PFSA Review
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Information
For physicians, there is new maintenance of certification (MOC) requirements. This self-assessment module helps you meet these new standards.
As part of recertification requirements, physicians must now participate in Maintenance of Certification Program (MOC) activities like this one to cultivate a focus on lifelong learning and competency throughout one’s profession. This module helps you hone in on clinical and practice management skills that are central to quality patient care and improved outcomes for patients with substance use disorders.
The American Board of Psychiatry and Neurology (ABPN) has reviewed the Kaufman Psychiatry Self-Assessment Module and has approved this program as part of a comprehensive self-assessment program, which is mandated by the American Board of Medical Specialties (ABMS) as a necessary component of maintenance of certification.
Learning Objectives:
At the end of this educational activity, participants should be able to:
- Recognize the presentation of psychiatric disorders
- Diagnose and treat patients with psychiatric disorders
Target Audience:
The target audience for this module is psychiatrists.
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Question 1 of 200
1. Question
The police found a 26-year-old man partially undressed, wandering in the snow. When the police approached him, he was aggressive and assaultive. He appeared insensitive to pain. Several officers were required to restrain him. Upon arrival in the ER, the staff find elevated BP and tachycardia. A neurologist finds vertical nystagmus, muscle rigidity, and ataxia. What is the most likely diagnosis?
Correct
PCP intoxication is characterized by unpredictable and violent behavior. Dissociative and psychotic symptoms can occur. Individuals intoxicated with PCP are frequently agitated, impulsive, and insensitive to pain. Physical findings include autonomic hyperactivity, muscle rigidity, and ataxia. Although rotary or horizontal nystagmus may be observed they are nonspecific, but vertical nystagmus in this setting is virtually pathognomonic of PCP intoxication. Vertical nystagmus is not seen with any other drug of abuse. Treatment includes placing the patient in a quiet area with low stimulation. Haloperidol and/or a benzodiazepine may reduce the agitation and psychosis.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
PCP intoxication is characterized by unpredictable and violent behavior. Dissociative and psychotic symptoms can occur. Individuals intoxicated with PCP are frequently agitated, impulsive, and insensitive to pain. Physical findings include autonomic hyperactivity, muscle rigidity, and ataxia. Although rotary or horizontal nystagmus may be observed they are nonspecific, but vertical nystagmus in this setting is virtually pathognomonic of PCP intoxication. Vertical nystagmus is not seen with any other drug of abuse. Treatment includes placing the patient in a quiet area with low stimulation. Haloperidol and/or a benzodiazepine may reduce the agitation and psychosis.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 2 of 200
2. Question
Which of the following would NOT be helpful in the pharmacologic management of serotonin syndrome?
Correct
Pharmacological management strategies for serotonin syndrome include the use of benzodiazepines (for control of agitation) and 5-HT2A antagonists, such as cyproheptadine. In severe cases, especially to control hyperthermia, if the excessive muscular activity is not suppressed by a benzodiazepine, the use of a non-depolarizing agent, such as vecuronium (with appropriate supportive measures), may be necessary. Since the hyperthermia is a direct result of muscular hyperactivity, antipyretics, such as acetaminophen have no benefit.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (10th ed). Lippincott Williams & Wilkins.
Incorrect
Pharmacological management strategies for serotonin syndrome include the use of benzodiazepines (for control of agitation) and 5-HT2A antagonists, such as cyproheptadine. In severe cases, especially to control hyperthermia, if the excessive muscular activity is not suppressed by a benzodiazepine, the use of a non-depolarizing agent, such as vecuronium (with appropriate supportive measures), may be necessary. Since the hyperthermia is a direct result of muscular hyperactivity, antipyretics, such as acetaminophen have no benefit.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (10th ed). Lippincott Williams & Wilkins.
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Question 3 of 200
3. Question
Which is true regarding the epidemiology of mood disorders?
Correct
Major Depressive Disorder is twice as common in women, and it tends to have a later age of onset than bipolar disorder. Bipolar disorder occurs with equal frequency in men and women. Rapid cycling occurs much more frequently in women than men.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (10th ed). Lippincott Williams & Wilkins
Incorrect
Major Depressive Disorder is twice as common in women, and it tends to have a later age of onset than bipolar disorder. Bipolar disorder occurs with equal frequency in men and women. Rapid cycling occurs much more frequently in women than men.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (10th ed). Lippincott Williams & Wilkins
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Question 4 of 200
4. Question
Which of the following developmental phases described by Erikson coincides with the Concrete Operations Stage in the Cognitive Developmental Schema of Piaget?
Correct
In Piaget’s cognitive development theory, the period from 7 years to puberty coincides with the Concrete Operational Stage. Piaget defines this stage as the one during which operational thought and logical thinking dealing with a large amount of information replace egocentric thought. Also, according to Piaget, this is the stage when the child can take another’s perspective. In the psychodynamically-informed Developmental Stage Theory of Erik Erikson, the stage of Industry versus Inferiority is described as extending from age 5 years to adolescence and coinciding with the onset of latency. During this phase, the child learns new skills, enters systematic instruction, and discovers the joy of productivity.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
In Piaget’s cognitive development theory, the period from 7 years to puberty coincides with the Concrete Operational Stage. Piaget defines this stage as the one during which operational thought and logical thinking dealing with a large amount of information replace egocentric thought. Also, according to Piaget, this is the stage when the child can take another’s perspective. In the psychodynamically-informed Developmental Stage Theory of Erik Erikson, the stage of Industry versus Inferiority is described as extending from age 5 years to adolescence and coinciding with the onset of latency. During this phase, the child learns new skills, enters systematic instruction, and discovers the joy of productivity.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 5 of 200
5. Question
Which of the following antiepileptic medications does NOT induce the CYP 450 3A4 enzyme system?
Correct
Carbamazepine, phenytoin, phenobarbital all induce CYP 450 3A4 enzymes, leading to decreased levels of co-administered drugs that are also metabolized by this enzyme. Important substrates are oral contraceptives, warfarin, atypical antipsychotics, imipramine, methadone, statins, and some antineoplastic agents. In addition, since carbamazepine is also metabolized by 3A4, it can “auto-induce” its own metabolism, leading to its own decreased serum levels. Valproic acid can increase the levels of several co-administered drugs through a variety of metabolic pathways; however, it has no induction properties. Of most significance in psychiatry, valproic acid can increase levels of lamotrigine (thereby increasing the risk of developing a rash), carbamazepine, and amitriptyline.
Schacter S. (2023). Antiseizure medications: Mechanism of action, pharmacology, and adverse effects. In Dashe, LF (Ed), UpToDate. Retrieved February 11, 2023 from https://www.uptodate.com
Incorrect
Carbamazepine, phenytoin, phenobarbital all induce CYP 450 3A4 enzymes, leading to decreased levels of co-administered drugs that are also metabolized by this enzyme. Important substrates are oral contraceptives, warfarin, atypical antipsychotics, imipramine, methadone, statins, and some antineoplastic agents. In addition, since carbamazepine is also metabolized by 3A4, it can “auto-induce” its own metabolism, leading to its own decreased serum levels. Valproic acid can increase the levels of several co-administered drugs through a variety of metabolic pathways; however, it has no induction properties. Of most significance in psychiatry, valproic acid can increase levels of lamotrigine (thereby increasing the risk of developing a rash), carbamazepine, and amitriptyline.
Schacter S. (2023). Antiseizure medications: Mechanism of action, pharmacology, and adverse effects. In Dashe, LF (Ed), UpToDate. Retrieved February 11, 2023 from https://www.uptodate.com
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Question 6 of 200
6. Question
Which is true about tardive dyskinesia?
Correct
Choreoathetotic movements of the head, neck, extremities and trunk characterize tardive dyskinesia. Oral-buccal-lingual movements are characteristic. Older females are at greatest risk. Other risk factors include early onset of extrapyramidal symptoms (EPS), mood disorders, and high doses of medication. In contrast, tardive dystonia is characterized by slow, sustained, powerful muscular contractions of the neck, trunk, and limb muscles. Blepharospasm and facial grimacing frequently occur. Tardive dystonia usually has an earlier onset than tardive dyskinesia, and males are at increased risk. Unlike in tardive dyskinesia, anticholinergic medications may improve symptoms of tardive dystonia. Although not FDA approved, botulinum toxin and dopamine depleting agents may also be effective in the treatment of tardive dystonia. VMAT-2 inhibitors (e.g., valbenazine) show efficacy in reducing symptoms of tardive dyskinesia. Lowering the dose of medication or switching to a second-generation antipsychotic may be helpful in both conditions.
Kaufman DM, Geyer HL, Milstein MJ, Rosengard JL. (2023). Kaufman’s Clinical Neurology for Psychiatrists (9th ed). Elsevier
Incorrect
Choreoathetotic movements of the head, neck, extremities and trunk characterize tardive dyskinesia. Oral-buccal-lingual movements are characteristic. Older females are at greatest risk. Other risk factors include early onset of extrapyramidal symptoms (EPS), mood disorders, and high doses of medication. In contrast, tardive dystonia is characterized by slow, sustained, powerful muscular contractions of the neck, trunk, and limb muscles. Blepharospasm and facial grimacing frequently occur. Tardive dystonia usually has an earlier onset than tardive dyskinesia, and males are at increased risk. Unlike in tardive dyskinesia, anticholinergic medications may improve symptoms of tardive dystonia. Although not FDA approved, botulinum toxin and dopamine depleting agents may also be effective in the treatment of tardive dystonia. VMAT-2 inhibitors (e.g., valbenazine) show efficacy in reducing symptoms of tardive dyskinesia. Lowering the dose of medication or switching to a second-generation antipsychotic may be helpful in both conditions.
Kaufman DM, Geyer HL, Milstein MJ, Rosengard JL. (2023). Kaufman’s Clinical Neurology for Psychiatrists (9th ed). Elsevier
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Question 7 of 200
7. Question
The the medical service has requested a psychiatrist to evaluate a 25-year-old actress described as “manic.” The psychiatrist finds that she has word-finding difficulties and memory impairment as well as inattention, pressured speech, and a flight of ideas. She adamantly denies drug and alcohol use, any symptoms prior to ten days before her hospitalization, and family history of psychiatric illness. A neurologist confirms the psychiatrist’s findings and also notes dyskinesia of her left hand. An EEG and MRI both show minor, nonspecific abnormalities, but the CSF shows a lymphocytic pleocytosis and elevated protein. Another consultant finds a cystic ovarian mass of mixed density. Which is the most likely diagnosis?
Correct
Psychiatric symptoms may be the first or most prominent manifestation of NMDA-receptor encephalitis, a recently described cause of delirium and first psychotic break. In addition to mood and thought disturbances, seizures, and involuntary movements, typically called “dyskinesias,” occur regularly. Ovarian teratomas frequently give rise to the disorder. Removing a teratoma, if present, will reverse all the synptoms. Conditions with similar symptoms include infectious encephalitis, non-infectious inflammatory encephalitis, such as lupus, and abuse of PCP or ketamine. NMDA-receptor encephalitis may develop in children as well as men predominantly, older than 45 years. However, it most commonly affects adult females between 25 and 35 years, and females four times more then males.
Dalmau J, Armangue T, Planaguma J, et al. (2019). An update on anti-NMDA receptor encephalitis for neurologists and psychiatrists: mechanisms and models. Lancet Neurol, 18(11); 1045-1057.
Debopam S, Forshing L. Anti-NMDA Receptor Encephalitis. StatPearls. 2022. Ncbi.nlm.nih.gov/books/NBK551672/Incorrect
Psychiatric symptoms may be the first or most prominent manifestation of NMDA-receptor encephalitis, a recently described cause of delirium and first psychotic break. In addition to mood and thought disturbances, seizures, and involuntary movements, typically called “dyskinesias,” occur regularly. Ovarian teratomas frequently give rise to the disorder. Removing a teratoma, if present, will reverse all the synptoms. Conditions with similar symptoms include infectious encephalitis, non-infectious inflammatory encephalitis, such as lupus, and abuse of PCP or ketamine. NMDA-receptor encephalitis may develop in children as well as men predominantly, older than 45 years. However, it most commonly affects adult females between 25 and 35 years, and females four times more then males.
Dalmau J, Armangue T, Planaguma J, et al. (2019). An update on anti-NMDA receptor encephalitis for neurologists and psychiatrists: mechanisms and models. Lancet Neurol, 18(11); 1045-1057.
Debopam S, Forshing L. Anti-NMDA Receptor Encephalitis. StatPearls. 2022. Ncbi.nlm.nih.gov/books/NBK551672/ -
Question 8 of 200
8. Question
Emergency workers bring six subway passengers to the Emergency Room. All are delirious, dyspneic, nauseated, and weak. One is in generalized status epilepticus. They all have copious pulmonary secretions, wheezing, miosis, poor vision, and flaccid paresis with fasciculations. What is the most likely diagnosis?
Correct
Sarin is an organophosphate, a group of chemicals that constitute the active element of poison gases as well as insecticides and pesticides. Organophosphates inhibit acetylcholinesterase and thereby allow acetylcholine to accumulate, precipitating a cholinergic crisis.
Hulse EJ, Halsam J, Emmett SR, et al. (2019). Organophosphorus nerve agent poisoning: managing the poisoned patient. British Journal of Anesthesia, 123;457-463.
Nelson LS, Howland MA, Lewin NA, et al. (2018). Goldfrank’s Toxicologic Emergencies. McGraw-Hill.
Incorrect
Sarin is an organophosphate, a group of chemicals that constitute the active element of poison gases as well as insecticides and pesticides. Organophosphates inhibit acetylcholinesterase and thereby allow acetylcholine to accumulate, precipitating a cholinergic crisis.
Hulse EJ, Halsam J, Emmett SR, et al. (2019). Organophosphorus nerve agent poisoning: managing the poisoned patient. British Journal of Anesthesia, 123;457-463.
Nelson LS, Howland MA, Lewin NA, et al. (2018). Goldfrank’s Toxicologic Emergencies. McGraw-Hill.
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Question 9 of 200
9. Question
A family brings its 70-year-old patriarch for an evaluation for visual hallucinations that have developed during the previous two months. A psychiatrist finds cognitive impairment, confirmed by a Mini Mental Status Examination score of 22/30, and that the patient has a masked face, bradykinesia, rigidity, and gait impairment, although no tremor. What is the most likely diagnosis?
Correct
Salient features of this case are dementia, parkinsonism, and visual hallucinations. These three symptoms constitute the core features of dementia with Lewy body disease. In addition, its suggestive features are rapid eye movement (REM) disorder and hypersensitivity to antipsychotic agents. By way of contrast, dementia usually does not complicate Parkinson disease until it has been present for five or more years. Parkinsonism does not complicate Alzheimer disease. Unlike dopaminergic substances, such as cocaine, dopamine-blocking substances do not produce euphoria and are unlikely to be taken surreptitiously.
Kaufman DM, Geyer HL, Milstein MJ, Rosengard JL. (2023). Kaufman’s Clinical Neurology for Psychiatrists, 9th edition. Philadelphia, PA. Elsevier
Incorrect
Salient features of this case are dementia, parkinsonism, and visual hallucinations. These three symptoms constitute the core features of dementia with Lewy body disease. In addition, its suggestive features are rapid eye movement (REM) disorder and hypersensitivity to antipsychotic agents. By way of contrast, dementia usually does not complicate Parkinson disease until it has been present for five or more years. Parkinsonism does not complicate Alzheimer disease. Unlike dopaminergic substances, such as cocaine, dopamine-blocking substances do not produce euphoria and are unlikely to be taken surreptitiously.
Kaufman DM, Geyer HL, Milstein MJ, Rosengard JL. (2023). Kaufman’s Clinical Neurology for Psychiatrists, 9th edition. Philadelphia, PA. Elsevier
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Question 10 of 200
10. Question
A 45-year-old female presents with symptoms of Major Depressive Disorder. You begin treatment with citalopram 20 mg daily. After four weeks, the patient tells you she has experienced some improvement in her sleep and concentration, and although her mood is still depressed, it is less so. She continues to complain of anhedonia and decreased energy. What should you do?
Correct
Because SSRIs have a flat dose response curve, higher doses of SSRIs will not necessarily offer additional therapeutic benefit, although some patients may show a response to higher doses. Premature dose increases can also increase the risk of side effects. In general, partial response in the first 4 weeks predicts more complete response over the next 8 weeks, even if the dose is held constant. If a given dose is tolerated and not producing partial benefits at 4 weeks (unlike in this patient), the dose should be increased rather than the medication switched.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
Incorrect
Because SSRIs have a flat dose response curve, higher doses of SSRIs will not necessarily offer additional therapeutic benefit, although some patients may show a response to higher doses. Premature dose increases can also increase the risk of side effects. In general, partial response in the first 4 weeks predicts more complete response over the next 8 weeks, even if the dose is held constant. If a given dose is tolerated and not producing partial benefits at 4 weeks (unlike in this patient), the dose should be increased rather than the medication switched.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
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Question 11 of 200
11. Question
Following his usual swim at his gym, a 68-year-old man, who had always been entirely healthy, could not find his locker. Even after a friend located it, the man could not recall the lock’s combination number. At the hospital, his vital signs, general physical examination, and physical neurologic examination were normal; however, he was distraught, befuddled, and unable to recall the name of the physician examining him, more than 2 of 6 digits, or any of 3 objects after 3 minutes. In contrast, he was fully alert and attentive, able to recite, without hesitancy, his home address, his and his wife’s cell phone numbers, and his social security number. After 4 hours, with no treatment, his disturbance entirely cleared. What is the most likely diagnosis?
Correct
This man had a several hour period of almost entirely anterograde amnesia that developed after vigorous exercise. During that time, he retained personal, well-learned information. This is the well-known syndrome of transient global amnesia (TGA). Physically stressful activities, including sexual intercourse and exposure to cold may precipitate an episode of TGA, but episodes rarely recur. Postulated mechanisms have included transient ischemia, cerebral venous insufficiency, and seizures. Although research has not identified a specific cause, the consensus has always been that TGA is a physiologic disorder. In contrast to TGA, the diagnostic criteria for Dissociative Amnesia require loss of important autobiographical information, even if only for a specific event. Dissociative identity disorder’s criteria essentially require two or more personalities as well as amnesia for autobiographical information or traumatic events. Because he was fully alert and attentive, this patient could not have been having a partial complex seizure.
Mahler M. (2020). Transient global amnesia. in Wilterdink, JL (Ed), UpToDate. February 11, 2023, from https://www.uptodate.com
Incorrect
This man had a several hour period of almost entirely anterograde amnesia that developed after vigorous exercise. During that time, he retained personal, well-learned information. This is the well-known syndrome of transient global amnesia (TGA). Physically stressful activities, including sexual intercourse and exposure to cold may precipitate an episode of TGA, but episodes rarely recur. Postulated mechanisms have included transient ischemia, cerebral venous insufficiency, and seizures. Although research has not identified a specific cause, the consensus has always been that TGA is a physiologic disorder. In contrast to TGA, the diagnostic criteria for Dissociative Amnesia require loss of important autobiographical information, even if only for a specific event. Dissociative identity disorder’s criteria essentially require two or more personalities as well as amnesia for autobiographical information or traumatic events. Because he was fully alert and attentive, this patient could not have been having a partial complex seizure.
Mahler M. (2020). Transient global amnesia. in Wilterdink, JL (Ed), UpToDate. February 11, 2023, from https://www.uptodate.com
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Question 12 of 200
12. Question
A patient admitted involuntarily to a locked inpatient unit with psychotic and suicidal thoughts, refuses to take any medication. The psychiatrist takes the patient to court for medication over objection. Which one of the following is essential for the psychiatrist to prove in order to win the case?
Correct
When doctors go to court for medication over objection, they need to demonstrate that the patient lacks the capacity to make a refusal and that the treatment is in the patient’s best interests. Involuntary hospitalization does not negate the presumption that a patient is competent to refuse medication. If the patient represents an acute danger to self or others, this situation constitutes an emergency for which medication can be given over a patient’s objection without going to court. Even if the patient were willing to contract for safety, the contract would not resolve the issue of a refusal to take medication.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (10th ed). Lippincott Williams & Wilkins.
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins.
Incorrect
When doctors go to court for medication over objection, they need to demonstrate that the patient lacks the capacity to make a refusal and that the treatment is in the patient’s best interests. Involuntary hospitalization does not negate the presumption that a patient is competent to refuse medication. If the patient represents an acute danger to self or others, this situation constitutes an emergency for which medication can be given over a patient’s objection without going to court. Even if the patient were willing to contract for safety, the contract would not resolve the issue of a refusal to take medication.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (10th ed). Lippincott Williams & Wilkins.
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins.
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Question 13 of 200
13. Question
Of the following choices, which one is most likely to be the cause of a psychiatric malpractice suit?
Correct
While suicide or attempted suicide represents the most frequent cause of loss related to malpractice claims against psychiatrists, the listed choices are each represented to varying degrees. Breach of confidentiality was cited in 15 percent of malpractice claims, the highest among the answer choices. Boundary violation was named as the primary allegation in 3 percent of cases, whereas a “duty to warn/protect” (e.g., a Tarasoff case), and abandonment are each cited in only 1 percent.
Frierson RL, Joshi KG. (2019). Malpractice law and psychiatry: an overview. Focus: the journal of lifelong learning in psychiatry, 17(4): 332-336.Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins
Incorrect
While suicide or attempted suicide represents the most frequent cause of loss related to malpractice claims against psychiatrists, the listed choices are each represented to varying degrees. Breach of confidentiality was cited in 15 percent of malpractice claims, the highest among the answer choices. Boundary violation was named as the primary allegation in 3 percent of cases, whereas a “duty to warn/protect” (e.g., a Tarasoff case), and abandonment are each cited in only 1 percent.
Frierson RL, Joshi KG. (2019). Malpractice law and psychiatry: an overview. Focus: the journal of lifelong learning in psychiatry, 17(4): 332-336.Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins
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Question 14 of 200
14. Question
A 30 y.o man believed that he was sent by God to cleanse the Earth of sinners. He heard what he believed to be God’s voice telling him to act. He purchased a hunting knife and killed two prostitutes. In order to be found guilty of murder the prosecution must prove that this man had which one of the following:
Correct
A socially harmful act is not enough to have committed a crime. To be found guilty, the accused must also have mens rea (evil intent) and actus reus (voluntary conduct). Because the man is psychotic, he could be deemed not-guilty-by-reason-of-insanity. Respondeat superior states that a person occupying a high position in a hierarchy is responsible for those in lower positions. Non-malfeasance is the duty of physicians to do no harm. Parens patriae is a doctrine that allows the state to intervene and act as a surrogate parent for those who are unable to care for themselves.
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins.
Incorrect
A socially harmful act is not enough to have committed a crime. To be found guilty, the accused must also have mens rea (evil intent) and actus reus (voluntary conduct). Because the man is psychotic, he could be deemed not-guilty-by-reason-of-insanity. Respondeat superior states that a person occupying a high position in a hierarchy is responsible for those in lower positions. Non-malfeasance is the duty of physicians to do no harm. Parens patriae is a doctrine that allows the state to intervene and act as a surrogate parent for those who are unable to care for themselves.
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins.
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Question 15 of 200
15. Question
Which one of the following paraphilias is the least likely to lead to legal involvement?
Correct
The paraphilias that most commonly lead to legal consequences include pedophilia, exhibitionism, and sexual sadism resulting in rape or murder. Persons with fetishism rarely become entangled in the legal system.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
The paraphilias that most commonly lead to legal consequences include pedophilia, exhibitionism, and sexual sadism resulting in rape or murder. Persons with fetishism rarely become entangled in the legal system.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 16 of 200
16. Question
A 25-year-old woman with schizophrenia has been using heroin with increasing frequency. She went into a department store and stole merchandise, expecting to sell it to buy heroin. She was caught on camera and arrested. Because she was noted to be internally preoccupied while in jail, she was evaluated for fitness to stand trial. Which of the following tools would be most useful in evaluating her?
Correct
The McGarry instrument is a clinical guide that evaluates 13 areas of functioning in order to determine a patient’s competence to stand trial. The McNaughton (M’Naghten) rule states that people are not guilty by reason of insanity if they have a mental disease such that they are unaware of the nature, quality, and consequences of the actions, or if they are incapable of realizing that their acts are wrong. The McGann instrument and the McInnis instrument are not real and are just distractors.
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins.
Incorrect
The McGarry instrument is a clinical guide that evaluates 13 areas of functioning in order to determine a patient’s competence to stand trial. The McNaughton (M’Naghten) rule states that people are not guilty by reason of insanity if they have a mental disease such that they are unaware of the nature, quality, and consequences of the actions, or if they are incapable of realizing that their acts are wrong. The McGann instrument and the McInnis instrument are not real and are just distractors.
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins.
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Question 17 of 200
17. Question
A 27 y.o. woman was diagnosed with schizophrenia 6 months ago. She is currently treated with iloperidone (Fanapt) 8mg. BID. She now reports new onset of symptoms of depression for which the psychiatrist will add paroxetine 20 mg. QD. What adjustment to the dosage of iloperidone should be made?
Correct
Iloperidone (Fanapt) is metabolized by CYP 2D6 and CYP 3A4 P450 enzymes. It is necessary to reduce the dosage of iloperidone by 50% if it is given concomitantly with a strong inhibitor of either enzyme. Paroxetine is a strong inhibitor of 2D6. When the inhibitor is discontinued, the dosage should be returned to its previous level. Side effects of iloperidone include sedation, orthostatic hypotension, dizziness, and tachycardia. Iloperidone can also cause QTC prolongation and EPS. The usual starting dose is 1 mg. BID with a gradual titration to a 6-12 mg. BID.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
Incorrect
Iloperidone (Fanapt) is metabolized by CYP 2D6 and CYP 3A4 P450 enzymes. It is necessary to reduce the dosage of iloperidone by 50% if it is given concomitantly with a strong inhibitor of either enzyme. Paroxetine is a strong inhibitor of 2D6. When the inhibitor is discontinued, the dosage should be returned to its previous level. Side effects of iloperidone include sedation, orthostatic hypotension, dizziness, and tachycardia. Iloperidone can also cause QTC prolongation and EPS. The usual starting dose is 1 mg. BID with a gradual titration to a 6-12 mg. BID.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
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Question 18 of 200
18. Question
Which of the following would most likely be observed on a standard MRI brain of a patient with PTSD?
Correct
MRI studies in patients with PTSD show decreased hippocampal volume. The answer choice involving the putamen and caudate is a distractor. Increased size of the lateral ventricles is seen in schizophrenia. Decreased metabolic activity in the prefrontal cortex is seen in schizophrenia, not PTSD. In addition, metabolic activity is evaluated using fMRI or PET, not a standard MRI.
Ben-Zion Z, Artzi M, Niry D, et al. (2020). Neuroanatomical risk factors for posttraumatic stress disorder in recent trauma survivors. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 5; 311-319.
Incorrect
MRI studies in patients with PTSD show decreased hippocampal volume. The answer choice involving the putamen and caudate is a distractor. Increased size of the lateral ventricles is seen in schizophrenia. Decreased metabolic activity in the prefrontal cortex is seen in schizophrenia, not PTSD. In addition, metabolic activity is evaluated using fMRI or PET, not a standard MRI.
Ben-Zion Z, Artzi M, Niry D, et al. (2020). Neuroanatomical risk factors for posttraumatic stress disorder in recent trauma survivors. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 5; 311-319.
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Question 19 of 200
19. Question
Of the people listed below, who is most associated with the theory of Operant Conditioning?
Correct
B.F. Skinner is associated with operant conditioning. In operant conditioning, voluntary behavior is modified using positive and negative reinforcement to shape the desired behavior. Ivan Pavlov is associated with classical conditioning. In classical conditioning a neutral (conditioned) stimulus is paired with a stimulus that evokes a response (unconditioned), such that the neutral stimulus eventually comes to evoke the same response. Martin Seligman is associated with learned helplessness, which is a model of depression in which an individual repetitively fails at tasks and eventually stops trying, adopting a hopeless apathetic position. Salvador Minuchin is associated with structural family therapy. Structural family therapy focuses on the organization of the family and how that organization promotes or impedes the family from functioning successfully.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (10th ed). Lippincott Williams & Wilkins.
Incorrect
B.F. Skinner is associated with operant conditioning. In operant conditioning, voluntary behavior is modified using positive and negative reinforcement to shape the desired behavior. Ivan Pavlov is associated with classical conditioning. In classical conditioning a neutral (conditioned) stimulus is paired with a stimulus that evokes a response (unconditioned), such that the neutral stimulus eventually comes to evoke the same response. Martin Seligman is associated with learned helplessness, which is a model of depression in which an individual repetitively fails at tasks and eventually stops trying, adopting a hopeless apathetic position. Salvador Minuchin is associated with structural family therapy. Structural family therapy focuses on the organization of the family and how that organization promotes or impedes the family from functioning successfully.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (10th ed). Lippincott Williams & Wilkins.
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Question 20 of 200
20. Question
A young man presents to the psychiatrist’s office with a history of having panic attacks for the past several months. The attacks have increased in frequency to the point where he is now having panic attacks 2-3 times per day. Following an evaluation, the psychiatrist prescribes medication and cognitive behavioral therapy (CBT). Which one of the following is LEAST likely to be part of the prescribed therapy?
Correct
CBT has been well-studied and shown to be very effective for panic disorder. It often includes psychoeducation, continuous panic monitoring, breathing retraining, cognitive restructuring, and exposure to fear cues. Developing discrepancy between the patient’s goals and current behavior is an important element of Motivational Interviewing, which is used in substance abuse treatment; however, it is not considered a central element of CBT.
Wright JH, Thase ME, Beck AT. (2019). The American Psychiatric Publishing Textbook of Psychiatry (7th ed). American Psychiatric Publishing, Inc.
Incorrect
CBT has been well-studied and shown to be very effective for panic disorder. It often includes psychoeducation, continuous panic monitoring, breathing retraining, cognitive restructuring, and exposure to fear cues. Developing discrepancy between the patient’s goals and current behavior is an important element of Motivational Interviewing, which is used in substance abuse treatment; however, it is not considered a central element of CBT.
Wright JH, Thase ME, Beck AT. (2019). The American Psychiatric Publishing Textbook of Psychiatry (7th ed). American Psychiatric Publishing, Inc.
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Question 21 of 200
21. Question
A 10-year-old boy has a history of motor tics and attention deficit hyperactivity disorder (ADHD). He has received treatment with methylphenidate. Over the past few weeks, the tics have worsened, and he has developed a snorting sound that is likely a new vocal tic. The patient’s pediatrician discontinued the methylphenidate, but the tics persisted. In addition,his impulsivity and hyperactivity worsened. A child psychiatry consultation was obtained, and the diagnosis of Tourette disorder was made. What would be the most appropriate next medication trial for this patient?
Correct
In the treatment guidelines for children with ADHD and moderate tic disorders, guanfacine and clonidine are considered first line treatments. These medications are effective both for tic control and decrease in impulsivity and hyperactivity. Moreover, they have a favorable safety margin compared with the antipsychotic medications.
Ogundele MO, Ayyash HF. (2018). Review of the evidence for the management of co-morbid tic disorders in children and adolescents with attention deficit hyperactivity disorder. World Journal of Clinical Pediatrics, 7(1);36-42.
Osland ST, Steeves TD, Pringsheim T. (2018). Pharmacological treatment for attention deficit hyperactivity disorder (ADHD) in children with comorbid tic disorders. The Cochrane database of systematic reviews, 6(6);CD007990
Incorrect
In the treatment guidelines for children with ADHD and moderate tic disorders, guanfacine and clonidine are considered first line treatments. These medications are effective both for tic control and decrease in impulsivity and hyperactivity. Moreover, they have a favorable safety margin compared with the antipsychotic medications.
Ogundele MO, Ayyash HF. (2018). Review of the evidence for the management of co-morbid tic disorders in children and adolescents with attention deficit hyperactivity disorder. World Journal of Clinical Pediatrics, 7(1);36-42.
Osland ST, Steeves TD, Pringsheim T. (2018). Pharmacological treatment for attention deficit hyperactivity disorder (ADHD) in children with comorbid tic disorders. The Cochrane database of systematic reviews, 6(6);CD007990
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Question 22 of 200
22. Question
Parents of a 3-year-old boy report that their child has not begun to talk. Since his birth, he has been difficult to sooth and has had difficulty with transitions. He has also been a difficult sleeper and, over the past year, has had frequent violent temper tantrums. What should the physician do next?
Correct
The most important first intervention in a child who presents with language delay is a full hearing evaluation.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (10th ed). Lippincott Williams & Wilkins
Incorrect
The most important first intervention in a child who presents with language delay is a full hearing evaluation.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (10th ed). Lippincott Williams & Wilkins
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Question 23 of 200
23. Question
Which of the following disorders frequently diagnosed in childhood and adolescence, requires symptoms to be present in two or more settings?
Correct
Problems with attention and behavior typically occur in several settings and may vary depending on the level of structure and supervision provided, the interest in and/or novelty of an activity or setting, as well as the level of concentration and effort required. Therefore, to make the diagnosis of ADHD, the patient must exhibit symptoms during at least two settings.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins
Incorrect
Problems with attention and behavior typically occur in several settings and may vary depending on the level of structure and supervision provided, the interest in and/or novelty of an activity or setting, as well as the level of concentration and effort required. Therefore, to make the diagnosis of ADHD, the patient must exhibit symptoms during at least two settings.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins
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Question 24 of 200
24. Question
An adolescent presents with developmental delays, cleft palate, heart abnormalities. and symptoms of an evolving schizophreniform disorder. Which of the following genetic disorders is this child likely to have?
Correct
Velocardiofacial Syndrome (VCFS), also called Shprintzen syndrome or DiGeorge syndrome, is caused by a microdeletion in the long arm of chromosome 22 at band 22q11.2. The phenotypic spectrum of VCFS is wide and includes congenital cardiac anomalies, abnormal facies, palatal abnormalities, hypocalcemia, T-cell immunodeficiencies, cognitive deficits, and psychiatric manifestations including schizophrenia.
Cirillo A, Lioncino M, Maratea A, et al. (2022). Clinical manifestations of 22q11.2 deletion syndrome. Heart Failure Clinics, 18(1):155-164.
Incorrect
Velocardiofacial Syndrome (VCFS), also called Shprintzen syndrome or DiGeorge syndrome, is caused by a microdeletion in the long arm of chromosome 22 at band 22q11.2. The phenotypic spectrum of VCFS is wide and includes congenital cardiac anomalies, abnormal facies, palatal abnormalities, hypocalcemia, T-cell immunodeficiencies, cognitive deficits, and psychiatric manifestations including schizophrenia.
Cirillo A, Lioncino M, Maratea A, et al. (2022). Clinical manifestations of 22q11.2 deletion syndrome. Heart Failure Clinics, 18(1):155-164.
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Question 25 of 200
25. Question
Which of the following was a finding of the CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) trial Phase 1?
Correct
The CATIE study was a randomized controlled, double-blind trial comparing the effectiveness of second-generation antipsychotics to the conventional antipsychotic perphenazine. More than 1400 patients were enrolled. The results indicated that 74% of patients in the trial discontinued their medication during the 18 months of the study duration, confirming that adherence is a substantial problem in the treatment of patients with schizophrenia. The most likely cause of perphenazine discontinuation was EPS; however, there was no overall significant difference in the proportion of patients with EPS across groups. Olanzapine was associated with more weight gain and metabolic abnormalities. Regarding efficacy, perphenazine was found to be similar to quetiapine, risperidone, and ziprasidone. Olanzapine was found to be the most effective of the agents tested based on longest time to discontinuation, greater decrease in psychopathology, and lower rates of rehospitalization.
Kim J, Ozzoude M, Nakajima S. (2019). Insight and medication adherence in schizophrenia: an analysis of the CATIE trial. Neuropharmacology, 168;107634
Incorrect
The CATIE study was a randomized controlled, double-blind trial comparing the effectiveness of second-generation antipsychotics to the conventional antipsychotic perphenazine. More than 1400 patients were enrolled. The results indicated that 74% of patients in the trial discontinued their medication during the 18 months of the study duration, confirming that adherence is a substantial problem in the treatment of patients with schizophrenia. The most likely cause of perphenazine discontinuation was EPS; however, there was no overall significant difference in the proportion of patients with EPS across groups. Olanzapine was associated with more weight gain and metabolic abnormalities. Regarding efficacy, perphenazine was found to be similar to quetiapine, risperidone, and ziprasidone. Olanzapine was found to be the most effective of the agents tested based on longest time to discontinuation, greater decrease in psychopathology, and lower rates of rehospitalization.
Kim J, Ozzoude M, Nakajima S. (2019). Insight and medication adherence in schizophrenia: an analysis of the CATIE trial. Neuropharmacology, 168;107634
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Question 26 of 200
26. Question
Which of the following statements is true regarding lithium?
Correct
Lithium is excreted in the urine. Because lithium levels can be increased 30%-50% when taken with thiazide diuretics, adjustments in its dosage are required when the two medicines are used concomitantly. NSAIDs, ACE inhibitors, and calcium channel blockers can also increase lithium levels. Lithium levels are decreased by theophylline and osmotic diuretics. Salt and water intake can also affect lithium levels. If GFR is increased, for example with pregnancy, lithium levels will decrease. On the other hand, if GFR is decreased, for example in the elderly or in patients with renal disease, lithium levels will increase.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc
Incorrect
Lithium is excreted in the urine. Because lithium levels can be increased 30%-50% when taken with thiazide diuretics, adjustments in its dosage are required when the two medicines are used concomitantly. NSAIDs, ACE inhibitors, and calcium channel blockers can also increase lithium levels. Lithium levels are decreased by theophylline and osmotic diuretics. Salt and water intake can also affect lithium levels. If GFR is increased, for example with pregnancy, lithium levels will decrease. On the other hand, if GFR is decreased, for example in the elderly or in patients with renal disease, lithium levels will increase.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc
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Question 27 of 200
27. Question
Which food is safe to ingest by patients treated with nonreversible monoamine oxidase inhibitors (MAOIs)?
Correct
When patients treated with nonreversible MAOIs ingest tyramine containing foods, they are at risk to develop a hypertensive crisis. They should avoid foods with high tyramine content, including beer, red wine, aged cheeses, aged or fermented meats, fava beans, smoked fish, and yeast extracts. Chocolate, caffeine, and other alcoholic beverages can be a problem if ingested in large amounts but are acceptable if used in moderation. Foods that are safe to ingest include cottage cheese, cream cheese, figs, and raisins.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
Incorrect
When patients treated with nonreversible MAOIs ingest tyramine containing foods, they are at risk to develop a hypertensive crisis. They should avoid foods with high tyramine content, including beer, red wine, aged cheeses, aged or fermented meats, fava beans, smoked fish, and yeast extracts. Chocolate, caffeine, and other alcoholic beverages can be a problem if ingested in large amounts but are acceptable if used in moderation. Foods that are safe to ingest include cottage cheese, cream cheese, figs, and raisins.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
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Question 28 of 200
28. Question
Which is not a feature of schizoid personality disorder?
Correct
Schizoid personality disorder is characterized by social detachment, isolation, and constricted affect. Affected individuals lack close friends, do not take pleasure in activities, and appear cold, aloof, and indifferent to others. Suspiciousness and mistrust is a core feature of paranoid personality disorder.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
Schizoid personality disorder is characterized by social detachment, isolation, and constricted affect. Affected individuals lack close friends, do not take pleasure in activities, and appear cold, aloof, and indifferent to others. Suspiciousness and mistrust is a core feature of paranoid personality disorder.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 29 of 200
29. Question
Which of the following agents would be the LEAST effective pharmacologic treatment for a patient experiencing an acute manic episode?
Correct
Medications with proven efficacy in acute mania include antipsychotics (both typical and atypical, with generally equal benefit) and certain mood stabilizers, namely lithium, valproic acid, and carbamazepine. Lamotrigine, while an effective treatment for bipolar depression, has not been shown to be effective in treatment of acute mania.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
Incorrect
Medications with proven efficacy in acute mania include antipsychotics (both typical and atypical, with generally equal benefit) and certain mood stabilizers, namely lithium, valproic acid, and carbamazepine. Lamotrigine, while an effective treatment for bipolar depression, has not been shown to be effective in treatment of acute mania.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
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Question 30 of 200
30. Question
You have been treating a patient diagnosed with atypical depression with fluoxetine for three months without success. You wish to start a trial of an MAOI, such as phenelzine (Nardil). You will discontinue the fluoxetine today. How long must you wait until you start the MAOI?
Correct
Due to fluoxetine’s long half-life, when switching from it to an MAOI, a 5-week washout period is advised to reduce the risk of developing serotonin syndrome. When transitioning from an MAOI to fluoxetine, the recommended washout period is two weeks. When switching between an MAOI and other SSRIs, the washout period is two weeks.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
Incorrect
Due to fluoxetine’s long half-life, when switching from it to an MAOI, a 5-week washout period is advised to reduce the risk of developing serotonin syndrome. When transitioning from an MAOI to fluoxetine, the recommended washout period is two weeks. When switching between an MAOI and other SSRIs, the washout period is two weeks.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
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Question 31 of 200
31. Question
Which is the most common method used to complete suicide in the United States?
Correct
According to 2020 data published by Center for Disease Control, firearms account for 52.8% of completed suicides in the United States. Suffocation or hanging accounts for 27.2% and poisoning resulted in 12.9 % of suicides. Worldwide, ingestion of pesticide, hanging, and firearms are the most common methods of suicide, according to the World Health Organization.
CDC (2022, June 28). Suicide prevention: Suicide data and statistics. Retrieved February 11, 2023, from https://www.cdc.gov/suicide/suicide-data-statistics.html
WHO (2021, June 17). Suicide. Retrieved February 11, 2023 from https://www.who.int/news-room/fact-sheets/detail/suicide.html
Incorrect
According to 2020 data published by Center for Disease Control, firearms account for 52.8% of completed suicides in the United States. Suffocation or hanging accounts for 27.2% and poisoning resulted in 12.9 % of suicides. Worldwide, ingestion of pesticide, hanging, and firearms are the most common methods of suicide, according to the World Health Organization.
CDC (2022, June 28). Suicide prevention: Suicide data and statistics. Retrieved February 11, 2023, from https://www.cdc.gov/suicide/suicide-data-statistics.html
WHO (2021, June 17). Suicide. Retrieved February 11, 2023 from https://www.who.int/news-room/fact-sheets/detail/suicide.html
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Question 32 of 200
32. Question
A 32-year-old female has been treated for bipolar disorder with lithium carbonate 600 mg. BID. She was recently admitted with symptoms of depression and psychosis. Haloperidol 2mg. BID, and citalopram 20mg. QD were added to her regimen. The following morning, she began complaining of nausea and abdominal discomfort. She had a temperature of 1010F and was shivering and diaphoretic. She was noted to be mildly agitated and confused. Her physical examination was notable for hyperactive bowel sounds, hyperreflexia, and bilateral myoclonus of her lower extremities. Her lithium level was 0.7meq/l. Other laboratory findings were unremarkable. What is the most likely cause of her presentation?
Correct
Serotonin syndrome can present with a wide array of symptoms that vary in severity. In a patient who has recently received serotonergic agents or has had a dosage adjustment, hyperreflexia, myoclonus, and tremor are highly suggestive of the disorder. Other symptoms of the serotonin syndrome include diarrhea, tachycardia, elevated temperature, diaphoresis, shivering, elevated BP, and muscular rigidity (which can mask the other neuromuscular symptoms). Mental status changes, ranging from agitation and confusion to frank delirium, can also occur. Lithium toxicity would be unlikely to occur at a level of 0.7meq.l. In contrast, in neuroleptic malignant syndrome, severe muscle rigidity (“lead pipe rigidity”), mutism, and decreased bowel sounds would be seen. Anticholinergic toxicity is characterized by hyperthermia, tachycardia, dry mouth, decreased or absent bowel sounds, agitation and delirium, normal neuromuscular tone, and normal reflexes.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
Serotonin syndrome can present with a wide array of symptoms that vary in severity. In a patient who has recently received serotonergic agents or has had a dosage adjustment, hyperreflexia, myoclonus, and tremor are highly suggestive of the disorder. Other symptoms of the serotonin syndrome include diarrhea, tachycardia, elevated temperature, diaphoresis, shivering, elevated BP, and muscular rigidity (which can mask the other neuromuscular symptoms). Mental status changes, ranging from agitation and confusion to frank delirium, can also occur. Lithium toxicity would be unlikely to occur at a level of 0.7meq.l. In contrast, in neuroleptic malignant syndrome, severe muscle rigidity (“lead pipe rigidity”), mutism, and decreased bowel sounds would be seen. Anticholinergic toxicity is characterized by hyperthermia, tachycardia, dry mouth, decreased or absent bowel sounds, agitation and delirium, normal neuromuscular tone, and normal reflexes.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 33 of 200
33. Question
Which of the following medications is most likely to increase the levels of lamotrigine, if co-administered?
Correct
Valproic acid can double serum levels of lamotrigine. This interaction is of particular concern because of the increased risk of rash that occurs in patients taking lamotrigine. While most often the rash is benign, it can herald Steven’s Johnson syndrome, a potentially fatal reaction. The risk of developing a rash is increased by rate of titration and starting dosage. Therefore, lower dosage and slower titration of lamotrigine is recommended if valproic acid is used together with lamotrigine. Neither paroxetine, a 2D6 inhibitor, nor iloperidone affects lamotrigine levels.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
Incorrect
Valproic acid can double serum levels of lamotrigine. This interaction is of particular concern because of the increased risk of rash that occurs in patients taking lamotrigine. While most often the rash is benign, it can herald Steven’s Johnson syndrome, a potentially fatal reaction. The risk of developing a rash is increased by rate of titration and starting dosage. Therefore, lower dosage and slower titration of lamotrigine is recommended if valproic acid is used together with lamotrigine. Neither paroxetine, a 2D6 inhibitor, nor iloperidone affects lamotrigine levels.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
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Question 34 of 200
34. Question
For how long must a patient be observed at the treating facility after receiving an IM injection of long-acting olanzapine (Zyprexa Relprevv)? v
Correct
The long-acting injectable formulation of olanzapine has a black box warning because it is associated with the development of post-sedation delirium syndrome (PDSS). Symptoms can range from sedation, which may be severe, to coma or delirium. This formulation of olanzapine can only be administered in a registered health care facility, and patients must be observed for at least 3 hours before they can be sent home.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
The long-acting injectable formulation of olanzapine has a black box warning because it is associated with the development of post-sedation delirium syndrome (PDSS). Symptoms can range from sedation, which may be severe, to coma or delirium. This formulation of olanzapine can only be administered in a registered health care facility, and patients must be observed for at least 3 hours before they can be sent home.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 35 of 200
35. Question
A 50-year-old female diagnosed with schizophrenia and treated with haloperidol 5mg. BID for several years develops symptoms of tardive dyskinesia. Which management strategy is most likely to worsen her symptoms of tardive dyskinesia?
Correct
Anticholinergic agents do not improve and in some cases may exacerbate symptoms of tardive dyskinesia and should be discontinued or avoided. Switching to clozapine or a second-generation antipsychotic agent may decrease symptoms of tardive dyskinesia. Lowering the dose of a medication may also be effective, but initially the symptoms may appear to worsen, as a result of withdrawal emergent dyskinesias. Benzodiazepines may offer some partial or temporary relief.
Kaufman DM, Geyer HL, Milstein MJ, Rosengard JL. (2023). Kaufman’s Clinical Neurology for Psychiatrists (9th ed). Elsevier.
Incorrect
Anticholinergic agents do not improve and in some cases may exacerbate symptoms of tardive dyskinesia and should be discontinued or avoided. Switching to clozapine or a second-generation antipsychotic agent may decrease symptoms of tardive dyskinesia. Lowering the dose of a medication may also be effective, but initially the symptoms may appear to worsen, as a result of withdrawal emergent dyskinesias. Benzodiazepines may offer some partial or temporary relief.
Kaufman DM, Geyer HL, Milstein MJ, Rosengard JL. (2023). Kaufman’s Clinical Neurology for Psychiatrists (9th ed). Elsevier.
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Question 36 of 200
36. Question
Which personality disorder most commonly occurs in the relatives of people diagnosed with schizophrenia?
Correct
There is an increased risk of schizotypal personality disorder in the relatives of people diagnosed with schizophrenia. This relationship provides support for the concept that schizotypal personality disorder and schizophrenia are spectrum disorders. In addition, an increased risk for developing schizophrenia occurs in the relatives of people with schizotypal personality disorder. Paranoid personality disorder can also be found in relatives of people with schizophrenia, but it is not as common as schizotypal personality disorder.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
There is an increased risk of schizotypal personality disorder in the relatives of people diagnosed with schizophrenia. This relationship provides support for the concept that schizotypal personality disorder and schizophrenia are spectrum disorders. In addition, an increased risk for developing schizophrenia occurs in the relatives of people with schizotypal personality disorder. Paranoid personality disorder can also be found in relatives of people with schizophrenia, but it is not as common as schizotypal personality disorder.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 37 of 200
37. Question
Which medication auto-induces its own metabolism?
Correct
Carbamazepine is both a substrate and an inducer at CYP 450 3A4. It can induce its own metabolism, which leads to decreased plasma levels even though dosing remains constant.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.Incorrect
Carbamazepine is both a substrate and an inducer at CYP 450 3A4. It can induce its own metabolism, which leads to decreased plasma levels even though dosing remains constant.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc. -
Question 38 of 200
38. Question
A patient recently diagnosed with schizophrenia was treated on an inpatient unit with risperidone 4 mg. per day. After his auditory hallucinations resolved, he was discharged. Several weeks later, his outpatient psychiatrist added an antidepressant to treat symptoms of depression. Three days later the patient complains of stiffness in his arms and legs. Which medication did the psychiatrist most likely prescribe?
Correct
Fluoxetine is a potent inhibitor of the cytochrome P450 enzyme CYP2D6 and a less potent inhibitor of CYP3A4, which can reduce the clearance of risperidone and increase plasma concentrations of risperidone. This interaction may lead to toxic plasma risperidone concentrations and parkinsonism and EPS. In addition to careful clinical observation, monitoring plasma risperidone levels may be of value in patients given adjunctive therapy with fluoxetine.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
Incorrect
Fluoxetine is a potent inhibitor of the cytochrome P450 enzyme CYP2D6 and a less potent inhibitor of CYP3A4, which can reduce the clearance of risperidone and increase plasma concentrations of risperidone. This interaction may lead to toxic plasma risperidone concentrations and parkinsonism and EPS. In addition to careful clinical observation, monitoring plasma risperidone levels may be of value in patients given adjunctive therapy with fluoxetine.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
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Question 39 of 200
39. Question
Which side effect is most commonly encountered by patients treated with trazodone?
Correct
Sedation is the most common side effect of trazodone. Orthostatic hypotension and dizziness also frequently occur. Priapism and cardiac arrhythmias are uncommon adverse effects.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
Incorrect
Sedation is the most common side effect of trazodone. Orthostatic hypotension and dizziness also frequently occur. Priapism and cardiac arrhythmias are uncommon adverse effects.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
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Question 40 of 200
40. Question
Which would NOT be seen in an individual presenting with a hypomanic episode?
Correct
Psychotic symptoms are seen in patients during a manic episode but not during hypomania. All of the other symptoms are consistent with both mania and hypomania. Another distinction between hypomania and mania is that social and occupational functioning is not significantly impaired in the hypomania.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
Psychotic symptoms are seen in patients during a manic episode but not during hypomania. All of the other symptoms are consistent with both mania and hypomania. Another distinction between hypomania and mania is that social and occupational functioning is not significantly impaired in the hypomania.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 41 of 200
41. Question
What is the most common acquired cause of mild-moderate intellectual disability?
Correct
Fetal Alcohol Syndrome, caused by maternal excessive alcohol consumption during pregnancy, is the most common acquired and potentially preventable, cause of intellectual disability. Down’s syndrome is the most common genetic cause of intellectual disability. Because trisomy 21 (Down’s syndrome) is not present in either parent, it is not inheritable. Fragile X, in contrast, is probably the most common inheritable rather than acquired cause of intellectual disability. The mutation (excessive trinucleotide repeats) is often present in parents, but in small enough size that symptoms occur in only mild forms. When the size of the mutation is large, children are at risk for the full-blown illness. Autism spectrum disorder is associated in ~70% of cases of Fragile X.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
Fetal Alcohol Syndrome, caused by maternal excessive alcohol consumption during pregnancy, is the most common acquired and potentially preventable, cause of intellectual disability. Down’s syndrome is the most common genetic cause of intellectual disability. Because trisomy 21 (Down’s syndrome) is not present in either parent, it is not inheritable. Fragile X, in contrast, is probably the most common inheritable rather than acquired cause of intellectual disability. The mutation (excessive trinucleotide repeats) is often present in parents, but in small enough size that symptoms occur in only mild forms. When the size of the mutation is large, children are at risk for the full-blown illness. Autism spectrum disorder is associated in ~70% of cases of Fragile X.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 42 of 200
42. Question
Which of the following is true about velo-cardio-facial syndrome (VCFS)?
Correct
VCFS is best known for its association with psychiatric disorders. It is particularly well-known for representing a genetic risk for schizophrenia. In VCFS, early loss of temporal grey matter seems to predict the early signs of significant psychiatric problems. Except for having two parents with schizophrenia or being the monozygotic twin of someone with schizophrenia, VCFS is the highest risk factor for developing schizophrenia. VCFS is also associated with autism, ADHD, mood disorders, and phobias. In the very young, management is related to treatment of cardiac, immune, and palatal difficulties along with developmental delays. In the school years, cognitive difficulties are prominent. In young adulthood, psychiatric difficulties may develop. VCFS is not a sex-linked condition; it is caused by a micro-deletion at 22.11.2. Answer A refers to tuberous sclerosis, which presents with nodules seen on the malar surface of the face, refractory epilepsy, and progressive intellectual disability. It is associated with autism-like symptoms. The microdeletion syndromes at 15Q are Prader-Willi (usually paternal deletion) and Angelman (usually maternal deletion). In general, abnormal sex chromosomes produce physical findings and not necessarily intellectual dysfunction, whereas abnormal autosomal chromosomes are usually associated with intellectual disability.
Cirillo A, Lioncino M, Maratea A, et al. (2022). Clinical manifestations of 22q11.2 deletion syndrome. Heart Failure Clinics, 18(1):155-164.
Incorrect
VCFS is best known for its association with psychiatric disorders. It is particularly well-known for representing a genetic risk for schizophrenia. In VCFS, early loss of temporal grey matter seems to predict the early signs of significant psychiatric problems. Except for having two parents with schizophrenia or being the monozygotic twin of someone with schizophrenia, VCFS is the highest risk factor for developing schizophrenia. VCFS is also associated with autism, ADHD, mood disorders, and phobias. In the very young, management is related to treatment of cardiac, immune, and palatal difficulties along with developmental delays. In the school years, cognitive difficulties are prominent. In young adulthood, psychiatric difficulties may develop. VCFS is not a sex-linked condition; it is caused by a micro-deletion at 22.11.2. Answer A refers to tuberous sclerosis, which presents with nodules seen on the malar surface of the face, refractory epilepsy, and progressive intellectual disability. It is associated with autism-like symptoms. The microdeletion syndromes at 15Q are Prader-Willi (usually paternal deletion) and Angelman (usually maternal deletion). In general, abnormal sex chromosomes produce physical findings and not necessarily intellectual dysfunction, whereas abnormal autosomal chromosomes are usually associated with intellectual disability.
Cirillo A, Lioncino M, Maratea A, et al. (2022). Clinical manifestations of 22q11.2 deletion syndrome. Heart Failure Clinics, 18(1):155-164.
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Question 43 of 200
43. Question
Which is true regarding paraphilias?
Correct
The vast majority of paraphilias occur in men. Close to 100% of exhibitionists are males exposing themselves to women. Fetishism, a disorder in which sexual arousal involves the use of inanimate objects that are typically associated with the body – e.g., shoes, gloves, undergarments – also almost always occurs in men. About 95% of pedophiles are heterosexual. Most pedophiles also have engaged in voyeurism, exhibitionism and rape.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
The vast majority of paraphilias occur in men. Close to 100% of exhibitionists are males exposing themselves to women. Fetishism, a disorder in which sexual arousal involves the use of inanimate objects that are typically associated with the body – e.g., shoes, gloves, undergarments – also almost always occurs in men. About 95% of pedophiles are heterosexual. Most pedophiles also have engaged in voyeurism, exhibitionism and rape.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 44 of 200
44. Question
An 8-year-old profoundly intellectually disabled boy is referred to you for hyperactivity and features of autism. On exam he is noted to smile, laugh, and have ataxic movements. Mother tells you that his pediatrician said he had a small head and was diagnosed with an inherited condition. What is his diagnosis?
Correct
Angelman Syndrome is a heritable cause of intellectual disability that occurs when the deletion at 15q is maternally inherited. It occurs in boys and girls and is comprised of profound intellectual disability, microcephaly, paroxysms of laughter, ataxia, and autistic features. Rett syndrome is inheritable but present exclusively in girls (and XXY boys) so this is an incorrect diagnosis. Young girls with Rett have characteristic hand stereotypies. They do have microcephaly but not bursts of laughter or ataxia. Prader- Willi is an inheritable cause of intellectual disability (paternal deletion at 15q) characterized by hyperphagia, obesity, nonfood-related obsessions, and severe behavior problems. Children with Williams syndrome often have “elfin” facies, loquaciousness, and some level of intellectual disability.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (10th ed). Lippincott Williams & Wilkins.
Incorrect
Angelman Syndrome is a heritable cause of intellectual disability that occurs when the deletion at 15q is maternally inherited. It occurs in boys and girls and is comprised of profound intellectual disability, microcephaly, paroxysms of laughter, ataxia, and autistic features. Rett syndrome is inheritable but present exclusively in girls (and XXY boys) so this is an incorrect diagnosis. Young girls with Rett have characteristic hand stereotypies. They do have microcephaly but not bursts of laughter or ataxia. Prader- Willi is an inheritable cause of intellectual disability (paternal deletion at 15q) characterized by hyperphagia, obesity, nonfood-related obsessions, and severe behavior problems. Children with Williams syndrome often have “elfin” facies, loquaciousness, and some level of intellectual disability.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (10th ed). Lippincott Williams & Wilkins.
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Question 45 of 200
45. Question
Which is a common side effect of stimulants?
Correct
Mild elevations of pulse and blood pressure are a common side effect of stimulants. A recommendation for pediatric or cardiology consultation and EKG or further work-up is indicated if there is a family history of early/sudden death or congenital cardiac condition or dysrhythmia in the child. Stimulants do not cause evening sedation. Lithium may cause increased thirst. SSRIs and antipsychotics increase appetite (stimulants typically decrease appetite.)
Storeb OJ, Pedersen N, Ramstad E. (2018). Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents – assessment of adverse events in non-randomized studies. Cochrane Database of Systematic Reviews, 5(5) CD012069.
Incorrect
Mild elevations of pulse and blood pressure are a common side effect of stimulants. A recommendation for pediatric or cardiology consultation and EKG or further work-up is indicated if there is a family history of early/sudden death or congenital cardiac condition or dysrhythmia in the child. Stimulants do not cause evening sedation. Lithium may cause increased thirst. SSRIs and antipsychotics increase appetite (stimulants typically decrease appetite.)
Storeb OJ, Pedersen N, Ramstad E. (2018). Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents – assessment of adverse events in non-randomized studies. Cochrane Database of Systematic Reviews, 5(5) CD012069.
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Question 46 of 200
46. Question
A 24-year-old woman experiences anxiety in multiple social situations. She avoids going to parties, sharing her opinions in the weekly staff meeting at her job, and eating out in restaurants because she worries that she will be embarrassed or judged negatively by others. When forced to speak in a public setting, she experiences flushing, palpitations, and tremulousness. Which medication is LEAST likely to be effective?
Correct
This woman suffers from Social Anxiety Disorder. Paroxetine, sertraline and venlafaxine have FDA approval for the treatment. Off-label, all SSRIS, MAOIs, and benzodiazepines have demonstrated efficacy. β-blockers are effective off-label treatments for performance anxiety but are not useful in generalized social anxiety. Tricyclic antidepressants, which are effective in the treatment of both GAD and panic disorder, have not been shown to be helpful in the treatment of social anxiety disorder.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
Incorrect
This woman suffers from Social Anxiety Disorder. Paroxetine, sertraline and venlafaxine have FDA approval for the treatment. Off-label, all SSRIS, MAOIs, and benzodiazepines have demonstrated efficacy. β-blockers are effective off-label treatments for performance anxiety but are not useful in generalized social anxiety. Tricyclic antidepressants, which are effective in the treatment of both GAD and panic disorder, have not been shown to be helpful in the treatment of social anxiety disorder.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
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Question 47 of 200
47. Question
Which of the following is a common side effect of extended release guanfacine?
Correct
Guanfacine (and extended release guanfacine) as well as clonidine, both alpha 2-adrenergic agonists, commonly present with side effects of drowsiness, dizziness, and dry mouth. Bradycardia and decreased appetite are also seen with these medicines. Increased urination is seen with lithium, but not guanfacine, treatment.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
Incorrect
Guanfacine (and extended release guanfacine) as well as clonidine, both alpha 2-adrenergic agonists, commonly present with side effects of drowsiness, dizziness, and dry mouth. Bradycardia and decreased appetite are also seen with these medicines. Increased urination is seen with lithium, but not guanfacine, treatment.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, (9th ed). American Psychiatric Publishing, Inc.
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Question 48 of 200
48. Question
Which of the following is a side effect of bupropion?
Correct
Bupropion acts to enhance transmission of dopamine and norepinephrine and does not exert influence on serotonin receptors. Common side effects include headache, anxiety, insomnia, GI upset, and sweating. Tremor and akathisia may also occur. Bupropion is not associated with weight gain (and may cause weight loss), sexual dysfunction, or cardiac conduction problems. It does not cause daytime sedation or orthostatic hypotension. Bupropion is not associated with anticholinergic side effects. Daily dosage should not exceed 450 mg. as dose dependent-seizures can occur above this level. Because it facilitates dopamine transmission, bupropion may be a good choice for use in patients with Parkinson’s disease.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
Bupropion acts to enhance transmission of dopamine and norepinephrine and does not exert influence on serotonin receptors. Common side effects include headache, anxiety, insomnia, GI upset, and sweating. Tremor and akathisia may also occur. Bupropion is not associated with weight gain (and may cause weight loss), sexual dysfunction, or cardiac conduction problems. It does not cause daytime sedation or orthostatic hypotension. Bupropion is not associated with anticholinergic side effects. Daily dosage should not exceed 450 mg. as dose dependent-seizures can occur above this level. Because it facilitates dopamine transmission, bupropion may be a good choice for use in patients with Parkinson’s disease.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 49 of 200
49. Question
Which of the following medications is LEAST likely to be effective in the treatment of fibromyalgia?
Correct
Since 2007, the FDA has approved 3 medications for the treatment of fibromyalgia: pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran (Savella). Pregabalin acts as an alpha2-delta ligand, while the latter two are serotonin-norepinephrine reuptake inhibitors (SNRI). Selective-serotonin reuptake inhibitors and tricyclic antidepressants have been shown to be helpful. However, bupropion, a norepinephrine-serotonin reuptake inhibitor, is not among medications with demonstrated efficacy.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th edition. Philadelphia, PA. Lippincott Williams & Wilkins.
Incorrect
Since 2007, the FDA has approved 3 medications for the treatment of fibromyalgia: pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran (Savella). Pregabalin acts as an alpha2-delta ligand, while the latter two are serotonin-norepinephrine reuptake inhibitors (SNRI). Selective-serotonin reuptake inhibitors and tricyclic antidepressants have been shown to be helpful. However, bupropion, a norepinephrine-serotonin reuptake inhibitor, is not among medications with demonstrated efficacy.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th edition. Philadelphia, PA. Lippincott Williams & Wilkins.
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Question 50 of 200
50. Question
A 71-year-old man develops confusion after undergoing a coronary artery bypass graft (CABG). What is the primary cardiac concern with the use of antipsychotics?
Correct
The use of antipsychotics has been recognized to increase the risk for markers of cardiac dysfunction (e.g., prolonged QTc), ventricular arrhythmias (including torsade de pointe), and even sudden cardiac death. The association may be more common in elderly patients and with the use of typical antipsychotic agents.
Beach SR, Celano CM, Sugrue AM. (2018). QT prolongation, torsades de pointes, and psychotropic medications: a 5-year update. Psychosomatics, 59(2);105-122
Incorrect
The use of antipsychotics has been recognized to increase the risk for markers of cardiac dysfunction (e.g., prolonged QTc), ventricular arrhythmias (including torsade de pointe), and even sudden cardiac death. The association may be more common in elderly patients and with the use of typical antipsychotic agents.
Beach SR, Celano CM, Sugrue AM. (2018). QT prolongation, torsades de pointes, and psychotropic medications: a 5-year update. Psychosomatics, 59(2);105-122
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Question 51 of 200
51. Question
A 45-year-old woman admitted to the hospital with Crohn’s disease was treated with prednisone for a month. The prednisone was stopped two weeks ago upon her discharge from the hospital. She has had apathy, crying spells, low energy, and poor appetite since leaving the hospital. Her BP is low. What is likely to be the best treatment?
Correct
Adrenal insufficiency or Addison’s Disease is an often-overlooked endocrine condition with prominent fatigue that can mimic depression. Other common symptoms include nausea, vomiting, diarrhea, muscle pain, and sweating. Weight loss and postural hypotension are common signs. The treatment involves replacement corticosteroids.
Kumar R, Wassif W. (2022). Adrenal insufficiency. J Clin Pathol. 75(7):435-442.
Incorrect
Adrenal insufficiency or Addison’s Disease is an often-overlooked endocrine condition with prominent fatigue that can mimic depression. Other common symptoms include nausea, vomiting, diarrhea, muscle pain, and sweating. Weight loss and postural hypotension are common signs. The treatment involves replacement corticosteroids.
Kumar R, Wassif W. (2022). Adrenal insufficiency. J Clin Pathol. 75(7):435-442.
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Question 52 of 200
52. Question
Bupropion is contraindicated in which disorder?
Correct
Bupropion doses should not exceed 450mg. daily due to increased risk of seizures at higher doses. Bupropion use is contraindicated in patients with bulimia and anorexia, as these patients demonstrated an increased susceptibility to seizures in premarketing trials. Bupropion has been shown to be effective in treating patients with seasonal affective disorder and is a second line treatment for ADHD. Marketed under the name Zyban, it is an approved treatment for smoking cessation. Bupropion may be useful in the treatment of depression in bipolar disorder because it is less likely to induce a switch to mania. Bupropion may exacerbate anxiety symptoms in patients with panic disorder or other anxiety disorders.
Sadock BJ, Sussman N, Sadock VA. (2019). Kaplan & Sadock’s Pocket Handbook of Psychiatric Drug Treatment (7th ed.). Wolters Kluwer
Incorrect
Bupropion doses should not exceed 450mg. daily due to increased risk of seizures at higher doses. Bupropion use is contraindicated in patients with bulimia and anorexia, as these patients demonstrated an increased susceptibility to seizures in premarketing trials. Bupropion has been shown to be effective in treating patients with seasonal affective disorder and is a second line treatment for ADHD. Marketed under the name Zyban, it is an approved treatment for smoking cessation. Bupropion may be useful in the treatment of depression in bipolar disorder because it is less likely to induce a switch to mania. Bupropion may exacerbate anxiety symptoms in patients with panic disorder or other anxiety disorders.
Sadock BJ, Sussman N, Sadock VA. (2019). Kaplan & Sadock’s Pocket Handbook of Psychiatric Drug Treatment (7th ed.). Wolters Kluwer
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Question 53 of 200
53. Question
A patient with anorexia, restricting type is more likely to have which of the findings below than a patient with bulimia who purges regularly:
Correct
Compared to those with bulimia, patients with anorexia nervosa have a lower nutrition status and thus higher rates of medical complications, including effects on thyroid (euthyroid sick syndrome) and sex hormones (including decreased LH and FSH), amenorrhea, electrolyte abnormalities, osteoporosis, cardiac malfunction (including bradycardia and arrhythmia), and overall mortality. An elevated amylase is associated with purging in either condition. In this case the bulimic patient who purges is more likely to have an elevated amylase than a non-purging anorexic patient.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
Compared to those with bulimia, patients with anorexia nervosa have a lower nutrition status and thus higher rates of medical complications, including effects on thyroid (euthyroid sick syndrome) and sex hormones (including decreased LH and FSH), amenorrhea, electrolyte abnormalities, osteoporosis, cardiac malfunction (including bradycardia and arrhythmia), and overall mortality. An elevated amylase is associated with purging in either condition. In this case the bulimic patient who purges is more likely to have an elevated amylase than a non-purging anorexic patient.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 54 of 200
54. Question
A 40-year-old man with a history of coronary artery disease (CAD), hypothyroidism, and obesity comes to your clinic for an evaluation of depression. The patient says he has been upset because he was demoted from a delivery truck driver to a mail room clerk last month because he has been falling asleep at work. The patient says he was having trouble staying asleep, but he is now taking eszopiclone and is sleeping fine. He lists fatigue, guilt (over feeling lazy), overeating, and poor concentration as his other symptoms. He denies a history of manic or psychotic symptoms, substance abuse, or suicidality. His TSH is in the normal range. What do you recommend?
Correct
Obstructive sleep apnea (OSA) occurs in up to 17% of men. OSA can lead to symptoms that mimic depression: fatigue, lack of energy, and poor concentration. Compared to controls, patients are more likely to be involved in car accidents. In patients with OSA, medications may be used to increase alertness or to treat associated depressive symptoms, but continuous positive airway pressure (CPAP) has been shown to decrease somnolence and to improve the quality of life, mood, and alertness. First, however, patients must be evaluated with polysomnography. Morning cortisol should be checked in patients with presentations suspicious for adrenal insufficiency, which would include those with prominent fatigue, nausea/anorexia, weight loss, and hypotension.
Akashiba T, Inoue Y, Uchimura N. (2022). Sleep apnea syndrome (SAS) clinical practice guidelines 2020. Respiratory Investigation, 60(1):3-32.
Incorrect
Obstructive sleep apnea (OSA) occurs in up to 17% of men. OSA can lead to symptoms that mimic depression: fatigue, lack of energy, and poor concentration. Compared to controls, patients are more likely to be involved in car accidents. In patients with OSA, medications may be used to increase alertness or to treat associated depressive symptoms, but continuous positive airway pressure (CPAP) has been shown to decrease somnolence and to improve the quality of life, mood, and alertness. First, however, patients must be evaluated with polysomnography. Morning cortisol should be checked in patients with presentations suspicious for adrenal insufficiency, which would include those with prominent fatigue, nausea/anorexia, weight loss, and hypotension.
Akashiba T, Inoue Y, Uchimura N. (2022). Sleep apnea syndrome (SAS) clinical practice guidelines 2020. Respiratory Investigation, 60(1):3-32.
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Question 55 of 200
55. Question
Which antidepressant is least likely to be associated with sexual dysfunction?
Correct
The SSRIs and SNRIs can all cause sexual dysfunction. Mirtazapine and bupropion are notable for their lack of association with sexual dysfunction. Common side effects of mirtazapine include weight gain, sedation, and dizziness.
Sadock BJ, Sussman N, Sadock VA. (2019). Kaplan & Sadock’s Pocket Handbook of Psychiatric Drug Treatment (7th ed.). Wolters Kluwer.
Incorrect
The SSRIs and SNRIs can all cause sexual dysfunction. Mirtazapine and bupropion are notable for their lack of association with sexual dysfunction. Common side effects of mirtazapine include weight gain, sedation, and dizziness.
Sadock BJ, Sussman N, Sadock VA. (2019). Kaplan & Sadock’s Pocket Handbook of Psychiatric Drug Treatment (7th ed.). Wolters Kluwer.
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Question 56 of 200
56. Question
Which medication is most likely to worsen psoriasis?
Correct
Psoriasis is a chronic, relapsing skin disease presenting with erythematous, scaling papules, and indurated plaques, arising preferentially on the elbows, knees, and scalp. Common triggers include psychological stress, physical trauma, infections, certain drugs (lithium, antimalarials, interferon), corticosteroid withdrawal, and alcohol use.
Sadock BJ, Sussman N, Sadock VA. (2019). Kaplan & Sadock’s Pocket Handbook of Psychiatric Drug Treatment (7th ed.). Wolters Kluwer.
Incorrect
Psoriasis is a chronic, relapsing skin disease presenting with erythematous, scaling papules, and indurated plaques, arising preferentially on the elbows, knees, and scalp. Common triggers include psychological stress, physical trauma, infections, certain drugs (lithium, antimalarials, interferon), corticosteroid withdrawal, and alcohol use.
Sadock BJ, Sussman N, Sadock VA. (2019). Kaplan & Sadock’s Pocket Handbook of Psychiatric Drug Treatment (7th ed.). Wolters Kluwer.
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Question 57 of 200
57. Question
What medication is most likely to improve cognitive functioning in patients with HIV dementia?
Correct
HIV-associated dementia (HAD) is one of the leading causes of dementia in individuals under 60 years of age. Risk factors for HAD include high viral load, low educational level, anemia, older age, and female sex. The incidence of HAD has significantly decreased since the advent of highly active antiretroviral medication regimens.
Kolson D. (2022). Developments in neuroprotection for HIV-associated neurocognitive disorders (HAND). Current HIV/AIDS Reports, 19: 344-357
Incorrect
HIV-associated dementia (HAD) is one of the leading causes of dementia in individuals under 60 years of age. Risk factors for HAD include high viral load, low educational level, anemia, older age, and female sex. The incidence of HAD has significantly decreased since the advent of highly active antiretroviral medication regimens.
Kolson D. (2022). Developments in neuroprotection for HIV-associated neurocognitive disorders (HAND). Current HIV/AIDS Reports, 19: 344-357
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Question 58 of 200
58. Question
All of the following interventions have shown efficacy in the treatment of nicotine dependence except:
Correct
FDA approved medications for nicotine dependence include varenicline (Chantix), bupropion SR (Zyban), and nicotine replacement therapy. Physician advice has been shown to be effective as part of the “5 A’s” (Ask, Advise, Assess, Assist, Arrange). Acupuncture has not been shown to demonstrate efficacy.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
Incorrect
FDA approved medications for nicotine dependence include varenicline (Chantix), bupropion SR (Zyban), and nicotine replacement therapy. Physician advice has been shown to be effective as part of the “5 A’s” (Ask, Advise, Assess, Assist, Arrange). Acupuncture has not been shown to demonstrate efficacy.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Lippincott Williams & Wilkins.
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Question 59 of 200
59. Question
A 19-year-old woman is brought to the ER from the Electronic Dance Music (EDM) festival with elevated blood pressure, temperature of 103.5, agitation, and paranoia. Which of the following drugs is the most likely cause of her presentation?
Correct
The most likely cause of her delirium is MDMA (Ecstasy, Molly), which can cause agitation and paranoia; however, the greatest concern is her hypertension and hyperthermia, which can lead to cardiovascular collapse. The other drugs do not produce this combination of symptoms.
Hoffman R. (2020). MDMA (ecstasy) intoxication. In Grayzel, JG (Ed), UpToDate. Retrieved February 11, 2023 from https://www.uptodate.com
Incorrect
The most likely cause of her delirium is MDMA (Ecstasy, Molly), which can cause agitation and paranoia; however, the greatest concern is her hypertension and hyperthermia, which can lead to cardiovascular collapse. The other drugs do not produce this combination of symptoms.
Hoffman R. (2020). MDMA (ecstasy) intoxication. In Grayzel, JG (Ed), UpToDate. Retrieved February 11, 2023 from https://www.uptodate.com
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Question 60 of 200
60. Question
A 55 y.o. male with a long history of alcohol abuse, presents with symptoms consistent with alcohol withdrawal. He was diagnosed with cirrhosis of the liver last year. Which benzodiazepine would be the best choice to treat his withdrawal symptoms?
Correct
When benzodiazepines are given to patients with cirrhosis, those with short half-lives and without active metabolites, like lorazepam and oxazepam, are preferrable. Benzodiazepines that undergo oxidative metabolism in the liver can accumulate to toxic levels in patients with cirrhosis. Despite its short half-life, alprazolam, which also undergoes oxidation, can also accumulate to dangerous levels in patients with cirrhosis.
Sadock BJ, Sussman N, Sadock VA. (2019). Kaplan & Sadock’s Pocket Handbook of Psychiatric Drug Treatment (7th ed.). Wolters Kluwer.
Incorrect
When benzodiazepines are given to patients with cirrhosis, those with short half-lives and without active metabolites, like lorazepam and oxazepam, are preferrable. Benzodiazepines that undergo oxidative metabolism in the liver can accumulate to toxic levels in patients with cirrhosis. Despite its short half-life, alprazolam, which also undergoes oxidation, can also accumulate to dangerous levels in patients with cirrhosis.
Sadock BJ, Sussman N, Sadock VA. (2019). Kaplan & Sadock’s Pocket Handbook of Psychiatric Drug Treatment (7th ed.). Wolters Kluwer.
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Question 61 of 200
61. Question
Which of the following psychiatric disorders is most likely to co-occur with adolescent substance abuse?
Correct
Conduct disorder both precedes and predicts substance abuse in adolescents. Its risk is greater than for ADHD, PTSD, and Bipolar Disorder.
Taylor BP, Schlussel D, Hollander E. (2019). The American Psychiatric Publishing Textbook of Psychiatry, (7th ed). American Psychiatric Publishing, Inc.
Incorrect
Conduct disorder both precedes and predicts substance abuse in adolescents. Its risk is greater than for ADHD, PTSD, and Bipolar Disorder.
Taylor BP, Schlussel D, Hollander E. (2019). The American Psychiatric Publishing Textbook of Psychiatry, (7th ed). American Psychiatric Publishing, Inc.
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Question 62 of 200
62. Question
Which of the following statements is true about patients with co-occurring psychiatric and substance use disorders?
Correct
Patients with co-occurring disorders my benefit from self-help groups (e.g., “Double Trouble”). Clinicians should treat psychosis, irrespective of etiology, with neuroleptics. No medications have proven to be effective for cocaine use. Benzodiazepines may be effective in anxiety disorders where patients have not responded to SSRIs, buspirone, etc, where they are stable in an Methadone Maintenance Treatment Program (MMTP) with a good therapeutic alliance. Avery J, Adam T, Levounis P. (2019). The American Psychiatric Publishing Textbook of Psychiatry, (7th ed). American Psychiatric Publishing, Inc.
Kaye A, Vadivelu N, Urman RD. (2015). Substance Abuse Inpatient and Outpatient Management for Every Clinician. Springer. New York.
Ruiz P, Strain E (eds). (2011). Lowinson and Ruiz’s Substance Abuse: A Comprehensive Textbook, 5th Edition. Lippincott Williams & Wilkins. Philadelphia.
Incorrect
Patients with co-occurring disorders my benefit from self-help groups (e.g., “Double Trouble”). Clinicians should treat psychosis, irrespective of etiology, with neuroleptics. No medications have proven to be effective for cocaine use. Benzodiazepines may be effective in anxiety disorders where patients have not responded to SSRIs, buspirone, etc, where they are stable in an Methadone Maintenance Treatment Program (MMTP) with a good therapeutic alliance. Avery J, Adam T, Levounis P. (2019). The American Psychiatric Publishing Textbook of Psychiatry, (7th ed). American Psychiatric Publishing, Inc.
Kaye A, Vadivelu N, Urman RD. (2015). Substance Abuse Inpatient and Outpatient Management for Every Clinician. Springer. New York.
Ruiz P, Strain E (eds). (2011). Lowinson and Ruiz’s Substance Abuse: A Comprehensive Textbook, 5th Edition. Lippincott Williams & Wilkins. Philadelphia.
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Question 63 of 200
63. Question
The primary physician of a retired 67-year-old waitress sends her for a psychiatric consultation because she has been acting strangely. The psychiatrist determines that she has dementia, inattention, and myoclonus. Further evaluation finds normal routine blood tests, HIV testing, cerebrospinal fluid (CSF) profile, and MRI, but it discloses periodic complexes on her electroencephalogram (EEG). She declines rapidly and expires six months after the consultation. Which is the most likely cause of her dementia and death?
Correct
Her dementia, accompanied by myoclonus and an EEG showing periodic complexes, progressing to death in 6 months characterizes Creutzfeldt-Jakob disease. Finding a 14-3-3 protein in her CSF would have given further diagnostic support. A brain biopsy would have shown spongiform changes, but clinicians do not routinely perform biopsies in suspected Creutzfeldt-Jakob disease cases because the material, which is infectious, would contaminate the surgical instruments and expose the surgical and pathology teams. Another reason for not performing a biopsy is that the illness remains untreatable. Creutzfeldt-Jakob disease is a frequently occurring neurodegenerative cause of dementia that follows a rapid, fatal course. As Dr. Stanely Prusiner, the Nobel- prize winning discoverer of the mechanism underlying Creutzfeldt-Jakob disease and related illnesses, explained at the American Psychiatric Association’s 2013 meeting, prions cause these illnesses by conformational conversion of prion proteins.
Uttley L, Carroll C, Wong R. (2020). Creutzfeldt-Jakob disease: a systematic review of global incidence, prevalence, infectivity, and incubation. Lancet Infect Dis, 20; 2–10
Incorrect
Her dementia, accompanied by myoclonus and an EEG showing periodic complexes, progressing to death in 6 months characterizes Creutzfeldt-Jakob disease. Finding a 14-3-3 protein in her CSF would have given further diagnostic support. A brain biopsy would have shown spongiform changes, but clinicians do not routinely perform biopsies in suspected Creutzfeldt-Jakob disease cases because the material, which is infectious, would contaminate the surgical instruments and expose the surgical and pathology teams. Another reason for not performing a biopsy is that the illness remains untreatable. Creutzfeldt-Jakob disease is a frequently occurring neurodegenerative cause of dementia that follows a rapid, fatal course. As Dr. Stanely Prusiner, the Nobel- prize winning discoverer of the mechanism underlying Creutzfeldt-Jakob disease and related illnesses, explained at the American Psychiatric Association’s 2013 meeting, prions cause these illnesses by conformational conversion of prion proteins.
Uttley L, Carroll C, Wong R. (2020). Creutzfeldt-Jakob disease: a systematic review of global incidence, prevalence, infectivity, and incubation. Lancet Infect Dis, 20; 2–10
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Question 64 of 200
64. Question
Which is true about the relationship between tics/Tourette’s and ADHD?
Correct
ADHD is always more impairing than tics when the two are co-morbid. The severity of ADHD, not tics, is a good predictor of social difficulties, particularly with peers. Methylphenidate and clonidine can be used either alone or in combination when patients have comorbid tics/Tourette’s and ADHD, no matter which condition is worse. By history, ADHD will precede tics, usually by 2-3 years.
Osland ST, Steeves TD, Pringsheim T. (2018). Pharmacological treatment for attention deficit hyperactivity disorder (ADHD) in children with comorbid tic disorders. Cochrane Database Syst Rev (2018 06 26) 6:CD007990
Incorrect
ADHD is always more impairing than tics when the two are co-morbid. The severity of ADHD, not tics, is a good predictor of social difficulties, particularly with peers. Methylphenidate and clonidine can be used either alone or in combination when patients have comorbid tics/Tourette’s and ADHD, no matter which condition is worse. By history, ADHD will precede tics, usually by 2-3 years.
Osland ST, Steeves TD, Pringsheim T. (2018). Pharmacological treatment for attention deficit hyperactivity disorder (ADHD) in children with comorbid tic disorders. Cochrane Database Syst Rev (2018 06 26) 6:CD007990
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Question 65 of 200
65. Question
Neonatal abstinence was shown to be mildest with use of which medication for the treatment of opiate dependence in pregnant women?
Correct
While methadone and buprenorphine have both been demonstrated to be safe during pregnancy for the mother and fetus, the National Institute of Drug Abuse (NIDA)–sponsored MOTHER study showed milder neonatal abstinence with buprenorphine compared to methadone.
Lemon LS, Caritis SN, Venkataramanan R, et al. (2018). Methadone versus buprenorphine for opioid use dependence and risk of neonatal abstinence syndrome. Epidemiology, 29(2);261–268.
Incorrect
While methadone and buprenorphine have both been demonstrated to be safe during pregnancy for the mother and fetus, the National Institute of Drug Abuse (NIDA)–sponsored MOTHER study showed milder neonatal abstinence with buprenorphine compared to methadone.
Lemon LS, Caritis SN, Venkataramanan R, et al. (2018). Methadone versus buprenorphine for opioid use dependence and risk of neonatal abstinence syndrome. Epidemiology, 29(2);261–268.
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Question 66 of 200
66. Question
A 53-year-old man is brought in by his uncle for a psychiatric evaluation because he has been acting aggressively, smoking excessively, and losing his ability to run his family’s restaurant business. The patient’s father had developed dementia when he was 60-years-old. A neurologist found no abnormal neurologic physical signs and an internist eliminated general medical conditions. The psychiatrist found that the patient was disinhibited and apathetic. Although he lacked empathy and impaired executive ability, he scored 27 out of 30 on the Mini-Mental Status Test and performed satisfactorily of other tests. Of the following, which is the most likely cause of the patient’s deterioration?
Correct
Frontotemporal dementia, a neurodegenerative illness, causes dementia that is initially overshadowed by personality changes and behavioral disturbances. The diagnostic criteria require 3 of 6 of the following disturbances: disinhibition, apathy, loss of sympathy, perseveration or compulsive behaviors, hyperorality, and impaired executive ability. Physicians might easily misdiagnosis frontotemporal dementia for bipolar disorder or late-life depression. Frontotemporal dementia is a common cause of dementia that characteristically has a relatively young age of onset (53 years), follows a rapidly fatal course (4 years), develops in men more than women, and occurs in multiple family members.
Kaufman DM, Geyer HL, Milstein MJ, Rosengard JL. (2023). Kaufman’s Clinical Neurology for Psychiatrists (9th ed). Elsevier.
Incorrect
Frontotemporal dementia, a neurodegenerative illness, causes dementia that is initially overshadowed by personality changes and behavioral disturbances. The diagnostic criteria require 3 of 6 of the following disturbances: disinhibition, apathy, loss of sympathy, perseveration or compulsive behaviors, hyperorality, and impaired executive ability. Physicians might easily misdiagnosis frontotemporal dementia for bipolar disorder or late-life depression. Frontotemporal dementia is a common cause of dementia that characteristically has a relatively young age of onset (53 years), follows a rapidly fatal course (4 years), develops in men more than women, and occurs in multiple family members.
Kaufman DM, Geyer HL, Milstein MJ, Rosengard JL. (2023). Kaufman’s Clinical Neurology for Psychiatrists (9th ed). Elsevier.
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Question 67 of 200
67. Question
Which of the following is UNLIKELY in a patient with Illness Anxiety Disorder?
Correct
Illness anxiety disorder is characterized by a preoccupation with having or developing a serious illness. Despite these concerns, somatic symptoms are not present or, if so, are minimal. These individuals have excessive anxiety about their health and engage in excessive health related behaviors (e.g., frequently checking body parts). Yet, they exhibit maladaptive avoidance of doctor appointments and hospitals. Attempts by physicians to provide reassurance generally do not alleviate anxiety and may heighten the individual’s concerns.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders Fifth Edition DSM-5-TR, 2022.Incorrect
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Question 68 of 200
68. Question
Which of the following is true regarding trisomy 21?
Correct
Trisomy 21, also known as Down syndrome, includes mild to moderately severe intellectual disability; characteristic physical findings including simian palm creases, stunted growth, low muscle tone, small genitalia, and facial dysmorphia; and risk of dementia in later life. This risk is of concern because people with Down syndrome now have a relatively long life expectancy. Their intellectual decline in their 40s and 50s is associated with an excess of beta-amyloid. In contrast, Down syndrome is negatively associated with autism. Prader-Willi syndrome, caused by a paternally-inherited translocation at 15Q, consists of hyperphagia, non-food-related compulsive behavior, and borderline-moderate intellectual disability. Fragile X syndrome, caused by a mutation on the X chromosome (Xq27.3), is the most common inherited cause of intellectual disability. This syndrome consists primarily of moderate to severe intellectual disability but also ADHD, autism, and social anxiety. Most boys with the disorder have a long face with large ears and macro-orchidism.
Fortea J, Vilaplana E, Carmona-Iragui M, et al. (2020). Clinical and biomarker changes of Alzheimer’s disease in adults with Down syndrome: a cross-sectional study. Lancet, 395(10242):1988-1997.
Incorrect
Trisomy 21, also known as Down syndrome, includes mild to moderately severe intellectual disability; characteristic physical findings including simian palm creases, stunted growth, low muscle tone, small genitalia, and facial dysmorphia; and risk of dementia in later life. This risk is of concern because people with Down syndrome now have a relatively long life expectancy. Their intellectual decline in their 40s and 50s is associated with an excess of beta-amyloid. In contrast, Down syndrome is negatively associated with autism. Prader-Willi syndrome, caused by a paternally-inherited translocation at 15Q, consists of hyperphagia, non-food-related compulsive behavior, and borderline-moderate intellectual disability. Fragile X syndrome, caused by a mutation on the X chromosome (Xq27.3), is the most common inherited cause of intellectual disability. This syndrome consists primarily of moderate to severe intellectual disability but also ADHD, autism, and social anxiety. Most boys with the disorder have a long face with large ears and macro-orchidism.
Fortea J, Vilaplana E, Carmona-Iragui M, et al. (2020). Clinical and biomarker changes of Alzheimer’s disease in adults with Down syndrome: a cross-sectional study. Lancet, 395(10242):1988-1997.
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Question 69 of 200
69. Question
A child is able to recognize that a ball made of playdoh has “the same amount of playdoh” when it is rolled into a flat shape by the examiner. This is an example of:
Correct
This recognition is an example of the concept of operational thought, described by Piaget. It typically emerges between the ages of 7-11 years. Normally developing children in this developmental stage are able to use logical thought to order, seriate, and group objects based on common characteristics. The concept of conservation attained in this developmental phase refers to the ability to recognize that even when the shape of an object changes, the amount of matter is conserved.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Wolters Kluwer. Philadelphia.
Incorrect
This recognition is an example of the concept of operational thought, described by Piaget. It typically emerges between the ages of 7-11 years. Normally developing children in this developmental stage are able to use logical thought to order, seriate, and group objects based on common characteristics. The concept of conservation attained in this developmental phase refers to the ability to recognize that even when the shape of an object changes, the amount of matter is conserved.
Boland R, Verduin M, Ruiz P. (2022). Kaplan & Sadock’s Synopsis of Psychiatry (12th ed.). Wolters Kluwer. Philadelphia.
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Question 70 of 200
70. Question
Which of the following conventional antipsychotic medications is most likely to cause anticholinergic side effects?
Correct
High-potency conventional antipsychotics, like haloperidol, are most likely to cause extrapyramidal side effects. In contrast, low-potency agents, like thioridazine, are more likely to cause anticholinergic side effects (blurred vision, dry mouth, urinary hesitancy, constipation, tachycardia), alpha-adrenergic side effects (orthostasis), weight gain, and sedation (mediated by histamine and alpha-adrenergic receptors). Perphenazine and thiothixene, both midrange in potency, are less likely to cause anticholinergic side effects.
Schatzberg AF, Debattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology (9th ed.). American Psychiatric Publishing. Washington, DC.
Incorrect
High-potency conventional antipsychotics, like haloperidol, are most likely to cause extrapyramidal side effects. In contrast, low-potency agents, like thioridazine, are more likely to cause anticholinergic side effects (blurred vision, dry mouth, urinary hesitancy, constipation, tachycardia), alpha-adrenergic side effects (orthostasis), weight gain, and sedation (mediated by histamine and alpha-adrenergic receptors). Perphenazine and thiothixene, both midrange in potency, are less likely to cause anticholinergic side effects.
Schatzberg AF, Debattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology (9th ed.). American Psychiatric Publishing. Washington, DC.
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Question 71 of 200
71. Question
In addition to preventing measles, measles vaccination either prevents or attenuates subacute sclerosing panencephalitis (SSPE). Which of the following is not a characteristic of SSPE?
Correct
Hemorrhagic changes at the base of the frontal and temporal lobes characterize herpes simplex encephalitis. The incidence of SSPE, which had been the most common cause of dementia of childhood, has dramatically fallen with widespread, complete measles immunization.
Jafri SK, Kumar R, Ibrahim S. (2018). Subacute sclerosing panencephalitis – current perspectives. Pediatric Health, Med Therapy, 9;67–71
Incorrect
Hemorrhagic changes at the base of the frontal and temporal lobes characterize herpes simplex encephalitis. The incidence of SSPE, which had been the most common cause of dementia of childhood, has dramatically fallen with widespread, complete measles immunization.
Jafri SK, Kumar R, Ibrahim S. (2018). Subacute sclerosing panencephalitis – current perspectives. Pediatric Health, Med Therapy, 9;67–71
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Question 72 of 200
72. Question
A 23-year-old man is brought into the emergency Room with symptoms of increase heart rate, dilated pupils, agitation, paranoia, and auditory hallucinations. His urine test for benzoylecgonine is negative. What is the most likely etiology of his presentation?
Correct
This patient is most likely using crystal methamphetamine. The presentation is similar to cocaine, but with cocaine use, the urine would be positive for benzoylecgonine, which is the metabolite of cocaine. PCP does not cause dilated pupils. Schizophrenia in and of itself would not cause increased heart rate or dilated pupils, but otherwise may be similar.
Courtney K, Ray LA. (2014). Methamphetamine: An update on epidemiology, pharmacology, clinical phenomenology, and treatment literature. Drug Alcohol Depend, 143;11–21
Incorrect
This patient is most likely using crystal methamphetamine. The presentation is similar to cocaine, but with cocaine use, the urine would be positive for benzoylecgonine, which is the metabolite of cocaine. PCP does not cause dilated pupils. Schizophrenia in and of itself would not cause increased heart rate or dilated pupils, but otherwise may be similar.
Courtney K, Ray LA. (2014). Methamphetamine: An update on epidemiology, pharmacology, clinical phenomenology, and treatment literature. Drug Alcohol Depend, 143;11–21
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Question 73 of 200
73. Question
A psychiatrist has been following a 22-year-old woman for an eating disorder. For six weeks after she underwent gastric bypass to alleviate obesity, she had intractable postoperative vomiting. During a subsequent visit with her psychiatrist, she was confused. Further testing revealed amnesia (particularly in an anterograde pattern), ataxia, nystagmus, and signs of a peripheral neuropathy. Which is the essential immediate treatment for the patient?
Correct
At one to six months after bariatric surgery, particularly when they have vomiting, patients are at risk for Wernicke encephalopathy and other nutritional deficiencies. In this case, she had the classic signs of Wernicke encephalopathy. In many cases, atypical features are also present. Surprisingly, Wernicke encephalopathy rarely develops in patients with anorexia with or without bulimia.
Oudman E, Wijnia JW, Dam MV. (2018). Preventing Wernicke encephalopathy after bariatric surgery. Obesity Surgery, 28(7);2060–2068
Incorrect
At one to six months after bariatric surgery, particularly when they have vomiting, patients are at risk for Wernicke encephalopathy and other nutritional deficiencies. In this case, she had the classic signs of Wernicke encephalopathy. In many cases, atypical features are also present. Surprisingly, Wernicke encephalopathy rarely develops in patients with anorexia with or without bulimia.
Oudman E, Wijnia JW, Dam MV. (2018). Preventing Wernicke encephalopathy after bariatric surgery. Obesity Surgery, 28(7);2060–2068
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Question 74 of 200
74. Question
All of the following statements about prescription drug abuse are true except:
Correct
Prescription drug abuse is a major epidemic resulting in loss of life now exceeding motor vehicle accidents. Its use is enhanced by its perceived safety and increased availability. Because of prescription opiates’ greater expense, people transition to heroin.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2011). Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-41, HHS Publication No. (SMA) 11-4658
Incorrect
Prescription drug abuse is a major epidemic resulting in loss of life now exceeding motor vehicle accidents. Its use is enhanced by its perceived safety and increased availability. Because of prescription opiates’ greater expense, people transition to heroin.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2011). Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-41, HHS Publication No. (SMA) 11-4658
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Question 75 of 200
75. Question
During almost every night’s sleep an 80-year-old man began to thrash about, seemed to run, and, on several occasions, beat his wife. A polysomnogram (PSG) revealed that this physical activity occurred exclusively during rapid eye movement (REM) periods, which contained no paroxysmal EEG activity. When awake, he has a normal mental status and no physical abnormalities. What is the most likely diagnosis of this sleep disturbance?
Correct
His physical outbursts during REM periods indicates REM sleep behavior disturbance. Seizures would have been reflected in paroxysmal EEG activity, such as bursts of spike-and-wave activity.
Arnulf I. (2012). REM sleep behavior disorder: motor manifestations and pathophysiology. Move Dis, 27(6);677–689
Incorrect
His physical outbursts during REM periods indicates REM sleep behavior disturbance. Seizures would have been reflected in paroxysmal EEG activity, such as bursts of spike-and-wave activity.
Arnulf I. (2012). REM sleep behavior disorder: motor manifestations and pathophysiology. Move Dis, 27(6);677–689
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Question 76 of 200
76. Question
Which of the following is not a typical polysomnogram(PSG) change in depression?
Correct
The most consistent PSG changes in depression are decreased REM latency, increased total REM sleep time, and decreased slow wave sleep. Even with remission of symptoms, these changes may persist. If so, they are a risk factor for recurrence of depression.
Palagini L, Baglioni C, Ciapparelli A, et al. (2013). REM sleep dysregulation: State of the art. Sleep Med Rev, 17; 377-390
Incorrect
The most consistent PSG changes in depression are decreased REM latency, increased total REM sleep time, and decreased slow wave sleep. Even with remission of symptoms, these changes may persist. If so, they are a risk factor for recurrence of depression.
Palagini L, Baglioni C, Ciapparelli A, et al. (2013). REM sleep dysregulation: State of the art. Sleep Med Rev, 17; 377-390
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Question 77 of 200
77. Question
Acute thiamine deficiency (Wernicke’s disease) from alcohol use is characterized by all of the following symptoms except:
:Correct
Ataxia, confusion and ocular abnormalities are the hallmarks of acute thiamine deficiency (Wernicke’s Disease). In contrast, anterograde amnesia is a defining symptom of chronic thiamine deficiency (Korsakoff’s Dementia).
Kosten T, Haile C, Woods S. (2015). The American Psychiatric Association Publishing Textbook of Neuropsychiatry and Clinical Neurosciences (5th ed). APA Press. Washington, D.C.
Incorrect
Ataxia, confusion and ocular abnormalities are the hallmarks of acute thiamine deficiency (Wernicke’s Disease). In contrast, anterograde amnesia is a defining symptom of chronic thiamine deficiency (Korsakoff’s Dementia).
Kosten T, Haile C, Woods S. (2015). The American Psychiatric Association Publishing Textbook of Neuropsychiatry and Clinical Neurosciences (5th ed). APA Press. Washington, D.C.
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Question 78 of 200
78. Question
A 22-year-old male has decided to become a professional football player. As a child he frequently got into trouble for excessively aggressive behavior, which resolved during his teenage years. He played intramural sports in high school and college. What defense mechanism does he use?
Correct
Sublimation is a mature defense mechanism in which an individual channels unacceptable impulses into socially acceptable alternatives. In this case, the man’s unacceptable aggressive behavior has been redirected into sports, which allows him to discharge his aggressive impulses in this socially acceptable context. Displacement is a defense mechanism in which unacceptable feelings or impulses are redirected towards a less threatening object. Reaction formation is when an unacceptable thought or feeling is converted into its opposite. Projection is when one’s own unwanted or unacceptable thoughts or impulses are attributed to someone else.
Roberts LW (eds). (2019). The American Psychiatric Publishing Textbook of Psychiatry, 7th ed. American Psychiatric Publishing. Philadelphia.
Incorrect
Sublimation is a mature defense mechanism in which an individual channels unacceptable impulses into socially acceptable alternatives. In this case, the man’s unacceptable aggressive behavior has been redirected into sports, which allows him to discharge his aggressive impulses in this socially acceptable context. Displacement is a defense mechanism in which unacceptable feelings or impulses are redirected towards a less threatening object. Reaction formation is when an unacceptable thought or feeling is converted into its opposite. Projection is when one’s own unwanted or unacceptable thoughts or impulses are attributed to someone else.
Roberts LW (eds). (2019). The American Psychiatric Publishing Textbook of Psychiatry, 7th ed. American Psychiatric Publishing. Philadelphia.
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Question 79 of 200
79. Question
On the one-year anniversary of sustaining a massive brainstem stroke, a 65-year-old man remains with a tracheostomy and dependent on a ventilator, fed through a gastrotomy tube, unable to speak, and quadriplegic. He seems to sleep and looks toward visitors, establishing eye contact. He has resided in a nursing home ever since discharge from the hospital. His brother, who is his sole living relative, has established communication with him through a system of eye movements an eyelid blinks. One day, the brother announces that the patient has full knowledge of his condition and prognosis, and has decided to terminate his life by having the artificial ventilation withdrawn. The nursing home staff disagrees, stating that the patient is incompetent and cannot make medical decisions. A psychiatry consultation is brought in to determine if the patient possesses decisional capacity. What will the psychiatrist probably determine?
Correct
The patient is in the locked-in syndrome or state. He characteristically can communicate with eye movements and eyelid blinks. Most important, his cognitive function is preserved. Because he is in the locked-in syndrome, he retains his autonomy and decisional capacity. Most cases of locked-in syndrome result from a brainstem stroke due to an occlusion of the basilar artery. Other causes are brainstem trauma, amyotrophic lateral sclerosis (ALS), and, at least temporarily, Guillain-Barré syndrome.
Kaufman D, Milstein M, Geyer HL. (2017). Kaufman’s Clinical Neurology for Psychiatrists. 8th edition,
Elsevier, Philadelphia.Kuehlmeyer K, Racine E, Palmour N, et al. (2012). Diagnostic and ethical challenges in disorders of consciousness and locked-in syndrome. J Neurol, 259;2076-2089
Incorrect
The patient is in the locked-in syndrome or state. He characteristically can communicate with eye movements and eyelid blinks. Most important, his cognitive function is preserved. Because he is in the locked-in syndrome, he retains his autonomy and decisional capacity. Most cases of locked-in syndrome result from a brainstem stroke due to an occlusion of the basilar artery. Other causes are brainstem trauma, amyotrophic lateral sclerosis (ALS), and, at least temporarily, Guillain-Barré syndrome.
Kaufman D, Milstein M, Geyer HL. (2017). Kaufman’s Clinical Neurology for Psychiatrists. 8th edition,
Elsevier, Philadelphia.Kuehlmeyer K, Racine E, Palmour N, et al. (2012). Diagnostic and ethical challenges in disorders of consciousness and locked-in syndrome. J Neurol, 259;2076-2089
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Question 80 of 200
80. Question
REM sleep behavior disturbance is often a risk factor for which two illnesses?
Correct
REM sleep behavior disorder often develops along with or up to 15 years before the onset of either Parkinson disease or dementia with Lewy bodies. It ultimately affects almost one-third of Parkinson disease patients. In both of these illnesses, which neurologists classify as synucleinopathies, REM sleep behavior disorder correlates with cognitive impairment.
Arnulf, I. (2012). REM sleep behavior disorder: Motor manifestations and pathophysiology. Move Disord, 27(6);677–689
Sixel-Doring F, Trautmann E, Mollenhauer B, et al. (2011). Associated factors for REM sleep behavior disorder in Parkinson disease. Neurology, 77;1048-1054
Incorrect
REM sleep behavior disorder often develops along with or up to 15 years before the onset of either Parkinson disease or dementia with Lewy bodies. It ultimately affects almost one-third of Parkinson disease patients. In both of these illnesses, which neurologists classify as synucleinopathies, REM sleep behavior disorder correlates with cognitive impairment.
Arnulf, I. (2012). REM sleep behavior disorder: Motor manifestations and pathophysiology. Move Disord, 27(6);677–689
Sixel-Doring F, Trautmann E, Mollenhauer B, et al. (2011). Associated factors for REM sleep behavior disorder in Parkinson disease. Neurology, 77;1048-1054
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Question 81 of 200
81. Question
Which substance do patients with chronic schizophrenia most commonly abuse?
Correct
Approximately 50% of patients diagnosed with schizophrenia have a co-morbid substance use disorder. Cannabis is found to be the most commonly used substance of abuse by first episode patients, but with long term illness, alcohol use is most frequent. Nicotine use is extremely common with rates as high as 90% of patients with schizophrenia.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology. American Psychiatric Publishing. Philadelphia.
Incorrect
Approximately 50% of patients diagnosed with schizophrenia have a co-morbid substance use disorder. Cannabis is found to be the most commonly used substance of abuse by first episode patients, but with long term illness, alcohol use is most frequent. Nicotine use is extremely common with rates as high as 90% of patients with schizophrenia.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology. American Psychiatric Publishing. Philadelphia.
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Question 82 of 200
82. Question
A young teenage boy is brought to see you for symptoms of ADHD and learning problems. You learn from the history that he was shy as a child and you notice in your mental status that there is some perseveration of speech. In your review of systems, the mother tells you that the pediatrician has remarked that his testicles are enlarged in the last few years and you notice on exam that his face seems abnormally long. You consider getting cognitive testing, as he seems to have low cognitive functioning. What other test might you consider?
Correct
This boy has the presumptive diagnosis of Fragile X, which is associated with ADHD, learning problems, some language dysfluency and social anxiety. There may be a history of infertility or autism spectrum disorder in the family. Physically, as the child grows, there is progressive elongation of the head and ears. DNA testing will reveal between 230 and >1000 trinucleotide repeats when the syndrome is present with fragility at
Xq27.3. Rett Syndrome is an X-linked dominant disorder with a mutation at MECP2 and is seen in girls only – and in XXY boys – so would not likely be seen in this teenage boy. An ADOS evaluation would not be
specific for Rett but the patient could score in the autistic range if she was evaluated during that part of her clinical course. Uric acid testing might help diagnose Lesch Nyhan syndrome, but the boy would have characteristic self-mutilation, spasticity and psychomotor retardation. The patient with tuberous sclerosis can present with CNS tubers; tubers are characteristically seen across the malar surface of the face and the syndrome is associated with autism, epilepsy and worsening dementia.Dulcan MK. (2016). Dulcan’s Textbook of Child and Adolescent Psychiatry (2nd ed.). American Psychiatric Association. Arlington.
Incorrect
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Question 83 of 200
83. Question
Which of the following is true of adults with ADHD?
Correct
Approximately 50% of children diagnosed with ADHD will continue into adulthood with the diagnosis. Typically, as children age into adolescence and adulthood, the gross manifestations of hyperactivity become less prominent, though restlessness can still remain as a residual symptom. Whereas DSM-IV-TR required that symptoms be present prior to the age of 7, DSM-5 only requires that symptoms (“several”) be present prior to the age of 12. In childhood, the diagnosis of ADHD is made far more often in boys than girls; adult men with ADHD seem to still outnumber women, though previously the ratio had thought to be equal; women are likely oversampled in treatment groups as they seem to preferentially seek help, making these statistics variable from study to study.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. American Psychiatric Association Press. Washington, D.C.
Incorrect
Approximately 50% of children diagnosed with ADHD will continue into adulthood with the diagnosis. Typically, as children age into adolescence and adulthood, the gross manifestations of hyperactivity become less prominent, though restlessness can still remain as a residual symptom. Whereas DSM-IV-TR required that symptoms be present prior to the age of 7, DSM-5 only requires that symptoms (“several”) be present prior to the age of 12. In childhood, the diagnosis of ADHD is made far more often in boys than girls; adult men with ADHD seem to still outnumber women, though previously the ratio had thought to be equal; women are likely oversampled in treatment groups as they seem to preferentially seek help, making these statistics variable from study to study.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. American Psychiatric Association Press. Washington, D.C.
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Question 84 of 200
84. Question
A 32 year old woman, Ms. L. presents to your office as a referral from her primary care doctor. The PCP asks you to evaluate Ms. L for depression, as she has been worked up numerous times for a variety of complaints over the years including chronic back and pelvic pain, as well as bouts of nausea and vomiting. Recently she has been discharged from the hospital where she presented with abdominal pain, and headaches. Her work up once again failed to reveal a physiologic cause. She denies depression or anxiety but endorses an inability to orgasm and recent memory difficulties have kept her from keeping her job. For what type of treatment is there the best evidence?
Correct
The vignette describes a patient with classic symptoms of Somatic Symptom Disorder (according to DSM-V): She has four pain symptom (abdominal, head, pelvic and back), two gastrointestinal complaints (N/V), a pseudoneurologic problem (memory difficulty) and a sexual complaint (anorgasmia). Since her symptoms are already chronic at the age of 32, she meets the DSM-IV TR requirement that the symptoms begin before the age of 30. In his 2007 review of treatments for somatoform disorders, Kroenke found a total of 34 randomized controlled trials. Most of the studies involved patients with somatization disorder or similar lower threshold variants. Cognitive behavioral therapy (CBT) was effective in 11 of 13 studies, while antidepressants were helpful in 4 of 5 of studies. Only 1 of 3 RCTs for conversion disorder showed benefit. There were no studies of pain disorder.
American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). American Psychiatric Association. Arlington.
Kurlansik SL, Maffei MS. (2016). Somatic Symptom Disorder. Amer Fam Physician, 93(1), 49–54
Incorrect
The vignette describes a patient with classic symptoms of Somatic Symptom Disorder (according to DSM-V): She has four pain symptom (abdominal, head, pelvic and back), two gastrointestinal complaints (N/V), a pseudoneurologic problem (memory difficulty) and a sexual complaint (anorgasmia). Since her symptoms are already chronic at the age of 32, she meets the DSM-IV TR requirement that the symptoms begin before the age of 30. In his 2007 review of treatments for somatoform disorders, Kroenke found a total of 34 randomized controlled trials. Most of the studies involved patients with somatization disorder or similar lower threshold variants. Cognitive behavioral therapy (CBT) was effective in 11 of 13 studies, while antidepressants were helpful in 4 of 5 of studies. Only 1 of 3 RCTs for conversion disorder showed benefit. There were no studies of pain disorder.
American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). American Psychiatric Association. Arlington.
Kurlansik SL, Maffei MS. (2016). Somatic Symptom Disorder. Amer Fam Physician, 93(1), 49–54
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Question 85 of 200
85. Question
Which of the following pairs of psychological tests would be most helpful in identifying Reading Disorder in a 10 year old?
Correct
Learning Disorders are defined as persistent difficulties learning keystone academic skills that are chronic, well below average for age, and not attributable to intellectual disability. The full assessment of such a learning disability requires IQ testing (such as the WISC or Stanford Binet) and psychoeducational testing of the relevant learning area, for example reading (Kaufman), mathematics (standardized mathematics examination) or writing( Test of Written Language/ TOWL). Frame LB, Vidrine, SM, Hinojosa R. (2016). Test review: Kaufman, A. S, Kaufman, N. L. (2014). Kaufman Test of Educational Achievement, 3rd Ed. J Psychoeduca Assess, 34(8);811–818
Incorrect
Learning Disorders are defined as persistent difficulties learning keystone academic skills that are chronic, well below average for age, and not attributable to intellectual disability. The full assessment of such a learning disability requires IQ testing (such as the WISC or Stanford Binet) and psychoeducational testing of the relevant learning area, for example reading (Kaufman), mathematics (standardized mathematics examination) or writing( Test of Written Language/ TOWL). Frame LB, Vidrine, SM, Hinojosa R. (2016). Test review: Kaufman, A. S, Kaufman, N. L. (2014). Kaufman Test of Educational Achievement, 3rd Ed. J Psychoeduca Assess, 34(8);811–818
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Question 86 of 200
86. Question
A 10-year-old boy with attention deficit hyperactivity disorder diagnosed at age 7 years has been successfully treated with methylphenidate. He has recently required several upward dosage adjustments due to worsening symptoms. These adjustments have failed to treat his symptoms and he is reported to be disruptive in the classroom, with recent worsening of test scores. Which of the following is the appropriate next intervention?
Correct
The following medications are approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD: dextroamphetamine, D- and D, L-methylphenidate, mixed salts amphetamine, and atomoxetine. The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) have recommended stimulants as the first line of treatment for ADHD. After two failed trials of
each of the two stimulant classes, it is recommended that the third line choice for ADHD treatment is atomoxetine. However atomoxetine, a noradrenergic reuptake inhibitor, can be considered as the first line medication for ADHD in individuals with an active substance abuse problem, comorbid anxiety, or tics.Schatzberg AF, DeBattista C. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric Publishing, Inc. Washington, D.C.
Incorrect
The following medications are approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD: dextroamphetamine, D- and D, L-methylphenidate, mixed salts amphetamine, and atomoxetine. The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) have recommended stimulants as the first line of treatment for ADHD. After two failed trials of
each of the two stimulant classes, it is recommended that the third line choice for ADHD treatment is atomoxetine. However atomoxetine, a noradrenergic reuptake inhibitor, can be considered as the first line medication for ADHD in individuals with an active substance abuse problem, comorbid anxiety, or tics.Schatzberg AF, DeBattista C. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric Publishing, Inc. Washington, D.C.
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Question 87 of 200
87. Question
Which is true regarding bupropion?
Correct
Bupropion’s mechanism of action is believed to involve reuptake inhibition of norepinephrine and dopamine. There is an increased risk of seizures at doses above 450 mg. Because patients with eating disorders are particularly susceptible to developing seizures while taking bupropion, its use in these patients is contraindicated. Due to its amphetamine like properties, appetite tends to be suppressed, so weight gain is not a problem. In addition, it is not associated with sexual dysfunction.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology. American Psychiatric Publishing. Philadelphia.
Incorrect
Bupropion’s mechanism of action is believed to involve reuptake inhibition of norepinephrine and dopamine. There is an increased risk of seizures at doses above 450 mg. Because patients with eating disorders are particularly susceptible to developing seizures while taking bupropion, its use in these patients is contraindicated. Due to its amphetamine like properties, appetite tends to be suppressed, so weight gain is not a problem. In addition, it is not associated with sexual dysfunction.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology. American Psychiatric Publishing. Philadelphia.
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Question 88 of 200
88. Question
Which of the following is a new criteria for substance use disorder in DSM-5?
Correct
Use in physically hazardous situations and persistent desire or unsuccessful effort to cut down have been retained from DSM-IV-TR to DSM-5. Recurrent legal problems have been deleted. The only new criteria is craving or a strong desire or urge to use the substance and can even persist in remission.
American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: Dsm-5 (5th ed.). American Psychiatric Association. Arlington.
Incorrect
Use in physically hazardous situations and persistent desire or unsuccessful effort to cut down have been retained from DSM-IV-TR to DSM-5. Recurrent legal problems have been deleted. The only new criteria is craving or a strong desire or urge to use the substance and can even persist in remission.
American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: Dsm-5 (5th ed.). American Psychiatric Association. Arlington.
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Question 89 of 200
89. Question
Which of the following statements concerning sleep is true?
Correct
Sleeping shorter or longer than the optimal sleep duration imperils health. The optimum nightly sleep duration is 7-9 hours. Nevertheless, one-third of the U.S. population sleeps less than 7 hours at night. Sleep difficulties impair numerous activities. From most to least, sleep difficulties impair concentrating (about 30%), remembering, working on a hobby, driving, and performing work (about 12%). Sleep deprivation has a cumulative detrimental effect on both mental and physical well-being. Moreover, it exacerbates chronic disease.
Roberts LW (eds). (2019). The American Psychiatric Publishing Textbook of Psychiatry, 7th ed. American Psychiatric Publishing. Philadelphia.
Incorrect
Sleeping shorter or longer than the optimal sleep duration imperils health. The optimum nightly sleep duration is 7-9 hours. Nevertheless, one-third of the U.S. population sleeps less than 7 hours at night. Sleep difficulties impair numerous activities. From most to least, sleep difficulties impair concentrating (about 30%), remembering, working on a hobby, driving, and performing work (about 12%). Sleep deprivation has a cumulative detrimental effect on both mental and physical well-being. Moreover, it exacerbates chronic disease.
Roberts LW (eds). (2019). The American Psychiatric Publishing Textbook of Psychiatry, 7th ed. American Psychiatric Publishing. Philadelphia.
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Question 90 of 200
90. Question
A 26-year-old man believes that he is clairvoyant, and often offers to “read tea leaves” for his colleagues at
work. He is comfortable spending his free time with his widowed aunt, with whom he lives, but otherwise he has no close friends. He is often suspicious of his coworkers, and worries that they rummage through his desk when he is on a break. He is often anxious at social events, and usually declines invitations. What is the most likely diagnosis?Correct
This vignette describes several diagnostic features of schizotypal personality disorder including odd beliefs or magical thinking, having few or no close friends other than first degree relatives, suspiciousness or paranoid ideation, and social anxiety. While each feature may be seen in other personality disorders (absence of close friends-schizoid; suspiciousness-paranoid; social anxiety-avoidant personality) the cluster of these 4 features occurring together is consistent with a diagnosis of schizotypal personality disorder.
American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). American Psychiatric Association. Arlington.
Incorrect
This vignette describes several diagnostic features of schizotypal personality disorder including odd beliefs or magical thinking, having few or no close friends other than first degree relatives, suspiciousness or paranoid ideation, and social anxiety. While each feature may be seen in other personality disorders (absence of close friends-schizoid; suspiciousness-paranoid; social anxiety-avoidant personality) the cluster of these 4 features occurring together is consistent with a diagnosis of schizotypal personality disorder.
American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). American Psychiatric Association. Arlington.
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Question 91 of 200
91. Question
Which of the following medicines is most closely linked to hyponatremia?
Correct
Of the choices, oxcarbazepine (most closely) and carbamazepine (second most closely) are linked with hyponatremia. One study (Dong) found serum sodium levels <128 mEq/L in 12% of patients taking oxcarbazepine and 3% of ones taking carbamazepine. The mechanism of hyponatremia probably involves renal dysfunction rather than either pituitary insufficiency or inappropriate secretion of antidiuretic hormone (ADH). Risk factors include high doses of the medicine, concurrent use of other medicines, and advanced age.
Pimozide is a classic antipsychotic agent that blocks D2 dopamine receptors. Its distinguishing features are that it has an indication for treatment of Tourette's disorder, for which it is still used, and its half-life is one of the longest of all of the antipsychotics (55 hours). As with other D2 dopamine receptor antagonists, pimozide use may be complicated by acute dystonic reactions, other extrapyramidal side effects, and the neuroleptic malignant
syndrome. Likewise, it may also dangerously prolong the QTc interval.Lithium itself does not induce hyponatremia. However, if patients taking lithium or the other medicines develop psychogenic polydipsia or take diuretic, they may develop hyponatremia.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology. American Psychiatric Publishing. Philadelphia.
Lin CH, Lu CH, Wang FJ, et al. (2010). Risk factors of oxcarbazepine-induced hyponatremia inpatients with epilepsy. Clin Neuropharmacol, 3;293-296
Incorrect
Of the choices, oxcarbazepine (most closely) and carbamazepine (second most closely) are linked with hyponatremia. One study (Dong) found serum sodium levels <128 mEq/L in 12% of patients taking oxcarbazepine and 3% of ones taking carbamazepine. The mechanism of hyponatremia probably involves renal dysfunction rather than either pituitary insufficiency or inappropriate secretion of antidiuretic hormone (ADH). Risk factors include high doses of the medicine, concurrent use of other medicines, and advanced age.
Pimozide is a classic antipsychotic agent that blocks D2 dopamine receptors. Its distinguishing features are that it has an indication for treatment of Tourette's disorder, for which it is still used, and its half-life is one of the longest of all of the antipsychotics (55 hours). As with other D2 dopamine receptor antagonists, pimozide use may be complicated by acute dystonic reactions, other extrapyramidal side effects, and the neuroleptic malignant
syndrome. Likewise, it may also dangerously prolong the QTc interval.Lithium itself does not induce hyponatremia. However, if patients taking lithium or the other medicines develop psychogenic polydipsia or take diuretic, they may develop hyponatremia.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology. American Psychiatric Publishing. Philadelphia.
Lin CH, Lu CH, Wang FJ, et al. (2010). Risk factors of oxcarbazepine-induced hyponatremia inpatients with epilepsy. Clin Neuropharmacol, 3;293-296
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Question 92 of 200
92. Question
Which of the following is a sign of opiate withdrawal?
Correct
Signs and symptoms of opiate withdrawal can occur within minutes to several days after cessation following heavy or prolonged use, or receiving an opiate antagonist. They include stomach cramps, nausea, vomiting, and /or diarrhea. Individuals may report dysphoria, muscle aches and difficulty sleeping. Yawning , lacrimation, rhinorrhea can occur, as does pupillary dilation, piloerection, diaphoresis and elevated temperature. On PE, needle “tracks” may be visible. Seizures can occur during withdrawal from sedatives, hypnotics or alcohol.
Galanter M, Kleber HD, Brady K. (2015). The American Psychiatric Publishing Textbook of Substance Abuse Treatment. American Psychiatric Publishing. Washington, D.C.
Incorrect
Signs and symptoms of opiate withdrawal can occur within minutes to several days after cessation following heavy or prolonged use, or receiving an opiate antagonist. They include stomach cramps, nausea, vomiting, and /or diarrhea. Individuals may report dysphoria, muscle aches and difficulty sleeping. Yawning , lacrimation, rhinorrhea can occur, as does pupillary dilation, piloerection, diaphoresis and elevated temperature. On PE, needle “tracks” may be visible. Seizures can occur during withdrawal from sedatives, hypnotics or alcohol.
Galanter M, Kleber HD, Brady K. (2015). The American Psychiatric Publishing Textbook of Substance Abuse Treatment. American Psychiatric Publishing. Washington, D.C.
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Question 93 of 200
93. Question
In regards to neural tube defects, which statement is true?
Correct
The neural tube forms in the first trimester of gestation. If the lower (caudal) end of the neural tube fails to close, the failure will cause a meningomyelocele, meningocele, or spina bifida. If the upper (cephalad) end fails to close, the failure will cause anencephaly, encephalocele, or similar defect. Supplementing breakfast cereals with folic acid or taking prenatal vitamins with folic acid has significantly lowered the incidence of neural tube defects. Nevertheless, the mother’s taking folic acid while taking medicines associated with the defect remains unsafe. Neural tube defects are readily detectable with MRI or ultrasound. Elevated levels of maternal serum alpha-fetoprotein indicate the presence of a neural tube defect. Not all mood stabilizers taken during pregnancy have been associated with neural tube defects. Valproate and, to a less extent, carbamazepine have been linked
to neural tube defect. Other medical teratogens and genetic mutations have also been linked to the defect.Gool JDV, Hirche H, Lax H, et al. (2018). Folic acid and primary prevention of neural tube defects: A review. Reprod Toxicol, 80;73–84
Incorrect
The neural tube forms in the first trimester of gestation. If the lower (caudal) end of the neural tube fails to close, the failure will cause a meningomyelocele, meningocele, or spina bifida. If the upper (cephalad) end fails to close, the failure will cause anencephaly, encephalocele, or similar defect. Supplementing breakfast cereals with folic acid or taking prenatal vitamins with folic acid has significantly lowered the incidence of neural tube defects. Nevertheless, the mother’s taking folic acid while taking medicines associated with the defect remains unsafe. Neural tube defects are readily detectable with MRI or ultrasound. Elevated levels of maternal serum alpha-fetoprotein indicate the presence of a neural tube defect. Not all mood stabilizers taken during pregnancy have been associated with neural tube defects. Valproate and, to a less extent, carbamazepine have been linked
to neural tube defect. Other medical teratogens and genetic mutations have also been linked to the defect.Gool JDV, Hirche H, Lax H, et al. (2018). Folic acid and primary prevention of neural tube defects: A review. Reprod Toxicol, 80;73–84
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Question 94 of 200
94. Question
Orthostatic hypotension is NOT a side effect of which medication?
Correct
Orthostatic hypotension is a side effect of trazodone, iloperidone, and phenelzine. Venlafaxine is associated with hypertension, especially diastolic blood pressure.
Roberts LW (eds). (2019). The American Psychiatric Publishing Textbook of Psychiatry, 7th ed. American Psychiatric Publishing. Philadelphia
Incorrect
Orthostatic hypotension is a side effect of trazodone, iloperidone, and phenelzine. Venlafaxine is associated with hypertension, especially diastolic blood pressure.
Roberts LW (eds). (2019). The American Psychiatric Publishing Textbook of Psychiatry, 7th ed. American Psychiatric Publishing. Philadelphia
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Question 95 of 200
95. Question
JS a 19 y.o. college student was brought to the ER by his roommate after he was found profusely sweating, vomiting and agitated. He had been studying for exams over the past five days. His roommate noted that he was staying up most nights, and was becoming increasingly irritable, hypervigilant and easily angered. An empty, unlabeled pill bottle was found in his nightstand. In the emergency room, J.S. was agitated, and somewhat confused. He was diaphoretic, had an elevated BP, and dilated pupils. What substance was he most likely using?
Correct
Behavioral Signs and symptoms of amphetamine intoxication include initial euphoria or affective blunting that gives way to changes in sociability, hypervigilance, and interpersonal sensitivity in which individuals can become easily angered. Anxiety, tension and stereotyped behaviors can also occur. Impairment in judgment and function frequently result. Individuals can exhibit psychomotor agitation or retardation. Other clinical manifestations may include changes in heart rate and blood pressure, nausea and vomiting, and/or dilated pupils. Individuals may also present with respiratory depression, muscular weakness and/or chest pain. Weight loss is common. Confusion, seizures, dyskinesia, cardiac arrhythmias and coma can occur.
Galanter M, Kleber HD, Brady K. (2015). The American Psychiatric Publishing Textbook of Substance Abuse Treatment. American Psychiatric Publishing. Washington, D.C.
Incorrect
Behavioral Signs and symptoms of amphetamine intoxication include initial euphoria or affective blunting that gives way to changes in sociability, hypervigilance, and interpersonal sensitivity in which individuals can become easily angered. Anxiety, tension and stereotyped behaviors can also occur. Impairment in judgment and function frequently result. Individuals can exhibit psychomotor agitation or retardation. Other clinical manifestations may include changes in heart rate and blood pressure, nausea and vomiting, and/or dilated pupils. Individuals may also present with respiratory depression, muscular weakness and/or chest pain. Weight loss is common. Confusion, seizures, dyskinesia, cardiac arrhythmias and coma can occur.
Galanter M, Kleber HD, Brady K. (2015). The American Psychiatric Publishing Textbook of Substance Abuse Treatment. American Psychiatric Publishing. Washington, D.C.
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Question 96 of 200
96. Question
In patients who are asymptomatic but are destined to develop Alzheimer’s disease dementia because they carry certain genetic mutations, what will cerebral amyloid imaging reveal?
Correct
Cerebral amyloid accumulation and other biomarkers, such as abnormal concentrations of CSF Aβ42 and tau, precede cognitive impairment in Alzheimer’s disease by several years. Cerebral tau accumulation and then atrophy also precede cognitive impairment in Alzheimer’s disease.
Palomo MSM. (2019). Amyloid hypothesis in Alzheimer´s disease. Alzheimer’s disease: pathological and clinical findings. Recent Advances in Alzheimer Research, 3;1–15
Incorrect
Cerebral amyloid accumulation and other biomarkers, such as abnormal concentrations of CSF Aβ42 and tau, precede cognitive impairment in Alzheimer’s disease by several years. Cerebral tau accumulation and then atrophy also precede cognitive impairment in Alzheimer’s disease.
Palomo MSM. (2019). Amyloid hypothesis in Alzheimer´s disease. Alzheimer’s disease: pathological and clinical findings. Recent Advances in Alzheimer Research, 3;1–15
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Question 97 of 200
97. Question
A 46-year-old jazz musician, who routinely used cocaine, began to have periods lasting for several hours during which he would fold a napkin or place dozens of utensils in squares. When he was in the midst these activities his friends described him as being “dull” and reluctant to join their jazz “set.” When asked about his behavior, he said that he derived no pleasure or excitement from it, but “loved” the cocaine. Which is the best term to describe this behavior?
Correct
He is punding – performing mindless, repetitive, purposeless, and unrewarding activities. Punding, which is similar to stereotypies, but more complex, would include incessantly arranging clothing in a drawer, building and taking apart paper constructions, and repeatedly aligning pens and pencils into diagrams. Parkinson’s disease patients, as well as individuals who regularly use amphetamine or cocaine, engage in punding. Excessive dopamine activity is its most likely cause.
Sanchez-Ramos J. (2015). Neurologic complications of psychomotor stimulant abuse. International review of neurobiology. The Neuropsychiatric Complications of Stimulant Abuse, 4;131–160.
Spencer AH, Rickards H, Fasano A, et al. (2011). The prevalence and clinical characteristics of punding in Parkinson’s disease. Mov Disord, 26;578-86
Incorrect
He is punding – performing mindless, repetitive, purposeless, and unrewarding activities. Punding, which is similar to stereotypies, but more complex, would include incessantly arranging clothing in a drawer, building and taking apart paper constructions, and repeatedly aligning pens and pencils into diagrams. Parkinson’s disease patients, as well as individuals who regularly use amphetamine or cocaine, engage in punding. Excessive dopamine activity is its most likely cause.
Sanchez-Ramos J. (2015). Neurologic complications of psychomotor stimulant abuse. International review of neurobiology. The Neuropsychiatric Complications of Stimulant Abuse, 4;131–160.
Spencer AH, Rickards H, Fasano A, et al. (2011). The prevalence and clinical characteristics of punding in Parkinson’s disease. Mov Disord, 26;578-86
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Question 98 of 200
98. Question
A 67 y.o. man with Parkinson’s Disease continues to experience hallucinations and agitation. Which antipsychotic would be preferred?
Correct
Quetiapine has very low rates of EPS. Studies indicate that when used in patients with Parkinson’s disease and Lewy Body disease treatment with quetiapine results in improvement in psychosis without exacerbation of motor function. Low doses of clozapine have also been used with similar benefit, but its side effect profile renders it less desirable.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology. American Psychiatric Publishing. Philadelphia.
Incorrect
Quetiapine has very low rates of EPS. Studies indicate that when used in patients with Parkinson’s disease and Lewy Body disease treatment with quetiapine results in improvement in psychosis without exacerbation of motor function. Low doses of clozapine have also been used with similar benefit, but its side effect profile renders it less desirable.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology. American Psychiatric Publishing. Philadelphia.
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Question 99 of 200
99. Question
Which of the following antipsychotic medications should be taken with food in order to promote adequate absorption?
Correct
Taking lurasidone on an empty stomach can decrease absorption and result in plasma levels that are up to 50% lower than when taken with food. This is also true for ziprasidone. Patients prescribed either of these medications should be advised to take their doses with meals.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology. American Psychiatric Publishing. Philadelphia.
Incorrect
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Question 100 of 200
100. Question
A 37 year old woman comes for a psychiatric evaluation. She fears that she is “going crazy” because she has episodes of feeling like her legs are distorted and her head is “wrapped in cotton.” Which term best describes her symptoms?
Correct
Depersonalization is a sense of detachment from oneself and one’s identity; whereas derealization is a sense that people and the environment are not real. In contrast, an illusion is a misperception of an actual sensory output.
Roberts LW. (2019). The American Psychiatric Association Publishing Textbook of Psychiatry (7th ed). American Psychiatric Association Publishing. Washington, D.C.
Incorrect
Depersonalization is a sense of detachment from oneself and one’s identity; whereas derealization is a sense that people and the environment are not real. In contrast, an illusion is a misperception of an actual sensory output.
Roberts LW. (2019). The American Psychiatric Association Publishing Textbook of Psychiatry (7th ed). American Psychiatric Association Publishing. Washington, D.C.
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Question 101 of 200
101. Question
Impaired performance on executive functioning tests has been best described in which of the following personality disorders?
Correct
Patients with schizotypal personality disorder have been shown to have deficits on tests of executive function. They also have deficits in tests of attention (including the Wisconsin Card Sorting Test), working memory, and learning. Because of these findings, schizotypal personality disorder is classified with schizophrenia in ICD-10.
Roberts LW. (2019). The American Psychiatric Association Publishing Textbook of Psychiatry (7th ed). American Psychiatric Association Publishing. Washington, D.C.
Incorrect
Patients with schizotypal personality disorder have been shown to have deficits on tests of executive function. They also have deficits in tests of attention (including the Wisconsin Card Sorting Test), working memory, and learning. Because of these findings, schizotypal personality disorder is classified with schizophrenia in ICD-10.
Roberts LW. (2019). The American Psychiatric Association Publishing Textbook of Psychiatry (7th ed). American Psychiatric Association Publishing. Washington, D.C.
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Question 102 of 200
102. Question
A patient is hospitalized medically for a gangrenous toe. Three physicians stated that it requires amputation. The psychiatry consultation team has been asked to see the patient to determine capacity because he refuses surgery in that he believes the toe will heal on its own. Which component of capacity does he lack?
Correct
In this scenario, the patient has clearly indicated a choice that he was able to communicate to the team. He was also able to state his condition, treatment, risks, and benefits, which demonstrate that he has understanding of the situation. However, he is unable to acknowledge the medical condition and likely outcomes, which shows the patient lacks appreciation. Delusions, distortions, and denial are common causes of impairment in appreciation. Competency is not a component of a capacity evaluation.
Appelbaum PS. (2007). Assessment of patients’ competence to consent to treatment. NEJM, 357(18);1834–1840.
Incorrect
In this scenario, the patient has clearly indicated a choice that he was able to communicate to the team. He was also able to state his condition, treatment, risks, and benefits, which demonstrate that he has understanding of the situation. However, he is unable to acknowledge the medical condition and likely outcomes, which shows the patient lacks appreciation. Delusions, distortions, and denial are common causes of impairment in appreciation. Competency is not a component of a capacity evaluation.
Appelbaum PS. (2007). Assessment of patients’ competence to consent to treatment. NEJM, 357(18);1834–1840.
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Question 103 of 200
103. Question
All of the following medications have been approved for chronic use in treatment of insomnia except which one?
Correct
Although all of the medications can be used to treat chronic insomnia, clonazepam is not approved for chronic use.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Association Publishing Textbook of Psychopharmacology (5th ed). American Psychiatric Association Publishing. Arlington.
Incorrect
Although all of the medications can be used to treat chronic insomnia, clonazepam is not approved for chronic use.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Association Publishing Textbook of Psychopharmacology (5th ed). American Psychiatric Association Publishing. Arlington.
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Question 104 of 200
104. Question
Which is the greatest advantage of second generation (SGAs) given intramuscular (IM) over first generation antipsychotics (FGAs) administered IM in use of an acutely agitated patient?
Correct
The primary advantages of (SGAs) given IM are fewer extrapyramidal side effects (EPS), including dystonic reactions, and more rapid onset of action. Studies have shown SGAs to be not more effective than FGAs and that they are more costly.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology. American Psychiatric Association Publishing. Washington, D.C.
Incorrect
The primary advantages of (SGAs) given IM are fewer extrapyramidal side effects (EPS), including dystonic reactions, and more rapid onset of action. Studies have shown SGAs to be not more effective than FGAs and that they are more costly.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology. American Psychiatric Association Publishing. Washington, D.C.
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Question 105 of 200
105. Question
A Chinese-American man is being treated by a psychiatrist in the outpatient setting. Pharmacogenomic testing may be indicated if the patient is going to be treated with which of the following medications:
Correct
The HLA-B1502 gene substantially increases the risk of Stevens Johnson syndrome in Han Chinese individuals being treated with carbamazepine. In 2007, the FDA recommended pharmacogenomic testing in at-risk populations.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology. American Psychiatric Association Publishing. Washington, D.C.
Incorrect
The HLA-B1502 gene substantially increases the risk of Stevens Johnson syndrome in Han Chinese individuals being treated with carbamazepine. In 2007, the FDA recommended pharmacogenomic testing in at-risk populations.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology. American Psychiatric Association Publishing. Washington, D.C.
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Question 106 of 200
106. Question
Stimulants are FDA approved for the treatment of all of the following disorders except:
Correct
Although several studies indicate potential use for stimulants as an adjunctive treatment for depression, they do not have an FDA indication.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology. American Psychiatric Association Publishing. Washington, D.C.
Incorrect
Although several studies indicate potential use for stimulants as an adjunctive treatment for depression, they do not have an FDA indication.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology. American Psychiatric Association Publishing. Washington, D.C.
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Question 107 of 200
107. Question
Which of the following SSRIs has been shown to increase the risk of fetal cardiac abnormalities?
Correct
Paroxetine has an association with fetal cardiac abnormalities, including atrial and septal defects, and thus is generally avoided in pregnancy. Most of the data on other SSRI exposure during pregnancy does not show a higher risk of birth anomalies.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology. American Psychiatric Association Publishing. Washington, D.C.
Incorrect
Paroxetine has an association with fetal cardiac abnormalities, including atrial and septal defects, and thus is generally avoided in pregnancy. Most of the data on other SSRI exposure during pregnancy does not show a higher risk of birth anomalies.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology. American Psychiatric Association Publishing. Washington, D.C.
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Question 108 of 200
108. Question
Which of the following features distinguishes neuroleptic malignant syndrome (NMS) from other neurologic side-effects of antipsychotic medications?
Correct
Although all of the answer choices can be seen in NMS, hyperthermia with oral temperature of >100.4F or >38.0C on at least 2 occasions will distinguish NMS from other drug-induced side effects.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
Incorrect
Although all of the answer choices can be seen in NMS, hyperthermia with oral temperature of >100.4F or >38.0C on at least 2 occasions will distinguish NMS from other drug-induced side effects.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
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Question 109 of 200
109. Question
At what age range do typically developing children begin expressing gendered behavior and interests?
Correct
Children 2-4 years of age will begin to express gender-specific interest. This is also the age of onset of cross-gender behaviors, including expressed desire to be the other gender or labeling oneself as the other gender.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
Incorrect
Children 2-4 years of age will begin to express gender-specific interest. This is also the age of onset of cross-gender behaviors, including expressed desire to be the other gender or labeling oneself as the other gender.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
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Question 110 of 200
110. Question
An adolescent female presents with significant weight loss and nutritional deficiency. Both the patient and her mother describe aversion to specific textures of food; however, the patient is not concerned about weight gain. The diagnosis that best fits this patient’s presentation is:
Correct
Diagnostic criteria for Avoidant/Restrictive Food Intake Disorder including eating or feeding disturbance associated with one of the following: significant weight loss, nutritional deficiency, dependence on nutritional supplementation, marked interference with functioning. There is no disturbance in body image as seen in anorexia. Patients with autism may have sensory issues; however, they do not result in significant weight loss/nutritional deficiency. Rumination Disorder includes repeated regurgitation of food.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
Incorrect
Diagnostic criteria for Avoidant/Restrictive Food Intake Disorder including eating or feeding disturbance associated with one of the following: significant weight loss, nutritional deficiency, dependence on nutritional supplementation, marked interference with functioning. There is no disturbance in body image as seen in anorexia. Patients with autism may have sensory issues; however, they do not result in significant weight loss/nutritional deficiency. Rumination Disorder includes repeated regurgitation of food.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
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Question 111 of 200
111. Question
Ways of expressing an emotion, such as “nerves,” “depression,” or “dizziness,” through collective, shared methods within a culture is best described as:
Correct
Cultural idioms of distress are ways of expressing distress that may not involve specific symptoms or syndromes but provide a shared expression of personal or social concerns. Cultural syndromes are clusters of symptoms that tend to co-occur among individuals in a particular community. A cultural explanation is a model for a culturally recognized meaning or etiology for a symptom or illness.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
Incorrect
Cultural idioms of distress are ways of expressing distress that may not involve specific symptoms or syndromes but provide a shared expression of personal or social concerns. Cultural syndromes are clusters of symptoms that tend to co-occur among individuals in a particular community. A cultural explanation is a model for a culturally recognized meaning or etiology for a symptom or illness.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
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Question 112 of 200
112. Question
Which of the following is not a risk factor for development of bipolar I disorder?
Correct
Bipolar disorder is more common in high versus low-income countries (1.4% vs 0.7%). Family history is one of the strongest risk factors for bipolar disorder. Although women have increased risk for rapid cycling and mixed episodes, gender ratio is almost equal in the prevalence of bipolar I disorder.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
Incorrect
Bipolar disorder is more common in high versus low-income countries (1.4% vs 0.7%). Family history is one of the strongest risk factors for bipolar disorder. Although women have increased risk for rapid cycling and mixed episodes, gender ratio is almost equal in the prevalence of bipolar I disorder.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
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Question 113 of 200
113. Question
Which of the following medications would reverse antipsychotic-induced sexual dysfunction?
Correct
. Bromocriptine is a dopamine agonist, that decreases elevated prolactin levels caused by antipsychotic medications. This return to normal levels may improve sexual functioning; however, there may be concern for increase of psychotic symptoms given this mechanism of action.
Krysiak R, Szkróbka W, Okopień B. (2018). The effect of bromocriptine treatment on sexual functioning and depressive symptoms in women with mild hyperprolactinemia. Pharm Report, 70(2), 227–232.
Steffens DC, Blazer DG, Thakur ME. (2015). The American Psychiatric Publishing Textbook of Geriatric Psychiatry, Fifth Edition. American Psychiatric Publishing, Inc. Arlington.
Incorrect
. Bromocriptine is a dopamine agonist, that decreases elevated prolactin levels caused by antipsychotic medications. This return to normal levels may improve sexual functioning; however, there may be concern for increase of psychotic symptoms given this mechanism of action.
Krysiak R, Szkróbka W, Okopień B. (2018). The effect of bromocriptine treatment on sexual functioning and depressive symptoms in women with mild hyperprolactinemia. Pharm Report, 70(2), 227–232.
Steffens DC, Blazer DG, Thakur ME. (2015). The American Psychiatric Publishing Textbook of Geriatric Psychiatry, Fifth Edition. American Psychiatric Publishing, Inc. Arlington.
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Question 114 of 200
114. Question
Which of the following statements is true regarding treatment of major depression with ECT in the elderly population?
Correct
Several studies have shown that ECT is a highly effective treatment for major depression in older adults and several studies have shown at least equivalent improvement among older adults in comparison to middle-age patients.
Steffens DC, Blazer DG, Thakur ME. (2015). The American Psychiatric Publishing Textbook of Geriatric Psychiatry, Fifth Edition. American Psychiatric Publishing, Inc. Arlington.
Incorrect
Several studies have shown that ECT is a highly effective treatment for major depression in older adults and several studies have shown at least equivalent improvement among older adults in comparison to middle-age patients.
Steffens DC, Blazer DG, Thakur ME. (2015). The American Psychiatric Publishing Textbook of Geriatric Psychiatry, Fifth Edition. American Psychiatric Publishing, Inc. Arlington.
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Question 115 of 200
115. Question
In patients with dementia with behavioral/psychological symptoms who have responded to antipsychotic treatment, an attempt to taper or withdraw the antipsychotic medication should be made within which time frame after initiation of the medicine if the patient does not experience a recurrence of symptoms?
Correct
As per the APA practice guidelines, an attempt to taper or withdraw an antipsychotic medication in a patient with dementia with behavioral/psychological symptoms should begin at 4 months. During this taper, the APA also recommends that the patient be assessed for reemergence of symptoms at least monthly during the taper and for at least 4 months after discontinuation.
American Psychiatric Association. (2016). The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Amer J Psychiatry, 5(173);543–546.
Incorrect
As per the APA practice guidelines, an attempt to taper or withdraw an antipsychotic medication in a patient with dementia with behavioral/psychological symptoms should begin at 4 months. During this taper, the APA also recommends that the patient be assessed for reemergence of symptoms at least monthly during the taper and for at least 4 months after discontinuation.
American Psychiatric Association. (2016). The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Amer J Psychiatry, 5(173);543–546.
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Question 116 of 200
116. Question
Rates of which of the following psychiatric disorders increase after a traumatic brain injury?
Correct
Both anxiety and mood disorders increase after a TBI, whereas rates of psychotic, somatoform, eating and adjustment disorders appear comparable to the general population.
Silver JM, McAllister TW, Arciniegas DB. (2019). Textbook of Traumatic Brain Injury. American Psychiatric Association Publishing. Washington, D.C.
Incorrect
Both anxiety and mood disorders increase after a TBI, whereas rates of psychotic, somatoform, eating and adjustment disorders appear comparable to the general population.
Silver JM, McAllister TW, Arciniegas DB. (2019). Textbook of Traumatic Brain Injury. American Psychiatric Association Publishing. Washington, D.C.
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Question 117 of 200
117. Question
All of the following are methods to improve engagement during Motivational Interviewing (MI) except:
Correct
Engaging is a crucial process of establishing and building rapport in MI. Ways to improve rapport in MI include the use of
OARS (open questions, affirmations, reflections and summaries).Levounis P. (2017). Motivational Interviewing for Clinical Practice. American Psychiatric Association. Arlington.
Incorrect
Engaging is a crucial process of establishing and building rapport in MI. Ways to improve rapport in MI include the use of
OARS (open questions, affirmations, reflections and summaries).Levounis P. (2017). Motivational Interviewing for Clinical Practice. American Psychiatric Association. Arlington.
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Question 118 of 200
118. Question
Which of the following is NOT an instance in which confidentiality can be broken within a patient-doctor relationship?
Correct
There are several instances when a psychiatrist can and is required to break confidentiality, such as the following: 1. When a patient presents a danger to themselves or others, 2. Mandatory reports of child/elder abuse, 3. Protecting a third party and 3. Proceedings where mental health issues are raised. Patients also waive their right to confidentiality when they ask to bring others into sessions, explicitly sign a release of information, or when they sue their providers.
Roberts LW. (2019). The American Psychiatric Association Publishing Textbook of Psychiatry (7th ed). American Psychiatric Association Publishing. Washington, D.C.
Incorrect
There are several instances when a psychiatrist can and is required to break confidentiality, such as the following: 1. When a patient presents a danger to themselves or others, 2. Mandatory reports of child/elder abuse, 3. Protecting a third party and 3. Proceedings where mental health issues are raised. Patients also waive their right to confidentiality when they ask to bring others into sessions, explicitly sign a release of information, or when they sue their providers.
Roberts LW. (2019). The American Psychiatric Association Publishing Textbook of Psychiatry (7th ed). American Psychiatric Association Publishing. Washington, D.C.
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Question 119 of 200
119. Question
All of the following are true regarding schemas according to a CBT model except:
Correct
Schema or core beliefs are deep cognitive structures that contain the basic rules for screening, coding, and filtering information from the environment that allow an individual to process information and facilitate decision making. Although the schemas are largely influenced from early childhood experiences, subsequent formative influences can alter them.
Roberts LW. (2019). The American Psychiatric Association Publishing Textbook of Psychiatry (7th ed). American Psychiatric Association Publishing. Washington, D.C.
Incorrect
Schema or core beliefs are deep cognitive structures that contain the basic rules for screening, coding, and filtering information from the environment that allow an individual to process information and facilitate decision making. Although the schemas are largely influenced from early childhood experiences, subsequent formative influences can alter them.
Roberts LW. (2019). The American Psychiatric Association Publishing Textbook of Psychiatry (7th ed). American Psychiatric Association Publishing. Washington, D.C.
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Question 120 of 200
120. Question
An adolescent male with long-standing history of ADHD presents with symptoms of schizophrenia. Which would be the next best step in treatment of his ADHD symptoms after his symptoms of schizophrenia are well controlled?
Correct
If a patient has comorbid schizophrenia and ADHD, it is important first to treat the symptoms of schizophrenia. If the patient continues to have significant ADHD symptoms, it is best to choose a non-stimulant option because stimulants may precipitate psychosis. Although stimulants can be trialed with patients with schizophrenia, non-stimulants would be the next best step.
Gough A, Morrison J. (2016). Managing the comorbidity of schizophrenia and ADHD. J Psychiatry Neurosci, 41(5);79–80.
Incorrect
If a patient has comorbid schizophrenia and ADHD, it is important first to treat the symptoms of schizophrenia. If the patient continues to have significant ADHD symptoms, it is best to choose a non-stimulant option because stimulants may precipitate psychosis. Although stimulants can be trialed with patients with schizophrenia, non-stimulants would be the next best step.
Gough A, Morrison J. (2016). Managing the comorbidity of schizophrenia and ADHD. J Psychiatry Neurosci, 41(5);79–80.
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Question 121 of 200
121. Question
Which of the following oral medications is most associated with QTc prolongation?
Correct
Low potency phenothiazines (thioridazine, chlorpromazine, mesoridazine) are most closely associated with QTc prolongation. IV haloperidol has been shown to increase QTc. The oral formulation of haloperidol can as well, although to a much lesser extent. Atypical antipsychotics, while less likely, can also cause QTc prolongation. Ziprasidone and iloperidone have the greatest propensity.
Leucht S, Cipirani A, Spineli L, et al. (2013). Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple treatments meta-analysis. Lancet, 382(9896);951-962.
Incorrect
Low potency phenothiazines (thioridazine, chlorpromazine, mesoridazine) are most closely associated with QTc prolongation. IV haloperidol has been shown to increase QTc. The oral formulation of haloperidol can as well, although to a much lesser extent. Atypical antipsychotics, while less likely, can also cause QTc prolongation. Ziprasidone and iloperidone have the greatest propensity.
Leucht S, Cipirani A, Spineli L, et al. (2013). Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple treatments meta-analysis. Lancet, 382(9896);951-962.
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Question 122 of 200
122. Question
Which of the following medications appears to be the safest for an infant of a breastfeeding mother?
Correct
. Lamotrigine is transmitted through breast milk in relatively high concentrations. Carbamazepine is considered safe, but there have been reports of hepatic dysfunction and transient seizure-like activity. Lithium is associated with several adverse effects, including cyanosis, poor muscle tone, and EKG changes. Most atypical antipsychotics have low milk/plasma ration and low infant serum levels.
Incorrect
. Lamotrigine is transmitted through breast milk in relatively high concentrations. Carbamazepine is considered safe, but there have been reports of hepatic dysfunction and transient seizure-like activity. Lithium is associated with several adverse effects, including cyanosis, poor muscle tone, and EKG changes. Most atypical antipsychotics have low milk/plasma ration and low infant serum levels.
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Question 123 of 200
123. Question
Which of the following medications is most weight-neutral in the treatment of bipolar disorder?
Correct
Medications most commonly associated with weight gain include olanzapine, clozapine, risperidone, quetiapine, gabapentin, divalproex, and lithium. Medications associated with less weight gain include carbamazepine, lamotrigine, and ziprasidone.
Yatham LN, Kennedy SH, Parikh SV, et al. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2);140–144.
Incorrect
Medications most commonly associated with weight gain include olanzapine, clozapine, risperidone, quetiapine, gabapentin, divalproex, and lithium. Medications associated with less weight gain include carbamazepine, lamotrigine, and ziprasidone.
Yatham LN, Kennedy SH, Parikh SV, et al. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2);140–144.
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Question 124 of 200
124. Question
Which of the following sedative agents has been associated with a decrease in incidence of delirium?
Correct
A meta-analysis of 16 randomized controlled trials comparing the above agents demonstrated a reduction in length of stay, duration of mechanical ventilation, and delirium incidence in patients who received dexmedetomidine versus the other agents.
Levenson JL. (2019). The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry. American Psychiatric Association Publishing. Washington, D.C.
Incorrect
A meta-analysis of 16 randomized controlled trials comparing the above agents demonstrated a reduction in length of stay, duration of mechanical ventilation, and delirium incidence in patients who received dexmedetomidine versus the other agents.
Levenson JL. (2019). The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry. American Psychiatric Association Publishing. Washington, D.C.
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Question 125 of 200
125. Question
An 83 year old retired barber, who has had Parkinson disease for 12 years, has become confined to a wheelchair when not in bed. He has almost no facial expression and marked rigidity of his limbs. When the neurologist increases the strength of his medication regimen, the patient develops vivid, frightening dreams and equally disturbing daytime hallucinations. Which of the following medications would be most likely to suppress the hallucinations and least likely to increase his Parkinson motor disability?
Correct
Usually after having their illness for longer than five years, Parkinson disease patients are at risk of developing cognitive impairment and psychosis manifested by hallucinations and delusions. The illness, its treatments that increase dopamine activity, or a combination of those factors may be responsible for the psychosis. The FDA has recently given pimavanserin (Nuplazid), a novel selective inverse agonist of the serotonin 5-HT2A receptor, an indication for suppression of hallucinations and delusions in Parkinson disease. Unlike most dopamine receptor antagonists used in this situation, pimavanserin does not increase Parkinson motor disability. Nevertheless, pimavanserin carriers a Black Box warning about the risk of death in elderly individuals with dementia. Clozapine (Clozaril) may be effective, but it has not received FDA indication for hallucinations and delusions in Parkinson disease. Moreover, potential dangers and rigorous monitoring requirements probably prevent physicians and their patients from using it. Quetiapine has received mixed reviews as to its effectiveness in suppressing hallucinations and delusions in Parkinson disease. Benzodiazepines may help anxiety and insomnia, but they carry a risk of amnesia, confusion, falls, and other side effects, especially in the elderly. Additional carbidopa-levodopa will likely increase hallucinations and delusions. In fact, one of the first strategies in combating hallucinations and delusions in Parkinson disease patients is to reduce the total dose of carbidopa-levodopa or, at least, avoid administering it during the evening.
Coombs BL, Coz AG. (2017). Update on the treatment of Parkinson disease psychosis. Neuropsychiatr Dis Treat, 13;737-744.
Mathis MV, Muoio BM, Anfreaso P, et al. (2017). The US Food and Drug Administration’s perspective on the new antipsychotic pimavanserin. J Clin Psychiatry, 78;e668-e673.
Moreno G, Gandhi R, Lessig S, et al. (2018). Mortality in patient with Parkinson disease psychosis receiving pimavanserin and quetiapine. Neurology, 91;797-799.
Incorrect
Usually after having their illness for longer than five years, Parkinson disease patients are at risk of developing cognitive impairment and psychosis manifested by hallucinations and delusions. The illness, its treatments that increase dopamine activity, or a combination of those factors may be responsible for the psychosis. The FDA has recently given pimavanserin (Nuplazid), a novel selective inverse agonist of the serotonin 5-HT2A receptor, an indication for suppression of hallucinations and delusions in Parkinson disease. Unlike most dopamine receptor antagonists used in this situation, pimavanserin does not increase Parkinson motor disability. Nevertheless, pimavanserin carriers a Black Box warning about the risk of death in elderly individuals with dementia. Clozapine (Clozaril) may be effective, but it has not received FDA indication for hallucinations and delusions in Parkinson disease. Moreover, potential dangers and rigorous monitoring requirements probably prevent physicians and their patients from using it. Quetiapine has received mixed reviews as to its effectiveness in suppressing hallucinations and delusions in Parkinson disease. Benzodiazepines may help anxiety and insomnia, but they carry a risk of amnesia, confusion, falls, and other side effects, especially in the elderly. Additional carbidopa-levodopa will likely increase hallucinations and delusions. In fact, one of the first strategies in combating hallucinations and delusions in Parkinson disease patients is to reduce the total dose of carbidopa-levodopa or, at least, avoid administering it during the evening.
Coombs BL, Coz AG. (2017). Update on the treatment of Parkinson disease psychosis. Neuropsychiatr Dis Treat, 13;737-744.
Mathis MV, Muoio BM, Anfreaso P, et al. (2017). The US Food and Drug Administration’s perspective on the new antipsychotic pimavanserin. J Clin Psychiatry, 78;e668-e673.
Moreno G, Gandhi R, Lessig S, et al. (2018). Mortality in patient with Parkinson disease psychosis receiving pimavanserin and quetiapine. Neurology, 91;797-799.
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Question 126 of 200
126. Question
A psychiatrist treats a 12 year old boy for attention-deficit hyperactivity disorder (ADHD) and a reading coach helps him for mild dyslexia. His parents ask the psychiatrist about the risks of their son’s participating in high school sports. Which of the following statements is most accurate?
Correct
Probably because of their inattention and impulsiveness, student athletes with ADHD may have five times the risk of sustaining a concussion and they are more apt to have multiple concussions compared to non-ADHD student athletes. The sports with the greatest frequency of traumatic brain injury are boxing, football, wrestling, soccer, and hockey.
Iaccarino MA, Fitzgerald M, Pulli A, et al. (2018). Sport concussion and attention deficit hyperactivity disorder in student athletes. Neurol Clin Practice, 8;403-411.
Liou YJ, Wei HT, Chen, et al.(2018). Risk of traumatic brain injury among children, adolescents, and young adults with attention-deficit hyperactivity disorder in Taiwan. J Adolesc Health, 63;233-238.
Incorrect
Probably because of their inattention and impulsiveness, student athletes with ADHD may have five times the risk of sustaining a concussion and they are more apt to have multiple concussions compared to non-ADHD student athletes. The sports with the greatest frequency of traumatic brain injury are boxing, football, wrestling, soccer, and hockey.
Iaccarino MA, Fitzgerald M, Pulli A, et al. (2018). Sport concussion and attention deficit hyperactivity disorder in student athletes. Neurol Clin Practice, 8;403-411.
Liou YJ, Wei HT, Chen, et al.(2018). Risk of traumatic brain injury among children, adolescents, and young adults with attention-deficit hyperactivity disorder in Taiwan. J Adolesc Health, 63;233-238.
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Question 127 of 200
127. Question
After a night of heavy drinking, a 23 year old soldier was involved in a motor vehicle crash in which he sustained major traumatic brain injury. He was initially in coma because of intracranial bleeding and brain swelling. By the end of three months, although he remained quadriplegic, his eyes were open, he seemed to have sleep-wake cycles, and he no longer needed mechanical ventilation. Also, he had no pain or seizures. A psychiatrist was called to assess his level of consciousness. She found that he responded appropriately by nodding “yes” or “no” to her asking him several simple questions; he looked, on her request, to his left or right; he held her and his family members in his gaze when they moved about; and he appropriately manipulated a fork and then a spoon. However, he was unable to speak or communicate in any manner, including not blinking in response to “yes” or “no” questions. Also, he was unable to respond to questions about wishes for his medical care. Which is the best description of his level of consciousness?
Correct
He has evolved from coma, possibly through a vegetative state, to the minimally conscious state. Patients in both the persistent vegetative state and the minimally conscious state have their eyes open and maintain sleep-wake cycles. The essential difference in the first three levels is that those in coma have their eyes closed, are unaware of their surroundings and their situation, and they are unresponsive except for reflex activity; those in the persistent vegetative state have their eyes open, show roving eye movements that may briefly alight on the examiner or relative but do not establish eye contact, cannot communicate, and do not respond except for reflex activity; and those in the minimally conscious state also have their eyes open, but they show a modicum of ability to follow verbal or gestured requests and to communicate, and exhibit some purposeful behavior. In each of these altered levels of consciousness, patients lack capacity for making informed decisions.
Giacino JT, Ashwal A, Childs N, et al. (2002). The minimally conscious state: Definition and diagnostic criteria. Neurology, 58;349-353.
Rosenbaum AM, Giacino JT. (2015). Clinical management of the minimally conscious state. Handb Clin Neurol, 127;395-410.
Incorrect
He has evolved from coma, possibly through a vegetative state, to the minimally conscious state. Patients in both the persistent vegetative state and the minimally conscious state have their eyes open and maintain sleep-wake cycles. The essential difference in the first three levels is that those in coma have their eyes closed, are unaware of their surroundings and their situation, and they are unresponsive except for reflex activity; those in the persistent vegetative state have their eyes open, show roving eye movements that may briefly alight on the examiner or relative but do not establish eye contact, cannot communicate, and do not respond except for reflex activity; and those in the minimally conscious state also have their eyes open, but they show a modicum of ability to follow verbal or gestured requests and to communicate, and exhibit some purposeful behavior. In each of these altered levels of consciousness, patients lack capacity for making informed decisions.
Giacino JT, Ashwal A, Childs N, et al. (2002). The minimally conscious state: Definition and diagnostic criteria. Neurology, 58;349-353.
Rosenbaum AM, Giacino JT. (2015). Clinical management of the minimally conscious state. Handb Clin Neurol, 127;395-410.
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Question 128 of 200
128. Question
In a rehabilitation facility where she was recovering from a stroke from a right-sided posterior cerebral artery occlusion, a 78-year old woman told her physicians that she was seeing dogs, plates of food, and children playing in her left visual field, which was blind. She realized that the visions were hallucinations. On examination, the neurologist found that she had a dense left homonymous hemianopsia and inability to identify objects placed in her left hand, but she was alert, articulate, and oriented with good memory and judgment. However, when the visions of dogs appeared, she became agitated. Which diagnosis would an astute psychiatrist most likely apply to her symptom of visual hallucinations?
Correct
This patient experiences visions, which she recognizes as hallucinations, in a hemianopic visual field. This constitutes the essence of Charles Bonnet syndrome, a classic neuropsychiatric disorder. Neurologists generally require that the patient has no confabulations, denial, or dementia. The Charles Bonnet syndrome most often follows a stroke that causes a homonymous hemianopsia, but visual loss from ocular disease, injury, or surgery may lead to this phenomenon. The hallucinations, which appear in blind areas, may be frightening or bothersome in some other way. Neurologists often suppress them with small doses of dopamine-blocking antipsychotic medicines, but ones that block serotonin have been suggested. Neurologists usually attribute the hallucinations to a deafferentation phenomenon in which the lack of visual input allows spontaneous visual cortex neuronal activity.
In contrast, Anton syndrome is a perceptual disorder in which patients with blindness, from either ocular or cerebral injury, believe and often act as if their vision were intact. Sometimes called visual agnosia, Anton syndrome induces denial, confabulations, and other defense mechanisms. Medications may calm the patient while physicians and family reassure and orient the patient.
Visual hallucinations also occur in the context of dementia or delirium. They are a hallmark of dementia with Lewy bodies disease and Parkinson disease dementia.
The clinical correlate of these relationships is that the physician who encounters a patient with visual hallucinations should test the visual acuity, visual fields, and cognitive function.Chen JJ, Chang HF, Hsu YC, et al. (2015). Anton-Babinski syndrome in an old patient: A case report and literature review. Psychogeriatrics, 5;58-61.
Frenke M, Rauschenberger L. (2018). Challenges of diagnosing and treating Charles Bonnet syndrome. Neurology Practice 8;359-361.
Gold K, Rabins PV. (1998). Isolated visual hallucinations and the Charles Bonnet syndrome: A review of the literature and presentation of six cases. Compre Psychiatry, 30;90-98.
Schadlu AP, Schadlu R, Shepherd JB. (2009). Charles Bonnet syndrome: A review. Current Opinion Ophthalmology 20;219-222.
Incorrect
This patient experiences visions, which she recognizes as hallucinations, in a hemianopic visual field. This constitutes the essence of Charles Bonnet syndrome, a classic neuropsychiatric disorder. Neurologists generally require that the patient has no confabulations, denial, or dementia. The Charles Bonnet syndrome most often follows a stroke that causes a homonymous hemianopsia, but visual loss from ocular disease, injury, or surgery may lead to this phenomenon. The hallucinations, which appear in blind areas, may be frightening or bothersome in some other way. Neurologists often suppress them with small doses of dopamine-blocking antipsychotic medicines, but ones that block serotonin have been suggested. Neurologists usually attribute the hallucinations to a deafferentation phenomenon in which the lack of visual input allows spontaneous visual cortex neuronal activity.
In contrast, Anton syndrome is a perceptual disorder in which patients with blindness, from either ocular or cerebral injury, believe and often act as if their vision were intact. Sometimes called visual agnosia, Anton syndrome induces denial, confabulations, and other defense mechanisms. Medications may calm the patient while physicians and family reassure and orient the patient.
Visual hallucinations also occur in the context of dementia or delirium. They are a hallmark of dementia with Lewy bodies disease and Parkinson disease dementia.
The clinical correlate of these relationships is that the physician who encounters a patient with visual hallucinations should test the visual acuity, visual fields, and cognitive function.Chen JJ, Chang HF, Hsu YC, et al. (2015). Anton-Babinski syndrome in an old patient: A case report and literature review. Psychogeriatrics, 5;58-61.
Frenke M, Rauschenberger L. (2018). Challenges of diagnosing and treating Charles Bonnet syndrome. Neurology Practice 8;359-361.
Gold K, Rabins PV. (1998). Isolated visual hallucinations and the Charles Bonnet syndrome: A review of the literature and presentation of six cases. Compre Psychiatry, 30;90-98.
Schadlu AP, Schadlu R, Shepherd JB. (2009). Charles Bonnet syndrome: A review. Current Opinion Ophthalmology 20;219-222.
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Question 129 of 200
129. Question
A psychiatrist wishing to reduce the involuntary movements of a patient’s oral-buccal-lingual form of tardive dyskinesia decides to prescribe valbenazine. What is this medication’s mechanism of action?
Correct
Vesicular monoamine transporter (VMAT), a transporter protein, brings dopamine from the cellular cytosol into vesicles of the presynaptic neuron’s terminal. Valbenazine (Ingrezza), tetrabenazine (Xenazine), and deutetrabenazine (Austedo) inhibit VMAT. By depleting presynaptic dopamine storage, these medicines reduce dopamine activity. Their primary clinical action reduces involuntary movements, such as oral-buccal-lingual form of tardive dyskinesia and chorea in Huntington disease. Haloperidol blocks dopamine receptors and thereby, in the short run, reduces the involuntary movements of tardive dyskinesia. In the long run, however, that strategy will reset the receptors and cause additional movement. Nevertheless, the general idea is that reduction in dopamine activity reduces involuntary movements. Thus, physicians prescribe medications that inhibit VMAT on an off-label basis to patients with Tourette disorder, hemiballismus, and athetosis.
Incorrect
Vesicular monoamine transporter (VMAT), a transporter protein, brings dopamine from the cellular cytosol into vesicles of the presynaptic neuron’s terminal. Valbenazine (Ingrezza), tetrabenazine (Xenazine), and deutetrabenazine (Austedo) inhibit VMAT. By depleting presynaptic dopamine storage, these medicines reduce dopamine activity. Their primary clinical action reduces involuntary movements, such as oral-buccal-lingual form of tardive dyskinesia and chorea in Huntington disease. Haloperidol blocks dopamine receptors and thereby, in the short run, reduces the involuntary movements of tardive dyskinesia. In the long run, however, that strategy will reset the receptors and cause additional movement. Nevertheless, the general idea is that reduction in dopamine activity reduces involuntary movements. Thus, physicians prescribe medications that inhibit VMAT on an off-label basis to patients with Tourette disorder, hemiballismus, and athetosis.
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Question 130 of 200
130. Question
In the previous question, of the following potential adverse reactions to valbenazine, which is the most important?
Correct
Of the choices offered, valbenazine’s potential effect on cardiac rhythms is the most important. This and similar medications may also cause sleepiness, anticholinergic effects, parkinsonism, and even akathisia. Some medicines in this group carry a risk of suicidality and parkinsonism.
Caroff SN, Aggarwal S, Yonan C. (2018) Treatment of tardive dyskinesia with tetrabenazine or valbenazine. J Comp Eff Res, 7;135-148.
Epping EA, Kim JI, Craufurd D, et al. (2016). Longitudinal psychiatric symptoms in prodromal Huntington’s disease: A decade of data. Am J Psychiatry, 173;184-192.
Hauser RA, Factor SA, Marder SR, et al. (2017). KINECT 3: A phase 3 randomized, double-blind, placebo-controlled trial of valbenazine for tardive dyskinesia. Am J Psychiatry, 174;476-484.
Kenney C, Hunter C, Davidson A, et al. (2007). Short-term effects of tetrabenazine on chorea associated with Huntington’s disease. Mov Disord, 22;10-13.
Kenney C, Hunter C, Jankovic J. (2007). Long-term tolerability of tetrabenazine in the treatment of hyperkinetic movement disorders. Mov Disord 22;193-197.
Müller T. (2017). Valbenazine for the treatment of tardive dyskinesia. Expert Rev Neurother, 17;1135-1144.
Ondo WG, Hanna PA, Jankovic J. (1999). Tetrabenazine treatment for tardive dyskinesia: Assessment by randomized videotape protocol. Am J Psychiatry, 156;279-1281.
Incorrect
Of the choices offered, valbenazine’s potential effect on cardiac rhythms is the most important. This and similar medications may also cause sleepiness, anticholinergic effects, parkinsonism, and even akathisia. Some medicines in this group carry a risk of suicidality and parkinsonism.
Caroff SN, Aggarwal S, Yonan C. (2018) Treatment of tardive dyskinesia with tetrabenazine or valbenazine. J Comp Eff Res, 7;135-148.
Epping EA, Kim JI, Craufurd D, et al. (2016). Longitudinal psychiatric symptoms in prodromal Huntington’s disease: A decade of data. Am J Psychiatry, 173;184-192.
Hauser RA, Factor SA, Marder SR, et al. (2017). KINECT 3: A phase 3 randomized, double-blind, placebo-controlled trial of valbenazine for tardive dyskinesia. Am J Psychiatry, 174;476-484.
Kenney C, Hunter C, Davidson A, et al. (2007). Short-term effects of tetrabenazine on chorea associated with Huntington’s disease. Mov Disord, 22;10-13.
Kenney C, Hunter C, Jankovic J. (2007). Long-term tolerability of tetrabenazine in the treatment of hyperkinetic movement disorders. Mov Disord 22;193-197.
Müller T. (2017). Valbenazine for the treatment of tardive dyskinesia. Expert Rev Neurother, 17;1135-1144.
Ondo WG, Hanna PA, Jankovic J. (1999). Tetrabenazine treatment for tardive dyskinesia: Assessment by randomized videotape protocol. Am J Psychiatry, 156;279-1281.
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Question 131 of 200
131. Question
An elementary school teacher consulted a psychiatrist because, compared to previous years, numerous children in pre-kindergarten, kindergarten, and the first two grades exhibited irritability, hyperactivity, and antisocial behavior. Some had learning disabilities, slow language development and delayed acquisition of developmental milestones. None had physical symptoms or signs except for several who complained of constipation. Of the following tests, which one should be performed first?
Correct
Blood lead levels should be determined because of the wide-spread behavioral, developmental, and cognitive disorders in these young children. The neurocognitive symptoms, their variable nature, and the constipation are consistent with lead poisoning. Although neuropsychologic and other testing is advisable, additional tests once a poisoning is suspected would delay diagnosis, identifying the source, and instituting treatment. The most common cause of lead poisoning had been young children eating lead-containing paint, but nowadays the most common cause is probably industrial pollution. Incidentally, the radiation required for head CT, which may be small, has nevertheless been associated with a significant risk for cancer in later life.
Bellinger DC, Stiles KM, Needleman HL. (1992). Low-level lead exposure, intelligence and academic achievement: A long-term follow-up study. Pediatrics, 90;855-861.
Canfield RL, Kreher DA, Cornwell C, et al. (2003). Low-level lead exposure, executive functioning, and early learning in childhood. Child Neuropsychol, 9;35-53.
Chandramouli K, Steer CD, Ellis M, et al. (2009). Effects of early childhood lead exposure on academic performance and behavior of school age children. Arch Dis Child, 94;844-848.
Hanna-Attisha M, Kuehn BM. (2016) Pediatrician sees long road ahead for Flint after lead poisoning crisis. JAMA, 315;967-969.
Liu J, Liu X, Wang W, et al. (2014). Blood lead concentrations and children’s behavioral and emotional problems. JAMA Pediatr, 168;737-745.
Incorrect
Blood lead levels should be determined because of the wide-spread behavioral, developmental, and cognitive disorders in these young children. The neurocognitive symptoms, their variable nature, and the constipation are consistent with lead poisoning. Although neuropsychologic and other testing is advisable, additional tests once a poisoning is suspected would delay diagnosis, identifying the source, and instituting treatment. The most common cause of lead poisoning had been young children eating lead-containing paint, but nowadays the most common cause is probably industrial pollution. Incidentally, the radiation required for head CT, which may be small, has nevertheless been associated with a significant risk for cancer in later life.
Bellinger DC, Stiles KM, Needleman HL. (1992). Low-level lead exposure, intelligence and academic achievement: A long-term follow-up study. Pediatrics, 90;855-861.
Canfield RL, Kreher DA, Cornwell C, et al. (2003). Low-level lead exposure, executive functioning, and early learning in childhood. Child Neuropsychol, 9;35-53.
Chandramouli K, Steer CD, Ellis M, et al. (2009). Effects of early childhood lead exposure on academic performance and behavior of school age children. Arch Dis Child, 94;844-848.
Hanna-Attisha M, Kuehn BM. (2016) Pediatrician sees long road ahead for Flint after lead poisoning crisis. JAMA, 315;967-969.
Liu J, Liu X, Wang W, et al. (2014). Blood lead concentrations and children’s behavioral and emotional problems. JAMA Pediatr, 168;737-745.
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Question 132 of 200
132. Question
A 59 year old schoolteacher developed a dull personality and cognitive impairment over the course of six weeks. He had no prior neurologic or psychiatric disorder and his routine medical evaluation, including blood and urine tests, showed no significant abnormality. On the MMSE, the patient scored 21. The neurologist found impaired executive function, apathy, and inattention as well as cognitive impairments. Extraocular movements were full, and no nystagmus was present. Pupils were round, equal and reactive. To the extent that the patient cooperated, there was no weakness. Muscle tone and bulk were normal. Reflexes and sensation were intact. The gait was uncertain, and the stance was broad. Although no tremor was present, when the patient began to perform the finger-to-nose test or the neurologist tapped the patient’s shoulder, the movements elicited a jerk of the entire arm. Further blood testing that was performed included ones for B12 level, HIV, thyroid function, liver function, heavy metal, syphilis and ceruloplasmin. MRI with contrast showed a faint cortical ribbon. EEG showed periodic discharges.
What is the implication of the neurologist’s finding that the patient’s extraocular movements were full and that there was no nystagmus?
Correct
An intricate network relying on the brainstem, cranial nerves 3, 4, and 6, and cerebellum, controls the movement and stability of the eyes (extraocular movements). The term “extraocular” does not pertain to size, shape, or reflex movement of the pupils. PSP and acute WKS both cause mental status changes and abnormalities in extraocular movements. Alzheimer disease and most other dementia-producing illnesses do not impair extraocular movements.
Incorrect
An intricate network relying on the brainstem, cranial nerves 3, 4, and 6, and cerebellum, controls the movement and stability of the eyes (extraocular movements). The term “extraocular” does not pertain to size, shape, or reflex movement of the pupils. PSP and acute WKS both cause mental status changes and abnormalities in extraocular movements. Alzheimer disease and most other dementia-producing illnesses do not impair extraocular movements.
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Question 133 of 200
133. Question
Which of the following illnesses is characterized by the rapid onset of dementia?
Correct
Neurologists say that patients who have developed dementia during a period of six months or less have had the “rapid onset of dementia.” Assuming that preliminary tests have excluded brain tumors, hydrocephalus, and other structural lesions; metabolic aberrations, such as hypothyroidism and B12 deficiency; common infectious illnesses, such as syphilis and HIV disease; and inflammatory encephalitis, particularly paraneoplastic syndromes, Creutzfeldt-Jakob disease, the quintessential degenerative illness, leads to the rapid onset of dementia. Its characteristic physical sign is myoclonus, but ataxia of the trunk and limbs is also a common finding. Early in the illness, about 50% of patients show agitation, hallucination or anxiety. As far as the rapidity of onset, Alzheimer disease and frontotemporal dementia, in contrast, usually evolve over several years. The dementia from cerebrovascular disease, Parkinson disease, and progressive supranuclear palsy usually also evolves over years and physical abnormalities usually precede or accompany it.
Incorrect
Neurologists say that patients who have developed dementia during a period of six months or less have had the “rapid onset of dementia.” Assuming that preliminary tests have excluded brain tumors, hydrocephalus, and other structural lesions; metabolic aberrations, such as hypothyroidism and B12 deficiency; common infectious illnesses, such as syphilis and HIV disease; and inflammatory encephalitis, particularly paraneoplastic syndromes, Creutzfeldt-Jakob disease, the quintessential degenerative illness, leads to the rapid onset of dementia. Its characteristic physical sign is myoclonus, but ataxia of the trunk and limbs is also a common finding. Early in the illness, about 50% of patients show agitation, hallucination or anxiety. As far as the rapidity of onset, Alzheimer disease and frontotemporal dementia, in contrast, usually evolve over several years. The dementia from cerebrovascular disease, Parkinson disease, and progressive supranuclear palsy usually also evolves over years and physical abnormalities usually precede or accompany it.
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Question 134 of 200
134. Question
Which of the following is the most likely cause of Creutzfeldt-Jakob disease?
Correct
Creutzfeldt-Jakob disease is a prion disease. The infective agent that contains neither DNA nor RNA but consists of a misfolded protein that is usually designated PrPSc, which is named after the prion that caused scrapie. It spreads through the brain in an orderly fashion converting normal proteins to the isoform, PrPSc. The infection produces a characteristic spongiform change in the brain.
Incorrect
Creutzfeldt-Jakob disease is a prion disease. The infective agent that contains neither DNA nor RNA but consists of a misfolded protein that is usually designated PrPSc, which is named after the prion that caused scrapie. It spreads through the brain in an orderly fashion converting normal proteins to the isoform, PrPSc. The infection produces a characteristic spongiform change in the brain.
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Question 135 of 200
135. Question
Which is currently the most specific and sensitive test for Creutzfeldt-Jakob disease?
Correct
Real-time quake-induce conversion has the greatest specificity and sensitivity for the diagnosis of Creutzfeldt-Jakob and other prion diseases. CSF concentrations of the 14-3-3 protein are less specific because the CSF of patients with encephalitis or a brain tumor may show this protein. The EEG and MRI are usually both abnormal, but the abnormalities are neither consistent, sensitive, nor specific.
Krasnianski A, Bohling GT, Harden M, et al. (2015). Psychiatric symptoms in patients with sporadic Creutzfeldt-Jakob disease in Germany. J Clin Psychiatry, 76;1209-1215
McGuire LI, Poleggi A, Pogiolini I, et al. (2016). Cerebrospinal fluid real-time quaking-induced conversion is a robust and reliable test for sporadic Creutzfeldt-Jakob disease. Ann Neurol, 80;160-165
Zerr I, Parchi P. (2018). Sporadic Creutzfeldt-Jakob disease. Handb Clin Neurol, 153;155-174
Incorrect
Real-time quake-induce conversion has the greatest specificity and sensitivity for the diagnosis of Creutzfeldt-Jakob and other prion diseases. CSF concentrations of the 14-3-3 protein are less specific because the CSF of patients with encephalitis or a brain tumor may show this protein. The EEG and MRI are usually both abnormal, but the abnormalities are neither consistent, sensitive, nor specific.
Krasnianski A, Bohling GT, Harden M, et al. (2015). Psychiatric symptoms in patients with sporadic Creutzfeldt-Jakob disease in Germany. J Clin Psychiatry, 76;1209-1215
McGuire LI, Poleggi A, Pogiolini I, et al. (2016). Cerebrospinal fluid real-time quaking-induced conversion is a robust and reliable test for sporadic Creutzfeldt-Jakob disease. Ann Neurol, 80;160-165
Zerr I, Parchi P. (2018). Sporadic Creutzfeldt-Jakob disease. Handb Clin Neurol, 153;155-174
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Question 136 of 200
136. Question
The maternal grandparents of a 12 year old boy brought him to a child psychiatrist, on the recommendation of his teachers, because they have found that he has had declining ability to perform his schoolwork. In addition, his grandparents as well as his teachers have noticed that he has become withdrawn. The boy’s father developed an illness at 35 years and died, in a mental hospital, at the age of 42 years. His mother was financially and emotionally unable to raise him and his two sisters. His examination showed that he had impairments in memory, executive function, and, to a lesser extent, language function. He was apathetic. He had impaired saccadic and slow pursuit eye movements. His limbs had little spontaneous or voluntary movement and when his limbs were flexed and extended, he had diffuse rigidity. However, he had no tremor, chorea, or other involuntary movement. A neurologist suggested genetic testing for Huntington disease (formerly called Huntington’s chorea). Which of the following statements about this case is true?
Correct
. In childhood, the onset of cognitive decline and withdrawal, with akinesia and rigidity of the limbs, strongly suggests several illnesses: juvenile, akinetic, or rigid form of Huntington disease; Wilson disease; drug abuse; and several other, rare neurodegenerative diseases. Impaired saccadic and slow pursuit eye movement is also indicative of Huntington disease as well as several neurodegenerative illnesses, but it is also found in schizophrenia. The inheritance pattern of the juvenile form of Huntington disease follows a trend of earlier appearance of symptoms and signs in successive generations, which is called “anticipation.” This case is typical in that the father developed signs of the illness at 35 years and the boy at 12 years.
Incorrect
. In childhood, the onset of cognitive decline and withdrawal, with akinesia and rigidity of the limbs, strongly suggests several illnesses: juvenile, akinetic, or rigid form of Huntington disease; Wilson disease; drug abuse; and several other, rare neurodegenerative diseases. Impaired saccadic and slow pursuit eye movement is also indicative of Huntington disease as well as several neurodegenerative illnesses, but it is also found in schizophrenia. The inheritance pattern of the juvenile form of Huntington disease follows a trend of earlier appearance of symptoms and signs in successive generations, which is called “anticipation.” This case is typical in that the father developed signs of the illness at 35 years and the boy at 12 years.
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Question 137 of 200
137. Question
Genetic testing of children is ethically problematic, but if it were performed in this case, what would it most likely show?
Correct
Huntington disease is attributable to an expansion of 36 or greater CAG trinucleotide repeats on Chromosome 4. When the CAG trinucleotide repeats reach or exceed 60, the illness’ signs and symptoms appear in carriers younger than 21 years. Also, unlike the adult form, the juvenile form is characterized by the presence of akinesia and rigidity and the absence of chorea.
Gonzalez-Alegre P, Afifi AK. (2006). Clinical characteristics of childhood-onset (juvenile) Huntington disease: Report of 12 patients and review of the literature. J Child Neurol, 21;223-229.
Grabska N, Rudzinska M, Wojcik-Pedziwiatr M, et al. (2014). Saccadic eye movements in juvenile variant of Huntington disease. Neurol Neurochir pol, 48;236-241.
Kieburtz K, Reilmann R, Olanow CW. (2018). Huntington’s disease: Current and future therapeutic prospects. Move Dis, 33;1033-1040.
Marinez-Horta S, Perez-Perez J, Sampedro F, et al. (2018). Structural and metabolic correlates of apathy in Huntington’s disease. Move Dis, 33;1151-1159.
Myles JB, Rossell SL, Phillipou A, et al. (2017). Insights to the schizophrenia continuum: A systemic review of saccadic eye movements in schizotypy and biological relatives of schizophrenic patients. Neurosci Biobehav Rev, 72;278-300.
Incorrect
Huntington disease is attributable to an expansion of 36 or greater CAG trinucleotide repeats on Chromosome 4. When the CAG trinucleotide repeats reach or exceed 60, the illness’ signs and symptoms appear in carriers younger than 21 years. Also, unlike the adult form, the juvenile form is characterized by the presence of akinesia and rigidity and the absence of chorea.
Gonzalez-Alegre P, Afifi AK. (2006). Clinical characteristics of childhood-onset (juvenile) Huntington disease: Report of 12 patients and review of the literature. J Child Neurol, 21;223-229.
Grabska N, Rudzinska M, Wojcik-Pedziwiatr M, et al. (2014). Saccadic eye movements in juvenile variant of Huntington disease. Neurol Neurochir pol, 48;236-241.
Kieburtz K, Reilmann R, Olanow CW. (2018). Huntington’s disease: Current and future therapeutic prospects. Move Dis, 33;1033-1040.
Marinez-Horta S, Perez-Perez J, Sampedro F, et al. (2018). Structural and metabolic correlates of apathy in Huntington’s disease. Move Dis, 33;1151-1159.
Myles JB, Rossell SL, Phillipou A, et al. (2017). Insights to the schizophrenia continuum: A systemic review of saccadic eye movements in schizotypy and biological relatives of schizophrenic patients. Neurosci Biobehav Rev, 72;278-300.
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Question 138 of 200
138. Question
Which of the following criteria/symptoms of Substance Use Disorders may persist even in full remission?
Correct
Cravings may persist even in full recovery and can be triggered by exposure to cues in the environment (“people, places, and things”). Patient’s awareness of this vulnerability is important in successful recovery. DWI is an indication of relapse and patient is no longer in remission. Not fulfilling role obligations or desire to cut down indicates the patient has not achieved full remission.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
Incorrect
Cravings may persist even in full recovery and can be triggered by exposure to cues in the environment (“people, places, and things”). Patient’s awareness of this vulnerability is important in successful recovery. DWI is an indication of relapse and patient is no longer in remission. Not fulfilling role obligations or desire to cut down indicates the patient has not achieved full remission.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
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Question 139 of 200
139. Question
Which of the following medications is not indicated for the ongoing treatment of opioid use disorder?
Correct
Naltrexone, an opioid antagonist, is indicated for the ongoing treatment of opioid use disorder. Suboxone, a partial antagonist, and methadone, a full antagonist, are proven effective maintenance treatment as well. Naloxone is only indicated for opioid overdose and not for ongoing treatment.
Miller SC, Fiellin DA, Rosenthal RN (eds). (2018). Principles of Addiction Medicine. Wolters Kluwer. Philadelphia.
Incorrect
Naltrexone, an opioid antagonist, is indicated for the ongoing treatment of opioid use disorder. Suboxone, a partial antagonist, and methadone, a full antagonist, are proven effective maintenance treatment as well. Naloxone is only indicated for opioid overdose and not for ongoing treatment.
Miller SC, Fiellin DA, Rosenthal RN (eds). (2018). Principles of Addiction Medicine. Wolters Kluwer. Philadelphia.
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Question 140 of 200
140. Question
Which of the following drugs do not increase metabolism of methadone?
Correct
Phenytoin, rifampin, and carbamazepine are all inducers of hepatic metabolism of methadone, potentially requiring an increase in methadone dose to maintain stabilization. Harvoni is an effective treatment of Hepatitis C and does not induce metabolism of methadone.
Miller SC, Fiellin DA, Rosenthal RN (eds). (2018). Principles of Addiction Medicine. Wolters Kluwer. Philadelphia.
Incorrect
Phenytoin, rifampin, and carbamazepine are all inducers of hepatic metabolism of methadone, potentially requiring an increase in methadone dose to maintain stabilization. Harvoni is an effective treatment of Hepatitis C and does not induce metabolism of methadone.
Miller SC, Fiellin DA, Rosenthal RN (eds). (2018). Principles of Addiction Medicine. Wolters Kluwer. Philadelphia.
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Question 141 of 200
141. Question
Which of the following medications would be best indicated for the treatment of an adult with Tobacco Use Disorder and Co-Occurring Major Depressive Disorder?
Correct
Bupropion is a proven effective treatment for Tobacco Use Disorder. It is also indicated for MDD. Sertraline and venlafaxine are effective treatment for MDD, but not for Tobacco Cessation. Bupropion is indicated for anxiety only. Varenicline is an effective treatment of Tobacco Use Disorder. Although early reports warned of increasing depressive symptoms and even suicidality, which required a Black Box Warning, that problem has been resolved because association has not been proven.
Miller SC, Fiellin DA, Rosenthal RN (eds). (2018). Principles of Addiction Medicine. Wolters Kluwer. Philadelphia.
Thomas KH, Martin RM, Knipe DW, et al. (2015). Risk of neuropsychiatric adverse events associated with varenicline: Systematic review and meta-analysis. BMJ, 350;h1109.
Incorrect
Bupropion is a proven effective treatment for Tobacco Use Disorder. It is also indicated for MDD. Sertraline and venlafaxine are effective treatment for MDD, but not for Tobacco Cessation. Bupropion is indicated for anxiety only. Varenicline is an effective treatment of Tobacco Use Disorder. Although early reports warned of increasing depressive symptoms and even suicidality, which required a Black Box Warning, that problem has been resolved because association has not been proven.
Miller SC, Fiellin DA, Rosenthal RN (eds). (2018). Principles of Addiction Medicine. Wolters Kluwer. Philadelphia.
Thomas KH, Martin RM, Knipe DW, et al. (2015). Risk of neuropsychiatric adverse events associated with varenicline: Systematic review and meta-analysis. BMJ, 350;h1109.
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Question 142 of 200
142. Question
Which of the following psychiatric disorders tend to occur after onset of Substance Use Disorder (SUD) rather than precede onset of SUD in adolescents?
Correct
Social Anxiety Disorder, PTSD, and Conduct Disorder tend to precede onset of SUD. In contrast, MDD more often occurs after onset of SUD.
Galanter M, Kleber HD (eds). (2008). The American Psychiatric Press Textbook of Substance Abuse Treatment. APA Press. Washington, D.C.
Incorrect
Social Anxiety Disorder, PTSD, and Conduct Disorder tend to precede onset of SUD. In contrast, MDD more often occurs after onset of SUD.
Galanter M, Kleber HD (eds). (2008). The American Psychiatric Press Textbook of Substance Abuse Treatment. APA Press. Washington, D.C.
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Question 143 of 200
143. Question
A 49 year old woman is experiencing 2-3 minute episodes of increased temperature in her chest and face that spreads throughout her body, associated with sweating. She has anywhere from 5 to 20 episodes per day and they often awaken her at night. Her menses have become irregular over the last year. What medication may be helpful?
Correct
Several studies demonstrated benefits of SSRIs and SNRIs for the treatment of hot flashes and nights sweats in menopausal women.
Nelson HD, Vesco KK, Haney E, et al. (2006). Nonhormonal therapies for menopausal hot flashes: Systematic review and meta-analysis. JAMA, 295(17);2057–2071.
Incorrect
Several studies demonstrated benefits of SSRIs and SNRIs for the treatment of hot flashes and nights sweats in menopausal women.
Nelson HD, Vesco KK, Haney E, et al. (2006). Nonhormonal therapies for menopausal hot flashes: Systematic review and meta-analysis. JAMA, 295(17);2057–2071.
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Question 144 of 200
144. Question
A 77 year old man is admitted to the ICU with sepsis. He is hallucinating and agitated. An EKG shows QTc of 520 msec. Which of the following is true about the treatment of his agitation?
Correct
There is no absolute QTc cutoff for antipsychotic use. Haloperidol, if given orally, has no more risk of QTc prolongation and torsade de pointes than most atypical antipsychotics. Ziprasidone has a higher risk profile. Benzodiazepines in general are likely to make a delirious patient more confused. Given this patient’s risk factors – advanced age, sepsis, and prolonged QTc – a cardiology consult will help the treatment team weigh the cardiac risks against the need for control of psychosis.
Funk MC, Beach SR, Bostwick JR, et al. (2018). APA resource document on QTc prolongation and psychotropic medications. Am J Psychiatry, 177(3);273-274.
Incorrect
There is no absolute QTc cutoff for antipsychotic use. Haloperidol, if given orally, has no more risk of QTc prolongation and torsade de pointes than most atypical antipsychotics. Ziprasidone has a higher risk profile. Benzodiazepines in general are likely to make a delirious patient more confused. Given this patient’s risk factors – advanced age, sepsis, and prolonged QTc – a cardiology consult will help the treatment team weigh the cardiac risks against the need for control of psychosis.
Funk MC, Beach SR, Bostwick JR, et al. (2018). APA resource document on QTc prolongation and psychotropic medications. Am J Psychiatry, 177(3);273-274.
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Question 145 of 200
145. Question
Which of the following conditions involves loss or change in bodily functions that result from a psychological conflict or need?
Correct
Conversion disorder involves a loss or change in sensory or motor function that is suggestive of a neurological disorder but that is caused by psychological factors.
Braun IM, et al. (2010). Functional Somatic Symptoms, Deception Syndromes, and Somatoform Disorders (in) Massachusetts General Hospital Handbook of General Hospital Psychiatry (6th ed), 2010. Elsevier. Philadelphia.
Incorrect
Conversion disorder involves a loss or change in sensory or motor function that is suggestive of a neurological disorder but that is caused by psychological factors.
Braun IM, et al. (2010). Functional Somatic Symptoms, Deception Syndromes, and Somatoform Disorders (in) Massachusetts General Hospital Handbook of General Hospital Psychiatry (6th ed), 2010. Elsevier. Philadelphia.
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Question 146 of 200
146. Question
A 25 year old man with schizophrenia and asthma, developed akathisia. What medication is contraindicated?
Correct
A 25 year old man with schizophrenia and asthma, developed akathisia. What medication is contraindicated?
Incorrect
A 25 year old man with schizophrenia and asthma, developed akathisia. What medication is contraindicated?
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Question 147 of 200
147. Question
In a patient with bulimia and depression, which medication is contraindicated?
Correct
Bupropion is contraindicated in patients with eating disorders as those patients have a higher risk of seizures, likely secondary to electrolyte disturbances.
Incorrect
Bupropion is contraindicated in patients with eating disorders as those patients have a higher risk of seizures, likely secondary to electrolyte disturbances.
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Question 148 of 200
148. Question
A 21 year old woman develops new onset seizures. What is the best test to differentiate psychogenic non-epileptic seizures from epileptic events?
Correct
Video EEG monitoring allows for correlation of the semiologic features of the episodes with the electrical activity in the brain. Lack of encephalographic correlate during a seizure event indicates a non-epileptic event. An MRI can help evaluate a potential seizure focus, but it is not diagnostic. Serum prolactin is likely, though not always, to be elevated after an epileptic seizure. The Wada test involves an injection of sodium amobarbital into the carotid arteries to help determine which side of the brain is used for language.
Perez, D., & LaFrance, W. (2016). Nonepileptic seizures: An updated review. CNS Spectrum, 21(3);239-246
Incorrect
Video EEG monitoring allows for correlation of the semiologic features of the episodes with the electrical activity in the brain. Lack of encephalographic correlate during a seizure event indicates a non-epileptic event. An MRI can help evaluate a potential seizure focus, but it is not diagnostic. Serum prolactin is likely, though not always, to be elevated after an epileptic seizure. The Wada test involves an injection of sodium amobarbital into the carotid arteries to help determine which side of the brain is used for language.
Perez, D., & LaFrance, W. (2016). Nonepileptic seizures: An updated review. CNS Spectrum, 21(3);239-246
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Question 149 of 200
149. Question
A 17 year old patient with anorexia is admitted to the hospital due to malnutrition. What lab should be re-drawn on the second day?
Correct
As this patient is malnourished upon admission, she is likely to receive artificial feeding (either enterally or parenterally). Refeeding syndrome is due to shifts in fluids and electrolytes when malnourished patients are fed. Although other imbalances may occur, the hallmark of refeeding syndrome is hypophosphatasemia.
Boateng AA, Sriram K, Meguid MM, et al. (2010). Refeeding syndrome: Treatment considerations based on collective analysis of literature case reports. Nutrition, 26, 156-167.
Mehanna HM, Moledina J, Travis J. (2008). Refeeding syndrome: what it is, and how to prevent and treat it. BMJ (Clinical research ed.), 336(7659);1495-1498
Incorrect
As this patient is malnourished upon admission, she is likely to receive artificial feeding (either enterally or parenterally). Refeeding syndrome is due to shifts in fluids and electrolytes when malnourished patients are fed. Although other imbalances may occur, the hallmark of refeeding syndrome is hypophosphatasemia.
Boateng AA, Sriram K, Meguid MM, et al. (2010). Refeeding syndrome: Treatment considerations based on collective analysis of literature case reports. Nutrition, 26, 156-167.
Mehanna HM, Moledina J, Travis J. (2008). Refeeding syndrome: what it is, and how to prevent and treat it. BMJ (Clinical research ed.), 336(7659);1495-1498
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Question 150 of 200
150. Question
What ages are associated with Erickson’s identity versus role confusion?
Correct
During adolescence, teenagers explore their independence. Those who receive encouragement and acceptable reinforcement will develop a strong sense of self, including feelings of independence and control.
American Psychological Association. (2007). APA Dictionary of Psychology. American Psychological Association. Washington, D.C.
Incorrect
During adolescence, teenagers explore their independence. Those who receive encouragement and acceptable reinforcement will develop a strong sense of self, including feelings of independence and control.
American Psychological Association. (2007). APA Dictionary of Psychology. American Psychological Association. Washington, D.C.
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Question 151 of 200
151. Question
A 33 year old man becomes sexually aroused by wearing women’s clothes. Transvestic disorder is usually associated with?
Correct
Transvestic disorder is a paraphilia according to the DSM-5, and as with most paraphilias, is seen most frequently in heterosexual men.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
Incorrect
Transvestic disorder is a paraphilia according to the DSM-5, and as with most paraphilias, is seen most frequently in heterosexual men.
American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed). American Psychiatric Association. Arlington.
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Question 152 of 200
152. Question
What is the most common neuropsychiatric effect of chronic use of anabolic steroids?
Correct
While not well studied, the most consistent finding associated with chronic anabolic steroid use reported in the literature is increased aggressiveness. Mania and depression are also not uncommon, but psychosis is rare. Anabolic steroids are not associated with seizures.
Wood RI. (2008). Anabolic–angiogenic steroid dependence? Insights from animals and humans. Front Neuroendocrinol, 29(4);490–506.
Incorrect
While not well studied, the most consistent finding associated with chronic anabolic steroid use reported in the literature is increased aggressiveness. Mania and depression are also not uncommon, but psychosis is rare. Anabolic steroids are not associated with seizures.
Wood RI. (2008). Anabolic–angiogenic steroid dependence? Insights from animals and humans. Front Neuroendocrinol, 29(4);490–506.
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Question 153 of 200
153. Question
Decisions regarding competence are made by:
Correct
Competence is a determination made by a judge based on a person’s ability to make a sound judgement. In the event that someone is declared incompetent, a legal guardian may be appointed. That legal guardian may be the patient’s next of kin, but the guardian does not determine that the patient is incompetent. Only a judge can do that. Notably, the presence of a mental illness alone is not enough for someone to be found incompetent; nor does admission to a mental hospital imply that someone is incompetent.
Incorrect
Competence is a determination made by a judge based on a person’s ability to make a sound judgement. In the event that someone is declared incompetent, a legal guardian may be appointed. That legal guardian may be the patient’s next of kin, but the guardian does not determine that the patient is incompetent. Only a judge can do that. Notably, the presence of a mental illness alone is not enough for someone to be found incompetent; nor does admission to a mental hospital imply that someone is incompetent.
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Question 154 of 200
154. Question
While driving home after dropping her children off at school, Ms. Anthony was involved in a car accident. You see her 8 hours after the accident when she presents with hypervigilance, avoidance, and dissociation. What is the most appropriate diagnosis?
Correct
Ms. Anthony is beginning to show symptoms commonly associated with PTSD or ASD. A critical factor is the length of time she has had the symptoms. To meet PTSD criteria, symptoms must be present for longer than 1 month. Also, to meet ASD criteria, symptoms must be present for at least 3 days. This patient does not meet either of those time criteria. She does not meet panic disorder or Major Depressive criteria. Therefore, the best choice at this time is no psychiatric diagnosis.
Incorrect
Ms. Anthony is beginning to show symptoms commonly associated with PTSD or ASD. A critical factor is the length of time she has had the symptoms. To meet PTSD criteria, symptoms must be present for longer than 1 month. Also, to meet ASD criteria, symptoms must be present for at least 3 days. This patient does not meet either of those time criteria. She does not meet panic disorder or Major Depressive criteria. Therefore, the best choice at this time is no psychiatric diagnosis.
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Question 155 of 200
155. Question
Your patient’s attorney requests a copy of your records as part of a lawsuit involving Ms. Anthony. You ask your office staff to prepare a copy of the chart for release. Your secretary asks if she should include a copy of your psychotherapy notes with the copy of the patient’s chart. The best course of action is:
Correct
Ms. Anthony has a right to a copy of her medical record. It can be subpoenaed and reviewed by attorneys and the court. Psychotherapy notes are different, however. Psychotherapy notes are your notes to yourself about what you are doing in therapy with the patient. They should be kept separate from the medical record and are not considered part of the patient’s chart. They belong to the therapist who wrote them, and the patient, court, or attorney does not have any right to see them. As such you would not include them in copies of the record. The attorney has no right to subpoena them as in choice 3. The judge does not have a right to order you to release them as in choice 4.
Incorrect
Ms. Anthony has a right to a copy of her medical record. It can be subpoenaed and reviewed by attorneys and the court. Psychotherapy notes are different, however. Psychotherapy notes are your notes to yourself about what you are doing in therapy with the patient. They should be kept separate from the medical record and are not considered part of the patient’s chart. They belong to the therapist who wrote them, and the patient, court, or attorney does not have any right to see them. As such you would not include them in copies of the record. The attorney has no right to subpoena them as in choice 3. The judge does not have a right to order you to release them as in choice 4.
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Question 156 of 200
156. Question
Ms. Clark is a 45 year old mother of three. While driving to work one morning she had to pull her car off the road due to the abrupt onset of shaking, shortness of breath, tachycardia, sweating, stomach pain and tingling in her hands and fingers. The episode lasted for about 10 minutes before it began to subside. Which one of the following is most important to rule out?
Correct
Ms. Clark is experiencing symptoms of a panic attack. Cardiac arrhythmias, such as supraventricular tachycardia, are part of the organic differential for panic. Other illnesses associated with panic symptoms include pheochromocytoma, myocardial infarction, asthma, pulmonary embolus, multiple sclerosis, endocrine disorders (such as Addison disease, Cushing disease, diabetes, hyper and hypothyroid, hypoglycemia, hypoparathyroidism), drug intoxication (amphetamines, cocaine, cannabis, hallucinogens) and drug withdrawal (alcohol, opiates, benzos), B12 deficiency, electrolyte disturbances, and heavy metal poisoning…to name a few. Polymyalgia rheumatica is characterized by diffuse muscle pain and joint stiffness and is not associated with panic. Hyperalgesia is disproportionately greater pain in response to a mildly noxious stimulus. It is not associated with panic attacks. Russell’s sign refers to abrasions or callouses on the knuckles or back of the hand as seen in anorexia with long-term self-induced vomiting. Though this is a good term to know, it is not associated with panic. Thoracic outlet compression syndrome occurs when blood vessels and nerves in the thoracic outlet are compressed, leading to shoulder pain, and numbness in the hands … but not panic attacks.
Incorrect
Ms. Clark is experiencing symptoms of a panic attack. Cardiac arrhythmias, such as supraventricular tachycardia, are part of the organic differential for panic. Other illnesses associated with panic symptoms include pheochromocytoma, myocardial infarction, asthma, pulmonary embolus, multiple sclerosis, endocrine disorders (such as Addison disease, Cushing disease, diabetes, hyper and hypothyroid, hypoglycemia, hypoparathyroidism), drug intoxication (amphetamines, cocaine, cannabis, hallucinogens) and drug withdrawal (alcohol, opiates, benzos), B12 deficiency, electrolyte disturbances, and heavy metal poisoning…to name a few. Polymyalgia rheumatica is characterized by diffuse muscle pain and joint stiffness and is not associated with panic. Hyperalgesia is disproportionately greater pain in response to a mildly noxious stimulus. It is not associated with panic attacks. Russell’s sign refers to abrasions or callouses on the knuckles or back of the hand as seen in anorexia with long-term self-induced vomiting. Though this is a good term to know, it is not associated with panic. Thoracic outlet compression syndrome occurs when blood vessels and nerves in the thoracic outlet are compressed, leading to shoulder pain, and numbness in the hands … but not panic attacks.
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Question 157 of 200
157. Question
Ms. Johnson with OCD goes into a public restroom. She meticulously covers the toilet seat in several layers of toilet paper so as to avoid contamination with germs. After going to the bathroom her hand accidently brushes against the side of the toilet seat. She fears she may be contaminated. What is the most therapeutic action she can take?
Correct
This question asks about therapeutic approaches to OCD. The treatment of choice for OCD is Exposure with Response Prevention. In Exposure with Response Prevention the patient is exposed to feared stimuli or obsessions while the rituals which accompany them are prevented. In this case of feared contamination, the goal of therapy would be for the patient to sit with the anxiety and refrain from doing any ritual that would lessen it. As such, excessive washing, scrubbing the toilet, or hair picking would all be considered counter therapeutic. Using a potentially addictive benzodiazepine every time the patient uses a restroom does not help her to develop control over her anxiety or accompanying rituals and is likely to lead to benzodiazepine addiction.
Incorrect
This question asks about therapeutic approaches to OCD. The treatment of choice for OCD is Exposure with Response Prevention. In Exposure with Response Prevention the patient is exposed to feared stimuli or obsessions while the rituals which accompany them are prevented. In this case of feared contamination, the goal of therapy would be for the patient to sit with the anxiety and refrain from doing any ritual that would lessen it. As such, excessive washing, scrubbing the toilet, or hair picking would all be considered counter therapeutic. Using a potentially addictive benzodiazepine every time the patient uses a restroom does not help her to develop control over her anxiety or accompanying rituals and is likely to lead to benzodiazepine addiction.
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Question 158 of 200
158. Question
Which of the following is a potent inducer of Clozapine at CYP 1A2?
Correct
Cigarette smoke is an inducer of Clozapine at CYP 1A2, leading to decreased levels of Clozapine and psychosis. Fluvoxamine is a potent inhibitor across multiple P450 CYP enzymes. Fluoxetine and Paroxetine are inhibitors of CYP 2D6.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology, 5th ed. American Psychiatric Association. Washington, D.C.
Incorrect
Cigarette smoke is an inducer of Clozapine at CYP 1A2, leading to decreased levels of Clozapine and psychosis. Fluvoxamine is a potent inhibitor across multiple P450 CYP enzymes. Fluoxetine and Paroxetine are inhibitors of CYP 2D6.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology, 5th ed. American Psychiatric Association. Washington, D.C.
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Question 159 of 200
159. Question
An elderly man’s wife passes away after almost 60 years of marriage. He endorses multiple depressive symptoms during his initial visit. Which symptom would speak more to Major Depressive Disorder rather than Bereavement?
Correct
Differentiating between bereavement and major depressive disorder can be difficult, since DSM-5 guidelines excluded the bereavement exclusion for MDD. For a diagnosis of bereavement, there may be some depressive symptoms but usually not suicidal ideation, morbid feelings of guilt or worthlessness, or psychomotor retardation. Usually, the surviving partner becomes dysphoric when thinking about the loved one. The onset of symptoms is within the first 2 months of the bereavement, and the duration of symptoms is usually less than 2 months. Additionally, there is mild functional impairment, but there is no family or personal history of major depression.
Saddock BJ, Kaplan VA. (2014). Death, Dying, and Bereavement. Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
Incorrect
Differentiating between bereavement and major depressive disorder can be difficult, since DSM-5 guidelines excluded the bereavement exclusion for MDD. For a diagnosis of bereavement, there may be some depressive symptoms but usually not suicidal ideation, morbid feelings of guilt or worthlessness, or psychomotor retardation. Usually, the surviving partner becomes dysphoric when thinking about the loved one. The onset of symptoms is within the first 2 months of the bereavement, and the duration of symptoms is usually less than 2 months. Additionally, there is mild functional impairment, but there is no family or personal history of major depression.
Saddock BJ, Kaplan VA. (2014). Death, Dying, and Bereavement. Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
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Question 160 of 200
160. Question
A 77-year-old woman with memory impairments was admitted to the inpatient psychiatry unit for vivid visual and tactile hallucinations of mosquitos encircling and biting her skin and worsening depression. After initiation of an antipsychotic medication, her cognitive functioning worsened, and she begins to develop leg stiffness. Which antipsychotic is considered first line for the treatment of psychosis in this disorder?
Correct
The patient was likely given haloperidol or another typical antipsychotic during her hospitalization, which worsened her functioning and led to EPS side effects. Neuroleptic sensitivity, which effects up to 50% of Lewy body disease (LBD) patients who are treated with typical antipsychotic medications, and is characterized by worsening cognition, sedation, and increased or possibly irreversible acute onset parkinsonism. Some evidence suggests that risperidone and olanzapine, higher potency atypical antipsychotics, also worsen EPS and can lead to neuroleptic malignant syndrome. Quetiapine and clozapine have less risk of EPS and Parkinsonism and are considered first line.
Gomperts, S. N. (2016). Dementia with Lewy bodies and Parkinson disease dementia. CONTINUUM, 22;435-463.
Stinton C, McKeith I, Taylor J, et al. (2015). Pharmacological management of Lewy body Dementia: A systematic review and meta-analysis. Amer J Psychiatry, 172(8);731-742.
Incorrect
The patient was likely given haloperidol or another typical antipsychotic during her hospitalization, which worsened her functioning and led to EPS side effects. Neuroleptic sensitivity, which effects up to 50% of Lewy body disease (LBD) patients who are treated with typical antipsychotic medications, and is characterized by worsening cognition, sedation, and increased or possibly irreversible acute onset parkinsonism. Some evidence suggests that risperidone and olanzapine, higher potency atypical antipsychotics, also worsen EPS and can lead to neuroleptic malignant syndrome. Quetiapine and clozapine have less risk of EPS and Parkinsonism and are considered first line.
Gomperts, S. N. (2016). Dementia with Lewy bodies and Parkinson disease dementia. CONTINUUM, 22;435-463.
Stinton C, McKeith I, Taylor J, et al. (2015). Pharmacological management of Lewy body Dementia: A systematic review and meta-analysis. Amer J Psychiatry, 172(8);731-742.
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Question 161 of 200
161. Question
A college student was referred to your office by a gynecologist after she presented for vaginal pain during intercourse and was found to have an underdeveloped labia and clitoris. Her vaginal depth was also shorter than normal. Karyotyping showed 46 XY. What other physical features are typically associated with this disorder?
Correct
The above described condition is complete androgen insensitivity syndrome, where despite the 46 XY karyotype, there is a complete inability of the cell to respond to androgens. The person appears phenotypically female at birth, except for minimal internal sexual organs. Secondary sexual characteristics at puberty are female because of the small amount of estrogen. Gonads are testicles rather than ovaries.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
Incorrect
The above described condition is complete androgen insensitivity syndrome, where despite the 46 XY karyotype, there is a complete inability of the cell to respond to androgens. The person appears phenotypically female at birth, except for minimal internal sexual organs. Secondary sexual characteristics at puberty are female because of the small amount of estrogen. Gonads are testicles rather than ovaries.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
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Question 162 of 200
162. Question
All of the following features of depression may increase suspicion of bipolar vs unipolar illness except?
Correct
Several features of depression may increase suspicion of bipolarity and prompt further investigation: earlier age of illness onset, highly recurrent depressive episodes, a family history of bipolar disorder, depression with psychotic features, psychomotor agitation, atypical depressive symptoms, such as hypersomnia, hyperphagia, leaden paralysis, postpartum depression and psychosis, past suicide attempts, and antidepressant‐induced manic symptoms or rapid cycling.
Yatham LN, Kennedy SH, Parikh SV, et al. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2);97-170.
Incorrect
Several features of depression may increase suspicion of bipolarity and prompt further investigation: earlier age of illness onset, highly recurrent depressive episodes, a family history of bipolar disorder, depression with psychotic features, psychomotor agitation, atypical depressive symptoms, such as hypersomnia, hyperphagia, leaden paralysis, postpartum depression and psychosis, past suicide attempts, and antidepressant‐induced manic symptoms or rapid cycling.
Yatham LN, Kennedy SH, Parikh SV, et al. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2);97-170.
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Question 163 of 200
163. Question
Which psychoanalyst is responsible for coining the term “good enough” mother?
Correct
The “good enough mother” was first coined in 1953 by Donald Winnicott, a British pediatrician and psychoanalyst. Winnicott observed thousands of babies and their mothers, and he came to realize that babies and children actually benefit when their mothers (or primary caretakers) fail them in tolerable ways on a regular basis so they can learn to live in an imperfect world.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
Incorrect
The “good enough mother” was first coined in 1953 by Donald Winnicott, a British pediatrician and psychoanalyst. Winnicott observed thousands of babies and their mothers, and he came to realize that babies and children actually benefit when their mothers (or primary caretakers) fail them in tolerable ways on a regular basis so they can learn to live in an imperfect world.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
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Question 164 of 200
164. Question
Which of the following is typically associated with psychophysiological insomnia?
Correct
Psychophysiological insomnia typically presents as difficulty going to sleep (sleep-onset insomnia). Usually this insomnia is a chronic condition and not associated with stressful periods. Because objects associated with sleep, such as one’s bed or bedroom, become conditioned stimuli that evoke insomnia, people with sleep-onset insomnia do better away from their bedroom. In contrast to individuals with insomnia from psychiatric conditions, those with psychophysiological insomnia usually have good daily adaptation and functioning; however, tiredness can persist.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
Incorrect
Psychophysiological insomnia typically presents as difficulty going to sleep (sleep-onset insomnia). Usually this insomnia is a chronic condition and not associated with stressful periods. Because objects associated with sleep, such as one’s bed or bedroom, become conditioned stimuli that evoke insomnia, people with sleep-onset insomnia do better away from their bedroom. In contrast to individuals with insomnia from psychiatric conditions, those with psychophysiological insomnia usually have good daily adaptation and functioning; however, tiredness can persist.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
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Question 165 of 200
165. Question
A 20-year-old woman was brought to the ED by ambulance after being found unconscious at a college party. She is agitated, dizzy, vomiting, with a respiratory rate of 16 and heart rate of 60. What is the most likely drug she ingested?
Correct
The physical signs of intoxication with GHB include dizziness, vomiting, nausea, agitation, decreased respiratory rate (especially in combination with alcohol) and decreased heart rate; however, the hallmark of GHB intoxication is amnesia. Thus, GHB is notorious as the “date rape drug.” PCP intoxication symptoms include sustained horizontal and vertical nystagmus, hyperactivity, motor rigidity, hyperpyrexia, hyperacusis, and psychosis. Marijuana intoxication symptoms include conjunctival injection, increased appetite, and tachycardia. LSD intoxication symptoms include lightheadedness, mydriasis, flushing, tachycardia, and hyperreflexia.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, Ninth Edition. American Psychiatric Association. Washington, D.C.
Incorrect
The physical signs of intoxication with GHB include dizziness, vomiting, nausea, agitation, decreased respiratory rate (especially in combination with alcohol) and decreased heart rate; however, the hallmark of GHB intoxication is amnesia. Thus, GHB is notorious as the “date rape drug.” PCP intoxication symptoms include sustained horizontal and vertical nystagmus, hyperactivity, motor rigidity, hyperpyrexia, hyperacusis, and psychosis. Marijuana intoxication symptoms include conjunctival injection, increased appetite, and tachycardia. LSD intoxication symptoms include lightheadedness, mydriasis, flushing, tachycardia, and hyperreflexia.
Schatzberg AF, DeBattista C. (2019). Schatzberg’s Manual of Clinical Psychopharmacology, Ninth Edition. American Psychiatric Association. Washington, D.C.
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Question 166 of 200
166. Question
A 25 year old woman presents with multiple erythematous and pigmented maculae on her face, arms, and scalp. She also reports repeated instances of this rash during the past several years. All of the following treatments have shown some efficacy in treating her condition except:
Correct
She has excoriation or skin-picking disorder which is characterized by compulsive and repetitive picking of the skin. The repetitive nature of skin-picking is similar to Obsessive Compulsive Disorder (OCD) and is associated with high rates of OCD. Other comorbid conditions include trichotillomania, substance use, Major Depressive Disorder (MDD), and anxiety disorders. There is evidence that fluoxetine treatment is effective, and naltrexone decreases urges of skin picking-behavior. Habit reversal therapy and CBT are the gold standard treatments.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
Incorrect
She has excoriation or skin-picking disorder which is characterized by compulsive and repetitive picking of the skin. The repetitive nature of skin-picking is similar to Obsessive Compulsive Disorder (OCD) and is associated with high rates of OCD. Other comorbid conditions include trichotillomania, substance use, Major Depressive Disorder (MDD), and anxiety disorders. There is evidence that fluoxetine treatment is effective, and naltrexone decreases urges of skin picking-behavior. Habit reversal therapy and CBT are the gold standard treatments.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
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Question 167 of 200
167. Question
Which of the following drugs is not eliminated unchanged by the kidneys?
Correct
Gabapentin, pregabalin, and lithium are all excreted unchanged by the kidneys. They do not undergo metabolism in the liver. They are susceptible to changes in hydration status. Mirtazapine is found mostly bound to plasma proteins and is metabolized primarily in the liver by via cytochrome P450 enzymes, CYP1A2, CYP2D6, CYP3A4.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology, 5th ed. American Psychiatric Association. Washington, D.C.
Incorrect
Gabapentin, pregabalin, and lithium are all excreted unchanged by the kidneys. They do not undergo metabolism in the liver. They are susceptible to changes in hydration status. Mirtazapine is found mostly bound to plasma proteins and is metabolized primarily in the liver by via cytochrome P450 enzymes, CYP1A2, CYP2D6, CYP3A4.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology, 5th ed. American Psychiatric Association. Washington, D.C.
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Question 168 of 200
168. Question
A normally developing 18 month old child would be expected to do all of the following except?
Correct
An 18-month child can hurl a ball, but kicking a ball requires more motor coordination and can be expected by a child of 2 years. Additionally, an 18 month old can also scribble spontaneously and imitate a writing stroke, feed himself in part (usually spilling), and carry a toy, such as a doll.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
Incorrect
An 18-month child can hurl a ball, but kicking a ball requires more motor coordination and can be expected by a child of 2 years. Additionally, an 18 month old can also scribble spontaneously and imitate a writing stroke, feed himself in part (usually spilling), and carry a toy, such as a doll.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
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Question 169 of 200
169. Question
What is the most common psychiatric illness among women?
Correct
The National Institute of Mental Health (NIMH) found that between 8.7% and 18.1% of Americans suffer from phobias, making it the most common mental illness among women in all age groups and the second most common illness among men older than 25.
McLean CP, Asnaani A, Litz BT, et al. (2011). Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. J Psychiatric Res, 45(8);1027–1035
Bajwa M, Akhtar M, Saeed R. (2014). Prevalence and factors associated with phobias among women. ASEAN J Psychiatry, 15(2);140-145Incorrect
The National Institute of Mental Health (NIMH) found that between 8.7% and 18.1% of Americans suffer from phobias, making it the most common mental illness among women in all age groups and the second most common illness among men older than 25.
McLean CP, Asnaani A, Litz BT, et al. (2011). Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. J Psychiatric Res, 45(8);1027–1035
Bajwa M, Akhtar M, Saeed R. (2014). Prevalence and factors associated with phobias among women. ASEAN J Psychiatry, 15(2);140-145 -
Question 170 of 200
170. Question
You are asked to evaluate a patient who recently had a unilateral left hemisphere stroke. The patient can understand what you are asking, and has relatively fluent speech, but when you ask him to repeat words or phrases, he struggles. Which area of the left hemisphere was most likely damaged to account for this defect?
Correct
This patient has conduction aphasia, a relatively rare aphasia. The cause is damage to the arcuate fasciculus – the connection between Wernicke’s and Broca’s areas. Broca’s aphasia is characterized by nonfluent speech, but intact comprehension and somewhat impaired repetition. It results from damage to Broca’s area, which is the left inferior frontal convolution until the suprasylvian fissure. Wernicke’s aphasia is characterized by fluent speech, but impaired comprehension, and somewhat impaired repetition. It results from damage to Wernicke’s area, which is the superior temporal gyrus.
Kaufman DM, Geyer HL, Milstein M. (2017). Kaufman’s Clinical Neurology for Psychiatrists (8th ed). Elsevier. Philadelphia.
Incorrect
This patient has conduction aphasia, a relatively rare aphasia. The cause is damage to the arcuate fasciculus – the connection between Wernicke’s and Broca’s areas. Broca’s aphasia is characterized by nonfluent speech, but intact comprehension and somewhat impaired repetition. It results from damage to Broca’s area, which is the left inferior frontal convolution until the suprasylvian fissure. Wernicke’s aphasia is characterized by fluent speech, but impaired comprehension, and somewhat impaired repetition. It results from damage to Wernicke’s area, which is the superior temporal gyrus.
Kaufman DM, Geyer HL, Milstein M. (2017). Kaufman’s Clinical Neurology for Psychiatrists (8th ed). Elsevier. Philadelphia.
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Question 171 of 200
171. Question
In patients with chronic schizophrenia, what is the most common structural brain change found on MRI?
Correct
Abnormalities in the structure and functioning of the prefrontal cortex (PFC) and the amygdala, the key components of the neural system that serve emotional processing, are commonly found in major depressive disorder (MDD). Aberrant white matter microstructure of the corpus callosum and fronto-limbic pathways, seen on diffusion tensor imaging (DTI) but not MRI, has been reported in bipolar disorder. Whole-brain atrophy is seen in Alzheimer’s disease.
Tang Y, Kong L, Wu F, et al. (2013) Decreased functional connectivity between the amygdala and the left ventral prefrontal cortex in treatment-naive patients with major depressive disorder: a resting-state functional magnetic resonance imaging study. Psychol Med, 43(9);1921-1927.
Linke JO, Stavish C, Adleman NE et al. (2020). White matter microstructure in youth with and at risk for bipolar disorder. Bipolar Disorders, 22(2);163-173.Dietsche B, Kircher T, Falkenberg I. (2017). Structural brain changes in schizophrenia at different stages of the illness: A selective review of longitudinal magnetic resonance imaging studies. Aust N Z J Psychiatry, 51(5);500-508.
Femminella GD, Thayanandan T, Calsolaro V, et al. (2018). Imaging and molecular mechanisms of Alzheimer’s disease: A review. Int J Molec Sci, 19(12);3702
Incorrect
Abnormalities in the structure and functioning of the prefrontal cortex (PFC) and the amygdala, the key components of the neural system that serve emotional processing, are commonly found in major depressive disorder (MDD). Aberrant white matter microstructure of the corpus callosum and fronto-limbic pathways, seen on diffusion tensor imaging (DTI) but not MRI, has been reported in bipolar disorder. Whole-brain atrophy is seen in Alzheimer’s disease.
Tang Y, Kong L, Wu F, et al. (2013) Decreased functional connectivity between the amygdala and the left ventral prefrontal cortex in treatment-naive patients with major depressive disorder: a resting-state functional magnetic resonance imaging study. Psychol Med, 43(9);1921-1927.
Linke JO, Stavish C, Adleman NE et al. (2020). White matter microstructure in youth with and at risk for bipolar disorder. Bipolar Disorders, 22(2);163-173.Dietsche B, Kircher T, Falkenberg I. (2017). Structural brain changes in schizophrenia at different stages of the illness: A selective review of longitudinal magnetic resonance imaging studies. Aust N Z J Psychiatry, 51(5);500-508.
Femminella GD, Thayanandan T, Calsolaro V, et al. (2018). Imaging and molecular mechanisms of Alzheimer’s disease: A review. Int J Molec Sci, 19(12);3702
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Question 172 of 200
172. Question
A 30 year old woman comes into your office for psychotherapy stating she has difficulty with intimacy and close relationships, invests little emotion in social and romantic relationships, doesn’t feel distress when relationships end, and prefers casual sexual encounters. As a child, her parents were frequently distant and disengaged, and she learned to believe her needs would probably go unmet. Which attachment style does the patient most likely have?
Correct
Different attachment styles were introduced by Mary Ainsworth in the famous “Strange Situations” study, where she observed how mothers and babies interacted and responded to each other. In a secure attachment, the child feels safe enough to explore the world, trusts the mother will return when she leaves, and feels comforted when the mother does return. In ambivalent attachment, the mother’s responses are inconsistent, changing between sensitive and neglectful responsiveness, leaving the child to feel their needs will not be met. The child is anxious as if anticipating separation and desires the mother’s attention, but rejects it angrily when it’s achieved. Disorganized attachment is the most disturbing, as the mother often has extreme, erratic, intrusive behaviors that make it difficult for the child to form coherent coping strategies. The child might simply freeze, become depressed, or rock back and forth. In avoidant attachment, the mother is mostly disengaged and has no response when the child shows distress. This leads the child to avoid contact, ignore, and be emotionally distant with the mother, and in future relationships.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
Incorrect
Different attachment styles were introduced by Mary Ainsworth in the famous “Strange Situations” study, where she observed how mothers and babies interacted and responded to each other. In a secure attachment, the child feels safe enough to explore the world, trusts the mother will return when she leaves, and feels comforted when the mother does return. In ambivalent attachment, the mother’s responses are inconsistent, changing between sensitive and neglectful responsiveness, leaving the child to feel their needs will not be met. The child is anxious as if anticipating separation and desires the mother’s attention, but rejects it angrily when it’s achieved. Disorganized attachment is the most disturbing, as the mother often has extreme, erratic, intrusive behaviors that make it difficult for the child to form coherent coping strategies. The child might simply freeze, become depressed, or rock back and forth. In avoidant attachment, the mother is mostly disengaged and has no response when the child shows distress. This leads the child to avoid contact, ignore, and be emotionally distant with the mother, and in future relationships.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
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Question 173 of 200
173. Question
A 60 year old intellectually disabled, unemployed man, with alcohol abuse disorder lives with his elderly mother who believes the neighbors have installed cameras in the walls and are spying on her. Recently, her son has started expressing this same delusion of the neighbors spying on them. All of the following factors are associated with this particular psychotic disorder except:
Correct
The following case describes shared psychotic disorder, folie a deux, or according to DSM-5 a diagnosis of Delusional Symptoms in Partner of Individual with Delusional Disorder. This disorder is characterized by the transfer of delusions from one person to another (usually within the same family), who are closely related and have been living in social isolation together. The second person who develops the delusion is usually less intelligent, passive, or lacking self-esteem. Old age, low intelligence, sensory impairment, cerebrovascular disease, and alcohol abuse are among the factors associated with this psychotic disorder.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
Incorrect
The following case describes shared psychotic disorder, folie a deux, or according to DSM-5 a diagnosis of Delusional Symptoms in Partner of Individual with Delusional Disorder. This disorder is characterized by the transfer of delusions from one person to another (usually within the same family), who are closely related and have been living in social isolation together. The second person who develops the delusion is usually less intelligent, passive, or lacking self-esteem. Old age, low intelligence, sensory impairment, cerebrovascular disease, and alcohol abuse are among the factors associated with this psychotic disorder.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
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Question 174 of 200
174. Question
You are seeing a 22 year old woman in your office who was recently diagnosed with Schizoaffective Disorder and started on a second generation atypical antipsychotic. She is now complaining of galactorrhea and loss of libido, her hCG test is negative, and her prolactin level is 35 ng/ml (normal range for non-pregnant or breast-feeding women is 0-25 ng/ml). Which medication is most likely responsible for her symptoms?
Correct
All antipsychotics have the potential to raise prolactin and are associated with hyperprolactinemia to varying degrees. Of the atypicals, the greatest prevalence is with risperidone. Hyperprolactinemia has been reported in 48%–93% of premenopausal women and 42%–47% of men taking antipsychotic medications. The effect of antipsychotics on prolactin appears to be dose-related.
Melmed S. (2011). Diagnosis and treatment of Hyperprolactinemia: An endocrine society clinical practice guideline. J Clin Endocrin Metab, 96(2);273–288
Incorrect
All antipsychotics have the potential to raise prolactin and are associated with hyperprolactinemia to varying degrees. Of the atypicals, the greatest prevalence is with risperidone. Hyperprolactinemia has been reported in 48%–93% of premenopausal women and 42%–47% of men taking antipsychotic medications. The effect of antipsychotics on prolactin appears to be dose-related.
Melmed S. (2011). Diagnosis and treatment of Hyperprolactinemia: An endocrine society clinical practice guideline. J Clin Endocrin Metab, 96(2);273–288
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Question 175 of 200
175. Question
You are seeing an 18 year old college student for an initial evaluation, who is requesting a stimulant medication for ADHD. Upon further questioning, you discover that the patient has had neuropsychiatric testing in high school that confirmed ADHD and an Individualized Education Plan (IEP). He said that he was tried on stimulant medication though he could not remember the name. However, he stopped it because it made him feel anxious and unable to sleep at night. He also reports a history of binge drinking alcohol every other night. Which pharmacological intervention is the best for the management of his symptoms?
Correct
Atomoxetine or a non-stimulant medication is recommended for patients who find stimulants too activating or who have a history of substance abuse, as there is little or no addictive potential. Guanfacine is another non-stimulant medication; however, in patients with alcohol abuse, it can lower blood pressure, increase sedation, and thus increase fall risk.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
Incorrect
Atomoxetine or a non-stimulant medication is recommended for patients who find stimulants too activating or who have a history of substance abuse, as there is little or no addictive potential. Guanfacine is another non-stimulant medication; however, in patients with alcohol abuse, it can lower blood pressure, increase sedation, and thus increase fall risk.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
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Question 176 of 200
176. Question
An orthodox Jewish woman has been referred to you by a gynecologist after she presented for an infertility work-up and was found to have an intact hymen. She has been married for several months now and is distressed that she is not pregnant. Which of the following would be the LEAST helpful intervention?
Correct
Unconsummated marriages happen in insular communities, such as religious orthodoxy, and are associated with lack of sexual education, sexual prohibitions by parents or society, immaturity of both partners, and distorted concepts about genitalia. Therefore, speaking with the patient’s family or parents may perpetuate shame and feelings of inadequacy. Many patients can be helped by simple education about genital anatomy and physiology, encouraging sexual exploration, and information from physicians. Seeing both members of the couple together for dual-sex therapy is the preferred treatment.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
Incorrect
Unconsummated marriages happen in insular communities, such as religious orthodoxy, and are associated with lack of sexual education, sexual prohibitions by parents or society, immaturity of both partners, and distorted concepts about genitalia. Therefore, speaking with the patient’s family or parents may perpetuate shame and feelings of inadequacy. Many patients can be helped by simple education about genital anatomy and physiology, encouraging sexual exploration, and information from physicians. Seeing both members of the couple together for dual-sex therapy is the preferred treatment.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 11th ed. Lippincott Williams & Wilkins. Philadelphia.
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Question 177 of 200
177. Question
Which medication can be used to treat antipsychotic-induced hyperprolactinemia?
Correct
Several studies have demonstrated effectiveness of aripiprazole as an add-on to normalize prolactin levels. However, before add-on therapy is considered, aripiprazole monotherapy should be evaluated and tried where possible. As add-on therapy, the dose of aripiprazole is 5mg with prolactin levels should be measured weekly. Doses greater than 5mg appear unnecessary.
Chang CK, Huang YS, Ree SC, et al. (2010). Differential add-on effects of aripiprazole in resolving hyperprolactinemia induced by risperidone in comparison to benzamide antipsychotics. Prog Neuropsychopharmacol Biol Psychiatry, 4(8);1495-1499
Yasui-Furukori N, et al. Dose-dependent effects of adjunctive treatment with aripiprazole on hyperprolactinemia induced by risperidone in female patients with schizophrenia. J Clin Psychopharmacol. 2010;30(5):596-9.
Incorrect
Several studies have demonstrated effectiveness of aripiprazole as an add-on to normalize prolactin levels. However, before add-on therapy is considered, aripiprazole monotherapy should be evaluated and tried where possible. As add-on therapy, the dose of aripiprazole is 5mg with prolactin levels should be measured weekly. Doses greater than 5mg appear unnecessary.
Chang CK, Huang YS, Ree SC, et al. (2010). Differential add-on effects of aripiprazole in resolving hyperprolactinemia induced by risperidone in comparison to benzamide antipsychotics. Prog Neuropsychopharmacol Biol Psychiatry, 4(8);1495-1499
Yasui-Furukori N, et al. Dose-dependent effects of adjunctive treatment with aripiprazole on hyperprolactinemia induced by risperidone in female patients with schizophrenia. J Clin Psychopharmacol. 2010;30(5):596-9.
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Question 178 of 200
178. Question
All of the following can cause significant elevations in serum creatine kinase except?
Correct
Moderate-intensity exercise (maintaining heart rate between 55% and 90% of maximum) may elevate creatine kinase (CK) levels but walking or pacing should not significantly elevate its level. Prolonged periods in restraints (given that the patient is likely agitated), repeat IM injections, and dystonic reactions, as well as NMS and substance use, can significantly elevate it.
Kindermann W. (2016). Creatine kinase levels after exercise. Deutsches Arzteblatt International, 113(19);344.
Incorrect
Moderate-intensity exercise (maintaining heart rate between 55% and 90% of maximum) may elevate creatine kinase (CK) levels but walking or pacing should not significantly elevate its level. Prolonged periods in restraints (given that the patient is likely agitated), repeat IM injections, and dystonic reactions, as well as NMS and substance use, can significantly elevate it.
Kindermann W. (2016). Creatine kinase levels after exercise. Deutsches Arzteblatt International, 113(19);344.
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Question 179 of 200
179. Question
All of the following risk factors are associated with metabolic syndrome except?
Correct
Metabolic syndrome can be diagnosed when three or more of the five risk factors are present: 1. waist measurement > 35 inches in women and > 40 inches in men, 2. elevated blood pressure ≥ 130 mm Hg systolic or ≥85 mm Hg diastolic or receiving treatment for hypertension, 3. fasting blood glucose > 100 mg/dl or receiving treatment for diabetes, 4. elevated triglycerides ≥ 150mg/dl or receiving treatment for elevated triglycerides, and 5. low HDL-cholesterol ( 40 in men, 50 in women or receiving treatment for low HDL-cholesterol.
WebMD https://webmd.com/heart.metabolic-syndrome/metabolic-syndrome-what-is-it
Incorrect
Metabolic syndrome can be diagnosed when three or more of the five risk factors are present: 1. waist measurement > 35 inches in women and > 40 inches in men, 2. elevated blood pressure ≥ 130 mm Hg systolic or ≥85 mm Hg diastolic or receiving treatment for hypertension, 3. fasting blood glucose > 100 mg/dl or receiving treatment for diabetes, 4. elevated triglycerides ≥ 150mg/dl or receiving treatment for elevated triglycerides, and 5. low HDL-cholesterol ( 40 in men, 50 in women or receiving treatment for low HDL-cholesterol.
WebMD https://webmd.com/heart.metabolic-syndrome/metabolic-syndrome-what-is-it
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Question 180 of 200
180. Question
What is generally considered the first step in treating neuroleptic malignant syndrome (NMS)?
Correct
Although treatment of NMS is individualized and based on clinical presentation, the first step in essentially all cases is cessation of the suspected offending neuroleptic pharmacologic agent. If the syndrome has occurred in the setting of abrupt withdrawal of a dopaminergic medication, that medication should be reinstated as quickly as possible. The next step in management is supportive medical therapy. Other steps are aggressive hydration, reduction of hyperthermia, and correction of metabolic abnormalities. Anecdotal reports and meta-analyses suggest that bromocriptine and dantrolene may shorten the course of the syndrome.
Berman BD. (2011). Neuroleptic malignant syndrome: a review for neurohospitalists. Neurohospitalist, 1(1);41–47.
Incorrect
Although treatment of NMS is individualized and based on clinical presentation, the first step in essentially all cases is cessation of the suspected offending neuroleptic pharmacologic agent. If the syndrome has occurred in the setting of abrupt withdrawal of a dopaminergic medication, that medication should be reinstated as quickly as possible. The next step in management is supportive medical therapy. Other steps are aggressive hydration, reduction of hyperthermia, and correction of metabolic abnormalities. Anecdotal reports and meta-analyses suggest that bromocriptine and dantrolene may shorten the course of the syndrome.
Berman BD. (2011). Neuroleptic malignant syndrome: a review for neurohospitalists. Neurohospitalist, 1(1);41–47.
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Question 181 of 200
181. Question
A 35 year old female with unknown past medical or psychiatric history presents to the emergency room with posturing, waxy flexibility, and mutism. What is the most common cause of her presentation?
Correct
This case indicates a diagnosis of catatonia. Recent studies have reported that the prevalence of catatonia rates is approximately 10% among acute psychiatric inpatients. Prevalence ranges vary according to the underlying or comorbid condition, e.g., 4%–67% for schizophrenia, 14%–71% mood disorders, and 4%–46% medical conditions.
Solmi M, Pigato GG, Roiter B, et al. (2018). Prevalence of Catatonia and its moderators in clinical samples: Results from a meta-analysis and meta-regression analysis. Schizophrenia Bull, 44(5), 1133-1159.
Incorrect
This case indicates a diagnosis of catatonia. Recent studies have reported that the prevalence of catatonia rates is approximately 10% among acute psychiatric inpatients. Prevalence ranges vary according to the underlying or comorbid condition, e.g., 4%–67% for schizophrenia, 14%–71% mood disorders, and 4%–46% medical conditions.
Solmi M, Pigato GG, Roiter B, et al. (2018). Prevalence of Catatonia and its moderators in clinical samples: Results from a meta-analysis and meta-regression analysis. Schizophrenia Bull, 44(5), 1133-1159.
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Question 182 of 200
182. Question
Autism Spectrum Disorder is diagnosed how many times more often in males than females?
Correct
It is well established that autism spectrum disorder is four times more prevalent in males than females.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Incorrect
It is well established that autism spectrum disorder is four times more prevalent in males than females.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C: American Psychiatric Association.
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Question 183 of 200
183. Question
You are concerned a patient may have symptoms consistent with Reactive Attachment Disorder. Which of the following disorders should most likely be part of your differential diagnosis?
Correct
Patients with Reactive Attachment Disorder and Autism Spectrum Disorder can both present as withdrawn and lacking social reciprocity. There is less overlap for symptomology of Reactive Attachment Disorder with the other diagnoses listed.
Charles H. Zeanah, MD, Tessa Chesher, DO, Neil W. Boris, MD, and the American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). (2016). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder. J Am Acad Child Adolesc Psychiatry, 55(11), 990–100.
Incorrect
Patients with Reactive Attachment Disorder and Autism Spectrum Disorder can both present as withdrawn and lacking social reciprocity. There is less overlap for symptomology of Reactive Attachment Disorder with the other diagnoses listed.
Charles H. Zeanah, MD, Tessa Chesher, DO, Neil W. Boris, MD, and the American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). (2016). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder. J Am Acad Child Adolesc Psychiatry, 55(11), 990–100.
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Question 184 of 200
184. Question
All of the following statements about Family based treatment (FBT) for anorexia nervosa in adolescents are true except:
Correct
Family based treatment emphasizes the need for the family to take control of the feeding and nutritional requirements of the child. Discussion of the child’s distorted body image would take the focus away from this priority.
James Lock, MD, PhD, AND Maria C. La Via, MD, and the American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). (2015). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Eating Disorders. J Am Acad Child Adolesc Psychiatry, 54(5): 412–425.
Incorrect
Family based treatment emphasizes the need for the family to take control of the feeding and nutritional requirements of the child. Discussion of the child’s distorted body image would take the focus away from this priority.
James Lock, MD, PhD, AND Maria C. La Via, MD, and the American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). (2015). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Eating Disorders. J Am Acad Child Adolesc Psychiatry, 54(5): 412–425.
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Question 185 of 200
185. Question
Common premorbid difficulties in children and adolescents diagnosed with schizophrenia include all of the following except:
Correct
All of the other answer choices are characteristics that can commonly be seen in patients prior to the development of symptoms consistent with schizophrenia.
Jon McClellan, M.D., Saundra Stock, M.D., and the American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). (2013). Practice Parameter for the Assessment and Treatment of Children and Adolescents with Schizophrenia. J Am Acad Child Adolesc Psychiatry, 52(9), 976–990.
Incorrect
All of the other answer choices are characteristics that can commonly be seen in patients prior to the development of symptoms consistent with schizophrenia.
Jon McClellan, M.D., Saundra Stock, M.D., and the American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). (2013). Practice Parameter for the Assessment and Treatment of Children and Adolescents with Schizophrenia. J Am Acad Child Adolesc Psychiatry, 52(9), 976–990.
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Question 186 of 200
186. Question
The following statement about the black box warning for use of antidepressants in patients under 25 years of age is correct:
Correct
The data that was used to justify the black box warning only showed a higher risk of suicidal thinking or behaviors. It did not show a higher risk of completed suicides. It is also important to note that this warning is applicable to all antidepressant medications.
Feder J, Tien E, Puzantian T. (2018). Child Medication Fact Book for Psychiatric Practice. Carlat Publishing, Newburyport, MA
Incorrect
The data that was used to justify the black box warning only showed a higher risk of suicidal thinking or behaviors. It did not show a higher risk of completed suicides. It is also important to note that this warning is applicable to all antidepressant medications.
Feder J, Tien E, Puzantian T. (2018). Child Medication Fact Book for Psychiatric Practice. Carlat Publishing, Newburyport, MA
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Question 187 of 200
187. Question
All of the following statements about use of olanzapine is true except:
Correct
Children often tend to be more susceptible to adverse effects of medication, and this is certainly the case for olanzapine. Risperidone and aripiprazole are the two medications that are FDA indicated for treating irritability or aggression in children and adolescents with autism spectrum disorder. There is evidence supporting the use of olanzapine for chemotherapy-induced nausea and vomiting.
Feder J, Tien E, Puzantian T. (2018). Child Medication Fact Book for Psychiatric Practice. Carlat Publishing, Newburyport, MA.
Incorrect
Children often tend to be more susceptible to adverse effects of medication, and this is certainly the case for olanzapine. Risperidone and aripiprazole are the two medications that are FDA indicated for treating irritability or aggression in children and adolescents with autism spectrum disorder. There is evidence supporting the use of olanzapine for chemotherapy-induced nausea and vomiting.
Feder J, Tien E, Puzantian T. (2018). Child Medication Fact Book for Psychiatric Practice. Carlat Publishing, Newburyport, MA.
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Question 188 of 200
188. Question
All of the following characteristics can be associated with Avoidant Restrictive Food Intake Disorder except:
Correct
Avoidant Restrictive Food Intake Disorder was a new diagnosis in the DSM-5. Diagnostic criteria includes food restriction or avoidance without shape or weight concerns or intentional efforts to lose weight that results in significant weight loss, nutritional deficiencies, and is associated with disturbances in psychological development and functioning.
Practice Parameters for the Assessment and Treatment of Children and Adolescents with Eating Disorders, American Academy of Child and Adolescent Psychiatry, 2014.
Incorrect
Avoidant Restrictive Food Intake Disorder was a new diagnosis in the DSM-5. Diagnostic criteria includes food restriction or avoidance without shape or weight concerns or intentional efforts to lose weight that results in significant weight loss, nutritional deficiencies, and is associated with disturbances in psychological development and functioning.
Practice Parameters for the Assessment and Treatment of Children and Adolescents with Eating Disorders, American Academy of Child and Adolescent Psychiatry, 2014.
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Question 189 of 200
189. Question
Which of the following is a correct characteristic of Disruptive Mood Dysregulation Disorder?
Correct
Disruptive Mood Dysregulation Disorder was a new diagnosis in the DSM-5. Temper outbursts must occur at least three times per week, the diagnosis should not be made for the first time prior to age 6 years, it cannot coexist with Oppositional Defiant Disorder, and the onset of symptoms should be prior to age 10 years.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association
Incorrect
Disruptive Mood Dysregulation Disorder was a new diagnosis in the DSM-5. Temper outbursts must occur at least three times per week, the diagnosis should not be made for the first time prior to age 6 years, it cannot coexist with Oppositional Defiant Disorder, and the onset of symptoms should be prior to age 10 years.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association
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Question 190 of 200
190. Question
Gender dysphoria in children consists of all of the following diagnostic criteria except:
Correct
Gender dysphoria was a new diagnosis in the DSM-5, replacing the previous diagnosis of Gender Identity Disorder. It refers to a patient’s gender identity, and does not refer at all to the patient’s sexual orientation.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Incorrect
Gender dysphoria was a new diagnosis in the DSM-5, replacing the previous diagnosis of Gender Identity Disorder. It refers to a patient’s gender identity, and does not refer at all to the patient’s sexual orientation.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
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Question 191 of 200
191. Question
Social Communication Disorder differs from Autism Spectrum Disorder because:
Correct
Social Communication Disorder is a new diagnosis in the DSM-5. It captures patients that experience significant impairment in social communication, but do not have the restricted or repetitive patterns of behavior that are seen in patients with autism spectrum disorder.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Incorrect
Social Communication Disorder is a new diagnosis in the DSM-5. It captures patients that experience significant impairment in social communication, but do not have the restricted or repetitive patterns of behavior that are seen in patients with autism spectrum disorder.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C: American Psychiatric Association.
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Question 192 of 200
192. Question
Which statement is true concerning the effect of fluoxetine on motor recovery and mood in patients who have sustained a stroke?
Correct
In the post-stroke period, fluoxetine treatment, compared to treatment with a placebo, has been followed by no greater motor recovery. Moreover, fluoxetine treatment was associated with a higher incidence of complications, including falls, fractures, and seizures. Nevertheless, fluoxetine treatment was associated with improved mood.
Hankey GJ, Hackett ML, Almeida OP, et al. (2020). Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY): A randomized, double-blind, placebo-controlled trial. Lancet Neurol, 19, 651-660.
Incorrect
In the post-stroke period, fluoxetine treatment, compared to treatment with a placebo, has been followed by no greater motor recovery. Moreover, fluoxetine treatment was associated with a higher incidence of complications, including falls, fractures, and seizures. Nevertheless, fluoxetine treatment was associated with improved mood.
Hankey GJ, Hackett ML, Almeida OP, et al. (2020). Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY): A randomized, double-blind, placebo-controlled trial. Lancet Neurol, 19, 651-660.
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Question 193 of 200
193. Question
Asked to consult on a 25-year-old policeman because he had become agitated, combative, disoriented, and hallucinatory, a psychiatrist made a diagnosis of delirium. When he noticed the patient’s weakness, the psychiatrist found areflexic quadriparesis. On re-reading the chart, the psychiatrist found that the patient had presented with abdominal pain that had not yet been diagnosed. The initial laboratory tests showed hyponatremia, hypokalemia, and hypomagnesaemia. Of the following, which should be the recommendation that would be the most likely to reach the correct diagnosis?
Correct
The development of abdominal pain followed by flaccid quadriparesis, and delirium, psychosis, or seizures indicates acute intermittent porphyria (AIP). In that illness, the urine will contain excessive porphobilinogen. Holding porphobilinogen-containing urine in the sunlight will turn it purple (Greek, porphura, purple). In AIP, inappropriate ADH secretion dilutes serum electrolytes. Alternatively, examining the CSF for signs of Guillain-Barré syndrome would also have been appropriate. Delirium and other changes in mental status usually do not occur in Guillain-Barré syndrome; however, if that illness is complicated by respiratory failure or inappropriate ADH secretion, mental status changes may ensue. Diabetic ketoacidosis might also lead to confusion, delirium, and diluted serum electrolytes, but usually not abdominal pain and a history of the illness.
Duque-Serrano l, Patarroyo-Rodriguez L, Gotlib D, et al. (2018). Psychiatric aspects of acute porphyria: A comprehensive review. Current Psychiatry Reports, 20(1):5.
Suh Y, Gandhi J, Seyam O, et al. (2019). Neurological and neuropsychiatric manifestations of porphyria. Int J Neurosci, 129, 1226-1233.
Incorrect
The development of abdominal pain followed by flaccid quadriparesis, and delirium, psychosis, or seizures indicates acute intermittent porphyria (AIP). In that illness, the urine will contain excessive porphobilinogen. Holding porphobilinogen-containing urine in the sunlight will turn it purple (Greek, porphura, purple). In AIP, inappropriate ADH secretion dilutes serum electrolytes. Alternatively, examining the CSF for signs of Guillain-Barré syndrome would also have been appropriate. Delirium and other changes in mental status usually do not occur in Guillain-Barré syndrome; however, if that illness is complicated by respiratory failure or inappropriate ADH secretion, mental status changes may ensue. Diabetic ketoacidosis might also lead to confusion, delirium, and diluted serum electrolytes, but usually not abdominal pain and a history of the illness.
Duque-Serrano l, Patarroyo-Rodriguez L, Gotlib D, et al. (2018). Psychiatric aspects of acute porphyria: A comprehensive review. Current Psychiatry Reports, 20(1):5.
Suh Y, Gandhi J, Seyam O, et al. (2019). Neurological and neuropsychiatric manifestations of porphyria. Int J Neurosci, 129, 1226-1233.
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Question 194 of 200
194. Question
Which of the following strategies to reverse atypical antipsychotic-induced sexual dysfunction is least likely to be effective?
Correct
Switching from a second to a first generation antipsychotic agent will probably exacerbate sexual dysfunction. Studies have found that sexual dysfunction is associated with hyperprolactinemia. Administering antipsychotic medicines and other conditions that elevate prolactin levels, which may reduce testosterone effectiveness, will cause or worsen sexual dysfunction.
Downing L, Kim DD, Procyshyn RM, et al. (2019). Management of sexual adverse effects induced by atypical antipsychotic medication. J Psychiatry Neurosci, 44, 287-288.
Incorrect
Switching from a second to a first generation antipsychotic agent will probably exacerbate sexual dysfunction. Studies have found that sexual dysfunction is associated with hyperprolactinemia. Administering antipsychotic medicines and other conditions that elevate prolactin levels, which may reduce testosterone effectiveness, will cause or worsen sexual dysfunction.
Downing L, Kim DD, Procyshyn RM, et al. (2019). Management of sexual adverse effects induced by atypical antipsychotic medication. J Psychiatry Neurosci, 44, 287-288.
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Question 195 of 200
195. Question
Before prescribing carbamazepine treatment for a mood disorder to a 28-year-old woman of South-East Asian heritage, a psychiatrist wanted to guard against development of an adverse reaction. Which test should the psychiatrist order?
Correct
Of the numerous human leukocyte antigens (HLAs) and other components of blood, HLA-B*15.02 is the one most closely associated with toxic epidermal necrosis and Stevens-Johnson syndrome when patients of Asian descent are exposed to carbamazepine. The FDA has indicated that individuals of Asian descent not receive carbamazepine if they carry this antigen.
Khor AH, Lim KS, Tan, et al. (2014). HLA-B*15.02 association with carbamazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis in an Indian population. Epilepsia, 55, e120-124.
Incorrect
Of the numerous human leukocyte antigens (HLAs) and other components of blood, HLA-B*15.02 is the one most closely associated with toxic epidermal necrosis and Stevens-Johnson syndrome when patients of Asian descent are exposed to carbamazepine. The FDA has indicated that individuals of Asian descent not receive carbamazepine if they carry this antigen.
Khor AH, Lim KS, Tan, et al. (2014). HLA-B*15.02 association with carbamazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis in an Indian population. Epilepsia, 55, e120-124.
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Question 196 of 200
196. Question
Tarasoff v. Regents of the University of California was heard twice by the Supreme Court of California. Which was the main difference between the rulings from the California Supreme Court from the first time they heard the case (1974) to the second time they heard the case (1976)?
Correct
Both rulings affirm breaking confidentiality in order to protect the safety of a 3rd party. Tarasoff I (1974) established a duty to simply warn the potential victim. Tarasoff II (1976) went further by adding a duty to protect to the duty to warn the potential victim.
Liza H. Gold, M.D. and Richard L. Frierson, M.D. The American Psychiatric Association Publishing Textbook of Forensic Psychiatry, 3rd ed. American Psychiatric Association. Arlington.Incorrect
Both rulings affirm breaking confidentiality in order to protect the safety of a 3rd party. Tarasoff I (1974) established a duty to simply warn the potential victim. Tarasoff II (1976) went further by adding a duty to protect to the duty to warn the potential victim.
Liza H. Gold, M.D. and Richard L. Frierson, M.D. The American Psychiatric Association Publishing Textbook of Forensic Psychiatry, 3rd ed. American Psychiatric Association. Arlington. -
Question 197 of 200
197. Question
Which of the following mild hallucinogens is generally obtained by licking the back of the cane toad (Rhinella marina)?
Correct
The slimy substance on the back of the cane toad contains bufotenin. MDMA is not a natural substance but synthesized in organic chemistry labs. Psilocybin is the active hallucinogen found in several species of fungus (“magic mushrooms”). Ayahuasca is brew made from vegetation found mostly in the Amazon River basin. Ibogaine is a naturally occurring hallucinogen found in the Iboga tree of West Africa.
James L. Levenson, M.D. The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry, 3rd ed. American Psychiatric Publishing, Inc. Washington, D.C.
Incorrect
The slimy substance on the back of the cane toad contains bufotenin. MDMA is not a natural substance but synthesized in organic chemistry labs. Psilocybin is the active hallucinogen found in several species of fungus (“magic mushrooms”). Ayahuasca is brew made from vegetation found mostly in the Amazon River basin. Ibogaine is a naturally occurring hallucinogen found in the Iboga tree of West Africa.
James L. Levenson, M.D. The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry, 3rd ed. American Psychiatric Publishing, Inc. Washington, D.C.
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Question 198 of 200
198. Question
Which of the following elements need not be proven for a court to conclude medical malpractice has occurred?
Correct
Malpractice does not require any deception on behalf of the physician. It must, by a standard of preponderance of the evidence, include: a duty to care for the patient, a deviation from the standard of care established for treatment of the condition, and damage that resulted directly from the deviation from the standard of care. If there are no damages, there is no malpractice, regardless of how ill-informed the treatment, but malpractice can allow for other types of negligence to be alleged.
Richard Rosner, M.D. and Charles L. Scott M.D. Principles and Practice of Forensic Psychiatry, 3rd ed. Taylor and Francis Group. Boca Raton, Fla.
Incorrect
Malpractice does not require any deception on behalf of the physician. It must, by a standard of preponderance of the evidence, include: a duty to care for the patient, a deviation from the standard of care established for treatment of the condition, and damage that resulted directly from the deviation from the standard of care. If there are no damages, there is no malpractice, regardless of how ill-informed the treatment, but malpractice can allow for other types of negligence to be alleged.
Richard Rosner, M.D. and Charles L. Scott M.D. Principles and Practice of Forensic Psychiatry, 3rd ed. Taylor and Francis Group. Boca Raton, Fla.
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Question 199 of 200
199. Question
Which of the following paraphilias is defined, “recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviors.”
Correct
. Frotteuristic Disorder is defined verbatim from DSM 5 in the question stem. Paraphilias generally follow the same definition pattern, but it is the object or activity that defines the differences among them. Voyeuristic Disorder is defined similarly with the behavior being viewing unsuspecting people naked on engaged in sexual behavior. Exhibitionistic Disorder is defined by the behavior of exposing one’s genitals to an unsuspecting person. Fetishistic Disorder is defined by intense sexual arousal from nonliving objects of focus on nongential body parts. Transvestic Disorder is defined by intense sexual arousal from cross-dressing into clothing generally worn by another gender. Notably, not all paraphilic disorders require the distress qualifier found in almost all psychiatric diagnoses in DSM 5.
American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). American Psychiatric Association. Arlington.
Incorrect
. Frotteuristic Disorder is defined verbatim from DSM 5 in the question stem. Paraphilias generally follow the same definition pattern, but it is the object or activity that defines the differences among them. Voyeuristic Disorder is defined similarly with the behavior being viewing unsuspecting people naked on engaged in sexual behavior. Exhibitionistic Disorder is defined by the behavior of exposing one’s genitals to an unsuspecting person. Fetishistic Disorder is defined by intense sexual arousal from nonliving objects of focus on nongential body parts. Transvestic Disorder is defined by intense sexual arousal from cross-dressing into clothing generally worn by another gender. Notably, not all paraphilic disorders require the distress qualifier found in almost all psychiatric diagnoses in DSM 5.
American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). American Psychiatric Association. Arlington.
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Question 200 of 200
200. Question
Which of the following statements concerning transcranial magnetic stimulation (TMS), used within guidelines, is correct?
Correct
Used within guidelines, repetitive TMS is no more likely than single-pulse TMS to cause seizures. Also, the risk of seizures is small except if the patient has a cerebral lesion or epilepsy or is being treated with medications that lower the seizure threshold. Moreover, TMS probably causes less cognitive impairment than ECT.
Cycowicz YM, Rowny SB, Luber B, et al. (2018). Differences in seizure expression between magnetic seizures therapy and electroconvulsive shock. J ECT 34;95-103.
Lerner AJ, Wasserman EM, Tamir DI. (2019). Seizures from transcranial magnetic stimulation 2012-2016. Clinical Neurophysiology 130;1409-1416.
Incorrect
Used within guidelines, repetitive TMS is no more likely than single-pulse TMS to cause seizures. Also, the risk of seizures is small except if the patient has a cerebral lesion or epilepsy or is being treated with medications that lower the seizure threshold. Moreover, TMS probably causes less cognitive impairment than ECT.
Cycowicz YM, Rowny SB, Luber B, et al. (2018). Differences in seizure expression between magnetic seizures therapy and electroconvulsive shock. J ECT 34;95-103.
Lerner AJ, Wasserman EM, Tamir DI. (2019). Seizures from transcranial magnetic stimulation 2012-2016. Clinical Neurophysiology 130;1409-1416.