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Case 1: Dr. B, a 42-year-old Irish-American psychiatrist, presented to a medical clinic with the following complaint: "I am in a daze, confused, disoriented, staring. My thoughts do not flow, my mind is arrested . . . I seem to lack any sense of direction, purpose . . . I have such an inertia, I cannot assert myself. I cannot fight, I have no will." He explains that this feeling came on him suddenly, and he had felt quite well only a few weeks ago. He admits that, as a result, he has begun to start drinking 4-8 beers at night in an attempt “to feel better” but that it has not helped. He is clear that he did not drink to excess at any time in the past. |
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1.
Dr. B’s symptoms are most consistent with a.
a major depressive episode b.
a psychotic episode c.
a panic attack d.
a delirium. |
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2.
Though further tests are indicated, the diagnosis
is likely a.
Cognitive Disorder not otherwise specified. b. Dysthmic disorder. c.
Major depressive disorder d.
Bipolar disorder |
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3.
Which clinical or epidemiological feature could be considered
a poor prognostic factor? a. The patient’s gender. b.
The comorbid alcohol use c.
The sudden onset of symptoms d.
The patient’s age |
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4.
Which of the epidemiologic aspects of his presentation could be considered
relatively more unusual for this disorder.
a. Dr. B’s occupation. b. Dr. B’s ethnicity. c. Dr. B’s gender. d. Dr. B’s age. |
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5.
A PET scan of Dr. B’s brain, if done before and after treatment, is
most likely to show changes in what area? a. frontal lobe. b. temporal lobe. c. parietal lobe. d. ear lobe. |
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6. It turns out that Dr. B
has 2 siblings, one of which is an identical
twin. What is the relative risk
of the twin having the same disorder as compared with the other sibling? a.
The twin has about quadruple the risk of the other sibling. b.
The twin has about the same risk as the other sibling. c.
The twin has about one and a half times the risk of the other sibling.
d.
The twin has more than 50 times the risk as the other sibling. |
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7.
If untreated, Dr. B is likely to remain in his present state of distress
for around a. 6-9 months b. 4-6 weeks c.
5 years. d. 1-2 weeks |
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8.
Dr. B is reluctant to take medication, but is willing to consider other
options. Among the following, which is the most efficacious option for his disorder. a.
psychotherapy. b.
vagal nerve stimulation. c.
transcranial magnetic stimulation. d.
electroconvulsive therapy. |
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a. psychoanalysis b. supportive psychotherapy c. cognitive behavioral therapy d. interpersonal therapy |
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10.
Dr. B gradually worsens and has to be hospitalized. About
what percent of patients hospitalized for this disorder will someday take their
own life? a.1% b.1% c. 10% d. 100% |
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Case 2: A 55-year-old successful businessman with a strong family history for unipolar depression started to feel mentally sluggish, and developed depressed mood, psychomotor retardation, and ruminative self-doubts. A medical work-up revealed high serum calcium that led to a diagnosis of hyperparathyroidism, which was ultimately treated surgically. Once the parathyroid problem was corrected, the mood disorder disappeared without further treatment. |
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11.
The patient’s current state could be best described
as: a.
Anxious b.
Retarded d. Psychotic. d.
Depressed |
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12.
His diagnosis is most consistent with: a. Bipolar disorder, depressive episode. b. Major depression, recurrent type. c. An adjustment
disorder. d. Mood disorder due to a medical disorder.
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Case 3:
Ms. S. was a 25-year-old student who was referred
for a psychiatric evaluation from the medical emergency room at a larger
university-based medical center. Ms. S. had
been evaluated three times over the preceding 3 weeks in this emergency
room. Her first visit was prompted by a paroxysm of extreme dyspnea
and terror that occurred while she was working on a term paper. The dyspnea was accompanied by palpitations, choking sensations,
sweating, shakiness, and a strong urge to flee. Ms.
S. thought that she was having a heart attack, and she immediately went
to the emergency room. She received a full
medical evaluation, including an electrocardiogram (ECG) and routine
blood work, which revealed no sign of cardiovascular, pulmonary, or
other illness. Although Ms. S. was given the number of a local psychiatrist,
she did not make a follow-up appointment, since she did not think that
her episode would recur. She developed two other similar episodes, one while she was
on her way to visit a friend and a second that woke her up from sleep.
She immediately went to the emergency room after experiencing both paroxysms,
receiving full medical workups that showed no sign of illness. |
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13. These symptoms are most
consistent with a. a panic attack b. a somatic delusional c. an adjustment disorder d. an anxiety attack.
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a. Norepinephrine b.
Serotonin c. Dopamine d. Gamma amino butyric acid
(GABA) |
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15. Which of the following procedures is likely
to confirm the diagnosis. a. Epinephrine injection b. Echocardiogram c. Carbon dioxide inhalation d.
Hypnosis |
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Case 4: A young, unmarried woman, age 20, was admitted
to a psychiatric hospital because she had become violent toward her
parents, had been observed gazing into space with a rapt expression,
and had been talking to invisible persons. She
had been seen to strike odd postures. Her speech
had become incoherent. She had been a good student in high
school, then went to business school and, a year before admission to
the hospital started to work in an office as a stenographer.
She had always been shy, and although she was quite attractive,
she had not been dating much. Another girl, who worked in the same office,
told the patient about boys and petting and began to exert a great deal
of influence over her. The second girl would communicate with her from
across the room. Even when they went home at night, the patient would
hear the girl’s voice telling her to do certain things. Then pictures
began to appear on the wall, most of them ugly and sneering. Those pictures
had names—one was named shyness, another distress, another envy.
Her office friend sent her messages to knock on the wall, to
hit the pictures. |
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16.
Her thought can be best characterized as: a.
Delusional b.
Dissociative c.
Loose d.
Grandiose |
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17.
Her diagnosis is most consistent with a.
Bipolar Disorder, psychotic type b.
Schizophrenia c.
Psychotic Depression d. Paranoia. |
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18.
Initial management would include initiation of a.
Risperidone b.
Lorazepam c. Lithium d. Sodium Valproate |
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19.
Which of the following possible etiological clues is most likely to be
found on further investigation. a.
inconsistent parenting during infancy b.
a family history of the disorder c.
a viral illness during fetal development d.
low premorbid social status |
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| (Case
4 cont’d:) Over
the course of many years the patient’s voicing of beliefs about her friend
subsided. However, she continued to decline.
She remained in the hospital, spoke little, and showed little interest
in hospital activities or in other patients.
Currently, she is largely mute
and practically devoid of any spontaneity, but she responds to simple requests. She stays in the same position for hours or sits curled-up
in a chair. Her facial expression is fixed and stony. |
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20. At this point, the symptomatic
syndrome she is demonstrating is most consistent with a. First rank Schneiderian symptoms
of schizophrenia. b. Residual
symptoms of schizophrenia. c. Late onset autism d. The negative symptoms of
schizophrenia |
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21.
Pharmacological treatment at this point would likely have to target which
neurotransmitter a.
Gamma amino butyric acid (GABA) b.
Norepinephrine c. Dopamine d. Serotonin |
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Case 5: A 43-year-old Navy Captain began to experience episodes of severe chest
pains, profound sweating, and fear that he was about to die. He had
gone to the emergency room on several occasions, and each time had a
normal electrocardiogram (ECG) and other tests. His capacity to work
was impaired, and he started to stay at home rather than drive to work,
since all his episodes began while he was driving. Although he had no
prior history of significant alcohol abuse, he also began drinking large
amounts of vodka in the past two weeks in an effort to stave off the
attacks. |
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22. These symptoms are most
consistent with a. panic attacks b. alcohol withdrawal c. delusions. d. depression |
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23.
In addition to his primary diagnosis, what syndrome or disorder appears
now to be comorbid. a.
Agoraphobia b.
Hypochondria c. Delusions d. Alcohol dependence |
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Case 6:
A 37-year-old engineer,
was admitted to the hospital after an episode of agitation in which
he had badly beaten his wife. When
asked how he could do such a thing, he explained that , "Ordinary
mortals will never, never understand the supreme state which I'm privileged
to experience every few years. It is so vivid,
so intense, so compelling. It enters through my left brain like laser
beams, transforming my sluggish thoughts, recharging them, galvanizing
them. My thoughts acquire such momentum,
they rush out of my head, to disseminate knowledge to psychiatrists
and all others concerned.” |
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24. The patients thought is best described as: a. Pressured b. Disorganized c. Circumstantial d. Grandiose. |
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25. His current state could best be described as a. Depressed b. Disorganized. c. Manic d. Catatonic |
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26. His diagnosis
is most consistent with which diagnosis? a. Schizophrenia. b. Anxiety Disorder Not Otherwise
Specified c. Bipolar Disorder d. Major
depression. |
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27. If the patient continues
to be agitated, which medication will most likely help with rapid control
this patient in the emergency setting? a. lithium b. fluoxetine c. clozapine. d. lorazepam |
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28. If your diagnosis is correct,
the medication that will be most likely useful for long
term management will be a. clozapine. b. lithium c. fluoxetine d. lorazepam |
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29.
Which of the following neuropathological findings is most likely to be
found in this disorder. a. supersensitivity on monoamine receptor challenge. b. clinical significant enlarged third ventricles. c. decreased blink rate on photic
stimulation. d. hypofrontality on testing
of the frontal lobes. |
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Case 7: A 15-year-old
girl attended a summer camp where she had difficulties in getting along
with the other children and developed animosity toward one of the counselors.
On her return home, she refused to listen to her parents, and
she heard the voice of a man talking to her, although she could not
see him. She rapidly began to show bizarre behavior, characterized by
grimacing, violent outbursts, and inability to take care of herself. Her school record had always been good,
and she was fluent in three languages. Her parents described her as
having been a quiet, rather shut-in child, with few friends, but she
had no obvious illnesses psychiatric or otherwise in her childhood. Her family was relatively affluent, and her
family relations were reported as having been satisfactory.
There was a family history of major depression. When the patient was admitted to a
psychiatric hospital, her speech was incoherent. She
showed marked disturbances of formal thinking and blocking of thoughts.
She was impulsive and seemed to be hallucinating. She stated that she
heard voices in her right ear and that a popular singer was running
after her with a knife. She also thought that her father was intent
on killing her and that she was pregnant because she had hugged one
of the residents. |
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30. Her diagnosis is most consistent
with a. Bipolar Disorder b. Schizoid personality c. Schizoaffective disorder d. Schizophrenia |
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31. Though less likely (given
the time course) which of these drugs of abuse should also be considered
in the differential diagnosis? a. marijuana b. heroin c. alcohol d. PCP |
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32. Overall, currently her
prognosis is a. relatively good b. relatively bad c. impossible to determine. |
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33. Features of her history
that might suggest a bad prognosis include: a. her socioeconomic status b. her social history. c. her family history. d. her prior school record |
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34.
She begins treatment. After about
a month, she is noted to showing less affect,
and to be moving much more slowly. At
this point her doctor should a.
Attempt to lower her medication. b.
Add a dopamine-blocking agent. c.
Investigate the possibility of a comorbid disorder. d.
Treat her disorder more aggressively |
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Case 8: This is taken from a mental status examination of a patient: Mental Status Examination Appearance, Attitude, and Activity This is a young, slightly obese white female, dressed casually but wearing makeup. She frequently walks about the room, and gesticulates vigorously while speaking. She is partially cooperative with the exam, but says that she came in only because her husband insisted and that she "feels wonderful and doesn't need a doctor." At times, she appears to dance. Mood and Affect She is cheerful and describes her mood as "great." She is very expressive of her cheerful mood, but affect is mildly labile, with several angry comments and irritability when interrupted by the examiner. Affect is appropriate to thought content but inappropriate to her situation. Speech and Language Speech is loud and pressured. Fluent and grammatical. Normal prosody. Thought Content and Process and Perception Tangentiality bordering on flight of ideas. Has grandiose delusions, feeling that others are jealous of her looks and intelligence. Denies hallucinations, suicidal ideation, or thoughts of harming others. Cognition Alert and fully oriented. She is intermittently distractible and performs poorly on serial sevens, and refuses to answer long-term memory questions, but recalls 3/3 objects at five minutes. Normal performance on similarities and proverbs. Refuses to cooperative with cognitive testing. Insight and Judgment
Acknowledges that "I need to get back
on my medication," but minimizes mood and thinking disturbances. Enjoys her euphoria and does not see a problem. |
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35. This presentation is most associated with what diagnosis? a.
Bipolar Disorder b.
Panic disorder c.
Schizoaffective disorder d.
Schizophrenia |
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36.
If left untreated, what is the likely course of her disorder a. rapid, downward deterioration over time, with a change
toward negative symptoms. b. continued exacerbations and
remissions, occurring at the same rate over time. c. a gradual decrease in the interepisode periods of feeling normal. |
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Case 9: Kevin, a 15-year-old boy, was referred to a sleep center to rule out narcolepsy. His main complaints were fatigue, boredom, and a need to sleep all the time. Although he had always started the day somewhat slowly, he now could not get out of bed to go to school. That alarmed his mother, prompting sleep consultation. Formerly a B student, he had been failing most of his courses in the 6 months before referral. Psychological counseling, predicated on the premise that his family's recent move from another city had led to Kevin's isolation, had not been beneficial. Extensive neurological and general medical workup had also proven negative. He slept 12 to 15 hours a day but denied cataplexy, sleep paralysis, and hypnagogic hallucinations. During psychiatric interview he denied being depressed but admitted that he had lost interest in everything except his dog. He had no drive, participated in no activities, and had gained 30 pounds in 6 months. He believed he was "brain damaged" and wondered whether it was worth living like that. The question of suicide disturbed him as it was contrary to his religious beliefs. |
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37. The boy’s current state
could be best described as a.
Anxious b. Narcoleptic. c. Psychotic. d.
Depressed |
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38.
Kevin’s diagnosis is most consistent with a. Bipolar disorder. b. Schizophrenia. c. Major depression. d. Insomnia. |
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39.
The medication most likely to help him and cause the fewest side effects
would be a. Methamphetamine. b.
Haloperidol c. Diphenhydramine d. Bupropion |
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40.
With proper treatment, he should be expected
to show some improvements within a. 2 days b. 5 weeks. c. 2 months d. 6 months.
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41.
Which of the following tests is most likely to show an abnormality consistent
with the disorder? a. lactic acid infusion. b. dexamethasone suppression test. c. urine catecholamine metabolite
assay. d. MRI head. |
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42.
Kevin agrees to a medication, and says that he wants the medication that
has the best likelihood of helping him recover quickly. The best predictor of this would be a. Any family history of prior medication response. b.
The degree to which the medication aids sleep. c. The affect of the drug on the
neurotransmitter most affected. d.
The half-life and of
the particular medication |
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Case 10: A
woman who had been hospitalized for several years kept repeating (in an
otherwise quite rational conversation) the word "polamolalittersjitterstittersleelitla."
Her psychiatrist asked her to spell it out, and she proceeded to
explain the meaning of the various components, which she insisted were
to be used as one word."Polamolalitters" was
intended to recall the disease poliomyelitis, because the patient wanted
to indicate that she felt she was suffering from a serious disease affecting
her nervous system; the component "litters" stood for untidiness
or messiness, the way she felt inside; "jitterstitters" reflected
her inner nervousness and lack of ease; "leelita" was a reference
to the French le lit la (that bed there), meaning that she both depended
on and felt handicapped by her illness. |
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43.
This type of thinking is best described as (a) a. neologism b. perseveration. c. loose association d. clanging |
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44. This type of thinking is
illustrative of a a. disorder of thought process b. disorder of thought content c. disorder of thought organization. d. disorder of thought formation. |
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answer:
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45. This type of thinking is most consistent with which of these disorders? a.
panic disorder. b.
major depressive disorder. c.
schizophrenia, paranoid type d.
bipolar disorder |
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Antidepressants |
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First Generation |
Tricyclics (TCAs) |
amitriptyline, imipramine, nortriptyline, desipramine |
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MAOIs |
phenelzine, tranycypromine |
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Second Generation |
Serotonin Reuptake Inhibitors |
fluoxetine, sertraline, paroxetine, citalopram, escitalopram,
fluvoxamine |
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Else |
Bupropion, Trazodone |
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Third Generation |
Venlafaxine |
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Buproprion |
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Nefazodone |
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Mirtazapine |
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Antipsychotics |
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Phenothiazines |
chlorpromazine, thioridazine |
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Butyrophenones |
haloperidol |
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Atypicals |
clozapine, olanzapine |
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Anxiolytics |
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Benzodiazepines |
diazepam (Valium), chlordiazepoxide (Librium), lorazepam
(Ativan), alprazolam (Xanax), clonazepam (Klonopin) |
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Barbituates |
phenobarbital |
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Azapirone |
buspirone (Buspar) |
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Antihistamines |
diphenhydramine (Benadryl) |
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Beta blockers |
propranolol (inderal) |
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Mood Stabilizers |
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Lithium Carbonate |
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Anticonvulsants |
Sodium Valproate (Depakote) |
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