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Pretest Psychiatry – Flashcards

Jose Escobar

7 July 2022

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question

1. A 42-year-old man comes to the emergency room with the chief com- plaint that "the men are following me." He also complains of hearing a voice telling him to hurt others. He tells the examiner that the news anchorman gives him special messages about the state of the world every night through the TV. Which of the following psychiatric findings best describes this last belief of the patient?

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d. Idea of reference

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2. A 32-year-old woman is seen in an outpatient psychiatric clinic for the chief complaint of a depressed mood for 4 months. During the interview, she gives very long, complicated explanations and many unnecessary details before finally answering the original questions. Which of the fol- lowing psychiatric findings best describes this style of train of thought?

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b. Circumstantiality

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3. A 23-year-old man comes to the psychiatrist with a chief complaint of a depressed mood. He is very anxious and obviously uncomfortable in the physician's office. Which of the following actions should be used to help develop rapport with this patient?

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b. Express compassion with the difficult position the patient is in.

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4. An 18-year-old man is seen by a psychiatrist in the emergency room. During the history, the patient is asked to describe his mood. He answers the following, "My mood is flextitating, I am up and down." The patient is exhibiting which of the following thought disorders?

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e. Neologism

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5. A 56-year-old man has been hospitalized for a myocardial infarction. Two days after admission, he awakens in the middle of the night and screams that there is a man standing by the window in his room. When the nurse enters the room and turns on a light, the patient is relieved to learn that the "man" was actually a drape by the window. This misperception of reality is best described by which of the following psychiatric terms?

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c. Illusion

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6. A 22-year-old woman is seen by a psychiatrist in the emergency room after she is found walking in the middle of a busy street with no shoes on. During her interview she is asked to count backwards from 100 by 7's. Which of the following best describes the cognitive functions being tested by this request?

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d. Concentration

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7. A 72-year-old woman is admitted to the burn unit with second- and third-degree burns covering 35% of her body, which she received in a house fire. At 8 pm on the fourth day of her hospital stay, she pulls out her IV and begins screaming that people are trying to hurt her. Several hours later she is found to be difficult to arouse and disoriented. Which of the following is the most likely diagnosis?

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d. Delirium

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8. A psychiatric resident is called to consult on the case of a 75-year-old woman who had undergone a hip replacement 2 days before. On examination, the resident notes that the patient states the date as 1956, and she thinks she is at her son's house. These impairments best illustrate which aspect of the mental status examination?

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d. Orientation

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9. A 52-year-old man is sent to see a psychiatrist after he is disciplined at his job because he consistently turns in his assignments late. He insists that he is not about to turn in anything until it is "perfect, unlike all of my colleagues." He has few friends because he annoys them with his demands for "precise timeliness" and because of his lack of emotional warmth. This has been a lifelong pattern for the patient, though he refuses to believe the problems have anything to do with his personal behavior. Which of the following is the most likely diagnosis for this patient?

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b. Obsessive-compulsive personality disorder

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10. A 23-year-old woman comes to the psychiatrist because she "cannot get out of the shower." She tells the psychiatrist that she has been unable to go to her job as a secretary for the past 3 weeks because it takes her at least 4 hours to shower. She describes an elaborate ritual in which she must make sure that each part of her body has been scrubbed three times, in exactly the same order each time. She notes that her hands are raw and bloody from all the scrubbing. She states that she hates what she is doing to herself but becomes unbearably anxious each time she tries to stop. She notes that she has always taken long showers, but the problem has been worsening steadily for the past 5 months. She denies problems with friends or at work, other than the problems that currently are keeping her from going to work. Which of the following is the most likely diagnosis?

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b. Obsessive-compulsive disorder

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11. A 37 year-old man with chronic schizophrenia is brought to see a new psychiatrist for treatment. While taking the history, the psychiatrist finds that the patient functions with a flat affect and circumstantial speech all the time. He has few friends. He is able to hold a menial job at the halfway house where he lives, and his behavior is not influenced by delusions or hallucinations currently. What should the psychiatrist rate the patient on Axis V (global assessment of functioning)?

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c. 55

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12. A 28-year-old man comes to the psychiatrist because his employer required it. The patient says that he does not know why the employer required it--that his job is good and that he likes it because it requires him to sit in front of a computer screen all day. He notes he has one friend whom he has had for more than 20 years and "doesn't need anyone else." The friend lives in another state and the patient has not seen him for at least a year. The patient denies any psychotic symptoms. His eye contact is poor and his affect is almost flat.

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c. Schizoid personality disorder

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13. A 42-year-old woman is admitted to the hospital for complaints of abdominal pain. Her history notes that her mother was a nurse and she herself is trained as a phlebotomist. On physical examination, she presents with multiple abdominal scars and marked abdominal tenderness. The patient is evasive when asked where she had the surgeries, but she can describe in great detail what was done in each.

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f. Factitious disorder

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14. An 18-year-old man is brought to the emergency room by his college roommate, after the roommate discovered that the patient had not left his room for the past 3 days, neither to eat nor to go to the bathroom. The roommate noted that the patient was kind of "weird." Mental status examination reveals that the patient has auditory hallucinations of two voices commenting upon his behavior. The patient's parents note that their son has always been somewhat of a loner and unpopular, but otherwise did fairly well in school.

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h. Schizophreniform disorder

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15. A 32-year-old woman comes to the psychiatrist with a chief complaint of anxiety. She notes that she worries about paying the mortgage on time, whether or not she will get stuck in traffic and be late for appointments, her husband's and daughter's health, and the war in Iraq. She notes that she has always been anxious, but since the birth of her daughter 2 years ago, the anxiety has worsened to the point that she feels she cannot function as well as she did previously.

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b. Generalized anxiety disorder

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16. A 23-year-old woman comes to the emergency room with the chief complaint that she has been hearing voices for 7 months. Besides the hallucinations, she has the idea that the radio is giving her special messages. When asked the meaning of the proverb "People in glass houses should not throw stones," the patient replies, "Because the windows would break." Which of the following mental status findings does this patient display?

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b. Concrete thinking

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17. A 22-year-old woman is seen in the emergency room after a suicide attempt. She swallowed 10 aspirin in the presence of her mother, with whom she had just had an argument. The patient has a long history of cutting herself superficially with razor blades, which her psychiatrist of the last 5 years confirms by telephone. The patient currently lives in a stable environment (a halfway house) where she has been for 3 years. Which of the following option is the best course of action for the physician in the emergency room?

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e. Discharge the patient back to outpatient therapy and the halfway house

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18. A 69-year-old man is brought to see his physician by his wife. She notes that over the past year he has experienced a slow, stepwise decline in his cognitive functioning. One year ago she felt his thinking was "as good as it always had been," but now he gets lost around the house and can't remember simple directions. The patient insists that he feels fine, though he is depressed about his loss of memory. He is eating and sleeping well. Which of the following is the most likely diagnosis?

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a. Multi-infarct dementia

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19. An 18-year-old man is brought to the emergency room by police after he is found wandering in the street, screaming loudly at passersby. In the emergency room he is placed in an examination room, and paces the floor and pounds his fist against the door repeatedly. Which of the following actions should be taken by the psychiatrist first?

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d. Make sure the physical environment is safe for the interviewer

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20. A 6-year-old girl is brought to the physician by her mother, who says the child has been falling behind at school. She notes that the girl did not speak until the age of 4. She is friendly at school, but is unable to complete most tasks, even when aided. She is noted to have a very short attention span and occasional temper tantrums at school and at home. Which of the following tests would be most helpful in establishing the diagnosis?

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c. IQ testing

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21. A 30-year-old man is brought to the emergency room after threatening to kill his 19-year-old girlfriend after she told him she was breaking up with him. The patient smells strongly of alcohol. The patient is from a high socioeconomic status and reports many social supports. Which of the following pairs of factors make this patient's risk of violent behavior higher?

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b. His alcohol use and the impending breakup with the girlfriend

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22. The patient above becomes physically violent in the emergency room, attempting to strike a nurse and struggling with security. Which of the following actions should the psychiatrist take now?

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a. Order full leather restraints

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23. The patient in question 21 is eventually placed in full leather restraints. He struggles against them and screams racial slurs repeatedly. What action should the psychiatrist take next?

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a. Give haloperidol 5 mg IM and lorazepam 2 mg IM

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24. A psychiatrist is seeing a patient in his outpatient practice. The patient treats the psychiatrist as if he were unreliable and punitive, though he had not been either. The patient's father was an alcoholic who often did not show up to pick her up from school and frequently hit her. The psychiatrist begins to feel as if he must overprotect the patient and treat her gingerly. Which of the following psychological mechanisms best describes the psychiatrist's behavior?

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c. Countertransference

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25. A patient is able to appreciate subtle nuances in thinking and can use metaphors and understand them. This patient's thinking can be best defined by which of the following terms?

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b. Abstract

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26. A 65-year-old man, who had been hospitalized for an acute pneumonia 3 days previously, begins screaming for his nurse, stating that "there are people in the room out to get me." He then gets out of bed and begins pulling out his IV line. On examination, he alternates between agitation and somnolence. He is not oriented to time or place. His vital signs are as follows: pulse, 126 beats per minute; respiration, 32 breaths per minute; blood pressure (BP), 80/58; temperature, 39.2°C (102.5°F). Which of the following diagnoses best fits this patient's clinical picture?

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d. Delirium

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27. A 59-year-old man goes to a psychiatrist for a 3-month history of panic attacks. He notes for the past 3 months he has experienced "out of the blue," extreme episodes of fearfulness that last about 20 minutes. During that time he experiences palpitations, sweating, shortness of breath, and trembling. He denies any substance abuse, and has never had symptoms like this before these past 3 months. Which of the following signs or symptoms would likely lead the physicians to expect a diagnosis of anxiety secondary to a general medical condition in this case?

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a. The patient's age

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28. A 24-year-old man returns from Iraq after a 13-month tour of duty. During that tour he was involved in battle situations and saw one of his friends injured by a car bomb. What percentage of American soldiers returning home from Iraq have posttraumatic stress disorder (PTSD)?

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c. 15% to 20%

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29. A 23-year-old man presents to the emergency room with the history of a fever up to 38°C (100.5°F) intermittently over the past 2 weeks, a persistent cough, and a 10-lb weight loss in the past month. He notes that he has also been becoming increasingly forgetful for the past month and that his thinking is "not always clear." He has gotten lost twice recently while driving. Which of the following diagnostic tests will be most helpful with this patient?

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d. HIV antibody test

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30. A 19-year-old woman presents to the emergency room with the chief complaint of a depressed mood for 2 weeks. She notes that since her therapist went on vacation she has experienced suicidal ideation, crying spells, and an increased appetite. She states that she has left 40 messages on the therapist's answering machine telling him that she is going to kill herself and that it would serve him right for leaving her. Physical examination reveals multiple well-healed scars and cigarette burns on the anterior aspect of both forearms. Which of the following diagnoses best fits this patient's clinical presentation?

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d. Borderline personality disorder

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31. A 29-year-old man is brought to the emergency room by his wife after he woke up with paralysis of his right arm. The patient reports that the day before, he had gotten into a verbal altercation with his mother over her intrusiveness in his life. The patient notes that he has always had mixed feelings about his mother, but that people should always respect their mothers above all else. Which of the following diagnoses best fits this patient's clinical picture?

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b. Conversion disorder

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32. A 28-year-old business executive sees her physician because she is having difficulty in her new position, as it requires her to do frequent public speaking. She states that she is terrified she will do or say something that will cause her extreme embarrassment. The patient says that when she must speak in public, she becomes extremely anxious and her heart beats uncontrollably. Based on this clinical picture, which of the following is the most likely diagnosis?

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e. Social phobia

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33. Which of the following terms best fits the definition "the proportion of a population affected by a disorder at a given time"?

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a. Prevalence

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34. A diagnostic test has a sensitivity of 64% and a specificity of 99%. Such a test would carry the risk of which kind of problem?

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c. False negatives

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35. A 56-year-old man is brought to the physician's office by his wife because she has noted a personality change during the past 3 months. While the patient is being interviewed, he answers every question with the same three words. Which of the following symptoms best fits this patient's behavior?

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d. Perseveration

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36. A 32-year-old patient is being interviewed in his physician's office. He eventually answers each question, but he gives long answers with a great deal of tedious and unnecessary detail before doing so. Which of the following symptoms best describes this patient's presentation?

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c. Circumstantiality

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37. An 18-year-old man is brought to the emergency room by the police after he is found walking along the edge of a high building. In the emergency room, he mumbles to himself and appears to be responding to internal stimuli. When asked open-ended questions, he suddenly stops his answer in the middle of a sentence, as if he has forgotten what to say. Which of the following symptoms best describes this last behavior?

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b. Blocking

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38. A 26-year-old woman with panic disorder notes that during the middle of one of her attacks she feels as if she is disconnected from the world, as though it were unreal or distant. Which of the following terms best describes this symptom?

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e. Derealization

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39. A patient with a chronic psychotic disorder is convinced that she has caused a recent earthquake because she was bored and wishing for something exciting to occur. Which of the following symptoms most closely describes this patient's thoughts?

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b. Magical thinking

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40. Malingering

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b. Conscious, intentional production of symptoms with secondary gain

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41. Factitious disorder

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a. Conscious, intentional production of symptoms with primary gain

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42. Somatization disorder

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c. Unconscious, unintentional production of symptoms

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43. Conversion disorder

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c. Unconscious, unintentional production of symptoms

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44. A 45-year-old man with a chronic psychotic disorder is interviewed after being admitted to a psychiatric unit. He mimics the examiner's body posture and movements during the interview. Which of the following terms best characterizes this patient's symptom?

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d. Echopraxia

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45. A 32-year-old man complains of depressed mood, poor concentration, a 25-lb weight gain, and hypersomnia. He is subsequently diagnosed with hypothyroidism.

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c. Axis III

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46. A 46-year-old college professor has been unable to go to work for the past 6 weeks because of his psychiatric symptoms.

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e. Axis V

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47. A 23-year-old woman works in a sheltered workshop. She is unable to make change for a dollar or read beyond a second-grade level. She has a genetic makeup of 47 chromosomes with three copies of chromosome 21.

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b. Axis II

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48. A 6-month-old male infant is noted by his mother to be difficult to care for. He is very difficult to feed or soothe, and often responds to cuddling by crying and becoming rigid in his mother's arms. Physical examination and laboratory work are all entirely normal. Which of the following psychiatric disorders is this infant at a higher risk to display in his early school years?

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a. Conduct disorder

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49. A 2-year-old girl is being toilet trained by her parents. Each time she soils her diaper, she is told that she is a very bad girl and she is punished by having a toy taken away. When she uses the toilet appropriately, she is not praised by her parents. Which of the following sequelae is the child most likely to experience as a result of this kind of parental behavior?

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b. Shame and self-doubt

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50. A 20-month-old boy loves running around and exploring the environment, but every few minutes he returns to his mother to check on her and solicit a quick hug. Which of the following best describes this behavior, according to Margaret Mahler?

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d. Rapprochement

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51. A woman brings her 18-month-old child to the psychiatrist, worried that he is not developing normally. The psychiatrist tests the child in three arenas, motor & sensory behavior, adaptive behavior, and personal & social behavior and finds the following (the highest level of skill the child achieves during these tests is outlined): Motor & Sensory Behavior Adaptive Behavior Personal & Social Behavior Can hurl ball and walk up Can build a tower Has separation anxiety stairs with one hand held of 3-4 cubes; when taken away scribbles from his mother; holds spontaneously own bottle

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e. Delayed development in all three areas

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52. Which of the following theorists focused primarily on the importance of early parental behavior, such as mirroring, leading to the development of a cohesive and stable sense of self?

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e. Kohut

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53. Piaget is best known for which of the following theories?

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a. Cognitive development

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54. A 2-year-old child carries around an old, tattered blanket wherever he goes. When he is sad or upset, he calms himself by hugging and stroking his blanket. He also needs it to settle down before sleep. For this child, which of the following does his blanket best represent?

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c. Transitional object

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55. A 4-year-old child is brought to the psychiatrist by her mother. Although the child is developing normally, she is scheduled to have her tonsils removed. The mother wishes to make this operation as smooth and atraumatic as possible. Using Piaget's theory, what should the psychiatrist tell the mother about how this upcoming event should be explained to the child?

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c. Verbal explanations will not be helpful. The upcoming event should be role played with the child through the use of dolls and toys.

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56. A 32-year-old woman is given the news by her physician that she has breast cancer and will need surgery, followed by chemotherapy. She returns home after the appointment, and her husband asks how the visit went. She tells him that "everything was fine." For the rest of the evening, she behaves as if there had been no bad news given to her. In fact, she appears to be in good spirits. Which of the following defense mechanisms is likely being employed by this woman?

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a. Denial

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57. A 3-year-old boy stands on one side of a large sculpture and is asked to describe what he sees. When asked to describe what a person on the other side of the sculpture sees, the child answers that the other person sees just what he

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c. Cognitive development

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58. A 70-year-old woman is admitted to the hospital after a fall in which she broke her left hip. She is a difficult patient during her rehabilitation phase, passively resisting attempts to get her up and walking, contending that it does not matter whether she regains her capacity to walk on her own since she is so advanced in age. She states that while she is fearful of dying, she feels disgust at her own body because it is "falling apart." Which of the following Eriksonian states is this patient most likely working through?

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a. Integrity versus despair

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59. Normality is an idealized fiction.

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a. Sigmund Freud

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60. Normality is the ability to acculturate and be content in one's world.

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d. Karl Menninger

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61. Normality is the ability to take responsibility for one's own actions and live without fear, guilt, or anxiety.

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f. Otto Rank

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62. Normality is characterized by strength of character, the capacity to deal with conflicting emotions, the ability to love, and to experience pleasure without conflict.

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b. Melanie Klein

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63. Normality is the ability to be socially connected and be productive, this leads to mental health and the capability of adaption.

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e. Alfred Adler

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64. Normality is the ability to master the progressive life stages successfully. (ie, trust vs. mistrust through ego integrity vs. despair).

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c. Erik Erikson

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65. A young woman with a history of childhood neglect feels suddenly worthless and devastated when her supervisor makes a mildly negative comment about her work performance. According to Heinz Kohut, which of the following explanations accounts for her hypersensitivity to criticism?

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d. A fragmented sense of self due to the empathic failure of her parents

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66. A 23-year-old woman constantly goes to great lengths to avoid being criticized, even when this requires going against her own beliefs and wishes. Although she is good-looking and successful, she is tormented by doubts about her abilities and her physical appearance. According to Kohutian theory, which of the following is most likely to explain her behavior?

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c. A lack of self-esteem, which causes a constant need for validation

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67. A 16-year-old boy is diagnosed with osteosarcoma. Surgery and chemotherapy are not successful as treatments, and it is apparent that the child will die from his disease. The child, rather than focusing on his death, seems more concerned with the fact that he has lost all his hair from the chemotherapy. He is difficult to work with in the hospital, as he insists on seeing visitors only when he chooses to and wants to work with only his favorite nurses. Which of the following is the best explanation for his behavior?

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b. He is an adolescent and these responses are quite typical for the age group.

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68. A 23-year old man impulsively steals a pack of gum at a convenience store. He has never stolen anything previously, and almost immediately upon exiting the store with the gum, he begins to feel extremely guilty. Which of the following concepts introduced by Freud is most likely responsible for this man's emotional response to his theft?

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c. Superego

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69. A 20-month-old girl is admitted to a pediatric ward because she weighs only 15 lb. An extensive medical work-up does not reveal any organic cause for the child's failure to thrive. The child is listless and apathetic and does not smile. The parents rarely come to visit, and when they do, they do not pick the child up and do not play or interact with her. Which of the following statements best explains this scenario?

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a. Lack of adequate emotional nurturance causes depression and failure to thrive in infants.

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70. A 25-year-old woman sees a psychiatrist for a chief complaint of having a depressed mood for her "entire life." She begins psychotherapy and sees the physician once per week. After 3 months of therapy, she tells the psychiatrist that she is very afraid of him because he is "so angry all the time." She behaves as if this is true and that the psychiatrist will explode with rage at any minute. The psychiatrist is not normally seen as an angry person and is unaware of any anger toward the patient. Which of the following defense mechanisms is this patient likely displaying?

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d. Projection

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71. A healthy 9-month-old girl is brought to her pediatrician by her concerned parents. Previously very friendly with everyone, she now bursts into tears when she is approached by an unfamiliar adult. Which of the following best describes this child's behavior?

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e. Stranger anxiety

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72. A 25-month-old boy plays with a ball, which rolls under a couch. The boy promptly crawls under the couch to retrieve the ball. According to Piaget's theories of cognitive development, which thinking process best describes this child's behavior?

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a. Object permanence

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73. According to Sigmund Freud, which of the following best describes primary processes?

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b. Nonlogical and primitive

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74. Erikson's developmental theories differ from Freud's in that Erikson placed greater emphasis on which of the following?

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a. Cultural factors in development

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75. A woman has a verbal altercation with her boss at work. She meekly accepts his harsh words. That night, she picks a fight with her husband. Which of the following defense mechanisms is being used by this woman?

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a. Displacement

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76. A 24-year-old woman lives with her mother, whom she intensely dislikes. She feels embarrassed by this, and compensates by hovering over her mother, attending to her every need. Which of the following defense mechanisms is being used by this woman?

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c. Reaction formation

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77. A writer of mystery novels, who has never had legal problems, jokes about his "dark side" and his hidden fantasies about leading an exciting life of crime. Which of the following defense mechanisms is being used by this man?

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b. Sublimation

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78. A 35-year-old man is being seen by his psychiatrist for depressed mood. The patient is irritated at his therapist for pushing him on several issues in the last session. The patient does not show up or call for his next session. Which of the following defense mechanisms is this patient displaying?

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d. Acting out

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79. A 45-year-old man accidentally crashes his car into another vehicle. He feels extremely guilty, and in order to avoid these feelings of selfreproach, he explains in meticulous detail to anyone listening all of the steps leading up to his accident. Which of the following defense mechanisms is this patient displaying?

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c. Intellectualization

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80. A 45-year-old woman is admitted to the hospital after her son finds her unconscious at home. She is treated for diabetic ketoacidosis and her recovery is a difficult one, necessitating that she stay in the hospital for 5 days. During this period of time, she is often angry, irrational, and demanding, all of which are not her usual modes of behavior or thinking, according to her husband. What is the most likely explanation for the change in this woman's behavior?

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c. The stress of her illness and hospital stay is causing her to regress.

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81. A 38-year-old woman comes to a psychiatrist for help with the management of her obsessive-compulsive disorder. She describes an impulse that she has frequently and that frightens her. This impulse is to murder her three children by blowing out the pilot light on her home's heater, thereby blowing up her house. As a result, she finds herself checking on the pilot light in her home at least 30 times a day. She carries a book of matches with her during these checks so that she might immediately relight the pilot light if she finds that it is out. Which of the following defense mechanisms does this act of checking the pilot light represent?

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c. Undoing

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82. A 20-month-old male infant is placed in an emergency department of children and family services shelter after his mother is hospitalized as the result of a car accident. Three days after the separation, the child spends almost every waking moment crying and calling and searching for his mother. The fourth day after the separation, when the mother of the child comes to the shelter to reclaim her child, he rejects her offers of affection, instead clinging to the nurse's aide who has been his caretaker. Which of the following terms most accurately describes this infant's reactions to a forced separation?

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a. Protest

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83. A 17-month-old girl is playing with her mother. Her mother hides a large red ball from the child and encourages her to find it. The girl looks under several pieces of furniture and finally finds the ball hidden behind the couch. The mother enjoys this game, because 2 months previously, if she had tried to play this game, the child simply would not have been able to understand that once the ball was out of sight it still existed. This advance in cognitive ability is most accurately described by which of the following terms?

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e. Object permanence

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84. A 3-year-old boy is brought to the physician by his mother, who is concerned about his behavior. She states that he repeatedly is physically aggressive toward a doll. He throws the doll around the room and hits it with his hand while saying, "Bad Johnny." The boy had not displayed this behavior until 3 months previously. The mother mentions that the only change she can think of that occurred approximately 3 months previously is that the boy started in day care. Which of the following is the most likely explanation for this behavior?

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b. The boy is engaging in fantasy play.

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85. A woman brings her 2-year-old (27 month) son to a psychiatrist for evaluation of his language development. She notes that her son can respond to simple directions and can refer to himself by name. He is intelligible approximately 30% of the time, and he can use language to ask for his needs. He does not understand most adjectives. Which of the following most accurately describes the status of this child's language development?

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a. Delayed in the mastery of comprehension; delayed in the mastery of expression.

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86. A woman brings her 3-year-old son to a psychiatrist for evaluation of his cognitive development. She notes that he can understand the concepts of egocentrism ("I am eating this and I want you to eat it too.") as well as that of irreversibility ("I left that store and now I don't know how to get back to it."), but not the idea of reversibility (cannot play a game of checkers backwards). He can count several objects, but does not understand humor or understand good and bad. Which of the following most accurately describes the status of this child's cognitive development?

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d. Normal in cognitive spatial changes development; normal in cognitive achievement development.

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87. A woman brings her 5-year-old daughter in to a psychiatrist for an evaluation of her emotional development. The child can understand the causes of many emotions, but cannot react to the feelings of others correctly. The daughter likes attention and approval, but does not show sensitivity to criticism or care about the feelings of others. Which of the following most accurately describes the status of this child's emotional development?

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c. Normal in the mastery of emotional skills; delayed in the mastery of emotional behavior.

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88. The parents of a 2-year-old child come to see the child's pediatrician because their once happy-go-lucky infant has become oppositional and obstinate. Which Freudian theory best describes the developmental stage this child is in?

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b. Anal

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89. A 5-year-old girl loves her father's attention and becomes irritated with her mother when her mother kisses her father. The child tells her father she wants to marry him when she grows up. Which Freudian theory best describes the developmental stages this child is in?

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d. Oedipal

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90. Which of Freud's theories deals with a model of the mind divided into three regions--conscious, unconscious, and preconscious?

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d. Topographic

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91. Which of the following is the single most significant developmental event of middle childhood (typically defined as between the ages of 6 and 12)?

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b. Going to school

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92. Which of the following best represents the process that transforms the raw unconscious wishes and impulses of a dreamer into images more acceptable to the superego?

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c. Dream work

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93. The illogical, bizarre, and incoherent images that often make up dreams are an example of what type of thinking?

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a. Primary process

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94. A young man is often the object of his friends' jokes because he drops to the floor whenever he is having a good laugh. Which of the following is this man most likely suffering from?

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a. Cataplexy

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95. An 18-year-old man is admitted to the psychiatric unit after his parents find him in his room muttering to himself and convinced that people are going to hurt him. During his stay in the hospital, the patient is frequently found standing in the center of his room with both arms over his head, immobile. The patient can maintain this position for hours at a time. Which of the following best describes this patient's posturing?

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e. Catalepsy

question

96. Benzodiazepines, barbiturates, and many anticonvulsants exert their influence through which of the following types of receptors?

answer

e. γ-Aminobutyric acid (GABA)-ergic

question

97. The observation that levodopa (a drug used to treat Parkinson disease) can cause mania and psychosis in some patients supports which neurochemical theory of psychiatric behavior?

answer

b. Dopamine

question

98. A 24-year-old man with Tourette disorder comes to his psychiatrist because he has just gotten engaged. He states that his father also has Tourette's and he is worried that when he becomes a father he will pass the disorder on to his children. No one on his mother's side of the family has Tourette's that he is aware of. What is the best response for the psychiatrist to give this patient?

answer

d. There is a definite genetic component to Tourette's, but this is multigenic and so difficult to characterize the chances of your children having it. Only 10% of Tourette's patients do not have a relative with it, so you are likely to pass this disorder on.

question

99. A 46-year-old man is being monitored in a sleep study laboratory. After he has been asleep for 90 minutes, his EEG shows low-voltage, random fast activity with sawtooth waves. When awakened during this period, the patient reports that he was dreaming. Which of the following sleep stages was this patient in when awakened?

answer

e. Rapid eye movement (REM)

question

100. After being struck on the head by a four-by-four piece of wood, a previously serious and dependable construction worker starts making inappropriate sexual remarks to his coworkers, is easily distracted, and loses his temper over minor provocations. What part of his brain has most likely been damaged?

answer

e. Frontal lobe

question

101. A young girl who was underweight and hypotonic in infancy is obsessed with food, eats compulsively, and at age 4, is already grossly overweight. She is argumentative, oppositional, and rigid. She has a narrow face, almond-shaped eyes, and a small mouth. Which of the following is the most likely diagnosis?

answer

e. Prader-Willi syndrome

question

102. A 36-year-old moderately retarded man with a long head, large ears, and hyperextensible joints is very shy and starts rocking and flapping his hands when he is upset. His disorder, the second most common single cause of mental retardation, is which of the following?

answer

d. Fragile X syndrome

question

103. Monoamine oxidase inhibitors (MAOIs) exert their influence primarily by which of the following mechanisms?

answer

b. Blocking inactivation of biogenic amines

question

104. A 36-year-old woman is being evaluated in the sleep laboratory. She is noted to have a decreased latency of REM. Which of the following disorders is this woman most likely to be suffering from?

answer

b. Major depression

question

105. A 17-year-old boy is brought to the emergency room by his friends after he "took a few pills" at a party and developed physical symptoms, including his neck twisting to one side, his eyes rolling upward, and his tongue hanging out of his mouth. The patient responds immediately to 50 mg of diphenhydramine intramuscularly with the resolution of all physical symptoms. Which of the following substances is most likely to have caused the symptoms?

answer

e. Haloperidol

question

106. A 52-year-old housewife has gained weight, although she has no increased appetite. She feels tired all the time and does not seem to care about anything anymore. She complains of being cold all the time. On examination, she appears depressed, and her hair is dry and brittle. Which of the following laboratory findings is she likely to display?

answer

c. Elevated thyroid-stimulating hormone (TSH)

question

107. A 32-year-old woman is brought to the emergency room when she complains of chest pain. She is noted to be hypervigilant and anxious, with a pulse of 120 beats per minute and BP of 140/97. She has widely dilated pupils. Her toxicology screen is positive. Which of the following drugs is she most likely to have used?

answer

a. Cocaine

question

108. A 42-year-old woman comes to the psychiatrist with complaints of short-term memory loss. She has lost her way home several times in past weeks. Mini Mental Status Exam scores 18 of 30 points. An MRI shows the loss of brain volume. The patient's mother died of the same disease at age 46. Which of the following genes in this patient (and her mother) are likely to show a mutation on chromosome 14?

answer

a. Presinilin 1

question

109. A 65-year-old woman with a history of chronic alcohol abuse cheerfully greets the resident doctor of her nursing home, whom she has met many times before, and calls him, "My dear friend Jack." The physician explains who he is and tells the patient his name. Two minutes later, when he asks the patient if she knows who he is, she answers with a smile, "Of course, you are my cousin Anthony from New Jersey." What vitamin deficiency can cause this form of amnestic disorder?

answer

c. Thiamine

question

110. A 24-year-old woman comes to the emergency room because she "can't stand the addiction to cocaine anymore." She tells the physician that she has been using cocaine in increasing amounts for the past 2 years, and now her use is totally out of control. Which of the following systems is involved in this drug's capacity for such a high addiction potential in human beings?

answer

c. Dopaminergic

question

111. A 50-year-old man notes that several times per week he has a hallucination of the smell of burning rubber. He is diagnosed with partial complex seizures. Which of the following regions is most likely to show a discharging focus on EEG?

answer

b. Temporal lobe

question

112. During a study on schizophrenia, a sample of children from 12 to 15 years is recruited. Any child already showing signs of schizophrenia is excluded from the sample. Histories are taken to look for a variety of risk factors for developing schizophrenia. Every year thereafter, the children are evaluated to determine how many have developed schizophrenia. Which kind of study is this?

answer

b. Cohort study

question

113. Which of the following findings is associated with non-REM (NREM) sleep?

answer

e. Night terrors

question

114. A 48-year-old man is being treated for a major depression. He complains of depressed mood, anergia, anhedonia, and suicidal ideation with a plan. Which of the following neurochemicals is likely to be abnormal in this patient's CSF?

answer

a. 5-Hydroxyindoleacetic acid (5-HIAA)

question

115. A 34-year-old man comes to see a psychiatrist because he has been fired for constantly being late to his job. The man states that he feels as if he is in danger of contamination from germs and as a result, he must take showers continuously, often for as many as 8 h/day. Which of the following transmitters is thought to be involved in this disorder?

answer

e. Serotonin

question

Questions 116 and 117 116. A 71-year-old man has been treated by a neurologist for Parkinson disease for the past 2 years. One week after his last visit, he called his neurologist, reporting that he suddenly began seeing little people walking all over his furniture. Which of the following is the most likely cause of this hallucination?

answer

c. L-dopa was increased at the last visit.

question

117. The patient above has never previously reported symptoms as described in the vignette. Which of the following is the most appropriate next step in the management of this patient?

answer

a. Reduce the L-dopa

question

118. A 76-year-old man is diagnosed with dementia of the Alzheimer type. Which of the following chemicals has been most commonly associated with this disease?

answer

d. Acetylcholine

question

119. Which of these substances is primarily affected by fluoxetine?

answer

h. Serotonin

question

120. Which of these substances is most associated with the classic antidepressant drugs, as well as venlafaxine, mirtazapine, and bupropion?

answer

c. Norepinephrine

question

121. Which of these substances is most prominently associated with the mediation of the perception of pain?

answer

e. Substance P

question

122. Which of these substances has been shown to stimulate the appetite?

answer

a. Neuropeptide Y

question

123. Nonfluent spontaneous speech, poor auditory comprehension, poor repetition, poor naming.

answer

d. Global

question

124. Fluent spontaneous speech, poor auditory comprehension, poor repetition, poor naming.

answer

b. Wernicke

question

125. Nonfluent spontaneous speech, good auditory comprehension, poor repetition, poor naming.

answer

a. Broca

question

126. Which of the following sites is thought to be significant for formation and storage of immediate and recent memories?

answer

d. Hippocampus

question

127. A 54-year-old man is a chronic alcoholic. He has been diagnosed with Korsakoff syndrome (a severe inability to form new memories and a variable inability to recall remote memories). Where in the brain is the damage causing this memory loss likely located?

answer

b. Mammillary bodies

question

128. A 35-year-old man presents to his physician with a slowly developing difficulty of movement and thinking. The patient tells the physician that his father had similar problems. His wife notes that the patient appears depressed and apathetic. On examination, the patient has involuntary choreiform movements of his face, hands, and shoulders. Which of the following areas of the brain is likely to show atrophy with this disease?

answer

a. Caudate nucleus

question

129. A 58-year-old man has a brain lesion that causes him to feel euphoric, laugh uncontrollably, and joke and make puns. Where is this brain lesion most likely located?

answer

b. Right prefrontal cortex

question

130. A 28-year-old man with a 6-month history of symptoms is noted to have disinhibition, lability, and euphoria. He is also noted to have a lack of remorse. Which area of the man's brain is likely to be dysfunctional?

answer

a. Orbitofrontal region of frontal lobe

question

131. A 44-year-old man has had a traumatic injury to his brain. Since the accident, he has appeared inattentive and undermotivated. He tends to linger on trivial thoughts and echoes the examiner's questions. Which area of the man's brain is likely to have been traumatized?

answer

b. Dorsolateral region of frontal lobe

question

132. A 48-year-old man with Huntington disease experiences irregular, involuntary spasmodic movements of his limbs and facial muscles, as well as psychosis. In a postmortem autopsy, which structure in his brain will likely be markedly shrunken?

answer

e. Caudate nucleus

question

133. A 5-year-old boy is brought to the psychiatrist because he has difficulty paying attention in school. He fidgets and squirms and will not stay seated in class. It is noted that at home he talks excessively and has difficulty waiting for his turn. His language and motor skills are appropriate for his age. Which of the following is the most likely diagnosis?

answer

b. Attention-deficit hyperactivity disorder (ADHD)

question

134. A 4-year-old girl is brought to her pediatrician because her parents think she does not seem to be "developing normally." The girl's mother states that her daughter seemed normal for at least the first 2 to 3 years of her life. She was walking and beginning to speak in sentences. She was able to play with her mother and older sister. The mother has been noticing that over the past 2 months her daughter has lost these previously acquired abilities. She will no longer play with anyone else and has stopped speaking entirely. She has lost all bowel control, when previously she had not needed a diaper for at least a year. Which of the following is the most likely diagnosis?

answer

b. Childhood disintegrative disorder

question

135. The parents of an 8-year-old boy with a normal IQ are concerned because he is a very slow reader and does not appear to understand what he reads. When the boy reads aloud, he misses words and changes the sequence of the letters. They also note that he has problems with spelling, though he is otherwise quite creative in his ability to write stories. On examination, the child displays verbal language defects as well, though primarily he communicates clearly. His hearing and vision are normal and he has no trouble with motor skills. Which of the following is the most likely diagnosis for this child?

answer

b. Dyslexia

question

136. For the past 3 months, a 15-year-old girl has had to turn her light on and off 23 times at exactly 10:30 PM before she can go to bed. She can spend from 1 to 2 hours on this ritual because she has to start again if she is interrupted or loses count. She is upset if the position or the order of the objects she has on her desk is changed even slightly and cannot stop worrying about her family's safety. The girl knows that this behavior is not "normal" and is concerned and unhappy about it. In conjunction with pharmacologic treatment, which of the following therapies has been proven effective for this disorder?

answer

d. Cognitive-behavioral therapy

question

137. A 13-year-old boy is brought to the emergency room by his parents after he set fire to their home. He has been seen in the emergency room on multiple occasions for a variety of symptoms, including suicidality, homicidality, uncontrollable tantrums, and pica. Of those symptoms, which is most commonly seen by psychiatrists in the emergency room in children under the age of 12?

answer

b. Suicidality

question

138. A 5-year-old is being evaluated for ADHD. He has a past history of failure to thrive and he is still at the 15th percentile for weight and height. The evaluator notices that he has unusually small eyes with short palpebral fissures, as well as a thin upper lip with a smooth philtrum. Which substance did his mother most likely abuse during pregnancy?

answer

d. Alcohol

question

139. A 7-year-old boy avoids sleepovers because he wets his bed one to two times per week and is afraid his friends would tease him. He has never achieved a year-long period of dryness throughout the night. A physiologic work-up shows no evidence of an organic cause for this problem, and there is no evidence of a psychiatric disorder in any other category. Which of the following treatments is likely to be effective and should be tried first?

answer

c. Classic conditioning with a bell-and-pad apparatus

question

140. A 13-year-old girl grunts and clears her throat several times in an hour, and her conversation is often interrupted by random shouting. She also performs idiosyncratic, complex motor activities such as turning her head to the right while she shuts her eyes and opens her mouth. She can prevent these movements for brief periods of time, with effort. Which of the following is the most appropriate treatment for this disorder?

answer

d. Haloperidol

question

141. A 6-year-old boy has been diagnosed with ADHD and started on Ritalin. Which of the following serious side effects should the child psychiatrist warn the boy's parents about?

answer

a. Tics

question

142. Every morning on school days, an 8-year-old girl becomes tearful and distressed and claims she feels sick. Once in school, she often goes to the nurse, complaining of headaches and stomach pains. At least once a week, she misses school or is picked up early by her mother due to her complaints. Her pediatrician has ruled out organic causes for the physical symptoms. The child is usually symptom free on weekends, unless her parents go out and leave her with a babysitter. Which of the following is the most likely diagnosis?

answer

a. Separation anxiety disorder

question

143. A 1-year-old girl has been hospitalized on numerous occasions for periods of apnea. Each time, her mother called an ambulance after her daughter had stopped breathing suddenly. All work-ups in the hospital have been negative, and the patient has never had an episode in front of anyone but her mother. The patient's mother seems very involved with the child and the staff on the unit, and she does not seem hesitant about consenting to lab tests on her daughter, even if the tests are invasive. Which of the following statements is true about the disorder described in this case?

answer

c. It constitutes a form of child abuse

question

144. A social worker makes a routine visit to a 3-year-old boy who has just been returned to his biological mother after spending 3 months in foster care as a result of severe neglect. The child initially appears very shy and clings fearfully to his mother. Later on, he starts playing in a very destructive and disorganized way. When the mother tries to stop him from throwing blocks at her, he starts kicking and biting. The mother becomes enraged and starts shouting. Which of the following is the most likely diagnosis for this child?

answer

c. Reactive attachment disorder

question

145. A first-grade teacher is concerned about a 6-year-old girl in her class who has not spoken a single word since school started. The little girl participates appropriately in the class activities and uses gestures and drawings and nods and shakes her head to communicate. The parents report that the little girl talks only in the home and only in the presence of her closest relatives. Which of the following is the most likely diagnosis?

answer

e. Selective mutism

question

146. A 4-year-old boy is brought to the physician by his parents because he experiences episodes of waking in the middle of the night and screaming. The parents state that when they get to the boy's room during one of these episodes, they find him in his bed, thrashing wildly, his eyes wide open. He pushes them away when they try to comfort him. After 2 minutes, the boy suddenly falls asleep, and the next day he has no memory of the episode. Which of the following medications should be the first choice to treat this disorder?

answer

b. Diazepam

question

147. A 14-year-old boy is brought to the physician because he told his mother he wished he were dead. He has been irritable for the past several weeks, and has been isolating himself in his room, avoiding his friends. He has been complaining of general aches and pains as well. Which of the following statements is true about this disorder?

answer

d. Psychotic symptoms are common.

question

148. A 12-year-old boy is brought to the psychiatrist because his mother says the boy is driving her "nuts." She reports that he constantly argues with her and his father, does not follow any of the house rules, and incessantly teases his sister. She says that he is spiteful and vindictive and loses his temper easily. Once he is mad, he stays that way for long periods of time. The mother notes that the boy started this behavior only about 1 year previously. While she states that this behavior started at home, it has now spread to school, where his grades are dropping because he refuses to participate. The patient maintains that none of this is his fault--his parents are simply being unreasonable. He denies feeling depressed and notes that he sleeps well through the night. Which of the following is the most likely diagnosis?

answer

a. ODD

question

149. A 5-year-old boy shows no interest in other children and ignores adults other than his parents. He spends hours lining up his toy cars or spinning their wheels but does not use them for "make-believe" play. He rarely uses speech to communicate, and his parents state that he has never done so. Physical examination indicates that his head is of normal circumference and his gait is normal. Which of the following is the most likely diagnosis for this boy?

answer

d. Autism

question

150. A 15-year-old boy is arrested for shooting the owner of the convenience store he tried to rob. He has been in department of youth services custody several times for a variety of crimes against property, possession of illegal substances, and assault and battery. He is cheerful and unconcerned during the arrest, more worried about losing his leather jacket than about the fate of the man he has injured. Which of the following is the most likely diagnosis in this case?

answer

d. Conduct disorder

question

151. For the past 10 years, the memory of a 74-year-old woman has progressively declined. Lately, she has caused several small kitchen fires by forgetting to turn off the stove, she cannot remember how to cook her favorite recipes, and she becomes disoriented and confused at night. She identifies an increasing number of objects as "that thing" because she cannot recall the correct name. Her muscle strength and balance are intact. Which of the following is the most likely diagnosis?

answer

d. Alzheimer disease

question

152. A 70-year-old man with a dementing disorder dies in a car accident. During the previous 5 years, his personality had dramatically changed and he had caused much embarrassment to his family because of his intrusive and inappropriate behavior. Pathological examination of his brain shows frontotemporal atrophy, gliosis of the frontal lobes' white matter, characteristic intracellular inclusions, and swollen neurons. Amyloid plaques and neurofibrillary tangles are absent. Which of the following is the most likely diagnosis?

answer

b. Pick disease

question

153. A 24-year-old previously healthy man is brought to the emergency room after he began yelling that people on the bus were out to hurt him. In the emergency room, he is agitated, hypervigilant, and anxious. He is unable to give much history other than to say that he is a graduate student and nothing like this has ever happened before. Which of the following is the most likely cause of this behavior?

answer

e. Cocaine intoxication

question

154. An emaciated and lethargic 16-year-old girl arrives at the emergency room. Her blood pressure is 75/50, her heart rate is 52 beats per minute, her potassium is 2.8 meq/L, and her bicarbonate is 40 meq/L. The girl's parents report that she has lost 35 lb in 3 months but is still convinced that she is overweight. She eats only very small amounts of low-calorie food, and she runs 2 to 3 hours every day. What other activities is this patient most likely to have engaged in?

answer

c. Purging

question

155. A 69-year-old woman slips on the ice and hits her head on the pavement. During the following 3 weeks, she develops a persistent headache, is increasingly distractible and forgetful, and becomes fearful and disoriented at night. Which of the following is the most likely cause of these changes?

answer

a. Subdural hematoma

question

156. A 43-year-old man is admitted to the neurology service after he went blind suddenly on the morning of admission. The patient does not seem overly concerned with his sudden lack of vision. The only time he gets upset during the interview is when he is discussing his mother's recent death in Mexico--he was supposed to bring his mother to the United States, but did not because he had been using drugs and did not save the necessary money. Physical examination is completely negative. Which of the following is the most likely diagnosis?

answer

a. Conversion disorder

question

157. A 76-year-old woman was admitted to the hospital after she was found lying on the floor of her bedroom by her daughter. In the hospital, the patient was found to be incoherent. She was also hypervigilant and had disorganized thoughts. The woman's medications before hospitalization included digoxin and a benzodiazepine which has been recently started because the patient had been complaining of insomnia. What is the most likely diagnosis?

answer

b. Delirium secondary to substance intoxication

question

158. A 24-year-old man smells burnt rubber, then turns his head and upper body to the right, makes chewing movements, and fumbles with his clothes. During the episode, which lasts 1 minute, he appears dazed. Which of the following is the most likely diagnosis?

answer

e. Partial complex seizure

question

159. A 55-year-old man comes to the physician with the chief complaint of daytime drowsiness. He states that although he goes to bed at 10 PM and doesn't get up until 6 AM, he is chronically tired and must take naps during the day. He wakes up in the morning with a headache and a dry mouth. His wife states that he snores loudly. Which of the following is the most likely diagnosis?

answer

a. Obstructive sleep apnea

question

160. A 28-year-old woman is a patient of the internal medicine service, being treated for diabetic ketoacidosis. The attending physician consults the psychiatric service because the patient is refusing to learn how to measure her blood glucose levels, and the physicians note that she is "difficult to deal with." The patient states, and can demonstrate that she understands the reasons for monitoring her blood glucose levels and, further, is not afraid of the needle sticks necessary to draw her blood for testing. Which of the following is the most likely reason for this patient's noncompliance?

answer

b. The patient is experiencing a negative transference to her physician.

question

161. A 24-year-old woman is hospitalized after a suicide gesture during which she superficially slashed both her wrists. At the team meeting 3 days later, the male resident argues that the patient has been doing quite well, seems to be responding to therapy, and should be allowed to leave on a pass. The nursing staff angrily argues that the resident is showing favoritism to the patient, and because of her poor compliance with the unit rules, she should not be allowed out. The resident insists the nurses are being punitive. The defense mechanism being used by the patient in this scenario is a feature of which of the following personality disorders?

answer

c. Borderline

question

162. A 45-year-old woman, who has been on chronic steroid treatment for her asthma, has thin arms and legs but has a large amount of fat deposited on her abdomen, chest, and shoulders. Her skin is thin and atrophic, and she bruises easily. She has purple striae on her abdomen. Physical examination shows elevated blood pressure and laboratory tests show decreased glucose tolerance. Which of the following psychiatric conditions is the most likely diagnosis?

answer

c. Substance-induced mood disorder

question

163. A 69-year-old man with a diagnosis of delirium has symptoms of psychosis which include: frightening auditory and visual hallucinations and paranoid delusions. Which of the following medications should be chosen first for this man's symptoms?

answer

a. Haloperidol

question

164. A 34-year-old man recurrently perceives the smell of rotten eggs. This kind of hallucination is most commonly seen in patients with which of the following diagnoses?

answer

d. Partial complex seizures

question

165. A 40-year-old woman's cognitive functions have progressively deteriorated for several years, to the point where she needs nursing home-level care. She is depressed, easily irritated, and prone to aggressive outbursts, a dramatic change from her premorbid personality. She also presents with irregular, purposeless, and asymmetrical movements of her face, limbs, and trunk, which worsen when she is upset and disappear in sleep. Her MRI shows atrophy of the caudal nucleus and the putamen. Which of the following is the most likely diagnosis of this patient?

answer

c. Huntington disease

question

166. A 37-year-old mildly retarded man with trisomy 21 syndrome has been increasingly forgetful. He makes frequent mistakes when counting change at the grocery store where he has worked for several years. In the past, he used to perform this task without difficulty. He often cannot recall the names of common objects, and he has started annoying customers with his intrusive questions. Which of the following is the most likely diagnosis of this patient?

answer

c. Alzheimer disease

question

167. A 72-year-old retired English professor with a long history of hypertension has been having difficulties with tasks he used to find easy and enjoyable, such as crossword puzzles and letter writing, because he cannot remember the correct words and his handwriting has deteriorated. He has also been having difficulty remembering the events of previous days and he moves and thinks at a slower pace. These symptoms have been progressing slowly in a step-wise fashion over time. Subsequently, he develops slurred speech. Which of the following is the most likely diagnosis?

answer

a. Multi-infarct dementia

question

168. A previously healthy 60-year-old man undergoes a corneal transplant. Three months later, he is profoundly demented, demonstrates myoclonic jerks on examination, and has an EEG that shows periodic bursts of electrical activity superimposed on a slow background. Which of the following is the most likely diagnosis?

answer

c. Creutzfeldt-Jakob disease

question

169. A 53-year-old man is admitted to the cardiac intensive care unit after a myocardial infarction. The day after he is admitted, when the physician enters the room, the patient loudly declares that he "feels fine" and proceeds to get down on the floor to demonstrate this assertion by doing pushups. Once persuaded to get back into bed, the patient becomes angry about the poor food quality and feels that only the "most qualified" specialist in the hospital should be treating him because he is, after all, the CEO of his own company. The patient's wife notes that this demanding behavior and haughty attitude are not unusual for him. Which of the following psychiatric diagnoses is most likely for this patient?

answer

c. Narcissistic personality disorder

question

Questions 170 to 171 170. A 22-year-old college student comes to the physician with the complaint of shortness of breath during anxiety-provoking situations, such as examinations. She also notes perioral tingling, carpopedal spasms, and feelings of derealization at the same time. All of the symptoms pass after the anxiety over the situation has faded. The episodes have never occurred "out of the blue." Which of the following is the most likely diagnosis?

answer

c. Hyperventilation

question

171. Which of the following treatments should the physician suggest first for the patient in the vignette above?

answer

c. Rebreathe into a paper bag during the episode

question

172. A 25-year-old woman is brought to the physician by her boyfriend after he noticed a change in her personality over the preceding 6 months. He states that she frequently becomes excessively preoccupied with a single theme, often religious in nature. She was not previously a religious person. He also notes that she often perseverates on a theme while she is speaking, and that she is overinclusive in her descriptions. Finally, he notes that while previously the two had a satisfying sexual life, now the patient appears to have no sex drive whatsoever. The physician finds the patient to be very emotionally intense as well. Physical examination was normal. Which of the following is the most likely diagnosis?

answer

b. Temporal lobe epilepsy

question

173. A 23-year-old man comes to the physician with the complaint that his memory has worsened over the past 2 months and that he has difficulty concentrating. He has lost interest in his friends and his work. He has difficulty with abstract thoughts and problem solving. He has also felt depressed. MRI scan shows parenchymal abnormalities. Which of the following is the most likely diagnosis?

answer

c. HIV-related dementia

question

Questions 174 to 175 174. A 37-year-old alcoholic is brought to the emergency room after he was found unconscious in the street. He is hospitalized for dehydration and pneumonia. While being treated, he becomes acutely confused and agitated. He cannot move his eyes upward or to the right, and he is ataxic. Which of the following is the most likely diagnosis?

answer

d. Wernicke encephalopathy

question

175. Which of the following is the most appropriate treatment for the patient in the vignette above?

answer

e. Thiamine

question

176. A 65-year-old woman is brought to the physician because she has become easily distractible, apathetic, and unconcerned about her appearance. She has trouble remembering familiar words and locations, and she experiences urinary incontinence. On physical examination, her gait is seen to be ataxic. When copying a complex picture, she makes many mistakes. The patient most likely has which of the following disorders?

answer

e. Normal-pressure hydrocephalus

question

Questions 177 to 178 177. A 43-year-old woman comes to the emergency room with a temperature of 38.3°C (101°F) and a large suppurating ulcer on her left shoulder. This is the third such episode for this woman. Her physical examination is otherwise normal, except for the presence of multiple scars on her abdomen. Which of the following is the most likely diagnosis?

answer

d. Factitious disorder

question

178. Which of the following etiologies is most likely underlying the behavior of the woman in the vignette above?

answer

a. Primary gain

question

179. A 26-year-old man comes to the emergency room with the chief complaint of suicidal ideation. He is admitted to the psychiatric ward, where he is noncompliant with all treatment regimens and does not show any psychiatric symptoms other than his insistence that he is suicidal. It is subsequently discovered that he is wanted by the police, who have a warrant for his arrest. Which of the following best describes this behavior?

answer

b. Secondary gain

question

Questions 180 to 181 180. A 32-year-old woman who has a chronic psychiatric disorder, multiple medical problems, and alcoholism comes to the physician because her breasts have started leaking a whitish fluid. Which of the following is the most likely cause of this symptom?

answer

a. Haloperidol

question

181. Which of the following endogenous substances is likely to have caused this phenomenon from the vignette above?

answer

d. Prolactin

question

182. A 3-year-old child is brought to the emergency room by his parents after they found him having a generalized seizure at home. The child's breath smells of garlic, and he has bloody diarrhea, vomiting, and muscle twitching. Which of the following poisons is it likely that this child has encountered?

answer

c. Arsenic

question

Questions 183 to 184 183. A 34-year-old woman comes to the physician with the chief complaint of abdominal pain. She states that she has been reading on the internet and is convinced that she has ovarian cancer. She says that she is particularly concerned because the other physicians she has seen for this pain have all told her that she does not have cancer, and she has been having the pain for over 8 months. She reports that she has undergone pelvic examinations, ultrasounds, and other diagnostic work-ups, all of which have been negative. She tells the physician that she is initially reassured by the negative tests, but then the pain returns and she becomes convinced that she has cancer again. She notes that she has taken so much time off from work in the past 8 months that she has been reprimanded by her boss. Which of the following is the most likely diagnosis?

answer

d. Hypochondriasis

question

184. Which of the following courses of action is most likely to be helpful in the case of the woman in the vignette above?

answer

c. Have the patient see a primary care physician at regular intervals

question

185. A man given a sugar pill for mild pain reports that 15 minutes later the pain has completely resolved. Which of the following conclusions is most appropriate about this occurrence?

answer

d. The man is demonstrating a placebo response.

question

186. A 53-year-old woman has consumed over 1 pint of bourbon per day for the past 24 years. She presents with severe cognitive deficits and is diagnosed with Korsakoff's syndrome. Which of the following is she most likely to display on mental status examination?

answer

a. Impaired recent memory and anterograde amnesia

question

187. A 55-year-old man comes to the physician with the chief complaint of weight loss and a depressed mood. He feels tired all the time and is no longer interested in the normal activities he previously enjoyed. He feels quite apathetic overall. He has also noticed that he has frequent, nonspecific abdominal pain. Which of the following diagnoses needs to be ruled out for this man?

answer

b. Pancreatic carcinoma

question

188. A 15-year-old girl develops generalized tonic-clonic seizures after a brain injury. She is started on valproic acid and is well controlled for the next 3 years. She leaves for college at 18, and the seizures are noted to dramatically increase in frequency, though her valproate levels remain therapeutic. If administered within 20 minutes after one of these episodes, which of the following tests may help in the differential diagnosis of seizure versus pseudoseizure?

answer

a. Prolactin level

question

189. Which of the following is the most common cause of delirium in the elderly?

answer

d. Use of multiple medications

question

190. A 61-year-old woman comes to the physician with a 6-month history of mild memory loss. She also has had mild-moderate difficulty with calculations which she had previously been able to perform without difficulty. Physical examination and laboratory tests were all within normal limits. Which medication is indicated and should be a first choice for therapy in this case?

answer

e. Donepezil

question

191. A 52-year-old man undergoes a successful mitral valve replacement. He is sent to the intensive care unit to recover. The day after the surgery, he appears irritable and restless. Hours later he is agitated, disoriented, hypervigilant, and uncooperative. This agitation alternates with periods of somnolence. Which of the following is most likely to be helpful?

answer

c. Modification of environment

question

192. A 23-year-old woman comes to the physician with the chief complaint of a depressed mood for 6 months. She states that she has felt lethargic, does not sleep well, and has decreased energy and difficulty concentrating. She notes that she has gained over 15 lb without attempting to do so, and seems to bruise much more easily than previously. On physical examination, she is noted to have numerous purple striae on her abdomen, proximal muscle weakness, and a loss of peripheral vision. A brain tumor is found on MRI. In which of the following areas of the brain was this tumor most likely found?

answer

d. Pituitary

question

193. A 34-year-old man comes to the physician with the chief complaint of new-onset visual hallucinations for 1 month. He states that he sees flashing lights and movement when he knows that there is no one in the room with him. He also complains of a headache that occurs several times per week and is dull and achy in nature. Physical examination reveals papilledema and a homonymous hemianopsia. A brain tumor is found on MRI. In which of the following areas of the brain is this tumor most likely found?

answer

c. Occipital lobe

question

194. A 26-year-old man comes to the physician with the chief complaint that he has been uncharacteristically moody and irritable. On several occasions his wife has noted that he has had angry outbursts directed at the children and that they were so severe that she had to step in between him and them. He states that he has "spells" in which he smells the odors of rotten eggs and burning rubber. During this time he feels disconnected from his surroundings, as if he were in a dream. A brain tumor is found on MRI. In which of the following areas of the brain is this tumor most likely found?

answer

d. Temporal lobe

question

195. A 43-year-old man comes to the physician with the chief complaint of nervousness and excitability for 3 months. He states that he feels this way constantly and that this is a dramatic change for his normally relaxed personality. He notes that on occasion he becomes extremely afraid of his own impending death, even when there is no objective evidence that this would occur. He notes that he has lost 20 lb and frequently has diarrhea. On mental status examination, he is noted to have pressured speech. On physical examination, he is noted to have a fine tremor and tachycardia. Which of the following disorders is this patient most likely to have?

answer

a. Hyperthyroidism

question

196. Nonepileptic seizures

answer

b. Prolactin

question

197. Neuroleptic malignant syndrome

answer

d. CPK

question

198. Hepatic encephalopathy

answer

i. Serum ammonia

question

199. Tertiary syphilis

answer

h. Venereal Disease Research Laboratory (VDRL)

question

200. Pheochromocytoma

answer

g. Urine vanillylmandelic acid (VMA)

question

201. A 28-year-old woman comes to the physician requesting genetic counseling. Her father has been diagnosed with Huntington disease. What is this woman's risk of developing this disease?

answer

a. 1 in 2.

question

202. Which of the following is the most common cause of dementia?

answer

b. Alzheimer disease

question

203. A 32-year-old man is admitted to the hospital after he is hit by a car and breaks his femur. Three days into his hospital stay, he tells the nurse that he is repeatedly hearing the voice of his mother telling him to protect himself from danger. He also notes that he sees movement out of the corners of his eyes. He states that these things have never happened to him previously. His vital signs are BP, 160/92; respirations, 12 breaths per minute; pulse, 110 beats per minute; and temperature, 38°C (100.4°F). Which of the following is the most likely diagnosis for this patient?

answer

a. Delirium tremens

question

204. A 56-year-old retired boxer is brought to the physician by his wife because his memory is "not what it used to be." On examination, he is noted to have a moderately severe cognitive impairment. He shows little facial expression and he walks with small, rigid steps. Which of the following is the most likely cause of his disorder?

answer

b. Chronic trauma

question

205. A 24-year-old man with chronic schizophrenia is brought to the emergency room after his parents found him in his bed and were unable to communicate with him. On examination, the man is confused and disoriented. He has severe muscle rigidity and a temperature of 39.4°C (103°F). His blood pressure is elevated, and he has a leucocytosis. Which of the following is the best first step in the pharmacologic treatment of this man?

answer

c. Bromocriptine

question

206. A 54-year-old man with a chronic mental illness seems to be constantly chewing. He does not wear dentures. His tongue darts in and out of his mouth, and he occasionally smacks his lips. He also grimaces, frowns, and blinks excessively. Which of the following disorders is most likely in this patient?

answer

c. Tardive dyskinesia

question

207. A 58-year-old woman with a chronic mental disorder comes to the physician with irregular choreoathetoid movements of her hands and trunk. She states that the movements get worse under stressful conditions. Which of the following medications is most likely to have caused this disorder?

answer

c. Perphenazine

question

Questions 208 to 211 208. A 19-year-old woman is brought to the emergency room by her roommate after the patient told her that "the voices are telling me to kill the teacher." The roommate states the patient has always been isolative and "odd" but for the past 2 weeks she has been hoarding food, talking to herself, and appearing very paranoid. Which of the following tests are likely to be abnormal in this patient?

answer

e. All of these tests may be abnormal.

question

209. In the patient in the above vignette, which of the following features would be indicative of a good prognosis with this disease?

answer

d. Family history of mood disorders

question

210. The patient in question 208 becomes very agitated in the emergency room, screaming that the nurses were there to kill her and that she had to escape. She tried to strike one of the nurses before being restrained. Which of the following treatment options is recommended first?

answer

a. Haloperidol and lorazepam IM

question

211. The patient in the above vignette was admitted and started on a daily dose of fluphenazine. After discharge from the hospital, she was kept on a low dose of the medication for 6 weeks. She showed only a minimal response to the drug, even after it was raised to a moderate dosage level. Which of the following is the next therapeutic step?

answer

e. Give a low dose of olanzapine

question

212. A 24-year-old woman comes to the emergency room with the chief complaint that "my stomach is rotting out from the inside." She states that for the last 6 months she has been crying on a daily basis and that she has decreased concentration, energy, and interest in her usual hobbies. She has lost 25 lb during that time. She cannot get to sleep, and when she does, she wakes up early in the morning. For the past 3 weeks, she has become convinced that she is dying of cancer and is rotting on the inside of her body. Also, in the past 2 weeks she has been hearing a voice calling her name when no one is around. Which of the following is the most likely diagnosis?

answer

e. Major depression with psychotic features

question

213. A 19-year-old man is brought to the physician by his parents after he called them from college, terrified that the Mafia was after him. He reports that he has eaten nothing for the past 6 weeks other than canned beans because "they are into everything--I can't be too careful." He is convinced that the Mafia has put cameras in his dormitory room and that they are watching his every move. He occasionally hears the voices of two men talking about him when no one is around. His roommate states that for the past 2 months the patient has been increasingly withdrawn and suspicious. Which of the following is the most likely diagnosis?

answer

c. Schizophreniform disorder

question

214. A 36-year-old woman is brought to the psychiatrist by her husband because for the past 8 months she has refused to go out of the house, believing that the neighbors are trying to harm her. She is afraid that if they see her they will hurt her, and she finds many small bits of evidence to support this. This evidence includes the neighbors' leaving their garbage cans out on the street to try to trip her, parking their cars in their driveways so they can hide behind them and spy on her, and walking by her house to try to get a look into where she is hiding. She states that her mood is fine and would be "better if they would leave me alone." She denies hearing the neighbors or anyone else talk to her, but is sure that they are out to "cause her death and mayhem." Which of the following is the most likely diagnosis?

answer

a. Delusional disorder

question

215. A 35-year-old woman has lived in a state psychiatric hospital for the past 10 years. She spends most of her day rocking, muttering softly to herself, or looking at her reflection in a small mirror. She needs help with dressing and showering, and she often giggles and laughs for no apparent reason. Which of the following is the most likely diagnosis?

answer

a. Schizophrenia

question

216. A 20-year-old woman is brought to the emergency room by her family because they have been unable to get her to eat or drink anything for the past 2 days. The patient, although awake, is completely unresponsive both vocally and nonverbally. She actively resists any attempt to be moved. Her family reports that during the previous 7 months she became increasingly withdrawn, socially isolated, and bizarre; often speaking to people no one else could see. Which of the following is the most likely diagnosis?

answer

d. Catatonia

question

217. A 21-year-old man is brought to the emergency room by his parents because he has not slept, bathed, or eaten in the past 3 days. The parents report that for the past 6 months their son has been acting strangely and "not himself." They state that he has been locking himself in his room, talking to himself, and writing on the walls. Six weeks prior to the emergency room visit, their son became convinced that a fellow student was stealing his thoughts and making him unable to learn his school material. In the past 2 weeks, they have noticed that their son has become depressed and has stopped taking care of himself, including bathing, eating, and getting dressed. On examination, the patient is dirty, disheveled, and crying. He complains of not being able to concentrate, a low energy level, and feeling suicidal. Which of the following is the most likely diagnosis for this patient?

answer

a. Schizoaffective disorder

question

218. A 47-year-old woman is brought to the emergency room after she jumped off an overpass in a suicide attempt. In the emergency room she states that she wanted to kill herself because the devil had been tormenting her for many years. After stabilization of her fractures, she is admitted to the psychiatric unit, where she is treated with risperidone and sertraline. After 2 weeks she is no longer suicidal and her mood is euthymic. However, she still believes that the devil is recruiting people to try to persecute her. In the past 10 years, the patient has had three similar episodes prior to this one. Throughout this time, she has never stopped believing that the devil is persecuting her. Which of the following is the most appropriate diagnosis for this patient?

answer

b. Schizoaffective disorder

question

219. A 40-year-old woman is arrested by the police after she is found crawling through the window of a movie star's home. She states that the movie star invited her into his home because the two are secretly married and "it just wouldn't be good for his career if everyone knew." The movie star denies the two have ever met, but notes that the woman has sent him hundreds of letters over the past 2 years. The woman has never been in trouble before and lives an otherwise isolated and unremarkable life. Which of the following is the most likely diagnosis?

answer

a. Delusional disorder

question

Questions 220 to 226 220. A 48-year-old woman becomes convinced that her next door neighbor hates her and wants her to move. She states she has evidence, and when asked to explain, tells the psychiatrist that the neighbor gives her "looks," puts excessive junk in her mailbox, and leaves yard clippings on her side of the yard to harass her.

answer

d. Persecutory

question

221. A 62-year-old man is arrested for disturbing people on their way to work by insisting they take his prepared reading materials with them. The topic of the materials was the man's special communications with God and his instructions for following him on a special path to heaven.

answer

b. Grandiose

question

222. A 49-year-old man was arrested for beating up on his wife. He stated he had to punish her for having an affair--which she vehemently denied. The man's wife states to the police that the man has accused her of being interested in many other men over the course of their marriage. He now seems fixated on the topic

answer

c. Jealous

question

223. A 39-year-old woman is arrested for breaking into the compound of a famous television star. She said she knew the star loved her and was giving her special messages to contact him from his weekly show.

answer

a. Erotomanic

question

224. A 19-year-old college student came to his primary care doctor for help with a foul odor he believed he was unintentionally emitting. The student stated that the odor left him socially isolated and that he was miserable about it. The primary care doctor could detect no odor.

answer

e. Somatic

question

225. A 22-year-old college student told his parents that on his plane ride home from college to see them over the holidays, all the seatmates on the plane had been replaced by aliens that were identical doubles to the humans that they had replaced.

answer

g. Unspecified

question

226. A 58-year-old man called the police on his neighbors because he felt they were against him. When asked why, the man explained that the neighbors knew that he was a genius inventor, and they were unhappy about this because his impending fame would disrupt the neighborhood.

answer

f. Mixed

question

227. A 30-year-old man is brought to the emergency room after he was found wandering on the streets with no shoes on in the middle of winter. He is admitted to the inpatient psychiatric unit and stabilized on antipsychotic medication. Looking at past records, his psychiatrist notes that he is repeatedly noncompliant with his medication postdischarge, and each time he relapses within 6 months. Which of the following medications is the best one for this patient to be maintained on?

answer

b. Haloperidol decanoate

question

228. A 26-year-old woman is brought to the emergency room by her husband after she begins screaming that her children are calling to her and becomes hysterical. The husband states that 2 weeks previously, the couple's two children were killed in a car accident, and since that time the patient has been agitated, disorganized, and incoherent. He states that she will not eat because she believes he has been poisoning her food, and she has not slept for the past 2 days. The patient believes that the nurses in the emergency room are going to cause her harm as well. The patient is sedated and later sent home. One week later, all her symptoms remit spontaneously. Which of the following is the most likely diagnosis for this patient?

answer

d. Brief psychotic disorder

question

229. A 28-year-old woman is brought to see a psychiatrist by her mother. The patient insists that nothing is wrong with her, but the mother notes that the patient has been slowly but progressively isolating herself from everyone. She now rarely leaves the house. The mother says she can hear the patient talking to "people who aren't there" while she's in her room. On examination, the patient is noted to have auditory hallucinations and the delusional belief that her mother is going to kick her out of the house so that it can be turned into a theme park. Which of the following is the lifetime prevalence for this disorder?

answer

a. 1%

question

230. A 25-year-old woman is diagnosed with schizophrenia when, after the sudden death of her mother, she begins complaining about hearing the voice of the devil and is suddenly afraid that other people are out to hurt her. Her history indicates that she has also experienced a 3-year period of slowly worsening social withdrawal, apathy, and bizarre behavior. Her family history includes major depression in her father. Which of the following details of her history leads the physician to suspect that her outcome may be poor?

answer

d. She had an insidious onset of her illness.

question

231. A 22-year-old man is brought to the emergency room after he became exceedingly anxious in his college dormitory room, stating that he was sure the college administration was sending a "hit squad" to kill him. He also notes that he can see "visions" of men dressed in black who are carrying guns and stalking him. His thought process is relatively intact, without thought blocking or loose associations. His urine toxicology screen is positive for one of the following drugs. Which drug is the most likely cause of these symptoms?

answer

d. Amphetamines

question

232. A 72-year-old woman is brought to the emergency room by her daughter after she found her mother rummaging in the garbage cans outside her home. The daughter states that the patient has never had any behavior like this previously. On interview, the patient states she sees "martians hiding around her home, and on occasion, hears them too." She also demonstrates a constructional apraxia, with difficulty drawing a clock and intersecting pentagons. All of these symptoms point to a medical cause for this patient's behavior except one. Which symptom is common in patients with a psychiatric cause for their behavior (ie, not a medical cause)?

answer

d. Auditory hallucinations

question

233. Families of patients with schizophrenia, who are overtly hostile and overly controlling, affect the patient in which one of the following ways?

answer

a. Increased relapse rate

question

234. A 62-year-old man with chronic schizophrenia is brought to the emergency room after he is found wandering around his halfway house, confused and disoriented. His serum sodium concentration is 123 meq/L and urine sodium concentration is 5 meq/L. The patient has been treated with risperidone 4 mg/day for the past 3 years with good symptom control. His roommate reports that the patient often complains of feeling thirsty. Which of the following is the most likely cause of this patient's symptoms?

answer

d. Psychogenic polydipsia

question

235. A 23-year-old woman was diagnosed with schizophrenia after a single episode of psychosis (hallucinations and delusions) that lasted 7 months. She was started on a small dose of olanzapine at the time of diagnosis, which resulted in the disappearance of all her psychotic symptoms. She has now been symptom free for the past 3 years. Which of the following treatment changes should be made first?

answer

a. Her olanzapine should be decreased and then stopped if she remains symptom free.

question

236. A 75-year-old man is being cared for in a hospice setting. He has widely spread prostatic carcinoma and is considered terminal. Which of the following psychiatric symptoms are seen in 90% of all terminal patients?

answer

a. Delusions

question

237. A 52-year-old man is seen by a psychiatrist in the emergency room because he is complaining about hearing and seeing miniature people who tell him to kill everyone in sight. He states that these symptoms developed suddenly during the past 48 hours, but that he has had them "on and off" for years. He states that he has never previously sought treatment for the symptoms, but that this episode is particularly bad. He denies the use of any illicit substances. The patient is alert and oriented to person, place, and time. His mental status examination is normal except for his auditory and visual hallucinations. His thought process is normal. His drug toxicology screen is positive for marijuana. He is quite insistent that he needs to be "put away" in the hospital for the symptoms he is experiencing. Which of the following is the most likely diagnosis?

answer

e. Malingering

question

238. A 25-year-old man is brought to the physician after complaining about a visual hallucination of a transparent phantom of his own body. Which of the following specific syndromes is this patient most likely to be displaying?

answer

d. Autoscopic psychosis

question

239. A 40-year-old woman with a history of chaotic interpersonal relationships enters psychoanalytic psychotherapy. She alternates between periods in which she idealizes the therapist and the progress of the therapy and periods of unrelenting anger when she is convinced that the therapist is unhelpful and that the therapeutic work is worthless. Which of the following defense mechanisms is being used by the patient in this scenario?

answer

e. Splitting

question

240. A patient comes to the psychiatrist for treatment of his posttraumatic stress disorder (PTSD), which he developed from his experiences escaping the World Trade center collapse. He is adamantly opposed to taking medications. He chooses EMDR (eye movement desensitization and reprocessing) as his treatment of choice. Which of the following describes this treatment regiment?

answer

e. The patient focuses on the lateral movement of the therapist's finger while maintaining a mental image of the stressful event.

question

241. A 45-year-old man is diagnosed as having diabetes and will require insulin. His physician explains the use of the medication and tells the patient that he will need to be seen at frequent intervals until his glucose levels come under good control. The patient has always been somewhat hostile with the physician, but upon hearing this news, he says angrily, "You doctors are always the same! You always want control--of my time, of my money, and now of my every action!" As far as the physician knows, this patient has never had an unpleasant encounter with a physician before. Which of the following is the most likely explanation for the patient's reaction to his doctor?

answer

b. The patient is experiencing transference to this authority figure

question

Questions 242 and 243 242. A 45-year-old woman comes to the psychiatrist requesting help in coping with her life. The patient states both of her parents have recently been diagnosed with cancer and her husband has just instituted divorce proceedings. She states she feels overwhelmed and anxious, with bouts of crying and panic attacks. Which one of the following therapies should be offered to this patient?

answer

e. Supportive psychotherapy

question

243. In the above patient, which of the following signs or symptoms should push the physician to recommend insight-oriented psychodynamic psychotherapy once the patient's life had returned to a less-stressful state?

answer

b. High tolerance for frustration

question

244. A 32-year-old woman presented to the psychiatric emergency room after a suicide attempt in which she swallowed a bottle of aspirin. On the inpatient unit it was noted that she was stealing needles and injecting feces under her skin to cause infections. She has a long history of multiple surgical procedures for unclear reasons. Which of the following guidelines is most useful for therapy with patients with this disorder?

answer

b. Consider using face-saving behavioral strategies to promote healing.

question

245. What is the most common reason that psychotherapy for personality disorders is so difficult to carry out successfully?

answer

d. The patients often see the source of their problems in others, not themselves.

question

246. Under hypnosis, a woman who was sexually abused by her father throughout most of her childhood sobbingly pleads, "Daddy, please don't hurt me." At the end of the session, she states that she understands better why she always had a strong sense of revulsion when any man touched her. This experience is an example of which of the following?

answer

e. Abreaction

question

247. A patient in psychodynamic therapy has been coming late to the last few sessions and complaining in the sessions that he has nothing to talk about. His therapist points out that up until several weeks ago they were making very rapid progress into uncovering some of the difficult thoughts and feelings the patient had about his parents. What therapeutic principle best exemplifies the recent changes in the patient's behavior?

answer

e. Resistance

question

248. A 24-year-old woman with bulimia joins an eating disorder support group on the advice of her psychiatrist. After years of being deeply ashamed of her disorder and keeping it secret, she is relieved to hear that others in the group have binged and purged as she has. Which of the following terms best describes this phenomenon, which is common in selfhelp groups?

answer

a. Universalization

question

249. A 22-year-old student is in therapy because he has a long history of chaotic interpersonal relationships, episodes of psychosis, and multiple hospitalizations. He has attempted suicide three times, mostly precipitated by his feeling overwhelmed in some social setting. One session, he comes to his therapist greatly upset and anxious because he forgot to study some material that will be on an upcoming examination. The therapist reminds the patient that he has done well on previous examinations and suggests that they spend the session devising a study plan for the time the patient has left before the test. Such an intervention is commonly used in which of the following therapies?

answer

d. Supportive psychotherapy

question

Questions 250 and 251 250. A 37-year-old man comes to the psychiatrist for treatment of a depressed mood. The patient has anhedonia, anergia, decreased concentration, obsessive ruminations of guilt, insomnia, and a 5-lb weight loss over the past 2 weeks. He avoids going out in public secondary to the belief that people won't like him. In the psychiatrist's office, he was helped to verbalize the fact that whenever he met new people, his immediate reaction was to believe that these people could see he was "a loser." This last is a verbalization of which kind of behavior, often seen in patients with this diagnosis?

answer

a. Automatic thought

question

251. In the vignette above, the patient's verbalization that "when people see me they think I'm a loser" is most often used directly in the context of which kind of therapy?

answer

c. Cognitive therapy

question

252. A 36-year-old woman comes to see a psychiatrist with the chief complaint, "I feel like I'm going to die, I get so anxious." She describes occasions when she feels her heart beat faster, and then suddenly she becomes overwhelmed with the notion that she is going to die or go crazy. She notes that she hyperventilates, her fingers and toes tingle, and she feels as if her heart is going to break because it beats so fast. Which of the following should the psychiatrist, a cognitive therapist, urge the patient to do during their visit?

answer

b. Recreate the panic attack

question

253. A 26-year-old man comes to the psychiatrist because he becomes extremely anxious in social situations. He is unable to talk to anyone and experiences sweaty palms and a rapid heartbeat. Which of the following treatment options will provide the most effective and longest lasting results for this patient?

answer

d. Cognitive-behavioral therapy

question

254. A 45-year-old woman comes to a therapist with the chief complaint of feeling depressed. The therapist asks the patient to talk about her experiences, both in daily life and in the past. As the therapy progresses, the patient realizes that much of her depressive emotion comes from her feelings of abandonment as a child, when her mother was hospitalized for a long illness and was thus unavailable. The patient sees the therapist once a week. The therapist uses primarily clarification, confrontation, and interpretation as tools. Which of the following therapies is this patient most likely undergoing?

answer

a. Dynamic psychotherapy

question

255. A patient perceives his analyst as wise, caring, and helpful. During his session, he talks at length about his warm feelings toward the therapist. Which of the following is the most appropriate next step the analyst should take?

answer

e. Ask the patient to explore related feelings he has about the topic.

question

Questions 256 to 262 256. A patient starts complaining of chest pain and coughing whenever her therapist confronts her. She insists, however, that she is not at all distressed or angry.

answer

e. Somatization

question

257. A woman feels jealous and hurt when, at a family gathering, her husband flirts with her younger cousin. She makes a conscious decision to put her feelings aside and to wait for a more appropriate moment to confront her husband and convey her emotions.

answer

g. Suppression

question

258. A young man gets into an argument with his teacher. Although he is very upset, he remains silent as she chastises him severely and calls him a failure as a student. Once he gets home from school, the young man picks a fight with his younger brother over nothing and begins screaming at him.

answer

n. Displacement

question

259. A 34-year-old man is deeply envious of his younger but much more successful brother. Although it is difficult for him to admit, he believes the younger brother was their parents' favorite as well. He tells his friends that his younger brother is envious of his good looks and successes with women, even though there is some evidence that this is not so.

answer

j. Projection

question

260. A 28-year-old woman is in psychotherapy for a long-standing depressed mood and poor self-esteem. One day during the session, the therapist yawns because she is very tired, though she is interested in what the patient has to say. The patient immediately bursts into tears, saying that the therapist must be bored and uninterested in her and must have been so for quite some time.

answer

a. Distortion

question

261. A man who, as a child, was beaten by his parents for every small infraction nonetheless idealizes them and describes them as "good parents who did not spoil their children." He is baffled and angry when he is ordered to start parenting classes after the school nurse reports that his children consistently come to school with bruises.

answer

k. Identification with the aggressor

question

262. A 52-year-old man is hospitalized after a severe myocardial infarction. On the second day in the hospital, when his physician comes by on rounds, the patient insists on jumping out of bed and doing several pushups to show the physician that "they can't keep a good man down--there is nothing wrong with me!"

answer

m. Denial

question

Questions 263 to 265 263. A 24-year-old man comes to the therapist after being discharged from the hospital following treatment for a psychotic episode. The patient is currently stable on antipsychotic medication. He visits the therapist every other week and during the sessions he describes troubles in his relationship with his parents and in finding a job, and his occasional hallucinations. The therapist responds empathically to his difficulties and occasionally makes a suggestion as to how he might handle his job search more effectively.

answer

b. Supportive psychotherapy

question

264. A 22-year-old man comes to the therapist with the chief complaint of incredible anxiety during multiple-choice examinations. He reports that he becomes unable to focus, begins to sweat, and is unable to retrieve the information he knows he has learned. During sessions, the therapist hooks the patient up to a machine that measures galvanic skin response and trains the patient in relaxation techniques.

answer

f. Behavioral therapy

question

265. A 35-year-old woman comes to the therapist because she feels pessimistic about her life and is unable to enjoy her successful job and two healthy children. She has multiple symptoms, including feeling chronically depressed, anxious, phobic, and compulsive. She has a history of childhood sexual abuse. She notes that these problems have been long standing. The therapist teaches the patient relaxation skills and begins to have her talk about her childhood sexual abuse.

answer

h. Eclectic or integrated therapy

question

266. A 48-year-old woman comes to the psychiatrist because she has an overwhelming fear of spiders. She has had this fear her entire life, but it has increased now secondary to living in a wooded area where there are greater numbers of them. She wishes to get rid of this phobia. Which of the following actions should the psychiatrist take next?

answer

d. Have the patient create a hierarchical list of feared situations involving spiders

question

267. A 42-year-old woman comes to the psychiatrist asking for help with recovering a memory from her past. She was in a bad car accident and had become obsessed with knowing whether or not she had seen before impact the car that had hit her. She asked to be treated with hypnosis to recover this memory. Which of the following are relatively contraindicated in the use of hypnosis?

answer

b. The presence of paranoid delusions

question

268. A patient in psychotherapy is always anxious to please. Recently, he stated that he has begun to feel frightened in the presence of the therapist and that he has had fantasies about the analyst attacking him. Subsequently, the patient talks about his father and his lifelong struggle to please him at any cost. After listening to these comments, the therapist says that the patient's fantasies about him appear to be closely connected with the patient's way of relating to his father. The therapist also says that the passive and compliant relationship the patient has with his idealized father may represent a reaction to his fear of his father's retaliation. These comments best represent which kind of therapeutic intervention?

answer

b. Interpretation

question

269. A 29-year-old woman is in psychodynamic psychotherapy for a longstanding inability to have close and meaningful relationships. During her sessions with the therapist, she often comes 10 minutes late or misses sessions altogether. At the beginning of the next session after a session has been missed, the therapist points out this behavior to the patient. These comments best represent which kind of therapeutic intervention?

answer

a. Confrontation

question

270. The parents of a 20-year-old schizophrenic are having difficulty dealing with their son's decline in function. Once a good student with friends and a social life, the son now spends his days barricaded in his room, mumbling to himself, or watching the street with binoculars. Which of the following family interventions would be most helpful in this situation?

answer

a. Teaching the parents about reducing expressed emotions in the family's interactions

question

271. A 27-year-old man comes to the physician with the chief complaint of premature ejaculation. He has been married for 4 months but has been unable to consummate the marriage because of his sexual problem. No organic cause for his premature ejaculation was found on work-up. Which of the following treatments will be most helpful for the man's premature ejaculation?

answer

d. Squeeze technique and stop-and-start technique

question

272. A 49-year-old man comes to the doctor with high blood pressure and anxiety. Preferring to try something other than medication at first, the patient agrees to try another approach. He is attached to an apparatus that measures skin temperature and emits a tone proportional to the temperature. Which of the following techniques is being used with this patient?

answer

e. Biofeedback

question

273. A 45-year-old man, with no prior psychiatric history, comes to see a therapist. He states that for the past 6 weeks he has been unable to sleep well because he is "stuck." He notes that he has been offered a job that is a large step up from his current one and that this is making him very nervous. While he has never seen a therapist before, is very successful at work, and has a good relationship with his wife, he reports that he gets very anxious when thinking about this job. He comments that his father was not so successful in the job market, and perhaps this is why the patient cannot move forward. The therapist agrees with the patient's assessment. What kind of therapy is most likely to be used with this patient?

answer

c. Short-term dynamic psychotherapy

question

274. A high school teacher is respected and loved by both his students and his colleagues because he can easily defuse tense moments with an appropriate light remark and he always seems to be able to find something funny in any situation. Which of the following defense mechanisms is this man using?

answer

d. Humor

question

Questions 275 to 278 275. A young woman with no previous psychiatric history develops an incapacitating fear of driving after being involved in a minor automobile accident.

answer

d. Behavioral therapy

question

276. A 40-year-old, married, successful businessman with a satisfying family life becomes preoccupied with thoughts of becoming involved with a younger woman. He has no prior psychiatric history and no other complaints.

answer

b. Brief individual psychotherapy

question

277. A 16-year-old girl begins acting out sexually and skipping school. These symptoms coincide with the onset of frequent arguments between her parents, who have been threatening marital separation.

answer

e. Family therapy

question

278. An intelligent 25-year-old single woman who has a successful career complains of multiple failed relationships with men, unhappiness, and a wish to sort out her life. A previous experience in individual psychotherapy was somewhat helpful.

answer

a. Psychoanalysis

question

279. A 29-year-old woman comes to a cognitive therapist with a 6-month history of sudden feelings that she is going to die. The patient reports that during these episodes her pulse races, she feels short of breath, and she gets chest pain. She notes that she feels like she is going to die on the spot and therefore has begun to restrict her movement outside the house so that she can remain near a phone in case she needs to call an ambulance. Which of the following treatment interventions should the therapist employ first to begin to help this patient with her problem?

answer

c. Educating the patient about the harmless nature of the physical symptoms experienced during a panic attack

question

280. A physician with a very busy practice feels satisfied and fulfilled when he can make a difference in the lives of his patients. Which of the following defense mechanisms is being used, according to psychoanalytic theory?

answer

b. Altruism

question

281. An 18-year-old girl comes to the psychiatrist because she pulls out her hair in patches when she is anxious or upset. She is taught to make a tight fist whenever she has this impulse rather than pull out her hair. Which of the following techniques is this?

answer

a. Habit reversal training

question

282. A 34-year-old man comes to the psychiatrist complaining of marital problems, which seemed to begin just after the death of his mother. In therapy, it is discovered that the patient had an intensively ambivalent relationship with his mother. However, when he discusses his mother, the patient appears unemotional and detached. Which of the following defense mechanisms is this patient using?

answer

b. Isolation of affect

question

283. A 32-year-old man comes to a therapist with the chief complaint of not being able to have a successful and happy relationship with a woman. During the course of the therapy, it becomes obvious that the patient has deep-seated anger against women, even though he is consciously unaware of it. Around the time that this interpretation is being worked on in therapy, the patient begins to go to bars and drink to excess--something he had not previously done. When confronted about the behavior, he denies that this has anything to do with what is going on in the therapy, though the therapist does not believe this to be true. Which of the following best describes this patient's new behavior?

answer

a. The patient is acting out

question

284. Interpersonal psychotherapy was developed in the 1970s by Gerard Klerman as a time-limited treatment for major depressive disorders. Which of the following does this type of therapy focus on?

answer

b. Current relationships

question

285. A young woman with obsessive-compulsive disorder has suffered from contamination fears for years, and now her hands are raw from so much washing. Her therapist takes her to the bathroom and asks her to touch the toilet seat. Afterward, he stops her from washing her hands. The patient's anxiety rapidly increases, and after a peak, declines. Which of the following is the name of this technique?

answer

a. Exposure

question

286. A 30-year-old woman presents to the psychiatrist with a 2 month history of difficulty in concentrating, irritability, and depression. She has never had these symptoms before. Three months prior to her visit to the psychiatrist, the patient noted that she had experienced a short-lived flulike illness with a rash on her calf, but has noted no other symptoms since then until the mood symptoms began. Her physical examination was within normal limits. Which of the following is the most likely diagnosis?

answer

c. Lyme disease

question

287. Which of the following medications should be used to treat the patient above?

answer

d. Doxycycline

question

Questions 288 and 289 288. A 37-year-old woman comes to the physician with a chief complaint of a depressed mood. The patient states she has anhedonia, anergia, a 10-lb weight loss in the last 3 weeks, and states she "just doesn't care about anything anymore." She also admits to suicidal ideation without intent or plan. Which of the following physiologic disturbances will likely also be found in this patient?

answer

d. Increased phasic REM sleep

question

289. The patient in the case above is started on an SSRI. After 1 week of the medication, no improvement is seen and the dosage is raised to the maximum recommended level. For how many weeks should this new dosage be maintained before determining that the drug trial is unsuccessful if there is no improvement shown?

answer

b. 4 to 5 weeks

question

290. A 25-year-old woman delivers a healthy baby boy by Caesarean section. She notes over the next week that she has become irritable and is not sleeping very well. She worries that her child will die and fantasizes that if the child died, she would kill herself as well. She reports not being able to sleep, and has lost 10 lb within 1 week. Over the course of the following week, she begins to investigate how she might commit suicide and calls a friend to see whether the friend will babysit so that the woman will not be leaving the child alone should this occur. Which of the following is the most likely diagnosis?

answer

a. Postpartum depression

question

291. A 25-year-old man comes to the psychiatrist with a chief complaint of depressed mood for 1 month. His mother, to whom he was very close, died 1 month ago, and since that time he has felt sad and been very tearful. He has difficulty concentrating, has lost 3 lb, and is not sleeping soundly through the night. Which of the following is the most likely diagnosis?

answer

e. Uncomplicated bereavement

question

Questions 292 and 293 292. A 32-year-old woman is brought to the emergency room by the police after she was found standing in the middle of a busy highway, naked, commanding the traffic to stop. In the emergency room she is agitated and restless, with pressured speech and an affect that alternates between euphoric and irritable. Her father is contacted and states that this kind of behavior runs in the family. Which of the following is the most likely diagnosis?

answer

b. Bipolar disorder, manic

question

293. The resident on call decides to start the patient above on a medication to control this disease. The patient refuses the medication, stating that she has taken it in the past and it causes her to be constantly thirsty and break out in pimples and makes her food taste funny. Which of the following medications is being discussed?

answer

d. Lithium

question

294. A 28-year-old woman is diagnosed with bipolar disorder, manic type, when she was hospitalized after becoming psychotic, hypersexual, severely agitated, and unable to sleep. She is started on a medication in the acute phase of her illness. Which of the following medications, recommended for acute use in manic patients, is recommended to be continued on into maintenance therapy?

answer

c. Lithium

question

295. A 30-year-old man comes to the psychiatrist for the evaluation of a depressed mood. He states that at least since his mid-20s he has felt depressed. He notes poor self-esteem and low energy, and feels hopeless about his situation, though he denies suicidal ideation. He states he does not use drugs or alcohol, and has no medical problems. His last physical examination by his physician 1 month ago was entirely normal. Which of the following treatment options should be tried first?

answer

d. Venlafaxine

question

296. A 26-year-old man comes to the physician with the chief complaint of a depressed mood for the past 5 weeks. He has been feeling down, with decreased concentration, energy, and interest in his usual hobbies. Six weeks prior to this office visit, he had been to the emergency room for an acute asthma attack and was started on prednisone. Which of the following is the most likely diagnosis?

answer

b. Substance-induced mood disorder

question

297. What percentage of new mothers is believed to develop postpartum depression?

answer

b. 10% to 15%

question

298. How long after a stroke is a patient at a higher risk for developing a depressive disorder?

answer

e. 2 years

question

299. A 22-year-old college student calls his psychiatrist because for the past week, after cramming hard for finals, his thoughts have been racing and he is irritable. The psychiatrist notes that the patient's speech is pressured as well. The patient has been stable for the past 6 months on 500 mg of valproate twice a day. Which of the following is the most appropriate first step in the management of this patient's symptoms?

answer

c. Prescribe clonazepam 1 mg qhs

question

300. A 24-year-old woman, 5 days after delivery of a normal, full-term infant, is brought to the obstetrician because she is so tearful. She states that her mood is quite labile, often changing within minutes. She has trouble sleeping, both falling asleep and awakening early. She notes anhedonia, stating she doesn't enjoy "much of anything" right now. Which of this patient's symptoms point preferentially to a postpartum depression?

answer

e. Anhedonia

question

301. A 28-year-old woman sees her physician with the chief complaint of a depressed mood. She also notes that she is sleeping more than usual--up to 14 hours per night--but does not feel rested and that she feels tired and fatigued all the time. She has gained 14 lb in the last month, something that she is very unhappy about, but she says that she seems to have such a craving for sweets that the weight gain seemed inevitable. Which of the following is the most likely diagnosis?

answer

d. Seasonal affective disorder

question

302. A 38-year-old woman with bipolar disorder has been stable on lithium for the past 2 years. She comes to her psychiatrist's office in tears after a 2-week history of a depressed mood, poor concentration, loss of appetite, and passive suicidal ideation. Which of the following is the most appropriate next step in the management of this patient?

answer

d. Start an antidepressant and continue the lithium

question

303. A 27-year-old woman has been feeling blue for the past 2 weeks. She has little energy and has trouble concentrating. She states that 6 weeks ago she had been feeling very good, with lots of energy and no need for sleep. She says that this pattern has been occurring for at least the past 3 years, though the episodes have never been so severe that she couldn't work. Which of the following is the most likely diagnosis?

answer

c. Cyclothymic disorder

question

304. A 19-year-old woman comes to the psychiatrist for a history of anger and irritability, which occurs on monthly on an average. During this time the patient also reports feeling anxious and "about to explode," which alternates rapidly with crying spells and angry outbursts. The patient notes during this time she can't concentrate and sleeps much more than she usually needs to do. During the several days these symptoms last, the patient must skip most of her classes because she cannot function. Which of the following is the most likely diagnosis?

answer

c. Premenstrual dysphoric disorder

question

305. A 42-year-old woman sees her physician because she has been depressed for the past 4 months. She also notes that she has gained 20 lb without trying to. She notes that she does not take pleasure in the activities that she once enjoyed and seems fatigued most of the time. These symptoms have caused the patient to withdraw from many of the social functions that she once enjoyed. The physician diagnoses the patient with hypothyroidism and starts her on thyroid supplementation. Six weeks later, the patient's thyroid hormone levels have normalized, but she still reports feeling depressed. Which of the following is the most appropriate next step in the management of this patient?

answer

c. Start the patient on an antidepressant medication

question

306. A 54-year-old man sees a physician complaining of a depressed mood and inability to sleep for the past 3 weeks. He tells the physician that in the past when he has had similar episodes, he was placed on a monoamine oxidase inhibitor, which proved effective. The physician diagnoses the patient with major depression and agrees to use an MAOI. Which of the following foods must be completely avoided by this patient while on this medication?

answer

d. Cheddar cheese

question

307. A 64-year-old man is admitted to the psychiatric unit after an unsuccessful suicide attempt. Following admission, he attempts to cut his wrists three times in the next 24 hours and refuses to eat or drink anything. He is scheduled to have electroconvulsive therapy (ECT) because he is so severely depressed that an antidepressant is deemed too slow acting. Which of the following side effects should the patient be informed is most common after ECT?

answer

a. Headache

question

308. A 14-year-old boy is brought to the psychiatrist because for the past 15 months he has been irritable and depressed almost constantly. The boy notes that he has difficulty concentrating, and he has lost 5 lb during that time period without trying. He states that he feels as if he has always been depressed, and he feels hopeless about ever feeling better. He denies suicidal ideation or hallucinations. He is sleeping well and doing well in school, though his teachers have noticed that he does not seem to be able to concentrate as well as he had previously. Which of the following is the most likely diagnosis?

answer

b. Dysthymic disorder

question

309. A 29-year-old man is brought to the hospital because he was found running around on the streets with no shoes on in the middle of winter, screaming to everyone that he was going to be elected president. Upon admission to the hospital, he was stabilized on olanzapine and lithium and then discharged home. Assuming the patient is maintained on the olanzapine and the lithium, which of the following tests should be performed at least once per year?

answer

c. Creatinine level

question

310. A 45-year-old woman comes to her physician for help with her insomnia. She states "ever since my husband died, I just can't sleep." The patient states her 57-year-old husband died suddenly of a heart attack 9 weeks ago. Since that time, the patient has had a very depressed mood, had been crying, has lost interest in activities, is fatigued, and has insomnia. Which of the following symptoms, if present, should make the physician think this patient has a major depression instead of bereavement?

answer

b. The patient has marked functional impairment.

question

311. A 10-year-old boy is brought to the psychiatrist by his mother. She states that for the past 2 months he has been increasingly irritable, withdrawn, and apathetic. He has been refusing to do his homework, and his grades have dropped. Which of the following is the best next step in management?

answer

d. The child should receive an antidepressant medication.

question

312. A 35-year-old woman is seeing a psychiatrist for treatment of her major depression. After 4 weeks on fluoxetine at 40 mg/day, her psychiatrist decides to try augmentation. Which of the following is the most appropriate medication?

answer

a. Lithium

question

313. Which of the following is a relative contraindication for ECT?

answer

a. Space-occupying lesion in the brain

question

314. A 32-year-old man is admitted to the psychiatric unit after his wife brought him to the emergency room in a severe major depression. The patient signs himself in voluntarily because he "didn't think he is safe" at home. Which of the following factors most increases a patient's risk of suicide while on the inpatient unit?

answer

a. The patient is in his first week of hospitalization.

question

315. A middle-aged woman presents with a variety of cognitive and somatic symptoms, fatigue, and memory loss. She denies feeling sad, but her family physician is aware of this patient's lifelong inability to identify and express feelings. He suspects she is depressed. Which of the following results is most likely to confirm a diagnosis of depression?

answer

a. Reduced metabolic activity and blood flow in both frontal lobes on PET scan

question

316. A 32-year-old man is being treated for a severe major depression. Which of the following symptoms, if present, is one of the most accurate indicators of long-term suicidal risk?

answer

c. Hopelessness

question

Questions 317 to 320 317. An elderly man has been profoundly depressed for several weeks. He cries easily and is intensely preoccupied with trivial episodes from his past, which he considers unforgivable sins. This patient awakens every morning at 3 AM and cannot go back to sleep. Anything his family has tried to cheer him up has failed. He has completely lost his appetite and appears gaunt and emaciated.

answer

d. Melancholic depression

question

318. A young woman, who has felt mildly unhappy and dissatisfied with herself for most of her life, has been severely depressed, irritable, and anhedonic for 3 weeks.

answer

b. Double depression

question

319. For the past 6 weeks, a middle-aged woman's mood has been mostly depressed, but she cheers up briefly when her grandchildren visit or in coincidence with other pleasant events. She is consistently less depressed in the morning than at night. When her children fail to call on the phone to inquire about her health, her mood deteriorates even more. She sleeps 14 hours every night and has gained 24 lb.

answer

a. Atypical depression

question

320. Since he moved to Maine from his native Florida 3 years earlier, a college student has had great difficulty preparing for the winter-term courses. He starts craving sweets and feeling sluggish, fatigued, and irritable in late October. These symptoms worsen gradually during the following months, and by February he has consistently gained several pounds. His mood and energy level start improving in March, and by May he is back to baseline.

answer

f. Seasonal affective disorder

question

321. A 23-year-old woman arrives at the emergency room complaining that, out of the blue, she had been seized by an overwhelming fear, associated with shortness of breath and a pounding heart. These symptoms lasted for approximately 20 minutes, and while she was experiencing them, she feared that she was dying or going crazy. The patient has had four similar episodes during the past month, and she has been worrying that they will continue to recur. Which of the following is the most likely diagnosis?

answer

c. Panic disorder

question

322. A middle-aged man is chronically preoccupied with his health. For many years he feared that his irregular bowel functions meant he had cancer. Now he is very worried about having a serious heart disease, despite his physician's assurance that the occasional "extra beats" he detects when he checks his pulse are completely benign. Which of the following is the most likely diagnosis?

answer

b. Hypochondriasis

question

Questions 323 to 327 323. A 20-year-old woman comes to her primary care doctor with multiple symptoms which are present across several organ systems. She has seen five doctors in the past 3 months, and has had six surgeries since the age of 18.

answer

a. Somatization disorder

question

324. A 24-year-old woman from a rural and low socioeconomic background with a fifth-grade education develops sudden left-arm paralysis that is not compatible with known neural patterns.

answer

b. Conversion disorder

question

325. A 49-year-old man calls his physician repeatedly demanding a workup for his severe back pain. The physical examination is within normal limits and a CT of his back is also normal, but this is only temporarily reassuring to the patient.

answer

c. Hypochondriasis

question

326. A 17-year-old girl presents to a physician complaining that her face is "out of proportion" and that she looks like "Mr Hyde--like a monster." On examination, the girl is a pleasant-looking young woman with no facial deformities of any kind.

answer

d. Body dysmorphic disorder

question

327. A 45-year-old woman presents to her physician with a chief complaint of a severe headache that is increasing in severity over the past 3 weeks. The patient states that 1 month ago she was in an auto accident and was diagnosed with a concussion. The patient states that the headache has been increasing since then and she is completely unable to work. The MRI of her head is normal.

answer

e. Pain disorder

question

328. A 28-year-old taxi driver is chronically consumed by fears of having accidentally run over a pedestrian. Although he tries to convince himself that his worries are silly, his anxiety continues to mount until he drives back to the scene of the "accident" and proves to himself that nobody lies hurt in the street. This behavior best exemplifies which of the following?

answer

a. A compulsion secondary to an obsession

question

329. A young woman, who has a very limited memory of her childhood years but knows that she was removed from her parents because of their abuse and neglect, frequently cannot account for hours or even days of her life. She hears voices that alternately plead, reprimand, or simply comment on what she is doing. Occasionally, she does not remember how and when she arrived at a specific location. She finds clothes she does not like in her closet, and she does not remember having bought them. Her friends are puzzled because sometimes she acts in a childish dependent way and at other times becomes uncharacteristically aggressive and controlling. These symptoms are most commonly seen in which of the following disorders?

answer

d. Dissociative identity disorder

question

Questions 330 to 331 330. A 34-year-old secretary climbs 12 flights of stairs every day to reach her office because she is terrified by the thought of being trapped in the elevator. She has never had any traumatic event occur in an elevator; nonetheless, she has been terrified of them since childhood. Which of the following is the most likely diagnosis?

answer

d. Specific phobia

question

331. Which of the following is the treatment of choice for the patient described in the previous vignette?

answer

d. Exposure therapy

question

332. A 23-year-old woman presents to her physician with the chief complaint that she is anxious about the way she looks. She notes that for "as long as she can remember," she has been obsessed about the fact that something must be wrong with her face. She notes that her eyes are too far apart and her nose is misshapen. She states that this concern is "ruining her life" because she spends all her time isolated from others so that they cannot see her face. The physician did not notice anything unusual about the patient's face, but the patient cannot be consoled by this statement. Which of the following is the most likely diagnosis?

answer

a. Body dysmorphic disorder

question

333. A 26-year-old woman comes to the psychiatrist with a 1-month history of severe anxiety. The patient states that 1 month ago she was a "normal, laid-back person." Since that time she rates her anxiety an 8 on a scale of 1 to 10, and also notes she is afraid to leave the house unless she checks that the door is locked at least five times. Which of the following medical conditions could commonly cause this kind of symptom presentation?

answer

c. Hyperparathyroidism

question

334. A 33-year-old man comes to his physician for an HIV test. The test is positive. The patient has no signs or symptoms of AIDS. Which of the following psychiatric diagnoses may develop in as many as 25% of patients informed of a positive HIV test?

answer

a. Adjustment disorder with anxiety

question

Questions 335 to 337 335. A 45-year-old policeman who has demonstrated great courage on more than one occasion while on duty is terrified of needles.

answer

f. Specific phobia

question

336. For several months, a 32-year-old housewife has been unable to leave her house unaccompanied. When she tries to go out alone, she is overwhelmed by anxiety and fears that something terrible will happen to her and nobody will be there to help.

answer

a. Agoraphobia

question

337. A 17-year-old girl blushes, stammers, and feels completely foolish when one of her classmates or a teacher asks her a question. She sits at the back of the class hoping not to be noticed because she is convinced that the other students think she is unattractive and stupid.

answer

d. Social phobia

question

Questions 338 to 342 338. Two years after she was saved from her burning house, a 32-year-old woman continues to be distressed by recurrent dreams and intrusive thoughts about the event.

answer

f. Posttraumatic stress disorder

question

339. A 20-year-old student is very distressed by a small deviation of his nasal septum. He is convinced that this minor imperfection is disfiguring, although others barely notice it.

answer

g. Body dysmorphic disorder

question

340. A nun is found in a distant city working in a cabaret. She is unable to remember anything about her previous life.

answer

e. Dissociative fugue

question

341. A 35-year-old woman is often late to work because she must shower and dress in a very particular order or else she becomes increasingly anxious.

answer

d. Obsessive-compulsive disorder

question

342. For the past 3 years, a 24-year-old college student has suffered from chronic headaches, fatigue, shortness of breath, dizziness, ringing ears, and constipation. He is incensed when his primary physician recommends a psychiatric evaluation because no organic cause for his symptoms could be found

answer

a. Somatization disorder

question

Questions 343 to 346 343. A woman washes her hands hundreds of times a day out of a fear of contamination. She cannot stop herself, although her hands are raw and chafed.

answer

e. SSRI

question

344. A Vietnam veteran startles and starts hyperventilating whenever he hears a sharp noise

answer

f. Beta-blocker

question

345. A middle-aged bank teller with a past history of alcohol abuse, who describes himself as a chronic worrier, has been promoted to a position with increased responsibilities. Since the promotion, he has been constantly worrying about his job. He fears his superiors have made a mistake and they will soon realize he is not the right person for that position. He ruminates about unlikely future catastrophes, such as not being able to pay his bills and having to declare bankruptcy if he is fired. He has trouble falling asleep at night and suffers from acid indigestion.

answer

b. Antianxiety agent (non-benzodiazepine)

question

346. A talented 21-year-old violinist's musical career is in jeopardy because he becomes acutely anxious whenever he is asked to play in front of an audience.

answer

f. Beta-blocker

question

347. A 24-year-old woman comes to the psychiatrist with a 2-month history of short episodes of "feeling like I am going to die." During these episodes, she also notes feelings of dizziness and nausea, along with a feeling of choking. She describes these episodes as very frightening and she is terrified of having another. She denies substance use of any medical problems. Which of the following treatment regimens should be started?

answer

d. Paroxetine and alprazolam

question

348. A 47-year-old man with a master's degree in chemistry lives alone in a halfway house and subsists on panhandling and collecting redeemable cans. Ten years ago he lost his job in a large firm because he was found to have repeatedly stolen company money and used it to bet on horse racing. Afterward, he had several other jobs but always lost them because he stole money. He also stole and borrowed money from friends and relatives. When asked about this behavior, the patient stated that he felt very guilty about it but "couldn't seem to stop" himself. Which of the following diagnoses best fits this patient's symptoms?

answer

c. Pathological gambling

question

349. A 7-year-old girl is brought to the physician because her parents note that she gets up at night and, still asleep, walks around the house for a few minutes before returning to bed. When she is forced to awaken during one of these episodes, she is confused and disoriented. Her parents are afraid that she will accidentally hurt herself during one of these episodes. Which of the following is the most appropriate intervention the physician should recommend?

answer

a. Tell the parents to maintain a safe environment and monitor the patient's symptoms

question

350. A 65-year-old woman lives alone in a dilapidated house, although her family members have tried in vain to move her to a better dwelling. She wears odd and out-of-fashion clothes and rummages in the garbage cans of her neighbors to look for redeemable cans and bottles. She is very suspicious of her neighbors. She was convinced that her neighbors were plotting against her life for a brief time after she was mugged and thrown onto the pavement by a teenager, but now thinks that this is not the case. She believes in the "power of crystals to protect me" and has them strewn haphazardly throughout her house. Which of the following is the most likely diagnosis?

answer

c. Schizotypal personality disorder

question

351. A 17-year-old man comes to the physician because he has been falling asleep in inappropriate places, even though he has been getting enough rest at night. The patient states that he has fallen asleep while eating and driving. He notes that he stays asleep approximately 20 minutes and when he first wakes up, he is unable to move. He notes that sometimes he can even fall asleep while standing, and has been told by others that during those times he simply drops to the floor suddenly. He is fitted with a portable monitor, and it is found that during these episodes he enters an REM sleep

answer

a. Narcolepsy

question

352. A 32-year-old man is diagnosed with a major depression. He and his psychiatrist discuss starting an antidepressant. The patient is concerned about the chance for impairment of his ability to get an erection on these kinds of medications. Which of the following medications should the patient be started on to treat his depression but avoid these symptoms?

answer

c. Fluoxetine

question

353. An attractive and well-dressed 22-year-old woman is arrested for prostitution, but on being booked at the jail, she is found to actually be a male. The patient tells the consulting physician that he is a female trapped in a male body and he has felt that way since he was a child. He has been taking female hormones and is attempting to find a surgeon who would remove his male genitals and create a vagina. Which of the following is the most likely diagnosis?

answer

b. Gender identity disorder

question

354. A 38-year-old man comes to his physician with complaints of impaired ejaculation. He is on the following medications: perphenazine, digoxin, and propranolol. He is also receiving methadone treatment and admits to periodic cannabis use. Which substance is the most likely culprit in his problems with ejaculation?

answer

a. Perphenazine

question

355. Every 4 or 5 weeks, a usually well-functioning and mild-mannered 35-year-old woman experiences a few days of irritability, tearfulness, and unexplained sadness. During these days, she also feels fatigued and bloated and eats large quantities of sweets. Which of the following is the most likely diagnosis?

answer

d. Premenstrual dysphoric disorder

question

356. A 65-year-old retired steelworker who has never had any sexual dysfunction experiences difficulty in obtaining and maintaining an erection shortly after he starts taking a medication prescribed by his primary care physician. Which of the following medications is most likely to cause such a side effect?

answer

a. Propranolol

question

357. A 38-year-old married man comes to the psychiatrist because he felt his "sexuality is out of control." He notes that he never feels that he has had enough sex, even though he masturbates 3 to 4 times per day and has sex with his wife daily. He states he has tried to stop but feels he can not control the behavior. He feels a lot of guilt about this, especially when he masturbates at his workplace. Which of the following medications would be most helpful to this man?

answer

b. SSRIs

question

358. A demanding 25-year-old woman begins psychotherapy stating that she is both desperate and bored. She reports that for the past 5 or 6 years she has experienced periodic anxiety and depression and has made several suicidal gestures. She also reports a variety of impulsive and self-defeating behaviors and sexual promiscuity. She wonders if she might be a lesbian, though most of her sexual experiences have been with men. She has abruptly terminated two previous attempts at psychotherapy. In both cases she was enraged at the therapist because he was unwilling to prescribe anxiolytic medications. Which of the following is the most likely diagnosis?

answer

d. Borderline personality disorder

question

359. A 36-year-old woman comes to her physician for help with weight reduction. Her BMI is 32. Which of the following disorders is she most at risk for at this weight?

answer

b. Breast cancer

question

Questions 360 to 363 360. A 28-year-old woman begins seeing a psychiatrist because, she says, "I am just so very lonely." Her speech is excessively impressionistic and lacks specific detail. She flirts constantly with the physician and is "hurt" when the therapist does not notice her new clothes or hairstyle.

answer

f. Histrionic

question

361. A 42-year-old man comes to the psychiatrist at the insistence of his boss because he constantly misses important deadlines. The man states that everyone at work is lazy and that no one lives up to his own standards for perfection. He is angry when the physician starts the interview 3 minutes later than the appointed time. He notes that he is always fighting with his wife because he is a "pack rat" and is unable to throw anything out. During the interview, he appears very rigid and stubborn.

answer

h. Obsessive-compulsive

question

362. A 34-year-old woman comes to the psychiatrist on the advice of her mother, because the patient still lives at home and will not make any decisions without her mother's reassurance. The patient's mother accompanies the patient to the appointment. She states that the patient becomes anxious when her mother must leave the home because the patient is terrified that her mother will die and the patient will have to take care of herself, something she feels incapable of doing.

answer

i. Dependent

question

363. A 25-year-old high school dropout has been arrested more than 12 times for various assault, fraud, and attempted murder charges. He has been in many physical fights, usually after he got caught cheating at cards. On examination, he seems relaxed and even cocky, and he shows no remorse for his actions.

answer

g. Antisocial

question

Questions 364 to 367 364. This temperament type is noted for being industrious and determined. Being lazy and spoiled is not a characteristic of this type.

answer

d. Persistence

question

365. This temperament type is noted for being open, sentimental, and affectionate. Opposite characteristics not seen in this temperament type are aloofness, detachment, and independence.

answer

c. Reward dependence

question

366. This temperament type is noted for being impulsive and extravagant. It is not noted for being deliberate or thrifty

answer

b. Novelty seeking

question

367. This temperament type is often seen as fearful, shy, and fatigable. It is not known for being seen as daring, outgoing, or energetic.

answer

a. Harm avoidance

question

368. A 52-year-old man comes to the psychiatrist with complaints of problems sleeping. He has problems falling asleep, tossing and turning for several hours before finally getting to sleep. The next day the patient is tired, and this has caused him some problems at work. The patient denies signs or symptoms of major depression. Which of the following is the best sleep hygiene recommendation to help this patient sleep?

answer

c. Get up at the same time every day

question

369. A 21-year-old man comes to the physician because of excessive sleepiness. He states that for the past 4 months he becomes so sleepy that he must sleep, even when he is in the middle of an important meeting. These episodes occur daily and the patient must sleep for 10 to 20 minutes at each episode. The patient also says that on several occasions he has had a sudden loss of muscle tone during which his knees become weak and he drops to the floor. He remains conscious during these episodes. He denies any substance abuse or medical problems. Which of the following is the most appropriate treatment to be started?

answer

d. Modafinil

question

Questions 370 to 371 370. A young librarian has been exceedingly shy and fearful of people since childhood. She longs to make friends, but even casual social interactions cause her a great deal of shame and anxiety. She has never been at a party, and she has requested to work in the least active section of her library, even though this means lower pay. She cannot look at her rare customers without blushing, and she is convinced that they see her as incompetent and clumsy. Which of the following personality disorders is most likely?

answer

b. Avoidant

question

371. Which anxiety disorder is most likely to be confused with the personality disorder described in the vignette above?

answer

d. Social phobia

question

372. A 38-year-old man is seen by a psychiatrist because he has recurrent and intense sexually arousing fantasies involving wearing women's clothing. He notes that at first, he could wear women's underwear in his own home when he masturbated, and that this was sufficient. He now notes that he increasingly has the urge to wear women's clothes in public and masturbate somewhere less private. He comes in for help because he does not want to be caught at this behavior, though he is intensely attracted to it. He notes that he is a heterosexual, but that this cross-dressing behavior is sexually exciting to him. Which of the following disorders best describes this patient's symptoms?

answer

d. Transvestic fetishism

question

373. A 48-year-old male has been unable to have intercourse with his wife of 20 years since she disclosed to him that she was having an affair with his younger and more attractive work partner. He continues having spontaneous nocturnal erections. This patient's sexual dysfunction is most likely caused by which of the following?

answer

b. A psychogenic determinant

question

374. A 21-year-old man comes to the psychiatrist with the complaint of chronic unhappiness. He states that his usual mood is unhappy, and his selfesteem is always low. He states he spends time brooding and worrying about all manner of issues, in particular over his own inadequacy. He states he is pessimistic about things as a general rule, and feels guilty a lot because he is "such a bad friend." Which of the following is the most likely diagnosis?

answer

a. Personality disorder NOS

question

375. A young woman presents to the emergency room vomiting bright red blood. Once she is medically stable, the intern who performs her physical examination notices that the enamel of her front teeth is badly eroded and her parotid glands are swollen. Which of the following best describes the source of these medical complications?

answer

b. Purging

question

Questions 376 to 377 376. An off-Broadway actor consistently bores his friends and acquaintances by talking incessantly about his exceptional talent and his success on the stage. He does not seem to realize that other people do not share his high opinion of his acting talent and are not interested in his monologues. When a director criticizes the way he delivers his lines during rehearsal, the actor goes into a rage and accuses the director of trying to jeopardize his career out of jealousy. Which personality disorder represents the most likely diagnosis?

answer

b. Narcissistic

question

377. The patient in the vignette above seeks out a psychiatrist because, he says, "It is depressing when no one understands your talent." Which of the following treatments would be most appropriate?

answer

e. Psychodynamic psychotherapy

question

378. A 52-year-old woman is diagnosed with breast cancer that is metastatic to her bones. She comes to the psychiatrist for help in managing her depressed mood and anxiety secondary to this diagnosis. Which of the following would most likely indicate an increased vulnerability to suicide if found in this patient, in addition to her anxiety and depressed mood?

answer

c. A feeling of a loss of control

question

379. A 3-year-old girl's preferred make-believe game is playing house with her dolls. She loves to experiment with her mother's makeup and states that when she grows up, she will be a mommy. She is very offended when someone mistakes her for a boy. This scenario best demonstrates that which of the following is well established at this girl's age?

answer

c. Gender identity

question

Questions 380 to 383 380. A woman complains about her husband moving his legs constantly while he sleeps. She ends up being kicked several times every night. The husband has no memory of this nighttime activity, but he reports that he wakes up tired every morning despite getting what he considers an adequate amount of sleep (7 to 8 hours per night).

answer

f. Periodic limb movement disorder

question

381. Because of her job's requirements, a per diem nurse works different shifts almost every week. She is constantly sleepy and fatigued. However, even when she has days off, she has great difficulty falling asleep at night and remaining asleep for more than 2 to 3 hours at a time.

answer

d. Circadian sleep disorder

question

382. For the past 2 years a 28-year-old man has found himself in many dangerous or embarrassing situations because of his inconvenient habit of falling abruptly asleep in the middle of any activity. Once he hit a pole because he fell asleep while driving. His wife still teases him for "taking a nap" while they are having sex. The man reports that he starts dreaming as soon as his eyes close, and when he wakes up, 10 to 20 minutes later, he feels wide awake and refreshed.

answer

b. Narcolepsy

question

383. A young man has felt consistently sleepy during the day for as long as he can remember. Although he sleeps from 9 to 11 hours every night, he wakes up unrefreshed and needs to take a nap at least once a day in order to function. According to his wife and bed partner, he does not snore and he does not kick her while sleeping. Aside from the difficulties caused by his chronic sleepiness, his history is unremarkable.

answer

a. Primary hypersomnia

question

Questions 384 to 387 384. A 24-year-old woman drops out of college after 2 weeks. When asked why, she states that although she would desperately like to have friends, she is afraid to approach anyone because "they would think I'm just a nerd." Furthermore, in the middle of a class, one of the professors asked her a question and she became extremely uncomfortable. She has never had a significant relationship with anyone other than her parents and sister

answer

j. Avoidant

question

385. A 32-year-old man comes to the psychiatrist because he is anxious about his new job. He notes that he previously held a job shelving books in the back of a library, but because of budget cuts he has been forced to interact with customers. He states he doesn't like being around people and prefers being by himself. He appears emotionally cold and detached during the interview.

answer

c. Schizoid

question

386. A 19-year-old man comes to the psychiatrist because he can't leave the house without checking the stove, furnace, and water heater 25 times in a specific order. He notes that while he hates to perform this behavior, if he does not, he feels overwhelmingly anxious. It sometimes takes him 3 hours to leave the house in the morning because of this behavior.

answer

k. No personality disorder apparent

question

387. A 32-year-old woman is admitted to the obstetrics ward to deliver a normal full-term infant. Ten hours after the delivery, she tries to steal the infant out of the nursery because she believes that the government of Myanmar is after her and will steal her child. When confronted by a nurse, she attempts to scratch the nurse and grab her child.

answer

k. No personality disorder apparent

question

Questions 388 and 389 388. A 19-year-old man is brought to the emergency room by his distraught parents, who are worried about his vomiting and profuse diarrhea. On arrival, his pupils are dilated, his blood pressure is 175/105 mm Hg, and his muscles are twitching. His parents report that these symptoms started 2 hours earlier. For the past few days he has been homebound because of a sprained ankle, and during this time he has been increasingly anxious and restless. He has been yawning incessantly and has had a runny nose. Which of the following drugs is this man most likely to be withdrawing from?

answer

a. Heroin

question

389. The physician tells this patient from the vignette above that the withdrawal symptoms will peak how long after stopping the use of this substance?

answer

c. 48 hours

question

390. A 28-year-old woman is seen for postpartum blues by the psychiatrist. She states she is depressed because she "did this to her child." The infant has growth retardation, microphthalmia, short palpebral fissures, midface hypoplasia, a short philtrum, a thin upper lip, and microcephaly. Which is the most likely diagnosis of the mother (besides the postpartum blues)?

answer

d. Alcohol dependence

question

Questions 391 and 392 391. A 50-year-old man is brought to the emergency department by ambulance. His respirations are shallow and infrequent, his pupils are constricted, and he is stuporous. He was noted to have suffered a grand mal seizure in the ambulance. Which of the following drugs is this man most likely to have overdosed on?

answer

c. Meperidine

question

392. After ensuring adequate ventilation for the patient in the previous vignette, which of the following interventions should be next?

answer

a. Intravenous naloxone

question

393. A 22-year-old man arrives at an emergency room accompanied by several friends. He is agitated, confused, and apparently responding to frightening visual and auditory hallucinations. The patient is put in restraints after he tries to attack the emergency room physician. The patient's friends report that he had "dropped some acid" 6 or 7 hours earlier. How much longer will intoxication with this substance last?

answer

a. 1 to 6 hours

question

394. A college freshman, who has never consumed more than one occasional beer, is challenged to drink a large quantity of alcohol during his fraternity house's party. In a nontolerant person, signs of intoxication usually appear when the blood alcohol level reaches what range?

answer

a. 20 to 30 mg/dL

question

395. A 27-year-old man is seen in the emergency room after getting into a fight at a local bar and being knocked unconscious. Upon his arrival in the emergency room, he is alert and oriented X 3. He states that he smokes marijuana 2 to 3 times per week and has done so for years. The last time he smoked was 2 days prior to admission to the emergency room. He also admits using PCP 5 days previously, and he took some of his wife's alprazolam the day prior to coming to the emergency room. Which of the following test results would likely be seen if the patient's urine were tested for substances of abuse in the emergency room? Substance-Related Disorders 227 Marijuana PCP Alprazolam a. + + + b. + − + c. + + − d. − − − e. − + +

answer

Marijuana PCP Alprazolam a. + + +

question

Questions 396 and 397 396. A 35-year-old man stumbles into the emergency room. His pulse is 100 beats per minute, his blood pressure is 170/95 mm Hg, and he is diaphoretic. He is tremulous and has difficulty relating a history. He does admit to insomnia the past two nights and sees spiders walking on the walls. He has been a drinker since age 19, but has not had a drink in 3 days. Which of the following is the most likely diagnosis?

answer

c. Alcohol withdrawal delirium

question

397. Which of the following is the most appropriate initial treatment for the patient from the previous vignette?

answer

d. Oral chlordiazepoxide

question

398. A 45-year-old housewife has been drinking in secret for several years. She started with one or two small glasses of Irish cream per night to help her sleep, but, over time, her nightly intake has increased to four to five shots of hard liquor. Now she needs a few glasses of wine in the early afternoon to prevent shakiness and anxiety. During the past year, she could not take part in several important family events, including her son's high school graduation, because she was too ill or she did not want to risk missing her nightly drinking. She is ashamed of her secret and has tried to limit her alcohol intake but without success. Which of the following is the most likely diagnosis?

answer

d. Alcohol dependence

question

399. A 26-year-old woman presents to the psychiatrist with a 1 month history of severe anxiety. She states that before 1 month ago she was a 'normal, laid-back person." Since that time she rates her anxiety as an 8 on a scale of 1-10. She notes she is afraid to leave the house unless she checks that the door is locked at least 5 times. Which of the following substancerelated conditions would most likely cause these kinds of symptoms?

answer

d. Cocaine intoxication

question

400. A 37-year-old woman is admitted to an inpatient treatment program for withdrawal from heroin. Eighteen hours after her last injection of heroin, she becomes hypertensive, irritable, and restless. She also has nausea, vomiting, and diarrhea. Which medication would be best to treat some of the symptoms of opioid withdrawal?

answer

e. Clonidine

question

401. A 36-year-old woman comes to the emergency room after she is found unresponsive at a party. Urine toxicology is positive for cocaine. Upon awakening, the patient is interviewed and is found to have a history consistent with cocaine abuse. Which of the following is this patient at an increased risk for having?

answer

a. Death by suicide

question

402. Three policemen, with difficulty, drag an agitated and very combative young man into an emergency room. Once there, he is restrained because he reacts with rage and tries to hit anyone who approaches him. When it is finally safe to approach him, the resident on call notices that the patient has very prominent vertical nystagmus. Shortly thereafter, the patient has a generalized seizure. Which of the following substances of abuse is most likely to produce this presentation?

answer

b. PCP

question

Questions 403 and 404 403. A 64-year-old man is admitted to the emergency room after he was witnessed having a seizure on the sidewalk. Postictally, the patient was noted to be agitated and disoriented. Vital signs include: blood pressure 165/105 mm Hg, pulse 120 beat/min. From the following list, which is the most likely diagnosis?

answer

b. Alcohol withdrawal

question

404. In the vignette above, which of the following medications is most likely to be helpful to this patient postictally?

answer

e. Lorazepam IM

question

405. A 20-year-old man is admitted to the emergency department after an automobile accident, in which his friend drove their car into a light pole. In the emergency department, the man smells strongly of alcohol, and his blood alcohol level is 300 mg/dL. However, he does not show any typical signs of intoxication. His gait is steady, his speech is clear, and he does not appear emotionally disinhibited. Which of the following is the most likely explanation for such a presentation?

answer

c. The man has developed a tolerance to the effects of alcohol.

question

406. A woman swallows two amphetamines at a party and quickly becomes disinhibited and euphoric. Afterward, she slaps a casual acquaintance because she takes a benign comment as a major offense and starts raving about being persecuted. What mechanism is most responsible for these behaviors?

answer

a. Increased release of dopamine and norepinephrine in the synaptic cleft

question

407. A 25-year-old woman is dropped on the doorstep of a local emergency room by two men who immediately leave by car. She is agitated and anxious, and she keeps brushing her arms and legs "to get rid of the bugs." She clutches at her chest, moaning in pain. Her pupils are wide, and her blood pressure is elevated. Which of the following substances is she most likely using?

answer

e. Cocaine

question

408. A 22-year-old woman comes to the physician with complaints of problems in sleeping. She notes that she has a hard time falling asleep, and when she does finally get to sleep, she awakens multiple times during the night. The patient says that this problem has been getting worse over the last 2 months. She states that she has also noted that she feels both nervous and fatigued during the day. Her mental status examination is otherwise normal. Toxicology screen is negative. Which of the following is the most likely diagnosis?

answer

c. Caffeine-induced sleep disorder

question

409. A 22-year-old Asian woman becomes flushed and nauseated immediately after drinking half a glass of wine. She is noted to have slurred speech, ataxia, and nystagmus as well. She is brought to the emergency department by her concerned friends. Which of the following is the most likely diagnosis?

answer

e. Alcohol intoxication

question

410. A 35-year-old man comes to the psychiatrist for treatment of his heroin addiction. He has been an addict for over 6 years, and has been injecting heroin for 5 of those 6 years. Three previous attempts at quitting have all been unsuccessful. Which of the following medications is the best option for this man?

answer

a. Methadone

question

411. A 55-year-old man comes to his physician because he wants to stop smoking. He tells the physician that he is desperate to stop because his wife was just diagnosed with emphysema. The patient is willing to work with the physician on behavioral strategies to quit smoking but would also like some medications to help. Which of the following medications should the physician prescribe for this patient?

answer

d. Bupropion

question

412. A 22-year-old man is brought to the emergency room after his friends noted he became agitated and was "acting crazy" at a party. The patient was belligerent and agitated in the emergency room as well. On physical examination, vertical nystagmus, ataxia, and dysarthria were noted. The patient has no previous mental or physical disorders. Which of the following is the best treatment option to give immediately?

answer

b. Minimization of sensory inputs

question

413. A 16-year-old male with a long record of arrests for breaking and entering, assault and battery, and drug possession is found dead in his room with a plastic bag on his head. For several months he had been experiencing headaches, tremors, muscle weakness, unsteady gait, and tingling sensations in his hands and feet. These symptoms (and the manner in which the boy died) suggest that he was addicted to which of the following substances?

answer

d. An inhalant

question

414. A 13-year-old girl is brought to the emergency department by her mother because the girl thinks she is "going crazy." The girl states that at a friend's party several hours previously she was given a white tablet to take, which she did. She is now agitated and restless and convinced that she can fly. She also notes that she is having visual, auditory, and tactile hallucinations. On examination, she is noted to have tachycardia, tremors, hypertension, and mydriasis. Which of the following substances did she most likely ingest?

answer

e. LSD

question

415. A 29-year-old man is brought to the psychiatrist by his wife because she is concerned about his increasing anger, irritability, and hostility over the past 4 months. The patient denies that any of these symptoms are problematic. On physical examination, the patient is noted to have bilateral muscle hypertrophy, especially in the upper body area, and an elevated fatfree mass index. Which of the following substances is most likely being abused by this man?

answer

c. Anabolic-androgenic steroids

question

416. A 16-year-old girl was brought to the emergency department by her mother, after the girl admitted that she had taken an unknown drug at a neighborhood party. The drug was identified as 3,4-methylenedioxymethamphetamine (MDMA), often known as Ecstasy. Which of the following side effects should the physician tell the patient's mother is common with use of this drug?

answer

b. Bruxism

question

Questions 417 to 419 417. A 22-year-old man continues to use alcohol on a once-weekly basis, despite the fact that every time he uses it he does something embarrassing, which he regrets. This has led him to lose some of his friends because they do not want to be around him when such behavior occurs.

answer

f. Substance abuse

question

418. A 36-year-old cocaine user notices that the longer he uses the drug, the more of it he requires to achieve the same effect.

answer

a. Tolerance

question

419. A 22-year-old woman passes out in a bar after one drink of wine. She normally can drink two glasses before she feels any effects from the alcohol. Her psychiatrist has recently started her on a new medication for her nerves.

answer

b. Potentiation

question

420. A 25-year-old man is brought to the emergency room after he became unconscious at a party. In the emergency room, the patient's respirations are 8/min. and he is unresponsive. Eye witnesses at the party state the patient was observed taking several kinds of pills, drinking alcohol, and snorting cocaine. The patient is given a total of 1.5 mg of flumazenil, at which time he gradually awakens. Which of the following drugs was most likely the agent in this patient's unconsciousness?

answer

d. A benzodiazepine

question

Questions 421 and 422 421. A 40-year-old man comes to the emergency room with symptoms of tachycardia, diaphoresis, mydriasis, and hyperthermia. He also shows muscle twitching and clonus. His medications include a protease inhibitor (for AIDS) and fluoxetine 20 mg daily which was started 1 week ago. What is the problem which most likely brought this man into the emergency room?

answer

c. Serotonin syndrome

question

422. In the vignette above, what is the most likely pathophysiology of this disease process?

answer

e. The protease inhibitor inhibits the metabolism by P450, thus increasing the level of the SSRI.

question

423. A 32-year-old man is started on Lithium after being diagnosed with bipolar disorder. His psychiatrist explains the risks and benefits of the drug and tells the patient that the drug can affect several organs in the body and he will need blood tests every 6 months. Which of the following labs should be drawn that often on this patient?

answer

b. TSH.

question

424. An 85-year-old man is brought to the psychiatrist by his wife. She states that for the last 4 months, since the death of his son, the patient has been unable to sleep, has lost 20 lb, has crying spells, and in the last week has been starting to talk about suicide. She notes that he has numerous other medical problems, including prostatic hypertrophy, hypertension, insulin-dependent diabetes, and a history of myocardial infarction. Which of the following medications is most appropriate for the treatment of this patient?

answer

c. Sertraline

question

425. A 12-year-old boy is very distraught because every time he thinks or hears the word God or passes in front of a church, swear words pop into his mind against his will. He also feels compelled to repeat the end of every sentence twice and to count to 20 before answering any question. If he is interrupted, he has to start from the beginning. Which of the following medications has been proven effective with this disorder?

answer

b. Clomipramine

question

426. A 7-year-old boy is brought to the physician with a 1-year history of making careless mistakes and not listening in class and at home. He is easily distracted and forgetful and loses his schoolbooks often. He is noted to be fidgety, talking excessively, and interrupting others. Which of the following medications is most likely to help with this boy's symptoms?

answer

d. Methylphenidate

question

427. A patient with schizophrenia is being treated with clozapine. He is told he needs an initial CBC, then weekly CBCs for the first 6 months of treatment, which he agrees to do. Four months into the therapy, the patient's WBC count is noted to be 3250 per mm3. The patient complains of a mild sore throat. Which of the following actions should the physician take first?

answer

a. Start twice per week CBCs with differential counts. Continue the clozapine

question

428. A 36-year-old man is admitted to the hospital after a suicide attempt, in which he swallowed his entire bottle of lithium pills. In the emergency room, he is noted to be stuporous, with a lithium level of 4.5 meq/L. His urine output is noted to be less than one-half what would normally be expected for a patient of his age. Which of the following procedures should be performed next?

answer

b. Emergency dialysis

question

Questions 429 to 430 429. A 32-year-old man comes to the physician with complaints of insomnia. He states for the past 3 weeks he has had difficulty going to sleep, though once he finally gets to sleep, he stays asleep without difficulty. The patient states that he is having no other difficulties. The patient has a past history of alcohol dependence, though he has been sober for over 3 years. Which of the following medications is the best choice to prescribe to help the patient with his sleep?

answer

a. Ramelteon

question

430. In the patient in the vignette above, it is most important to rule out which of the following medical problems before using the desired sleep aid?

answer

c. Severe hepatic impairment

question

431. A 57-year-old woman is seeing a psychiatrist for her bipolar disorder. She is started on carbamazepine. Which of the following tests should be done every 3 months during her second year of treatment with this drug?

answer

c. SGOT

question

432. A 52-year-old woman is brought to the emergency room after her husband finds her unresponsive at home. The patient left behind a suicide note, and two empty bottles of pills (sertraline and lorazepam) plus an empty bottle of vodka were found next to the patient. In the emergency room the patient's vital signs are: blood pressure 90/60 mm Hg, pulse 60 beats/min, respirations 6 breaths/min. Which of the following medications is most likely to be helpful in the emergency room setting in this situation?

answer

c. Flumazenil

question

433. A 32-year-old woman comes to the psychiatrist because she is "tired of worrying all the time." She notes that she can't control the worrying, and that she worries about everything; money, her children, who will run the country, "even stupid things." She also reports she has difficulty sleeping and concentrating, and is frequently irritable. She reports that her physician put her one a benzodiazepine to help her sleep, but that it "doesn't work." She requests buspirone, which she read about on-line. Why is this drug a poor choice for this patient?

answer

b. She has been taking benzodiazepines.

question

Questions 434 and 435 434. A 48-year-old woman with a past history of recurrent psychotic depression is admitted to a locked ward during a relapse. On the day of admission, she is placed on nortriptyline 50 mg and risperidone 2 mg at bedtime. Ten days later, the patient reports with great concern that her nipples are leaking. Which class of medications is most commonly known to cause this condition?

answer

b. Neuroleptics

question

435. Which of the following mechanisms is responsible for the condition in the previous vignette?

answer

d. Dopamine receptor blockade

question

436. A 44-year-old woman comes to the psychiatrist for treatment of a major depression. Her BMI is 28. She states she has lost 50 lb in the past year and is determined not to gain it back. Which of the following medications would be the best choice to treat her depression, given these circumstances?

answer

e. Sertraline

question

437. A 41-year-old woman comes to the physician for her yearly physical examination. She states her medications include hydrochlorothiazide, omeprazole, and atorvastatin (Lipitor). In addition, she is taking St. John's wort and ginseng. These two alternative medications are most commonly used by many patients for which of the following symptoms?

answer

b. For depressed mood

question

438. A 30-year-old woman is diagnosed as bipolar. At the same time that this illness is diagnosed, it is discovered that she is pregnant. Which of the following drugs has the highest risk to the fetus if used?

answer

a. Valproic acid

question

439. A 35-year-old woman with bipolar disorder has been stable on lithium for 2 years. For the past 3 months, she has been easily fatigued, more sensitive to cold, and excessively sleepy. Her hair is dry and brittle, and her face is puffy. Which of the following lab results will most likely be found?

answer

a. Elevated TSH

question

440. A 25-year-old woman with bipolar disorder develops a high fever with chills, bleeding gums, extreme fatigue, and pallor 3 weeks after starting on carbamazepine. Which of the following is she most likely experiencing?

answer

b. Acute aplastic anemia

question

441. A 28-year-old woman is brought to the emergency room after her mother called an ambulance. The patient has a history of chronic schizophrenia, which is being treated with antipsychotics. The dosage was recently increased on these medications. In the emergency room the patient has a temperature of 39.44°C (103°F), is rigid, and has a blood pressure alternating between 120/65 and 100/45. Which of the following levels should be closely monitored?

answer

b. Creatine phosphokinase (CPK)

question

442. A 24-year-old woman comes to the emergency room with complaints of feeling "stiffness and twisting" of her neck and jaw. She describes these symptoms as very uncomfortable and completely involuntary. She has not had these symptoms previously. Her medications include: lithium and trifluophenazine. The patient looks uncomfortable, and her jaw and neck are tense and twisted. Which of the following actions should the physician take first in the emergency room setting?

answer

b. Benztropine IM

question

443. A 42-year-old man is diagnosed with a psychotic depression and is started on imipramine and perphenazine. When he develops a dystonia, he is begun on benztropine 2 mg/day. One week later, his wife reports that the patient has become unusually forgetful and seems disoriented at night. On physical examination, the man appears slightly flushed, his skin and palms are dry, and he is tachycardic. He is oriented to name and place only. He showed none of these symptoms during his last appointment. Which of the following is the most likely diagnosis?

answer

a. Anticholinergic syndrome

question

444. A 36-year-old woman is diagnosed with a paranoid delusional disorder after she repeatedly called police to her home, convinced the neighbors were about to harm her by electrocuting her in her sleep. She is started on olanzapine. Which of the following side effects is this patient at greater risk for while on this medication?

answer

d. Glucose abnormalities

question

445. A 56-year-old woman who was diagnosed with paranoid schizophrenia in her early twenties has received daily doses of various typical neuroleptics for many years. For the past 2 years, she has had symptoms of tardive dyskinesia. Discontinuation of the neuroleptic is not possible because she becomes aggressive and violent in response to command hallucinations when she is not medicated. Which of the following actions should be taken next?

answer

e. Switch the patient to clozapine

question

446. A 27-year-old man is started on several new medications for treatment of a depressed mood. He returns to the physician's office after 2 weeks stating that on two separate occasions his wife noted that he got up from bed, went to the kitchen, and consumed large quantities of food in the middle of the night. The patient has no memory of this behavior. Which one of the following drugs could have been given that can produce this paradoxical response?

answer

c. Zolpidem

question

447. A 23-year-old man was admitted to a psychiatric inpatient service for treatment of auditory hallucinations of a command nature, telling him to kill himself. He is started on perphenazine. One day later he is noted to be increasingly anxious and pacing the halls. He states he feels as if he "has to move" and that pacing helps a little. He denies that his mind is racing. Which of the following actions should the psychiatrist take next?

answer

e. Give propranolol

question

Questions 448 and 449 448. A 53-year-old man is admitted to psychiatry after a serious suicide attempt. He remains nearly catatonic on the unit, refusing to either eat or drink. He also remains quite suicidal, and requires one-to-one observation at all times. Which of the following is the most appropriate treatment?

answer

e. ECT

question

449. The patient in the vignette above is to be given ECT. Which of the following anesthetic agents should be used prior to the procedure?

answer

c. Methohexital

question

450. A 25-year-old man is brought to the emergency room after taking a large overdose of benzodiazepines. He is treated with flumazenil and slowly awakens. Shortly thereafter, he has a seizure. Which of the following is the most likely precipitant?

answer

d. Preexisting seizure disorder

question

451. A 72-year-old man develops acute urinary retention and blurred vision after taking an antidepressant for 3 days. Which of the following medications is most likely to cause such side effects?

answer

e. Amitriptyline

question

452. A 43-year-old woman comes to the physician because she wants a medication to help her stop smoking. On history, it is also found that she meets the criteria for a hypoactive sexual desire disorder. Which of the following medications will be the most helpful for this patient?

answer

b. Bupropion

question

453. A 9-year-old girl is brought to the physician because she is noted to be easily distractible and fidgety and is generally difficult to get focused at school. The physician starts the girl on Ritalin. Which of the following cautions about the drug should the physician give the child's mother?

answer

b. Do not give the medication after noon.

question

454. An 8-year-old boy has been constantly clearing his throat and blinking his eyes for the past 3 weeks. He has had these symptoms intermittently for several years and has never been completely free of them for more than a day or two. Which of the following medications should be considered first?

answer

c. Haloperidol

question

455. During a 2-month period, a 72-year-old woman who has senile dementia becomes increasingly withdrawn, shows little interest in food, has trouble sleeping, and appears to become more severely demented. Her medical status is unchanged. Which of the following is the most appropriate course of treatment?

answer

e. Sertraline in the morning

question

Questions 456 and 457 456. A 34-year-old woman with a history of alcohol abuse has her first relapse after 2 years of sobriety. Fearing that she may not be able to stay away from alcohol, she asks her primary care physician to prescribe disulfiram. The following week, she arrives at the emergency room with facial flushing, hypotension, tachycardia, nausea, and vomiting. She denies any recent ingestion of alcohol. Which of the following is most likely to have caused her symptoms?

answer

b. Cough syrup

question

457. The effect of disulfiram depends on which of the following mechanisms?

answer

e. Acetaldehyde dehydrogenase inhibition

question

458. A 24-year-old man comes to see his physician after he is involved in a serious car crash because he fell asleep while driving. For several years, he has had severe daytime sleepiness, episodes of falling asleep without warning, and hypnagogic hallucinations. Which of the following is the most appropriate medication for this patient?

answer

c. Methylphenidate

question

459. For several weeks, a 72-year-old retired physician with Parkinson disease and mild dementia has been talking about "those horrible people that come to bother me every night." He is convinced that someone is plotting against him, and he has nailed his window shut for fear of intruders. More recently, he has started showing signs of thought disorder, mostly in the evening and at night. Which of the following antipsychotic medications is best to use on a patient with Parkinson disease?

answer

d. Clozapine

question

460. A 38-year-old woman is being seen by her psychiatrist for the treatment of her bipolar disorder. She is taking carbamazepine and sertraline and has been well-controlled. At her last visit, her carbamazepine level was above therapeutic. She states she has not taken extra, but has recently started taking another medication prescribed by her physician. Which of the following medications is most likely to increase carbamazepine concentrations in this manner?

answer

b. Erythromycin

question

Questions 461 and 462 461. A 29-year-old woman with a previous diagnosis of bipolar disorder is hospitalized during an acute manic episode. She is elated, sexually provocative, and speaks very fast, jumping from one subject to another. She tells the nurses that she has been chosen by God to be "the second virgin Mary." BUN, creatinine, electrolytes, TSH, and an ECG are within normal limits. What other test is necessary before starting the patient on lithium?

answer

a. Pregnancy test

question

462. After appropriate tests are obtained to the patient in the previous vignette, lithium treatment is started. Within what time interval does this medication come to steady state with regular administration?

answer

c. 5 to 8 days

question

463. A 25-year-old woman with schizophrenia is started on an antipsychotic medication to control her symptoms. While her hallucinations decrease on the medication, she notes that she feels as if her "skin is crawling" and her legs "want to move by themselves." She is very uncomfortable with these symptoms and paces the floor continuously because of them. Her psychiatrist recommends propranolol to help control these symptoms. For which of the following comorbid medical conditions would this medication be contraindicated for this patient?

answer

b. Asthma

question

464. Which of the following hormones is most commonly used in the adjuvant treatment of depression?

answer

d. Levothyroxine

question

465. A 32-year-old woman is prescribed nortriptyline for her first episode of major depression. The initial dose is 25 mg at bedtime, gradually increased over the next week to 50 mg at bedtime. Two days after the dosage increase, the woman develops urinary retention, blurred vision, and severe constipation. Her blood level is 280 ng/mL (recommended therapeutic window is 50 to 150 ng/mL) 12 hours after the last dose. Which of the following best explains this toxic blood level?

answer

e. The patient is a poor metabolizer.

question

466. A patient with refractory schizophrenia has been almost free of active psychotic symptoms and has been functioning considerably better since he was placed on clozapine 500 mg/day, but he has experienced two episodes of grand mal seizure. Which of the following steps should be taken next?

answer

e. Temporarily stop the clozapine and start phenobarbital

question

467. A patient reports that she has become depressed with the onset of winter every year for the past 6 years. Which of the following treatments is most likely to be helpful?

answer

a. Phototherapy

question

468. A 19-year-old girl is taken hostage with other bystanders during an armed robbery. She is freed by police intervention after 10 hours of captivity, but only after she has witnessed the shooting death of two of her captors. Months after this event, she has flashbacks and frightening nightmares. She startles at every noise and experiences acute anxiety whenever she is reminded of the robbery. Which of the following medications would most likely help decrease this patient's hyperarousal?

answer

a. Clonidine

question

469. A 72-year-old man with a long history of recurrent psychotic depression is hospitalized during a relapse. He has prostatic hypertrophy, coronary heart disease, and recurrent orthostatic hypotension. Which of the following is the most appropriate antipsychotic medication for this patient?

answer

d. Haloperidol

question

470. A 47-year-old businessman who has taken paroxetine 40 mg/day for 6 months for depression leaves for a 2-week business trip overseas and forgets his medication at home. Since his depression has been in full remission for at least 3 months, he decides to stop the treatment without talking with his psychiatrist. Two days later, he becomes very irritable, tearful, dizzy, and nauseated. He shivers and feels like he has a bad cold. Which of the following is the most likely cause of such symptoms?

answer

c. SSRI discontinuation syndrome

question

471. The benzodiazepines' action depends on their interaction with which of the following receptors?

answer

a. GABA

question

Questions 472 and 473 472. A 42-year-old woman with atypical depression who has responded well to an MAOI presents to an emergency room with severe headache. Her blood pressure is 180/110 mm Hg. She states that she has been carefully avoiding high-tyramine foods as she was told, but she admits that a friend gave her two tablets of a cold medication shortly before her symptoms started. Which of the following over-the-counter medications is contraindicated with MAOI treatment?

answer

a. Pseudoephedrine

question

473. If the woman's symptoms from the vignette above were caused by a dietary indiscretion, which of the following foods would be the most probable cause of her symptoms?

answer

a. A slice of pepperoni pizza

question

474. A 28-year-old woman is embarrassed by her peculiar tendency to collapse on the floor whenever she feels strong emotion. Since this disorder is caused by REM sleep intrusion during daytime, a neurologist prescribes a medication that reduces and delays REM sleep. Which of the following medications did the neurologist most likely prescribe?

answer

d. Desipramine

question

Questions 475 to 476 475. A mentally retarded male adolescent who has been increasingly aggressive and agitated receives several consecutive IM doses of haloperidol, totaling 30 mg in 24 hours, as a chemical restraint. The next day, he is rigid, confused, and unresponsive. His blood pressure is 150/95 mm Hg, his pulse is 110 beats/min, and his temperature is 38.9°C (102°F). Both his WBC count and CPK levels are very high. Which of the following is the most likely diagnosis?

answer

d. Neuroleptic malignant syndrome

question

476. Which of the following medications can be effective in treating the condition from the vignette above?

answer

a. Bromocriptine

question

477. A 7-year-old boy who wets the bed at least three times a week and has not responded to appropriate behavioral interventions is diagnosed with ADHD. Which of the following medications is indicated to treat both disorders?

answer

e. Imipramine

question

478. A 47-year-old man comes to a physician for treatment of his impotence. He has had a 20-year history of IDDM, well-controlled, and a 12-year history of alcohol dependence, though he has been sober for 3 years. He is prescribed sildenafil. Which of the following adverse effects is most commonly associated with this drug?

answer

d. Myocardial infarction

question

479. Which of the following serum level ranges is the target for lithium use in acute mania?

answer

b. 1.0 to 1.5 meq/L

question

480. Which of the following cardiovascular effects can be most problematic secondary to TCA use?

answer

b. Slowing of cardiac conduction

question

Questions 481 to 484 481. A 35-year-old painter is very frustrated by a fine tremor of her hands that worsens when she works and causes her to smudge her paintings. She was started on a medication several months ago after she had begun to believe that she was the "next Picasso." During that time, she was also hypersexual and bought a car on her husband's credit card.

answer

h. Lithium-induced tremor

question

482. An 18-year-old male is admitted to a locked psychiatric unit after he assaulted his father. He is convinced that his family members have been replaced with malevolent aliens and hears several voices that comment on his actions and call him demeaning names. Two days after initiating treatment, he develops a painful spasm of the neck muscles and his eyes are forced into an upward gaze.

answer

d. Dystonia

question

483. A 55-year-old man was diagnosed with a mental illness at the age of 20. At that time, he was noted to have hallucinations of two men commenting on his behavior and delusions that God was going to punish him for not finishing college. Once started on medications, the hallucinations and delusions lessened, though he remained socially isolative and apathetic. After 35 years on the same medication, he has a coarse, pill-rolling tremor that worsens at rest and improves during voluntary movements.

answer

a. Parkinsonian tremor

question

484. A 45-year-old woman with schizoaffective disorder has received neuroleptic medications, antidepressants, and mood stabilizers for at least 20 years. She presents with very rapid chewing movements. Other facial muscles, her trunk, and extremities are not affected, and her tongue does not dart in and out of her mouth when she is asked to protrude it.

answer

g. Rabbit syndrome

question

485. In order to successfully sue for medical malpractice, a plaintiff must prove four elements. Three of these elements are negligent performance of patient care, harm to the patient as a direct result of the physician's actions, and damage or harm to the patient. Which of the following is the fourth element?

answer

d. There was a duty on the part of the physician to treat the patient

question

486. A 56-year-old woman in the last stages of amyotrophic lateral sclerosis asks for her life support to be stopped and to be allowed to die. Her family members disagree with her decision and go to court to keep the patient alive. A psychiatric evaluation finds the patient mentally sound and fully able to understand the consequences of her decision. Which of the following actions should be taken next?

answer

e. The patient is competent, and as such she has the right to refuse unwanted medical treatment--her life support should be withdrawn.

question

Questions 487 and 488 487. An emaciated 26-year-old man is brought to the emergency room by the local police late one night in the dead of winter. The police tell the psychiatrist on call that the man was preaching loudly at a nearby busy intersection, sometimes walking into traffic to approach drivers while dressed only in a thin robe despite the freezing temperatures. On interview, the psychiatrist notes that the man displays delusions of special connections to God and discounts any concern for his physical safety, as he will leave his fate to God. The patient refuses voluntary admission, stating that he must get back to his divine mission. On what grounds would the emergency room psychiatrist be most justified in hospitalizing the patient involuntarily?

answer

a. The patient is so disorganized as to be unable to attend to his basic physical needs.

question

488. The patient in the vignette above is admitted to the hospital involuntarily. On the inpatient unit, he is noted to be mild-mannered and soft-spoken. He refuses all forms of treatment, stating that God is his only healer. While the patient is not particularly disruptive and not aggressive in any way, staff are nevertheless concerned about his refusal of treatment. In fact, he is noted to be trying very persistently to "convert" the other patients and staff on the unit, sometimes to their marked irritation. A decision is made by the staff to medicate the patient against his will. Subsequently, members of the patient's family bring suit against the clinical team working with the patient. On what grounds would the lawsuit initiated by the family most likely be brought?

answer

c. The patient had a right to refuse treatment because he was not in any immediate danger.

question

489. The family of a 49-year-old chronic schizophrenic male brings a lawsuit against the community mental health center where he has been treated for the past 14 years. They express concern that the patient has developed some persistent chewing movements of his mouth, over which he appears to have no control. On what grounds would such a lawsuit most likely be successful?

answer

a. The patient had not been given adequate disclosure of the risks and benefits of his treatment

question

490. A 46-year-old man is on a ventilator and has been irreversibly and severely brain damaged as a result of a motorcycle accident. Prior to the crash, he had told his wife during conversations about this kind of incapacity that he would not wish to have the life support withdrawn because he said he had "seen stories of medical miracles occurring where people awoke from these states." He had not, however, signed a living will. The patient's parents are requesting that the life support be withdrawn because they cannot bear to see their son existing in this manner. Which of the following actions should be taken (and why), given these circumstances?

answer

c. The life support should be continued because the patient's wishes are clearly known, even though there is no living will.

question

491. A 4-year-old boy is brought to the emergency room by his mother secondary to a fracture of his left femur. The mother states that the boy fell down the stairs at home, and that he has "always been clumsy." X-rays of the boy's leg confirm the fracture, and physical examination reveals bruises of various ages on the boy's chest and abdomen. Which of the following should the physician do first?

answer

b. Ensure the child's safety

question

492. The landmark decision in Tarasoff I held that a therapist has an obligation to do which of the following?

answer

d. Warn the potential victim of a potentially violent patient

question

493. Which of the following is the most common cause of malpractice claims in psychiatric practice?

answer

a. Improper treatment resulting in physical injury

question

494. A 63-year-old physician comes to a psychiatrist because he "just can't handle it anymore." The physician states he had to tell a patient that she is dying, and it "tore him apart." He is concerned that he will be unable to care for this patient well because his own feelings keep getting in the way. Which of the following best describes a risk factor for physicians to develop such aversive reactions to the care of dying patients?

answer

d. The physician identifies the patient with someone in his own life.

question

495. Which of the following statements refers to the principle of beneficence?

answer

a. Prevent harm and promote well-being

question

496. In Tarasoff II, the second decision by the California Supreme Court on the case, the original Tarasoff ruling was revised by the addition of which of the following?

answer

d. Instituting a duty to protect potential victims, not just warn them

question

497. A 72-year-old psychiatrist is being sued by his patient for abandonment. The suit states that the physician told the patient he was retiring with 2 months notice. He provided the patient with three phone numbers of other psychiatrists in town, all of whom had agreed to see the patient, and all of whom took the patient's insurance. Two of these three physicians were female. Does this patient have a valid claim of abandonment?

answer

e. No--adequate notice and follow up care were given.

question

498. A 57-year-old man is seeing a psychiatrist for the treatment of his major depression. During the course of his treatment, the man describes in great detail the fact that he has molested several children. Some of these molestations occurred decades previously, but one, according to the patient, is ongoing, involving a 10-year-old boy who lives in an apartment next door to the patient. Which of the following actions should the psychiatrist take next?

answer

e. The psychiatrist should immediately report the patient's behavior to the appropriate state agency.

question

499. A 24-year-old woman sues her psychiatrist for abandonment because he retired from practice. She states that her mental condition has deteriorated significantly since he left because he had provided her care for over 5 years and knew her "better than anyone." She states that the psychiatrist gave her 6 months' notice of his retirement and gave her the names of four psychiatrists whom he had determined had treatment openings for new patients. She states that she had seen one of the psychiatrists on the list 1 month after her original psychiatrist retired, but that this new psychiatrist did not know her very well. Which of the following is the most likely outcome of this lawsuit?

answer

d. The psychiatrist will be found not guilty of abandonment, since he provided his patient with reasonable notice and a reasonable effort to find her a new therapist.

question

500. A 78-year-old man chooses his wife to be his surrogate for decision making because he has been diagnosed with Alzheimer disease and knows that he will not be capable of making such decisions in the future. Two years later, the disease is fairly advanced, and the patient is hallucinating at night, which often disrupts his ability to sleep. The patient's physician recommends a low dose of an antipsychotic medication for the patient. How should the patient's wife make the decision whether or not to have the medication administered?

answer

b. The wife should use substituted judgment, which requires her to decide what to do, based on what the patient would have wished if he were capable of making the decision.

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