
p tients w ho h ve d epressive sy pto s ore
often th n not for 2 ye rs. Schizophreni w ou ld
not be n p prop ri te d i gnosis s the p tient
d oes not h ve previou s psychi tric history,
d oes not h ve other p sychotic sy pto s, nd
the h llu cin tions re better ccou nted for by
bere ve ent.
43. (E) At this ti e, the p tient is exp eriencing
nor l bere ve ent nd no fu rther interven-
tions re necess ry. Shou ld the sy p to s
continu e for longer period of ti e, w orsen,
or the p tient beco es less fu nction l, ini-
ti ting n ntid ep ress nt su ch s flu oxetine
( n SSRI) or, less frequ ently, itriptyline (
TCA) w ou ld be p p rop ri te. The p tients
u d itory h llu cin tions re still consid ered to
be nor l p rt of bere ve ent t this ti e,
so n ntipsychotic like h loperid ol should
not be initi ted u nless the voices beco e ore
d istressing nd p erv sive. Lithiu is ood
st bilizer ind ic ted for bipol r d isord er.
44. (B) Ad ju st ent d isord er is ch r cterized by
the onset of e otion l or beh vior l d istu r-
b nces w ithin 3 onths of signific nt life
event th t y nifest s rked ch nge in

n ind ivid u ls bility to fu nction in school,
w ork, or interp erson l rel tionship s. The
d istu rb nces re not so severe, how ever, s
to su ggest the d i gnosis of nother d isord er
such s MDD. The d ifferenti l d i gnosis for
d ju st ent d isord er inclu d es ood d isord ers
such s MDD, nd nxiety d isord ers su ch
s PTSD, GAD, nd cute stress d isord er. In
this c se, the p tient y be su ffering fro
d ep ressed ood bu t d oes not h ve other neu -
roveget tive signs of d ep ression. Acu te stress
d isord er is d i gnosed w hen n ind ivid u l
w ho h s exp erienced n extre e stressor h s
d issoci tive exp eriences nd nxiety shortly
fter the tr u tic experience. In this c se, the
p tient h s exp erienced signific nt psycho-
soci l stressor, bu t it is not life-thre tening
event s is requ ired for the d i gnosis of cu te
stress d isord er. In d d ition, this p tient is not
d escribing these sy pto s. The p tient is not
suffering nxiety bout nu ber of events for
over 6 onths consistent w ith GAD. Grief is
the nor l response to the loss or d e th of n
ind ivid u l close to the p tient.
45. (D ) The d i gnosis of d ju st ent d isord er
d oes not u su lly require ph r cother peu tic
intervention, bu t inste d y resp ond to su p -
p ortive, ind ivid u l, or grou p psychother p y.
Di lect l beh vior l ther p y is the first-line
tre t ent for bord erline person lity d isord er
p tients, help ing d ecre se self-d estru ctive
beh viors nd i p roving ffect regu l tion.
Flu oxetine is n SSRI, nd nortrip tyline is
TCA, both ntid ep ress nts. Risp erid one is n
typic l or second -gener tion ntip sychotic.
46. (B) This p tient is d escribing sy p to s
ssoci ted w ith p nic d isord er. This d isor-
d er begins in l te d olescence or e rly d ult-
hood nd is ore co on in w o en th n in
en. Peop le typic lly d escribe recu rrent nd
u np rovoked p nic tt cks, consisting of feel-
ings of fe r, d re d , or intense d isco fort sso-
ci ted w ith v riety of so tic sy pto s,
inclu d ing t chyc rd i , chest p in, shortness
of bre th, tre u lousness, d i phoresis, n u-
se , fe r of d ying, p resthesi s, light he d ed -
ness, nd hot or cold fl shes. The d i gnosis of
gor p hobi is d d ition lly d e w hen fe rs
Answe rs : 3948 193
of h ving n tt ck or being u n ble to esc pe
d uring n tt ck force p tients to re in in
f ili r pl ces. The ed ic l w orku p for p nic
d isord er inclu d es CBC, electrolytes, f sting
glu cose, c lciu , liver fu nction tests, BUN ,
cre tinine, u rin lysis, toxicology screen, ECG,
nd thyroid fu nction stu d ies. A c refu l su b-
st nce u se nd c ffeine int ke history should
lso be obt ined . GAD occu rs in ind ivid u ls
exp eriencing continu ed nxiety nd w orry
over sever l events l sting for gre ter th n
6 onths. In contr st to p nic d isord er, there
re not u su lly d iscrete ep isod es in GAD. Sep -
r tion nxiety d isord er is u su lly d i gnosed
in you ng child ren w ho d isp l y excessive
nxiety w hen sep r ted fro their pri ry
c regiver. Soci l nxiety d isord er occu rs in
the context of pu blic p pe r nces or p erfor-
nces, w here ind ivid u ls exp erience nxiety
nd fe r. These feelings c u se gre t d istress
nd y c u se p eop le to void these settings.
This d isord er d iffers fro p nic d isord er by
h ving n id entifi ble trigger. Specific phobi s
lso h ve n id entifi ble trigger.
47. (D ) A v riety of ed ic tions, inclu d ing SSRIs
(sertr line), TCAs, MAOIs (tr nylcypro ine),
nd benzod i zepines ( lpr zol ) h ve been
used to tre t p nic d isord er. Althou gh ll h ve
show n so e effic cy in the tre t ent of p nic,
SSRIs re usu lly the first gent of choice
bec use they re gener lly w ell toler ted , w ith
few er sid e effects th n TCAs or MAOIs, nd
l ck the d epend ency potenti l of benzod i z-
epines. Co on sid e effects inclu d e sexu l
d ysfunction, g strointestin l d isturb nces, nd
inso ni . Lithiu is used in the tre t ent of
bipol r d isord er, nd propr nolol c n be used
to n ge the p hysic l sy pto s of nxiety in
soci l nxiety d isord er (soci l phobi ).
48. (B) The p tient likely h s obsessive-co pulsive
d isord er (OCD) s she su ffers fro recu r-
rent, intru sive, u nw nted thou ghts or i ges
(obsessions) nd repetitive beh viors or en-
t l cts (co pu lsions) th t re p erfor ed in
resp onse to these obsessions. P tients re l-
ize th t the obsessions nd co p u lsions re
u nre son ble, nd they c u se rked i p ir-
ent in their lives. M ny p tients w ith OCD
194 6: Diffe re ntia l Diag nos is a nd Ma na g e me nt
hid e their sy p to s nd y first co e to
the ttention of other ed ic l speci lists.
GAD is suit ble d i gnosis in ind ivid u ls
w ho h ve w orries nd concerns th t re not
li ited to one p rticu l r sp ect of their lives,
bu t w ith the nxiety signific ntly i p iring
their bility to fu nction. OCPD is person l-
ity d isord er in w hich p tients beco e p reoc-
cup ied w ith perfectionis nd ord erliness.
H ow ever, there re no recu rrent obsessions
or co pu lsions, nd the sy pto s re ego-
syntonic. P nic d isord er nifests s recur-
rent, d iscrete ep isod es of extre e nxiety
nd fe r th t occu r unexp ected ly nd re it
spont neously. So tic sy pto d isord er
p resents w ith t le st one p hysic l co p l int
th t c nnot be fully expl ined by the results of
ed ic l investig tions.
49. (A) A w id espre d nd effective tre t ent for
OCD is cognitive-beh vior l ther py, d u r-
ing w hich the p tient is exp osed to the thre t
or fe r (obsession) w ith the response (h nd
w shing) p revented for p rogressively longer
p eriod s of ti e u ntil the beh vior is extin-
gu ished . SSRIs h ve lso been su ccessfu l in
the tre t ent of OCD. Lithiu is u sed in the
tre t ent of bipol r d isord er nd h s not been
show n to be effective in the tre t ent of OCD.
Psychod yn ic p sychother p y is intensive,
long-ter ther p y th t y be help fu l for
p eople w ho w ish to better u nd erst nd the
n tu re of their rel tionship w ith others, bu t
it h s not d e onstr ted signific nt effic cy in
OCD. Risp erid one is n typ ic l ntip sychotic
th t is u sed to tre t psychotic d isord ers nd is
not first line for tre ting OCD.
50. (A) Sy pto s of excessive w orry nd nxi-
ety bou t sever l sp ects occu rring for over
6 onths re best ch r cterized by the d i g-
nosis of GAD. Other sy pto s of GAD
inclu d e sleep d ifficu lties, irrit bility, nd d if-
ficulty concentr ting. P tients w ith GAD y void ing leg l issues. If ny of these re sons re
lso su ffer fro u scle tension, f tigu e, nd
restlessness. Althou gh this p tient d oes d it
to nxiety, it d oes not occu r in resp onse to
p nic tt cks or in response to p ublic p erfor-
nces, s w ith p nic d isord er or soci l nxi-
ety d isord er, resp ectively. Si il rly, lthou gh
the sy pto s of nxiety nd w orry re in
excess of w h t w ou ld be exp ected , they d o not
re ch the gnitu d e ch r cteristic for OCD,
nor re ny sp ecific obsessions or co pu lsions
elicited . There is no evid ence of p sychosis in
this p tient consistent w ith schizophreni .
51. (A) The d i gnosis of conversion d isord er
(fu nction l neurologic l sy pto d isord er)
is ost likely given th t the p ri ry sy p -
to s re neurologic nd the w orkup is neg -
tive for evid ence of p thology th t w ould
ccount for the d eficits. N eu rologic d eficits
in conversion d isord er involve either otor
or sensory od lities nd re believed to be
resu lt of u nd erlying, u nconsciou s p sychologi-
c l conflicts or stressors. H d the sy pto s
been intention lly p rod u ced , the d i gnosis of
f ctitious d isord er or lingering w ould be
p p ropri te. If the p ri ry incentive for the
beh vior w s to ssu e the sick role, the d i g-
nosis w ou ld be f ctitiou s d isord er. If the sy p -
to s re feigned or ex gger ted in ord er to
g in onet ry rei bu rse ent or to void j il
or w ork, the d i gnosis w ou ld be lingering.
So tic sy pto d isord er is less ppropri te
in this c se bec u se this p tients sy p to s
rent d istressing to her nd re solely neu ro-
logic co p l ints. An u nd i gnosed neu rologic
cond ition is possibility, but given the p re-
sent tion nd physic l ex in tion, it is less
likely. More recent stu d ies h ve show n only
4% isd i gnosis of conversion d isord er w hen
there is n u nd erlying neu rologic l d isord er
c using the sy pto s.
52. (B) F ctitiou s d isord er (Mu nch u sens) is n
ppropri te d i gnosis w hen physic l or psy-
chologic l sy pto s re intention lly pro-
d uced in ord er to ssu e the sick role. It ust
be cle r th t these sy pto s re not intention-
lly prod uced for other re sons, such s void -
ing w ork, g ining onet ry co pens tion, or
present, the d i gnosis is lingering. So tic
sy pto d isord er presents w ith t le st one
or ore so tic sy pto s, w hich c n be p in.
The d i gnosis of illness nxiety d isord er is not
ppropri te s this p tient is not preoccupied
w ith the id e of h ving severe d ise se th t

is unrecognized d espite repe ted re ssur nces
by ed ic l personnel. Cl ssic lly, people w ith
f ctitious d isord er re ore likely to be fe le
nd to h ve experience in he lth c re. Often,
these p tients w ill h ve nu erous d issions
to ny d ifferent hospit ls w ith v riety of
sy pto s. The p sychologic l f ctors u nd erly-
ing this d isord er re not w ell und erstood . N o
effective for of psychother py or ph r co-
ther py h s been id entified for the tre t ent
of f ctitiou s d isord er.
53. (A) The ost likely d i gnosis in this p tient
is norexi nervos nd is su p p orted by the
f ct th t she p pe rs very u nd erw eight, exces-
sively exercises nd continu es to feel th t
she need s to lose ore w eight, thu s d e on-
str ting her d istu rbed bod y i ge. Buli i
nervos c n be exclu d ed bec u se she d oes
not h ve ny binge e ting. While the p tient
d oes h ve so e nxiety, it is not cle r th t her
nxiety h s re ched to level th t it is c u sing
ny typ e of d ysfu nction in her d ily ctivities,
consistent w ith GAD. P tients w ith bod y d ys-
orphic d isord er gener lly focu s on one sp e-
cific d efect r ther th n so ething s gener l
s w eight. While the p tient d oes h ve sy p -
to s su ggestive of MDD, su ch s proble s
w ith sleep , p oor concentr tion, nd f tigu e,
she d oes not ention feeling d ep ressed or
h ving nhed oni , w hich re requ ired for
d i gnosis of MDD.
54. (E) Obt ining height nd w eight is cruci l for
est blishing the d i gnosis of norexi nervos ,
s p tients w ith norexi nervos re u n ble
to chieve or int in gre ter th n 85% of
exp ected bod y w eight for height nd fr e
stru ctu re. Ad d ition lly, they h ve contin-
u ed concerns bout thinness nd bod y i ge
d esp ite being u nd erw eight. In contr st, ost
p tients w ith bu li i nervos re of nor l
height nd w eight or re slightly overw eight.
While the other tests listed y, ind eed , be
bnor l in norexi ( nd bu li i ), they re
not necess ry or su fficient for the d i gnosis.
55. (E) Given the p tients history of nger nd
ggressive outbursts w hen not und erst nd ing
schoolw ork, d ifficulties w ith soci liz tion nd
Answe rs : 4958 195
c ring for hi self, s w ell s f ily history
of le rning d is bilities, you shou ld su spect
the d i gnosis of intellectu l d is bility (ID).
ID is d efined by severely i p ired cognitive
nd soci l fu nctioning. The severity of intel-
lectu l d is bility is d eter ined now by d p -
tive fu nctioning r ther th n IQ score. Either
the WISC or the St nford -Binet Intelligence
Sc le is n d equ te instru ent for esti ting
IQ. The Good enou gh-H rris Dr w -A-Person
Test nd Kohs Block Test ssess visu l- otor
coord in tion. The MMPI-2 is frequ ently u sed
to ssess person lity stru cture. The Pe bod y-
Voc bu l ry Test is u sed w hen p tients su ffer
fro l ngu ge b rrier.
56. (B) This p tient su ffers fro Tou rette d isor-
d er, synd ro e of ultiple otor nd voc l
tics th t occu r d ily for t le st 1 ye r, w ith the
onset before ge 18. Tou rette d isord er occu rs
ore co only in boys th n girls. First-line
tre t ent for ild to od er te Tou rette d is-
ord er is n lp h -2 gonist, su ch s gu nf cine
or clonid ine. An ntipsychotic c n be used to
tre t the d isord er, bu t is u su lly reserved for
p tients w ith ore severe c ses. Ato oxetine
is selective norep inep hrine reu p t ke inhibi-
tor th t h s been used for the tre t ent of
ADH D; it c n be effective for child ren w ith
ADH D w ho d evelop tics fter u sing sti u -
l nts. L otrigine nd v lp ro te cid re
ood st bilizers u sed for the tre t ent of
bip ol r d isord er. Lor zep is benzod i z-
ep ine nd is typ ic lly u sed for cu te nxiety
d isord er nd git tion.
57. (D ) Given the signific nt i p rove ent d u e to
the ed ic tion, it w ou ld not be ppropri te
t this ti e to d iscontinu e or sw itch ed ic -
tions. Sed tion is the ost co on sid e effect
of clonid ine nd w ill often go w y fter few
w eeks. Gu nf cine, the other lph -2 gonist
is nother op tion if the sed tion continu es or
interferes in fu nctioning. A d os ge red u ction
shou ld be tte pted before king ny of the
other ch nges listed .
58. (B) Ep ilep sy is co p lex set of d isord ers
th t y initi lly co e to the ttention of
p sychi trist bec u se of u nu su l beh viors.
196 6: Diffe re ntia l Diag nos is a nd Ma na g e me nt
Co p lex p rti l seizures, in p rticul r, y u nlikely s they d o not p resent w ith the bove
be ssoci ted w ith w id e r nge of sy p-
to s, includ ing sensory ur s nd uto tic
beh viors. Prior to the seizure, the p tient
y notice b d s ell, n u nu su l t ste, or
g strointestin l sy pto s. During the event,
the p tient y look d zed or frightened nd
y exhibit nu ber of uto tis s su ch
s lip s cking, eye blinking, nd fu bling
w ith his or her clothes. Ad d ition lly, there is
i p ir ent of consciousness. Co plex p rti l
seizu res re usu lly ssoci ted w ith te por l
lobe epilepsy, but c n lso result fro lesions
elsew here in the br in. Another d i gnosis to
rule out w ould be phet ine intoxic tion.
A phet ines re co only u sed to tre t
ADH D nd y be d ru gs of buse in this ge
group. Intoxic tion w ith phet ines y ys l ex cerb tions re frequ ent. Anxiety,
present s seizu res nd c n be e sily ru led ou t
by urine toxicology screen, but the nor l
vit l signs ke this less likely. The other d i g-
noses w ou ld not ccount for this p resent tion.
59. (D ) Althou gh syphilitic infections h ve been
on the d ecline since World W r I, they ust
still be consid ered in the d ifferenti l for w id e
v riety of psychi tric d isord ers, especi lly
w hen co bined w ith neu rologic bnor li-
ties. In this c se, tw o for s of neurosyphilis
(t bes d ors lis nd gener l p resis) re co -
bined in one p tient. P tients d e onstr te
sensory t xi w ith w id e-b sed g it,
p ositive Ro berg sign, nd loss of vibr -
tory nd proprioceptive senses initi lly in
the low er extre ities. Deep tend on reflexes
re d ecre sed nd pu pil bnor lities re
co on, lthou gh the fu ll ArgyllRobertson
p up il ( pu p il th t cco od tes bu t d oes not
re ct to light) is infrequ ent. Gener l p resis is
u su lly ssoci ted w ith d e enting p rocess
long w ith neu rologic sy p to s su ch s p u pil
bnor lities, tre ors, d yscoord in tion, nd
sp sticity in the low er extre ities. Testing for
neu rosyp hilis shou ld inclu d e blood test for
VDRL nd flu orescent trep one l ntibod y
bsorp tion test (FTA-ABS). Consid er tion
shou ld lso be given to p erfor ing lu b r
p u nctu re to test cerebrosp in l flu id for evi-
d ence of trep one l infection. A d i gnosis
of ntipsychotic-ind uced d ystoni or N MS is
yri d neu rologic l sy p to s nd s the
p tient is not cu rrently t king n ntip sychotic
ed ic tion. Although this p tient h s so e
sy pto s consistent w ith Kors koff p sycho-
sis nd Wernicke enceph lop thy (both d u e
to thi ine d eficiency fro long-ter lcohol
u se), neither d i gnosis lone w ou ld ccou nt
for this p tients constell tion of neu ropsychi-
tric sy p to s.
60. (D ) Pheochro ocyto is tu or of the chro-
ffin cells, usu lly occu rring in the d ren l
ed u ll . Sy pto s y d iffer ccord ing to
the pred o in nt c techol ine rele sed . As
norep inep hrine-secreting tu ors re the ost
co on, b seline hypertension w ith p rox-
fe r, nd p lpit tions y cco p ny ex c-
erb tions of hyp ertension. Bec u se this y
i ic sy pto s of p nic tt ck or GAD, it
is essenti l to consid er this in the d ifferenti l
d i gnosis w hen p tients present w ith nxiety
cou pled w ith physiologic ch nges. Alcohol
w ithd r w l, r ther th n intoxic tion, w ou ld
p resent w ith nxiety, tre ors, nd elev ted
vit l signs. H yperc lce i inclu d es sy pto s
such s kid ney stones (stones), bone p in/
fr ctu res (bones), d ep ression/ irrit bility
( o ns), nd n u se / vo iting (gro ns).
Sy pto s of hypothyroid is re d epression,
w eight g in, constip tion, ed e , d ry skin,
ho rseness, nd thinning h ir. A posterior
circu l tion stroke w ou ld present w ith cute
vision loss, confusion he d che, p resthesi s,
w e kness, nd d izziness.
61. (B) H ep tic encep h lop thy c n p resent
in ny w ys nd y h ve flu ctu ting
cou rse, king it d ifficu lt to d i gnose w ith-
ou t p erip her l stig t . N eu rologic lly, the
p tient y exhibit sterixis, w hich, lthou gh
ch r cteristic for hep tic encep h lop thy,
is not sp ecific for the d isord er. P tients y
d isp l y 6- to 9-H z tre ors, ild ly incre sed
d eep tend on reflexes, nd n ltered senso-
riu . Typ ic l p sychi tric sy p to s y
inclu d e ch nges in p erson lity, bru p t ood
sw ings, nd ch nges in cognitive bility. In n
cu te d eco p ens tion, d ep ression, c t toni ,

p sychosis, nd d eliriu y d evelop . Physi-
c l stig t reflecting d ecre sed liver fu nc-
tion inclu d e ecchy osis, p erip her l ed e ,
scites for tion, p l r erythe , nd sp i-
d er ngio s.
62. (C) H IV c n p rod u ce spectru of neuropsy-
chi tric nifest tions s resu lt of opp ortu -
nistic infections, neopl s s, or d irect inv sion
of the CN S by the viru s. M jor neurocogni-
tive d isord er (d e enti ) d ue to H IV infection
is one of the ost co on nifest tions
of pri ry CN S inv sion. Criteri for jor
neu rocognitive d isord er (d e enti ) includ e
signific nt cognitive d ecline in one or ore
cognitive d o ins (le rning nd e ory,
ttention, executive function, l ngu ge, per-
ceptu l- otor, or soci l cognition). It y ex cerb tions or l te in the d ise se process.
present in v riety of w ys, includ ing otor
bnor lities, cognitive d ecline, or beh vior l
ch nges. This c se d escribes typic l beh vior l
ch nges, for ex ple, leth rgy nd soci l w ith-
d r w l. M jor neurocognitive d isord er d ue
to H IV infection y lso includ e neurologic
bnor lities such s w e kness, i b l nce, or
t xi , s w ell s irrit bility nd p thy. The
results of the MMSE support the d i gnosis of
jor neurocognitive d isord er.
63. (D ) This c se illu str tes present tion of
hyp erthyroid is , w ith d ep ression, irrit bility,
nd cognitive d ysfu nction. H yperthyroid is
y present w ith sy pto s consistent w ith
v riety of psychi tric d isord ers, inclu d ing
d ep ression, nxiety, psychosis, ni , nd , t
n extre e, d eliriu . P tients y rep ort hot
fl shes nd / or incre sed sensitivity to he t.
H yperthyroid is y lso c u se ild cogni-
tive d eficits in c lcu l tion nd recent e ory.
N eurologic lly, p tients y d e onstr te
fine 8- to 12-H z tre or, lid l g, brisk d eep ten-
d on reflexes, proxi l yop thy w ith uscle
w sting, nd y lgi s.
64. (G) So tic sy p to d isord er is ch r cter-
ized by t le st one so tic or p hysic l co -
p l int th t c nnot be verified by l bor tory
nd p hysic l find ings. The d isord er h s its
onset before ge 30 nd is ore co on in
w o en th n in en. Di gnosis is b sed on the
Answe rs : 5967 197
occurrence of physic l sy pto s, w hich y
be p red o in ntly p in, th t re d istressing
nd c u se soci l or occu p tion l d ysfu nction.
It is i p ort nt to d eter ine th t these sy p -
to s re not intention lly p rod uced or feigned
for other pu rposes. Si il rly, it is i port nt to
ensu re th t the p tient receive the p p rop ri te
ed ic l w orku p , bec u se nu ber of d ise se
p rocesses y present w ith constell tion of
sy pto s. B sic tests th t shou ld be ord ered
inclu d e blood tests, ECG, colonoscop y, or
gynecologic l ex in tions.
65. (H) Depression is co on sy pto of
SLE. Although neuropsychi tric cond itions
y rise t ny ti e d u ring the cou rse of the
d ise se, they re ost frequent d uring cute
Other sy pto s inclu d e d eliriu , person lity
ch nges, nxiety, nd psychosis. P tients y
lso exhibit cognitive i p ir ent on neuro-
psychologic l testing. N eu rologic lly, p tients
c n present w ith seizu res, stroke, cr ni l nerve
bnor lities, nd he d che.
66. (E) This p tient is exhibiting signs nd sy p -
to s consistent w ith d eliriu second ry to
hyp oglyce i . Signs of hyp oglyce i ni-
fested by this p tient inclu d e t chyc rd i ,
tre or, hyp ertension, nd seizu re. Deliriou s
st tes shou ld receive i ed i te w orku p for
n etiology s they c rry signific nt r te of
orbid ity nd ort lity. A st nd rd w orku p
consists of CBC w ith d ifferenti l, electro-
lytes, BUN , cre tinine, VDRL, vit in B12,
fol te, u rin lysis, thyroid -sti u l ting hor-
one (TSH ), c lciu , gnesiu , p hosp ho-
ru s, glu cose, u rine toxicology screen, liver
fu nction tests, p erip her l oxygen s tu r tion,
chest x-r y, ECG, s w ell s ent l st tu s nd
p hysic l ex in tion.
67. (C) P tients w ith jor neurocognitive d isor-
d er d ue to Alzhei er d ise se typic lly present
w ith e ory proble s th t gr d u lly w orsen,
s w ell s one other cognitive d o in (e.g.,
p h si , pr xi , gnosi , or d istu rb nces in
executive functioning). In this c se, the p tient
de onstr tes e ory proble s nd n gnosi
(un ble to n e pencil).
198 6: Diffe re ntia l Diag nos is a nd Ma na g e me nt
68. (F) M jor neu rocognitive d isord er d u e to
Lew y bod y d ise se typ ic lly p resents w ith
w ell-for ed visu l h llu cin tions (p ed u ncu -
l r h llu cinosis or Lillip u tionis ) l te in life
w ithou t p reviou s p sychi tric d istu rb nces.
Motor d istu rb nces re si il r to th t of
P rkinson d ise se bu t in Lew y bod y d ise se
occu r l ter th n the cognitive d eficits. Motor
p roble s inclu d e cogw heel rigid ity, shu ffling
g it, nd red u ced r sw ing. The typ ic l p ill-
rolling tre or of P rkinson d ise se is less
co on.
69. (D ) Pick d ise se is ch r cterized by ch nges
in p erson lity e rly in the illness. Pri itive
reflexes re seen, su ch s the su ck, B binski,
nd snou t. Other cognitive fe tu res of the
d e enti typ ic lly occu r l te in the d ise se.
I ging is u su lly ch r cterized by p referen-
ti l trop hy of the front l nd te por l lobes.
Confir tion of the d i gnosis is d e vi
biop sy or u top sy nd reve ls Pick inclu sion
bod ies.
70. (A) Deliriu is synd ro e consisting of
flu ctu tion in the level of ttention nd cogni-
tion, sy p to s of w hich c n w x nd w ne.
It is essenti l to look for one or ore u nd erly-
ing c u ses, su ch s electrolyte bnor lities,
infections, nd sid e effects of ed ic tions.
In contr st to jor neu rocognitive d isord er
(d e enti ), d eliriu h s n cu te onset of
sy pto s nd is typic lly reversible once the
u nd erlying etiology is corrected .
71. (B) Pseudode enti is ter referring to the
cognitive disturb nces (de enti ) c used by
depressive illness, such s jor depression.
P tients typic lly present with depressed ffect,
neuroveget tive sy pto s, nd e ory prob-
le s. During ex in tion, p tients de on-
str te poor concentr tion nd effort such th t
they h ve difficulty co pleting questioning.
Pseudode enti is reversible once the depres-
sion is tre ted.
72. (E) M jor neu rocognitive d isord er d ue to
H untington d ise se is n utoso l d o in nt
d ise se c used by CAG repe t on the short
r of chro oso e nu ber 4. The d ise se
typic lly c uses p sychi tric d istu rb nces su ch
s d ep ression or nxiety, h llu cin tions, e -
ory proble s, nd choreifor ove ents.
On i ging, p tients y h ve boxc r ventri-
cles th t ppe r s h ving corners r ther th n
rou nd ed ed ges.
M jor neurocognitive d isord er d ue to Prion
(Creu tzfeld tJ cob) d ise se is d e enti
c used by prion, su ch s in d cow d is-
e se. Ind ivid u ls p resent w ith cognitive d efi-
cits, t xi , bnor l ove ents, nd often
st rtle reflex. It h s r pid p rogression. M jor
v scu l r neurocognitive d isord er (for lly
referred to v scu l r or u lti-inf rct d e en-
ti ) is c u sed by cerebrov scu l r events, such
s strokes or e boli. In d d ition to the cog-
nitive d eficits, it is not u nco on to d ispl y
p erson lity nd ood ch nges. In contr st to
Alzhei er d ise se, jor neu rocognitive d is-
ord er d ue to v scu l r d ise se cl ssic lly p res-
ents w ith step -w ise d eterior tion.
73. (C) Bec u se the d efense ech nis of d eni l is
p ri ry in lcohol u se d isord ers, often the best
p p ro ch in ev lu ting p tient is to explore
how lcohol ffects his life, r ther th n d irect
qu estions bou t d rinking beh vior. H e ring
bou t his d rinking fro his friend s nd f -
ily y p rovid e ore ccu r te d escrip tion
of p tients lcoholis th n the ind ivid u l
w ou ld p rovid e of hi self. Althou gh l bor -
tory w ork ight provid e clu es to the presence
of lcohol use d isord er, it c nnot be relied on
to ke the d i gnosis.
74. (B) GAD is d efined by excessive nxiety or
w orry occu rring for t le st 6 onths. Asso-
ci ted sy pto s includ e feeling restless,
f tigu ed , or irrit ble; u scle tension; d ifficu lty
w ith concentr tion; nd sleep d istu rb nce.
Dep end ent p erson lity d isord er rep resents
p ttern of the p erv sive need to be t ken
c re of, le d ing to su b issive, clinging beh v-
ior th t begins in e rly child hood . Althou gh
d ep ression nd p ersistent d ep ressive d isord er
sh re so e sy pto s w ith GAD, the d epres-
sive sy p to s re ore severe in the ood
d isord ers th n w ith the nxiety d isord ers. The
onset of nxiety w ith p nic d isord er is ore
sud d en nd intense, w ith the fe r of choking

or d ying co on, nd the p nic tt cks re
recu rrent nd u nexp ected . Soci l nxiety d is-
ord er requ ires nxiety in soci l situ tions w ith
fe rs of scru tiny or hu ili tion by others,
such s perfor nce nxiety or fe rs of pu blic
spe king.
75. (A) N eg tive thoughts reg rding the self, the
w orld, nd the future re know n s the Beck
cognitive tri d . Beck, w ho d eveloped the Beck
Depression Inventory, pioneered the use of
cognitive ther py for d epressive d isord ers.
This tri d of sy pto s is helpful in both und er-
st nd ing nd tre ting d epression through cog-
nitive ther py. The tri d is not ch r cteristic lly
seen in the other d isord ers listed .
76. (B) Cognitive ther py c n help to t rget these
neg tive w ys of perceiving the self nd the
environ ent. While often u sed in conju nction
w ith cognitive ther p y (i.e., cognitive-beh v-
ior l ther p y), p u re beh vior l ther p y is
only focu sed on beh vior od ific tion, not
on the u nd erlying f ctors (such s cognitive
errors) th t c u se or contribu te to the p rob-
le tic beh viors. Cou p les ther p y w ou ld be
less effic ciou s th n cognitive ther p y given
this p tients sy pto s. The jor focus of
interp erson l p sychother p y is the n lysis of
co u nic tion styles nd ones role in rel -
tionship s. In p r d oxic l ther py, d evelop ed
by B teson, the ther p ist su ggests th t the
p tient eng ge in the beh vior w ith neg tive
connot tions (e.g., phobi or co pu lsion).
77. (A) Abou t 40% of those w ith lcohol u se d is-
ord er w ill beco e severely d epressed w ithin
the first w eek of bst ining fro lcohol.
H ow ever, if they re ble to bst in fro lco-
hol for tot l of 4 w eeks, only 5% of p tients
w ill continu e to h ve signific nt sy p to s of
d ep ression.
78. (E) This p tient continu es to experience
d ep ressed ood nd neu roveget tive sy p -
to s (inso ni , nergi , poor concentr tion)
6 w eeks fter the cess tion of lcohol. Dep res-
sive sy pto s d uring the first 4 w eeks of
stopping the u se of lcohol re ore likely to
be su bst nce ind u ced . H ow ever, the f ct th t
Answe rs : 6880 199
the d epressive episod e h s l sted longer th n
4 w eeks fter the cess tion of lcohol points
to n und erlying (co orbid ) ood d isord er
such s jor d epressive d isord er (MDD)
r ther th n su bst nce-ind u ced ood d is-
ord er. Sertr line is n SSRI nd is first-line
gent for the tre t ent for MDD. While i-
triptyline ( tricyclic ntid epress nt) is n
option, bec use of its sid e effect profile nd
leth lity in overd ose, it is not u sed s first-
line gent for d ep ression. Bu sp irone is n nx-
iolytic u sed for the tre t ent of gener lized
nxiety d isord er. Lithiu is ood st bilizer
typic lly u sed for bip ol r d isord er ( ni )
nd not co only for u nip ol r d epression.
Lor zep ( benzod i zep ine) is lso n nx-
iolytic, bu t it w ou ld not d d ress the p tients
d ep ressive sy p to s nd c n c use physi-
ologic l d epend ence, esp eci lly in this p tient
w ith history of lcohol d d iction.
79. (D ) This p tient is experiencing n cu te Wer-
nicke enceph lop thy (d eliriu ) c u sed by
d inistr tion of glu cose w ithou t thi ine.
In p tients w ith long-ter lcohol u se d isor-
d er w ho re likely to h ve low levels of thi -
ine, giving glu cose p rior to giving thi ine
c n often precipit te this cond ition, s glucose
oxid tion requires thi ine, thu s d epleting
the re ining stores in the bod y; this d eple-
tion c n then c use r p id d rop in the thi -
ine levels w hich c uses the encep h lop thy.
80. (A) Alcohol-ind u ced jor neu rocognitive d is-
ord er (Kors koff synd ro e) is n nterogr d e
nestic d isord er c u sed by chronic thi ine
d eficiency, w hich cl ssic lly presents w ith
conf bul tion, in w hich the p tients ke up
sp ects of their life th t they c nnot re e -
ber. It is c u sed by d ge to the ill ry
bod ies th t is u su lly irreversible. Conversion
d isord er shou ld only be d i gnosed w hen there
re sy pto s of ltered neurologic l fu nction
(sensory or otor) not d equ tely expl ined
by recognized neu rologic l or ed ic l cond i-
tions. F ctitious d isord er w ou ld be d i gnosed
if the p tient f bric ted his sy p to s in the
bsence of extern l rew rd s (i.e., to ssu e
the sick role). M jor neu rocognitive d isord er
d ue to Alzhei er d ise se, w hich d oes present
200 6: Diffe re ntia l Dia g nos is a nd Ma na g e me nt
w ith e ory d isturb nces, does not usu lly
present so cutely, nd the history of lcohol
use d isord er ke Alzhei ers less likely eti-
ology. Wernicke enceph lop thy, lso c used
by thi ine deficiency, is gener lly reversible
cond ition resulting in t xi , confusion, nd
ocul r bnor lities. Wernickes y progress
to Kors koff synd ro e.
81. (C) Mood -congru ent d elu sions re co p t-
ible nd consistent w ith the st te of ind of
the p tient. In this c se, the p tient feels gu ilty
nd p resu bly believes he d eserves p u nish-
ent. H is d elu sions express these thou ghts.
If he d escribed d elu sions of gr nd iosity, th t
w ou ld be n ex p le of ood -incongru ent
d elusion. Biz rre d elusions d escribe circu -
st nces th t re i possible to be tru e, for
ex p le, schizop hrenic p tient believing
co pu ter chip is i pl nted in his br in. The
d elusions in this qu estion, how ever u nlikely,
re in so e sense conceiv ble. Ego-syntonic
d elusions re experienced by the su fferer s
ccept ble; for ex ple, the nic p tient
believing he is the gre test ctor in the w orld .
This p tients d elu sions re ego-d ystonic,
exp erienced s u n ccep t ble nd u np le s nt.
So tic d elu sions focus on bod ily fu nctions
nd integrity.
82. (C) Often, the n tu re of the d elu sion nd its
rel tion to ood st te c n p rovid e clu es to
d i gnosis. Delu sions rising out of severe
jor d epressive episod e, s in this c se, re
frequently ood congru ent. Bipol r d isord er,
nic cl ssic lly p rod uces d elu sions th t re
gr nd iose, rel ting to the infl ted self-estee .
The d elu sions of schizop hrenic p tients c n be
biz rre nd re often u nrel ted to ood st te.
The p resence of d elu sions ru le ou t d ju st ent
d isord er nd persistent d epressive d isord er s
these ffective illnesses d o not re ch severity
th t includ es d elu sion l thinking.
83. (C) P tients w ith schizoid person lity d isord er
re typic lly soci lly isol ted nd d istinctly
inept t for ing nd c rrying on interperson l
rel tionships. They often co e to the ttention
of physici ns s result of so e other issue,
s seen in this c se. Their pp rent p thy nd
ind ifference y rese ble the neg tive sy p-
to s of schizophreni , nd ind eed , th t is in
the differenti l here; but it would be difficult to
ke d i gnosis of schizop hreni w ithout
evid ence of psychosis. Although this p tient
y, ind eed , be d epressed nd eet criteri
for MDD, w e re given no d irect evid ence of
this. H e exhibits none of the istrust nd sus-
piciousness seen in p r noid person lity d is-
ord er. This p tient l cks the ctively od d nd
pecu li r nneris s or eccentric w y of think-
ing seen in schizotyp l person lity d isord er.
84. (D ) Bip ol r d isord er h s one of the l rgest
genetic co p onents of ll the ent l illnesses.
H ving onozygotic tw in w ith bipol r d is-
ord er incre ses the risk of d eveloping bipol r
d isord er u p to 70%.
85. (C) Fro s fety st nd point, the ost i por-
t nt fe tu re of h llucin tions of p tient w ith
schizophreni is the n ture of w h t the voices
re s ying. Co nd u d itory h llu cin -
tions telling p tient to h r or kill hi or
herself or so eone else re often psychi t-
ric e ergency, u su lly requ iring hosp it liz -
tion. A possible excep tion y be w here n
exp erienced clinici n know s the p tient w ell
nd believes the situ tion to be s fe. All of the
other choices in this qu estion spe k to i por-
t nt ch r cteristics of u d itory h llu cin tions
th t shou ld be ev lu ted , bu t the p resence of
co nd u d itory h llu cin tions requ ires
i ed i te ttention.
86. (D ) N rcolepsy is ch r cterized by p ersis-
tent d yti e hyperso nolence th t is te -
por rily relieved by brief n ps. N rcolepsy is
often cco p nied by pheno en co only
ssoci ted w ith in ppropri te REM sleep,
includ ing hypn gogic or hypnopo pic h l-
lucin tions (vivid h llucin tions upon f lling
sleep or w king up), c t plexy ( sud d en
dr tic loss of uscle tone, usu lly follow ing
n intense e otion l re ction), sleep p r lysis
( loss of volunt ry uscle tone t the begin-
ning or end of sleep, s seen in this c se), nd is
ssoci ted w ith hypocretin d eficiency. H yper-
so nolence d isord er is lso ch r cterized by
persistent sleepiness bu t c n be d istingu ished

fro n rcolepsy by the f ct th t the n ps
cco p nying it re often long nd unrefresh-
ing. Circ d i n rhyth sleepw ke d isord er,
d v nced sleep-ph se type refers to ind ivid u-
ls w hose soci l/ occup tion l functioning is
d isturbed by their d row siness d uring the eve-
ning, w here s d el yed sleep-ph se type refers
to those w hose soci l/ occup tion l function-
ing is d isturbed by d row siness in the orning
nd lertness in the evening. P r so ni s re
beh viors th t re w orsened or only occur d ur-
ing sleep nd includ e night re d isord er nd
non-REM sleep rous l d isord ers (e.g., sleep-
w lking or sleep terrors).
90. (E) P tients on high-dose steroids re t risk for
87. (C) The p tient in this qu estion h s p reviou s
opi te u se d isord er. Bec u se of this, choosing
non ddictive edic tions would be preferred
over ddictive edic tions. Diphenhydr ine
is hist ine blocker nd is not d d ictive.
It c n be help fu l for p tients w ith inso -
ni . Alpr zol nd zolp id e , w hile they
c n be benefici l, d o h ve n d d ictive poten-
ti l. Cod eine is n opi te, nd , w hile one sid e
effect is sed tion, it shou ld be u sed for the
relief of p in. Qu eti p ine is n ntip sychotic
w hich c u ses sed tion. H ow ever, d u e to its
sid e effect profile su ch s ove ent d isor-
d ers, w eight g in, incre sed cholesterol, nd
incre sed f sting su g rs, it shou ld not be u sed
s first-line gent for inso ni .
91. (A) As steroid -ind uced psychosis is co
88. (C) The p tient in this vignette h s d i gno-
sis of ADH D, w ith sy pto s of in ttention
nd hyp er ctivity. Tre t ent for ADH D is
u lti od l nd inclu d es ed ic tions nd
beh vior l od ific tions. First-line p h r -
cother py is ethylphenid te, sti ul nt.
Clonid ine, n lp h -2 gonist, is second -line
ed ic tion for ADH D. I ip r ine, TCA,
nd sertr line, n SSRI, re ntid ep ress nts
u sed to tre t nxiety nd d ep ression. Risperi-
d one is n typ ic l ntip sychotic.
92. (E) Serotonin syndro e is
89. (D ) This vignette illu str tes p tient w ho
is show ing signs of ild to od er te op i te
w ithd r w l. Sy p to s of op i te w ithd r w l
inclu d e l cri tion, rhinorrhe , y w ning,
u scle ches, bd o in l cr p ing, nd d i r-
rhe . Anticholinergic toxicity p resents w ith
Answe rs : 8192 201
fevers, d il ted p u p ils, d ry skin, nd confu sion.
H yp ertensive crisis occu rs w hen p tient
is on n MAOI nd consu es tyr ine-rich
food s resu lting in elev ted blood p ressu re,
he d ches, n u se , nd vo iting. Influ enz
is viru s resu lting in fevers, y lgi s, nd
resp ir tory sy p to s. Serotonin synd ro e is
life-thre tening cond ition d u e to i trogenic
serotonin excess; this p tient is only t king
one serotonergic ed ic tionvenl f xine.
Serotonin synd ro e is ch r cterized by leth-
rgy, confu sion, flu shing, clonu s, co , nd
p ossibly d e th.
developing steroid-induced psychotic disorder
or ni . This p tient is h ving uditory h l-
lucin tions nd is thus experiencing psycho-
sis r ther th n ni . Bipol r disorder due to
nother edic l cond ition (hyperthyroidis )
is less likely given the p tients nor l thyroid
studies. In order to h ve di gnosis of brief
psychotic disorder, edic tion or edic lly
induced psychosis ust be ruled out; steroids
re well-known c use of psychosis. MDD with
psychotic fe tures requires pri ry ood
disorder which this p tient does not h ve. This
p tient h s cute onset of uditory h llucin -
tions nd does not ppe r to h ve pri ry
thought disorder, such s schizophreni .
only
seen in p tients requ iring high-d ose steroid s.
The first step in n ge ent of this p tient
w ould be to d ecre se the steroid d os ge. H er
TSH nd T4 levels re nor l nd she d oes not
require d just ent in her levothyroxine. There
is no ind ic tion to st rt nd SSRI or ood st -
bilizer. ECT c n be used for the n ge ent
of cute psychosis, how ever, w e h ve n id en-
tifi ble c use of this p tients psychosis nd
w ould first d ecre se the steroid s.
life-thre tening
cond ition d ue to i trogenic serotonin excess.
This p tient is on ultiple serotonergic ed i-
c tions, includ ing phenelzine, n MAOI, tr -
d ol, nd linezolid . Together these edic tions
c used the sy pto s of leth rgy, confusion,
flushing, clonus, di phoresis, co , nd y
202 6: Diffe re ntia l Dia g nos is a nd Ma na g e me nt
c use d e th. Bipol r d isord er is pri ry
ood d isord er; w hile the p tient h s p revi-
ou s d i gnosis of MDD w ith psychotic fe tu res,
there is no history or evid ence of ni . H yper-
tensive crisis occurs w hen p tient t king n
MAOI consu es tyr ine-rich food s resu lt-
ing in rked ly incre sed BP, he d ches, n u-
se , vo iting, nd confu sion. Migr ines w ith
ur re type of he d che w ith sy pto
( ur ) preced ing the he d che. N euroleptic
lign nt synd ro e is n id iop thic re ction
fro ntipsychotic ed ic tions. It is psychi-
tric e ergency ch r cterized by confusion
or d eliriu , fluctu ting vit l signs, nd le d
pipe rigid ity.
93. (B) Multiple ed ic tions in d d ition to psy-
chotropic ed ic tions (e.g., SSRIs, TCAs,
MAOIs) c n incre se serotonin nd re i por-
t nt to be w re of. These ed ic tions includ e
tr d ol, linezolid , nd tript ns. They shou ld
ll be d iscontinu ed in p tient w ith serotonin
synd ro e. The other choices re either not
i ed i te or not p p rop ri te.
94. (B) This p tient d e onstr tes ho rd ing d is-
ord er, n in bility to d isc rd p ossessions
reg rd less of v lu e, so u ch so th t he h s
cre ted n u nliv ble situ tion in his ho e.
The p tient find s hi self u n ble to w ork sec-
ond ry to incre sing stress levels. First-line
tre t ent for ho rd ing d isord er is CBT. GAD
is d i gnosis reserved for p tients w ho h ve
incre sed nxiety over u ltip le d o ins, sig-
nific ntly i p iring their bility to fu nction
in soci l or occu p tion l settings. P tients
w ith OCD h ve recu rrent, intru sive thou ghts
(obsessions) resu lting in rep etitive beh v-
iors (co p u lsions) s resp onse. OCPD is
p erson lity d isord er in w hich p tients re
rigid nd p erfectionistic, w ith no recu rrent
obsessions or co p u lsions. P nic d isord er
involves recu rrent, u np rovoked p nic tt cks
nd p eriod s of extre e nxiety l sting t le st
1 onth.
95. (C) The p tient in this vignette eets criteri
for d issoci tive nestic, w ith d issoci tive
fu gue, w hich is ch r cterized by the sud d en
tr vel fro ho e cco p nied by forgetting
self or other u tobiogr p hic l infor tion.
These p tients often h ve signific nt ou nt
of tr u or stressfu l event in their history.
Bord erline p erson lity d isord er is p erv -
sive d isord er w ith ffect d ysregu l tion, p t-
terns of unst ble rel tionships, nd su icid l/
self- util tion beh viors. Deperson liz tion
d isord er is d escribed s recu rrent feelings of
d et ch ent fro self s w ell s h ving occ -
sion l ou t of bod y experiences. Dissoci tive
id entity d isord er, for erly know n s u ltip le
p erson lity d isord er, is d i gnosis of h ving
tw o or ore d istinct person lities. Multiple
ch nges of id entity usu lly co-occu r w ith
e ory d eficits in p erson l d t nd d ily
events. M jor neu rocognitive d isord er d u e
to Alzhei er d ise se is d e enti d efined
by gr d u l d ecline in cognitive fu nctions of
e ory, le rning, nd l ngu ge.
96. (E) Restless legs synd ro e nifests s
u nco fort ble sens tions in the legs, w hich
re relieved w ith ove ent, ostly t rest nd
in the evening. This cond ition is p ro inent
c use of sleep d istu rb nce. Iron d eficiency is
know n risk f ctor ssoci ted w ith restless legs
synd ro e. GAD is d i gnosis inclu d ing sig-
nific nt nxiety over sever l re s of life th t
i p irs fu nctioning. Inso ni d isord ers re
collection of sy pto s th t d isru p t sleep
d ur tion nd qu lity. N on-REM sleep rou s l
d isord ers inclu d e sleep w lking nd sleep
terrors. While they y includ e ove ents,
they re p rt of beh viors such s w lking,
e ting, nd sitting u p in bed . Obstru ctive sleep
p ne , chronic sleep cond ition, is ch r cter-
ized by p neic ep isod es resu lting in excessive
d yti e sleepiness.
97. (B) Iron d eficiency is know n c u se of rest-
less legs synd ro e. Rep leting iron w ou ld be
the first step in n ging this p tient before
consid ering other ph r cother py options.
98. (E) The p tient in this vignette eets criteri
for inter ittent explosive d isord er, d i gno-
sis d escribed by frequent verb l or physic l
ou tbu rsts tow rd people or p roperty. These
ou tbu rsts of ggression re ou t of proportion
to the situ tion or stressor nd c u se d istress

to the p tient. P tients w ith ntisoci l p er-
son lity d isord er h ve p ttern of viol ting
the rights of others nd the f ilure to confor
to soci l nor s. While this p tient d ispl ys
nger ou tbu rsts, there re no other viol -
tion of rights nor leg l proble s consistent
w ith ntisoci l p erson lity d isord er. Bip ol r
II d isord er inclu d es ep isod es of n MDE and
hyp o ni ; ood d isord er is not d escribed
in this vignette. Bord erline p erson lity d isor-
d er p tients d escribe p ttern of inst bility
d e onstr ted throu gh poor ffect regu l tion,
self- util tion beh viors, nd unst ble rel -
tionship s. Cond uct d isord er is d i gnosed
in child hood / d olescence nd involves n
irrit ble/ ngry ood , d efi nt beh vior, nd
vind ictiveness th t y progress to ntisoci l
p erson lity d isord er in d ulthood .
99. (A) Person lity d isord ers re ego-syntonic,
l d p tive, p erv sive beh viors th t c u se
signific nt i p ir ent in soci l or occu p -
tion l fu nctioning. Antisoci l person lity d is-
ord er requ ires p tient to h ve history of
cond u ct d isord er prior to d ulthood . These
ind ivid u ls h ve no reg rd for b sic hu n
rights, re frequ ently violent, often f il to
bid e by the l w , ke i p u lsive d ecisions,
nd re reckless. They h ve little to no re orse
for their ctions.
100. (D ) Depend ent person lity d isord er d escribes
p tient w ith n excessive need to be t ken
c re of resulting in d ifficulty king everyd y
d ecisions nd the need for support fro others.
101. (I) Schizoid p erson lity d isord er p tients re
soci lly w ithd r w n nd d o not d esire close
rel tionship s. They p refer solit ry ctives nd
p pe r to h ve restricted e otions th t sp n
w id e r nge of environ ents.
102. (C) P tients w ith bord erline p erson lity d is-
ord er h ve chronic p tterns of i pu lsivity
nd u nst ble rel tionship s, ffect d ysregu l -
Answe rs : 93108 203
tion, nd often d e onstr te recu rrent suicid l
thre ts, tte pts, or self- u til tion.
103. (E) H istrionic p erson lity d isord er inclu d es
p tients w ith excessive e otion lity nd
ttention-seeking beh viors, w ith focu s on
p p e r nce nd ttr ctiveness. These inclu d e
sed u ctive beh viors, over-ex gger ted e o-
tion l resp onses, nd f lse p ercep tions s to
the extent of inti cy of their rel tionship s.
104. (F) P tients w ith n rcissistic p erson lity d isor-
d er h ve n overinfl ted sense of self-w orth,
sense of entitle ent, nd requ ire excessive
d ir tion.
105. (H) P r noid p erson lity d isord er involves
p tient th t h s consistent d istru st of others
w ithou t su bst nti l re soning. P tients often
h ve d oubts of loy lty nd perceive tt cks on
their ch r cter. While not overtly p sychotic,
they c n be extre ely p r noid nd litigiou s.
106. (B) Avoid nt p erson lity d isord er is d i g-
nosed in p tients w ho re extre ely sensitive,
often void ing situ tions (occu p tion l or
soci l) w here they re exp ected to for new
rel tionship s or friend ship s. These p tients
re extre ely shy nd feel inferior to others.
This c u ses the to be relu ct nt to eng ge in
new ctivities for fe r of e b rr ss ent or
rejection.
107. (G) P tients w ith obsessive-co pulsive per-
son lity d isord er re const ntly preoccupied
w ith p erfectionis nd control t the exp ense
of efficiency nd flexibility. This results in
u nw illingness to d eleg te, excessive d evotion
to w ork, nd in bility to d pt.
108. (J) P tients w ith schizotyp l person lity d isor-
d er re often looked t s eccentric nd h v-
ing od d beh vior. While not d elusion l, they
h ve unu su l beliefs, such s gic l thinking,
cl irvoy nce, or the p r nor l.
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 CHAPTER 7

Prac tic e Te s t 1
Que s tions

D IRECTION S (Questions 1 through 107): For each Questions 3 and 4

of the multiple-choice questions in this section,
select the lettered answ er that is the one best A 44-year-old w om an p resents to her p rim ary care
response in each case. d octor w ith m u ltip le com p laints, inclu d ing w eak-
ness in her low er extrem ities, bloating, head aches,
interm ittent loss of ap p etite, and back p ain. A care-
Questions 1 and 2 fu l review of sym p tom s reveals m any other vagu e
sym p tom s. H er com p laints d ate back to ad oles-
A 29-year-old m an w ith a history of bip olar d isor-
cence and she has seen m any d octors. Thorou gh
d er presents to the psychiatric em ergency d ep art-
w orku p s, inclu d ing an exp loratory lap arotom y,
m ent saying that he is the king of Pum bar and
have failed to u ncover any clear, anatom ic, or
need s everyones allegiance for the u p com ing w ar
p hysiologic cau se.
w ith the Martians. In the p ast few d ays, he has slep t
a total of 3 hou rs bu t says that he is not tired . H e has
3. Which of the follow ing is the best ap proach to
spent all of his m oney soliciting phone sex. N ow , he
this patient?
is agitated , d em and ing, and threatening.
(A) Tell her any physical w orku p is
1. Which of the follow ing is the best treatm ent u nnecessary.
for this p atient in the acu te setting? (B) Tell her to com e back in 1 m onth and , if
(A) Carbam azep ine (Tegretol) the sym ptom s are still present, you w ill
initiate a p hysical w orku p .
(B) Divalp roex sod iu m (Dep akote)
(C) Tactfu lly ask her w hy she is inventing
(C) H alop erid ol (H ald ol)
sym ptom s.
(D) H yd roxyzine (Atarax)
(D) Assess her for other p sychiatric
(E) Lithiu m illnesses.
(E) Initiate a p hysical w orku p and arrange
2. After treating the p atient acu tely, a m ed ica-
for follow -u p in a years tim e.
tion is requ ired for ongoing treatm ent of his
bip olar d isord er. You find that he has a history
4. Which of the follow ing p ersonality d isord ers
of agranulocytosis. Which of the follow ing
w ou ld m ost likely be com orbid in the above
m ed ications w ou ld be the best choice for his
p atient?
treatm ent?
(A) Avoid ant
(A) Antip sychotic m ed ication
(B) Bord erline
(B) Carbam azep ine
(C) Obsessive-com p u lsive
(C) Divalp roex sod iu m
(D) Schizoid
(D) Lithiu m
(E) Schizotyp al
(E) Lorazep am (Ativan)

205
206 7: Pra c tic e Te s t 1
Questions 5 and 6
A 50-year-old sin gle m an h as in creasin gly becom e
a con cern to his n eigh bors. H e w orks at a com ic-
book store, d resses in od d , ou td ated cloth es, an d
d isp lays p oor eye con tact. Althou gh h e tend s
to keep to him self, h e h as told neighborhood chil-
d ren th at th ere are w itch es w h o live d ow n th e
street.
5. Which of the follow ing is the m ost likely
d iagnosis?
(A) Bipolar d isord er
(B) Bord erline p ersonality d isord er
(C) Schizoid p ersonality d isord er
(D) Schizop hrenia
(E) Schizotyp al p ersonality d isord er
6. The patients brother brings him to a d octor
because, since the d eath of their mother, the
patients paranoia has cau sed him to qu estion
his neighbors activities. H e has since m oved
into a hotel that he could not afford in ord er
to get aw ay from the spies living next d oor.
Which of the follow ing is the most appropriate
intervention?
(A) Antip sychotic
(B) Benzod iazep ine
(C) N o treatm ent
(D) Psychod ynam ic p sychotherapy
(E) Selective serotonin reu p take inhibitor
(SSRI)
Questions 7 and 8
A 25-year-old fem ale college grad u ate is brou ght
to her d octor by her m other. Described as od d
since she lost her job a year ago, the p atient has
com p lained of hearing voices and believes that
her bod y is receiving Wi-Fi com m u nications for a
cou nterterrorist op eration. H er m other notes she
has been isolating herself in her room . She is alert
and oriented bu t su sp iciou s and gu ard ed on exam -
ination. H er affect is flat and her sp eech reveals
loose associations. A com p lete m ed ical w orku p is
negative.
7. Which of the follow ing sym p tom s is consi-
d ered a negative sym ptom in this patients
p resentation?
(A) Au d itory hallu cinations
(B) Delu sions
(C) Flat affect
(D) Loose associations
(E) Paranoia
8. The p atient is started on m ed ication and
m any of her sym p tom s im p rove. She begins
a new job and d oes w ell. One year later, she
is brou ght to her d octor florid ly p sychotic,
actively hearing voices, and extrem ely p ara-
noid . She believes that her boss is trying to kill
her. She has an u p p er respiratory viral illness
that she believes to be the w ork of a foreign
governm ent. She d iscontinu ed her m ed ica-
tion 4 w eeks ago becau se she felt too sed ated .
In the p ast year, her cigarette sm oking habit
has d ecreased to one p ack p er d ay. What is the
m ost likely cau se of her exacerbation?
(A) A reaction to the viral illness
(B) Decreased cigarette sm oking
(C) Med ication noncom p liance
(D) Stress from w ork
(E) Treatm ent refractory illness
Questions 9 and 10
A 44-year-old man complains to his doctor that he is
alw ays tired and is having d ifficulty getting out of
bed in the morning. Upon questioning, he reveals he
has three or four d rinks each night and perhaps more
on the w eekend s, but d enies he has any problem w ith
alcohol. A d iagnosis of alcohol use d isord er is mad e
and the patient comes to your office in acute alcohol
w ithd raw al. He subsequently has a w ithd raw al sei-
zure and is ad mitted to the intensive care unit.
9. Which of the follow ing laboratory find ings
w ou ld be m ost likely fou nd in this p atient?
(A) Decreased p rothrom bin tim e
(B) Elevated or d ep ressed liver enzym es
(C) H igh blood -alcohol level
(D) H yp erm agnesem ia
(E) Throm bocytosis
 Que s tions : 514 207

10. Which of the follow ing m ed ications w ou ld be to w orsening d epressive sym ptom s and acute sui-
m ost im portant to ad m inister? cid ality. She has had m u ltiple trials of m ed ications
w ithou t significant im p rovem ent. A cou rse of elec-
(A) Diazepam
troconvulsive therap y (ECT) is d eterm ined to be the
(B) H alop erid ol next ap p ropriate step.
(C) Lorazep am
(D) Phenytoin 12. While u nd ergoing the ECT, the treatm ent
(E) Valp roic acid team w ishes to m onitor im provem ent in her
d epression. Which of the follow ing tests has
11. A 28-year-old woman is brought to the emer- the greatest reliability and valid ity for this
gency department for active suicidal ideation p u rp ose?
with a plan to overdose on acetaminophen. (A) Beck Dep ression Inventory
She has no history of a psychiatric illness but
(B) Draw -A-Person Test
endorses many criteria for major depressive
disorder (MDD), including poor sleep for the (C) H alstead -Reitan N eu rop sychological
past 2 weeks. She recently lost her job and Battery
fears that she may not be able to pay her rent. (D) Rorschach Test
Attempts to obtain collateral information have (E) Them atic Ap p ercep tion Test (TAT)
been unsuccessful. You believe the patient
requires inpatient evaluation but her insurance 13. After one of her treatm ents, the p atient com -
company denies authorization for inpatient p laints of m em ory im p airm ent. Which of the
care, alternatively authorizing eight outpatient follow ing tests w ou ld be the m ost ap p rop riate
visits with a psychiatrist. You speak to the to assess her com plaint?
weekend on-call physician-reviewer and report
(A) Beck Dep ression Inventory
that the patient remains unsafe and wishes to
be discharged. Upon learning that the patient (B) Brow n-Peterson Task
does not have a history of psychiatric illness, the (C) Bu lim ia TestRevised
reviewer fails to authorize inpatient care, despite (D) Eating Disord er Inventory 2 (EDI-2)
your assessment. Which of the following is the (E) State-Trait Anxiety Inventory
most appropriate intervention?
(A) Ad m inister an antipsychotic m ed ication 14. A 67-year-old w oman w ith a history of
and reevalu ate the p atient in 1 hou r. d epression presents to your office for evaluation.
Her symptoms of poor appetite, insomnia,
(B) Ad m it the p atient on an em ergency
low energy, and feelings of hopelessness have
certificate to an inpatient facility.
w orsened recently. She has been on several
(C) Begin antid ep ressant therap y and d ifferent serotonin-specific reuptake inhibitors
arrange for outp atient follow -u p the (SSRIs), w hich you learn have not resulted in
next d ay. complete remission of her symptoms. Which of
(D) Explain to the p atient that her the follow ing med ications w ould be the most
insu rance com p any d id not au thorize appropriate to prescribe?
hosp italization and d ischarge her w ith
follow -u p care. (A) Citalopram
(E) Prescribe a m ed ication to help her (B) Flu voxam ine
sleep, arrange for follow -up care, and (C) Paroxetine
d ischarge her from the hospital. (D) Sertraline
(E) Venlafaxine
Questions 12 and 13

A 34-year-old w om an suffering from severe m ajor

d epressive d isord er is ad m itted to the hospital d u e
208 7: Pra c tic e Te s t 1

Questions 15 and 16 (D) H yp ochond riasis

(E) Panic d isord er
A 29-year-old w om an p resents to the em ergency
d ep artm ent w ith her 3-year-old child reporting that
18. Which of the follow ing m ed ications is the m ost
the child suffered a seizu re w hile at hom e. H ospi-
efficaciou s in the treatm ent of this illness?
tal record s verify that this is the third em ergency
d ep artm ent visit in as m any w eeks for the sam e (A) Clonid ine (Catap res)
p resentation. N eu rologic w orku p for seizu re d is- (B) H alop erid ol
ord er w as negative. Initiation of an anticonvu lsant (C) Lithiu m
has been ineffective. The m other becom es very fru s-
(D) Prop ranolol
trated , d em and ing that her son be ad m itted to the
hosp ital for further testing. (E) Sertraline (Zoloft)

15. Based on the above p resentation, w hich of 19. A w om an being treated for m ajor d ep ression
the follow ing d iagnoses is m ost likely in the is brou ght to the em ergency d ep artm ent after
child ? being fou nd u nconsciou s by a neighbor. The
neighbor states that over the p ast few d ays
(A) Conversion d isord er the w om an had been com plaining of severe
(B) Factitiou s d isord er head aches. She also m entions that the w om an
(C) N o d iagnosis often enjoys red w ine. The w om ans blood
(D) Seizu re d isord er pressu re is record ed as 220/ 110 m m H g.
Which of the follow ing shou ld be ad m inistered
(E) Sep aration anxiety d isord er
im m ed iately?
16. The m other is ad d itionally m ost likely to su f- (A) Alp ha-blocker
fer from w hich of the follow ing? (B) Beta-blocker
(A) Bipolar d isord er (C) Brom ocrip tine (Parlod el)
(B) Ep ilep sy (D) Calciu m channel blocker
(C) Major d ep ressive d isord er (E) Dantrolene sod iu m (Dantriu m )
(D) Posttrau m atic stress d isord er (PTSD)
Questions 20 and 21
(E) Schizop hrenia
A 38-year-old m an w ith schizop hrenia has had
Questions 17 and 18 nu m erou s hosp italizations and m any trials w ith
variou s antip sychotic m ed ications. H e continues to
A 26-year-old m an is being evalu ated in the em er-
be sym p tom atic, w ith d erogatory au d itory hallu ci-
gency d ep artm ent for su d d en onset of chest p res-
nations, p aranoia regard ing his neighbors, and poor
sure and d yspnea. This is his third em ergency
self-care. H e d enies su icid al or hom icid al id eation.
d ep artm ent visit for sim ilar sym p tom s for w hich he
H e has recently been started on clozap ine (Clozaril),
rep orts I feel like Im going to d ie. An electrocar-
w ith significant im p rovem ent in his cond ition. H e
d iogram (ECG) and stress test w ere norm al. Urine
d oes not d rink alcohol or u se illicit d rugs, and he
toxicology w as negative. The p atient d enies risk
d enies ad d itional m ed ical history.
factors for heart d isease and d oes not have a fam ily
history of heart d isease.
20. Which of the follow ing ad verse effects is
associated w ith this m ed ication?
17. Which of the follow ing is the m ost likely
d iagnosis? (A) Brad ycard ia
(A) Acu te m yocard ial infarction (B) Galactorrhea
(B) Acu te stress d isord er (C) H yp ertension
(C) Deliriu m (D) Seizu res
(E) Weight loss

21. Which of the follow ing blood tests w ill requ ire
frequ ent, regu lar m onitoring for this p atient?
(A) Calciu m level
(B) Com p lete blood cou nt w ith d ifferential
(C) Electrolytes
(D) Thyroid fu nction tests
(E) Urinalysis
Questions 22 and 23
You ad m it an 83-year-old w id ow ed fem ale for
fu rther evalu ation as she is no longer able to care
for herself at hom e. She has lost 30 lb in the p ast
year, has p oor hygiene, and ad m its to increasing
forgetfulness.
22. Which of the follow ing tests w ou ld best help
to m ake the correct d iagnosis?
(A) Blessed Rating Scale
(B) Folstein Mini-Mental State Exam ination
(MMSE)
(C) Geriatric Rating Scale
(D) Glasgow Com a Scale
(E) Mental Statu s Exam ination (MSE)
23. Which of the follow ing d isord ers w ou ld be
m ost im p ortant to ru le ou t as a cau se of her
clinical p resentation?
(A) Generalized anxiety d isord er
(B) Major d ep ressive d isord er
(C) Obsessive-com p u lsive d isord er
(D) Panic d isord er
(E) Posttrau m atic stress d isord er
24. A 35-year-old patient is encou raged to seek
p rofessional help by his cow orkers. H e
d enies pervasive d epression or anxiety, bu t
u pon interview he is od d ly d ressed , expresses
u nu sual beliefs and thinking, som e paranoia
regard ing his cow orkers m otivations, and
has few close friend s. H e d enies d elu sions
or hallu cinations, and there is no su icid al or
hom icid al id eation. Which of the follow ing
d iagnoses is the m ost appropriate to consid er?
(A) Avoid ant p ersonality d isord er
(B) N arcissistic p ersonality d isord er
Que s tions : 1527 209
(C) Paranoid p ersonality d isord er
(D) Schizoid p ersonality d isord er
(E) Schizotyp al p ersonality d isord er
25. A 28-year-old sep arated w om an is referred
from her p rim ary care d octor for evalu ation
for d ep ression. While she ad m its to occasional
p eriod s of d ysp horia, she claim s to alw ays
feel em p ty insid e. Up on fu rther qu estion-
ing she d em onstrates a p ervasive p attern
of u nstable relationship s, p oor self-im age,
im p u lsiveness, and irritability. Which of the
follow ing d iagnoses is the m ost ap p rop riate
to consid er?
(A) Antisocial p ersonality d isord er
(B) Bord erline p ersonality d isord er
(C) Dep end ent p ersonality d isord er
(D) H istrionic p ersonality d isord er
(E) Schizoid p ersonality d isord er
Questions 26 and 27
A 28-year-old single m an w ith a 10-year history of
schizophrenia has been taking his m ed ications reg-
u larly. H e now p resents w ith w orsening hallucina-
tions and prom inent thought d isorganization.
26. Which of the follow ing neu rop sychological
tests w ou ld best d eterm ine his ability to
organize and correctly p rocess inform ation?
(A) Bend er Gestalt Test
(B) Draw -A-Person Test
(C) Lu ria-N ebraska N eu rop sychological
Battery
(D) Mini-Mental State Exam ination
(E) Wisconsin Card Sorting Test (WCST)
27. The above test m easu res fu nctioning at w hich
of the follow ing lobes of the brain?
(A) Cerebellar
(B) Frontal
(C) Occip ital
(D) Parietal
(E) Tem p oral
210 7: Pra c tic e Te s t 1

Questions 28 and 29 31. The p atient retu rns 1 m onth later for a follow -
u p exam ination and rep orts th at he exp e-
A 30-year-old w om an w ithout prior p sychiatric his- rienced a gen eralized seizu re. Laboratory
tory is brought to the em ergency d epartm ent by the investigation reveals that the p henytoin level
p olice after being arrested for breach of the p eace. is 6.5 m g/ d L (norm al, 1020 m g/ d L). Which
The w om an w as observed acting irrationally at a of the follow ing is the m ost ap p rop riate
local bu siness w here she d em and ed to sp eak w ith intervention at this tim e?
the presid ent of the com p any claim ing that she had
new id eas for prod u ct d evelopm ent. The patient (A) Ad d a benzod iazep ine.
rep orts that she has not slep t for d ays and that (B) Ad d p henobarbital.
her m ood is fabulou s. Urine hum an chorionic (C) Assess com p liance.
gonad otrop in is p ositive. Illicit su bstances w ere not (D) Discontinu e p henytoin and begin
d etected . d ivalproex sod ium .
(E) Increase the p henytoin d ose.
28. Which of the follow ing ad d itional find ings
w ou ld m ost likely be p resent in her history or
32. A 24-year-old w om an w ith a history of
m ental status exam ination (MSE)?
schizophrenia tells you that she w ou ld like
(A) Daytim e sleepiness to becom e p regnant. H er husband has no
(B) Dep ressed affect history of m ental illness. What d o you tell
(C) Racing thou ghts her is the chance of her offsp ring d evelop ing
schizophrenia?
(D) Visu al hallu cinations
(E) Weight loss (A) 1%
(B) 2%
29. Which of the follow ing m ed ical d isord ers can (C) 5%
also present w ith sim ilar sym ptom s? (D) 8%
(A) Cirrhosis (E) 12%
(B) Diabetes m ellitu s
(C) H yp erglycem ia 33. A 28-year-old m arried fem ale p atient is ad m it-
ted to the hospital w ith bizarre behavior and
(D) Rheu m atoid arthritis
d isorganized thinking. Consid eration is given
(E) Thyroid d isord er to a d iagnosis of schizophreniform d isor-
d er. To help w ith the d iagnosis, the patient is
Questions 30 and 31 ad m inistered a test that consists of view ing a
A 24-year-old m an w ith a history of seizu re d is- set of 10 inkblots sequ entially. The exam iner
ord er, alcohol, and cocaine u se d isord er has been scores the patients responses to the blots by
incarcerated for assau ltive behavior. The p atient is noting the content of the p ercep tion, the area
evaluated by a neurologist, who prescribes phenytoin of the blot that form s the basis of the response,
(Dilantin). and the asp ects of the area that are u sed to
form the resp onse.
30. Which of the follow ing sid e effects is m ost In w hich of the follow ing classes d oes this
likely associated w ith this m ed ication? projective test belong?

(A) Ebstein anom aly (A) Associations

(B) Gingival hyp erp lasia (B) Choice of ord ering
(C) H ep atic failu re (C) Com p letions
(D) H yp ertension (D) Constru ctions
(E) Leu kocytosis (E) Self-exp ression
 Que s tions : 2839 211

34. A m other and her 17-year-old son p resent to 36. An 89-year-old m arried w om an w ith no p rior
you r p sychiatric clinic seeking fam ily therap y. p sychiatric history bu t a history of m u ltiple
The m other rep orts that she and her son have m ed ical p roblem s is ad m itted for failu re to
a tum ultu ou s relationship and are constantly thrive. Upon history, the patient d oes not seem
argu ing w ith each other. The son ad m its that acclim ated to her su rrou nd ings. Which of the
abou t a year ago he d isclosed to his m other follow ing tests w ou ld best help to d eterm ine
that he is gay. H e feels that because of his her level of confu sion?
m other s strong religiou s beliefs, she has not
(A) Fargo Map Test
accep ted his sexu ality and this has been the
sou rce of tension in their relationship. The (B) Sp atial Orientation Mem ory Test
m other firm ly believes that her son is ju st (C) Stroop Test
confu sed and need s cou nseling. She has (D) Tem p oral Orientation Test
heard of a particular therapy that can change (E) Wisconsin Card Sorting Test
the sexu al orientation of an ind ivid u al and
asks that you cond u ct this on her son. Which 37. A Malaysian m an is brou ght into cu stod y by
of the follow ing is the appropriate next step? the police after m u rd ering his friend . While
(A) Ask the son if he is w illing to p u rsu e he d oes not rem em ber com m itting the act, he
this treatm ent. d oes recall being insu lted by him at an earlier
tim e. Which of the follow ing cond itions is
(B) Engage the son in this therap y based off
m ost associated w ith this presentation?
on w hat you know .
(C) Inform the m other that su ch therap y is (A) Am ok
u nethical. (B) Dhat
(D) Learn m ore abou t the treatm ent first (C) Ganser synd rom e
and ask the fam ily to retu rn w hen you (D) Koro
are know led ge able enou gh to cond u ct (E) Latah
this.
(E) Refer the fam ily to a therap ist w ho Questions 38 and 39
specializes in such treatm ents.
A 26-year-old w oman is d iagnosed w ith schizophre-
35. An 18-year-old m an is referred to his college nia. The psychiatrist d ecid es to treat her symptom s
counseling center d ue to failing grad es. It is w ith a high-potency antipsychotic med ication. While
d eterm ined that he has stop ped attend ing her symptom s appear to improve on the med ication,
classes, preferring to rem ain in his d orm room . she d evelops acu te, painfu l muscle spasm s of her
H is room m ates claim that he stays u p all jaw .
night, w ith little ap parent sleep. The p atient
claim s that he has d iscovered som ething that 38. Which of the follow ing m ed ications shou ld be
w ill m ake him a m illionaire. On m ental sta- ad d ed ?
tu s exam ination, he app ears d iap horetic w ith (A) Benztrop ine (Cogentin)
p sychom otor agitation. H is speech is rap id (B) Cholinergic agonist
and his affect is eu phoric. H e d enies su icid al
(C) Clozap ine
or hom icid al id eation but d isp lays significant
grand iosity. H is insight is p oor. Which of the (D) Methylp henid ate (Ritalin)
follow ing is the m ost likely d iagnosis? (E) Risp erid one (Risp erd al)

(A) Cannabis intoxication 39. Despite compliance with the above regimen, the
(B) Cocaine (stim u lant) intoxication patient continues to suffer with extrapyrami-
(C) MDD w ith p sychotic featu res dal symptoms. As a result of this, she abruptly
(D) Schizoaffective d isord er stops taking her antipsychotic medication. It is
(E) Schizop hrenia decided to switch to another medication. Which
212 7: Pra c tic e Te s t 1
of the following medications would be the most
appropriate choice?
(A) H alop erid ol
(B) Loxapine (Loxitane)
(C) Perp henazine (Trilafon)
(D) Pim ozid e (Orap )
(E) Qu etiapine
Questions 40 and 41
A 30-year-old w om an presents w ith a history of
chronic but rapid and intense m ood sw ings, feelings
of em ptiness, low self-esteem , chronic suicid al id e-
ation, as w ell as frequ ent but brief sexu al relation-
ships, anger outbu rsts, and self-m u tilation.
40. Which of the follow ing d isord ers is this p atient
m ost likely to be su ffering from ?
(A) Avoid ant p ersonality d isord er
(B) Bipolar d isord er
(C) Bord erline p ersonality d isord er
(D) Depend ent personality d isord er
(E) N arcissistic personality d isord er
41. The above p atient is referred for d ialectical
behavioral therapy (DBT). Which of the fol-
low ing techniqu es is the m ost im portant in
her therapy?
(A) Aversion
(B) Eye-m ovem ent d esensitization and
rep rocessing (EMDR)
(C) Flood ing
(D) H om ew ork
(E) System atic d esensitization
42. A 21-year-old man presents w ith a 7-month
history of bizarre behavior, paranoid delusions,
and auditory hallucinations that comment on
his appearance. After a thorou gh evaluation,
you d iagnose him w ith schizophrenia and
prescribe haloperid ol 5 m g bid . One w eek later,
the patient retu rns for a follow -up exam ination
and reports that, althou gh his symptom s
have imp roved , he now experiences mu scle
stiffness in his arms and neck. You p rescribe
benztropine 1 mg bid and sched ule a follow -up
ap pointment in 2 w eeks. One w eek later, the
patients mother calls you and reports that her
son is more agitated and confused. Physical
examination reveals tachycardia, dilated pupils,
and flushed skin. Which of the following would
be the most appropriate next step?
(A) Discontinu e benztropine and p rescribe
am antad ine (Sym m etrel).
(B) Increase haloperid ol to 5 m g tid .
(C) Increase benztropine to 2 m g bid .
(D) Discontinu e halop erid ol and p rescribe
risp erid one.
(E) Prescribe lorazep am 1 m g bid .
Questions 43 and 44
A 25-year-old single w om an w ho carries the p rovi-
sional d iagnosis of d epend ent personality d isord er
is referred for p sychological testing. You d ecid e to
ad m inister the Rorschach.
43. Which of the follow ing asp ects of this typ e
of psychological testing w ou ld be the m ost
im p ortant in this case?
(A) Ask sp ecific qu estions w ith item ized
resp onses.
(B) Determ ine how a p atient feels abou t
you .
(C) Lack of stru ctu re allow s for a variety of
resp onses.
(D) Provid e nu m erical scores.
(E) Resu lts allow for easy statistical
analysis.
44. You ad d itionally d ecid e to ad m inister the
Minnesota Mu ltiphasic Personality Inventory
2 (MMPI-2). Which of the follow ing aspects of
this typ e of p sychological testing w ould be the
m ost im portant in this case?
(A) Assesses test-taking attitud es.
(B) Instru ctions are u nam bigu ou s in natu re.
(C) Item s d esigned to sep arate norm al
subjects from those w ith psychiatric
illness.
(D) More sensitive in p icking u p gend er-
specific issu es.
(E) Most researched and w ith norm ative
d ata.

45. A 28-year-old m ale m ed ical stu d ent is fou nd
to have an enlarged testicle d u ring a rou tine
p hysical exam ination. The stu d ent reports
that it has been grad ually enlarging for several
m onths. The physician asks w hy he d id not
report these find ings earlier. Im su re its
nothing, the stud ent replies. Which of the
follow ing typ es of resp onses d oes this m ost
likely rep resent?
(A) Confid ence
(B) Denial
(C) Rationalization
(D) Repression
(E) Su p p ression
46. A 45-year-old Asian-Am erican w om an is
brou ght to the em ergency d ep artm ent by her
hu sband , w ho rep orts that for the past 3 d ays
his w ife has not been sleeping w ell, has been
experiencing bad d ream s, and ap pears in a
d aze w ith a sense of feeling nu m b. The
patient end orses feeling anxiou s bu t d oes not
know w hy. She has been u nable to p erform
her u su al activities of d aily living, poorly con-
centrating on tasks and frequently ju m p ing
w hen startled . One w eek ago, the p atient w as
d ischarged from the hosp ital after exp erienc-
ing an anap hylactic reaction to IV contrast d ye
w hile u nd ergoing an im aging p roced u re for
sinusitis. Althou gh she cannot recall specifics,
her husband verifies the history, ad d ing that
the d octors thought she w as going to d ie.
Upon retu rning to the hosp ital, she exp eri-
ences intense fear abou t revisiting the sam e
hospital from w hich she w as recently d is-
charged . Which of the follow ing is the m ost
app rop riate d iagnosis?
(A) Acu te stress d isord er
(B) Ad ju stm ent d isord er
(C) Generalized anxiety d isord er (GAD)
(D) Major d ep ressive d isord er (MDD)
(E) Posttrau m atic stress d isord er (PTSD)
47. A 40-year-old w om an w ithou t p ast p sychiatric
history is ad m itted to the hospital for the treat-
m ent of d epression. Du ring m orning rou nd s,
the patient appears unresp onsive and d oes
not, ind eed , respond to verbal stim u li. There
Que s tions : 4049 213
are no signs of trau m a or overd ose. A review
of her chart reveals that the p atient w as w ell
the night before and w ent to sleep w ithou t
incid ent. You d eterm ine that the p atients
u nresponsiveness is psychogenic. Which of
the follow ing find ings is m ost likely to be
ap p arent on her exam ination?
(A) Abnorm al electroencep halogram (EEG)
(B) Cold -caloricind u ced nystagm u s
(C) Decreased resp irations
(D) Elevated tem p eratu re
(E) N onsaccad ic eye m ovem ents
48. A 24-year-old w om an is referred by her fam -
ily p ractice d octor after the Christm as holi-
d ay. She gives a significant history of fatigu e,
w eight gain, and hyp erp hagia d u ring the w in-
ter m onths. She d escribes a sad m ood , poor
sleep, problem s concentrating, and cant
w ait u ntil her vacation to Florid a. Which of
the follow ing is the m ost likely d iagnosis?
(A) Acu te stress d isord er
(B) Generalized anxiety d isord er
(C) Major d ep ressive d isord er w ith seasonal
p attern
(D) Persistent d ep ressive d isord er
(d ysthym ia)
(E) Su nd ow ning synd rom e
49. A 27-year-old w om an is brou ght to the em er-
gency d ep artm ent by her p arents, w ho rep ort
that their d au ghter is u nable to recall her
nam e. The em ergency d ep artm ent p hysician
rep orts that a com p lete neu rologic w orku p is
w ithin norm al lim its. Collateral inform ation
reveals that the p atient had ep isod es in w hich
she w ould take u nplanned trips, som etim es
for d ays or w eeks, w ithou t notice, and w ou ld
retu rn u nable to recall the ep isod e. A review of
her m ed ical chart notes a p ast history of pos-
sible sexual abu se as a child . Urine toxicology
is negative and she d oes not take any m ed ica-
tions. Which of the follow ing is the m ost likely
d iagnosis?
(A) Deliriu m
(B) Dissociative am nesia w ith d issociative
fu gu e
214 7: Pra c tic e Te s t 1
(C) Major d ep ressive d isord er
(D) Partial com p lex seizu res
(E) Posttrau m atic stress d isord er
Questions 50 and 51
A 20-year-old college stu d ent is referred for testing
to evaluate poor acad em ic perform ance. H e rep orts
that he has alw ays stru ggled to pass his classes
d espite stu d ying for m any hours. H e attend s all of
his lectures and is able to pay attention, yet he d oes
not seem to be able to ad equ ately learn the m aterial.
You susp ect he has a learning d isord er.
50. Which of the follow ing tests w ou ld be the m ost
ap prop riate to help d eterm ine this p atients
p roblem ?
(A) Draw -A-Person Test
(B) Minnesota Mu ltip hasic Personality
Inventory 2 (MMPI-2)
(C) Wechsler Ad u lt Intelligence Scale
Revised (WAIS-R)
(D) Wechsler Intelligence Scale for Child ren
(WISC)
(E) Wechsler Mem ory Test (WMT)
51. Which of the follow ing form u las is used to cal-
cu late the intelligence quotient (IQ)?
(A) Actu al IQ/ theoretical IQ 100
(B) Chronological age/ p erform ance IQ
100
(C) Mental age/ chronological age 100
(D) Mental age/ full-scale IQ 100
(E) Perform ance IQ/ verbal IQ 100
52. A 26-year-old female graduate student reports to
you a 4-week history of a depressed mood that
has caused her significant difficulty in attending
her classes. The patient reports difficulty falling
asleep at night, red uced appetite and weight
loss, poor energy, and passive suicidal ideation.
A careful review of her history reveals that for
the past 2 years she also experienced brief and
distinct periods of an elevated and expansive
mood, a decreased need for sleep, and an
increase in activities, although she was still able
to function adequately. Which of the following
is the most likely diagnosis?
(A) Bip olar I d isord er
(B) Bip olar II d isord er
(C) Cyclothym ic d isord er
(D) Major d ep ressive d isord er
(E) Persistent d ep ressive d isord er
(d ysthym ia)
53. You are asked to evalu ate a 30-year-old m ale
p risoner w ho reports a d ep ressed m ood and
suicid al id eation. Du ring your interview and
m ental statu s exam ination, you note that
the prisoner d oesnt give correct or sp ecific
answ ers, respond ing instead to you r qu es-
tions w ith approxim ate answ ers. Which of the
follow ing is the m ost ap p rop riate d iagnosis?
(A) Cap gras synd rom e
(B) Dissociative am nesia
(C) Ganser synd rom e
(D) Major neu rocognitive d isord er
(d em entia)
(E) Mu nchau sen synd rom e
54. A 75-year-old m an is ad m itted to the hospi-
tal follow ing a serious su icid e attem pt. The
p atient exhibits clinical featu res of d ep res-
sion w ith severe neu rovegetative sym ptom s
and has a p ast history of su icid e attem p ts.
The m ed ical chart reveals that he is p rescribed
levod op a/ carbid op a, atorvastatin, asp irin,
and nifed ip ine for a card iac arrhythm ia. H e
rem ains extrem ely help less and hop eless,
w ith little ap p etite, and ongoing su icid al
id eation w ith several lethal p lans. Which of
the follow ing treatm ents w ou ld be the m ost
ap p rop riate?
(A) Diazep am (Valiu m )
(B) Electroconvu lsive therap y (ECT)
(C) N ortrip tyline (Pam elor)
(D) Risp erid one
(E) Su p p ortive p sychotherap y
55. A 38-year-old w om an presents to your office
w ith an 8-w eek history of sym ptom s of
d ep ressed m ood w ith an increased appetite
and 10-lb w eight gain, hyp ersom nia, a heavy
feeling in her bod y, and rejection sensitivity.
Up on fu rther qu estioning she ad m its to being

able to brighten w hen sp end ing tim e in activi-
ties she u sually enjoys. She rep orts to you that
she recently enrolled in grad uate school and
is having trou ble w ith m any of her classes.
Which of the follow ing d iagnoses is the m ost
likely?
(A) Ad ju stm ent d isord er
(B) Major d epression w ith atypical features
(C) Major d ep ression w ith m elancholic
featu res
(D) Persistent d epressive d isord er
(d ysthym ia)
(E) Sleep d isord er
56. A 33-year-old m an changes his first nam e
to honor a m u sician w hom he id olizes. H e
recently bou ght the sam e gu itar as the m u si-
cian and form ed a rock band to play his m usic.
Du ring p ractice, the m an d resses like his id ol.
Which of the follow ing d efense m echanism s
d oes this behavior best rep resent?
(A) Fixation
(B) Id ealization
(C) Id entification
(D) Projection
(E) Regression
57. A 60-year-old m an w ith schizop hrenia sits
m otionless in his chair. The patient is m u te and
reacts very little to his environm ent. H is eyes
ap pear fixated on a d istant object. At tim es,
he assum es bizarre postu res and im itates the
m ovem ents of others. Which of the follow ing
is the best d escrip tion of his behavior?
(A) Absence seizu re
(B) Catalep sy
(C) Catap lexy
(D) Catatonia
(E) Partial com plex seizu re
58. A 37-year-old m arried m ale presents w ith a
history of m ultiple d epressive ep isod es. For
the past 5 w eeks he has felt sad , w ith crying
spells, term inal insom nia, low energy, but
increased ap p etite and w eight gain. H e has
had passive su icid al id eation of w anting to
Que s tions : 5060 215
d ie bu t d enies any plan or intent. Upon d is-
cussion w ith the w ife present, they both con-
firm a p ast episod e w here for several w eeks
last year he w as u p , w ith increased energy,
little sleep , w anting to have sex several tim es
p er d ay, talking fast, gam bling a large su m of
m oney, and attem pting to rem od el the hom e
d esp ite having no experience. H e d enies
hallu cinations or p aranoia. H e occasionally
d rinks one to tw o glasses of w ine on w eek-
end s and d enies any illicit d ru g u se. H e has
not been taking any m ed ications recently as
he thou ght he cou ld tou gh it ou t. Which of
the follow ing m ed ications w ou ld likely be the
m ost ap p rop riate to begin?
(A) H alop erid ol
(B) Lam otrigine
(C) Lithiu m
(D) Sertraline
(E) Valproic acid
Questions 59 and 60
A 42-year-old healthy m an is u nd ergoing a lot of
stress at his w ork. As a result, he is having a d if-
ficu lt tim e falling and staying asleep . H is p rim ary
care d octor has since p rescribed him a m ed ication
to help w ith his insom nia. While he is sleep ing bet-
ter, he calls one m orning several w eeks later w ith
com plaints of a very painfu l penile erection w hich
has lasted throu ghout the evening.
59. Which of the follow ing m ed ications has m ost
likely been p rescribed ?
(A) Flu oxetine (Prozac)
(B) N ortrip tyline (Pam elor)
(C) Paroxetine (Paxil)
(D) Sertraline (Zoloft)
(E) Trazod one (Desyrel)
60. Which of the follow ing is the m ost ap propri-
ate next step ?
(A) Tell him to d ecrease the d ose.
(B) Tell him to stop the m ed ication and
restart in 3 d ays.
(C) Tell him to stop the m ed ication and
m onitor his cond ition.
216 7: Pra c tic e Te s t 1

(D) Tell him to stop the m ed ication and go d ischarge, she is still exp eriencing significant p ain.
im m ed iately to the em ergency room . She has no other m ed ical problem s or allergies. She
(E) Tell him to stop the m ed ication and is cu rrently taking oral contracep tives and a m ono-
have sexual intercourse or m asturbate. am ine oxid ase inhibitor (MAOI) for her d epression.

Questions 61 and 62 63. Which of the follow ing analgesics shou ld be

m ost avoid ed in this p atient?
A 66-year-old man reports a history of excessive
w orry about his d aughter since she moved aw ay (A) Acetam inophen
from the area 1 year ago. H is w ife of 43 years verifies (B) Cod eine
his complaint, ad d ing he w orries about everything. (C) Ibu p rofen
Recently, his w ife mad e plans to travel abroad to (D) Mep erid ine
visit friend s. The patient is u nable to accomp any his (E) Oxycod one
w ife because of chronic obstructive pulmonary d is-
ease cau sed by years of heavy smoking and is very 64. Tw o m onths later the patient retu rns for a fol-
anxious about her leaving. H e reports su bsequent low -u p visit and rep orts that she is p regnant.
d ifficulty falling asleep, excessive d aytim e fatigue, Which of the follow ing interventions is the
and trou ble concentrating at w ork. m ost app rop riate?

61. Which of the follow ing m ed ications w ou ld be (A) Continu e the MAOI.
the m ost ap propriate to treat his sym p tom s? (B) Discontinu e the MAOI.
(A) Alprazolam (Xanax) (C) Discontinu e the MAOI and initiate
treatm ent w ith flu oxetine after 2 w eeks.
(B) Busp irone (Bu Spar)
(D) Discontinu e the MAOI d u ring the first
(C) Diazep am (Valiu m )
trim ester only.
(D) Lorazep am (Ativan)
(E) Discontinu e the MAOI and begin
(E) Propranolol (Ind eral) m aintenance ECT.

62. Several w eeks later, the patient rep orts that 65. A 62-year-old hom eless m an p resents to
the m ed ication you prescribed has helped the em ergency d epartm ent w ith confu sion,
everything bu t his d ifficu lty falling asleep . H e agitation, im p aired gait, and nystagm u s. H is
rep orts that d u ring the p ast w eek he has slep t vital signs are stable and an ophthalm ologic
only 4 hours p er night. After carefu l consid er- exam ination is w ithin norm al lim its. The
ation, you d ecid e to begin a trial of a 1-w eek p atient is u nable to recall the d ate and has
su pply of m ed ication to help his insom nia. d ifficu lty su staining attention. Which of
Which of the follow ing m ed ications w ou ld be the follow ing is the m ost appropriate initial
the m ost app rop riate to prescribe? intervention?
(A) Diphenhyd ram ine (Benad ryl) (A) Ad m inister IV d extrose.
(B) Lorazepam (Ativan) (B) Ad m inister p arenteral thiam ine.
(C) Oxazep am (Serax) (C) Obtain a com p u ted tom ograp hic scan of
(D) Tem azep am (Restoril) the brain.
(E) Zaleplon (Sonata) (D) Perform a breathalyzer.
(E) Perform a lu m bar p u nctu re.
Questions 63 and 64

A 25-year-old w om an w ith a history of m ajor 66. You are a community psychiatrist who is seeing
d epressive d isord er, single episod e, in rem ission is a patient for the first time. The patient informs
ad m itted to the hosp ital for rem oval of a fibroid . H er that he has ju st m oved into the area and
p roced u re is com pleted w ithout d ifficu lty, but u p on need s to establish him self w ith a p sychiatrist
 Que s tions : 6171 217

to continue his treatm ent for d ep ression and
anxiety. On fu rther evalu ation, you learn that
he w as previou sly arrested for child p ornog-
rap hy and served several years in p rison. H e
is cu rrently in therap y to ad d ress this issu e.
You are su rp rised to find that after the d isclo-
sure, you feel angry tow ard the patient as you
have tw o you ng d au ghters of you r ow n. You
are concerned abou t w hether it m ay be d iffi-
cult for you to treat the patient in an u nbiased ,
nonjud gm ental m anner becau se of his crim i-
nal history. Which of the follow ing is the next
m ost ap prop riate step ?
(A) Continu e to see the patient bu t lim it the
tim e spent w ith him .
(B) Im m ed iately refer the patient to another
p hysician in you r clinic.
(C) Inform the p atient that you are u nable
to see him and refer him back to the
com m unity.
(D) Obtain the patients therap y record s so
that you are aw are of his progress.
(E) Seek a consu ltation w ith an exp erienced
colleague regard ing you r feelings
tow ard the p atient.
67. A 39-year-old execu tive w ithout p sychiatric
history bu t a history of hyp ertension rep orts
d rinking up to six cu ps of caffeinated coffee
p er d ay. H e board s a p lane sched u led for an
18-hou r flight on w hich only d ecaffeinated
beverages are served . Which of the follow ing
sym ptom s is he m ost likely to experience?
(A) Depressed m ood
(B) H ead ache
(C) Irritability
(D) Mu scle cram p ing
(E) N au sea
Questions 68 and 69
A 25-year-old m an w ith a history of schizophrenia
p resents to the em ergency d ep artm ent w ith severe
m u scle stiffness and an elevated tem p eratu re. H is
casew orker claim s that he is com pliant w ith his
m ed ications and d enies that he u ses alcohol or
d rugs. H is vital signs d em onstrate elevated tem -
p erature, blood p ressu re, and p u lse. The p atient
ap p ears confu sed and is d iap horetic. A u rine toxi-
cology screen is negative.
68. Which of the follow ing is the m ost im portant
intervention?
(A) Ad m inister brom ocrip tine.
(B) Ad m inister IV d antrolene sod iu m .
(C) Ad m inister naloxone (N arcan).
(D) Ap p ly cooling blankets.
(E) Discontinu e m ed ications.
69. Which of the follow ing laboratory abnorm ali-
ties is m ost likely to be p resent in this patient?
(A) Anem ia
(B) Decreased transam inases
(C) Elevated blood u rea nitrogen (BUN )
(D) Elevated creatine p hosphokinase (CPK)
(E) Leu kop enia
70. An 18-year-old m an is brou ght to th e
emergency department by the paramedics after
being involved in a motor vehicle accident. His
medical chart reports a history of substance use.
Which of the following tests can most likely
confirm the diagnosis of chronic substance use
with physical dependence?
(A) Breath analysis
(B) Elevated heart rate
(C) N aloxone injection
(D) Seru m liver function stu d ies
(E) Urine toxicology screen
71. A 72-year-old man without prior psychiatric
history presents to the outpatient clinic with a
recent history of memory difficulty. The patient
has had a stable level of consciousness and
denies any current or past substance use. He has
not been prescribed any new medications. The
medical chart reveals a history of megaloblastic
anemia and a subtotal gastrectomy for severe
peptic ulcer disease. Which of the following ini-
tial interventions is the most appropriate?
(A) Discu ss long-term extend ed -care facility
ad m ission.
(B) Obtain a forensic exam ination to
evalu ate com p etency.
218 7: Pra c tic e Te s t 1
(C) Obtain a neu rologic consu lt.
(D) Ord er a m agnetic resonance im aging
scan of the brain.
(E) Ord er a thorou gh laboratory w orku p .
72. A 37-year-old w om an presents to the em er-
gency d ep artm ent com p laining of severe d iar-
rhea, nau sea, and a coarse trem or. The m ed ical
chart notes a history of bip olar I d isord er.
Which of the follow ing w ou ld be the m ost
ap prop riate initial intervention?
(A) Obtain renal fu nction stu d ies.
(B) Obtain a seru m m ed ication level.
(C) Obtain a u rine p regnancy test.
(D) Obtain a u rine toxicology screen.
(E) Prescribe antid iarrheal m ed ication.
Questions 73 and 74
A 72-year-old m an is brou ght into the em ergency
room via am bu lance after su ffering w hat is su s-
pected to be a stroke in his right p arietal region.
73. Which of the follow ing areas w ould be m ost
likely to have d eficits d u e to the stroke?
(A) Long-term im plicit m em ory
(B) Long-term p roced u ral m em ory
(C) Tactile m em ory
(D) Verbal m em ory
(E) Visu al nonverbal m em ory
74. Which of the follow ing tests w ould best id en-
tify the abnorm ality in that region?
(A) Minnesota Mu ltip hasic Personality
Inventory 2
(B) ReyOsterrieth Test
(C) Rorschach Test
(D) Wechsler Intelligence Scales
(E) Wisconsin Card Sorting Test
75. A 32-year-old m arried m an is d iagnosed w ith
bip olar I d isord er. Variou s treatm ent op tions
are d iscussed , and he agrees to begin lithiu m
carbonate to treat his sym ptom s of m ania.
Which of the follow ing tests is the m ost
im p ortant to ord er p rior to initiating treatm ent
w ith lithiu m ?
(A) BUN and creatinine
(B) CBC
(C) ECG
(D) Liver fu nction stu d ies
(E) Thyroid -stim u lating horm one
76. A 27-year-old w om an has been prescribed
flu oxetine for d ep ression for the p ast year. She
com es to you com plaining of m ed ication sid e
effects and w ishes to d iscontinu e her antid e-
p ressant. As her p hysician, you d iscu ss w ith
her the ap p rop riate risks and benefits, and
you d iscontinu e her treatm ent. Tw o w eeks
later, she retu rns com p laining of d ep ressive
sym p tom s characterized by sleep and appetite
changes, poor concentration, and a d epressed
m ood for m ost of the d ay. You d eterm ine that
she is experiencing a recurrent m ajor d ep res-
sive episod e and d ecid e to prescribe her a
d ifferent class of m ed ication to treat her sym p -
tom s. After d iscussing the appropriate precau -
tions w ith her, you prescribe an MAOI. Within
1 w eek, she begins exp eriencing irritability,
abd om inal pain and d iarrhea, and au tonom ic
instability characterized by hyp ertension and
tachycard ia. H er tem p eratu re is 103.5F. The
p atient also rep orts exp eriencing jerking of
her m uscles and vivid visu al hallucinations
of colorfu l flow ers spinning tow ard the sky.
She states that she has follow ed your d irec-
tions carefu lly w hile taking this m ed ication.
Which of the follow ing cond itions m ost likely
accou nt for this p resentation?
(A) H allu cinogen intoxication
(B) Malignant hyp ertherm ia
(C) N eu rolep tic m alignant synd rom e (N MS)
(D) Serotonin synd rom e
(E) Tyram ine-ind u ced hyp ertensive crisis
Questions 77 and 78
A 17-year-old girl is referred to the school nu rse for
frequ ent ep isod es of vom iting in the bathroom d u r-
ing lu nch breaks. H er friend s rep ort that, d esp ite
alw ays talking abou t w anting to lose w eight, she
eats tw ice as m u ch as anybod y else. The p arents
are called to the school and recall that a recent bill
from their charge accou nt at the local p harm acy
 Que s tions : 7282 219

ind icated a large nu m ber of laxative p u rchases. The 80. Which of the follow ing com p lications w ou ld
girl rep orts that her m ood is fine, and her record s be the m ost likely in this p atient?
at school ind icate that she is an above-average
(A) Diarrhea
stu d ent.
(B) H eat intolerance
77. Which of the follow ing m ed ical com p lications (C) Leu kocytosis
w ou ld be m ost likely in this p atient? (D) Menorrhagia
(A) Acid osis (E) Osteop orosis
(B) Dental carries
81. Which of the follow ing w ou ld be the m ost
(C) Diarrhea likely p red iction of a good ou tcom e in this
(D) H yp erkalem ia patient?
(E) H yp erchlorem ia
(A) 10%
78. Which of the follow ing m ed ications w ou ld be (B) 20%
the m ost ap propriate initial treatm ent for her (C) 50%
sym p tom s? (D) 75%
(A) Bu propion (E) 90%
(B) Citalop ram
Questions 82 and 83
(C) Lithiu m
(D) Risp erid one A 70-year-old w om an rep orts a d ep ressed m ood
(E) Valp roic acid an d insom n ia 1 m on th follow in g th e d eath of
her h u sban d . Im m ed iately after h is d eath , sh e
79. A 70-year-old m an w ith m u ltip le m ed ical began to feel th at sh e w ou ld be better off d ead ,
problem s is su sp ected to have had a stroke, alth ou gh d en ies an y active su icid al id eation . For
affecting his ability to speak. Which of the th e first several w eeks sh e h ad a red u ced ap p e-
follow ing tests w ou ld best assess the natu re of tite w ith a several p ou nd w eigh t loss, bu t this h as
his speech d ifficu lty? im p roved . At tim es, sh e believes th at sh e can h ear
his voice calling to her. Sh e d en ies any feelin gs
(A) Bend er Gestalt Test of w orthlessness bu t feels gu ilty abou t n ot bein g
(B) Boston Diagnostic Ap hasia Exam ination able to d o th e right th in gs for h im before h e d ied .
(C) Folstein MMSE Sh e occasionally gets d istracted and forgets that
(D) Sentence Com p letion Test he h as d ied . Sh e is able to brigh ten w hen sp eak-
in g abou t sp en d in g tim e w ith h er gran d ch ild ren .
(E) Stroop Test
Wh en talkin g w ith oth ers, sh e believes th at h er
feelin gs are n orm al.
Questions 80 and 81

A 16-year-old fem ale high school stu d ent is referred
by her parents for an evalu ation. One year prior to
the evalu ation, the girl began restricting her food
intake and started a rigorou s exercise program to
im prove her appearance. Aspiring to be a m od el,
the girl lost 25 lb bu t rem ained preoccu pied w ith her
app earance d espite w eighing only 85 lb. H er friend s
rep orted that she constantly referred to herself as
being fat and d id not seem interested in d ating.
The girl continu ed to lose w eight and w as relu ctant
to d iscu ss her cond ition.
82. Which of the follow ing is the m ost likely
d iagnosis?
(A) Ad ju stm ent d isord er w ith d ep ressed
m ood
(B) Bereavem ent
(C) Major d ep ressive ep isod e
(D) Persistent d ep ressive d isord er
(d ysthym ia)
(E) Schizoaffective d isord er
220 7: Pra c tic e Te s t 1

83. Which of the follow ing is the m ost app rop ri- 86. Which of the follow ing d iagnoses w ou ld be
ate course of action? the m ost likely cause of his sym ptom s?
(A) Ad m ission to a hosp ital. (A) Circad ian rhythm sleep w ake d isord er
(B) Evalu ate for a sleep d isord er. (B) Major d ep ressive d isord er
(C) N o treatm ent. (C) Obstru ctive sleep ap nea hyp op nea
(D) Prescribe antid ep ressant m ed ication. (D) Rap id eye m ovem ent (REM) sleep
(E) Prescribe sed ative-hyp notic m ed ication. behavior d isord er
(E) Restless legs synd rom e
84. A 25-year-old m an rep orts a 5-year history of
excessive hand w ashing and a p reoccu p ation 87. Which of the follow ing is the treatm ent of
w ith feeling clean. The thou ght of contracting choice for his sym ptom s?
an infectiou s d isease p ersists throu ghout the
(A) Antid ep ressant m ed ication
d ay even thou gh he m akes attem p ts to ignore
it. H is cond ition has p rogressively w orsened (B) Benzod iazep ine m ed ication
and has cau sed significant im p airm ent w hile (C) Breathing air u nd er p ositive p ressu re
at w ork and at hom e. Which of the follow ing (D) N asal su rgery
m ed ications w ou ld be the best initial choice to (E) Uvu lop alatop lasty
treat his sym ptom s?
(A) Antid epressant Questions 88 and 89
(B) Antiep ilep tic A 60-year-old m ale p atient w ith schizop hrenia w ho
(C) Antip sychotic has been stable for years on a low -p otency antip sy-
(D) Benzod iazep ine chotic agent begins exp eriencing parkinsonian-like
(E) Lithiu m sid e effects. H is p hysician p rescribes a d ru g to alle-
viate som e of these sid e effects. One w eek later, the
85. A 28-year-old w om an w ith no p sychiatric his- p atient is seen in the em ergency d ep artm ent w ith
tory is arrested for shop lifting. She claim s she d ilated pup ils, d ry m ou th, w arm skin, and tachycar-
d oes not rem em ber d etails of the crim e, and d ia. H e is also exp eriencing the new onset of visu al
that for a w hile she has had trou ble recalling hallu cinations.
d etails from things shes recently read . You are
called to assess her, bu t w ant to ensure shell 88. Which of the follow ing w ou ld be the m ost
give good effort on testing. Which of the fol- ap p rop riate m ed ication to ad m inister?
low ing tests w ou ld be the m ost ap p rop riate to (A) Anticholinesterase
ad m inister? (B) Atrop ine
(A) Benton Visu al Retention Test (C) Benzod iazep ine
(B) Clock Draw ing (D) Dantrolene sod iu m
(C) Test of Mem ory Malingering (E) H alop erid ol
(D) Wechsler Intelligence Scale
(E) Wisconsin Card Sorting Test 89. After the ap p rop riate intervention, the p atient
exp eriences nau sea and vom iting and su bse-
Questions 86 and 87 qu ently has a seizu re. Which of the follow ing
m ed ications shou ld be ad m inistered next?
A 52-year-old obese m an exp eriences excessive d ay-
(A) Atrop ine
tim e sleepiness and a d epressed m ood . H is w ife
rep orts that he snores lou d ly and is restless w hile (B) Ep inep hrine
sleeping. There is no evid ence of regu lar alcohol or (C) Lorazep am
illicit su bstance u se, and the p atient d oes not have a (D) Physostigm ine
p rior p sychiatric history. (E) Prochlorp erazine (Com p azine)
 Que s tions : 8395 221

90. A 40-year-old w om an com p lain s of 3 to 93. A 48-year-old w oman successfu lly completes
4 m onths of feeling sad , w ith trou ble falling an inpatient program for alcohol d etoxification
asleep , d ecreased ap petite and som e w eight for w hich she w as prescribed chlord iazepoxid e.
loss, d ifficu lty concentrating at w ork, and Upon d ischarge, the patient is prescribed
fatigu e. She ad m its to su icid al id eation w ithou t d isulfiram. Soon after d ischarge, the patient
sp ecific plan or intent. There is no history of attend s an office party w here she ad m its to
m ania. She also m entions longstand ing and having a few d rinks. She has been comp liant
repetitive thoughts w here she w orries abou t w ith her prescribed med ication and d oes not
germ s. As a resu lt, she w ashes her hand s have any active med ical problem s. Which of
very frequ ently, som etim es end ing u p w ith the follow ing symptom s is she most likely to
cracked and chapp ed skin. She realizes that experience?
her w orries are unrealistic, but she cannot
(A) Blu rred vision
keep from d oing it. Which of the follow ing
m ed ications w ou ld be the m ost app rop riate to (B) Eu p horia
p rescribe? (C) H igh blood p ressu re
(D) Urinary retention
(A) Busp irone
(E) Vom iting
(B) Clom ip ram ine (Anafranil)
(C) Doxep in (Sinequ an) 94. A 22-year-old m an w ith a history of bipolar d is-
(D) Flu voxam ine (Lu vox) ord er is prescribed lithium carbonate to treat
(E) Phenelzine (N ard il) his sym p tom s. Du ring a w eekend ru gby tou r-
nam ent, he hu rts his knee and an orthoped ic
Questions 91 and 92 physician p rescribes a m ed ication to red u ce
his sym p tom s of p ain and sw elling. Although
A 56-year-old m an w ith a long history of alcohol u se the patient reports relief from this m ed ication,
d isord er and elevated liver function tests is ord ered he begins to exp erience abd om inal pain, d iar-
by the court to enroll in an inp atient d etoxification rhea, and d row siness. Which of the follow ing
program for his alcohol u se d isord er after nu m erou s m ed ications w ou ld m ost likely contribu te to
DWIs. After 2 d ays in treatm ent, he begins to exp eri- the prod u ction of these sym p tom s?
ence trem ors, sw eating, flu shing, and anxiety.
(A) Acetam inophen
91. Which of the follow ing m ed ications w ou ld be (B) Asp irin
the m ost approp riate to prescribe? (C) Cod eine
(A) Alp razolam (D) Ibup rofen
(B) Chlord iazep oxid e (Libriu m ) (E) Mep erid ine
(C) Disu lfiram (Antabu se)
95. A 32-year-old new ly m arried m an w ith a p ast
(D) Lorazepam
history of m ajor d ep ressive d isord er p resents
(E) Phenobarbital w ith a 4-w eek history of d ep ression, insom -
nia, anergia, p oor concentration, and anhe-
92. Shortly after this tim e, the m an begins to d onia. H e has had p assive su icid al id eation
rep ort visu al hallu cinations and becom es agi- w ithou t a p lan, as w ell. H e has not taken
tated . Which of the follow ing m ed ications citalop ram for several years, and , d esp ite
shou ld be prescribed to treat these sym ptom s? rem ission of his sym p tom s, he had signifi-
(A) Fluoxetine cant sexu al d ysfu nction w hen taking it. H e
(B) H alop erid ol w ishes to restart a m ed ication bu t is greatly
concerned abou t the im p act on his m arriage.
(C) Lithiu m
Which of the follow ing m ed ications w ou ld be
(D) Lorazep am
the m ost ap p rop riate?
(E) Sertraline
222 7: Pra c tic e Te s t 1

(A) Citalop ram 99. Which of the follow ing is the m ost effective
(B) Flu voxam ine treatm ent for this type of d rug abuse?
(C) Paroxetine (A) Abstinence
(D) Mirtazapine (B) Antid ep ressant agents
(E) Venlafaxine (C) Antip sychotic agents
(D) Dialectic behavioral therapy
96. A patient w ho is hu m an im m u nod eficiency
(E) Exp osu re and resp onse p revention
viru s (H IV)-p ositive rep orts 4 w eeks of a
d epressed m ood , low energy, p oor sleep, and
100. A 30-year-old man w ith schizophrenia is
hopelessness. H is app etite is negligible, and
brought in w ith his mother, w ith w hom he
he has been refu sing to eat or d rink anything
lives. His med ical chart d ocuments numerous
for 2 d ays. Which of the follow ing m ed ications
but adequate medication trials including
w ou ld be the m ost appropriate to p rescribe?
risperidone, olanzapine, quetiapine, and halo-
(A) Bupropion perid ol. Despite his compliance he continues
(B) Buspirone to have significant paranoia, d elusions, and
(C) Flu oxetine aud itory hallucinations, telling him that he is
(D) Methylphenid ate going to die. H e has no other medical problems,
and both he and his mother d eny any alcohol or
(E) Sertraline
d rug use. Which of the follow ing medications
w ould be the most appropriate to prescribe for
97. A 43-year-old w om an p resents w ith a new
this patient?
history of d ep ressive sym p tom s, inclu d ing
insom nia, poor ap petite and w eight loss, low (A) Arip ip razole
energy, and d istractibility. On m ental statu s (B) Clozap ine
exam ination she is asked to cou nt backw ard (C) Flu p henazine
by 7s, beginning at 100. Which of the follow ing
(D) Qu etiap ine
asp ects is being assessed by this test?
(E) Zip rasid one
(A) Attention
(B) Fu nd of know led ge 101. You are treating a 32-year-old w om an for bip o-
(C) Mathem atics skills lar I d isord er w ith a com bination of m ed ica-
(D) Rem ote m em ory tions. She d evelops hair loss w hich eventually
resolves on its ow n. Which of the follow ing
(E) Verbal m em ory
m ed ications is m ost likely resp onsible for this
sid e effect?
Questions 98 and 99
(A) Carbam azepine
A 19-year-old college stu d ent rep orts that he and
(B) Clozap ine
his friend s have been experim enting w ith hu ffing
on cam pu s. H is room m ate rep orts that he has been (C) Divalp roex sod iu m
accu mu lating typew riter correction fluid , nail polish (D) Olanzap ine (Zyp rexa)
rem over, and m od el airp lane glu e. (E) Zip rasid one (Geod on)

98. Which of the follow ing w ou ld he m ost likely 102. A 34-year-old man is referred by his internist
exp erience d u ring intoxication? for depression. For the past 2 months he has
(A) Conju nctival injection been suffering from anhedonia, crying spells,
frequent aw akenings, poor appetite, and low
(B) Depressed reflexes
energy. He is subsequently diagnosed w ith a
(C) Dim inished response to pain major d epressive episod e and recommend ed to
(D) Increased ap petite begin citalopram 20 mg daily. After discussion
(E) Staring into space of the risks and benefits of the med ication, he

expresses concern about possible sexual d ys-
function as he is currently in a new relationship
w ith a cow orker. Which of the follow ing symp-
toms are the most likely w ith this med ication?
(A) Decreased libid o
(B) Prem ature ejaculation
(C) Priap ism
(D) Retrograd e ejaculation
(E) Sexually transm itted d isease
Questions 103 and 104
A 21-year-old m ale college stud ent w ithou t p rior
m ed ical or psychiatric history is evalu ated for p oor
w ork p erform ance. The stu d ent rep orts to the d ean
that he find s it hard to follow through w ith assign-
m ents and is easily d istracted by environm ental
stim uli. The d ean com m ents to the stu d ent abou t
how frequ ently he interru p ts others d u ring conver-
sations and observes that it seem s that the stud ent
is not p aying attention to w hat he is saying. Over-
all, his grad es are p oor excep t in the class he con-
sid ers the m ost interesting class I have ever had .
H e often forgets requ ired m aterials for classes and
his assignm ents are frequ ently late. The stu d ents
p arents report that he w as evaluated for sim ilar d if-
ficu lties w hile in p u blic school, bu t he seem ed to
im p rove w hen the fam ily m oved ou t of the area and
he attend ed p rivate school.
103. Which of the follow ing is the m ost likely
d iagnosis?
(A) Attention-d eficit/ hyperactivity d isord er
(ADH D)
(B) Bipolar I d isord er
(C) Bip olar II d isord er
(D) Cond u ct d isord er
(E) Learning d isord er
104. The p atient is p rescribed m ethylp henid ate for
the above sym ptom s. After an ad equate trial
and d ose, he continu es to d isp lay som e sym p -
tom s w hich interfere w ith his school fu nction-
ing, althou gh he d enies significant sid e effects.
Which of the follow ing actions w ou ld be the
m ost ap prop riate next step?
(A) Ad d a low -d ose am phetam ine.
(B) Ad d an antid ep ressant.
Que s tions : 96107 223
(C) Ad d an anxiolytic m ed ication.
(D) Discontinu e m ethylp henid ate and
p rescribe a m ixed am phetam ine
com pou nd .
(E) Discontinu e m ethylp henid ate and
p rescribe an antid ep ressant.
105. A 35-year-old w om an presents w ith ep isod ic
anxiety and com p laints that occasionally
w hen hearing som ething for the first tim e, that
she has actually heard it before. She expresses
her concern that she is going crazy. Which
of the follow ing term s best d escribes this
p henom enon?
(A) Dj entend u
(B) Dj vu
(C) Folie d eu x
(D) Jam ais vu
(E) La belle ind iffrence
106. A 19-year-old m an is brou ght to the em er-
gency d ep artm ent by the p olice for an evalu -
ation. The w ritten p olice rep ort states that
the p atient has been calling 911 for the past
5 w eeks, reporting that he is being spied on
by aliens from a d istant p lanet. The p atient
rep orts that he is receiving m essages from the
aliens throu gh his com pu ter and that he hears
voices in his head com m enting on his appear-
ance. H e has not been sleep ing w ell at night
becau se he has been gu ard ing his bed room .
You note that his affect is flat, and he ap p ears
tired d uring your examination. A urine toxicol-
ogy screen is negative. Which of the follow ing
is the m ost likely d iagnosis?
(A) Bip olar I d isord er w ith p sychotic
featu res
(B) Brief p sychotic d isord er
(C) Major d ep ressive d isord er (MDD) w ith
p sychotic featu res
(D) Schizoaffective d isord er
(E) Schizop hreniform d isord er
107. An 18-year-old w oman w ith recently d iag-
nosed schizophrenia is acutely psychotic and
in labor w ith her first child . The obstetrics ser-
vice requests a psychiatric consultation for an
appropriate and safe med ication to use in ord er
224 7: Pra c tic e Te s t 1

to control the patients psychotic symptoms. 110. A 7-year-old boy w ith d ifficu lty in school need s
Which of the follow ing w ould be the best fu rther evalu ation of acad em ic p otential.
choice?
(A) Chlorp rom azine (Thorazine) 111. You w ou ld like to ad d ress the d eficits of a
(B) H aloperid ol (H ald ol) 69-year-old m an w ith nonflu ent sp eech and
form u late a sp ecific treatm ent p lan.
(C) Loxap ine (Loxitane)
(D) Perphenazine (Trilafon)
Questions 112 through 116
(E) Thiorid azine (Mellaril)
Select the d ru g m ost likely to cause the associated
D IRECTION S (Questions 108 through 116): The
sym ptom s.
follow ing group of questions are preceded by a
list of lettered options. For each questions, select (A) Cocaine
the one lettered option that is most closely asso- (B) Lysergic acid d iethylam ine (LSD)
ciated w ith it. Each lettered option may be used (C) Mariju ana
once, multiple times, or not at all.
(D) N icotine
Questions 108 through 111 (E) Op iates
(F) Phencyclid ine (PCP)
Match the clinical presentation w ith the ap propriate
neu ropsychological test. 112. An 18-year-old high school student with con-
junctival redness, increased appetite, dry mouth,
(A) Beck Depression Inventory tachycardia, and a sensation of slowed time.
(B) Bend er Gestalt Test
(C) Blessed Rating Scale 113. A 31-year-old m an w ith m iosis, brad ycard ia,
(D) Boston Diagnostic Aphasia Exam ination hyp otension, hypotherm ia, and constipation.
(E) Mini-Mental state Exam ination (MMSE)
(F) Minnesota Mu ltiphasic Personality 114. An assau ltive 26-year-old m an w ith vertical
Inventory 2 (MMPI-2) nystagm u s, echolalia, paranoid id eation, and
(G) ReyOsterrieth Test hallucinations.
(H ) Rorschach Test
(I) Wad a Test 115. A 16-year-old girl w ith abd om inal cram ps,
(J) Wechsler Ad u lt Intelligence Scale confu sion, palpitations, and m u scle tw itching.
Revised (WAIS-R)
(K) Wechsler Intelligence Scale for Child ren 116. A 21-year-old m an w ith tachycard ia, d ilated
(WISC) p upils, hallucinations, and com p laints of chest
p ain.
108. A 65-year-old fem ale p hysician w ho is now
concerned about m em ory d ifficulties.

109. A 35-year-old w om an w ith a p rotein S d efi-

ciency show s evid ence of left sid e hem i-neglect.
 Ans we rs a nd Expla na tions
1. (C) Antip sychotics are ind icated for acu te
treatm ent of agitation and violence som etim es
seen in m anic patients. H aloperid ol w orks
relatively qu ickly (2030 m inu tes). Doses of
2 to 5 m g by m ou th (PO) or intram u scu larly
(IM) are u su al, althou gh it m ay be given IV
as w ell, especially in the intensive care u nit
(ICU). H yd roxyzine is an antihistam ine; it is
not effective in m ania. Lithium , d ivalproex
sod ium , and carbam azepine have all been
show n to control m ood fluctu ations in m anic
p atients. H ow ever, these agents take d ays to
w ork and are not effective in the im m ed iate
m anagem ent of this patient.
2. (D ) Lithium is not associated w ith signifi-
cant blood d yscrasias, althou gh it can cau se
a m od est benign increase in the w hite blood
cell (WBC) cou nt. Carbam azepine is com -
m only associated w ith a benign red u ction
in WBC cou nt, bu t severe blood d yscrasias
only occu r in app roxim ately 1 in 125,000
p atients. Agranulocytosis is also a rare com -
p lication w ith d ivalproex sod iu m , although a
benign throm bocytop enia is m ore com m on.
Agranulocytosis can also occu r in the setting
of antipsychotic m ed ication u se in rare cases
(clozap ine has a higher incid ence). Lorazep am
is not associated w ith WBC abnorm alities bu t
is not a m ood stabilizer.
3. (D ) This patient is m ost likely suffering from
som atic sym ptom d isord er, w hich often coex-
ists w ith other p sychiatric illnesses su ch as
anxiety, d ep ressive, and p ersonality d isor-
d ers. The su sp ected p resence of a som atic
sym ptom d isord er should prom pt a search for
other treatable illnesses. In m anaging patients
w ith som atic sym p tom d isord er, it is im p or-
tant to u nd erstand that sym ptom s are not con-
sciou sly prod u ced and to let p atients know
that you realize their sym p tom s are a source of
great consternation. Regard less of history, any
p atient presenting to a p hysician w ith p hysi-
cal com plaints d eserves a reasonable physical
investigation; p atients w ith som atic sym p -
tom d isord er are as likely, if not m ore likely,
to d evelop id entifiable m ed ical cond itions.
H ow ever, rather than rep eat tests, it m ay be
necessary to contact previous treaters. Send -
ing this p atient aw ay for a year w ou ld not be
help ful; rather regular, frequ ent checku ps and
fostering a therap eu tic alliance and su p p ort
are in ord er.
4. (C) Ap p roxim ately 50% of ind ivid u als w ith
som atic sym p tom d isord er have ad d itional
p sychiatric illnesses, esp ecially anxiety and
d ep ression. Personality traits or a d isord er is
not u ncom m on. Obsessive-com pu lsive per-
sonality d isord er is the m ost likely com orbid
p ersonality d isord er in som atic sym ptom -
d isord ered p atients.
5. (E) This patient is most likely suffering from
schizotypal personal disorder, which as with all
personality disorders, represents a lifelong mal-
adaptive approach to life and does not suddenly
develop in ad ulthood . Schizotypal personality
disorder with its attendant social isolation and
subtle distortions of reality may ind eed resem-
ble schizophrenia; the diagnosis can be sorted
out by a thorough history. Frank hallucinations
of any type are uncommon; only subtle dis-
tortion of environmental cues is seen. There is
no evidence of mania to justify a diagnosis of
225
226 7: Pra c tic e Te s t 1
bipolar disorder. While under stress, patients
with borderline personality disorder can have
so-called micropsychotic episodes, they dis-
play chronic feelings of emptiness, mood/ affect
lability, self-mutilation, and intense anger and
impulsivity. Schizoid personality disorder may
appear similar to schizotypal personality disor-
der, although it is characterized more by feel-
ings of d etachment, lack of friends, choosing
solitary activities, and anhedonia.
6. (A) In schizotyp al p ersonality d isord er, the
subtle d isconnection from reality, w hich m ay
be exacerbated in tim es of stress as in this case,
can be treated w ith low d oses of antip sychotic
m ed ication. These patients lack the cap abil-
ity, stable sense of self, and tru st to be able
to engage in, or benefit from , p sychod ynam ic
p sych oth erap y. An tid ep ressant m ed ication
of any type, includ ing tricyclics and SSRIs, is
helpful in the schizotypal patient w ho d isplays
significant affective (mood ) symptoms, w hich
are not seen in this case. Benzodiazepines are
not ind icated in this patient as there is no evi-
d ence of anxiety.
7. (C) This p atient is m ost likely su ffering from
schizophrenia. Sym ptom s of schizop hrenia
are com m only d ivid ed into positive and nega-
tive sym ptom s. Flat affect, a negative sym p-
tom , represents an absence of a norm ally
reactive and variable affect. Other negative
sym ptom s inclu d e alogia and avolition. Au d i-
tory hallucinations, d elu sions (inclu d ing p ar-
anoid d elu sions), and loose associations are
all positive sym p tom s.
8. (C) The exacerbation seen is m ost likely p re-
cip itated by m ed ication noncom p liance. A
viral illness or stress from w ork m ay ind eed
contribu te to a relap se, bu t they are less
strongly p red ictive of a reem ergence of p sy-
chotic sym p tom s than m ed ication noncom -
p liance. N icotine has been show n to low er
neu rolep tic levels, w hich has been offered
as a reason cigarette sm oking is ram p ant
am ong p atients w ith schizop hrenia. H ow -
ever, this p atients sm oking d ecreased , w hich
if anything w ou ld be exp ected to increase
antip sychotic levels. Since she has not been
com p liant w ith her m ed ication, her exacerba-
tion is not likely d u e to treatm ent refractory
schizop hrenia.
9. (B) Classically, p atients w ith hep atitis second -
ary to alcohol use d isord ers have elevated liver
enzym es (su ch as gam m a-glu tam yl transp ep -
tid ase, aspartate transam inase, or alanine
transam inase). H ow ever, in ad vanced alco-
holism , the liver m ay be bu rnt ou t and liver
fu nction tests m ay reveal low or norm al levels
of these enzym es. As a resu lt of liver d am -
age, prothrom bin tim e is typ ically increased .
H ypom agnesem ia, not hyperm agnesem ia, is
m ore likely to be fou nd in alcohol u se d isor-
d er, usu ally as a resu lt of d ietary d eficiency. In
the p atient having a w ithd raw al seizure, the
p roblem is the absence, not presence, of alco-
hol. H is blood alcohol w ou ld be exp ected to
be low or zero. A p atient w ith alcohol u se d is-
ord er is m ore likely to have throm bocytop enia
rather than throm bocytosis.
10. (C) The p atient has alcohol u se d isord er and
has su ffered a w ithd raw al seizu re. The m ain-
stay of alcohol d etoxification rem ains ben-
zod iazep ines, w hich m ay be ad m inistered
p arenterally. Lorazep am is com m only u sed ,
since it can be given PO, IM, or IV, and it is
not d ep end ent on ad equ ate liver fu nctioning
(w hich m ay be com p rom ised in alcoholics)
for its m etabolism . While d iazep am (Valiu m )
can be u sed , it has erratic absorp tion w hen
given IM, and , in a p atient w ith liver d am -
age, its p rolonged half-life can create a large
bu ild u p w ith su bsequ ent oversed ation and
p otential resp iratory d ep ression. H alop eri-
d ol is an antip sychotic m ed ication w hich
m ay help w ith agitation seen in alcohol w ith-
d raw al, bu t it d oesnt treat the u nd erlying
p roblem and m ay fu rther low er the seizu re
threshold . While antiseizu re m ed ications
su ch as carbam azep ine have been show n to
be effective in the m anagem ent of alcohol
w ithd raw al, they are not consid ered to be the
first-line treatm ent.
11. (B) While the p atient d oes not have a history
of m ental illness, w hich provid es inform ation
abou t p ast behaviors, she is actively su icid al

w ith a p lan, and attem p ts to contact collaterals
have been unsu ccessfu l. Collateral inform a-
tion w ou ld be help fu l to valid ate the p res-
ent history as w ell as to p rovid e d ata abou t
baseline m ental statu s. Given the absence of
collateral inpu t and the fact that she rem ains
suicid al, the p atient shou ld not be d ischarged
from the em ergency d epartm ent and shou ld
be involu ntarily ad m itted u nd er certificate
and petition. The p atient d oes not exhibit
p sychotic behavior and is not a m anagem ent
p roblem ; the ad m inistration of an antip sy-
chotic m ed ication can cau se sid e effects and
m ay affect fu tu re com pliance w ith p sycho-
tropic m ed ications. The other choices d o not
ad equ ately ad d ress her safety.
12. (A) The Beck Dep ression Inventory is a w id ely
u sed test that allow s clinicians to follow the
severity of previously d iagnosed d ep ression.
The Draw -A-Person Test, Rorschach Test, and
TAT are all typ es of p rojective testing. Projec-
tive tests, although useful clinical tools, often
suffer low reliability and valid ity. Projective
tests requ ire a person skilled at this type of
evalu ation and d o not alw ays have rigorou s
em p irical d ata and grou p com p arison. The
evalu ation of d ep ression u sing the H alstead -
Reitan Test is lim ited by the fact that m any
d ep ressed patients fail to show d eficits on
such classic neu ropsychological batteries.
In ad d ition, these tests, even w hen d em on-
strating d eficits in cognitive d om ains su ch as
attention and learning, still have very lim ited
u sefulness in evaluating the severity of the
d ep ression.
13. (B) The Brow n-Peterson Task is a test sp ecifi-
cally d esigned to evalu ate short-term m em ory,
a cap acity that can be affected d u ring ECT. The
Bulim ia TestRevised and the EDI-2 are both
u seful for the evalu ation of bu lim ia and eating
d isord ers, resp ectively. The Beck Depression
Inventory and State-Trait Anxiety Inventory
are u sed to evaluate d epression and anxiety
d isord ers, respectively.
14. (E) The patient has m u ltiple episod es of
d ep ression, u nfortunately w ithou t rem ission
d esp ite several m ed ication trials w ith SSRIs.
Answe rs : 617 227
Utilizing an antid ep ressant w ith a d ifferent
m echanism of action (affecting d ifferent
neu rotransm itters) m ay be beneficial. Venla-
faxine is a serotonin and norepinephrine reu p-
take inhibitor, w hich, in higher d oses, w ill
increase the intrasynap tic levels of both neu -
rotransm itters. All the other choices are SSRIs.
15. (C) This scenario represents a case of factitiou s
d isord er im posed on another (form ally facti-
tious d isord er by proxy), in w hich one person
falsifies illness in another to vicariously gain
m ed ical attention. Com m only, the victim is a
child and the perp etrator is the child s m other.
Ap p arent bleed ing, seizu res, and central ner-
vous system (CN S) d epression are typical pre-
sentations. The d isord er is und erd iagnosed
d ue both to the elu sive and crafty p lanning
of the perp etrator and the u nw illingness of
health care p rovid ers to accu se the ostensibly
caring parent. Given the age of the child , it is
extrem ely u nlikely that the child , him self, is
intentionally p rod u cing the sym p tom s, and
there is no evid ence that he is experiencing
p hysiologic seizu res. Conversion d isord er is
characterized by the p resence of one or m ore
neu rologic sym p tom s that are incom p atible
w ith a recognized m ed ical or neu rologic d isor-
d er. Paralysis, blind ness, and pseud oseizu res
are com m on conversion d isord er sym p tom s.
Sep aration anxiety d isord er is characterized
by excessive and inap p rop riate anxiety con-
cerning sep aration from hom e or to w hom
ind ivid u als are attached .
16. (C) Mothers w ith factitiou s d isord er im p osed
on another are m ost likely to have u nd erly-
ing m ajor d ep ressive d isord er. Bord erline
p ersonality d isord er is the m ost com m on
p ersonality d isord er associated w ith facti-
tiou s d isord er im p osed on another. Bip olar
d isord er and PTSD have not been clearly
d escribed in the literatu re. Ep ilep sy is not
associated w ith the d isord er to any sig-
nificant extent, and schizop hrenia has been
rep orted in only a few cases.
17. (E) Panic d isorder is characterized by the sud-
d en unexpected occurrence of panic attacks
(period s of intense anxiety or fear accompanied
228 7: Pra c tic e Te s t 1
by som atic sym p tom s), com m only cau sing
the m isd iagnosis of a m ed ical illness such as
m yocard ial infarction. The frequ ency of p anic
attacks varies w id ely from m any per d ay to a
few per year. Panic d isord er is often associated
w ith agorap hobia, the fear of being in p laces
w here escap e is d ifficu lt. The lifetim e p reva-
lence is up to 4%. Concerns of d eath from car-
d iac or respiratory d isord ers occu r frequ ently.
Acu te stress d isord er is d iagnosed in ind ivid -
u als w ho have experienced a trau m atic event
and subsequ ently d evelop sym p tom s w ithin
4 w eeks of the event that rem it after 1 m onth.
The trau m atic event m u st be reexp erienced
by the p atient, and this cau ses the p atient to
avoid stim uli that arouse recollections of the
trau m a. Other criteria necessary for the d iag-
nosis are the presence of d issociative sym p -
tom s and m arked anxiety or increased arou sal
not better accounted for by other m ed ical or
p sychiatric illnesses. Delirium is characterized
by the su d d en onset of a d istu rbance attention
and aw areness, as w ell as a change in cogni-
tion, cau sed by another m ed ical cond ition,
substance (alcohol, d ru g, m ed ication), and / or
toxin.
18. (E) Of the choices listed , sertraline, an SSRI,
is the m ost efficaciou s. In ad d ition, tricyclic
antid ep ressants, MAOIs, and the benzod i-
azep ines are also effective in the treatm ent
of p anic d isord er. Beta-ad renergic d ru gs like
p rop ranolol are not effective for the treatm ent
of p anic d isord er. H alop erid ol, an antip sy-
chotic agent; lithiu m , a m ood stabilizer; and
clonid ine, an alp ha-2-ad renergic agonist, are
ineffective.
19. (A) H yp ertensive crisis is a p otentially life-
threatening com plication that occu rs w hen
p atients taking an MAOI eat tyram ine-con-
taining food s su ch as w ine, beer, pickled food s,
and aged cheese. Clinical featu res includ e
hyp ertension, severe occipital head ache, stiff
neck, nausea, vom iting, and sw eating. IV
p hentolam ine, an alp ha-ad renergic recep tor
blocker, is the treatm ent of choice. It has been
show n to be m ore effective and safer than beta
blockers or calciu m channel blockers. Ad m is-
sion to an ICU and su pportive m easu res are
ind icated . N either brom ocrip tine, a d op am ine
agonist, nor d antrolene, a m u scle relaxant, is
ind icated .
20. (D ) Clozap ine is an effective antip sychotic
m ed ication that has been associated w ith
few er extrapyram id al sid e effects than the con-
ventional antipsychotics (w hich prim arily act
by blocking d op am ine typ e 2 recep tors). Over
4% of p atients taking m ore than 600 m g/ d
of clozap ine experience clozapine-associated
seizu res. Tachycard ia, hyp otension, sed ation,
fatigue, and w eight gain have all been asso-
ciated w ith clozapine treatm ent. Clozapine,
u nlike the conventional antip sychotic agents,
d oes not affect prolactin secretion and thus
d oes not cause galactorrhea.
21. (B) Agranu locytosis is a p otentially life-
threatening sid e effect of clozapine treatm ent.
It is d efined as a d ecrease in the nu m ber of
WBCs, w ith a sp ecific d ecrease in the nu m -
ber of neu trop hil granu locytes. It occu rs in
ap p roxim ately 1% of all p atients treated w ith
clozapine. Therefore, a com plete blood cou nt
w ith d ifferential is requ ired w eekly in the
beginning of treatm ent and frequ ently there-
after. Rou tine m onitoring w ith the other tests
are not requ ired or necessary w ith clozap ine
treatm ent.
22. (B) The Folstein MMSE is a frequently u sed
screening assessm ent for m ajor neu rocogni-
tive d isord er (d em entia), althou gh m ore in
d ep th and form al neu ropsychological test-
ing shou ld be p erform ed at som e p oint. It is
a 30-p oint scale w ith d ed u ctions for incorrect
answ ers. Scores less than 25 are su ggestive of
cognitive im p airm ent. Scores less than 20 ind i-
cate d efinitive im pairm ent. The Blessed Rat-
ing Scale is a tool that typ ically asks a p atients
friend s or relatives to assess the ability of the
p atient to fu nction in his or her cu rrent envi-
ronm ent. The Geriatric Rating Scale is a rat-
ing scale for nonp rofessional staff to evalu ate
p atients abilities to p erform their activities of
d aily living and interact w ith others. It m ay be
m ost help ful in evalu ation of the m od erately
to severely d em ented ind ivid ual. The Glasgow
Com a Scale is an easy-to-perform instrum ent

that evalu ates level of consciou sness. There
are three general categories that the exam -
iner tests: eye op ening, verbal resp onse, and
best m otor resp onse. Each category receives
a num ber for p atient resp onse. Overall scores
range from 3 to 15, w ith low er scores reflect-
ing m ore severely im p aired consciou sness. A
m ental statu s exam ination is the form al p sy-
chiatric exam ination that includ es m any item s
such as appearance, behavior, sp eech, assess-
m ent of m ood and affect, p resence of p sycho-
sis, and evaluation of insight and jud gm ent. It
is not a su bstitu te for the Folstein MMSE.
23. (B) When evaluating the MMSE score in elderly
patients, it is critical to consid er that major
d epression (also know n as pseud od ementia)
may prod uce similar impairments in cognition.
The other d iagnoses listed w ould not com-
monly red uce the Folstein MMSE score.
24. (E) Schizotyp al p ersonality d isord er is char-
acterized by a p ervasive p attern of social
and interp ersonal d eficits. Ind ivid u als d em -
onstrate a red u ced cap acity to establish any
close relationship s, and eccentric behavior is
p resent. The p resence of od d beliefs or m agi-
cal thinking sep arates schizotyp al p ersonality
d isord er from schizoid p ersonality d isord er.
Paranoid id eation is com m on in both schizo-
typ al and p aranoid p ersonality d isord ers
bu t not in the others. Avoid ant p ersonality
d isord er rep resents a p ervasive p attern of
behavior characterized by social inhibition,
feelings of inad equ acy, and hyp ersensitivity
to negative evalu ation. N arcissistic p ersonal-
ity d isord er rep resents a p ervasive p attern
of grand iosity, lack of em p athy, and a need
for ad m iration. Schizoid p ersonality d isord er
rep resents a p ervasive p attern of d etachm ent
from social relationship s and a restricted
range of exp ressed em otions.
25. (B) Bord erline p ersonality d isord er is a per-
vasive pattern of instability of interpersonal
relationships, self-im age, affect, and marked
impulsivity. Antisocial personality d isord er
d escribes ind ivid uals w ith long histories of
d isregard for the rights of others and often
d ishonesty used in attem pts to gain som ething
Answe rs : 1827 229
for themselves. Patients w ith d epend ent per-
sonality d isord er require an excessive amount
of ad vice, reassu rance, and approval from oth-
ers. Ind ivid u als w ith histrionic personality d is-
ord er, like those w ith bord erline personality
d isord er, may d isplay excessive emotionality
and attention-seeking behavior, but their core
sym ptoms center around su perficial sed u c-
tiveness and theatricality. Schizoid p ersonal-
ity d isord er represents a pervasive pattern of
d etachment from social relationships and a
restricted range of expressed emotions.
26. (E) In the WCST, exam inees are asked to sort
card s d ep icting variou s p ictu res and sym bols
accord ing to a variety of d ifferent criteria
that change over tim e w ithou t the su bjects
know ing. The WCST assesses a p ersons abil-
ity to sw itch sets, reason abstractly, and solve
p roblem s. These cap acities are also know n
as execu tive fu nctions and are localized in
the frontal lobes. Cu rrent research regard -
ing the p sychop athology of schizop hrenia
su ggests that there are abnorm alities in the
frontal lobes, sp ecifically in the d orsolateral
p refrontal cortex, that are reflected in p oor
p erform ance on the WCST. Peop le w ith
schizop hrenia p erform m ore p oorly on the
WCST than p eop le w ithou t schizop hrenia;
how ever, ind ivid u als w ith d am age to their
frontal lobes from a variety of cau ses also
show execu tive fu nction d eficits. The Bend er
Gestalt Test involves cop ying figu res, w hich
help s d eterm ine if organic brain d isease is
p resent. The Draw -A-Person Test requ ires
the exam inee to d raw a p erson. It w as ini-
tially d evised to test intelligence in child ren,
bu t is now u sed p rim arily as a screening test
for brain d amage. The Luria-N ebraska N eu-
ropsychological Battery is a com prehensive
set of neu ropsychological tests used to assess
specific cortical areas and aid s in assessm ent
of hem ispheric d om inance. The Mini-Mental
State Examination is a com monly used scale to
assess the possibility of a major neurocognitive
d isord er (d em entia).
27. (B) The WCST assesses a p ersons ability
to sw itch sets, reason abstractly, and solve
p roblem s. These cap acities are also know n as
230 7: Pra c tic e Te s t 1
execu tive fu nctions and are localized in the
frontal lobes. The cerebellum is responsible
for coord ination. The occipital lobe is d ed i-
cated to the sense of sight. The parietal lobe
hand les sensory inp u t, m otor outpu t, and
visu ospatial processing. The tem p oral lobe is
resp onsible for the sense of sou nd , taste, and
m em ory storage.
28. (C) This p atient is m ost likely su ffering from
bip olar I d isord er. Racing thou ghts, p ressu red
speech, expansive m ood , a d ecreased need for
sleep, and an increase in goal-d irected activity
are all com m on m anifestations of m ania. The
p atient is u su ally energized d u ring the d ay
even after only a few hou rs of sleep . Dep ressed
m ood and w eight loss are m ore characteristic
of a d ep ressive d isord er. Visu al hallu cinations
cou ld be present in severe cases of m ania but
are m ore com m only a sym ptom of a p rim ary
p sychotic d isord er su ch as schizophrenia.
29. (E) Many d isord ers can m im ic sym p tom s of
m ania. A com p lete history, physical exam i-
nation, and rou tine laboratory tests can su ffi-
ciently ru le ou t m ost m ed ical cau ses of m ania.
They inclu d e end ocrine d isord ers su ch as
thyrotoxicosis and Cu shing synd rom e, hypo-
glycem ia, electrolyte d isord ers, su bstance u se
and w ithd raw al, m ed ications su ch as steroid s
and anticholinergic agents, nu tritional d efi-
ciencies, and CN S insu lts.
30. (B) Gingival hyperplasia is associated w ith
ad m inistration of phenytoin. Other, d ose-
related sym p tom s inclu d e nystagm u s, d izzi-
ness, slu rred speech, ataxia, m ental confu sion,
and d ecreased coord ination. Ebstein anom aly
is associated w ith lithiu m therap y, and hep atic
failure is associated w ith d ivalproex sod iu m .
31. (C) Before any p harm acologic changes are
consid ered , the physician m u st assess com -
p liance w ith m ed ications. The subtherap eu tic
p henytoin level m ay be d ue to p atient non-
com pliance, especially if sid e effects are being
exp erienced .
32. (E) The risk of schizophrenia among first-degree
relatives w here one p arent has schizop hrenia
m ay be as high as 12%, com p ared w ith a > 1%
risk in the general p op u lation.
33. (A) The p atient is being evalu ated w ith the
Rorschach Test, w hich w as d evelop ed in
1921 by H erm ann Rorschach. It consists of
show ing a su bject a set of 10 inkblot stim u li
in a sequ ential m anner w hile noting (1) the
resp onses in relationship to the content of the
p ercep tion; (2) the area of the blot that form s
the basis of the resp onse; and (3) the asp ects
of the area that are u sed to form the resp onse.
In 1961, Lind zey p rop osed a m ethod of clas-
sifying p rojective tests based on the typ e of
activity. The Rorschach is classified in the
category of associations. Another test in this
category is the Word Association Test. In the
choice of ord ering category, p atients p lace
objects in a rank ord er w ith resp ect to p refer-
ence. Tests su ch as the Sentence Com p letion
Test fall into the category of com p letions, in
w hich a p erson com p letes an u ncom p leted
stim u lu s. The constru ction category requ ires
the su bject to constru ct content based on
a stim u lu s, su ch as a story in the Them atic
Ap p ercep tion Test. The self-exp ression cat-
egory consists of tests su ch as the Draw -A-
Person Test, in w hich the su bject p rod u ces a
resp onse w ithou t a stim u lu s.
34. (C) It is not ethical to engage in therapy (i.e.,
conversion therapy) to change the sexual orien-
tation of a patient. The American Psychiatric
Association opposes any psychiatric treatment,
such as reparative or conversion therapy w hich
is based u p on the assu m p tion that h om osex-
u ality p er se is a m en tal d isord er or based
u p on th e a p riori assu m p tion that th e p atien t
shou ld chan ge his/ h er sexu al h om osexu al
orien tation . Ultim ately, p er APAs p rin ci-
p les of m ed ical eth ics a p sych iatrist sh ou ld
not be a p arty to any typ e of p olicy that
exclu d es, segregates, or d em ean s the d ign ity
of any p atient becau se of ethn ic origin , race,
sex, creed , age, socioecon om ic statu s, or sex-
u al orien tation . All the other ch oices w ou ld
be consid ered u nethical.
35. (B) Cocaine (stim u lant) intoxication can
ap p ear sim ilar to a m anic ep isod e associated

w ith bip olar I d isord er w ith an increase
in energy, eu p horia, grand iosity, p ressu red
speech, and im p aired ju d gm ent. While can-
nabis intoxication can p resent w ith eup horia,
p aranoia, and im paired ju d gm ent (in associa-
tion w ith physical sym ptom s of conju nctival
injection, increased ap p etite, d ry m ou th, and
tachycard ia), a d ecreased need for sleep, d ia-
p horesis, and rap id speech are not consistent
w ith cannabis intoxication. The acu te onset
of sym ptom s m akes the d iagnosis of m ajor
d ep ression u nlikely. A d iagnosis of schizoaf-
fective d isord er requires that d u ring the p eriod
of illness there are sym ptom s that su ggest both
a schizophrenia and a m ood d isord er (m ajor
d ep ressive or m anic episod e). Schizophrenia
requ ires the p resence of significant p sychotic
sym ptom s d uring a 1-m onth p eriod , w hich
is not evid ent in this case; the p atient exp eri-
enced eu p horia w hich is not characteristic of
schizophrenia. N egative sym ptom s (e.g., flat-
tened affect, avolition, alogia) are also m ore
com m on in schizophrenia.
36. (D ) The Tem poral Orientation Test asks
the patient to id entify the appropriate d ay,
m onth, d ay of the w eek, and cu rrent tim e.
Deviation from the correct resp onse is d iffer-
entially scored in each category. Total score
and the d ata incorrectly id entified sep arate the
p atients into tw o grou ps: p atients w ith brain
d am age and patients w ithou t brain d am age.
The Tem p oral Orientation Test is also sensi-
tive to cognitive abnorm alities in d em enting
illnesses. The Fargo Map Test assesses recent
and rem ote sp atial m em ory and visu osp atial
orientation by using m aps of the United States
and d ifferent regions w ithin it. Patients are
asked to id entify certain areas. Ed u cation level
and age influ ence the score on this test. The
Spatial Orientation Mem ory Test evalu ates
the ability to im m ed iately recall the orienta-
tion of figu res and is u sed to evalu ate im m e-
d iate m em ory. The Stroop Test has a nu m ber
of d ifferent form ats, but the general concep t
is that it takes longer to correctly id entify a
color than to read w ord s and longer yet to cor-
rectly id entify a w ord (e.g., nam e of a color)
w hen that w ord is in a color d ifferent from
Answe rs : 2838 231
that w ord . This test seem s to be prim arily
an assessm ent of the ability to concentrate.
The WCST is u sed to evalu ate set shifting,
or execu tive fu nctioning of the brain.
37. (A) Culture-bound synd rom es d enote recu r-
rent, locality-sp ecific p atterns of behavior. The
synd rom e of am ok is a cu ltu re-bou nd syn-
d rom e of Malaysian origin that refers to a vio-
lent or fu riou s ou tbu rst w ith hom icid al intent.
Fou r d efining characteristics are p rod rom al
brood ing, a hom icid al ou tbu rst, p ersistence in
reckless killing w ithou t an ap p arent m otive,
and a claim of am nesia. The attack typ ically
resu lts in m u ltip le casu alties and is m ost com -
m on in you ng m en w hose self-esteem has been
inju red . Dhat is a Sou th Asian term referring
to anxiety regard ing the loss of sem en. Ganser
synd rom e is characterized by a patient w ho
resp ond s to qu estions by giving ap p roxim ate
or ou tright rid icu lou s answ ers. Ad d itional
features m ay also inclu d e altered consciou s-
ness, hallu cinations, conversion p henom enon,
and am nesia for the ep isod e. Koro is another
Malaysian term that refers to su d d en anxi-
ety that the p enis (or vu lva in fem ales) w ill
reced e into the bod y and cau se d eath. Latah
is also of Malaysian or Ind onesian origin,
m ore frequ ent in m id d le-aged w om en, and
is characterized by su d d en fear, often w ith
d issociation and catatonic-like featu res (e.g.,
echolalia, echop raxia).
38. (A) Antip sychotic (neu roleptic)-ind u ced extra-
pyram id al sid e effects d u e to the blockad e
of d opamine are comm on in the treatm ent of
psychosis. The higher-potency antipsychotic
med ications are more likely to cau se extrapy-
ram id al sid e effects than the low er-potency
ones. Extrap yram id al sid e effects includ e acu te
d ystonic reactions (as in this case), akathisia
(restlessness), pseud oparkinsonism, and tar-
d ive d yskinesia. Acute d ystonia is treated w ith
anticholinergic agents such as benztropine and
antihistamines. Other op tions inclu d e red ucing
the d ose or sw itching to a low er-p otency agent
or atypical antipsychotic (such as risperid one).
N either of these are preferable at this point as
the patients sym ptoms have im proved .
232 7: Pra c tic e Te s t 1
39. (E) Becau se of this p atients continu ed extra-
p yram id al sym ptom s d espite treatm ent w ith
an anticholinergic, the m ost app rop riate
choice w ou ld be to sw itch to an atypical anti-
p sychotic m ed ication. Atypical, or second -
generation antip sychotics, su ch as qu etiap ine,
are believed to act on variou s su bp op u lations
of d opam ine receptor su btyp es as w ell as on
other neurotransm itter system s, inclu d ing
serotonergic. They are consid ered atyp ical
agents because they are associated w ith a low er
risk of extrapyramid al sym ptoms. Clozapine,
introd uced to the United States in 1989, is the
first antipsychotic to be labeled atypical. Other
atyp ical or second -generation m ed ications
includ e risperid one, olanzapine, ziprasid one,
lu rasid one, asenap ine, and arip ip razole. The
other choices are all consid ered to be typical
antipsychotics.
40. (C) Bord erline p ersonality d isord er is a
p attern of instability in interpersonal rela-
tionships, self-im age, affect, and m arked
im p u lsivity, inclu d ing inap p rop riate anger
and self-m u tilation. Avoid ant personality
d isord er rep resents a p ervasive p attern of
behavior characterized by social inhibition,
feelings of inad equ acy, and hyp ersensitivity
to negative evaluation. Bipolar d isord er is an
affective illness characterized by alternating
p eriod s of m ania and m ajor d epression. Fea-
tu res of d epend ent personality d isord er are
an excessive need to be taken care of, clinging
behavior, and fears of sep aration. N arcissistic
p atients d em onstrate a pattern of grand iosity,
need for ad m iration, and lack of em pathy.
41. (D ) DBT is a m anu alized treatm ent for chroni-
cally parasuicid al patients su ch as those w ith
bord erline p ersonality d isord er. It incorp o-
rates elem ents of cognitive, behavioral, and
su pportive therapies, and it includ es tech-
niqu es of ad vice, confrontation, and u se of
hom ew ork. Aversion therapy is a controver-
sial techniqu e in behavioral therap y w here
an aversive stim u li is p aired w ith an u nd e-
sired behavior, hopefully su ppressing the
u nw anted behavior. EMDR is a cognitive-
behavioral techniqu e w hereby a p atient w ith
p osttrau m atic stress d isord er is told to think
abou t a stressful event w hile tracking an object
back and forth across their vision. Flood ing is
another behavioral intervention u sed for pho-
bias, w here a p atient is exp osed to a feared
object d irectly. This is in contrast w ith system -
atic d esensitization, w here a p hobic p atient is
grad u ally exp osed to increasingly feared situ -
ations u sing a hierarchy of anxiety-p rovoking
triggers.
42. (A) The p atient is exp eriencing anticholinergic
toxicity as evid enced by d ilated p up ils, d ry or
flu shed skin, agitation, confu sion, and tachy-
card ia. Ad d itional m anifestations includ e d is-
orientation and u rinary retention. More severe
toxicity m ay resu lt in hypertherm ia or com a.
In this case, the p atient rep orted benefit from
halop erid ol bu t experienced extrap yram i-
d al sid e effects, com m on to the high-p otency
antip sychotic m ed ications. Benztrop ine, an
anticholinergic m ed ication, is p rescribed to
alleviate extrap yram id al sid e effects, bu t in
this patient it cau sed anticholinergic sid e
effects. Am antad ine is an antiviral m ed ication
that is also used to help alleviate extrapyra-
m id al sid e effects and should be institu ted to
rep lace benztrop ine. The other choices w ou ld
not be appropriate in this case.
43. (C) Objective tests u sually involve questions
w ith lists of p ossible resp onses. These tests
p rovid e num erical scores on w hich statisti-
cal analyses are easily perform ed . Exam ples
inclu d e the United States Med ical Licensing
Exam inations. The m ain ad vantage to p rojec-
tive tests (such as the Rorschach) is that there
are a variety of resp onses w ithou t a single
correct answ er. The id ea behind projective
tests is that w hen presented w ith an am bigu-
ou s stim u lu s, patients cannot help bu t reveal
som ething about them selves both in how they
ad d ress the stim u lu s as w ell as the content of
their answ ers. Many of these tests, inclu d ing
the Rorschach Test, the Them atic Ap percep-
tion Test (TAT), the Sentence Com pletion Test,
and the Draw -A-Person Test, requ ire sp ecific
training in giving the test and interpreting the
resu lts. Projective tests d o not necessarily tell
the interview er how the patient feels about
him or her.

44. (C) The MMPI and MMPI-2 are objective tests
that have been u sed for over 50 years in the
assessm ent of p ersonality stru cture. They con-
sist of m ore than 500 statem ents, w hich are
cond ensed into clinical subscales. Item s on the
su bscales w ere d erived em pirically and w ere
chosen becau se d ata show ed they cou ld sepa-
rate p sychiatric p atients from norm al control
su bjects. Ad d itionally, qu estions are asked at
the tim e of exam ination to evaluate attitu d es
w hen taking the test. These qu estions help
to p rovid e inform ation abou t the valid ity of
the exam ination. Interpretation of the resu lts
requ ires an exp erienced evalu ator. Together
w ith the clinical history, this test p rovid es
valu able inform ation abou t personality stru c-
tu re. Its accuracy d oes not d epend on the
p atients gend er, and the results d o not reflect
how the exam inee feels about test taking.
45. (B) Denial, a narcissistic d efense, is an (uncon-
sciou s) em otional d efense m echanism used
to avoid becom ing aw are of a painfu l aspect
of reality. Denial can be used in both norm al
and p athologic states. As a d efense m echa-
nism it serves to keep internal or external
reality ou t of the consciou s to avert stress and
anxiety. Rationalization is a neu rotic d efense
m echanism in w hich unaccep table behavior,
feelings, or thou ghts are logically ju stified by
elaborate and reassuring answ ers. Regres-
sion, an im m ature d efense, is an em otional
and p hysical retreat from ad u lt stand ard s of
behavior tow ard an infantile level of p assiv-
ity and d ep end ence. Su p p ression, a m atu re
d efense, is a consciou s act of controlling and
inhibiting u naccep table im p u lses, em otions,
or id eas.
46. (A) The essential featu re of acu te stress d isor-
d er is the d evelop m ent of anxiety and d isso-
ciative sym p tom s w ithin 1 m onth of exp osu re
to an extrem ely traum atic stressor. Diagnosis
shou ld be consid ered if the sym ptom s persist
at least 3 d ays and cau se significant d istress
or im p airm ent. Du ring or after experiencing
the stressor, the ind ivid u al m ust experience
at least nine associated sym ptom s (e.g., sleep
d istu rbance; absence of em otional resp onsive-
ness; d issociative sym ptom s; reexp eriencing
Answe rs : 3948 233
the event in som e w ay, su ch as nightm ares);
anxiety or increased arou sal; avoid ance of the
stim u li that arou se recollections of the trau -
m atic event. The d iagnosis of PTSD requ ires
m ore than 1 m onth of sim ilar sym p tom s.
Ad ju stm ent d isord er can be consid ered for
those ind ivid u als w ho d o not m eet criteria
for acu te stress d isord er bu t d evelop sim ilar
sym ptom s in excess of w hat is to be expected
given the natu re of the stressor. GAD is char-
acterized by excessive anxiety and w orry
that occu r for at least 6 m onths. MDD can
exist in the context of an acute stress d isor-
d er. H ow ever, the sym p tom s are not su gges-
tive of a d ep ressive illness as there is no clear
d ep ressed m ood , change in ap p etite, energy,
or concentration.
47. (B) Psychogenic u nresp onsiveness can be
d elineated from com a by obtaining an EEG,
w hich is norm al in a p sychogenic state. On the
p hysical exam ination of a com atose patient,
d eep tend on reflexes m ay be su p p ressed . In
p atients w ho are aw ake, cold w ater intro-
d u ced into the ear p rod u ces nystagm u s w ith
the fast com p onent aw ay from the ear. In
com a, the eyes either d o not react or they m ay
slow ly and sm oothly d eviate tow ard the ear
in w hich the cold w ater w as introd u ced . Vol-
u ntary eye m ovem ents called saccad es are
rap id and sm ooth. Saccad ic eye m ovem ents
are elicited in p atients by asking them to stare
at an object at one sid e of the visu al field and
then ask them to shift their gaze to the op po-
site visual field . Typically, eye m ovem ents in
com a or persistent vegetative states are sp on-
taneou s and rand om . Abnorm al vital signs
su ch as tem perature and respiration w ou ld
not likely be affected in a p sychogenic state.
48. (C) A seasonal pattern can be associated with
major d epressive episodes in MDD, bipolar I
disorder, and bipolar II disorder. The essential
feature is the onset of depressive symptoms at
characteristic times of the year, most episod es
beginning in the fall or winter and remitting in
the spring. It occurs more commonly in women
and in higher latitudes. Major depressive epi-
sodes that occur in a seasonal pattern are typi-
cally characterized by anergia, hypersomnia,
234 7: Pra c tic e Te s t 1
overeating, weight gain, and carbohydrate
craving. Age is a strong predictor, with young
persons at higher risk. Acute stress disorder is
characterized by the development of anxiety,
reexperiencing, dissociative, and other symp-
toms within 1 month of exposure to a traumatic
event. Generalized anxiety d isorder patients
describe chronic anxiety over a number of
events lasting over 6 months. Persistent depres-
sive disorder (dysthymia) is a mood disorder
where the depressed mood occurs most of the
time for at least 2 years. Sundowning refers to
drowsiness, confusion, and falling, typically
seen in patients with major neurocognitive dis-
orders (dementias) when lights or other orient-
ing cues are removed.
49. (B) The essential featu res of d issociative am ne-
sia w ith fu gu e are the inability to recall im p or-
tant autobiographical inform ation, along w ith
p urp oseful travel or w and ering associated
w ith the am nesia. The d isord er is m ore com -
m on in w om en and is often associated w ith
a history of abu se in child hood . Delirium is
characterized by a d istu rbance in attention
and aw areness, along w ith a change in cogni-
tion that d evelop over a short period of tim e.
Major d ep ression is d iagnosed in ind ivid uals
w ith 2 w eeks of d epression and neu roveg-
etative sym p tom s (changes in sleep , ap p etite,
energy). Partial com p lex seizu res tend to be
brief and d o not last as long as the clinical
p icture presents. For the d iagnosis of p ost-
trau m atic stress d isord er, an ind ivid u al m u st
be exp osed to a trau m atic stressor, along w ith
sym ptom s of intrusion, alterations in cogni-
tion and m ood , d istu rbances of arou sal, and
avoid ance of stim u li.
50. (C) The DSM -5 recognizes three sp ecific learn-
ing d isord ers: im p airm ent in read ing, w ritten
com m u nication, and m athem atics. Learn-
ing d isord ers are id entified w hen a p atients
acad em ic skills in that area are below those
exp ected for the ind ivid u als chronological
age, as confirm ed by ad m inistered stand ard -
ized achievem ents m easu res and clinical
assessm ent. The Wechsler Ad ult Intelligence
Scale w as initially p u blished in 1955 and has
u nd ergone a series of revisions to reach the
current scale, the WAIS-R. The test is com -
p osed of 11 d ifferent su btests6 verbal and
5 p erform ancethat allow for the calculation
of the fu ll-scale IQ, p erform ance IQ, and ver-
bal IQ. The WAIS-R has high reliability, w hich
m eans that in norm al su bjects retesting d oes
not lead to significantly d ifferent evaluations;
therefore it can be u sed to follow peop le over
tim e. The Draw -A-Person Test is u sed to eval-
u ate for organic brain d isease, and the MMPI-2
is a test u sed for the assessm ent of p ersonality
stru ctu re. The WISC is used to d eterm ine IQ
in child ren from ages 6 to 16. The WMT w as
d esigned to evalu ate a variety of aspects of
m em ory fu nction in ad u lts.
51. (C) The IQ is calculated by d ivid ing the m ental
age by the chronological age and mu ltip lying
this by 100.
52. (B) While this patient m eets criteria for a
m ajor d ep ressive ep isod e, she has a history
of sym ptom s consistent w ith a hyp om anic
ep isod e (a d istinct p eriod of a p ersistently
elevated , exp ansive, or irritable m ood that
lasts at least 4 d ays). Bipolar II d isord er d iffers
from bipolar I d isord er in that, although the
m anic and hyp om anic episod es of these tw o
d isord ers have id entical criteria, bipolar II d is-
ord er is not severe enou gh to cau se m arked
im p airm ent in social or occu p ational fu nction-
ing or to cau se hosp italization, and d oes not
have p sychotic sym p tom s. Cyclothym ic d isor-
d er consists of chronic, flu ctuating m ood ep i-
sod es of hyp om ania alternating w ith period s
of d epression w hich d o not m eet criteria for
m ajor d ep ressive episod es. Persistent d epres-
sive d isord er (d ysthym ia) is characterized
by chronically d ep ressed m ood m ost of the
tim e for 2 years w ithou t hypom anic or m anic
ep isod es.
53. (C) The hallmark of Ganser synd rome is that
the patient respond s to qu estions by giving
ap proximate or rid iculous answ ers. It involves
the prod u ction of answ ers to qu estions that are
close bu t not qu ite correct (e.g., 4 5 = 19). Gan-
ser synd rome is primarily d escribed in m ales
in the prison population, most likely related
to malingering or factitiou s d isord er w ith

p sychological sym ptom s. Capgras synd rom e
d escribes a content-specific d elu sion in w hich
the patient believes that a significant other,
u su ally a fam ily m em ber, has been rep laced by
an id entical im p oster. Major neu rocognitive
d isord ers (d em entias) are cognitive d isord ers
associated w ith m em ory d eficits and p rob-
lem s w ith execu tive fu nctioning. Althou gh
p atients w ith d em entia m ay confabu late, this
p atients age is too you ng, and he has obvi-
ou s second ary gain. Mu nchausen synd rom e is
a factitious d isord er w ith physical sym p tom s,
w here the ind ivid u al feigns an illness in ord er
to assu m e the sick role, and is often associated
w ith traveling to d ifferent hosp itals.
54. (B) ECT provid es a safe and effective treat-
m ent of MDD in the eld erly, especially in a
p atient w ith a high risk of su icid e or m ed i-
cal contraind ications (e.g., heart d isease) to
the use of certain psychotropic m ed ications.
It is also ind icated w hen a m ore rap id onset
of action (several d ays) is im p ortant (com -
p ared w ith several w eeks for antid ep ressant
m ed ications). Diazepam is a benzod iazep ine
w hich is u sefu l in the treatm ent of sym p tom -
atic anxiety bu t not for d epression. N ortrip ty-
line, a tricyclic antid ep ressant (TCA), is lethal
in overd ose and shou ld not be p rescribed in
an acutely su icid al p atient. Certain card iac
arrhythm ias are also contraind ications to TCA
u se. Risperid one is an antip sychotic m ed ica-
tion u sed prim arily for psychotic d isord ers
such as schizophrenia and schizoaffective d is-
ord er, as w ell as for bipolar d isord er or m ajor
d epression w ith psychotic features. Supportive
psychotherapy may be helpful in conjunction
w ith med ications or ECT, but it is not indicated
as monotherapy for severe depression w ith
suicid ality.
55. (B) This p atient is su ffering from a m ajor
d ep ressive ep isod e w ith atyp ical featu res.
The sp ecifiers of m elancholic featu res and
atypical featu res can be ap plied to a cu rrent or
recent m ajor d epressive episod e that occurs in
the course of MDD, and to a major d ep ressive
episod e in bipolar I or bipolar II d isord er. The
atypical featu res sp ecifier can also be applied
to persistent d epressive d isord er (d ysthymia).
Answe rs : 4957 235
The essential features of the atypical specifier
are mood reactivity and tw o of the follow ing
four features: increased appetite or w eight
gain, hypersom nia, lead en paralysis, and
interpersonal rejection sensitivity. The essen-
tial featu re of a major d epressive episod e w ith
melancholic featu res is a loss of interest or p lea-
sure in all or almost all activities or a lack of
reactivity to usually pleasurable stimuli, along
w ith ad d itional sym ptoms of d epression (e.g.,
early morning aw akening, d epression w orse in
the morning). The patients d epressive symp -
toms are too acute and severe for ad ju stment
d isord er, and d ont last 2 years w hich w ould
be necessary for persistent d epressive d isor-
d er (d ysthymia). Although hypersomnia (and
insom nia) may be d ue to a sleep d isord er, the
patients symptom s are better accounted for by
a major d epressive d isord er.
56. (C) Id entification is an u nconsciou s d efense
m echanism in w hich the p erson incorporates
the characteristics and qu alities of another
p erson or object into his or her ow n ego sys-
tem . The d efense serves to strengthen the ego.
Fixation refers to an overactive attachm ent to
a p erson or object; id ealization is the attribu-
tion of near-perfect, u nrealistic attribu tes to
that person or object. Projection is the false
attribu tion of ones ow n u nacceptable feelings
to another. Regression, an im mature d efense,
is an em otional and physical retreat from ad ult
stand ard s of behavior tow ard an infantile level
of passivity and d ep end ence.
57. (D ) The essential featu re of the catatonia
observed in p atients w ith schizop hrenia (as
w ell as m ood d isord ers w ith p sychotic fea-
tu res) is a m arked p sychom otor d istu rbance
involving m otor im m obility, excessive m otor
activity, mutism, negativism, peculiar volun-
tary movements, echolalia (parrot-like senseless
repetition of w ord s or phrases), or echopraxia
(im itation of movem ents of another person).
Catalepsy, a term for an imm obile position
that is maintained , is one potential symptom
of catatonia, and is not a com p lete answ er.
Catap lexy is a su d d en and brief loss of m u scle
tone involving either a few m u scle grou p s or
m ost of the antigravity m u scles of the bod y;
236 7: Pra c tic e Te s t 1
it is not u ncomm on in patients w ith narco-
lepsy. H is d iagnosis of schizophrenia, and the
fact that the patient occasionally m imics the
movements of others, makes seizu re activity
unlikely.
58. (B) This patient w ou ld be d iagnosed w ith
bip olar d isord er, typ e I, cu rrent ep isod e
d ep ressed . The treatm ent of bipolar d epres-
sion is tricky. Lam otrigine is likely the m ost
effective in treating bip olar d ep ression and
as m aintenance treatm ent to prevent relapse
of d epression. First-generation antipsychotics
like halop erid ol are not effective in treating
bip olar d ep ression; how ever, atyp ical anti-
p sychotics (e.g., qu etiap ine) can be beneficial.
While lithiu m is first-line treatm ent for acu te
m ania and p reventing fu rther m anic ep isod es,
it is not as effective in treating the d ep ressed
p hase of bipolar d isord er. Monotherapy w ith
an antid ep ressant like sertraline shou ld be
avoid ed as it can p rovoke a m anic ep isod e in
p atients w ith bip olar d isord er. Valp roic acid
(Depakote) is another m ood stabilizer prim ar-
ily u sed to treat m ania and as m aintenance,
bu t it is not as efficaciou s in the treatm ent of
d ep ression in this popu lation.
59. (E) Priapism can occu r w ith a num ber of anti-
d ep ressant or antip sychotic agents bu t occurs
m ore frequ ently w ith the u se of trazod one
(1 in 1,000 to 1 in 10,000 incid ence). The three
serotonin-sp ecific reu ptake inhibitors (fluox-
etine, p aroxetine, and sertraline) listed can
cause d ecreased sex d rive and im potence, bu t
are u nlikely to cau se priap ism . N ortrip tyline
is a tricyclic antid ep ressant and not associated
w ith p riap ism .
60. (D ) While p riap ism u su ally occu rs w ithin
the first 4 w eeks of treatm ent, it can occu r at
any tim e. It is also ind ep end ent of d ose. Pria-
p ism , esp ecially lasting over several hou rs, is
a m ed ical em ergency and m ay requ ire su r-
gery to p revent p ossible necrosis, scarring,
and im p otence. Ejacu lation d oes not alw ays
red u ce the erection. Priap ism m ay requ ire
d raining blood from the corp u s caverno-
su m or intracavernosal injection of an alp ha-
ad renergic agonist to p rom ote d etu m escence
and constriction of veins. The offend ing m ed -
ication shou ld be im m ed iately stop p ed and
not restarted , as p rior p riap ism p red isp oses
to fu tu re ep isod es.
61. (B) The p atient is m ost likely su ffering from
generalized anxiety d isord er (GAD). Treat-
m ent of GAD inclu d es antid ep ressants su ch
as serotonin-sp ecific reup take inhibitors,
benzod iazep ines, bu sp irone, and cognitive-
behavioral therap ies. H ow ever, benzod iaz-
ep ines (su ch as alp razolam , d iazep am , and
lorazep am ) shou ld be avoid ed in p atients
w ith resp iratory com p rom ise, becau se these
m ed ications can exacerbate breathing-related
d isord ers, and they carry the risk of ad d iction.
Bu sp irone, a nonbenzod iazep ine anxiolytic,
is a logical alternative and has been d em -
onstrated to be effective in the treatm ent of
GAD. Beta-blocking agents such as proprano-
lol are effective in certain anxiety d isord ers,
such as social anxiety d isord er (social phobia),
bu t shou ld not be first-line therap y in p atients
w ith chronic obstru ctive p u lm onary d isease
or other respiratory d isord ers.
62. (E) The long-term u se of benzod iazepines
(lorazepam , oxazepam , and tem azepam ) for
sleep is controversial, especially in p atients
w ith su bstance u se or breathing-related d isor-
d ers. Zaleplon is not a m em ber of the benzo-
d iazepine class but d oes prod u ce its effects at
the gam m a-am inobu tyric acid (GABA)-ben-
zod iazepine recep tor and has a low er risk of
p hysical d ep end ence. A nonbenzod iazep ine
m ed ication is a logical alternative in cases in
w hich resp iratory fu nction is com p rom ised .
Dip henhyd ram ine shou ld be avoid ed in the
old er population d ue to its anticholinergic
effects and p otential d eliriu m .
63. (D ) H yp ertensive crisis is a life-threatening
em ergency that m ay resu lt from the com bina-
tion of m ep erid ine (Dem erol) and an MAOI.
The com bined u se of these m ed ications is
absolu tely contraind icated . The treatm ent of
hypertensive crisis is w ith IV alp ha-ad rener-
gic blocking agents and ICU ad m ission and
supp ort. All of the other m ed ications are safe
in com bination w ith MAOIs.

64. (C) The use of any m ed ications in pregnancy
requ ires exam ining the risks and benefits of
treatm ent. The u se of MAOIs is contraind i-
cated in pregnancy partly because they can
exacerbate pregnancy-ind u ced hypertension.
Althou gh ECT is safe in p regnancy, m ainte-
nance ECT is ind icated only after an initial
cou rse of ECT is com pleted . The safety of
new er antid epressants has not yet been com -
p letely established , bu t stu d ies of flu oxetine
su ggest that it is relatively safe. In this case,
after d iscontinu ing the MAOI, there w ou ld
have to be a 14-d ay w ashou t before initiating
flu oxetine. Most recom m end ations regard ing
the course of treatm ent for a single episod e
of MDD are for 9 to 12 m onths of p harm a-
cotherapy. The retu rn of sym ptom s su ggests
a recu rrent MDD that requ ires longer-term
p harm acotherap y. Of cou rse, ongoing d is-
cussion w ith and ed ucation of the patient are
essential.
65. (B) The patient presents w ith clinical sym p -
tom s of Wernicke encephalopathy, a m ed ical
em ergency, characterized by op hthalm op le-
gia, ataxia, and d eliriu m , cau sed by acu te thia-
m ine d eficiency. If the thiam ine d eficiency is
not corrected , Korsakoff synd rom e can em erge
characterized by chronic p ersisting am nesia.
Korsakoff synd rom e resu lts from chronic thi-
am ine d eficiency w ith resu ltant p athology in
the m am m illary bod ies and the thalam u s. A
history of heavy alcohol use is com m on bu t
other cau ses of thiam ine d eficiency su ch as
starvation, p rolonged vom iting, and gastric
carcinom a can cause this synd rom e. The u se
of IV d extrose prior to the ad m inistration of
thiam ine m ay aggravate Wernicke encepha-
lop athy. The other interventions m ay be
ap prop riate if thiam ine d oes not resolve the
sym ptom s.
66. (E) Accord ing to the AMAs cod e of ethics
A p hysician shall be d ed icated to provid -
ing com p etent m ed ical care, w ith com p assion
and resp ect for hu m an d ignity and rights.
In the event a p hysician is concerned abou t
w hether he or she is able to rem ain im p artial
and p rovid e ad equ ate p sychiatric treatm ent,
the physician shou ld seek a consu ltation w ith
Answe rs : 5869 237
an u nbiased colleagu e or su p ervisor to d is-
cuss the issues and ultim ately d eterm ine w hat
w ou ld be in the best interest of the p atient. It
m ay be that another physician in the clinic or
com m u nity w ou ld better serve the p atients
need s, but this w ould best be d eterm ined after
a consu ltation. To lim it the tim e spent w ith
the p atient is not ap prop riate and can consti-
tu te d iscrim ination. While it is im portant to
be aw are of the p atients p rogress in therap y,
the physician m u st first process his or her ow n
p artiality to d eterm ine w hether a therap eu tic
alliance can be established and m aintained .
67. (B) Caffeine withdrawal occurs after the abrupt
cessation or a m arked red uction in the use
of caffeinated prod ucts. Stud ies estimate that
approximately 50% of caffeine users w ill expe-
rience symptoms of w ithdraw al at some point.
Caffeine w ithd raw al sym p tom s have their
onset 12 to 24 hou rs after the last d ose, and
symptoms peak in 24 to 48 hours. Symptoms
typ ically rem it in 1 w eek. Althou gh all the
p ossible choices are associated w ith caffeine
w ithdraw al, up to 50% of sufferers experience
head ache, the most common symptom.
68. (E) This p atient is m ost likely su ffering from
neu roleptic m alignant synd rom e (N MS). N MS
is characterized by m u scu lar rigid ity, confu -
sion, m u tism , agitation, and elevated au to-
nom ic signs. Death is rep orted in u p to 20% of
cases, u su ally from a failu re to recognize the
synd rom e or from d elayed treatm ent. Discon-
tinu ation of the offend ing agent and sup port-
ive treatm ent in an ICU setting is im p erative.
IV d antrolene sod iu m and oral brom ocrip tine
have been u sed bu t their benefits are u nclear.
Cooling measures may reduce hyperthermia.
The exact frequency of NMS remains unknow n,
w ith some studies suggesting up to 2.4% of all
patients treated w ith antipsychotics experienc-
ing this synd rome. NMS may be more frequent
in men and younger patients. N aloxone d oes
not have a place in the treatment of N MS.
69. (D ) An elevated seru m CPK d em onstrates
m uscle inju ry. Since liver transam inases (AST,
ALT) are also fou nd in m u scle, these m ay be
elevated . Elevated BUN m ay occu r d u e to
238 7: Pra c tic e Te s t 1
d ehyd ration resu lting from N MS but is not as
com m on as creatinine or CPK elevation. Leu -
kocytosis is also seen in N MS. Anem ia is not
fou nd in N MS.
70. (C) Physical d epend ence emp hasizes the pres-
ence of tolerance or w ithd raw al. N aloxone
injection can precipitate opiate w ithd raw al in
d epend ent persons. Positive urine toxicology
or breath analysis can id entify only su bstance
use, not necessarily physiological d ep end ence.
Elevated heart rate can be p resent in m any
w ithd raw al synd rom es or m ed ical d isor-
d ers and is not sp ecific for any su bstance.
Elevated liver fu nction stu d ies can be p res-
ent in ind ivid u als w ho u se heavy am ou nts of
alcohol, bu t can also be p resent in other non
su bstance-related d isord ers.
71. (E) Major neu rocognitive d isord ers (d em en-
tias) are characterized by m em ory d eficits
and cognitive d istu rbances w ithou t im p aired
consciousness. (This d ifferentiates it from
d elirium characterized by a w axing and w an-
ing consciou sness.) The m ost com m on typ e of
m ajor neu rocognitive d isord er (d em entia) is
d ue to Alzheim er d isease (60%). Major vascu -
lar neu rocognitive d isord er is the second m ost
com m on typ e of d em entia, occu rring in 10%
to 20% of cases. Other d egenerative p rocesses
that cause m ajor neurocognitive d isord ers
(d em entias) are Parkinson d isease, H u n-
tington d isease, and Pick d isease. Infectious,
m etabolic, end ocrine, neop lastic, and toxic
p rocesses can also cau se neurocognitive d isor-
d ers (d em entias), so a com p lete w orkup for a
reversible cau se is essential. This p atients his-
tory reveals a m egaloblastic anem ia, the cau se
of w hich m ay be a vitam in B12 d eficiency,
likely second ary to a gastrectom y. Folate d efi-
ciency can also cau se m egaloblastic anem ia.
Vitam in d eficiencies su ch as B12 and folate can
cause clinical signs of m ajor neu rocognitive
d isord ers (d em entias), and they represent one
of a few possible reversible cau ses of this p ro-
cess. A com p lete reversible w orku p for neu-
rocognitive d isord ers (d em entias) shou ld also
inclu d e thyroid fu nction stu d ies and a rap id
p lasm a reagin to test for syp hilis. While an
MRI w ou ld be im portant, it is not necessarily
d iagnostic of a p articu lar neu rocognitive d is-
ord er (d em entia).
72. (B) Lithiu m , com m only u sed to treat bip olar
d isord er, can be d angerou s in intoxication
and can lead to d eath or p erm anent d am -
age to the nervou s system , p articu larly the
cerebellu m . Card iovascu lar and renal m ani-
festations m ay also be p resent. Lithiu m has
a narrow therap eu tic w ind ow w ith a thera-
p eu tic range of 0.6 to 1.2 m Eq/ L. Plasm a
concentrations above the therap eu tic range,
esp ecially greater than 2.0 m Eq/ L, p recip itate
severe CN S and renal impairm ent. Early clini-
cal signs of intoxication includ e d ysarthria,
coarse trem or, and ataxia. Im paired consciou s-
ness, fascicu lations or m yoclonu s, seizu res,
and com a are om inou s m anifestations. The
goal of treatm ent is rem oval of lithiu m from
the bod y. Gastric lavage, rehyd ration, and
hem od ialysis are possible interventions. Given
the d anger of lithiu m intoxication, a seru m
d rug level should be obtained before any of
the other interventions.
73. (E) A right parietal stroke w ould most likely
d emonstrate abnormalities in visual, nonverbal
m em ory.
74. (B) The ReyOsterrieth Test is a com p lex figu re
that the p atient is asked to cop y w hile looking
at the figu re. The figu re is then taken aw ay
and the p atient is asked to d raw the p ictu re
from im m ed iate m em ory. The p atient is again
asked to d raw the figu re 5 m inu tes and 30 m in-
u tes after the figu re has been rem oved . The
tasks assess visu al nonverbal m em ory. Peo-
p le w ith right p arietal lesions u su ally show
abnorm alities in cop ying the figu re correctly
by neglecting the item s in the left visu al field .
Conversely, a p atient w ith a right tem p oral
lobectom y m ay have no d ifficu lty in cop ying
the figu re, bu t show m arked abnorm alities in
d raw in g th e item from m em ory. Th e Min -
n esota Mu ltip h asic Person ality In ven tory,
Rorschach Test, Wechsler Intelligence Scales,
and Wisconsin Card Sorting Test w ou ld not
be as u sefu l in assessing a right p arietal lesion.

75. (A) Baseline m ed ical tests should be obtained
and d ocum ented before starting m any psycho-
tropic med ications, includ ing the mood stabi-
lizers lithium , carbam azepine, and d ivalproex
sod ium. As lithiu m has a narrow therapeu tic
w ind ow and is renally excreted , assessm ent
of kid ney function w ith BUN and creatinine
is essential prior to starting lithium. Lithium
can cause a benign leukocytosis, but a CBC
isnt necessary prior to initiation. Revers-
ible T-w ave changes on the ECG are also
com mon, but an ECG is only necessary in an
old er patient or one w ith card iac d isease. Liver
function tests are not necessary, but monitor-
ing thyroid function during treatment w ith
lithium is im portant.
76. (D ) The serotonin synd rome occurs w hen an
SSRI is combined w ith another d rug that can
potentiate serotonin, particularly the mono-
amine oxid ase inhibitors. Symptoms of the
synd rome includ e abd ominal pain, d iarrhea,
d iaphoresis, hyperpyrexia, tachycard ia, hyper-
tension, myoclonus, irritability, agitation, sei-
zu res, and d eliriu m. Com a, card iovascu lar
collapse, and d eath have been reported . In this
case, the serotonergic effects of fluoxetine are
potentiated by the MAOI. Fluoxetine has a
prolonged half-life w ith active metabolites that
require up to 6 w eeks clearance time. Treat-
ment w ith the MAOI w as initiated before ad e-
quate w ashout of the fluoxetine and resulted in
the serotonin syndrome. Management involves
d iscontinuation of the offending agent and
supportive care. There is no evid ence that the
patient w as not compliant w ith a tyramine-free
d iet, w as using hallucinogens, or that she w as
taking antipsychotics, w hich w ould be consis-
tent w ith the remaining choices.
77. (B) Bu lim ia nervosa, m ore com m on than
anorexia nervosa, consists of rep eated ep i-
sod es of binge eating of large am ou nts of
food associated w ith the feeling of being ou t
of control. The p atient u su ally p u rges by
self-ind u ced vom iting, rep eated laxative or
d iu retic u se, or excessive am ou nts of exer-
cise to p revent w eight gain. Unlike ind ivid u -
als w ith anorexia nervosa, ind ivid u als w ith
Answe rs : 7080 239
bu lim ia nervosa u su ally m aintain a norm al
or above-norm al bod y w eight. Med ical com -
p lications of bu lim ia nervosa are u su ally
second ary to either chronic vom iting or laxa-
tive abu se. They inclu d e flu id and electrolyte
im balances (su ch as alkalosis, hyp okalem ia,
hyp ochlorem ia, and d ehyd ration); d ental car-
ies and enam el loss; gastrointestinal d istu r-
bances su ch as esop hagitis, MalloryWeiss
tears, and constip ation; and sore throat.
78. (B) SSRIs, TCAs, MAOIs, and top iram ate
have all been show n to be effective in red u c-
ing bingeing and p u rging behavior, even in
the absence of a m ood d isord er. Bu p rop ion,
w hile an antid ep ressant, shou ld be avoid ed
d u e to the increased risk of seizu res from
electrolyte abnorm alities. N either antim anic
agents, su ch as lithiu m and valp roic acid , nor
antip sychotics, su ch as risp erid one, are ben-
eficial in treating bu lim ia nervosa.
79. (B) The Boston Diagn ostic Ap hasia Exam in a-
tion is a com p rehensive set of tests given by
a skilled interview er to evalu ate ap hasic d is-
ord ers and to help d efine fu rther interven-
tions to im p rove sp eech. The Bend er Gestalt
Test is a constru ctional test for evalu ation of
brain d am age and h as som e ability to d if-
ferentiate the location of th e lesion. The Fol-
stein MMSE is u sed for rap id screening for
neu rocogn itive d isord ers (d em en tias) and
d eliriu m . The Sentence Com p letion Test is
a p rojective test u sed to d escribe p ersonality
stru ctu re. The Stroop Test aid s in the evalu a-
tion of concentration.
80. (E) Anorexia nervosa is characterized by a
d eliberate self-im p osed starvation in the p u r-
su it of being thin, d riven by a fear of being
fat. The p atient refu ses to m aintain accep ted
norm al bod y w eight appropriate for age and
height. Und erd eveloped breasts, lanugo (fine,
d ow ny hair), abnorm al insu lin secretion,
end ocrine d isord ers, and am enorrhea are also
associated w ith this d isord er. Com plications
inclu d e osteop orosis, constip ation, cold intol-
erance, leu kop enia, thyroid d ysfu nction, and
card iac arrhythm ias.
240 7: Pra c tic e Te s t 1
81. (C) Anorexia nervosa has a fair p rognosis
overall; app roxim ately 50% of p atients have
good ou tcom es (inclu d ing significant w eight
gain), 25% have interm ed iate ou tcom es, and
25% have poor ou tcom es.
82. (B) Bereavem ent is consid ered to be a nor-
m al response to the d eath of a loved one, and
it is not a m ental illness. It is typ ical for the
bereaved to have intense feelings of em p tiness
that w ax and w ane. It is also not u nu su al to
believe they hear the voice of the d eceased ,
although these experiences are brief and
insight is m aintained . If this p atient m et cri-
teria for m ajor d epression, then she w ou ld be
d iagnosed as su ch; how ever, in this case she
d oes not m eet the fu ll criteria (e.g., ap p etite
change, poor concentration, anhed onia). Up to
30% of bereaved ind ivid u als d evelop a m ajor
d ep ressive ep isod e, so it is im p ortant to m oni-
tor sym ptom s closely. Ad ju stm ent d isord er
cannot be d iagnosed if the ind ivid u al su ffers
from norm al bereavem ent. Persistent d ep res-
sive d isord er (d ysthym ia) requ ires 2 years
of sym ptom s m arked by a d epressed m ood .
There is no evid ence of a p rim ary p sychotic
d isord er su ch as schizoaffective d isord er, nor
have the fu ll sym p tom s been present for the
ap prop riate am ou nt of tim e. In ad d ition, her
age of onset w ou ld be extrem ely u nu su al for
su ch a d iagnosis.
83. (C) Most bereaved d o fine w ithou t treatm ent.
Sup port and reassurance u sually com e from
fam ily, friend s, or clergy. When the bereaved
feel u nable to m ove beyond the grief, p sycho-
therapeu tic m easu res are appropriate. The
treatm ent of anxiety or insom nia w ith m ed i-
cations rem ains controversial, bu t m ed ica-
tions m ay be w arranted if cognitive or other
higher fu nctions of d aily living are su bstan-
tially affected .
84. (A) The treatm ent of p atients w ith obsessive-
com pu lsive d isord er (OCD) requ ires integrat-
ing m u ltip le treatm ent m od alities inclu d ing
m ed ications, p sychotherapy, and collateral
su pp ort system s. One of the first m ed ications
show n to be effective for OCD w as clom ip-
ram ine, a TCA, althou gh the sid e effects and
risk of overd ose m ake this a second -line m ed i-
cation. SSRIs are also very effective in treat-
ing sym p tom s of OCD, bu t u su ally at d oses
higher than those used to treat d ep ression.
Antip sychotic agents are u sed in conju nction
w ith antid ep ressants in very severe, intrac-
table cases, bu t are not u sually ind icated as
ind ivid u al agents. Antiep ilep tics and lithiu m
are not ind icated for the treatm ent of OCD.
Anxiolytic agents su ch as benzod iazep ines
are of little u se in treating the obsessions or
com pu lsions of OCD.
85. (C) The concern in this case is that the p atient
is lying abou t her m em ory p roblem , therefore
m alingering. When given tests of m em ory,
m alingerers tend to not put forth genuine
effort. The Test of Mem ory Malingering can
help assess this effort. It consists of a subject
being p resented 50 p ictures; they are then
p resented card s and asked if they had seen
a given card before. Perform ance below the
od d s of chance ind icates high likelihood of
intentionally changing a correct answ er to
an incorrect one in ord er to falsify resu lts.
The Benton Visu al Retention Test m easu res
visu al perception and m em ory, and is u sed to
help id entify learning d isabilities. The Clock
Draw ing is u sed as p art of a screen for cog-
nitive im pairm ent and spatial d ysfu nction in
neu rocognitive d isord ers, such as d em entias.
The Wechsler Intelligence Scale is an IQ test
for late ad olescents and ad u lts, w hile the Wis-
consin Card Sorting Test is a neuropsycholog-
ical test for set-shifting, d etecting frontal lobe
d am age from a variety of cau ses.
86. (C) Obstructive sleep apnea hypopnea is d iag-
nosed w ith polysomnographic evid ence of
either: (1) Five obstructive apneas or hypopneas
per hour w ith snoring/ gasping or d ay times
sleepiness/ fatigue or (2) 15 or more obstructive
apneas or hypopneas per hour regard less of
associated symptoms. It is increased in males,
old er ad ults, and the obese. Circad ian rhythm
sleepw ake d isord ers are characterized by pat-
terns of sleep d isruption d ue to alterations of
the circad ian rhythm system (e.g., shift w ork).
There is no other evidence for major depres-
sion in this patient. The criteria for REM sleep

behavior disorder include repeated episodes of
arousal during sleep w ith vocalization and/ or
motor behaviors occurring only d uring REM
sleep. Patients w ith restless legs synd rome
have an urge to move the legs accompanied
by feelings of uncomfortableness. The urges
are w orsened at rest and at night, and relieved
w ith movement.
87. (C) N asal continu ou s p ositive airw ay p ressu re
(CPAP) is the treatm ent of choice for obstruc-
tive sleep apnea. N o m ed ications are consis-
tently effective in norm alizing sleep in these
p atients. The use of nasal CPAP ap p ears to
p revent long-term m orbid ity and m ortality
and provid es restorative sleep . Su rgical p ro-
ced ures su ch as those listed are reserved for
CPAP treatm ent failures.
88. (A) Anticholinergic toxicity can be cau sed
by many psychotropic medications. The low -
p otency agen ts chlorp rom azine and thio-
rid azine and the TCAs am itrip tyline an d
im ip ram ine are p articu larly anticholinergic.
The synd rom e often resu lts w hen an anticho-
linergic m ed ication, su ch as benztrop ine, is
coad m inistered w ith an antipsychotic m ed i-
cation in ord er to prevent or treat extrap yra-
m id al sid e effects su ch as p arkinsonism and
d ystonia. Clinical features of anticholinergic
toxicity includ e d ecreased secretions, agita-
tion, d ry skin, flu shing of the skin, hyp er-
therm ia, tachycard ia, d ilated p upils, urinary
retention, constip ation, and hyp otension. Sei-
zu res, hallu cinations, and com a m ay resu lt
from severe intoxication. Drugs that inhibit
the enzym e that breaks d ow n acetylcholine
(anticholinesterase m ed ications such as phy-
sostigm ine) reverse the synd rom e and are
u su ally ad m inistered IV w ith ap p rop riate
m onitoring. Atrop ine w ou ld fu rther increase
the heart rate; benzod iazep ines are reserved
for u se in agitation and anxiety, and haloperi-
d ol m ay w orsen anticholinergic sym ptom s.
89. (A) Anticholinesterase toxicity, m anifesting as
nausea, vom iting, brad ycard ia, and seizu res,
resu lts from excessive action of acetylcholine at
specific receptors. Atropine, an antim uscarinic
agent, can reverse the symptoms. Epinephrine
Answe rs : 8191 241
w ould treat the brad ycard ia w ithout treat-
ing the und erlying cond ition. Physostigm ine
w ould w orsen the toxicity. Although prochlor-
perazine w ould com bat vomiting, it w ou ld not
treat the u nd erlying cond ition and also might
w orsen the anticholinergic toxicity.
90. (D ) This w om an appears to suffer from both a
major d epressive d isord er (MDD), single epi-
sod e, as w ell as obsessive-comp ulsive d isord er
(OCD). Serotonin-specific reuptake inhibitors
(SSRIs) are used to treat a variety of psychiatric
d isord ers, includ ing both MDD and OCD. Flu-
voxamine is an SSRI p articu larly ind icated for
both d epression and OCD. Buspirone is a non-
benzod iazepine m ed ication used to treat gen-
eralized anxiety d isord er but is not efficacious
for OCD. Clomipramine is a tricyclic antid e-
pressant (TCA) w ith significant serotonergic
effects and is particu larly u sefu l in OCD; d ox-
epin is also a TCA, bu t given the tolerability
and sid e effect profile and safety in overd ose,
SSRIs are preferred as first-line therapy for
MDD and OCD. Phenelzine is a m onoam ine
oxid ase inhibitor (MAOI) w hich can be u sed
for d epression. H ow ever, the d rugd rug inter-
actions and d ietary restrictions make MAOIs a
second - or third -line therapy.
91. (D ) The p atient is beginning to have sym p tom s
of alcohol w ithd raw al. Because they act at the
sam e GABA receptors as alcohol, the benzo-
d iazepines are the preferred m ed ications used
in d etoxification from alcohol. For u ncom -
p licated d etoxification, the long-acting ben-
zod iazepines su ch as chlord iazepoxid e and
d iazepam are appropriate because they are
essentially self-tap ering. The shorter-acting
benzod iazep ines su ch as lorazep am or oxaz-
ep am are u sed in p atients w ith im p aired liver
fu nction, such as in this case, becau se they
are not d ep end ent on liver fu nction for their
m etabolism and d o not accu m u late. Patients
w ith u nstable m ed ical p roblem s, cognitive
im p airm ent, or old age are also cand id ates
for the shorter-acting m ed ications. Disu lfi-
ram , w hich interferes w ith the m etabolism of
alcohol, is reserved for long-term behavioral
therapy of alcohol u se d isord er. Phenobarbital
w as form erly u sed for d etoxification and
242 7: Pra c tic e Te s t 1
has been replaced by benzod iazepines d u e
to safety concerns and the risk of respiratory
d ep ression.
92. (D ) The patient is experiencing hallucinations
likely due to alcohol w ithd raw al. Benzod iaz-
epines w ill treat the underlying w ithdraw al as
w ell as the hallucinations. The patient show s
no evid ence of either a d epressive d isord er that
should be treated w ith sertraline or fluoxetine
(SSRIs), or a bipolar disord er that w ould bene-
fit from lithium, a mood stabilizer. An antipsy-
chotic, such as haloperid ol, is unnecessary and
may also red uce the seizure threshold .
93. (E) Ethanol is metabolized in the liver via alco-
hol d ehyd rogenase to acetald ehyd e, w hich is
then enzymatically converted to acetate by the
enzyme acetaldehyde dehydrogenase. Disul-
firam is a med ication that irreversibly inhibits
the action of ald ehyd e d ehyd rogenase. Acet-
ald ehyde accumulates and accounts for the
aversive effects associated w ith the disulfiram
reaction. Flushing, sw eating, d yspnea, hyper-
ventilation, tachycard ia, hypotension, nausea,
and vomiting are common symptoms. Extreme
but rare reactions can result in respiratory
d epression, card iovascular collapse, myocar-
d ial infarction, seizures, and d eath. Blurred
vision an d u rinary retention are an ticholin -
ergic effects associated w ith an tip sych otic,
antid epressant, and antip arkinsonian m ed i-
cations. Eup horia w ou ld not be exp erienced
w hen alcohol is com bined w ith d isu lfiram .
H ypertension m ay be associated w ith, bu t is
not characteristic of, the d isu lfiram -ethanol
reaction. Disu lfiram is not recom m end ed for
p atients w ith m od erate to severe liver d isease,
renal failu re, severe card iac d isease, p reg-
nancy, or peripheral neu ropathy.
94. (D ) Many nonsteroid al anti-inflam m atory
d rugs can d ecrease the clearance of lithium and
p rod u ce significant increases in serum levels.
Ibu p rofen, ind om ethacin, ketop rofen, d iclof-
enac, nap roxen, and p iroxicam have all been
rep orted to p rod u ce su ch p otential d anger-
ou s interactions. The sym ptom s of abd om inal
p ain, d iarrhea, and d row siness ind icate m ild
to m od erate (1.52.0 m Eq/ L) lithiu m toxicity.
Acetaminophen, aspirin, and the opiates do not
interfere w ith lithium clearance. Meperid ine,
how ever, can cause d angerous interactions
w ith MAOIs.
95. (D ) Given the p atients p rior m ajor d ep ressive
ep isod e and cu rrent sym p tom s, treatm ent
w ith antid ep ressants is w arranted . H ow ever,
the patient is concerned abou t sexual d ysfunc-
tion, a very com m on sid e effect (up to 80% in
som e stu d ies) of serotonin-sp ecific reup take
inhibitors su ch as citalop ram . Mirtazap ine
is an antid ep ressant w hich has the effect of
increasing both ad renergic and serotonergic
neu rotransm ission, thu s im p roving d epres-
sion, bu t w ithout cau sing appreciable sexual
d ysfunction. All the other m ed ication choices
w ou ld likely equ ally cau se p roblem s w ith
sexual functioning.
96. (D ) While the u su al antid ep ressants (e.g.,
TCAs, SSRIs) are all effective in treating
d ep ression in a patient w ith H IV, the rapid
onset of action of stim ulants like m ethylphe-
nid ate w ou ld be p articu larly beneficial, esp e-
cially in a m ed ically com prom ised p atient
w ho is at risk of d ehyd ration and starvation.
Bu p rop ion, flu oxetine, and sertraline m ay take
u p to 4 to 6 w eeks for fu ll benefit. Bu sp irone
is a nonbenzod iazep ine anxiolytic m ed ication
not ind icated in the treatm ent of d ep ression as
m onotherap y.
97. (A) Attention refers to the ability to give focu s
to a cognitive task. Perform ing serial sevens
(as in this case) and spelling w orld back-
w ard are tests of attention. Althou gh a certain
facility w ith the rem aining choices is necessary
to perform each task (no cognitive function is
tested in absolu te isolation), the serial sev-
ens test p rovid es a w ind ow on a p atients
concentration. Fu nd of know led ge inclu d es
inform ation the p atient read ily has available
to him or her; know led ge of cu rrent events
is often u sed to assess this. The m ental sta-
tu s exam ination m ay contain tests of m ath-
em atics skills, bu t testing m athem atics skills
is not the p u rp ose of the serial sevens test.
Recent m em ory is recall of events occu rring
in the last several m inu tes. Rem ote m em ory

involves the recall of events long p ast, for
exam p le, inform ation from a p atients child -
hood . Any test of cognitive fu nction m u st
take into accou nt the p atients cu ltu ral, ed u -
cational, and social backgrou nd .
98. (B) Inhalant use is commonly a social activity
und ertaken in groups. Volatile or toxic solvents
such as toluene (found in glues and ad hesives),
trichloroethane (found in correction fluid ), or
hyd rocarbons (gasoline) are placed in a bag and
the fumes are inhaled . The practice is know n as
huffing, sniffing, or bagging. Effects are almost
immed iate because the substances are rapid ly
absorbed . Signs and symptoms of intoxication
includ e visual d isturbances, d yscoord ination
(a d runken appearance), d epressed reflexes,
euphoria, and nystagmus. Conjunctival injec-
tion and increased appetite are consistent w ith
cannabis use. A d iminished response to pain,
euphoria, and staring into space are character-
istic of PCP intoxication.
99. (A) Abstinence is the only treatm ent for inhal-
ant u se d isord er. Antid ep ressants have not
show n utility in inhalant u se d isord er. Anti-
p sychotic agents are also not effective and
m ay aggravate the p resentations of inhalant
intoxication. Agitation can be m anaged by
benzod iazep ine m ed ications su ch as loraz-
ep am . Dialectical-behavioral therap y is a form
of cognitive-behavioral therap y used in bor-
d erline personality d isord er. Exposu re and
resp onse p revention is a cognitive-behavioral
therapy u sed in the treatm ent of anxiety d isor-
d ers su ch as obsessive-com pu lsive d isord er.
100. (B) This p atient su ffers from treatm ent refrac-
tory schizophrenia. H e has had fou r m ed ica-
tion trials, includ ing both typical and atypical
antip sychotics. Given his ad equ ate trials, prior
com pliance, and ongoing sym ptom s, he is an
ap propriate cand id ate for clozap ine, the first
atypical antip sychotic and the only one that
d em onstrates su p erior efficacy in treatm ent-
refractory sch izop hren ia. While taking it
requ ires frequ ent m onitoring of his com p lete
blood cou nts, that fact that he lives w ith his
m other w ill increase the likelihood of his com -
p liance. N either aripiprazole and zip rasid one,
Answe rs : 92103 243
atyp ical or second -generation antip sychot-
ics, nor flu p henazine, a typ ical antip sychotic,
w ou ld be as effective as clozap ine in this
case. Given his ongoing sym p tom s, restarting
qu etiap ine w ou ld not be ap p rop riate in this
p atient.
101. (C) Divalp roex sod iu m , ind icated for the treat-
m ent of seizu res as w ell as bip olar d isord er,
can occasionally cau se significant hair loss
that is usu ally reversible. Other com m on sid e
effects associated w ith d ivalp roex sod iu m
are nausea, vom iting, and ind igestion. Sed a-
tion and m ild ly elevated seru m transam inase
levels m ay also be seen. Rare occu rrences of
hep atic failu re resu lting in fatalities have hap -
p ened , u sually d u ring the first 6 m onths of
treatm ent. H air loss is not associated w ith car-
bam azep ine, clozap ine, olanzap ine, or zip ra-
sid one, althou gh these m ed ications have their
ow n sid e effects.
102. (A) Sexual d ysfu nction is a very com m on sid e
effect associated w ith the serotonin-sp ecific
reu p take inhibitors (SSRIs), su ch as citalo-
p ram , w ith an incid ence of ap proxim ately 50%
to 80%. Decreased libid o and d elayed orgasm
are the m ost com m on sym p tom s, bu t erectile
d ysfunction is also not uncom m on. All SSRIs
ap p ear to be equally as likely to cau se sexu al
d ysfunction. Priapism is a rare bu t seriou s sid e
effect of trazod one. Retrograd e ejacu lation is
a know n sid e effect of certain antipsychotic
m ed ications. Sexually transm itted d iseases are
not increased w ith SSRI (or any antid ep res-
sant) use. Variou s p harm acologic strategies
aim ed at treating sexu al d ysfu nction inclu d e
bu p rop ion and p hosp hod iesterase-5 inhibi-
tors, and less commonly methylphenid ate and
bu sp irone.
103. (A) ADH D is a d isord er of u nclear etiology.
As m any as 5% of child ren su ffer from this
d isord er, and ap proxim ately half of those
d iagnosed carry the d iagnosis into ad u lthood .
The d isord er is characterized by sym p tom s
of inattention, hyperactivity, and im p ulsivity
that are inappropriate for age. Although the
DSM -5 criteria require that sym p tom s m ust
have been present before the age of 12 years,
244 7: Pra c tic e Te s t 1
m any cases are not d iagnosed u ntil ad oles-
cence or ad u lthood . In these cases, a retro-
spective history from both the patient and
the fam ily often su pport the presence of early
life sym p tom s. Althou gh som e sym p tom s are
rem iniscent of the m anic com p onent of bip o-
lar d isord er, these d isord ers rep resent tw o
separate entities. A carefu l history by astu te
p hysicians w ill secu re the p rop er d iagnosis.
Dep ressive, anxiety, and su bstance-u se d is-
ord ers are com m on com orbid cond itions that
often m ake the d iagnosis of ADH D m ore d if-
ficult. The absence of prom inent m ood sym p-
tom s and the relative d egree of im pairm ent
help d istingu ish ADH D from other d isord ers.
104. (D ) The app roach to the treatm ent of the core
sym ptom s of ADH D has been the initiation of
a trial of a p sychostim u lant m ed ication, su ch
as m ethylp henid ate. Often, if one stim u lant
fails to treat sym p tom s, another stim u lant is
p rescribed . Many patients benefit from one
stim ulant and not another. Given his par-
tial response and tolerability, the appropriate
choice in this case w ould be to try a second type
of stimulant before the alternative strategies
are im plem ented .
105. (A) Dj entend u is the feeling that one is hear-
ing som ething one has heard before. It is u su -
ally associated w ith anxiety states or fatigu e.
Dj vu is a sim ilar exp erience, bu t refers to
the sensation that som ething has been seen
before. Jam ais vu is the op p osite of d j vu in
that it refers to som ething that shou ld be fam il-
iar bu t seem s qu ite u nfam iliar. Folie d eu x is
a shared d elu sion arou sed in one person by
the influ ence of another. La belle ind iffrence
is the ind ifference show n tow ard a d eficit or
loss of fu nction, classically (bu t not alw ays)
seen in a conversion (fu nctional neu rologic
sym ptom ) d isord er.
106. (E) The ep id em iology and p rognosis of schizo-
p hreniform d isord er are p oorly u nd erstood ,
althou gh the lifetim e p revalence rate is ap prox-
im ately 0.2% and app roxim ately tw o-third s
eventu ally go on to d evelop schizop hrenia
or schizoaffective d isord er. The d iagnostic
criteria are sim ilar to those of schizophrenia,
but the episod e lasts betw een 1 and 6 months.
Distinguishing schizophrenia from mood dis-
ord ers w ith psychotic symptoms (e.g., bipolar
I d isorder w ith psychotic features, MDD w ith
psychotic features) and schizoaffective d isor-
d er can often be d ifficult in that a mood dis-
turbance is not uncommon d uring episod es
of schizophrenia and schizophreniform d isor-
d ers. If psychotic symptoms only occur w ith
the presence of mood symptoms, then MDD
w ith psychotic features is more likely. Brief
psychotic d isord er is d efined by the presence of
d elusions, hallucinations, d isorganized speech
or behavior, or catatonic behavior lasting for at
least 1 day but less than 1 month. Schizoaffec-
tive d isord er d escribes the presence of a major
d epressive or manic episod e concurrent w ith
symptoms that are characteristic of schizophre-
nia: d elusions, hallucinations, d isorganized
speech or behavior, or negative symptoms.
107. (B) In the context of p regnancy and labor,
high-p otency typ ical antip sychotics such as
halop erid ol are consid ered relatively safe to
u se to control psychosis. For a m other su f-
fering from p sychosis d u ring d elivery, the
benefit of u sing high-p otency antip sychotics
ou tw eighs the risk. All of the other antipsy-
chotics are low - or m ed ium -potency and m ay
low er blood p ressu re significantly d u e to their
alpha-blocking p rop erties.
108111. [108 (E), 109 (G), 110 (K), 111 (D )] The
MMSE is a qu ick, easily ad m inistered test
that allow s for im m ed iate screening for neu -
rocognitive d isord ers (e.g., d em entias). Scores
of less than 24 are su ggestive of a d em enting
p rocess. The ReyOsterrieth figu re is sensitive
to d eficits in copying and lack of attention to
d etail in people w ith right-sid ed parietal lobe
lesions. It ap p ears that this you ng w om an
m ay have had a stroke in this area resu lting
from her protein S d eficiency, a hypercoagu -
lable state. The ap p rop riate test to evalu ate the
intelligent qu otient (IQ) for child ren ages 5 to
15 is the WISC. The Boston Diagnostic Ap ha-
sia Exam ination is a series of tests given by an
exp erienced clinician to evalu ate and m ake
treatm ent recom m end ations for ind ivid u als
w ith ap hasia. The Beck Dep ression Inventory

(A) is a 21-item test, w ith three responses p er
item , that is an easily u sed screening tool to
evalu ate for d ep ression. The Bend er Gestalt
Test (B) involves copying figu res, w hich helps
assess neurological function or brain d isease.
The Blessed Rating Scale (C) is a tool that asks
friend s or fam ilies of the patient to assess the
ability of the p atient to fu nction in his u su al
environm ent. MMPI-2 (F) is an objective test
interp reted by skilled evalu ators u sed in p er-
sonality assessm ent. It is the m ost w id ely u sed
and highly stand ard ized test of p ersonality
stru ctu re. The Rorschach Test (H) is a p rojec-
tive test u sed to assess p ersonality stru ctu re.
The Wad a Test (I) is u sed to evalu ate hem i-
spheric langu age d om inance prior to surgical
am elioration of seizu re focu s. Whereas m ost
right-hand ed ind ivid u als show left hem i-
spheric d om inance for langu age, left-hand ed
ind ivid u als m ay either be right or left d om i-
nant. The test consists of injecting sod iu m
am ytal into the carotid artery and observing
the transient effects on sp eech. Injection into
the left carotid artery w ill anesthetize the left
sid e of the brain; those w ith left hem ispheric
langu age d om inance w ill show interru p ted
speech. The WAIS-R (J) is u sed to d eterm ine
the IQ for ind ivid u als age 15 and old er.
112. (C) Cannabis (m ariju ana) is the m ost com -
m only abu sed illicit d ru g in the United
States. The onset of action after sm oking is
im m ed iate, and sym p tom s inclu d e conju ncti-
val injection, m ild sed ation, d ose-d ep end ent
hyp otherm ia, d ry m ou th, increased ap p etite,
tachycard ia, and eu p horia. A sensation of
slow ed tim e and p aranoid id eation can also
occu r.
Answe rs : 104116 245
113. (E) The onset of action for opiates can be almost
immediate when smoked , about 5 minutes
w hen injected , an d lon ger if taken orally.
Sym p tom s inclu d e m iosis, brad ycard ia,
hyp otension, hypotherm ia, constipation, and
eu phoria. Intoxication can lead to fatal respi-
ratory d ep ression.
114. (F) PCP is a hallu cinogen that p rod u ces a d is-
sociative anesthesia. It can cause u npred ictable
beh avior, assau ltiveness, an d belligeren ce.
Agitation, nystagm u s (vertical or horizontal),
tachycard ia, a num bed resp onse to pain, m u s-
cle rigid ity, hyperacu sis (increased sensitivity
to sou nd ), hypertension, echolalia, and anti-
cholinergic effects are associated sym p tom s.
115. (D ) N icotine fou nd in tobacco sm oke p ro-
d u ces sym p tom s of excitem ent. Intoxication
w ith large am ou nts m ay p rod u ce sym p tom s
of confu sion, m u scle tw itching, w eakness,
abd om inal cram p s, d epression, p alp itations,
com a, and respiratory failu re.
116. (A) As a sym p athom im etic agent, cocaine
increases the heart rate and d ilates the p u p ils.
It can also cau se constriction of the coronary
arteries. The hallm ark of cocaine intoxication
is eu p horia. Use of LSD (B) or other hallu ci-
nogens (e.g., MDMA [3,4-m ethylened ioxy-
N -m ethylam p hetam ine], or Ecstasy) cau ses
sym p tom s that u su ally begin 1 hou r after
ingestion and generally last 8 to 12 hou rs.
Most hallucinogenic d rugs have stim u lant-
type effects and prod u ce elevated vital signs
and increased activity. H allu cinations and a
heightened sense of percep tion of objects and
colors are typical.
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 CHAPTER 8

Prac tic e Te s t 2
Que s tions

D IRECTION S (Questions 1 through 4): For each the lettered answ er that is the one best response in
of the follow ing vignettes, select the one lettered each case
option that is most closely associated w ith it. Each
lettered option may be used once, multiple times, 5. An 18-ye r-ol w o n recently i gnose
or not at all. w ith first e iso e of schizo hreni grees
to t ke n nti sychotic e ic tion to
(A) Cit lo r hel ecre se her h llu cin tions, bu t she is
(B) Flu oxetine ntly o ose to t king ny e ic tion
(C) Mirt z ine th t y c u se her to g in excessive w eight.
(D) P roxetine Which of the follow ing e ic tions w ou l be
(E) Sertr line the ost ro ri te to rescribe?
(F) Venl f xine (A) Cloz ine (Cloz ril)
(B) Ol nz ine (Zy rex )
1. A 29-ye r-ol new ly rrie le w ith (C) Qu eti ine (Seroqu el)
signific nt e ressive sy to s, inclu ing
(D) Ris eri one (Ris er l)
inso ni n w eight loss, w s nonco li nt
w ith e ic tions in the st u e to sexu l (E) Zi r si one (Geo on)
ysfunction.
6. A 40-ye r-ol rrie fe le w ithout st
sychi tric history is referre by her inter-
2. A 45-ye r-ol n w ith severe jor e res- nist. She h s been feeling ow n for sever l
sion on h igh ose of n n ti e ress nt w eeks, w ith little bility to enjoy herself. Since
evelo s incre se bloo ressu re. th t ti e, her slee h s been isru te , her
etite re uce , n shes felt tire . She
3. A 50-ye r-ol ivorce fe le being tre te for h s lso been king ist kes t w ork n is
jor e ression oesnt refill her rescri tion w orrie bou t being fire . She its to h v-
n 2 ys l ter h s he che, u scle ches, ing thou ghts of killing herself, bu t she enies
n n use . ny l n or intent to o so. She enies h llu -
cin tions or elu sions. Which of the follow ing
4. A 33-ye r-ol w o n w ith ersistent e re- e ic tions w ou l be the ost ro ri te
ssive isor er ( ysthy i ) h s history of oor for this tient?
co li n ce w ith e ic tion s, occ sion lly (A) Ari i r zole
issing oses. (B) Cit lo r
(C) Methyl heni te
D IRECTION S (Questions 5 through 41): For each of (D) N ortri tyline
the multiple-choice questions in this section select
(E) Tr nylcy ro ine

247
248 8: Pra c tic e Te s t 2

7. A 25-ye r-ol w o n resents to her ri ry oes not feel like her con ition w ill i rove,
c re octor co l ining of su en onset of she enies ny su ici l i e tion. She rinks
intense fe r n feeling th t she w s going one to tw o rinks once or tw ice er onth,
to ie, w hich occurre w hile she w s sto e bu t enies illicit ru gs. She is su bsequ ently
in tr ffic e rlier in the w eek. At th t ti e she begu n on flu oxetine, w hich is gr u lly
bec e short of bre th, i horetic, n tre - incre se to 60 g. She enies si e effects,
u lous, n she cou l feel her he rt oun ing. lthou gh she h s not ex erience signific nt
H er initi l i u lse w s to rive to n e er- lessening of her e ressive sy to s. H ow
gency e rt ent, bu t her istress su bsi e long shou l her cu rrent os ge be continu e
on its ow n in bou t 20 inu tes. Which of the before sw itching to nother e ic tion?
follow ing shou l be the next ost ro ri te
(A) 3 ys
cou rse of ction?
(B) 1 w eek
(A) Con u ct thorou gh e ic l screening (C) 2 w eeks
for he rt n lu ng ise se.
(D) 4 w eeks
(B) Prescribe selective-serotonin reu t ke
(E) 6 w eeks
inhibitor (SSRI) n sk to see the
tient b ck in 1 w eek.
10. A 56-ye r-ol w o n w ith schizo hreni h s
(C) Prescribe short- cting benzo i ze ine been st ble on h lo eri ol for ny ye rs.
s nee e in c se of nother e iso e. She enies ny current sychotic sy to s
(D) Re ssu re the tient th t her sy to s n h s been co li nt w ith her e ic tions.
re ost likely benign n not c u se She resents for rou tine follow -u oint-
for concern. ent. Which of the follow ing tests shou l be
(E) Refer the tient to sychi trist. inistere ?
(A) Abnor l Involu nt ry Move ent Sc le
8. You re seeing 45-ye r-ol n w ith his-
(AIMS)
tory of schizo hreni . H e is cu rrently co -
li nt w ith his nti sychotic e ic tions (B) Beck De ression Inventory (BDI)
bu t re ins sy to tic, w ith u itory h l- (C) Brief Psychi tric R ting Sc le (BPRS)
lu cin tions n r noi . On ent l st tu s (D) P tient H e lth Qu estionn ire (PH Q)
ex in tion (MSE), he s e ks coherently n (E) Positive n N eg tive Sy to Sc le
rticul tely, bu t kes no sense bec u se ny (PAN SS)
of the w or s he uses re of his ow n invention.
Which of the follow ing ter s best escribes 11. A n brings his w ife to the octor bec u se
this MSE sign? she h s beco e ore sy to tic over the
(A) Cl ng ssoci tions st sever l w eeks. She is i gnose w ith
schizo hreni n h s recently sto e her
(B) Echol li
e ic tions. She h s e thre ts tow r
(C) Flight of i e s her hu sb n bec u se she believes th t he is n
(D) N eologis s i ostor w ho looks ex ctly like her hu sb n .
(E) Wor s l Which of the follow ing ter s best escribes
this sy to ?
9. A 34-ye r-ol w o n resents to sychi -
(A) A ok
trist w ith 6-ye r history of e tiness n
e ression for ost of the ti e, w ith low (B) C gr s syn ro e
self-estee , chronic inso ni , n ifficulty (C) Cot r syn ro e
king ecisions. She enies ny roble s (D) Cou v e syn ro e
w ith her etite or energy, n , w hile she (E) Koro
 Que s tions : 717 249

12. A 69-ye r-ol w o n w ithout rior sychi tric (C) Echol li

history is seen by her ri ry c re hysici n (D) P lil li
ue to crying s ells. She st tes th t she h s (E) P r r xis
felt s since the su en e th of her husb n
5 w eeks go. Since th t ti e, she h s h iffi- Questions 15 and 16
culty slee ing n f tigue. She h s lso lost sev-
er l oun s ue to not enjoying her foo . She A w e lthy, ivorce 48-ye r-ol w o n resents
is ble to cheer u w hen s en ing ti e w ith to you fter being rreste for sho lifting. The
her chil ren, but feels es eci lly lonely t night. tient its th t she h s been ste ling for ye rs,
She is so ew h t nxious bec use she occ - lthou gh she is e sily ble to ffor the objects sto-
sion lly he rs her ece se husb n s voice, len. She st tes th t she ste ls on the s u r of the
es eci lly e rly in the orning or l te in the o ent n th t these i u lses see foreign n
evening. While she feels her future is ble k, istressing.
she enies ny suici l i e tion or l n. Which
of the follow ing i gnoses is ost likely? 15. Which of the follow ing i gnoses is the ost
likely?
(A) Bere ve ent
(B) Bi ol r isor er (A) Antisoci l erson lity isor er
(C) M jor e ressive isor er (MDD) (B) Inter ittent ex losive isor er
(D) Persistent e ressive isor er (C) Kle to ni
( ysthy i ) (D) Pyro ni
(E) Schizo ffective isor er (E) Trichotillo ni

Questions 13 and 14 16. Which of the follow ing ter s lies to the
f ct th t these i u lses re istressing to her?
You re ske to ev lu te 12-ye r-ol boy with his-
tory of Tourette isor er n obsessive-co ulsive (A) Delu sion l
isor er. He is brought in to the oint ent with his (B) Ego- ystonic
rents, who escribe the severity of his illness n (C) Ego-syntonic
how he is often te se in school. During the interview (D) Moo congruent
the boy inter ittently kes obscene gestures.
(E) Moo incongru ent
13. Which of the follow ing ter s best escribes
17. A 49-ye r-ol n co es to you co l in-
this sy to ?
ing of he ches, e ory loss, isorient -
(A) Ble h ros s tion , n occ sion l r lysis th t ffects
(B) Bru xis his r s n l sts sever l hou rs. Du ring
(C) Co ro r xi th e MSE, you notice th t th e tient is giv-
ing v gu e nsw ers to ny qu estions (e.g.,
(D) Echo r xi
th ere re six toes on th e foot n 2 + 2 = 5).
(E) Torticollis Which of th e follow in g ter s best escribes
th is resen t tion?
14. While obt ining the history, the tient is lso
note to re e t hr ses you u se i e i tely (A) A ok
fter you s y the . Which of the follow ing (B) Dere liz tion
ter s best escribes this sy to ? (C) G nser syn ro e
(A) Co rol li (D) N eg tivis
(B) Dys rthri (E) Piblokto
250 8: Pra c tic e Te s t 2

18. A sychi trist iscovers th t she is fru str te believe her thoughts coul be he r through the
n e sily ngere w ith one of her tients w lls. She feels th t this is n inv sion of her riv cy.
for no obvious re son. While t lking to col-
le gue, she its th t the tient re in s her 21. Which of the follow ing ter s best escribes
of her busive f ther. Which of the follow ing the belief th t the tients thoughts tow r
best escribes the clinici ns re ction? the neighbor w ere res onsible for the lost
regn ncy?
(A) Countertr nsference
(B) Dis l ce ent (A) Dis l ce ent
(C) Projection (B) I e s of reference
(D) Re ction for tion (C) M gic l thinking
(E) Tr nsference (D) Projection
(E) Re ction for tion
Questions 19 and 20
22. Which of the follow ing ter s best escribes
A 19-ye r-ol w o n resents w ith co l ints the tients fe r th t her thoughts cou l be
of fe r, rehension, n tre bling w ithou t ny overhe r ?
know n re is osing situ tions. On ex in tion,
you note brow n skin, s oky brow n rings on the (A) Echol li
ou ter corne , n occ sion l r i , jerky, u r ose- (B) Thou ght bro c sting
less sw inging of the r s w hich e rs to w orsen (C) Thou ght control
w ith volu nt ry ove ent. (D) Thou ght insertion
(E) Tr nsference
19. Which of the follow ing ter s best escribes
the tients ocul r fin ings?
Questions 23 and 24
(A) Arcus senilis
A 25-ye r-ol n resents to the e ergency roo
(B) Bru shfiel s ots
fter being brou ght in by his girlfrien . She h s
(C) K yserFleischer rings been concerne s he h s not been cting right.
(D) Su bconju nctiv l he orrh ge She st tes he h s been st ying u ll night over
(E) X nthel s the l st sever l ys but still very ctive uring
the yti e. H e h s re rr nge the fu rniture n
20. Which of the follow ing ter s best escribes tte te to re o el their b throo , es ite his
the bnor l ove ents seen in this tient? l ck of ex erience w ith constru ction. H e h snt
show n u for w ork recently, n she is fr i he
(A) Athetoi
w ill be fire . While he its th t he h snt sle t,
(B) Choreifor he cl i s to feel gre t! H e is so ew h t ifficu lt
(C) H e ib llis u s to interview s he w lks roun the roo , h n-
(D) Myoclonu s ling ll the equ i ent. When confronte w ith his
(E) Myotoni not going to his w ork, he st tes Why shou l I . . . I
on the verge of iscovering cu re for AIDS,
Questions 21 and 22 w hich lso h ens to be for u l for econo ics,
w hich w ill lso get ri of overty. H e enies lco-
A 21-ye r-ol w o n is brought to the sychi tric hol or ru g u se, bu t u on qu estioning, its to
e ergency e rt ent fter c lling the olice to erio in his l te teens w hen he felt e resse , w ith
tu rn herself in. She cl i s th t she w s res onsible ifficu lty slee ing, w eight loss, low energy, gu ilt,
for the loss of her neighbors regn ncy. She believes n hel lessness/ ho elessness. H e w s su bse-
her neg tive thoughts tow r the w o n c u se her qu ently tre te w ith so e sort of nti e ress nt
isc rri ge. On further qu estioning, she tells you for roxi tely 18 onths, bu t he never follow e
th t she felt thre tene by her neighbor bec u se she u fter th t ti e.
 Que s tions : 1829 251

23. Which of the follow ing is the ost ro ri te (A) Conversion isor er
i gnosis for this tient? (B) F ctitiou s isor er
(A) Bi ol r I isor er (C) Illness nxiety isor er
(B) Bi ol r II isor er (D) M lingering
(C) Cyclothy ic isor er (E) So tic sy to isor er
(D) M jor e ressive isor er w ith
sychotic fe tu res 27. Which of the follow ing ter s best escribes
this tients ini iz tion of the severity of
(E) Schizo hreni
his sy to s?
24. Which of the follow ing e ic tions w ou l be (A) Dj enten u
the ost ro ri te to rescribe? (B) Dj vu
(A) A itri tyline (C) Folie eu x
(B) Cloz ine (D) J is vu
(C) Flu oxetine (E) L belle in iffrence
(D) H lo eri ol
28. A 67-ye r-ol w o n w ith u l on ry c rci-
(E) V l roic ci
no n secon ry br in et st ses recently
r fte w ill in the resence of her f ily
25. A 36-ye r-ol w o n w s begu n on l r -
ttorney. She h s history of jor e ressive
zol (X n x) 3 ye rs go for nic isor er.
isor er (MDD) th t is now in re ission. She
After w tching new s re ort on television,
eci es th t her chil ren w ho re w ell est b-
she bec e frightene bou t iction. She
lishe in their c reers o not nee ny inheri-
bru tly sto e the e ic tion 2 ys go
t nce n th t her est te w oul best serve
n h s since been ex eriencing cu te, intense
ch rity. To secure the v li ity of the w ill, the
nxiety, tre ors, sw e ting, n l it tions.
tient sks her sychi trist to sub it let-
Which of the follow ing e ic tions w ou l be
ter to her ttorney reg r ing her co etency.
the ost ro ri te to rescribe?
Which of the follow ing w ou l be the ost
(A) Di ze i ort nt f ctor in eter ining this w o ns
(B) Flu zenil test ent ry c city?
(C) Pro r nolol (A) Actu s reu s
(D) Sertr line (B) A history of MDD
(E) V l roic ci (C) Know le ge of her n tu r l heirs
(D) The resence of conserv tor of erson
Questions 26 and 27
(E) The resence of ju ge to w itness the
A evou t hu sb n fin s th t his w ife is h ving n signing of the w ill
ff ir w ith his best frien . One w eek l ter, he fin s
th t he c nnot w lk. A thorou gh neurologic w orku 29. You re consu lte to see 77-ye r-ol H is-
f ils to reve l c u se to his su en r legi . H is nic le w ith schizo ffective isor er,
neu rologic ex in tion is not consistent w ith u er e ressive ty e, itte to the hos it l for
or low er otor neuron fin ings. Des ite this r - chest in. H is w orku h s reve le u l o-
tic is bility, he see s qu ite un ffecte by it n ry e bolis , n the e ic l te w ishes
e otion lly. to l ce chest tube in the tient, bu t the
tient refu ses. The ri ry te h s ske
26. Which of the follow ing i gnoses w ou l be you to eter ine his c city to refu se the
the ost ro ri te in this tient? roce u re. Which of the follow ing fe tures is
252 8: Pra c tic e Te s t 2

the ost i ort nt in eter ining ecision- Questions 32 and 33

king c city in this tient?
You re ske to erfor co etency to st n
(A) Ability to co u nic te tri l ev lu tion of n 18-ye r-ol n w ho w s
(B) Age of tient rreste for violently ss u lting his girlfrien . The
(C) Agree ent w ith tre t ent te tient h s no st sychi tric history, n frien s
reco en tions re ort th t he h s never e onstr te ny violent
(D) Presence of sychosis ten encies. The tient re orts th t his rel tion-
shi w ith his girlfrien w ent ow nhill shortly
(E) S nish s e king
fter they gr u te fro high school n his girl-
frien sto e c lling hi . On MSE, his ffect is
30. A e uty sheriff serves you su b oen for
constricte n his oo is re orte s cr zy.
the recor s of one of your tients w ho is the
Thou ght rocesses re go l irecte , n he enies
efen nt in civil li bility l w su it. Which of
ny h llu cin tions or elu sions. The tient is
the follow ing is the ost ro ri te cou rse
u n ble to correctly erfor si le c lcu l tions.
of ction?
E ch ti e he is ske to u lti ly, su btr ct, or
(A) Rele se the tients recor s to the ir of nu bers, his nsw ers re w rong by one
l intiff bec u se the su b oen overri es or tw o igits. For ex le, he res on s 22 w hen
tient consent. ske to u lti ly 7 by 3.
(B) H n over only the infor tion th t is
relev nt to the c se. 32. Which of the follow ing i gnoses is the ost
(C) Cont ct the tient n sk if she or he likely in this c se?
w ou l like the infor tion rele se . (A) Conversion isor er
(D) Rele se the tients recor s irectly to (B) F ctitiou s isor er
the cou rt. (C) M jor neu rocognitive isor er
(E) Refu se to s e k to the sheriff in or er to (D) M lingering
int in confi enti lity.
(E) Schizo hreni
31. A 23-ye r-ol gr u te stu ent you h ve
33. Which of the follow ing st te ents best
been seeing in long-ter sychother y h s
escribes the bove tients ro u ction of
sto e ying his bills, es ite being rei -
sy to s n otiv tion?
bu rse by his insu r nce co ny. Which of
the follow ing is the next ost ro ri te (A) Consciou s ro u ction of sy to s to
cou rse of ction? ssu e the sick role.
(A) Cont ct the tients insu r nce co ny (B) Consciou s ro u ction of sy to s to
n requ est th t they issue you nother obt in secon ry g in.
y ent. (C) Unconsciou s ro u ction of sy to s
(B) Directly ress this issu e w ith u e to u nconsciou s conflicts.
the tient t the next sche u le (D) Unconsciou s ro u ction of sy to s to
oint ent. ssu e the sick role.
(C) Inqu ire w ith f ily e bers w hether (E) Unconsciou s ro u ction of sy to s to
the tient h s fin nci l roble s. obt in secon ry g in.
(D) N otify collection gency to obt in
rei bu rse ent. 34. You re ske to ev lu te 68-ye r-ol n
on the in tient e icine service for incre s-
(E) Sen the tient letter of ter in tion.
ing confu sion. The tient w s itte
2 ys e rlier for neu oni . After erfor -
ing ent l st tu s ev lu tion, you su s ect
eliriu . Fu rther history fro the tients
 Que s tions : 3039 253

w ife in ic tes th t the tient ro e ou t 36. Which of the follow ing w ou l be the ost
of school in the seventh gr e. Which of the ro ri te next ste in the n ge ent of
follow ing tests w ou l best ssess his bility to this tient?
int in n focu s ttention?
(A) A inister thi ine or lly (PO) before
(A) Cou nting by 2s to 20 IV flu i s n glu cose.
(B) R n o letter test (B) A inister thi ine intr venou sly (IV)
(C) Seri l sevens before IV flu i s n glu cose.
(D) Seri l threes (C) A inister thi ine IV fter IV flu i s
(E) Si le c lcu l tions n glu cose.
(D) A inister n loxone IV before IV flu i s
35. A 7-ye r-ol girl is brou ght to the e ergency n glu cose.
e rt ent for ev lu tion of sore thro t (E) A inister n loxone IV fter IV flu i s
n fever. H er rents took her to the e i - n glu cose.
trici ns office bou t 1 w eek go n he rec-
o en e flu i s n be rest. Within the 37. The bove tient is st bilize n itte
l st 2 ys, the tient evelo e ys h gi to the ICU. After 3 ys, he begins to beco e
n severe b o in l in. H istory fro the confu se g in, w ith visu l h llu cin tions,
rents in ic tes the tient h s been nxiou s tre ors, i horesis, n elev te bloo res-
n i u lsive over the l st onth. There h s su re n u lse. Which of the follow ing is the
lso been rke ecline in school erfor- ost ro ri te tre t ent for this tient?
nce, n she h s not been intereste in
l ying w ith her frien s. Physic l ex in - (A) A inister b rbitu r te.
tion is re rk ble for signific nt erythe (B) A inister benzo i ze ine.
over the osterior h rynx w ith gr y exu - (C) A inister ition l thi ine.
te. There re br sions in the region of the (D) A inister n nti sychotic.
tients l bi . Co lete bloo cou nt show s (E) A inister hy r l zine.
w hite bloo cell (WBC) cou nt of 14,000/ L
w ith left shift. Which of the follow ing is the 38. A you ng w hite le, ge u nknow n, is brou ght
next ost ro ri te ste ? into the e ergency roo u nres onsive to
(A) Arr nge for f ily eeting to qu estioning. H is vit ls e onstr te nor l
eter ine s fe is osition. te er tu re, low u lse n bloo ressure,
(B) Cont ct the st tes Chil Protective n ecre se res ir tions. H e e rs le,
Services w hile kee ing the tient s fe. w ith u ils th t re constricte n ini lly
res onsive. A inistr tion of w hich of the
(C) Det in the rents w hile you notify the
follow ing w ou l be ost likely to i rove his
olice.
con ition?
(D) N otify the rob te court to h ve the
tient leg lly re ove fro the (A) Disu lfir (Ant bu se)
llege er etr tor. (B) Benzo i ze ines
(E) Refer the tient to the f ilys (C) Flu zenil
e i trici n. (D) N loxone
(E) Thi ine
Questions 36 and 37
A 48-ye r-ol le is brou ght into the e ergency 39. A 77-ye r-ol w o n w ithout rior sychi tric
roo (ER) vi n bu l nce. H e s ells of lcohol, is history is brought into her f ily hysici ns
covere in vo it, n not res onsive to qu estions. office w ith her husb n . H e is concerne th t
H e is unste y n u ncoo er tive w ith the hysic l she is e resse n nee s tre t ent. H e
ex in tion, bu t he is note to h ve isconju g te escribes her w ith r w ing e otion lly over
eye ove ents. the st ye r or tw o, w ith gr u l ecline in
254 8: Pra c tic e Te s t 2

her bility to c re for herself. They h ve been (D) R ce

un ble to t ke rt in their u su l soci l ctivi- (E) Religion
ties, n the tient ju st w n ers roun the
hou se uring the y. H e h s lso notice 41. The tient w its u ntil her f ily n ri ry
th t she is forgetful, often is l cing ite s, c re te le ve the roo . She then sks you to
n ixing u n es of cqu int nces. When hel her co it su ici e, s her rognosis is
ske , the tient enies ny ifficulties, st t- very oor. Wh t is the ost ro ri te next
ing she feels fine, n th t her husb n w or- course of ction?
ries too uch. She ntly refutes roble s
w ith her e ory, inste bl ing hi for (A) Discu ss her re sons for su ici e in ore
oving things roun in their house. She h s et il.
no signific nt e ic l roble s. U on MSE, (B) Ex l in how she c n obt in leth l oses
she is le s nt n coo er tive w ith questions, of e ic tion.
lthough efensive t ti es. H er ffect is neu- (C) Infor the f ily i e i tely.
tr l but full. There is no su ici l or ho ici l (D) Pl ce the tient in restr ints.
i e tion, n she enies ny sychotic sy - (E) Refer her to hysici n w ho erfor s
to s. H er Mini-Ment l St te Ex in tion is eu th n si .
20/ 30. H er hysic l is essenti lly u nre rk-
ble. Which of the follow ing w oul be the D IRECTION S (Questions 42 through 49): Match
ost ro ri te ri ry tre t ent for this the clinical presentation w ith the appropriate neu-
tient? ropsychological test. Each lettered heading may be
(A) Cit lo r selected once, more than once, or not at all.
(B) G l nt ine (A) Beck De ression Inventory (BDI)
(C) Ginkgo bilob (B) Ben er Gest lt Test
(D) Me ntine (C) Blesse R ting Sc le
(E) Zi r si one (D) Boston Di gnostic A h si Ex in tion
(E) Folstein Mini-Ment l St te Ex in tion
Questions 40 and 41 (MMSE)
You re ske to see 37-ye r-ol w hite C tholic (F) Minnesot Mu lti h sic Person lity
fe le w ith en -st ge ov ri n c ncer bec u se she Inventory 2 (MMPI-2)
h s tol her oncologist th t she w nts to ie. When (G) ReyOsterrieth Test
you ro ch the tients be , you see c chectic (H ) Rorsch ch Test
bu t s iling w o n su rrou n e by her hu sb n n (I) Stroo Test
tw o you ng u ghters. She h s history of e res-
(J) W Test
sion bu t is not un er ny tre t ent for it now . I
re y to go, Doctor, she s ys to you . H er oncologist (K) Wechsler A u lt Intelligence Sc le
h s tol you th t he w oul like to try new che o- Revise (WAIS-R)
ther y for w hich the tient is goo c n i te, (L) Wisconsin C r Sorting Test (WCST)
bu t the tient h s refu se ; he is concerne bou t
her suici l otenti l. 42. A 40-ye r-ol w o n w ho scores 26/ 30 on
the Folstein MMSE g ve ny nsw ers of, I
40. Which of the follow ing ch r cteristics incre se ont know, I too tire to nsw er. You w nt
this rticu l r tients risk of co itting to ssess for the ossibility of e ression.
su ici e?
(A) Age 43. A 65-ye r-ol n h s ifficu lty org nizing,
sequ encing, n l nning ctivities but no
(B) Gen er
i ir ent in e ory.
(C) M rit l st tu s
 Que s tions : 4051 255

44. The f ily of n 80-ye r-ol n w ith neu - chorionic gon otro in is ositive. The tients
rocognitive isor er ( e enti ) h s ske rents e n to know the resu lts. Which of
you to ev lu te his bility to continu e to live the follow ing is the ost ro ri te cou rse
in his cu rrent environ ent. You w ish to sk of ction?
his f ily n frien s their o inion of how he
(A) Disclose the resu lts in eeting w ith
h s been oing.
the tient n her rents.
(B) Encou r ge the tient to iscu ss the
45. A 16-ye r-ol boy w ith f ily history of resu lts w ith her rents.
intellectu l is bility resents w ith longst n -
(C) Invoke testi oni l rivilege.
ing oor school erfor nce n ggressive
beh vior tow r eers. (D) N otify the rents of the resu lts bec u se
they y her e ic l bills.
(E) Re ort the resu lts to Chil Protective
46. A 37-ye r-ol n h s history of voi ing
Services.
soci l situ tions, no close frien s, n ref-
erence for being lone. H e h s been escribe
Questions 51 and 52
by others s u ne otion l n et che . You
woul like to ev lu te this tients erson lity
The tient is 31-ye r-ol , ivorce le, w ithou t
style w ith rojective test.
rior sychi tric history, referre by his w ork for
ev lu tion. H e st tes he h s felt ow n since his
47. You w oul like to quickly ssess for oten- se r tion n ivorce sever l onths go. H e h s
ti l neurocognitive isor er in 75-ye r-ol been slee ing oorly, frequ ently w king u u ring
wo n itte to the e ergency e rt ent the night, then feeling exh u ste u ring the y.
for f ilure to thrive. He h s h little interest in foo , losing 10 lb, n
he h s been e sily istr cte t w ork, resu lting in
48. A 45-ye r-ol w o n h s long history of ist kes n re ri n . While he feels hel less
u nst ble rel tionshi s, self-injuriou s beh vior, n th t Ill never feel better, he enies ny su i-
n ffective inst bility. She oes not eet cri- ci l i e tion or ho ici l i e tion. H e rinks 1 to
teri for jor e ressive, bi ol r, or nxi- 2 beers on the w eeken s n enies illicit ru g u se.
ety isor er. You w ish to e loy n objective H e s okes 1/ 2 ck of cig rettes er y n h s
test to give fu rther evi ence for erson lity no jor e ic l roble s exce t for bor erline
isor er. hy ertension. H e t kes u ltivit in bu t no other
e ic tions regul rly. After fu rther iscu ssion, he
grees to begin tri l of e ic tion. The tient
49. You re ske to reo er tively ev lu te is begu n on flu oxetine 20 g ily. H e is co li nt
he is heric o in nce in n 18-ye r-ol w ith the e ic tion n follow s u regu l rly. After
left-h n e w o n w ith history of seizu re 4 w eeks he re orts slight i rove ent in his sy -
isor er w ho is bou t to u n ergo su rgery to to s. Of note, he initi lly h nxiety n loose
re ove seizu re focu s in her left he is here. stools, bu t he enies current si e effects.

DIRECTIONS (Questions 50 through 83): For each 51. Which of the follow ing w ou l be the ost
of the multiple-choice questions in this section select ro ri te next ste ?
the lettered answer that is the one best response in
(A) A ri i r zole.
each case.
(B) A lithiu .
50. A 16-ye r-ol girl is brou ght to you r office (C) Discontinu e the flu oxetine.
by her rents to get regn ncy test. She (D) Incre se flu oxetine to 40 g.
consents for the ev lu tion bu t requ ests th t (E) Sw itch to sertr line.
you kee the resu lts confi enti l. Bet hu n
256 8: Pra c tic e Te s t 2

52. H e eventu lly chieves fu ll re ission of his (D) Refer her for electroconvu lsive ther y
e ressive sy to s n continu es on the (ECT).
e ic tion. H ow ever, he is concerne bou t (E) Tell her to sto her e ic tion
his rognosis n otenti lly sto ing the i e i tely.
nti e ress nt in the fu tu re. Wh t o you tell
hi is his roxi te risk of evelo ing 55. A 45-ye r-ol n is brought to the sychi tric
fu rther e iso e in the fu tu re? e ergency roo by olice fter being foun
(A) 10% scre ing w hile cutting ow n tree in the loc l
rk. H e tells you th t the ghost of his w ife,
(B) 20%
w ho ie 3 onths go, is living in the tree.
(C) 30% The n h s no revious sychi tric history,
(D) 40% but he re orts being very e resse since the
(E) 50% e th of his w ife n h s h suici l i e tion.
H e is ishevele n e rs to h ve ignore
Questions 53 and 54 his erson l hygiene for so e ti e. H is vit l
signs re nor l. Which of the follow ing is the
A 35-ye r-ol w o n resents to you r office w ith
ost ro ri te next course of ction?
referr l fro sychologist for sychi tric tre t-
ent. She h s been su ffering the blues for sever l (A) Obt in u rine toxicology screen.
onths, inclu ing crying s ells, low energy, n (B) Prescribe n nti e ress nt.
hy erso ni . She is convince th t her fi nc is (C) Prescribe n nti sychotic.
bout to bre k u w ith her bec use she h s been e t- (D) Prescribe n nti sychotic n n
ing ore th n usu l. So eti es, how ever, she feels nti e ress nt.
ju st fine.
(E) Prescribe oo st bilizer.
53. Wh ich of th e follow in g w ou l be th e ost
Questions 56 and 57
ro ri te tre t en t of choice for th is
tient?
You re seeing 56-ye r-ol n w ith history of
(A) A itri tyline (El vil) lcohol u se isor er. H e co l ins bou t not being
(B) Div l roex so iu (De kote) ble to slee n requ ests slee ing i . H e enies
(C) Flu oxetine (Proz c) erv sive e ression or ny ch nge in his etite,
energy, or concentr tion. H e cl i s th t otherw ise
(D) Phenelzine (N r il)
everything is going w ell.
(E) Zi r si one (Geo on)
56. Which of the follow ing e ic tions w ou l
54. The tient res on s w ell to tre t ent, n
be the ost ro ri te to rescribe for this
fter sever l onths retu rns to you r office for
tient?
follow -u visit. She tells you she h s just
been rrie n w ou l like to beco e reg- (A) Al r zol (X n x)
n nt. She n her hu sb n h ve been h ving (B) Di ze (V liu )
u n rotecte sex for onth. Which of the fol- (C) Tr zo one (Desyrel)
low ing w ou l be the ost ro ri te next (D) Z le lon (Son t )
cou rse of ction?
(E) Zol i e (A bien)
(A) A nother nti e ress nt to revent
ost rtu e ression. 57. H e grees to begin the ro ri te bove e -
(B) Ask how i ort nt regn ncy is to her. ic tion. Which of the follow ing si e effects
(C) Discu ss the risks n benefits of w oul be ost i ort nt to w rn hi bout?
continu ing her tre t ent u ring (A) Anorg s i
regn ncy. (B) I otence
 Que s tions : 5261 257

(C) Incontinence Questions 60 and 61

(D) Pri is
(E) Retrogr e ej cul tion
Questions 58 and 59
58. You re seeing 9-ye r-ol boy w ith history
of e ression n suici l i e tion. H e h s
been t king flu oxetine (Proz c) for 6 onths
n h s h goo res onse. H is other
sks to see you fter his oint ent n tells
you th t she is concerne bou t new s re orts
s ying th t serotonin-s ecific reu t ke inhi-
bitors (SSRIs) incre se the risk of su ici e in
chil ren. She sks you to consi er sto ing
the e ic tion. Which of the follow ing is the
best cou rse of ction?
A 38-ye r-ol tient w ith history of bi ol r isor-
er h his first ( n only) nic e iso e 18 onths
go. H e w s tre te for 1 ye r w ith oo st bi-
lizer, n h s not t ken ny sychotro ics since th t
ti e. H e h s co e in for n ev lu tion t the urging
of his w ife, w ho is concerne bout his frequent cry-
ing s ells. The tient its th t he h s felt ore
e resse over the l st sever l w eeks, w ith ssoci-
te inso ni , low energy, oor etite n 5-lb
w eight loss, ifficu lty concentr ting, n nhe o-
ni . H e enies ny su ici l i e tion. Fortu n tely,
these sy to s h ve not interfere w ith his w ork.
H e h s no jor e ic l roble s n is on no
e ic tions. H e rinks one to tw o gl sses of w ine
sever l ti es er ye r n enies illicit ru g u se.

(A) Ask the other, Wh ts re lly 60. Which of the follow ing e ic tions w ou l be
bothering you bou t you r son being on the ost ro ri te to rescribe this tient?
nti e ress nts?
(A) Bu ro ion
(B) Discu ss the risks n benefits of
flu oxetine n other SSRIs in the (B) Flu oxetine
e i tric o u l tion. (C) H lo eri ol
(C) Sto the flu oxetine i e i tely s the (D) L otrigine
tient is inor n it is his others (E) V l roic ci
w ish.
(D) Sw itch to itri tyline (El vil). 61. Which of the follow ing si e effects w ou l be
(E) Sw itch to roxetine (P xil). the ost i ort nt to iscu ss w ith the tient
rior to st rting?
59. A onth l ter, the boy n his other return to (A) At xi
your office. She infor s you th t fter her sons (B) N u se
l st oint ent, she h s been giving hi
(C) N eu tro eni
St. John wort bec use she believes he nee s
n tur l re e y. Which of the following (D) R sh
woul be the ost ro ri te course of ction? (E) Se tion

(A) Incre se the ose of his nti e ress nt Questions 62 and 63

s St. John w ort w ill low er bloo
concentr tions of the nti e ress nt.
(B) Refer the c se to soci l services for chil
bu se.
(C) Tell the other there is no evi ence th t
St. John w ort is n effective tre t ent
for e ression.
(D) Tell the other to sto the St. John w ort
i e i tely.
(E) Tell the other to w tch ou t for si e
effects inclu ing hotosensitivity n
izziness.
A 60-ye r-ol w hite fe le w i ow is brought to you r
clinic by her ughter, w ho re orts th t her other
s i to her this fternoon th t she w nte to en it
ll. She re orts thou ghts of over osing on her ills,
w hich she h s stock ile . This tient h s no rior
history of su ici e tte ts bu t h s h thou ghts of
su ici e on ulti le rior occ sions over the cou rse
of her ne r-lifelong history of e ression. She lost
her hu sb n to su en he rt tt ck 1 ye r go, but
her u ghter s ys th t she still h s ny very su -
ortive frien s w ith w ho she s en s signific nt
258 8: Pra c tic e Te s t 2

ou nts of ti e. She still c rries on her vi hobby (C) 25%

of g r ening, lthough t slow er ce bec u se of (D) 50%
her w orsening rthritis. She ex resses w orries over (E) 75%
recent big ro in the v lu e of retire ent stocks
she h s. 66. A 24-ye r-ol gr u te stu ent resents to her
University He lth C re Syste w ith the chief
62. Which of the follow ing is the ost signific nt co l int of e ression. U on et ile ques-
f ctor itig ting her risk for su ici e? tioning she reve ls history of intense oo
(A) G r ening hobby sw ings since e rly olescence, w ith short
(B) N o rior su ici e tte ts (hours to ys) erio s of ys hori , ltern t-
ing w ith ti es w here she feels nor l. She
(C) R ce
its th t she is e sily ngere , occ sion lly
(D) Slow er ove ents secon ry to rthritis bre king ite s n su erfici lly cutting on her-
(E) Soci l su orts self w hen or bore . She h s been un ble to
kee boyfrien for ore th n sever l onths,
63. Which of the follow ing e ic l con itions but st tes th t she w ill frequently rtici te
w ou l be the ost i ort nt to ru le ou t s in one-night st n s bec use she often feels
otenti l c u se of e ression in this tient? lonely n e ty. She enies ersistent inso -
(A) H y ercholesterole i ni , nergi , or nhe oni , lthough gets e s-
ily istr cte w hile in lectures. While w hen
(B) Phos holi i et bolis isor ers
cutely u set she y feel ssively suici l,
(C) Thin b se ent e br ne ise ses she enies ny st or current l n. Which of
(D) Thyroi illness the follow ing tre t ents w oul be the ost
(E) Try to h n eficiency ro ri te to begin for this tient?
(A) Ari i r zole
Questions 64 and 65
(B) Cit lo r
A 20-ye r-ol college so ho ore is brou ght to the (C) Di lectic l beh vior l ther y (DBT)
e ergency e rt ent fter being fou n sse ou t
(D) Lithiu
in her b throo . She h been vo iting, w hich she
(E) V l roic ci
its now w s self-in u ce . H er history is not ble
for bre ku 4 onths go w ith her boyfrien of
67. A 24-ye r-ol n w ith history of schizo-
2 ye rs. H er w eight is in the 82n ercentile for her
hreni resents to the e ergency e rt-
height. She is enorrheic. There is no history of
ent. H e h reviou sly t ken h lo eri ol
binge e ting.
(H l ol), but now refuses to t ke it. Bec use of
this, you eci e to try flu hen zine (Prolixin),
64. Which of the follow ing o you ost ex ect to
w hich see s to itig te his sy to s. One
fin on her hysic l ex in tion?
w eek l ter, he le ves the hos it l. H e contin-
(A) C f u l it s ots ues the e ic tions you rescribe n on
(B) Dent l ec y follow -u visit you notice he oves slow ly
(C) P l ble s leen n h s festin ting g it. Block e of w hich
(D) Pectus exc v tu of the follow ing rece tors ost likely ccounts
for the bove si e effect?
(E) Pitting fingern ils
(A) B s l g ngli cetylcholine rece tors
65. Wh t is the likelihoo th t with tre t ent she (B) D 4 rece tors
will ke full recovery over the next 10 ye rs? (C) 5-hy roxytry t ine-2 (5-H T2)
(A) 5% (D) Mesoli bic D 2 rece tors
(B) 10% (E) N igrostri t l D 2 rece tors
 Que s tions : 6274 259

68. A 16-ye r-ol boy beg n h ving re etitive eye (D) Psycho yn ic sychother y
blinking t the ge of 6. By ge 12, he beg n (E) Pu nish ent
blu rting stereoty e hr ses su ch s B lls!
n Shitty! s w ell s king kissing noises. 71. The chil un ergoes lengthy tri l of the rec-
Conco it nt w ith this, he h incre sing if- o en e ther y s bove, but his con ition
ficu lty w ith ying ttention in school n continues without signific nt i rove ent.
occ sion lly is l ye w il , isinhibite Which of the following woul be the ost
beh vior. Which of the follow ing w ou l be ro ri te h r cologic tre t ent of choice?
the ost effective tre t ent for the ri ry
(initi l) con ition? (A) C rb ze ine (Tegretol)
(B) Cloni ine (C t res)
(A) Cloni ine (C t res)
(C) Des o ressin (D v )
(B) Flu oxetine (Proz c)
(D) Di henhy r ine (Ben ryl)
(C) Methyl heni te (Rit lin)
(E) I i r ine (Tofr nil)
(D) Ris eri one (Ris er l)
(E) To ir te (To x) Questions 72 and 73

69. A 12-ye r-ol boy h s recently been rreste An 8-ye r-ol boy is referre by his e i trici n for
for setting fire to neighbor s b rn. H e h s fu rther ev lu tion. H is history is not ble for being
been in trou ble before for l ying w ith fire- o te t ge 6 onths. H is f ily history is sig-
w orks in the neighborhoo , n w hen he w s nific nt for biologic l other w ith severe lcohol
10 ye rs ol he w s su s en e for lighting use isor er. H e h s stru ggle w ith ll of his su b-
tches t his school. Which of the follow ing jects n h s been in s eci l e u c tion cl sses s
i gnoses w ou l ost likely be co orbi in resu lt. H e cts ore concrete th n his eers, n h s
this tient? few frien s. Of note, his intelligence qu otient (IQ)
h s recently been e su re t 60.
(A) Au tis s ectru isor er
(B) Con u ct isor er 72. Which of the follow ing w ou l be this chil s
(C) Intellectu l is bility ost ro ri te i gnosis?
(D) M jor e ressive isor er (A) Au tistic s ectru isor er
(E) Tic isor er (B) Mil intellectu l is bility
(C) Mo er te intellectu l is bility
Questions 70 and 71
(D) Severe intellectu l is bility
A 9-ye r-ol boy w ith history of n or l evel- (E) Profou n intellectu l is bility
o ent l ilestones h s been w etting his be for
the l st 6 on ths. H is ren ts re ort th t th e be 73. Given the bove tients history, w hich of the
w etting initi lly occu rre s or ic lly, bu t for the follow ing hysic l fin ings w ou l ost likely
l st 2 onths it h s been h enin g bou t every be ex ecte ?
oth er n ight. This h s c u se hi sign ific nt
ou nt of sh e n h s been li iting his soci l (A) Cleft l te
inter ctions s he is u n ble to go to slee overs or (B) Congenit l blin ness
w y to c . (C) H y erextensible joints
(D) Microce h ly
70. Which of the follow ing interventions w ou l (E) Pro inent j w
be the ost ro ri te?
(A) Beh vior l ther y 74. A 5-ye r-ol girl h s co e un er the c re of
(B) Cognitive ther y st te Chil Protection Services. H er other w s
know n to be using cr ck coc ine n IV heroin,
(C) Di lectic l beh vior l ther y
n su orting her h bit w ith rostitution.
260 8: Pra c tic e Te s t 2

The girls te or ry foster rents re orte been ski ing cl sses n not turning in ssign ents
to st te w orkers th t she w s in iscri in tely s he believes he w ill u to tic lly gr u te n
soci l w ith u lts bu t often oesnt e r to ss the b r bec use of his bilities n intelligence.
seek or res on to co forting. In her soci l
inter ctions w ith other 5-ye r-ol chil ren t 76. Which of the follow ing w ou l be the ost
her reschool, she is note to often st y by her- likely i gnosis for this tient?
self but is escribe s being in ro ri tely
(A) Bi ol r isor er, cu rrent e iso e
ngry w ith her eers. Which of the follow ing
e resse
w ou l be the ost ro ri te i gnosis in
(B) Bi ol r isor er, cu rrent e iso e nic
this c se?
(C) Cyclothy ic isor er
(A) Attention- eficit/ hy er ctivity isor er (D) Persistent e ressive isor er
(ADH D) ( ysthy i )
(B) Au tis s ectru isor er (E) Schizo ffective isor er, bi ol r ty e
(C) Con u ct isor er
(D) L ngu ge isor er 77. Which of the follow ing w ou l be the ost
(E) Re ctive tt ch ent isor er ro ri te h r cologic tre t ent for this
tient?
75. A 39-ye r-ol n is rreste fter being (A) Cit lo r (Celex )
fou n in e rt ent store, stu rb ting by
(B) Div l roex so iu (De kote)
ru bbing w o ns shoe long his enis. H e
relu ct ntly its th t he h s co itte this (C) Flu oxetine
ct on nu erou s occ sions lthou gh h s not (D) I i r ine
gotten c u ght or rreste . H e feels gre t e l (E) Lor ze (Ativ n)
of sh e n guilt, bu t he is u n ble to sto the
beh vior. Which of the follow ing is the ost Questions 78 and 79
likely i gnosis?
A 36-ye r-ol w o n resents w ith 7 w eeks of
(A) Fetishistic isor er e resse oo ost of the ti e ( lthou gh w s
(B) Frotteu ristic isor er h y for short erio w hen she w on $150 in the
(C) Pe o hilic isor er lottery), sense of ho elessness, n thou ghts of
(D) Tr nsvestic isor er su ici e for the l st onth. She lso re orts incre se
etite n h s been slee ing u to 16 hou rs y.
(E) Voyeu ristic isor er
On ent l st tus ex in tion, her oo n ffect
re ys horic ost of the ti e, but she l u ghs in
Questions 76 and 77
res onse to hu orou s st te ents.
A 27-ye r-ol l w stu ent resents to you s
referr l for the tre t ent of first e iso e of jor 78. Which of the follow ing i gnoses w ou l be
e ression, initi lly i gnose by his ri ry c re the ost ro ri te in this tient?
hysici n 8 w eeks go. On his ent l st tu s ex i- (A) Bi ol r I isor er, cu rrent e iso e
n tion, the tients s eech is extre ely r i , if- e resse
ficult to interru t, n he quickly ju s fro one
(B) Bi ol r II isor er, cu rrent e iso e
to ic to nother. H e s ys th t his oo h s i rove
e resse
gre tly since he l st s w his ri ry c re octor: In
f ct, I on to of the w orl . The tient re orts 3 to (C) M jor e ressive isor er, w ith ty ic l
4 hou rs of slee er night for the l st w eek, not th t fe tu res
I nee th t uch slee nyw y. The tient h s (D) M jor e ressive isor er, w ith
been s en ing ll of his oney buying first e ition el ncholic fe tu res
textbooks n re rr nging the fu rniture in the l w (E) Persistent e ressive isor er
school inistr tion buil ing. H ow ever, he h s ( ysthy i )
 Que s tions : 7582 261

79. Which of the follow ing cl sses of e ic tions
w ou l be the ost effective in this tient?
(A) Anticonvu ls nts
(B) Lithiu
(C) Mono ine oxi se inhibitors (MAOIs)
(D) Tricyclic nti e ress nts (TCAs)
(E) Ty ic l (first-gener tion) nti sychotics
80. A 42-ye r-ol ccount nt resents for long-
ter sychother y tre t ent. In the first ses-
sion, you fin th t he h s been ivorce three
ti es. The oor qu lity of his ro ntic n
other rel tionshi s re the focus of his concerns.
Over the course of onths, you fin out th t he
is erfectionist n inflexible w ithin rel tion-
shi s. He ty ic lly i e lizes his rtner, then
ev lues her, before en ing the rel tionshi
su enly. At ti es, he loses sense of self in
rel tionshi s, not know ing w ho he is or w h t
he w nts. During this ti e, he relies on others
to vise hi on w h t he shoul o. H ow ever,
if he t kes this vice n his l ns f il, he uses
this to ev lue the one w ho vise hi . The
tient kes it very cle r th t he sought your
tre t ent s sychother ist bec use Ill
only cce t the best in the city. The tient lso
re orts to you th t he h s so e unique bilities
of erce tion th t llow hi to etect w h t or
w ho w ill rovi e the best ossible outco e for
hi . For ex le, he icke you s ther ist
not only bec use of your re ut tion, but lso
bec use of your office hone nu ber, w hich
h s igits in scen ing v lue or er. Which of
the following i gnoses is the ost ro ri te
for this tient?
(A) Bor erline erson lity isor er
(B) N rcissistic erson lity isor er
(C) Obsessive erson lity isor er
(D) Other s ecifie erson lity isor er
(E) Schizoty l erson lity isor er
81. A 43-ye r-ol w o n is hos it lize uring
sychotic e iso e in w hich she h the elu-
sion th t she is being controlle w ith co -
uter rogr evelo e by the De rt ent
of Ho el n Security. Accor ing to her f ily,
she sto e t king her regi en of queti ine
n lithiu 4 w eeks before this ission to
the hos it l, n she h s been telling her f -
ily bout her concerns reg r ing the govern-
ent controlling her for the l st 2 w eeks. The
tients st sychi tric history is signific nt
for three rior hos it liz tions over the l st
20 ye rs. At the ti e of her first ission,
she resente w ith 3-w eek history of nic
sy to s n sychosis. During her secon
hos it liz tion, she w s suici l n note to
be e resse w ith sychotic sy to s. During
her thir ission, she w s g in e resse
w ith ro inent isorg nize beh vior. Her
ent l st tus ex in tion u on resent tion
to the hos it l reve ls looseness of ssoci tion
n elusion l sy to s w ithout ro inent
oo co onent. Which of the follow ing is
the ost ro ri te i gnosis for this tient?
(A) Bi ol r isor er, w ith sychotic fe tu res
(B) M jor e ressive isor er (MDD) w ith
sychotic fe tu res
(C) Schizo ffective isor er
(D) Schizo hreni
(E) Uns ecifie sychotic isor er
Questions 82 and 83
The e ic l te on n in tient service c lls you
to hel the w ith 72-ye r-ol fe le tient w ho
w s itte for congestive he rt f ilu re. They
re ort th t t night she beco es confu se , think-
ing th t she is in hotel. She kes u nre son ble
e n s of the nu rsing st ff n beco es isru -
tive on the w r , interfering in the nu rses w ork.
She h s the ost ifficu lty fro 10 pm u ntil bou t
2 a m, w hen she u su lly f lls slee . In the orning,
she is better oriente n u ch ore coo er tive. A
review of her e ic tions reve ls th t she is t king
ci eti ine 400 g PO bi , fu rose i e 40 g PO q ,
tenolol 50 g PO q , igoxin 0.125 g PO q , n
i henhy r ine 50 g PO qhs n 25 g PO qhs
(secon ose 3 hou rs ost first ose for inso ni ).
82. Which of the follow ing e ic tions is ost
likely to c u se this tients confu sion?
(A) Atenolol
(B) Ci eti ine
(C) Digoxin
(D) Di henhy r ine
(E) Fu rose i e
262 8: Pra c tic e Te s t 2

83. Which of the follow ing neu rotr ns itter sys- bu t she re ins sychotic, w ith u itory
te s is ost irectly i lic te in the etiol- h llu cin tions telling her to kill herself.
ogy of her confu sion?
(A) Acetylcholine 87. A 53-ye r-ol rrie le with history of
(B) Do ine jor e ressive isor er n oor co li nce
ue to signific nt sexu l ysfunction now res-
(C) G - inobu tyric ci (GABA)
ents with recurrence of e ressive sy to s
(D) Serotonin with rke hy erso ni n low energy.
(E) N ore ine hrine
88. A 22-ye r-ol fe le gr u te stu ent w ith
D IRECTION S (Questions 84 through 89): The fol-
bi ol r isor er beco es regn nt.
low ing question is preceded by a list of lettered
options. For each of the questions in this section
match the clinical vignette with the most appropriate 89. A 37-ye r-ol n w ith history of nic
medication to prescribe. e iso es now h s 3 w eeks of e ression, w ith
inso ni , oor etite, w eight loss, low
M tch the clinic l vignette w ith the ost ro ri te energy, n ecre se concentr tion.
e ic tion to rescribe.
DIRECTIONS (Questions 90 through 112): For each
(A) Ari i r zole
of the multiple-choice questions in this section select
(B) Bu ro ion
the lettered answer that is the one best response in
(C) Chlor ro zine each case.
(D) Cloz ine
(E) H lo eri ol 90. A clinic l rese rch sychi trist t u niversity
(F) L otrigine A h s been running ou ble-blin l cebo-
(G) Lithiu controlle tri l of new nti e ress nt.
The sychi trist conclu es fter st tistic l
(H ) N ortri tyline
n lysis of the t th t there is no better
(I) P roxetine effect of the ru g co re to l cebo. The
(J) Ris eri one sychi trists colle gu es t five se r te
(K) Ris eri one Const institu tions (u niversities B, C, D, E, n F) h ve
(L) Sertr line ru n i entic l stu ies n eter ine th t there
(M) V l roic ci is tre t ent effect of the ru g co re
to l cebo. Given this infor tion, one y
(N ) Venl f xine
conclu e th t the rese rch tri l t u niversity A
resu lte in w hich of the follow ing?
84. A 32-ye r-ol n with schizo ffective isor er
h s goo benefit with nti sychotic e ic tions (A) H igh v ri nce
but is oorly co li nt ue to l ck of insight (B) Low - re ictive v lu e
n re uce cognition. (C) St n r error
(D) Ty e I error
85. A 48-ye r-ol ivorce w o n h s history (E) Ty e II error
of schizo hreni n is co li nt w ith her
e ic tion, bu t she resents to the e er- Questions 91 and 92
gency roo fter evelo ing severe su nbu rn
es ite only being ou tsi e for sever l hou rs. A 56-ye r-ol n w ith sever l ec e history
of schizo hreni h s been t king nu erou s if-
86. A 41-ye r-ol w o n w ith chronic schizo hre- ferent nti sychotics, lbeit regu l rly, for 27 ye rs.
ni h s been trie on sever l first- n secon - H is sy to s re re son bly w ell controlle , w ith
gener tion nti sychotics t ther eu tic oses, occ sion l, nonco n h llu cin tions n so e
 Que s tions : 8396 263

r noi . H e h s been ble to w ork s volu nteer 94. A 29-ye r-ol rrie n resents to you r
n lives in grou ho e. Abou t 5 ye rs go, he out tient sychi tric clinic co l ining of
evelo e w rithing ove ents of his w rists n nxiety n e ression. H is soci l history
fingers th t is e r w hen he goes to slee . reve ls th t he is ju nior f cu lty e ber of
loc l u niversity, w orking bout 60 hours er
91. Which of the follow ing si e effects is ost w eek. H e enjoys his job but re orts stress ris-
consistent w ith this c se? ing fro his rit l rel tionshi bec use his
w ife ccuses hi of not s en ing qu lity
(A) Ak thisi
ti e w ith her n his being rrie to the
(B) Dystoni job. Accor ing to Erik Erikson, in w hich st ge
(C) N eu role tic lign nt syn ro e (N MS) of evelo ent oes this tient currently
(D) P rkinsonis h ve conflict?
(E) T r ive yskinesi (A) Au tono y versu s sh e n ou bt
(B) I entity versu s role iffu sion
92. Which of the follow ing n to ic stru ctu res
is ost likely i lic te in the etiology of his (C) In u stry versu s inferiority
ove ents? (D) Inti cy versu s isol tion
(E) Tru st versu s istru st
(A) B s l g ngli
(B) Cerebellu Questions 95 and 96
(C) Front l cortex
(D) Mi br in A 46-ye r-ol n resents w ith e iso es of bl ck-
ing out, w here he w ill not re e ber erio s l sting
(E) Motor cortex
for sever l inutes. During those ti es, he is tol by
others th t he h s n o ex ression on his f ce n
93. You re seeing 66-ye r-ol Vietn veter n
oesnt res on to his n e. In ition, he co -
t Veter ns A inistr tion hos it l. H e
l ins of ifficulty in rel tionshi s u e to ecre se
h s been hos it lize nu erous ti es w ith
sex rive n irrit bility. H e s en s gre t e l of
si il r resent tions. H e co l ins of ongo-
ti e w riting ow n his thoughts in his e oirs.
ing night res reg r ing fighting in Vietn ,
w ith frequ ent fl shb cks, intru sive thou ghts,
95. Which of the follow ing ition l sy to s
oor slee , n incre se st rtle. Other th n
w ou l be ost likely resent in this tient?
co ing in for his oint ents, he h s been
u n ble to go out in ublic bec u se he often (A) De ression
feels th t he is u n er tt ck, fe ring th t so e- (B) H y erreligiosity
one is going to ju ou t of the bu shes n (C) Obsessive-co u lsive beh viors
bush hi . H e h s been tre te w ith the
(D) Slee isor ers
follow ing e ic tions, ll w ith only o er-
te i rove ent in his sy to s: flu oxetine, (E) Urin ry incontinence
sertr line, roxetine, cit lo r , irt z -
ine, i i r ine, n itri tyline. H e h s 96. A slee - e rive electroence h logr is
been co li nt w ith venl f xine 375 g ily. erfor e on the tient s rt of his co -
H e h s been sober fro lcohol n heroin for lete w orku . Which of the follow ing lobes
20 ye rs. Which of the follow ing e ic tions of the br in w oul ost likely e onstr te
w ou l be the ost benefici l for this tient? bnor lities in this tient?

(A) Bu ro ion (A) Front l

(B) H lo eri ol (B) Cerebell r
(C) Lor ze (C) Occi it l
(D) Pr zosin (D) P riet l
(E) V l roic ci (E) Te or l
264 8: Pra c tic e Te s t 2

97. After being c lle to the e ergency e rt- (A) Beets

ent to ev lu te you ng w o n w ho over- (B) Li be ns
ose on b rbitu r tes, you fin her in be w ith (C) Liver
her eyes close . She o ens her eyes briefly in
(D) Pe nu ts
res onse to in n e onstr tes flexion
fro in bu t kes no sou n s. Which of the (E) White w ine
follow ing best re resents her Gl sgow Co
Sc le score? 100. A 66-ye r-ol n w ith history of schizo hre-
ni h been int ine on thiori zine (Mel-
(A) 7 l ril) 700 g q for ny ye rs, fter nu erous
(B) 6 unsuccessful tri ls w ith v rious nti sychotics.
(C) 5 Over the l st 8 onths, he h s been co l in-
(D) 4 ing of he ring erog tory voices, n his ose
h s been gr u lly incre se to 1,000 g q .
(E) 3
H e h s no signs of t r ive yskinesi . Which
of the follow ing si e effects w oul be the ost
Questions 98 and 99
concerning t this ose?
You h ve been tre ting 34-ye r-ol n for jor (A) Consti tion
e ression w ith serotonin-s ecific reu t ke inhibi-
(B) Dry eyes
tor (SSRI) for the l st 2 onths. H e w s initi lly
st rte on flu oxetine 20 g/ for the first onth, (C) N e hrogenic i betes insi i u s
n then you r ise the ose to 40 g/ for the l st (D) Pig ent ry retino thy
onth. While he h s toler te the e ic tion w ith- (E) Urin ry retention
out signific nt si e effects, his e ressive sy to s
h ve re ine refr ctory es ite the incre se in os- 101. A 24-ye r-ol n w ithou t rior sychi tric
ge. You h ve eci e to sw itch his e ic tion to history is itte to the sychi tric w r
henelzine (N r il), ono ine oxi se inhibitor w ith isorg niz tion, r noi , git tion,
(MAOI), in ho es of eliciting better nti e ress nt n co n u itory h llu cin tions tell-
res onse. ing hi to kill hi self. H e is given tw o oses
of h lo eri ol 5 g or lly. A roxi tely
98. Which of the follow ing w ou l be the best 8 hou rs l ter, he evelo s torticollis. Which of
str tegy in king the tr nsition fro the the follow ing w ou l be the ost ro ri te
SSRI to the MAOI? tre t ent?
(A) Begin t ering the ose of the SSRI (A) Acet ino hen
w hile incre sing the ose of the MAOI (B) Benztro ine
si ult neou sly. (C) Cyclobenz rine
(B) St rt the MAOI u ntil ther eu tic levels (D) Ibu rofen
h ve been re che , then t er the SSRI.
(E) Pro r nolol
(C) Sto the SSRI bru tly n begin
the MAOI t n equi otent ose the 102. A 28-ye r-ol w o n w ith history of bi o-
follow ing y. l r isor er is itte to the e ic l service
(D) Sto the SSRI bru tly n i e i tely bec u se of w e kness, ent l st tu s ch nges,
begin the MAOI. n seru so iu of 154 ol/ L. Accor -
(E) T er the SSRI n 5 w eeks fter the ing to her boyfrien , for the l st 2 w eeks she
l st ose begin the MAOI. h s been rinking lo s n lo s of w ter
bu t co l ining of being thirsty often, n
99. After he is sw itche to the henelzine, w hich lso frequ ently u rin ting. Which of the follow -
of the follow ing foo s/ rink shoul the ing e ic tions w ou l be ost likely res on-
tient ost voi ? sible for this tients resent tion?
 Que s tions : 97107 265

(A) C rb ze ine enies ny suici l i e tion. H is st e ic l his-

(B) H lo eri ol tory is signific nt for i betes ellitu s, tw o yo-
(C) Lithiu c rbon te c r i l inf rctions, tri l fibrill tion, n coron ry
rtery by ss gr ft. The tients w ife w ishes hi to
(D) Qu eti ine
st rt e ic tion.
(E) V l roic ci
105. Which of the follow ing nti e ress nts shou l
Questions 103 and 104 be ost voi e in this rticu l r tient?
A 58-ye r-ol n w ith long history of o i te u se (A) Bu ro ion
isor er h s been u sing intr venou s heroin ily,
(B) I i r ine
roxi tely $5060 er y. H e h s not been
(C) Mirt z ine
ble to int in ny signific nt sobriety es ite
nu erous in tient n resi enti l reh bilit tion (D) Sertr line
rogr s. H e l st u se heroin 12 hou rs go n h s (E) Venl f xine
su bsequ ently been itte to the in tient sychi-
tric w r for etoxific tion. 106. Which of the follow ing nti e ress nts w ou l
ost likely resu lt in cognitive ecline in this
103. Which of the follow ing e ic tions w ou l be tient?
the ost ro ri te to tre t his w ith r w l (A) Bu ro ion
sy to s?
(B) Cit lo r
(A) A nt ine (Sy etrel) (C) Flu oxetine
(B) Cloni ine (D) P roxetine
(C) H lo eri ol (E) Venl f xine
(D) Lor ze
(E) N loxone 107. A 35-ye r-ol w o n w ith bi ol r isor er
n frequ ent hos it liz tions resents to the
104. After the tient co letes his etoxific tion e ergency e rt ent fter t king n over-
on the u nit, he continu es to be otiv te to ose of lithiu in su ici e tte t. Which
bst in fro heroin u se. H e is referre to n of the follow ing signs w ou l be ost likely to
out tient ictions rogr , bu t w ishes occur?
to t ke e ic tion to ecre se his heroin (A) Ab o in l in
u se fter isch rge. Which of the follow ing
(B) Acu te ystoni
e ic tions w ou l be the ost ro ri te to
rescribe? (C) Leg in
(D) P r noi elu sions
(A) D ntrolene
(E) P resthesi s
(B) Disulfir
(C) Flu zenil Questions 108 and 109
(D) Meth one
(E) Sertr line A 67-ye r-ol w o n resents to you r office w ith
long history of jor e ression. She h s trie
Questions 105 and 106 nu ber of ifferent nti e ress nt e ic tions
in the st bu t h s not h re ission w ith ny
A 75-ye r-ol n w ith jor neu rocognitive is- of the . Currently, she is on lithiu , venl f xine
or er u e to Alzhei er ise se resents w ith his (Effexor), nortri tyline (P elor), lor ze , ris-
w ife to you r clinic for ev lu tion. She is concerne eri one, n benztro ine. She is st rting to believe
bec u se he h s been ow n recently, co l ining th t her next- oor neighbors re ou t to h r her.
of e ression. H is slee h s been w orse, n his You eci e to begin tri l of electroconvulsive ther-
etite n energy h ve been oor. The tient y (ECT).
266 8: Pra c tic e Te s t 2

108. Which of the follow ing ini u ti es shou l 112. A 45-ye r-ol w o n w ith rior history of
the seizure l st for o ti l effectiveness in this jor e ression is itte to the sychi-
tient? tric in tient w r . She h s been severely
e resse , w ith oor slee , ecre se e-
(A) 10 secon s
tite, low energy, n su ici l i e tion. She
(B) 15 secon s now believes th t her neighbors re cons ir-
(C) 60 secon s ing to u r er her, n occ sion lly c n he r
(D) 120 secon s ns voice th t tells her she shou l ie.
(E) 180 secon s After s e king w ith the neighbors, you fin
ou t th t they brou ght her to the hos it l. They
109. Which of the follow ing verse effects w ou l h ve been goo frien s for 20 ye rs n h ve
be the ost likely u ring the cou rse of ECT? notice the tient h s not been le ving the
hou se uch, h s t ken to looking out of her
(A) Br in ge w in ow s w ith su s iciou s gl nces, n h s not
(B) C t toni cle ne her hou se in the l st 2 onths. Which
(C) Fr ctu res of the follow ing e ic tion co bin tions
(D) Me ory i ir ent w ou l be the ost ro ri te tre t ent for
(E) Vo iting this tient?
(A) Flu oxetine n ris eri one
Questions 110 and 111
(B) Lor ze n cloz ine
(C) P roxetine n thyroi u g ent tion
A 26-ye r-ol n w ithou t rior sychi tric history
resents to sychi tric e ergency e rt ent (D) Sertr line n lithiu
w ith r noi , visu l h llu cin tions, feelings of (E) Sertr line n lor ze
u nre lity, e erson liz tion, n extre e git tion.
A u rine toxicology screen is ositive for hencycli- Questions 113 through 116
ine (PCP).
M tch the clinic l vignette w ith the ost likely
su bst nce-in uce isor er. E ch lettere o tion
110. Which of the follow ing w ou l be the best
y be u se once, u lti le ti es, or not t ll.
i e i te tre t ent for the git tion in this
tient? (A) Alcohol intoxic tion
(A) Chlor ro zine (B) Alcohol w ith r w l
(B) Flu oxetine (C) C nn bis intoxic tion
(C) Lor ze (D) Coc ine intoxic tion
(D) Tr zo one (E) Coc ine w ith r w l
(E) Trihexy heni yl (Art ne) (F) H eroin intoxic tion
(G) H eroin w ith r w l
111. Which of the follow ing tre t ents w ou l be (H ) Inh l nt intoxic tion
the ost ro ri te if this tient w ere not (I) Meth het ine intoxic tion
git te ? (J) N icotine w ith r w l
(A) Aci ific tion of the urine (K) N itrou s oxi e intoxic tion
(B) Cheese (L) PCP intoxic tion
(C) Su ortive c re (M) Psilocybin w ith r w l
(D) Vit in B12 (N ) 3,4-Methylene ioxy eth het ine
(E) Vit in E (MDMA) (Ecst sy) intoxic tion
 Que s tions : 108118 267

113. A 23-ye r-ol n is brou ght to the e ergency lettere o tion y be u se once, u lti le ti es,
e rt ent by the olice. H e show s git tion, or not t ll.
vertic l nyst g us, n n lgesi .
(A) Benztro ine
(B) Cloz ine
114. A 62-ye r-ol ho eless n itte to sy-
(C) Desi r ine (N or r in)
chi tric unit begins h ving elev te vit l signs,
visu l h llucin tions, i horesis, tre or, n (D) Flu oxetine
seizu res. (E) H lo eri ol
(F) Lithiu
115. A 43-ye r-ol w o n resents to the sychi- (G) Lor ze
tric e ergency e rt ent co l ining of (H ) Ol nz ine
e ression n suici lity. She is observe to be (I) Phenelzine
f tigue , irrit ble, n with ys horic ffect. (J) V l roic ci
(K) Venl f xine
116. A 30-ye r-ol u sici n resents in the
ou t tient clinic. H e co l ins of fever n 117. A 34-ye r-ol n w ith schizo hreni
chills, runny nose, n use , bo y ches, i rrhe , resents w ith fever n chills. H e is foun to
n b o in l cr s for the l st 24 hours. be b ctere ic n h s WBC cou nt of 900/ L.

Questions 117 and 118 118. A 41-ye r-ol w o n on e ic tions for her
bi ol r isor er resents w ith f tigu e, w eight
For the follow ing scen rios, choose the e ic tion g in, col intoler nce, consti tion, n
ost likely ssoci te w ith the si e effects. E ch ecre se concentr tion.
 Ans we rs a nd Expla na tions

1. (C) Mirt z ine is n ty ic l nti e ress nt there re ny effic ciou s nti e ress nts
w ith nor renergic n serotonergic ctivity. to choose fro , serotonin-s ecific reu t ke
Its ech nis of ction inclu es block e of inhibitors (SSRIs) su ch s cit lo r re con-
the 2- renergic uto- n heterorece tors, si ere first-line tre t ent. Ari i r zole is
s w ell s block e of the 5-H T2 n 5-H T3 secon -gener tion (or ty ic l) nti sychotic.
serotonin rece tors n hist inergic (H 1) It w ou l be ro ri te to u se ri i r zole
rece tors. This unique co bin tion results in if this tient h sychotic sy to s (su ch
incre sing serotonin, n , in higher oses, nor- s h llu cin tions or elu sions) or tre t ent
e ine hrine; how ever, irt z ine oesnt cre- refr ctory e ression (w hich is not the c se in
te sexu l ysfunction n , es eci lly t low er this tient). Methyl heni te is sti ul nt
oses, c uses se tion n incre se etite. u se for ttention- eficit hy er ctivity isor-
er, lthou gh it y occ sion lly be u se s
2. (F) Venl f xine is n nti e ress nt th t n ju nct in the tre t ent of severe e res-
inhibits the reu t ke of both serotonin, n , sions or in cert in c ses w here r i onset is
in higher oses, nore ine hrine. Bec u se of necess ry (such s ehy r te tient). N or-
this, it y c u se incre se bloo ressure, tri tyline is tricyclic nti e ress nt (TCA).
rticu l rly in oses bove 300 g ily. While TCAs re ju st s effic cious s SSRIs,
their si e effects n leth lity in over ose
3. (D ) Although ost nti e ress nts c n c use resu lt in their not being u se s first-line
w ith r w l syn ro e (ch r cterize s flu- e ic tions for jor e ression. Tr nylcy-
like sy to s) if bru tly iscontinue , those ro ine is ono ine oxi se inhibitor
w ith shorter h lf-lives, es eci lly roxetine, (MAOI), rticu l rly u sefu l in MDD w ith
re ore likely to o so. ty ic l fe tu res (incre se etite, w eight
g in, n oo re ctivity), lthou gh the ru g
4. (B) Flu oxetine h s signific ntly longer h lf- ru g inter ctions n iet ry restrictions
life th n the other liste nti e ress nts. This of MAOIs li it their use.
tr nsl tes into few er w ith r w l sy to s
if su enly sto e n y lso be n v n- 7. (A) This tient h s escribe nic tt ck.
t ge in c ses of occ sion l oor co li nce. P nic tt cks re ch r cterize by su en
onset of intense fe r, re , or nxiety, n
5. (E) Most of the secon -gener tion nti sy- cco nie by v riety of hysic l sy -
chotics c u se w eight g in, inclu ing cloz - to s. Althou gh virtu lly ny org n syste
ine, ol nz ine, qu eti ine, n ris eri one. c n see to be the source of istress in nic
H ow ever, zi r si one, lu r si one, n ri i - isor er, co on sy to s inclu e i ho-
r zole re w eight neu tr l. resis, l it tions, shortness of bre th, tre u -
lou sness, flu shing, chest in, n izziness.
6. (B) This tient is su ffering fro jor e res- Reg r less of the clinic l setting or sychi tric
sive isor er (MDD), single e iso e. While history, tients resenting w ith sy to s

268
 Answe rs : 112 269

suggestive of nic isor er ust be thor- BPRS is short sc le evelo e to ssess sy-
ou ghly w orke u to ru le ou t hysiologic chi tric sy to tology ri rily in tients
thology s the sou rce of the sy to s. w ith sychosis or severe i ir ent. It is
Re ssu r nce y be re tu re u ntil other ore often use in rese rch settings. The PH Q
e ic l c u ses re ru le ou t. If no other e i- is self- inistere screening tool focu se
c l con itions re c u sing the sy to s n on co on ent l roble s th t often res-
the nic tt cks continu e, rescribing n SSRI ent to the ri ry c re hysici n (e.g., e res-
n / or referring her to sychi trist y be sive, nxiety, lcohol use, e ting, n so tic
ro ri te. Since nti e ress nts t ke sev- sy to isor ers). The PAN SS is st n r
er l w eeks to re ch fu ll benefit, benzo i ze- test to ssess tre t ent ou tco es in stu ies of
ines y be u se in the interi . Untre te , schizo hreni n other sychotic illnesses; it
nic isor er ten s to ru n chronic cou rse u tilizes three subsc les: ositive sy to s,
n c n c u se severe is bility. neg tive sy to s, n gener l sycho -
thology. Like the BPRS, it is ostly use for
8. (D ) N eologistic s eech, ositive sy to rese rch r ther th n clinic l r ctice.
of schizo hreni , consists of w or s eu
by the tient, h ving no est blishe e n- 11. (B) P tients w ith C gr s syn ro e su ffer
ing. Cl ng ssoci tions re w or s or hr ses fro the elusion th t so eone f ili r is
stru ng together bec u se of the soun s they n i entic l- e ring re l ce ent. A ok is
ke, not bec u se of the e ning they con- M l ysi n ter for issoci tive e iso e
vey. Echol li is sy to of c t toni , ch r cterize by erio of broo ing le -
w here the tient w ill re e t w h t is s i by ing to fit of violence follow e by ne-
so eone else, reg r less of the context, n si . Cot r syn ro e is nihilistic elu sion
often in re etitive nner. Flight of i e s is involving believing one is e , or th t the
the r i shifting of one i e to nother, n is bo y or org ns re ying. Cou v e syn ro e
ch r cteristic of ni . Wor s l is n illog- occurs w hen the husb n of regn nt
ic l, incoherent collection of w or s or hr ses. w o n h s si il r sy to s of regn ncy
n / or l bor. Koro is tr u tic fe r th t the
9. (E) This w o n suffers fro ersistent e res- enis is shrinking into the bo y c vity, seen in
sive isor er ( ysthy i ), low -gr e, chronic so e Asi n cu ltu res.
e ression. In ults, the sy to s ust be
resent for t le st 2 ye rs. Like jor e res- 12. (A) Bere ve ent is the sychologic l re c-
sive isor er (MDD), other th n subjective tion to loss, often the e th of signific nt
feeling of e resse oo , the key fe tures of other. It is not consi ere ent l isor er or
ysthy i re lter tions in etite n slee , thologic l re ction. While sy to s y
feelings of ho elessness, ifficulty concentr t- overl w ith MDD ( e ression, etite/
ing or king ecisions, low self-estee , n slee / energy ch nges), the intense sy -
low energy or f tigue. While ersistent e res- to s of e ression in bere ve ent re often
sive isor er y not res on s robustly to short-live n self-li iting, n there is little
e ic tions s MDD, n equ te ther eutic over ll fu nction l i ir ent. Occ sion l illu -
tri l (on xi u ose) shoul l st t le st sions or h llucin tions of the ece se re not
6 w eeks before eci ing th t it is f ilure. u nco on, bu t the in ivi u l ret ins insight
reg r ing these. Th t being s i , if the e res-
10. (A) The AIMS is st n r clinic l ex in - sive sy to s continue or w orsen, consi er-
tion n r ting sc le th t shoul be in- tion for MDD shou l be given. There is no
istere to tients receiving nti sychotics evi ence of rior or cu rrent nic e iso es to
(neu role tics) su ch s h lo eri ol. It is u sefu l ju stify the i gnosis of bi ol r isor er. Per-
for etecting the evelo ent of t r ive ys- sistent e ressive isor er ( ysthy i ) is
kinesi s w ell s tr cking ch nges over ti e. chronic, low -level e ression th t l sts t le st
The BDI is e ression screening tool. The 2 ye rs in u lts. There is lso no evi ence of
270 8: Pra c tic e Te s t 2
ri ry sychotic illness consistent w ith
schizo ffective isor er.
13. (C) Co ro r xi is co lex otor tic occ -
sion lly seen in Tou rette isor er, ch r cter-
ize by king obscene gestu res. Bru xis is
the grin ing of the teeth. Ble h ros s is the
s s of the eriorbit l u scles c using su s-
t ine or ex gger te blinking. Echo r xi is
lso co lex otor tic w here ove ents of
nother re re e te . It is cl ssic sy to
of c t toni . Torticollis is s s of the neck
u scles su ch s the sternoclei o stoi on
one or both si es, n c n be si e effect of
nti sychotic e ic tions.
14. (C) Echol li refers to re e ting nothers
w or s or hr ses. Co rol li is so eti es
seen in Tou rettes, w here tient w ill blu rt
ou t obscenities s rt of voc l tic. Dys rthri
refers to roble of w or rticu l tion, u su -
lly secon ry to cerebell r or otor control
bnor lities. P lil li is lso re etition of
w or s bu t is the re etition of ones ow n w or s
s if the erson gets stu ck on the s e w or
or hr se. P r r xis is the ter for sli of
the tongu e or Freu i n sli , ch r cterize by
n error in s eech occu rring u e to the inter-
ference of the u nconsciou s.
15. (C) Kle to ni is n i u lse control isor-
er w here n in ivi u l ste ls objects not out
of nee or onet ry v lu e. Antisoci l er-
son lity isor er is ch r cterize by l ck of
e thy n chronic, l tive ttern
of viol ting the rights of others; in this c se,
the tient is istu rbe by the ste ling n
show s no other evi ence of ntisoci l beh v-
ior. Inter ittent ex losive isor er is lso n
i u lse control isor er w here ggressive
i u lses resu lt in ss u lt or the estru ction
of ro erty. Pyro ni is n i u lse control
isor er of eliber te, recurrent fire setting.
Trichotillo ni (h ir- u lling isor er) is
isor er rel te to obsessive-co ulsive is-
or er, w here tients co u lsively u ll their
h ir resu lting in reci ble h ir loss.
16. (B) Ego- ystonic n ego-syntonic refer to
w hether thou ghts or beh viors re istressing
or not istressing to the tient, res ectively.
Delu sions re fixe f lse beliefs th t re in
es ite evi ence to the contr ry n re not
cultu r lly s nctione . Moo congru ent n
oo incongru ent refer to elu sions or h llu -
cin tions in sychi tric isor ers th t re con-
sistent w ith or not consistent w ith the ri ry
oo istu rb nce, res ectively.
17. (C) G nser syn ro e w s thou ght to be ty e
of issoci tive isor er, origin lly escribe
in risoners; how ever, it is now believe to be
consistent w ith lingering. It is ch r cterize
by giving roxi te nsw ers. A ok n
iblokto re issoci tive tr nce isor ers th t
re escribe s istu rb nces in consciou s-
ness n re in igenou s to rticu l r cu ltu res.
Dere liz tion is n ex erience of u nre lity or
et ch ent, often seen in nic tt cks n
issoci tive isor ers. N eg tivis is ch r c-
terize by o osition to su ggestion or vice,
inclu ing irect resist nce to being ove ; it
is co on sy to of c t toni .
18. (A) Cou ntertr nsference refers to feelings the
tient elicits in the ther ist, versu s tr nsfer-
ence, w hich refers to feelings the ther ist elic-
its in the tient. Dis l ce ent is consi ere
neu rotic efense ech nis w here feeling
is irecte tow r nother in ivi u l w ho
is less thre tening th n the origin l object of
th t feeling. Projection is ri itive efense
ech nis ch r cterize by re cting to u n c-
ce t ble feelings or i u lses by l cing the
in nother erson. Re ction for tion is
nother neurotic efense ech nis w here
n u n cce t ble i u lse is tr nsfor e into
its o osite.
19. (C) This tient likely h s Wilson ise se, n
utoso l recessive error of co er et bo-
lis . Wilson ise se c n resent with ulti le
hysic l s well s sychi tric sy to s n
signs, inclu ing e ression, irrit bility, l bility,
n erson lity ch nges. K yserFleischer rings
re one such hysic l sign: gol en brown or
gr y-green rings of ig ent t the corne l li -
bus. Arcus senilis is light gr y ring beginning
su eriorly n exten ing to the li bus. It c n
rese ble corne l rcus, which is ssoci te

with hy ercholesterole i , but in n el erly
tient it is often nor l fin ing. Brushfiel
s ots re lighter-colore re s in the outer thir
of the iris th t c n be ssoci te with Down syn-
ro e, but c n lso be nor l v ri nt. Sub-
conjunctiv l he orrh ge is the fin ing of bloo
in the re s of the eye surroun ing the iris. Also
ssoci te with hy ercholesterole i is x nthe-
l s , r ise yellow re s roun the eyeli s.
20. (C) H e ib llis us is n u ncontrolle sw ing-
ing of n extre ity ssoci te w ith Wilson is-
e se. It is u su lly su en, n once initi te
it c nnot be controlle . Athetoi ove ents,
or thetosis, re slow , sn ke-like ove ents
of the fingers n h n s. Choreifor ove-
ents re lso involu nt ry, irregu l r, n
jerky bu t l ck the b llistic-like n tu re of he i-
b llis u s. Choreo thetoi ove ents re
cl ssic lly seen in t r ive yskinesi , long-
ter si e effect of nti sychotic e ic tions.
Myoclonus is su en u scle s s , n
yotoni is rolonge u scle contr ction.
21. (C) M gic l thinking n i e s of reference
re tw o ty es of elusions th t c n be fou n
in sychotic isor ers, su ch s schizo hre-
ni . M gic l thinking is the belief th t ones
thoughts c n control outsi e events. I e s of
reference re beliefs th t other in ivi u ls
(e.g., govern ent, entert iners, the e i )
re referring to or t lking bou t the erson
ex eriencing the elu sion. Dis l ce ent, ro-
jection, n re ction for tion re ll ty es
of efense ech nis s. Dis l ce ent is the
tr nsferring of feeling tow r n object th t
is less thre tening, su ch s the f ily et or
ones s ou se or chil ren. Projection is the f lse
ttribution of ones ow n u n cce t ble feelings
to nother. Re ction for tion is the for -
tion of th ou gh ts th t re o osite to nxiety-
rovoking feelings.
22. (B) Thou ght bro c sting is the elu sion
th t ones thou ghts c n be he r by others.
It is often seen in schizo hreni . Echol li is
the re etition of nothers w or s or hr ses,
so eti es seen in c t toni . Thou ght con-
trol n thou ght insertion lso c n be seen
in schizo hreni , n re both elu sions th t
Answe rs : 1324 271
others c n control the tients thoughts or
insert thoughts into tients in , res ec-
tively. Tr nsference, in strict ter s, is the reex-
eriencing of st ex eriences with the ther ist
in the setting of sychother y. In gener l, this
ter h s co e to e n the tr nsferring of e o-
tions n feelings th t one h s fro ones st
to the hysici n or c re rovi er.
23. (A) This tient is cu rrently ex eriencing
nic e iso e. While this tient likely h
rior jor e ressive e iso e (MDE), w ith
one nic e iso e he eets criteri for bi o-
l r I isor er. Bi ol r II isor er consists of
n MDE n hy o nic e iso e. Criteri
for hy o ni re the s e s for ni ,
bu t the severity is less (i.e., the tient is not
sychotic, oes not nee hos it liz tion, or
oes not h ve signific nt soci l or occu -
tion l i ir ent). This tient h s sychotic
sy to s (gr n iose elusions) n sig-
nific nt i ir ent (re o eling hou se, not
going to w ork). Cyclothy ic isor er consists
of inor e ressive e iso es (i.e., th t o not
eet criteri for MDE) ltern ting w ith hy o-
nic e iso es. While this tient h s his-
tory of n MDE, he is currently su ffering fro
nic e iso e n not e ressive e iso e.
While he is sychotic ( elu sion l), his rior
fu nctioning n signific nt ffective sy -
to s ke ri ry sychotic isor er su ch
s schizo hreni u ch less likely.
24. (E) First-line h r cother y for tre ting
nic e iso e of bi ol r isor er is either
oo st bilizer (such s v l roic ci or
lithiu ) or secon -gener tion ( ty ic l)
nti sychotic (e.g., ris eri one, queti ine,
ol nz ine). Anti e ress nts such s itri -
tyline ( tricyclic) or flu oxetine ( serotonin-
s ecific reu t ke inhibitor) shou l be voi e ,
s they y w orsen the nic e iso e. While
cloz ine is secon -gener tion nti sychotic,
it is not first-line e ic tion given the risk
of gr nu locytosis n nee for rou tine bloo
onitoring. Although first-gener tion (ty i-
c l) nti sychotics such s h lo eri ol c n be
use , they re not consi ere to be s effic -
ciou s in cute ni s oo st bilizers or the
secon -gener tion nti sychotics.
272 8: Pra c tic e Te s t 2
25. (A) This tient is su ffering fro benzo i z-
e ine w ith r w l. The ost effic cious tre t-
ent for benzo i ze ine w ith r w l is to use
benzo i ze ine w ith long h lf-life (e.g.,
i ze ) n to slow ly t er it over ti e.
Flu zenil is nons ecific co etitive nt g-
onist of the benzo i ze ine rece tor, u se in
c ses of benzo i ze ine over ose. Giving it to
this tient w oul severely w orsen her sy - onstr ting th t the in ivi u l f ile to eet
to s of w ith r w l n ut her t risk of sei-
zu res. The other choices re not consi ere to
be s effective s benzo i ze ines in tre ting
w ith r w l.
26. (A) A conversion isor er (fu nction l neu ro-
logic l sy to isor er) is often r tic
set of neu rologic sy to s th t likely result
fro u nconsciou s conflicts. F ctitiou s isor-
ers involve the consciou s f bric tion of n
illness in or er to resent oneself s ill (i.e.,
ssu e the sick role n be t ken c re of). Ill-
ness nxiety isor er (hy ochon ri sis) is the
reoccu tion w ith fe rs of h ving seriou s
ise se b se on isinter ret tion of bo ily
sens tions. M lingering is the conscious f bri-
c tion of n illness in or er to obt in secon ry
g in (e.g., voi ing ilit ry u ty, w ork or j il,
or obt ining is bility), not i entifie in this
vignette. So tic sy to isor er is ch r c-
terize by one or ore so tic sy to s th t
re istressing or resu lt in isru tion of life; it
is likely ore rev lent in w o en.
27. (E) L belle in iffrence is the cl ssic l ck of
concern show n tow r eficit or loss of func-
tion so eti es seen in conversion isor er
(fu nction l neu rologic l sy to isor er).
Dj enten u is the feeling th t one is he ring
w h t one h s he r before. It is u su lly ssoci-
te w ith nxiety st tes or f tigu e. Dj vu is
si il r ex erience but refers to the sens tion
th t so ething h s been seen before. J is
vu is the o osite of j vu in th t it refers to
so ething th t shou l be f ili r but see s
qu ite unf ili r. Folie eux is sh re elu-
sion rou se in one erson by the influ ence of
nother.
28. (C) Test ent ry c city (the level of co -
etence requ ire to ke v li w ill) is b se
on the resence of ll of the follow ing: (1)
n u n erst n ing of the n tu re of the w ill;
(2) know le ge of ones ssets; (3) know le ge
of n tu r l heirs; (4) bsence of cu te sycho-
sis (i.e., elusions) w hich ight co ro ise
r tion l ecision king; n (5) free o
fro u n u e influ ence or coercion. The v li -
ity of the w ill y be u n er ine by e -
ny of the bove criteri . Actu s reu s refers to
the volu nt ry ct of co itting cri e n
is n ele ent u se in eter ining cri in l
res onsibility. A history of ent l illness is
not su fficient to inv li te ones test ent ry
c city. The resence of conserv tor of er-
son n history of ent l illness re i or-
t nt only insof r s they be r u on ny of the
bove note f ctors. The resence of ju ge t
the signing of w ill is not requ ire .
29. (A) Co etency is leg l eter in tion e
by the cou rt. C city, w hich is situ tion- n
ti e-s ecific, is frequ ent sychi tric consu lt
qu estion. Ele ents of c city inclu e the fol-
low ing bilities: to co u nic te ones w ishes,
to u n erst n ones illness, to u n erst n the
risks n benefits of tre t ent n nontre t-
ent, n to re son bou t ones o tions. The
ge of tient h s no be ring on the eter i-
n tion of c city. Whether the tient grees
w ith the tre t ent te reco en tions is
not the issu e; how ever, qu estions of c c-
ity o not u su lly co e u u nless the tient
is grees w ith the tre t ent te . The res-
ence of sychotic illness oes not, in n
of itself, eter ine c city. A tient being
too isorg nize to co unic te equ tely
or h ving elu sions involving the tre t ent
ro ose y in ic te l ck of c city. A l n-
gu ge b rrier w ou l not e onstr te l ck of
c city, so long s the tient int ins the
bility to co u nic te his or her references
n re sons.
30. (C) Confi enti lity is n integr l rt of the
hysici n tient rel tionshi n is es e-
ci lly i ort nt in est blishing tru st in
sychother eutic rel tionshi . The hysi-
ci n tient rivilege shou l be bre che
only in s ecific inst nces, such s the tients
 Answe rs : 2535 273

w iving of the rivilege (e.g., tient initi- (fu nction l neurologic l sy to isor er)
tes litig tion, consent to rele se infor tion escribes the ro u ction of neu rologic sy -
is obt ine , there is u ty to rotect, e er- to s thought to resu lt fro intr sychic
gency situ tion, or in c ses in w hich the cou rt nee s or conflicts. F ctitiou s isor er c n be
or ers rele se). In this c se, the infor tion ifferenti te fro lingering b se on the
shou l not be rele se unless the tient h s bsence of extern l incentives. In f ctitiou s
w ive his hysici n tient confi enti lity isor er, sy to s re intention lly feigne
rivilege. Lying to or isle ing the cou rt is to s tisfy n intr sychic incentive to ssu e
u nethic l n y su bject one to rosecu tion. the sick role. A jor neu rocognitive isor er
The re ining choices f il to int in confi- ( e enti ) is unlikely in this c se given the
enti lity. ge n resenting co l ints of the tient.
There is no evi ence to su ggest isorg niz -
31. (B) When tient h s sto e ying his or tion or sychotic sy to s consistent w ith
her bill, the hysici n shoul irectly ress schizo hreni .
the issu e w ith the tient. F ilu re to y ones
bills y reflect u n erlying issu es for w hich 33. (B) In ivi u ls w ith lingering consciou sly
the tient h s entere into sychother y feign sy to s for fin nci l incentives or to
or th t re rel te to sychi tric sy to s. voi w ork/ soci l oblig tions (i.e., secon ry
Cont cting collection gency before ress- g in). The consciou s ro u ction of sy to s
ing the issu e w ith the tient is in ro ri te. to ssu e the sick role is seen in f ctitiou s is-
If tient continu es to refu se y ent fter or er. Conversion isor er is the u nconsciou s
iscu ssing the issu e, the tient shou l be or involu nt ry ro uction of sy to s likely
notifie in w riting of the ou tst n ing b l nce, ue to intr sychic, or u nconsciou s, nee s
n referr l to collection gency ight be or conflicts. The unconscious ro u ction of
e. To reserve confi enti lity, c re shou l sy to s to ssu e the sick role or to obt in
be t ken to isclose the ini u infor - secon ry g in is not consistent w ith sychi-
tion nee e for collection (i.e., te of service tric illnesses.
n ch rge) w ithou t referring to i gnosis
or tre t ent ren ere . Asking the insu r nce 34. (B) In this inst nce, the r n o letter test,
co ny to y you fter check h s been w hich relies on concentr tion, coo er tion,
isbu rse to the tient is fu tile bec u se the n the bility to he r, is the test of choice. It
insu r nce co nys oblig tion tow r the consists of telling tient letter n then in
insu re h s been fu lfille . Disclosing the exis- onotone voice listing r n o string of
tence of rofession l rel tionshi w ith the letters. The tient res on s by r ising fin-
tient to his f ily is bre ch of confi enti- ger to in ic te w hen he or she he rs the key
lity. Ter in ting the ther eu tic rel tionshi letter. The other tests rely not only on ttention
before ex loring the yn ics behin the bu t lso on c lcu l tion bilities, n therefore
tients y ent elinqu ency ight h r e u c tion l level.
ny fu tu re ther eu tic lli nce.
35. (B) Sexu l bu se is esti te to occu r w ith n
32. (D ) M lingering is the intention l ro u ction inci ence of 1% of chil ren er ye r. Know n
of sy to s for secon ry g in (e.g., to voi cqu int nces (e.g., f thers, ste f thers, n
w ork, to ev e cri in l rosecu tion, or to g in le rel tives) re often the er etr tors. In
fin nci l rew r s). A i gnosis of linger- this vignette, the tient likely h s cqu ire
ing shou l be su s ecte in e ico-leg l c ses, N eisseria gonorrhoeae fro le er etr tor.
in in ivi u ls w ith ntisoci l erson lity is- Other hysic l fin ings y inclu e inju ries
or er, w hen sy to s re ou t of ro ortion to the genit li (i.e., hy en, v gin ) or the
to objective fin ings ( s in this c se), or w hen erineu . Psychi tric nifest tions of sexu l
tient in istress oes not coo er te w ith buse y inclu e nxiety, git tion, ggres-
ev lu tion or tre t ent. Conversion isor er sive or i u lsive beh vior, n exhibitionis .
274 8: Pra c tic e Te s t 2
When sexu l buse of chil is su s ecte , the
first ste is to ensure the s fety of the chil
n i e i tely notify the st tes Chil Pro-
tective Services. Re orting is n tory in
c ses of hysic l n sexu l chil bu se. The
other choices f il to rotect the chil n o co
not s tisfy st te- n te re orting st tu tes.
36. (B) This c se re resents Wernicke ence h -
lo thy, con ition seen in chronic lcohol
u se isor ers. The etiology is cute thi ine
eficiency n it resents w ith the cl s-
sic tri of confu sion, t xi , n o hth l-
o legi . Althou gh it is u su lly reversible
w ith thi ine re l ce ent, it is i ort nt to
inister the thi ine renter lly, rior to
giving flu i s n glu cose. A inistr tion of
glu cose n flu i s first y rovoke w ors-
ening of sy to s resu lting in er nent
ge. The inistr tion of n loxone is
u se for o i te w ith r w l.
37. (B) The tient is ex eriencing sy to s
consistent w ith severe lcohol w ith r w l,
n ely eliriu tre ens (DTs), ch r cterize
by eliriu , confu sion, co b tiveness, n
elev te vit l signs. DTs c rry signific nt
ort lity if not tre te . The tre t ent of choice
is IM or IV benzo i ze ines. Although b r-
bitur tes y lso tre t lcohol w ith r w l,
they h ve n rrow er ther eu tic in ex, w ith
higher risk of se tion n res ir tory e res-
sion. N either thi ine nor n nti sychotic
w ill tre t the un erlying lcohol w ith r w l,
n giving hy r l zine y be ngerou s s
it y sk the u tono ic sy to s of the
lcohol w ith r w l.
38. (D ) The tient is resenting w ith evi ence of
over ose w ith o i tes, w hich is ch r cterize
by the tri of so nolence, res ir tory e res-
sion, n in oint u ils. O i te intoxic tion
c n be r i ly reverse w ith IV inistr -
tion of n o i te nt gonist, su ch s n loxone.
Ant bu se blocks cet l ehy e ehy roge-
n se n is given to lcoholics s n versive
sti u lu s to voi lcohol consu tion. Ben-
zo i ze ines w ou l be u se in c ses of severe
lcohol w ith r w l, w hich w oul e on-
str te elev te vit l signs. Flu zenil is
benzo i ze ine nt gonist use in the e er-
gency tre t ent of over ose w ith benzo i-
ze ines, w hich oes not c use u ill ry
constriction. Thi ine w oul be given in c ses
of Wernicke ence h lo thy, c u se ost
only by chronic, he vy lcohol con-
su tion. It resents w ith sy to s of con-
fusion, t xi , n o hth l o legi .
39. (B) This w o n is show ing signs of jor
neu rocognitive isor er ( e enti ), likely
ue to Alzhei er ise se, the ost co on
c use of neu rocognitive isor ers ( e enti ).
The ri ry tre t ent o lity is to begin
n nticholinester se inhibitor, su ch s g l n-
t ine. Me ntine, n N - ethyl d - s rt te
(N MDA) rece tor nt gonist, is e ic tion
th t y be e to the regi en ition-
lly, bu t it is not s effective in il e en-
ti s. Anti e ress nts (e.g., cit lo r ) n
nti sychotic e ic tions (e.g., zi r si one)
y be u se for ssoci te e ression or gi-
t tion/ sychosis, res ectively, bu t they re
not ri ry tre t ents. Ginkgo bilob h s
not been show n to be effective for the e ory
eficits in neu rocognitive isor ers.
40. (D ) Risk f ctors for co lete su ici e inclu e
(1) ge > 45, (2) le gen er, (3) never rrie
> w i ow e / se r te / ivorce > rrie ,
(4) w hite r ce > bl ck r ce, n (5) religiou s
> not religiou s. Wo en tte t su ici e tw ice
s frequently s en; how ever, en re three
ti es ore likely to co lete su ici e th n
re w o en.
41. (A) Physici n- ssiste suici e involves the
octors f cilit ting ersons e th by rovi -
ing the infor tion or equi ent necess ry to
en his or her life. The AMAs Co e of Me ic l
Ethics strongly con e ns such ction s fun-
ent lly inco tible w ith the hysici ns
role s he ler. R ther, the ethic l oblig tion
of the hysici n is to equ tely res on to
tients en -of-life issues. Choices (B) n (E)
w oul both be ssisting the tient to co it
suici e n re u nethic l. Infor ing the f -
ily w oul be bre ch of confi enti lity n
not ro ri te t this oint, n l cing the
tient in restr ints is not in ic te .

4249. [42 (A), 43 (L), 44 (C), 45 (K), 46 (H), 47 (E), 48
(F), 49 (J)] The Beck De ression Inventory (A)
is 21-ite test w ith three res onses er ite
th t is n e sily use screening tool to ev lu te
for e ression. Bec u se it w ou l be u nu su l
for n in ivi u l so you ng to h ve neu ro-
cognitive isor er ( e enti ) n bec u se
ny of the nsw ers reflect l ck of interest,
the Beck De ression Inventory, in conju nction
w ith the Folstein MMSE, y hel istingu ish
e ression fro e enti . The WCST (L)
ssesses execu tive fu nctions of the br in su ch
s org niz tion l bilities, ent l flexibility,
n the bility to bstr ct n re son. These
c cities re believe to be loc te in the
front l lobes. D ge to the front l lobes c n
le to bnor lities on this test. The Blesse
R ting Sc le (C) is tool th t sks frien s or
f ily of the tient to ssess the bility of the
tient to fu nction in his or her u su l environ-
ent. The WAIS-R (K) is n ssess ent of IQ
u se in ges 16 onw r ; it c n be e loye to
hel better u n erst n the in ivi u ls intel-
lectu l level of fu nctioning n ru le ou t n
intellectu l is bility. IQ ssess ent w ill lso
i the school in evelo ing n in ivi u l-
ize stu y rogr for the stu ent. The Ror-
sch ch Test (H) is rojective test th t y shou l re in cogniz nt of the i
be u se to ssess erson lity stru ctu re. The
tient h s ch r cteristics of schizoi er-
son lity isor er, w hich y be better elu ci-
te w ith skille ssess ent in the context
of his clinic l history. The Folstein MMSE
(E) is qu ick, e sily inistere test th t
llow s for i e i te ssess ent of jor
neu rocognitive isor er ( e enti ). Scores
of less th n 24 re su ggestive of e enti .
The MMPI-2 (F) is n objective test consisting
of sever l hu n re tru e/ f lse qu estions u se
to ssess n in ivi u ls erson lity. It is the
ost w i ely use n highly st n r ize
test of erson lity. The W Test (J) is u se
to ev lu te he is heric l ngu ge o in nce
rior to surgic l elior tion of seizure focus.
Where s ost right-h n e in ivi u ls show
left he is heric o in nce for l ngu ge,
left-h n e in ivi u ls y be either right
or left o in nt. The test consists of inject-
ing so iu yt l into the c roti rtery
n observing the tr nsient effects on s eech.
Answe rs : 3651 275
Injection into the left c roti rtery nesthe-
tizes the left si e of the br in, n those w ith
left he is heric l ngu ge o in nce show
interru te s eech. The Ben er Gest lt Test
(B) involves co ying figu res, w hich hel s to
screen for evelo ent l isor ers or br in
ge. The Boston Di gnostic A h si
Ex in tion (D ) is series of tests given by
n ex erience clinici n to ev lu te n ke
tre t ent reco en tions for in ivi u -
ls w ith h si . The ReyOsterrieth figure
(G) is sensitive to eficits in co ying n l ck
of ttention to et il in in ivi u ls w ith right-
si e riet l lobe lesions. The Stroo Test
(I) ssesses execu tive function s the tient
h s to e l w ith istr ctions n h s to su -
ress n incorrect re ly before rovi ing the
correct one.
50. (B) Physici n tient confi enti lity in the
tre t ent of inors u st be int ine
u nless otherw ise n te by l w (e.g., chil
bu se or c ses of bortion in so e st tes)
or w hen rent l involve ent is necess ry
in king co lex n life-thre tenin g
e ic l ecision s. In this c se, th e hysici n
u st res ect the tients confi enti lity bu t
lic tions
this w ill h ve on the f ily syste . Therefore,
it is ost ro ri te to encou r ge the inor
to iscu ss the issu e w ith her rents. Testi o-
ni l rivilege refers to the rivilege invoke
to rotect hysici n tient confi enti lity
w hen e ic l infor tion is su b oen e
w ithou t tient consent. At this oint, there
is no in ic tion of chil h r or neglect th t
w ou l n te re orting to Chil Protective
Services. The re ining tw o choices f il to
int in hysici n tient confi enti lity.
51. (D ) This tient is ex eriencing jor e res-
sive isor er (MDD), single e iso e. Anti e-
ress nts re the tre t ent of choice. As this
tient is show ing so e i rove ent n
toler ting the e ic tion, the ost ro ri-
te next ste w ou l first be to xi ize the
ose. While u g enting w ith n ty ic l nti-
sychotic (e.g., ri i r zole) or lithiu c n be
hel ful in tre t ent refr ctory e ression, this
tient h s not h n equ te ose or tri l
276 8: Pra c tic e Te s t 2
of his cu rrent nti e ress nt. Discontinuing
his fluoxetine w ou l gre tly incre se his risk
of rel se. While sw itching to nother nti-
e ress nt (e.g., sertr line) y be in ic te ,
this w ou l only be reserve in c ses w here
he either i not res on to n equ te tri l
of xi l ose of n nti e ress nt, or if
he suffere signific nt si e effects fro the
current nti e ress nt.
52. (E) MDD ten s to be chronic illness. P tients
w ith one e iso e of e ression h ve 50%
risk of h ving fu tu re e iso es, lthou gh nti-
e ress nts hel to ini ize the risk.
53. (C) The tient is su ffering fro jor e res-
sive isor er (MDD), w ith ty ic l fe tures
(i.e., incre se etite/ slee , oo re ctiv-
ity). Bec u se of their si e effect rofile, the
tre t ent of choice in jor e ression is the
serotonin-s ecific reu t ke inhibitors (SSRIs),
such s flu oxetine (Proz c). A itri tyline n
other tricyclic nti e ress nts (TCAs) inclu e
the risk of rrhyth i s n c n be leth l in
over ose, u nlike the SSRIs. While the tient
re orts erio s u ring w hich she is ju st fine,
there is nothing to in ic te cycling ttern
(i.e., bi ol r isor er) th t w oul require
oo st bilizer su ch s iv l roex so iu .
Si il rly, being convince th t her fi nc is
bou t to le ve her is not likely sychotic, bu t
is inste istortion th t oes not requ ire n
nti sychotic su ch s zi r si one. Althou gh
MAOIs such s henelzine re thou ght to be
so ew h t ore effective (th n TCAs) in ty -
ic l e ression, they c rry the risk of hy er-
tensive crisis w hen co bine w ith foo s
cont ining try to h n.
54. (C) Flu oxetine is cl ss C ru g, e ning th t
it is otenti lly h r fu l to the evelo ing
fetu s, ccor ing to ni l stu ies, lthou gh
SSRIs s cl ss re not believe to be ter to-
genic or c u se birth efects. A iscu ssion of
the risks n benefits of tre t ent is therefore
ost ro ri te. There is no in ic tion th t
she is t rticu l r risk for ost rtu e res-
sion n no evi ence in the liter ture th t
ing secon nti e ress nt in regn ncy
w ill revent this isor er.
Asking the tient how i ort nt reg-
n ncy is to her w ou l be in ro ri te, since
it is erson l choice, n , ccor ing to the
infor tion rovi e in the vignette, it is not
so ething th t u ts her in nger of ny kin .
ECT y be n o tion s it is s fe in reg-
n ncy, bu t not before iscu ssion of the risks
n benefits of her cu rrent tre t ent. While
fluoxetine oes not h ve the w ith r w l syn-
ro e know n to occu r w ith roxetine, sto -
ing it i e i tely shou l be voi e u e to
the risk of rel se.
55. (A) This tient is exhibiting sychosis (cu t-
ting ow n tree th t his w ifes ghost lives
in) n e ression. There re ny ossible
etiologies, inclu ing jor e ressive isor-
er w ith sychotic fe tu res, bi ol r isor er,
schizo ffective isor er, n schizo hre-
ni . Reg r less of the eventu l i gnosis, it
is i ort nt to first ru le ou t other c u ses of
his beh vior su ch s illicit or rescribe rug
intoxic tion. Therefore, it is re tu re t this
oint to rescribe ny e ic tions for hi .
56. (C) Tr zo one, w hich w s evelo e s n
nti e ress nt, h s been show n to be n effec-
tive slee ing i n w ou l be useful in this
tient. The benzo i ze ines, such s l r -
zol n i ze , overl w ith lcohol
in bin ing to GABA rece torshence their
u se in lcohol w ith r w l n shoul be
voi e in tients w ith history of lcohol
u se isor er. Z le lon is rel tively contr in-
ic te in those w ith severe liver ysfu nction,
w hich is otenti l issu e in tient w ith
history of chronic lcohol u se. Zol i e h s
lso been show n to h ve si il r ictive
otenti l to the benzo i ze ines.
57. (D ) Tr zo one c rries 1 in 1,000 to 1 in 10,000
risk of ri is . The other sexu l si e effects
ong the choices re know n to occur w ith the
serotonin-s ecific reu t ke inhibitors, but not
rticul rly w ith tr zo one. Incontinence is
not frequent si e effect of ny nti e ress nt.
58. (B) All of the SSRIs h ve been in the new s
bec u se of controversy over t on incre se
suici l gestures ong chil ren t king these

e ic tions. As resu lt of nu erou s stu ies
n review , the FDA h s l ce bl ck box
w rning for ll nti e ress nts u e to the
s ll incre se risk of suici l thou ghts or
beh vior in chil ren t king nti e ress nts
co re w ith l cebo. H ow ever, flu ox-
etine is not only the ost stu ie in chil ren,
bu t, long w ith escit lo r (Lex ro), re
the only e ic tions FDA rove for the
tre t ent of chil hoo e ression, w hich
kes sw itching to roxetine or itri ty-
line in ro ri te in this setting. Asking the
chil s other w h t is re lly bothering her
is u nlikely to be ro u ctive, s it is so ew h t
ccu s tory n not ressing her legiti te
concerns. Fluoxetine oes not h ve the w ith-
r w l syn ro e know n to occu r w ith rox-
etine, bu t sto ing it i e i tely shou l still
be voi e .
59. (D ) Althou gh ny in ivi u ls think of n t-
u r l re e ies su ch s St. John w ort s s fe,
these su le ents c n h ve signific nt si e
effects. In rticu l r, St. John w ort y c u se
incre se hotosensitivity, sto ch u set,
r shes, f tigu e, restlessness, he che, ry
outh, izziness, n confu sion. These si e
effects re ore likely w hen St. John w ort is
co bine w ith SSRIs. The recise h r -
cokinetics of St. John w ort re u nknow n, bu t
St. John w ort is believe to ct like ono-
ine oxi se inhibitor (MAOI) n h s
conflicting evi ence reg r ing its effic cy
in tre ting il e ression. H ow ever, oses
of SSRIs shou l be ecre se w hile tients
re t king the su le ent bec u se of os-
sible otenti tion of si e effects. As w ith ny
nti e ress nt, it is not goo i e to sto it
bru tly. There is no re son to think th t chil
buse is involve , s the chil s other is not
utting her son in nger.
60. (D ) This tient is resenting w ith bi ol r
isor er, ost recent e iso e e resse .
Des ite the l ck of t reg r ing bi ol r
e ression, the i ct of e ressive e i-
so es y be signific ntly w orse th n th t of
nic e iso es. L otrigine, n ntie ile -
tic e ic tion, h s e onstr te effic cy in
( n h s been rove for) the tre t ent of
Answe rs : 5265 277
e ressive e iso es of bi ol r isor er. Anti-
e ress nts su ch s bu ro ion n fluox-
etine shou l be voi e (es eci lly w ithou t
n ition l oo st bilizer) s they y
reci it te nic e iso e or le to r i
cycling (> 3 oo e iso es er ye r). While
secon -gener tion nti sychotics (e.g., qu e-
ti ine) re likely benefici l in the tre t ent
of bi ol r e ression, first-gener tion nti-
sychotics (neu role tics), su ch s h lo eri ol,
re not effective n y w orsen e ressive
sy to s. V l roic ci is consi ere first-
line tre t ent of bi ol r ni , bu t the t
re f r less convincing for e resse bi ol r
tients.
61. (D ) L otrigine u se h s 7% risk of r sh;
u nfortu n tely, StevensJohnson syn ro e
( life-thre tening r sh) occu rs in 0.1% of
tients, n bec u se of this l otrigine u st
be titr te slow ly. Other signific nt bu t less
concerning verse events inclu e t xi ,
n u se , n se tion. N eu tro eni is oten-
ti lly ngerou s si e effect of c rb ze ine,
not l otrigine.
62. (B) H er l ck of rior su ici e tte ts is her
ost signific nt rotective f ctor; lesser ro-
tective f ctor w ou l be her soci l su orts.
The other f ctors o not l y s u ch of
role.
63. (D ) There re ny otenti l e ic l c u ses
of e ression, inclu ing thyroi ysfunction,
vit in B12 eficiency, ren l ise se, n
v scu l r ise se. The other choices o not
likely c u se e ressive illness.
64. (B) This tient is ost likely su ffering fro
norexi nervos . Excessive ent l ec y is
co on in tients w ith norexi or bu li-
i w ho urge by self-in u ce vo iting.
Althou gh the other choices y be resent
in severe st rv tion, excessive ent l ec y is
the ost co on n e rs the e rliest.
65. (D ) Anorexi nervos h s v rie course,
lthough oor rognosis over ll. Stu ies
ocu ent th t only bout 50% of tients h ve
goo outco e; 25% h ve oor ou tco e.
278 8: Pra c tic e Te s t 2

Unfortun tely, the ort lity r te of norexi h ve not been fou n to be s ecific lly hel fu l
nervos is roxi tely 4%. for this ri ry con ition. Althou gh eth-
yl heni te y hel this tients rent
66. (C) This tient likely h s bor erline er- ttention- eficit hy er ctivity isor er sy -
son lity isor er. The first-line tre t ent for to s, it y lso ex cerb te his tic isor er.
bor erline erson lity isor er re ins sy-
chother y, such s DBT. DBT is w ell-stu ie 69. (B) Fire setting in re e te ttern in chil-
v ri tion of CBT th t focu ses on suici l ren often cco nies other beh viors th t
beh vior, consisting of in ivi u l sychother- re efi nt of ru les n u thority, s in con-
y, grou ther y, n ho ew ork ssign- u ct isor er. Althou gh fire setting y occu r
ents. A v riety of e ic tions h ve been in chil ren i gnose w ith u tis s ectru
stu ie in bor erline erson lity isor er, isor er, intellectu l is bility, or tic isor-
inclu ing nti sychotics (e.g., ri i r zole), er, it is u ch ore u nu su l. Chil ren w ith
nti e ress nts (e.g., cit lo r ), n oo jor e ressive isor er o not eng ge in
st bilizers (e.g., lithiu n v l roic ci ). fire-setting s co on beh vior.
H ow ever, w hile the liste e ic tions h ve
e onstr te so e benefit in so e of the 70. (A) This chil is suffering fro nocturn l
sy to s of bor erline erson lity isor er, enu resis. Utilizing bell/ bu zzer n
in the bsence of nother sychi tric isor er evice ( for of beh vior l ther y) is the
(e.g., MDD, bi ol r isor er), sychother y ost effective intervention, hel fu l in gre ter
is the inst y of tre t ent. th n 50% of chil ren. Cognitive ther y, i -
lectic l beh vior l ther y ( for of cog-
67. (E) N igrostri t l D 2 rece tors th t re blocke nitive-beh vior l ther y esigne for the
by nti sychotic e ic tions c use n i b l- tre t ent of bor erline erson lity isor er),
nce betw een o ine n cetylcholine, n sycho yn ic ther y h ve not been
w hich ccounts for the rkinsoni n sy - foun to be effective in the tre t ent of enure-
to s seen in this c se. Block e of cetylcholine sis. Pu nish ent is not ty e of beh vior l con-
rece tors c n hel tre t extr yr i l itioning use to tre t sychi tric illnesses.
sy to s (EPS). D 4 or 5-H T2 rece tor block-
e oes not c u se EPS. Mesoli bic D 2 71. (C) While i i r ine w s consi ere the
rece tor block e is believe to ccou nt for tre t ent of choice, bec use of its si e effects
the nti sychotic effect of nti sychotics n (e.g., c r iotoxicity) es o ressin is consi -
oes not c u se extr yr i l sy to s. ere first-line h r cother y for enu resis.
Ty ic l nti sychotics block both nigros- Althou gh rel se is high fter sto ing the
tri t l n esoli bic o ine, w here s e ic tion, roxi tely 30% of tients
ty ic l (secon -gener tion) nti sychotics chieve tot l ryness, w ith nother 40% exhib-
referenti lly block esoli bic o ine, iting re u ction in be w etting. C rb ze-
ccou nting for the over ll ecre se extr y- ine is n nticonvu ls nt so eti es use s
r i l sy to li bility. oo st bilizer, n cloni ine is n ntihy er-
tensive often use to tre t o i te w ith r w l
68. (D ) This tient is ost likely suffering fro n ADH D; neither re ro ri te for the
Tou rette isor er. Aty ic l nti sychotic tre t ent of enuresis. Di henhy r ine is n
e ic tions (such s ris eri one) w hich block ntihist ine w ith nticholinergic ro erties,
o ine rece tors re consi ere the ost often use for inso ni or to tre t extr yr -
effic ciou s t ecre sing voc l n otor tics. i l sy to s, n r rely use for enuresis.
Cloni ine is benefici l in tre ting Tou rettes,
es eci lly in il c ses, lthough it y c u se 72. (B) B se on his c e ic ifficu lties n
excessive se tion n izziness. Flu oxetine IQ, this tient w ou l be cl ssifie s h ving
n to ir te y be effective for co orbi il intellectu l is bility (intellectu l evel-
con itions foun w ith Tourette isor er, but o ent l isor er). Intellectu l is bility is
 Answe rs : 6677 279

ch r cterize by eficits in intellectu l fu nc- is lso r hili w hereby the in ivi u l

tions confir e by clinic l ssess ent n s tisfies sexu l u rges by ru bbing g inst non-
st n r ize intelligence testing (e.g., IQ test- consenting in ivi u ls. Pe o hilic isor er
ing), s w ell s eficits in tive fu nctioning involves sexu l ctivity w ith re u bes-
th t resu lt in f ilure to eet evelo ent l cent chil . The focu s of tr nsvestic isor er
st n r s. While intellectu l is bilities re involves cross- ressing, n is u su lly seen in
co on in tients w ith u tistic s ectru heterosexu l les. The r hili of observ-
isor er, there is no history of restrictive, ing u nsu s ecting eo le n ke or involve
re etitive tterns of beh vior or interests in sexu l ctivity is i gnose s voyeu ristic
consistent w ith u tis . isor er.

73. (D ) Microce h ly, short l ebr l fissu res, 76. (B) Des ite his recent i gnosis of jor
fl t i f ce, n thin u er li re ll sso- e ressive isor er (MDD), this tient h s
ci te w ith fet l lcohol syn ro e (FAS), sy to s consistent w ith cu rrent nic
w hich w ou l be su s ecte in this tient w ith e iso e (e.g., eu hori , ecre se nee for
tern l history of chronic, severe, lcohol slee , i u lsivity, ressu re s eech, i ir-
u se. Cleft l te is not s ecific lly ssoci te ent in fu nctioning), n therefore w oul be
w ith FAS. Congenit l blin ness is not sso- i gnose w ith bi ol r isor er, current e i-
ci te w ith FAS, lthou gh ethyl lcohol so e nic. Bi ol r isor er, cu rrent e iso e
consu tion c n c use blin ness in u lts. e resse w oul be i gnose in tient
H y erextensible joints n ro inent j w w ith history of ni bu t cu rrent jor
re ssoci te w ith fr gile X syn ro e. e ressive e iso e. Criteri for cyclothy ic
isor er re e ressive e iso es (w hich o
74. (E) Chil ren w ith re ctive tt ch ent is- not eet criteri l for MDD) ltern ting w ith
or er is l y rke ly istu rbe n in - hy o nic e iso es (sy to s of ni
ro ri te tt ch ent beh viors ssoci te w ithou t i ir ent in fu nctioning, sychotic
w ith thologic l c re, su ch s seen in this sy to s, or the nee for hos it liz tion).
c se. Althou gh ADH D n con u ct isor- Persistent e ressive isor er ( ysthy i ) is
er re often co orbi in those chil ren w ho chronic, e ressive illness, l sting for t le st
h ve histories of re ctive tt ch ent isor- 2 ye rs. Althou gh the tient h s nic sy -
er, there is not enou gh evi ence to i gno- to s n qu estion ble sychosis ( gr n iose
sis either t this ti e. P tients w ith u tis elusion), there is no in ic tion th t he h s
s ectru isor er e onstr te ersistent h erv sive sychotic sy to s in the
i ir ent in reci roc l soci l co u nic - bsence of his oo sy to s, w hich w ou l
tion (si il r to re ctive tt ch ent isor er) be consistent w ith schizo ffective isor er,
bu t lso h ve restricte , re etitive tterns of bi ol r ty e.
beh vior, interests, or ctivities, not evi ent
in this c se. The criteri for l ngu ge isor- 77. (B) As this tient h s sy to s consistent
er inclu e ifficu lties in the cqu isition n w ith bi ol r isor er, ni , he w ou l ost
u se of l ngu ge u e to eficits, n o not benefit fro lithiu or nother oo st bi-
inclu e bnor lities in e otion l co u- lizer su ch s v l roic ci , or n ty ic l nti-
nic tion (e.g., is l ys of ggression tow r sychotic (e.g., ol nz ine). Anti e ress nts
other chil ren) fou n in re ctive tt ch ent such s cit lo r , flu oxetine, n i i r -
isor er. ine c n ex cerb te ni n shou l be
voi e . Lor ze , benzo i ze ine, y
75. (A) This tient w ou l ostly likely be i g- be u se to tre t sycho otor git tion n
nose w ith fetishistic isor er, r hili inso ni , bu t it oes not tre t the u n erlying
ch r cterize by the use of nonliving objects isor er n h s risk of iction if u se in
for sexu l gr tific tion. Frotteuristic isor er the long ter .
280 8: Pra c tic e Te s t 2

78. (C) A jor e ressive e iso e w ith ty i- erson lity isor er re erfectionists, inflex-
c l fe tu res is ch r cterize by oo re ctiv- ible, n overly e n ing of the selves
ity, rejection sensitivity, hy erso nolence, n others. Schizoty l tients re know n
incre se etite, n le en r lysis for their qu irkiness n see ingly gic l
(i.e., he vy feeling in extre ities). Mel ncholic thinking styles.
fe tures inclu e signific nt nhe oni , e res-
sion w orse in the orning, ter in l inso ni , 81. (C) The essenti l fe tu res of schizo ffective
rke sycho otor bnor lities, signifi- isor er re ro inent oo e iso es ( jor
c nt w eight loss, n in ro ri te guilt. To e ression, ni , or ixe e iso e) concu r-
i gnose bi ol r I isor er there ust be t rent w ith sy to s consistent w ith schizo-
le st one nic e iso e. Bi ol r II isor er is hreni . In ition, the i gnosis requ ires
ch r cterize by n e iso e of jor e res- erio of 2 w eeks of sychotic sy to s
sion n hy o nic e iso e. Persistent w ithou t ffective sy to s w hich ru les ou t
e ressive isor er ( ysthy i ) is chronic, bi ol r isor er or MDD w ith sychotic fe -
often less-intense e ression, l sting 2 ye rs. tu res. While tients w ith schizo hreni y
( n often o) beco e e resse , the oo
79. (C) Althou gh not co only u se bec u se sy to s re not resent for su bst nti l
of the risk of si e effects, MAOIs re consi - ortion of the illness. Uns ecifie sychotic
ere to be the ost effective cl ss of ru gs isor er is u su lly reserve for situ tions
for tre ting ty ic l e ression, es eci lly in w hich the clinici n oes not h ve enou gh
co re to TCAs. SSRIs re lso quite effec- historic l t to know w hether the tient
tive for tients w ith ty ic l fe tures. So e h s schizo hreni , oo isor er w ith
nticonvu ls nts n lithiu re u se for the sychotic fe tu res, su bst nce-in uce sy-
tre t ent of bi ol r isor er, bu t not ty i- chotic isor er, or sychotic isor er u e to
c lly for uni ol r e ression. First-gener tion nother e ic l con ition.
nti sychotics (e.g., h lo eri ol) re u se to
tre t sychotic isor ers su ch s schizo hre- 82. (D ) This w o n is su ffering fro eliriu ,
ni n schizo ffective isor er, s w ell s likely c u se by u lti le e ic tions. The
jor e ression w ith sychotic fe tu res, but el erly re rticu l rly vu lner ble to e i-
they re not ro ri te s onother y for c tions know n to h ve sycho ctive ro -
MDD. erties or si e effects. This is in rt ue to
the ecre se bility of geri tric tients to
80. (D ) This c se eliber tely brings together et bolize e ic tions n the ten ency of
ny ch r cter tr its r w n fro u re the rugs to bu il u to higher levels. A i-
i gnoses of erson lity (ch r cter) isor ers, tion lly, el erly ersons re gener lly ore
inclu ing bor erline, n rcissistic, e en ent, vu lner ble to the effects of e ic tions th t
obsessive-co ulsive, n schizoty l er- ct on the centr l nervou s syste (CN S). The
son lities. In clinic l r ctice, ny tients tient in this c se is on nu ber of e i-
o not eet criteri for ny one s ecific c tions th t y h ve CN S si e effects t
erson lity isor er; su ch ixe c ses re high oses. H ow ever, the signific nt nti-
referre to s other s ecifie erson lity cholinergic ro erties of i henhy r ine
isor er. P tients w ith i gnose bor er- ut this tient t rticu l r risk of e ory
line erson lity isor er re know n for their i ir ent n confu sion. Ci eti ine n
intense erson l rel tionshi s, oo l bility, fu rose i e re lso otenti l contribu tors
self- estru ctive beh viors, nger n ge ent to eliriu , bu t re uch less likely th n
issues, n oor sense of self-i ge. N rcissis- i henhy r ine. Bet blockers like tenolol
tic erson lity isor er is rke by gr n i- h ve been ssoci te w ith e ression, re-
ose sense of self-w orth, entitle ent, l ck of re l su bly ssoci te w ith block e of centr l
e thy, n ten ency to use others for ones renergic rece tors. A ition lly, in so e
ow n en s. P tients w ith obsessive-co ulsive vu lner ble tients, they y re u ce c r i c

ou t u t enou gh to c u se function l hy o er-
fu sion of the br in c using confusion n iz-
ziness. Digoxin y ctu lly ecre se so iu
ion con u ction enou gh in CN S neu rons to
ro uce eliriu in so e tients.
83. (A) Deliriu rel te to block e of cholinergic
rece tors is the ost co on c u se of e i-
c tion-in uce eliriu in the el erly. Ace-
tylcholine is u niqu ely involve w ith e ory
rocesses in the br in, n its involve ent in
the tho hysiology of jor neu rocognitive
isor er ( e enti ) ue to Alzhei er is-
e se h s been he vily rese rche . Dru gs th t
lter o ine neu rotr ns ission re ost
ssoci te w ith ove ent isor ers n
sychosis-rel te si e effects. Me ic tions
ffecting GABA rece tors (su ch s benzo i z-
e ines n b rbitu r tes) y c u se se tion
n t xi s w ell s e ory istu rb nces.
Dru gs cting on the serotonergic syste y n bi ol r isor er.
lter slee , etite, n oo , lthou gh few
non sychi tric ru gs w ork on this syste .
Me ic tions ffecting centr l nore ine hrine
tr ns ission (e.g., ntihy ertensives) y ference resu lt in ty e II error. In this c se,
r rely be ssoci te w ith e ression.
8489. [84 (K), 85 (C), 86 (D ), 87 (B), 88 (E), 89 (F)]
P tients w ith ent l illnesses y be non-
co li nt for v riou s re sons. Long- cting
nti sychotics su ch s ris eri one Const
(K) re goo choices in sychotic tients
w ho benefit fro n toler te nti sychot-
ics, bu t w ho re nonco li nt u e to l ck of
insight, confu sion, or forgetfu lness (not u e
to si e effects). Chlor ro zine (C) is ty i-
c l nti sychotic (neu role tic) w hich h s been
ssoci te w ith sensitivity to su nlight, w hich
c n c u se n ex gger te sunburn. Cloz -
ine (D ) w s the first ty ic l nti sychotic
evelo e ; it is rove for the tre t ent
of tients w ith refr ctory schizo hreni n
h s lso e onstr te effic cy in re u cing
suici lity in schizo hreni or schizo ffective
isor er. Bu ro ion (B) is n nti e ress nt
th t is believe to block reu t ke of o -
ine in the br in. Althou gh ll nti e ress nt
e ic tions h ve si il r effic cy, inclu ing
nortri tyline (H) (tricyclic nti e ress nt),
roxetine (I) n sertr line (L) (serotonin-
Answe rs : 7891 281
s ecific reu t ke inhibitors), n venl f x-
ine (N ) (co bine serotonin-nore ine hrine
reu t ke inhibitor), only bu ro ion h s
re u ce risk of sexu l ysfu nction, n in f ct
y be use to tre t nti e ress nt-in u ce
sexu l ysfu nction. While no sychotro ic
e ic tions re roven s fe in regn ncy,
nti nic gents su ch s c rb ze ine,
lithiu (G), n v l roic ci (M) re ssoci-
te w ith signific nt fet l bnor lities n
shou l be voi e . H lo eri ol (E) h s been
u se s fely in regn nt tients w ith bi ol r
isor er. L otrigine (F) is n ntie ile -
tic e ic tion in ic te for the inten nce
tre t ent of bi ol r isor er (to el y the
ti e to occurrence of oo e iso es) n
for the cute tre t ent of bi ol r e res-
sion. Ari i r zole (A) n ris eri one (J) re
secon -gener tion nti sychotic e ic tions
use for schizo hreni , schizo ffective isor er,
90. (E) Stu ies th t fin no st tistic l ifference
betw een grou s w hen there ctu lly is if-
the ositive fin ings t the other u niversities
ke the fin ing t u niversity A less likely
to be correct. University A y h ve nee e
l rger nu ber of su bjects in the stu y to
fin the tre t ent effect. Ty e I errors occu r
ore often th n ty e II errors n c u se the
rese rcher to conclu e th t there is if-
ference betw een grou s w hen in f ct there
is none. The v ri nce is the su of the if-
ferences of e ch t oint fro the e n.
Positive re ictive v lu e is the ro ortion of
bnor l test resu lts th t re tru e ositive,
w hile neg tive re ictive v lu e is the ro or-
tion of nor l test resu lts th t re true neg -
tive. St n r error is the egree to w hich
the e ns of sever l ifferent s les w oul
v ry if they w ere t ken re e te ly fro the
s e o u l tion.
91. (E) This tient h s signs ost consistent w ith
t r ive yskinesi , n extr yr i l syn-
ro e th t usu lly ffects erior l or li b
u scu l tu re n c u ses choreifor ove-
ents. Its onset is u su lly sever l ye rs fter
t king nti sychotics n it is ore likely to
282 8: Pra c tic e Te s t 2
ffect ol er tients. Ak thisi is escribe
s sycho otor restlessness th t y h ve
n onset of ys to w eeks fter beginning n
nti sychotic. Dystoni is n cu te re ction
to nti sychotics (neu role tics) in w hich r-
ticu l r uscle grou s (neck or ocu l r uscles
co only) contr ct involu nt rily. It c n be
infu l n shou l be tre te i e i tely
w ith nticholinergic e ic tions. N MS is
otenti lly leth l bu t r re e ic l e ergency
in w hich tients y h ve glob l rigi ity,
ent l st tu s ch nges, fever, c r iov scu l r
inst bility, elev te cre tine hos hokin ses,
n risk of rh b o yolysis. P rkinsonis y
look i entic l to P rkinson ise se (tre or,
br ykinesi , ske f ces) n usu lly h s
n onset w ithin ys to w eeks fter beginning
n nti sychotic e ic tion.
92. (A) The b s l g ngli , res onsible for the
tr ns ission of thought to ction n for con-
trolling the initi tion n qu lity of otor
ction, is centr l to the tho hysiology of
extr yr i l syn ro es, inclu ing ys-
toni , rkinsonis , k thisi , n t r ive
yskinesi . The cerebellu is i ort nt in
controlling the coor in tion of otor ove-
ents n ostu re. The front l cortex is gen-
er lly consi ere to be i ort nt for ecision
king, i u lse control, n ffect regu l -
tion. The i br in cont ins nuclei th t hel to
ensu re centr l nervou s syste ho eost sis by
regu l ting neu roveget tive, u tono ic, n
rou s l functions. The otor cortex serves s
the l st st ge of cerebr l rocessing of otor
infor tion before it escen s into the s in l
cor . An int ct otor cortex is requ ire for
initi tion of ove ent.
93. (D ) This tient is suffering fro chronic ost-
tr u tic stress isor er (PTSD) sy to s,
only rti lly tre te es ite co li nce
w ith e i tions n bstinence. Serotonin-
s ecific reu t ke inhibitors (SSRIs) re con-
si ere first-line tre t ent bec u se of their
effic cy n toler bility. Pr zosin, n l h -1
renergic rece tor blocker h s e onstr te
signific nt effic cy in tre ting ny of the
sy to s of PTSD (e.g., night res, fl sh-
b cks, hy er rou s l, voi nce). Bu ro ion
is n nti e ress nt u se to tre t jor
e ressive isor er, but its ctiv ting ro er-
ties ke it not s u sefu l for the tre t ent of
PTSD. Anti sychotics like h lo eri ol shou l
only be use in severe c ses of PTSD w ith
ro inent sychotic sy to s or git tion/
ggression. Lor ze n other benzo i ze-
ines shou l be voi e in tients w ith PTSD
ue to their l ck of effic cy n otenti l for
iction. Moo st bilizers su ch s v l roic
ci y be benefici l for so e tients w ith
PTSD, bu t re not likely s effic ciou s s SSRIs
or l h -blockers like r zosin.
94. (D) Erik Erikson w s sycho n lyst best
known for his escri tion of eight st ges of
hu n sychologic l ex erience s nning the
entire life s n. He believe th t successful
co letion of ll e rlier st ges w s necess ry
for successful co letion of future st ges. The
tient in this ex le is ble to ro uctively
work but h s ifficulty with inti cy in his
rel tionshi , hence the conflict between inti-
cy n isol tion. All of Eriksons eight st ges
center on st ge- ro ri te evelo ent l
conflicts: b sic trust versus istrust (birth to
1 ye r); utono y versus sh e n oubt
(13 ye rs); initi tive versus guilt (35 ye rs);
in ustry versus inferiority (611 ye rs); i entity
versus role iffusion (11 ye rs to en of oles-
cence); inti cy versus isol tion (2140 ye rs);
gener tivity versus st gn tion (4065 ye rs);
n integrity versus es ir (65 n ol er).
95. (B) H y erreligiou s thinking or reoccu tion
w ith or l beh vior, ltere sexu l beh viors,
hy ergr hi or over el bor tive co u-
nic tion styles ( lso referre to s viscosity),
n heightene ex erience of e otions for
cl ssic constell tion of erson lity tr its
ssoci te w ith co lex rti l e ile sy (or
te or l lobe seizu res). De ression, obses-
sive-co u lsive sy to s, n slee isor-
ers y be ssoci te w ith structur l br in
inju ry in front l n su bcortic l re s, bu t
they h ve not been escribe s being rel te
s ecific lly to co lex rti l e ile sy. Uri-
n ry incontinence is ore often ssoci te
w ith nor l ressu re hy roce h lu s or jor
neu rocognitive isor er ( e enti ).

96. (E) This tient ost likely w oul e on-
str te seizure ctivity in his te or l lobes,
consistent w ith te or l lobe e ile sy.
97. (B) The Gl sgow Co Sc le e su res
level of rou s l n r nges fro sc le of 3
( ee co ) to 14 (fu lly lert). The c tegories
ssesse re eye o ening, best otor res onse,
n best verb l res onse. Eye o ening r nges
fro score of 4 (o ening s ont neou sly) to 1
(not o ening t ll). In this c se, the eyes o en
to in, so score of 2 is given. Best otor
res onse is s follow s: obeys co n s, 5;
loc lizes in, 4; flexion, 3; extension, 2; n
no res onse, 1. In this c se, score of 3 is
given for the res onse. Best verb l res onse is
lso b se on sc le r nging fro 5 to 1. An
oriente tient receives score of 5 n no
res onse receives score of 1, s in this c se.
The scores re then e , n in this c se re
2 + 3 + 1 = 6.
98. (E) When ch nging fro n SSRI to n MAOI,
one u st llow w shout erio of bout
five h lf-lives for the SSRI to be ore th n
90% eli in te ; in the c se of flu oxetine, this
is roxi tely 5 w eeks. This rec u tion
voi s the serotonin syn ro e, w hich y ge l ystoni , l rger oses of benztro ine
occur w hen signific nt bloo levels of both
ru gs re resent. Serotonin syn ro e, w hich
c n be f t l, is rke by sy to s of tre or,
i horesis, rigi ity, yoclonu s, u tono ic
ysregu l tion, hy erther i , rh b o yoly-
sis, ren l f ilu re, n co . The other choices
w ou l ose signific nt risk of evelo ing
serotonin syn ro e.
99. (C) MAOIs revent the eri her l bre k ow n
of tyr ine, w hich y be ingeste w ith cer-
t in foo s su ch s liver, beer, re w ine, ge
cheeses, s oke fish, ry s u s ge, n f v
be ns. If too u ch tyr ine bu il s u in the
bloo , it y s tu r te eri her l sy thetic
nerve rece tors n c use hy ertensive crisis,
otenti lly f t l con ition. The other choices
o not contribu te to hy ertensive crisis.
100. (D ) Thiori zine is ty ic l nti sychotic,
r rely u se now u e to the risk of c r i c
rrhyth i . At oses of 1,000 g/ or higher,
Answe rs : 92102 283
thiori zine h s been ssoci te w ith ig en-
t ry retino thy, lso know n s retinitis ig-
entos . Therefore, oses shoul not excee
800 g/ . Pig ent ry retino thy c n c use
loss of retin l res onse to contr ction of the
visu l fiel . An e rly sign y be noctu rn l
confu sion. Consti tion, ry eyes, n uri-
n ry retention re ll si e effects fro the
nticholinergic ro erties of thiori zine, bu t
ty ic lly re not so severe s to co ro ise
he lth er nently. N e hrogenic i betes
insi i u s is not ssoci te w ith thiori zine.
101. (B) This tient is ex eriencing n cu te
ystonic re ction fro the h lo eri ol,
high- otency first-gener tion (ty ic l) nti-
sychotic, ty ic lly seen hours to ys fter
initi ting or incre sing the nti sychotic.
Acu te ystonic re ctions y resent s u s-
cle s s s, torticollis, oculogyric crisis, n
l rynge l s s . Benztro ine 1 to 2 g IM is
u seful in the tre t ent of cu te ystonic re c-
tions. Altern tively, i henhy r ine 50 g
IM c n lso be u se . If the sy to s o not
resolve w ithin 20 inu tes, l rger oses c n be
given. Benzo i ze ines c n lso be u se bu t
re not first-line tre t ent. For cu te l ryn-
shou l be given i e i tely, follow e by
lor ze IV if nee e . N one of the other
choices re in ic te for the tre t ent of cute
ystoni . While n lgesics su ch s cet ino-
hen n ibu rofen y hel w ith in, they
w ont resolve the u n erlying etiology. Cyclo-
benz rine is u scle rel xer w hich w ill not
equ tely tre t the ystoni . Pro r nolol is
B-blocker, u se for hy ertension, bu t it c n
lso be use to tre t k thisi , nother si e
effect of nti sychotics, ch r cterize by n
inner feeling of restlessness n nee to ove.
102. (C) The isor er escribe is ne hrogenic i -
betes insi i u s, ost likely c use by lithiu .
Lithiu inhibits the effect of nti iu retic hor-
one on the ki ney, c using olyuri , thirst,
oly i si , n otenti l hy ern tre i n
eliriu . Although c rb ze ine n v l-
roic ci (other oo st bilizers), h lo eri ol
( first-gener tion nti sychotic), n queti -
ine ( secon -gener tion nti sychotic) re ll
284 8: Pra c tic e Te s t 2
use to tre t bi ol r isor er, none re ssoci-
te w ith i betes insi i us.
103. (B) Cloni ine, centr l l h -2- utorece tor
gonist, h s been roven useful in the tre t ent
of the utono ic hy er ctivity ssoci te with
o ioi with r w l. A nt ine is use to tre t
P rkinson ise se n lso s n nti-influenz
gent. H lo eri ol, n nti sychotic, n lor z-
e , benzo i ze ine, y hel with signifi-
c nt git tion occ sion lly seen in with r w l,
but they will not tre t the un erlying sy -
to s. N loxone, n o i te nt gonist, is use in
o i te over ose n will signific ntly worsen
o i te with r w l sy to s in this tient.
104. (D ) Meth one h s been roven to signifi-
c ntly re uce the use of heroin w hen use s
inten nce e ic tion. P tients int ine
on oses low er th n 40 g/ of eth one
re f r ore likely to rel se th n those on
higher oses. D ntrolene is uscle-rel x nt
u se in the n ge ent of neu role tic lig-
n nt syn ro e, r re si e effect of nti sy-
chotic tre t ent. Disulfir is e ic tion
u se to revent lcohol consu tion by
c using n versive re ction if t ken in con-
ju nction w ith lcohol. Flu zenil is in ic te
for benzo i ze ine over ose. Sertr line is
serotonin-s ecific reu t ke inhibitor, u se in
the tre t ent of e ressive n nxiety isor-
ers, ong other sychi tric illnesses. While
it y be hel fu l for co orbi e ression
or nxiety, it h s not been show n to ecre se
o i te u se in in ivi u ls.
105. (B) I i r ine is tricyclic nti e ress nt
(TCA). TCAs re consi ere cl ss 1 A nti r-
rhyth ics bec use they ossess quini ine-like
effects th t ecre se con uction ti e through
the bun le of His. They h ve been show n to
incre se ort lity in c r i c tients. TCAs
c n lso incre se the he rt r te, n so tient
w ith co ro ise c r i c function y suf-
fer fro incre se oxygen e n . Fin lly,
TCAs re lso ssoci te w ith signific nt
orthost tic hy otension, w hich y be further
ex cerb te in tients w ith c r i c ise se.
Wellbutrin, serotonin-nore ine hrine reu t ke
inhibitors (such s irt z ine n venl f x-
ine), n serotonin-s ecific reu t ke inhibitors
(SSRIs) like sertr line y ll be s fely use in
tients w ith c r i c ise se; how ever, tten-
tion shoul be i to otenti l hy ertension
c use or w orsene by venl f xine n ny
c r i c e icines et bolize through the
P-450 cytochro e syste , s so e SSRIs (e.g.,
fluoxetine) y lter the e ic tion levels.
106. (D ) Acetylcholine is the neu rotr ns itter
ost i lic te in cognitive fu nctioning.
Anticholinergic effects of e ic tions re fre-
qu ently i lic te in cognitive ecline n
ru g-in u ce eliriu . Of the e ic tions
liste , roxetine h s the ost nticholinergic
effect, n therefore shou l be voi e in this
tient w ith jor neu rocognitive isor er
( e enti ).
107. (A) Lithiu toxicity is ch r cterize e rly on by
ys rthri , t xi , co rse tre or, n b o i-
n l in. L ter nifest tions inclu e seizures,
neuro uscul r irrit bility, n i ire con-
sciousness ( eliriu to co ). Acute ystoni s
re ssoci te w ith the use of ty ic l nti sy-
chotics. Leg in n resthesi s re not sso-
ci te w ith lithiu . P r noi elusions re
rt of the sy to rofile of schizo hreni
n so eti es of bi ol r isor er.
108. (B) For ECT to be effective, the seizu re shou l
l st t le st 15 secon s. Prolonge seizu res
gre ter th n 180 secon s shou l be ter in te
w ith n nesthetic (e.g., ro ofol) or intr ve-
nou s benzo i ze ines (e.g., i ze ).
109. (D ) Me ory i ir ent ( ostly u ring the
tre t ent) is quite co on, lthou gh ost
tients retu rn to their b seline by 6 onths.
There is no in ic tion th t ECT c u ses br in
ge. ECT y ctu lly be use to tre t
tients w ith c t toni . Fr ctu res n vo it-
ing re u nco only seen in ECT since the u se
of u scle rel x nts n ntie etics h ve been
i le ente .
110. (C) For extre e git tion, the benzo i ze ine
lor ze c n be effective. Another ltern tive

is the butyro henone nti sychotic h lo eri ol.
Phenothi zine nti sychotics su ch s chlor-
ro zine c n c u se u tono ic inst bility
w hen given to tient w ith PCP intoxic tion.
Tr zo one, use co only for inso ni , n
fluoxetine, n SSRI, re nti e ress nts, n
w ill not hel w ith git tion. Trihexy heni yl
is use to co b t extr yr i l sy to s
ssoci te w ith nti sychotic use n not for
git te st tes.
111. (C) Su ortive c re is the best tre t ent for
PCP intoxic tion th t is not co lic te by
extre e git tion or violence. Lor ze
benzo i ze ine, or h lo eri ol, ty ic l
nti sychotic, c n be u sefu l for extre e git -
tion. Aci ific tion of the u rine oesnt signifi-
c ntly incre se the excretion of PCP. Des ite
u rb n yths, neither cheese nor vit ins
h ve rticu l r ther eu tic benefits for PCP
intoxic tion.
112. (A) This tient is ost likely su ffering fro
jor e ression w ith sychotic fe tu res.
N either nti e ress nts nor nti sychotics
lone w ill s r i ly or effectively tre t jor
e ression w ith sychotic fe tu res s the
co bin tion. The co bin tion of lor ze
n cloz ine ( n ty ic l nti sychotic) w ill
not ro ri tely tre t the e ression. Si i-
l rly, the co bin tion of sertr line n lor z-
e w ill not equ tely tre t the sychotic
sy to s. Lith iu n synthroi c n both
effectively u g en t nti e ress nts su ch
s roxetine n sertr line. Lor ze , by eu hori , isorient tion, fe r, n f ci l
benzo i ze ine, y hel w ith nxiety, bu t
w ill not be effective g inst sychosis or
e ression.
113. (L) PCP ( k ngel u st) intoxic tion ro-
uces git tion, vertic l nyst g us, n
n lgesi s w ell s hy erther i , e erson-
liz tion, n h llu cin tions in u itory, t c-
tile, n visu l o lities.
114. (B) Alcohol w ith r w l y begin w ithin
24 hou rs fter the l st rink, n c n rogress
to seizures by 24 to 48 hou rs n eliriu
tre ens (DTs) fter roxi tely 72 hou rs.
Answe rs : 103116 285
DTs re ssoci te w ith signific nt risk of
ort lity.
115. (E) Sy to s ssoci te w ith coc ine w ith-
r w l ten to be il n l st sever l ys
fter the l st u se. Occ sion lly, how ever, the
e ression c n be severe enough to r ise
the risk of self-inju rious beh vior or su ici e
tte ts.
116. (G) H eroin w ith r w l e ks t bout
72 hou rs fter the l st u se in chronic u sers. It is
ex erience s v riou s flu -like sy to s n
, g strointestin l co l ints, su ch s fever n
chills, ru nny nose, n u se , bo y ches, i r-
rhe , n b o in l cr s. The e r nce
of iloerection in the syn ro e g ve rise to
the sl ng ter col tu rkey to escribe the
ction of tot l cess tion of u se of the ru g.
Alcohol intoxic tion (A) involves ch r cter-
istic beh vior l ch nges, s w ell s slu rre
s eech, t xi , n other neurologic fin ings.
It c n rogress to co if severe. C nn bis
intoxic tion (C) heightens sensitivity to exter-
n l sti u li n i irs otor skills, long
w ith t chyc r i , conju nctiv l injection, n
incre se etite (the u nchies). Coc ine
intoxic tion (D ) is rke by el te oo ,
ecre se slee , h llu cin tions, n git tion.
H eroin intoxic tion (F) is rke by n ltere
oo , sycho otor ret r tion, n row si-
ness, long w ith in oint u ils n consti-
tion. Intoxic tion by inh l nts (H) (vol tile
subst nces su ch s g soline fu es) is rke
r sh, lthou gh the sy to s re short-live .
The syn ro es of eth het ine (I) n
MDMA (N ) intoxic tion re si il r to those
of coc ine intoxic tion. MDMA u sers ty i-
c lly re ort n incre se sense of closeness
w ith other eo le. N icotine w ith r w l (J) is
ch r cterize by e resse oo , inso ni ,
irrit bility, ifficu lty concentr ting, ecre se
he rt r te, n incre se etite. N itrou s
oxi e intoxic tion (K) ro u ces eu hori n
light-he e ness, n u su lly su bsi es w ithin
hou rs w ithou t tre t ent. With r w l fro
silocybin (M), h llu cinogen erive fro
u shroo s, is not w ell escribe .
286 8: Pra c tic e Te s t 2
117. (B) Cloz ine ( n ty ic l nti sychotic)
c uses gr nu locytosis in bou t 1% of tients.
For this re son, w eekly bloo cou nts re e -
su re for the first 6 onths of tre t ent, every
2 w eeks for the next 6 onths, then every 4
w eeks there fter (u nless there is signific nt
ro in w hite bloo cell cou nts).
118. (F) Lithiu is ssoci te w ith clinic l hy othy-
roi is in t le st 5% of tients, signific ntly
ore often in w o en. Thyroi su le ent -
tion y be e to cou nter this si e effect.
A roxi tely 25% to 30% of tients y
show elev te thyroi -sti u l ting hor one
levels.
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A Alcohol w ithd raw al (Cont.):
Abnorm al Involu ntary Movem ent Scale
(AIMS), 248, 269
Acetylcholine, 262, 265, 281, 284
Acetylcysteine, 70
Acu te stress d isord er, 42, 66
d ifferential d iagnosis, 158, 168, 187188,
213, 233
Ad d erall, 24
ADH D. See Attention-d eficit/ hyp eractivity
d isord er
Ad ju stm ent d isord er, 39, 63
w ith d epressed m ood , 173, 192193
d iabetes m ellitu s w ith, 6, 22
MDD d istinguished , 6, 22
treatm ent, 173, 193
Ad olescents
antisocial personality d isord er, 13, 28
bip olar d isord er in, 3, 18
bulim ia nervosa, 20
d ep ression in, 1, 17
MDD in, 6, 18, 20
panic d isord er, 5, 19, 22, 27, 29
su icid e risk in, 1, 17
Ad ult psychop athology, 3358
Ad vance d irective, 147, 159
Agitation, 266, 284285
Agnosia, 28
Agorap hobia, panic d isord er w ith
d ifferential d iagnosis of, 173174, 193
treatm ent of, 174, 193
Agranu locytosis, 109, 113, 116, 120, 209,
228
AIMS. See Abnorm al Involu ntary
Movem ent Scale
Akathisia
antip sychotics and , 104
risperid one and , 98, 118
Alcohol abu se
d ep ression and , 179, 199
d isulfiram and , 221, 242
Alcohol d ep end ence, 66
Alcohol intoxication, 70, 79, 266, 285
Alcohol u se d isord er, 39, 63
Alcoholism
evalu ation, 178179, 198
m ed ications, 97, 118
thiam ine d eficiency and , 112, 116
Alcohol u se d isord er
elevated / d epressed liver enzym es and ,
206, 226
m ed ications for, 207, 226
Alcohol w ithd raw al, 267, 285
elevated / d epressed liver enzym es and ,
206, 226
hallucinations d u e to, 221, 242
lorazepam for, 189, 199, 221, 241242
Inde x
ArgyllRobertson p u p il, 196
seizu res and , 170, 189 Arip ip razole, 262, 281
treatm ent, 170, 189 Arnold -Chiari synd rom e, 62
Alexia, 13, 28 Ativan. See Lorazep am
Alp ha-blocker, 208, 228 Atropine, 220, 241
Alzheim er d isease Attention, assessing, 222, 242243
d ifferential d iagnosis, 178, 197 Attention-d eficit/ hyperactivity d isord er
treatm ent, 253254, 274 (ADH D)
AMA. See Am erican Med ical Association d ifferential d iagnosis, 223, 243244
AMA Cod e of Med ical Ethics, 158, 159160, treatm ent of, 223, 244
162163 behavioral therapy, 127
Am antad ine (Sym m etrel), 212, 232 sym p tom s, 15
Am erican Law Institute test (Mod el Penal m ethylp henid ate for, 8, 26, 181, 201
Cod e), 142, 155156. See also Legal m ania v., 10, 26
issu es Autistic d isord er, 15
Am erican Med ical Association (AMA), 157 Autonom y, 144, 156157
Am itrip tyline Avoid ant p ersonality d isord er, 184, 203
card iac effects of, 93, 114
m ania and , 50, 73 B
Am nesia, d issociative, 183, 202 Basal ganglia, 263, 282
anterograd e, 62 BDI. See Beck Dep ression Inventory
ECT and , 67 Beck Dep ression Inventory (BDI), 207, 227,
w ith fu gue, 213214, 234 254, 275
localized , 73 Behavioral therap y, enu resis, 259, 278
Am ok, 211, 231 Benad ryl. See Dip henhyd ram ine
Am phetam ine, 56, 79 Bend er Gestalt Test, 254, 275
Anom ia, 28 Benzod iazep ine
Anorexia nervosa ad verse effects, 110
com p lications, 258, 277 alcohol w ithd raw al, 116
d ifferential d iagnosis, 175, 195 bip olar d isord er, 167, 187
m ed ical com p lications, 219, 239 DTs, 253, 274
m ortality rate, 219, 240 high-p otency, 105
p rognosis, 258, 277278 Benztrop ine (Cogentin)
Anterograd e am nesia, 62 anticholinergic toxicity and , 211, 232
Anticholinergic toxicity, 211, 232 torticollis and , 264, 283
Anticholinesterase, 220, 241 Bereavem ent, 249, 269270
Antidepressants. See also specific antidepressants d ifferential d iagnosis, 219, 240
OCD and , 220, 240 MDE v., 173, 192
Antim otivational synd rom e, 100 treatm ent, 173, 192, 220, 240
Antip sychotic m ed ications Bipolar d isord er
akathisia and , 104105 genetics, 180181, 200
bipolar d isord er, 167, 187 lam otrigine for, 257, 277
d opam ine recep tors and , 114 m anic, 167, 187, 260, 279
N MS and , 105 treatm ent of, 260, 279
schizotypal p ersonality d isord er, 206, 226 Bipolar I d isord er, 210, 218, 230, 239,
sid e effects, 51, 75, 92, 113 250251, 271
TD and , 106 Bipolar II d isord er, 37, 40, 61, 64, 105, 165,
Antisocial p ersonality d isord er, 183, 203 185, 214, 234, 250251, 271
ad olescent, 22, 28, 29, 203, 229 Bipolar m ania, 113, 277
cond u ct d isord er and , 20, 22, 24, 28 Blessed Rating Scale, 228, 245, 255, 275
Anxiety Bord erline p ersonality d isord er (BPD), 184,
brain activity and , 55 203, 208, 212, 227, 232
p erform ance, 118 DBT, 258, 278
Anxiety d isord ers d ialectical behavioral therap y and , 171,
MDD and , 5, 20 191, 212, 232
Aphasia, 28 d ifferential d iagnosis, 171, 191, 209, 229
Apraxia, 28 treatm ent, 258, 278
291
292 Ind ex
Boston Diagnostic Aphasia Exam ination,
219, 224, 239, 244245, 254, 275
BPD. See Bord erline p ersonality d isord er
Brain
activity in, 55
d am age, Kl ver-Bucy synd rom e and , 62
frontal lobes, 209, 229230
receptors
antip sychotics and , 113
clozap ine and , 88
d op am ine, 94
haloperid ol and , 94, 115
m ed ications and , 60
Brief psychotic d isord er, 59, 62, 66, 71, 172,
191192
Brow n-Peterson Task, 207, 227
Bu limia nervosa
ad olescent, 4, 20
CBT, 20
com p lications, 277
m ed ical com plications, 219, 239
m ed ications, 113
p sychotherap y, 20
signs, 20
sym ptom s, 31
treatm ent, 219, 239
Bu p rop ion, 6, 22, 26, 37, 262, 281
Bu Spar. See Bu sp irone
Bu spirone (Bu Sp ar), 51, 75, 107, 109, 167,
169, 187, 216, 236
C Cyclothym ic d isord er, 43, 61
Caffeine, w ithd raw al, 217, 237
Cannabis, intoxication, 266, 285
Capgras synd rom e, 33, 54, 58, 77, 248, 269
Card iac arrhythm ia, TCAs and , 169, 189
Card iac effects
am itriptyline, 93, 113
lithiu m , 64, 71
Catalepsy, 74, 235
Catap lexy, 18, 51, 69, 74, 200
Catap res. See Clonid ine
Catatonia, 215, 235236
Charcot, Jean-Martin, 131, 140
Child abu se, 157
legal issu es, 12, 30, 144145, 157, 203
PTSD and , 19
Child cu stod y, 152, 163
Child ren
anxiety d isord ers, 19
bipolar d isord er in, 3, 11, 19, 26
clinical interview , 4
d evelopm ent, 15
MDD in, 5
treatm ent
parental refu sal of, 145146, 158
Chlorp rom azine, 262, 281
Citalopram , 247, 268
bulim ia nervosa, 219, 239
Clonid ine (Catapres), 59
ad verse effects, 11, 27
alcohol w ithd raw al, 189
opiate w ithd raw al, 265, 284
Tou rette d isord er, 6, 11, 22, 176, 195
Clozapine (Clozaril), 262, 281
agranulocytosis and , 209, 228
schizop hrenia, 222, 243
sid e effects, 208209, 228, 267, 286
Clozaril. See Clozap ine
Cocaine
intoxication, 211, 224, 230231, 245, 266, 285
w ithd raw al, 267, 285
Cod e of Ethics, AMA, 158, 159160, 162163
Cogentin. See Benztrop ine
Cognitive-behavioral therap y (CBT), OCD,
174, 194
Cognitive therap y, d ep ressive d isord er,
179, 199
Cold -caloricind u ced nystagm u s, 213, 233
Com p etency, 155, 251252, 272
Com p etency to stand trial, 143, 149150,
156, 160
Com p liance, m ed ication, 210, 230
Cond u ct d isord er, 16, 259, 278
antisocial personality d isord er and , 13
Confid entiality, 148, 158, 252, 272273
m inors and , 145, 157
p hysicianp atient confid entiality, 146,
158, 255, 275
violating, 145, 157
w aivers, 156, 158
Continu ou s p ositive airw ay pressu re
(CPAP), 220, 241
Conversion d isord er, 174175, 194, 211, 230,
251, 272
Coprop raxia, 249, 270
Cou ntertransference, 250, 270. See also
Patient-d octor relationship
CPAP. See Continuou s p ositive airw ay
p ressu re
Crim inal resp onsibility, 142, 156
Cu ltu re-bou nd d elu sions, 77
Cu ltu re-bou nd synd rom es, 211, 231
Cyp rohep tad ine, 103, 107
D d ep ression, 36, 60, 214, 235
DBT. See Dialectical behavioral therap y
Dd avp . See Desm op ressin
Defense m echanism s, 11, 12, 35, 59, 70, 80.
See also specific defense mechanisms
Dj entend u , 223, 244
Delirium , 262, 281
d ifferential d iagnosis, 172, 177, 178,
190191, 197, 198
m ed ications, 171, 191
Delirium trem ens (DTs), treatm ent, 253,
274
Delusional d isord er
p resentation, 166, 186
treatm ent, 166, 186
Delusions
Fregoli, 33
MDD, 180, 200
m ood congru ent, 180, 200
p aranoid , 142, 155
Dem entia
d ifferential d iagnosis, 209, 217218,
228229, 238
Folstein MMSE, 209, 228229
Lew y bod y, 178, 198
Dem erol. See Mep erid ine
Denial, 213, 233
Dep akote. See Divalp roex sod iu m
Dep end ent p ersonality d isord er, 183184,
203
Dep ressed reflexes, 222, 243
Depression
alcohol abu se and , 179, 199
electroconvu lsive therapy for, 214, 235
factitiou s d isord er by p roxy and , 208,
227
m ed ical cau ses of, 258, 277
w ith psychotic featu res, 266, 285
Depressive d isord ers
d ifferential d iagnosis, 179, 199
m ed ically ill p atients w ith, 222, 242
treatm ent, 179, 199, 248, 269
Desm op ressin (Dd avp), 259, 278
Desyrel. See Trazod one
Dialectical behavioral therap y (DBT)
BPD and , 171, 212, 232, 258, 278
Diazep am (Valiu m ), 251, 272
p ostp artu m d epression, 185
Differential d iagnosis, 165203
Diphenhyd ram ine (Benad ryl)
confu sion and , 261, 280281
insom nia, 181, 201
Discharging p atient, 149, 160
from care, 152, 162163
Disulfiram , alcohol abu se and , 221,
242
Divalp roex sod iu m , sid e effect, 222,
243
Divalp roex sod iu m (Dep akote), bip olar
d isord er, 260, 279
DTs. See Deliriu m trem ens
Du loxetine, 119
Dusky v. United States, 143, 156, 160
E
Echolalia, 249, 270
ECT. See Electroconvu lsive therap y
Effexor. See Venlafaxine
Ego-d ystonic, 249, 270
Ego-syntonic, 249, 270
Electroconvu lsive therap y (ECT)
am nesia, 43, 67
p regnancy and , 94, 115
seizure length and , 265, 284
seizures, 266, 284
sid e effects, 284
Enu resis
com orbid m ental illness, 8, 24
Dd AVP for, 24
m ed ication, 8, 24
second ary noctu rnal, 259, 278
treatm ent, 259, 278
Ep ilep sy
com p lex partial, 263, 282
d ifferential d iagnosis, 176, 195196
Erikson, Erik, 263, 282
Ethical issu es, 141163
Extrap yram id al sid e effects (EPS)
benztrop ine and , 211, 231
F
Factitiou s d isord er
d ifferential d iagnosis, 175, 194195
by proxy, 13, 208, 227 (See also Child
abu se)
Fetishistic d isord er, 260, 279
Fire setting, 259, 278
Flat affect, 206, 226
Flu oxetine (Prozac), 247, 268
d ose, 255, 275276
insom nia and , 172173, 192
MDD, 172, 192, 256, 266, 276, 285
p ostp artu m d epression, 166, 185
p regnancy and , 256, 276
and risp erid one, 266, 285
sid e effects, 173, 192
Flu voxam ine (Lu vox)
MDD, 221, 241
OCD, 221, 241

Fregoli d elusion, 33
Freu d , Sigm u nd , 140
Frotteurism , 169, 188
G Insanity d efense, 142, 144, 155156, 157
Galantam ine, 253254, 274
Ganser synd rom e, 214, 234235, 249, 270
Gend er, su icid e and , 17
Generalized anxiety d isord er (GAD)
buspirone for, 216, 236
d ifferential d iagnosis, 174, 179, 194,
198199
Genetics
bip olar d isord er, 180181, 200
schizop hrenia, 210, 230
Geod on. See Ziprasid one
Gingival hyperp lasia, 210, 230
Glasgow Com a Scale, 264, 283
H 285
H abeas corp u s, 151, 162
H allu cinations
alcohol w ithd raw al and , 221, 242
com m and au d itory, 167, 181, 187, 200
lorazepam for, 221, 242
H aloperid ol (H ald ol), 205, 225, 262, 281
d elirium , 171, 191
d op am ine recep tors and , 94, 115
forcing treatm ent, 144, 156157
lithiu m and , 168, 187
PCP intoxication, 285
postpartum d ep ression, 165, 185
pregnancy and , 223224, 244
torticollis and , 264, 283
H ead ache, 217, 237
H em iballism u s, 250, 271
H epatic encephalopathy, 177, 196197
H eroin
d isord er of, 64
intoxication, 266, 285
overd ose, 46, 70
w ithd raw al, 267, 285
H istrionic personality d isord er, 184, 203
H oard ing d isord er, 182, 202
H om icid al threats, confid entiality and , 141,
154
H osp italization
involuntary, 143144, 156
p ostpartum d ep ression, 147148, 159
partial hosp ital program s, 151, 162
H uffing, 222, 243
H um an im m unod eficiency viru s (H IV)
d ifferential d iagnosis, 177, 197
inform ed consent and testing for, 145,
157158
H untington d isease, 178, 198
H yperp lasia, gingival, 210, 230
H yperreligiou s thinking, 263, 282
H ypertensive crisis, 208, 216, 228, 236
H yperthyroid ism , 177, 197
H ypnotherap y, 123, 132
H ypoglycem ia, 177, 197
I d elu sions, 180, 200
Ibup rofen, 221, 242
Id entification, 215, 235
Im ipram ine (Tofranil)
contraind ications, 265, 284
Inform ed consent, 143, 156
cap acity to give, 151152, 162
H IV testing, 145, 157158
obtaining, 151, 162
Inhalant, abu se, 222, 243
Inhalant intoxication, 266, 285
Inp atient facility, ad m ittance, 207, 226227
Insanity, 144, 157
voluntary intoxication and , 150151, 161
Insom nia, SSRIs and , 173, 192
Insu rance, 149, 160
Intellectu al d isability, 259, 278279
Intelligence qu otient (IQ), calcu lation, 214,
234
Interm ittent exp losive d isord er, 183,
202203
IQ. See Intelligence qu otient
Iron d eficiency, restless legs synd rom e and ,
183, 202
J 3,4-Methylened ioxym etham p hetam ine
Jehovahs Witness, 146, 158
K Methylp henid ate (Ritalin)
KayserFleischer rings, 250, 270271
Klep tom ania, 249, 270
Korsakoff synd rom e, 180, 199200
L 209, 224, 228229, 244, 254, 255, 275
La belle ind iffrence, 251, 272
Lam otrigine, 262, 281
bipolar d ep ression, 215, 236
bipolar d isord er, 257, 277
sid e effects, 257, 277
Learning d isord ers
d ifferential d iagnosis, 214, 234
Legal issu es, 141163
child abu se, 144, 157
p aranoid d elu sions, 142, 155
w ills, 142, 155
Lew y bod y d em entia, 178, 198
Lithiu m (Eskalith), 205, 225, 262, 281
haloperid ol and , 168, 187
ibup rofen, 221, 242
laboratory tests before treatm ent w ith,
218, 238
nep hrogenic d iabetes insip id u s, 264265,
283284
sid e effects, 267, 286
toxicity, 265, 284
Living w ill, 151152, 162
Lorazep am (Ativan)
agitation and , 266, 284285
for alcohol u se d isord er, 207, 226
alcohol w ithd raw al, 170, 179, 189, 199,
221, 241242
for hallucinations, 221, 242
Lu vox. See Flu voxam ine
M N icotine, intoxication, 224, 245
Magical thinking, 250, 271
Major d ep ressive d isord er (MDD), 208,
227
w ith atyp ical featu res, 214215, 235, 260,
280
bereavem ent v., 173, 192
d ifferential d iagnosis, 168, 188, 209, 229
ECT for, 214, 235
m irtazap ine for, 221222, 242
OCD w ith, 221, 241
w ith p sychotic featu res, 171172, 191
recu rrent ep isod es of, 256, 276
w ith seasonal pattern, 213, 233234
treatm ent of, 172, 191, 255, 256, 275276
Ind ex 293
Malingering, 152, 162, 252, 273
conscious p rod u ction of sym ptom s, 252,
273
d ifferential d iagnosis, 220, 240
Malp ractice
harm or d am age in, 141, 154
p hysicians p rotection against, 142, 155
stand ard of care, 142, 145
su icid e and , 150, 161
Managem ent, 165203
Mariju ana, 224, 245
Med ical exp ert w itnesses, 151, 161162
Mellaril. See Thiorid azine
Mens rea, 142, 156
Meperid ine (Dem erol), 216, 236
Methad one, op iate w ithd raw al, 265, 284
Metham phetam ine intoxication, 266, 285
(MDMA) (Ecstasy) intoxication, 266,
ADH D, 181, 201, 223, 244
d ep ressive d isord er, 222, 242
Microcep haly, 259, 279
Mini-m ental state exam ination (MMSE),
Minnesota Multip hasic Personality
Inventory 2 (MMPI-2), 212, 233, 255,
275
Minors, confid entiality and , 145, 157
Mirtazap ine, 247, 268
MDD, 221222, 242
MMPI-2. See Minnesota Mu ltip hasic
Personality Inventory 2
MMSE. See Mini-m ental state exam ination
Monoam ine oxid ase inhibitor (MAOI)
MDD, w ith atyp ical featu res, 261, 280
p regnancy and , 216, 237
SSRIs and changing to, 264, 283
tyram ine and , 264, 283
N
N aloxone
opiate overd ose, 253, 274
su bstance d ep end ence and , 217, 238
N arcissistic p ersonality d isord er, 184,
203
N arcolepsy, d ifferential d iagnosis, 181,
200201
N eologism s, 248, 269
N eu rolep tic m alignant synd rom e (N MS),
217, 237
characteristics, 166167, 186187
laboratory abnorm alities, 217, 237238
treatm ent, 167, 187
N eu rosyp hilis, 176, 196
N igrostriatal D 2 recep tors, 258, 278
N itrous oxid e intoxication, 266, 285
N ortriptyline, 262, 281
N ot gu ilty by reason of insanity, 144, 157
O
Obsessive-com p u lsive d isord er (OCD)
antid ep ressants and , 220, 240
d ifferential d iagnosis, 174, 193194
MDD w ith, 221, 241
treatm ent, 174, 194
Obsessive-com p u lsive p ersonality d isord er,
184, 203, 205, 225
Obstru ctive sleep ap nea hyp opnea, 220,
240241
294 Ind ex
OCD. See Obsessive-com pu lsive d isord er
Ocu logyric crisis, 168, 188
Olanzap ine (Zyp rexa)
d elu sional d isord ers, 166, 186
hallucinations, 167, 187
Opiates. See also specific opiates
intoxication, 170, 190, 224, 245
overd ose, treatm ent of, 253, 274
w ithd raw al, 170, 181182, 190, 201
Opp ositional d efiant d isord er (ODD), 73
P Jehovahs Witness and , 146, 158
Panic attacks
d ifferential d iagnosis, 168169, 188
p hysiologic pathology, 248, 268269
Panic d isord er
w ith agoraphobia
d ifferential d iagnosis of, 173174, 193
treatm ent of, 174, 193
d ifferential d iagnosis, 208, 227228
sertraline, 207, 227
treatm ent of, 208, 228
Paranoid d elu sions, 142, 155
Paranoid personality d isord er, 184, 203
Paroxetine (Paxil), 247, 262, 268, 281
cognitive d ecline and , 265, 284
Partial hospital p rogram s, 151, 162
Patient-d octor relationship, 216217, 237
p aym ent and , 150, 161, 252, 273
sexual, 148, 159
Paxil. See Paroxetine
Personality d isord ers, 183, 203, 261, 280.
See also specific personality disorders
Phencyclid ine (PCP) intoxication, 224,
245, 267, 285
supportive care, 266, 285
treatm ent for, 266, 285
Pheochrom ocytom a, 176177, 196
Physician-assisted su icid e, 148, 160, 254,
274
Physicianp atient confid entiality, 146, 158,
252, 255, 272273, 275
Pick d isease. See also Dem entia
d ifferential d iagnosis, 178, 198
Postp artu m d epression
involuntary com m itm ent and , 147148,
159
w ith p sychosis, 165166, 185
treatm ent, 166, 185
Postp artu m psychosis, 165166, 185
Posttraum atic stress d isord er (PTSD)
treatm ent, 263, 282
Pow er of attorney, 147, 159
Prazosin, 263, 282
Pregnancy
fluoxetine and , 256, 276
haloperid ol and , 223224, 244
MAOI and , 216, 237
Priapism , 215216, 236, 256, 276
Prion (Creu tzfeld tJacob) d isease, 198
Pseud od em entia, 178, 198. See also
Dem entia
Psilocybin w ithd raw al, 266, 285
Psychiatric illnesses, 205, 225
Psychogenic unresponsiveness, 213, 233
Psychosis, postpartum , 165166, 185
Psychotherapy. See also specific
psychotherapies
ad ju stm ent d isord er, 173, 193
Psychotic d isord er, brief, 172, 191192
Psychotic featu res, MDD w ith, 171, 191
treatm ent of, 172, 192
Q Sexu al abu se, 273274
Qu etiapine (Seroqu el), 211212, 232
p ostp artu m d ep ression, 166, 185
R Sleep ap nea, 220, 240241
Racing thou ghts, 210, 230
Rand om letter test, 252253, 273
Reactive attachm ent d isord er, 259260,
279
Refu sal of treatm ent, 143, 147, 156
child ren and , 145146, 158
Rep orting im p aired colleagu es, 152153,
163
Restless legs synd rom e
d ifferential d iagnosis, 183, 202
treatm ent, 183, 202
Retinitis p igm entosa, 264, 283
ReyOsterrieth Test, 218, 224, 238, 244, 254,
275
Risp erid one, 262, 281
and flu oxetine, 266, 285
Risp erid one Consta, 262, 281
Risp erid one (Risperd al)
MDD
w ith p sychotic featu res, 172, 191
Tourette d isord er, 259, 278
Rorschach Test, 210, 212, 230, 232, 255, 275
S T
Schizoaffective d isord er
d iagnosis for, 261, 280
m ed ications, 165, 185
Schizoid p ersonality d isord er, 180, 184, 200,
203
Schizop hrenia
flat affect and , 206, 226
genetics, 210, 230
negative sym p tom , 206, 226
risk of, 210, 230
treatm ent, 222, 243, 248, 269
Schizophreniform d isord er
d ifferential d iagnosis, 169, 189, 210, 223,
230, 244
Schizotyp al p ersonality d isord er, 184, 203
d ifferential d iagnosis, 206, 209, 225226,
229
treatm ent, 206, 226
Seizures
alcohol w ithd raw al and , 170, 189
ECT, 266, 284
tem p oral lobe, 263, 283
Selective m u tism , 1315
Serotonin-sp ecific reu p take inhibitor (SSRI),
167, 187
insom nia and , 173, 192
MAOIs and changing from , 264, 283
sexu al d ysfu nction and , 169, 188,
222223, 243
sid e effects, 169, 188
su icid e and , 257, 276277
Serotonin synd rom e, 218, 239
d ifferential d iagnosis, 182, 201202
m anagem ent of, 182, 202
Sertraline (Zoloft)
MDD
w ith p sychotic featu res, 172, 191
p anic d isord er, 207, 227
w ith agorap hobia, 174, 193
for p anic d isord er, 208, 228
schizoaffective d isord er, 165, 185
Seru m liver fu nction stu d ies, 217, 238
Sexu al d ysfu nction, SSRIs and , 169, 188,
222223, 243
SLE. See System ic lu pu s erythem atosus
Som atic sym p tom d isord er, 177, 197
Sonata. See Zalep lon
SSRI. See Serotonin-specific reuptake inhibitor
St. John w ort, 257, 277
Steroid -ind u ced p sychotic d isord er
d ifferential d iagnosis, 182, 201
m anagem ent of, 182, 201
StevensJohnson synd rom e, 257, 277
Stress from w ork, 206, 226
Stroke, visual nonverbal m em ory and , 218,
238
Stroop Test, 254, 275
Subp oena to release m ed ical inform ation,
149, 160
Substance intoxication, insanity d efence
and , 150151, 161
Suicid e. See also Physician-assisted su icid e
m alp ractice and , 150, 161
risk factors, 150, 161, 254, 258, 274, 277
SSRI and , 257, 276277
Supportive care, for PCP intoxication, 266, 285
Sym m etrel. See Am antad ine
Systemic lupus erythematosus (SLE), 177, 197
Tarasoff v. Regents of University of California,
141, 154
Tard ive d yskinesia (TD), 262263, 281282
TD. See Tard ive d yskinesia
Tem p oral Orientation Test, 211, 231
Testam entary cap acity, 142, 155, 251, 272
Test of Mem ory Malingering, 220, 240
Thiam ine, Wernicke encep halopathy and ,
166, 180, 186, 199, 216, 237, 253, 274
Thiorid azine (Mellaril), 264, 283
Thou ght broad casting, 250, 271
Thyroid d isord er, 210, 230
Tofranil. See Im ip ram ine
Torticollis, 264, 283
Tou rette d isord er, 259, 278
cop rop raxia, 249, 270
echolalia and , 249, 270
treatm ent, 176, 195
Toxicology screen, 170, 189190
brief p sychotic d isord er and , 172, 192
u rine, 256, 276
Trazod one (Desyrel), 256, 276
p riap ism and , 215, 236, 256257, 276
Triazolam (H alcion), 170, 190
Tricyclic antid ep ressants (TCAs)
card iac arrhythm ia and , 169, 189
Type II error, 262, 281
V
Valp roic acid , 262, 281
bip olar I d isord er, 251, 271
Venlafaxine (Effexor), 247, 262, 268, 281
W
Wad a Test, 255, 275
WAIS-R. See Wechsler Ad u lt Intelligence
ScaleRevised
WCST. See Wisconsin Card Sorting Test
Wechsler Ad ult Intelligence ScaleRevised
(WAIS-R), 214, 234, 255, 275
Wechsler Intelligence Scale for Child ren
(WISC), 175176, 195, 224, 244
 Ind ex 295

Weight gain, 247, 268 WISC. See Wechsler Intelligence Scale for Z
Wernicke encephalop athy, 166, 186 Child ren Zalep lon (Sonata), 216, 236
m anagem ent, 166, 186 Wisconsin Card Sorting Test (WCST), 209, Zip rasid one (Geod on)
thiam ine and , 166, 180, 186, 199, 216, 237, 229, 254, 275 schizoaffective d isord er, 165,
253, 274 Withd raw al 185
WernickeKorsakoff synd rom e, 65 alcohol, 267, 285 w eight gain and , 247, 268
Wills caffeine, 217, 237 Zoloft. See Sertraline
legality, 142, 155 cocaine, 267, 285 Zolp id em (Am bien), 181, 201, 256,
living w ill, 151152, 162 heroin, 267, 285 276
Wilson d isease, 250, 270271 opiates, 170, 181182, 190, 201