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
A 26-year-old male is found partially undressed wandering in the snow. When the police approach him he is aggressive and assaultive. He appears insensitive to pain. Several officers are required to restrain him. Upon arrival in the ER, he is found to have elevated BP, tachycardia, and vertical nystagmus. He is also noted to have muscle rigidity and some ataxia. What is the most likely diagnosis?
Correct
PCP intoxication is characterized by unpredictable and violent behavior. Dissociative and psychotic symptoms can occur. Individuals frequently are agitated, impulsive, and exhibit decreased sensitivity to pain. Physical findings include autonomic hyperactivity, muscle rigidity, and ataxia. Although rotary or horizontal nystagmus may be observed, vertical nystagmus is virtually pathognomonic of PCP intoxication. It is not seen with any other drugs of abuse. Treatment includes placing the patient in a quiet area with low stimulation. Acidification of the urine with ammonium chloride or ascorbic acid can expedite drug excretion. Haloperidol and/or a benzodiazepine may be useful for agitation and psychosis.
Avery J, Adam T, Levounis P. (2019). The American Psychiatric Publishing Textbook of Psychiatry.
American Psychiatric Publishing. Philadelphia.
MacLean K, Johnson M, Griffiths R. (2014). The American Psychiatric Publishing Textbook of Substance
Abuse Treatment. American Psychiatric Publishing. Philadelphia.Incorrect
PCP intoxication is characterized by unpredictable and violent behavior. Dissociative and psychotic symptoms can occur. Individuals frequently are agitated, impulsive, and exhibit decreased sensitivity to pain. Physical findings include autonomic hyperactivity, muscle rigidity, and ataxia. Although rotary or horizontal nystagmus may be observed, vertical nystagmus is virtually pathognomonic of PCP intoxication. It is not seen with any other drugs of abuse. Treatment includes placing the patient in a quiet area with low stimulation. Acidification of the urine with ammonium chloride or ascorbic acid can expedite drug excretion. Haloperidol and/or a benzodiazepine may be useful for agitation and psychosis.
Avery J, Adam T, Levounis P. (2019). The American Psychiatric Publishing Textbook of Psychiatry.
American Psychiatric Publishing. Philadelphia.
MacLean K, Johnson M, Griffiths R. (2014). The American Psychiatric Publishing Textbook of Substance
Abuse Treatment. American Psychiatric Publishing. Philadelphia. -
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, 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 to control hyperthermia. Since the hyperthermia is a direct result of muscular hyperactivity, antipyretics such as acetaminophen have no effect.
Volpi-Abadie J, Kaye AM, Kaye AD. (2013). Serotonin syndrome. The Ochsner journal, 13(4);533–540
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, 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 to control hyperthermia. Since the hyperthermia is a direct result of muscular hyperactivity, antipyretics such as acetaminophen have no effect.
Volpi-Abadie J, Kaye AM, Kaye AD. (2013). Serotonin syndrome. The Ochsner journal, 13(4);533–540
-
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 tends to have a later age of onset than bipolar disorder. Bipolar disorder occurs with equal frequency in men and women. Rapid cycling is occurs much more frequently in women than men.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical
Psychiatry. Lippincott Williams & Wilkins. Philadelphia.Incorrect
Major Depressive Disorder is twice as common in women and tends to have a later age of onset than bipolar disorder. Bipolar disorder occurs with equal frequency in men and women. Rapid cycling is occurs much more frequently in women than men.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical
Psychiatry. Lippincott Williams & Wilkins. Philadelphia. -
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 as the stage during which egocentric thought is replaced by operational thought and a large amount of information is dealt with using logical thinking. This is also the stage during which the child can take another’s perspective according to Piaget. In the psychodynamically-informed developmental stage theory of Erik Erikson, the stage of Industry versus Inferiority is described as extending from age 5 years -adolescence, coinciding with the onset of latency. During this phase, the child learns new skills, enters systematic instruction and discovers the joy of productivity.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry. Lippincott Williams & Wilkins. Philadelphia.Incorrect
In Piaget’s cognitive development theory, the period from 7 years to puberty coincides with the concrete operational stage. Piaget defines this as the stage during which egocentric thought is replaced by operational thought and a large amount of information is dealt with using logical thinking. This is also the stage during which the child can take another’s perspective according to Piaget. In the psychodynamically-informed developmental stage theory of Erik Erikson, the stage of Industry versus Inferiority is described as extending from age 5 years -adolescence, coinciding with the onset of latency. During this phase, the child learns new skills, enters systematic instruction and discovers the joy of productivity.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry. Lippincott Williams & Wilkins. Philadelphia. -
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 coadministered drugs that are degraded 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.
Johannessen SI, Landmark C. (2010). Antiepileptic drug interactions – principles and clinical implications. Current Neuropharmacology, 8; 254-267.
Carlat D. (2015). Drug Metabolism in Psychiatry: A Clinical Guide. Carlat Publishing. Newburyport.Incorrect
Carbamazepine, phenytoin, phenobarbital all induce CYP 450 3A4 enzymes, leading to decreased levels of coadministered drugs that are degraded 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.
Johannessen SI, Landmark C. (2010). Antiepileptic drug interactions – principles and clinical implications. Current Neuropharmacology, 8; 254-267.
Carlat D. (2015). Drug Metabolism in Psychiatry: A Clinical Guide. Carlat Publishing. Newburyport. -
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. Oralbuccal-lingual movements are most common. 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 muscles of the neck, trunk, and limbs. Blepharospasm and facial grimacing also 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. Lowering the dose of
medication or switching to a second generation antipsychotic may be helpful in both conditions.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology. American Psychiatric Publishing. Philadelphia.
Kaufman D, Milstein M, Geyer HL. (2017). Kaufman’s Clinical Neurology for Psychiatrists. 8th edition,
Elsevier, Philadelphia.Incorrect
Choreoathetotic movements of the head, neck, extremities and trunk characterize tardive dyskinesia. Oralbuccal-lingual movements are most common. 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 muscles of the neck, trunk, and limbs. Blepharospasm and facial grimacing also 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. Lowering the dose of
medication or switching to a second generation antipsychotic may be helpful in both conditions.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology. American Psychiatric Publishing. Philadelphia.
Kaufman D, Milstein M, Geyer HL. (2017). Kaufman’s Clinical Neurology for Psychiatrists. 8th edition,
Elsevier, Philadelphia. -
Question 7 of 200
7. Question
A consulting psychiatrist is asked to evaluate a 25-year-old actress who the medical service has called “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 myoclonic left hand movements. 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. In addition to mood and thought disturbances, seizures and involuntary movements, which mimic myoclonus, occur regularly. Ovarian teratomas frequently give rise to the disorder. Removing a teratoma, if present, will reverse it. Conditions with similar symptoms include infectious encephalitis, non-infectious inflammatory encephalitis, such as lupus, and abuse of PCP or ketamine. NMDAreceptor encephalitis may develop in children as well as individuals, predominantly males, older than 45 years.
Chapman MR, Vause HE. (2011). Anti-NMDA receptor encephalitis: diagnosis, psychiatric presentation, and treatment. Am J Psychiatry, 168;245-251.
Dalmau J, Lancaster E, Martinez-Hernandez E, et al. (2011). Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis. Lancet Neurol, 10;63-74.
Kayser MS, Titulaer MJ, Gresa-Arribas N, et al. (2013). Frequency and characteristics of isolated psychiatric episodes in anti-N-methyl-D-aspartate receptor encephalitis. JAMA Neurol, 70;1133-1139.Incorrect
Psychiatric symptoms may be the first or most prominent manifestation of NMDA-receptor encephalitis – a recently described cause of delirium. In addition to mood and thought disturbances, seizures and involuntary movements, which mimic myoclonus, occur regularly. Ovarian teratomas frequently give rise to the disorder. Removing a teratoma, if present, will reverse it. Conditions with similar symptoms include infectious encephalitis, non-infectious inflammatory encephalitis, such as lupus, and abuse of PCP or ketamine. NMDAreceptor encephalitis may develop in children as well as individuals, predominantly males, older than 45 years.
Chapman MR, Vause HE. (2011). Anti-NMDA receptor encephalitis: diagnosis, psychiatric presentation, and treatment. Am J Psychiatry, 168;245-251.
Dalmau J, Lancaster E, Martinez-Hernandez E, et al. (2011). Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis. Lancet Neurol, 10;63-74.
Kayser MS, Titulaer MJ, Gresa-Arribas N, et al. (2013). Frequency and characteristics of isolated psychiatric episodes in anti-N-methyl-D-aspartate receptor encephalitis. JAMA Neurol, 70;1133-1139. -
Question 8 of 200
8. Question
Emergency workers bring six subway passengers to the Emergency Room. They are all delirious, dyspneic, nauseated, and weak, and 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 elements of insecticides and pesticides as well as poison gases. 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. New York.Incorrect
Sarin is an organophosphate – a group of chemicals that constitute the active elements of insecticides and pesticides as well as poison gases. 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. New York. -
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 test 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 and parkinsonism as well as the visual hallucinations. These three symptoms constitute the core features of dementia with Lewy body disease. Suggestive features are rapid eye movement (REM) disorder and hypersensitivity to antipsychotic agents. In 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.
Gomperts SN. (2016). Lewy Body Dementias: Dementia with Lewy bodies and Parkinson disease dementia. Continuum, 22;435–463.Incorrect
Salient features of this case are dementia and parkinsonism as well as the visual hallucinations. These three symptoms constitute the core features of dementia with Lewy body disease. Suggestive features are rapid eye movement (REM) disorder and hypersensitivity to antipsychotic agents. In 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.
Gomperts SN. (2016). Lewy Body Dementias: Dementia with Lewy bodies and Parkinson disease dementia. Continuum, 22;435–463. -
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. QD. After four weeks, the patient tells you that 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. Therefore when treating depression, “we recommend maintaining the usual therapeutic dose for at least 4 weeks. If no improvement is seen after 4 weeks, a trial of a higher dose may be warranted. If a partial response is evident after 4 weeks of therapy, the dose should remain constant for an additional two weeks…” Roberts LW (eds). (2019). The American Psychiatric Publishing Textbook of Psychiatry, 7th ed. American Psychiatric Publishing. Philadelphia.
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. Therefore when treating depression, “we recommend maintaining the usual therapeutic dose for at least 4 weeks. If no improvement is seen after 4 weeks, a trial of a higher dose may be warranted. If a partial response is evident after 4 weeks of therapy, the dose should remain constant for an additional two weeks…” Roberts LW (eds). (2019). The American Psychiatric Publishing Textbook of Psychiatry, 7th ed. American Psychiatric Publishing. Philadelphia.
-
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 and, after a friend located it, 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 telephone 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 partial complex 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, he could not have been having a partial complex seizure.
Bartsch T, Deuschl G. (2010). Transient global amnesia: functional anatomy and clinical implications. Lancet Neurology, 9;205-214.
Hunter G. (2011). Transient global amnesia. Lancet Neurology. 29;1045-1054. Spiegel DR, Smith J, Wade RR, et al. (2017). Transient global amnesia: current perspectives. Neuropsychiatric disease and treatment, 13;2691–2703.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 partial complex 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, he could not have been having a partial complex seizure.
Bartsch T, Deuschl G. (2010). Transient global amnesia: functional anatomy and clinical implications. Lancet Neurology, 9;205-214.
Hunter G. (2011). Transient global amnesia. Lancet Neurology. 29;1045-1054. Spiegel DR, Smith J, Wade RR, et al. (2017). Transient global amnesia: current perspectives. Neuropsychiatric disease and treatment, 13;2691–2703. -
Question 12 of 200
12. Question
Ms. Dolyn is admitted involuntarily to a locked inpatient unit because she is psychotic and suicidal. She refuses to take any medication. Her psychiatrist takes her 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 it constitutes an emergency and 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 her refusal to take medication.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th ed. Lippincott Williams & Wilkins. Philadelphia.
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins. Philadelphia.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 it constitutes an emergency and 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 her refusal to take medication.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th ed. Lippincott Williams & Wilkins. Philadelphia.
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins. Philadelphia. -
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
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins. Philadelphia.
Incorrect
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins. Philadelphia.
-
Question 14 of 200
14. Question
Mr. Newell 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 bought a hunting knife and killed two prostitutes. In order to be found guilty of murder the prosecution must prove that Mr. Newell 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 Mr. Newell is psychotic, he could be that a person occupying a high position in a hierarchy is responsible for those in lower positions. Nonmalfeasance 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.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th ed. Lippincott Williams & Wilkins. Philadelphia.
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins. Philadelphia.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 Mr. Newell is psychotic, he could be that a person occupying a high position in a hierarchy is responsible for those in lower positions. Nonmalfeasance 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.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th ed. Lippincott Williams & Wilkins. Philadelphia.
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins. Philadelphia. -
Question 15 of 200
15. Question
Which one of the following paraphilias is the least likely to lead to legal involvement?
Correct
Society has deemed that sexual behavior, which is not “healthy and non-harming,” can be punished by serious legal and societal consequences. The paraphilias that most commonly lead to legal consequences include pedophilia, exhibitionism, and sexual sadism resulting in rape or murder.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th ed. Lippincott Williams & Wilkins. Philadelphia.Incorrect
Society has deemed that sexual behavior, which is not “healthy and non-harming,” can be punished by serious legal and societal consequences. The paraphilias that most commonly lead to legal consequences include pedophilia, exhibitionism, and sexual sadism resulting in rape or murder.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th ed. Lippincott Williams & Wilkins. Philadelphia. -
Question 16 of 200
16. Question
Ms. Rowen is a heroin addict who also has schizophrenia. She went into Macy’s and stole merchandise expecting to sell it to buy heroin. She was caught on camera and arrested. Because in jail she was noted to be internally preoccupied, 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 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.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th ed. Lippincott Williams & Wilkins. Philadelphia.
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins. Philadelphia.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 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.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th ed. Lippincott Williams & Wilkins. Philadelphia.
Appelbaum PS, Gutheil TG. (2020). Clinical Handbook of Psychiatry and the Law. Lippincott Williams & Wilkins. Philadelphia. -
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. (2015). Manual of Clinical Psychopharmacology, 8th ed. American Psychiatric Publishing, Inc. Washington, D.C.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. (2015). Manual of Clinical Psychopharmacology, 8th ed. American Psychiatric Publishing, Inc. Washington, D.C. -
Question 18 of 200
18. Question
Mr. Melly suffers from PTSD. You order a standard MRI of his brain. Which one of the following is it most likely to show?
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.
-
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. Philadelphia.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. Philadelphia. -
Question 20 of 200
20. Question
Mr. Nathan has been having panic attacks for the past several months. They have increased in frequency to the point where he is now having panic attacks 2-3 times per day. He finally brought himself to a psychiatrist for help who prescribed 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.
Pompoli A, Furukawa TA, Imai H, et al. (2016). Psychological therapies for panic disorder with or without agoraphobia in adults: a network meta‐analysis. Cochrane Database of Systematic Reviews, 4;CD0110Incorrect
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.
Pompoli A, Furukawa TA, Imai H, et al. (2016). Psychological therapies for panic disorder with or without agoraphobia in adults: a network meta‐analysis. Cochrane Database of Systematic Reviews, 4;CD0110 -
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 been treated 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 and 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 while having 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 while having 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. -
Question 22 of 200
22. Question
Parents of a 3-year-old boy report that their child has not begun to talk. Since birth the child has been difficult to sooth and has difficulty with transitions. He has been a difficult sleeper and over the past year has had frequent violent temper tantrums. What is the first intervention the physician should recommend?
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. Philadelphia.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. Philadelphia. -
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, in order to make the diagnosis of ADHD, the patient must exhibit symptoms in at least two settings.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th ed. Lippincott Williams & Wilkins. Philadelphia.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, in order to make the diagnosis of ADHD, the patient must exhibit symptoms in at least two settings.
Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th ed. Lippincott Williams & Wilkins. Philadelphia. -
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, Shprintzen syndrome, DiGeorge syndrome) is caused by microdeletion in the long arm of chromosome 22 at band 22q11.2. The phenotypic spectrum of VCFS is extremely wide and includes congenital cardiac anomalies, abnormal facies, palatal abnormalities, hypocalcemia and T-cell immunodeficiencies, cognitive deficits and psychiatric manifestations including schizophrenia.
Hacıhamdioğlu B, Hacıhamdioğlu D, Delil K. (2015). 22q11 deletion syndrome: current perspective. The Application of Clinical Genetics, 8;123–132.Incorrect
Velocardiofacial Syndrome (VCFS, Shprintzen syndrome, DiGeorge syndrome) is caused by microdeletion in the long arm of chromosome 22 at band 22q11.2. The phenotypic spectrum of VCFS is extremely wide and includes congenital cardiac anomalies, abnormal facies, palatal abnormalities, hypocalcemia and T-cell immunodeficiencies, cognitive deficits and psychiatric manifestations including schizophrenia.
Hacıhamdioğlu B, Hacıhamdioğlu D, Delil K. (2015). 22q11 deletion syndrome: current perspective. The Application of Clinical Genetics, 8;123–132. -
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 secondgeneration antipsychotics to the conventional antipsychotic perphenazine. Over 1400 patients were enrolled and 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, overall there was no 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 secondgeneration antipsychotics to the conventional antipsychotic perphenazine. Over 1400 patients were enrolled and 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, overall there was no 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. -
Question 26 of 200
26. Question
Which of the following statements is true regarding lithium?
Correct
Lithium is excreted in the urine. Lithium levels can be increased 30%-50% when taken with thiazide diuretics, and dosage adjustments of lithium are required when 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, and if GFR is decreased, for example in the elderly or with renal disease, lithium levels will increase.
Schatzberg AF, DeBattista C. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric Publishing, Inc. Washington, D.C.Incorrect
Lithium is excreted in the urine. Lithium levels can be increased 30%-50% when taken with thiazide diuretics, and dosage adjustments of lithium are required when 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, and if GFR is decreased, for example in the elderly or with renal disease, lithium levels will increase.
Schatzberg AF, DeBattista C. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric Publishing, Inc. Washington, D.C. -
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. Foods with high tyramine content should be avoided and include aged cheeses, aged or
fermented meats, fava beans and other broad beans, sauerkraut, overripe or spoiled foods,, soy sauce, and yeast
extracts (marmite). Both alcoholic and non-alcoholic tap beer, and chianti wine should also be avoided . Foods
that are safe to ingest include fresh cheeses, fresh yogurt, other alcoholic beverages and smoked fish.
Chocolate and caffeine can be a problem if ingested in large amounts, but are acceptable if used in moderation.
Hales RF, Yudofsky SC, Gabbard GO (eds). (2019) The American Psychiatric Publishing Textbook of
Psychiatry: 7th ed. American Psychiatric Publishing, Inc. Washington, DC.
Schatzberg AF, DeBattista C. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric
Publishing, Inc. Washington, D.C.Incorrect
When patients treated with nonreversible MAOIs ingest tyramine containing foods, they are at risk to develop
a hypertensive crisis. Foods with high tyramine content should be avoided and include aged cheeses, aged or
fermented meats, fava beans and other broad beans, sauerkraut, overripe or spoiled foods,, soy sauce, and yeast
extracts (marmite). Both alcoholic and non-alcoholic tap beer, and chianti wine should also be avoided . Foods
that are safe to ingest include fresh cheeses, fresh yogurt, other alcoholic beverages and smoked fish.
Chocolate and caffeine can be a problem if ingested in large amounts, but are acceptable if used in moderation.
Hales RF, Yudofsky SC, Gabbard GO (eds). (2019) The American Psychiatric Publishing Textbook of
Psychiatry: 7th ed. American Psychiatric Publishing, Inc. Washington, DC.
Schatzberg AF, DeBattista C. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric
Publishing, Inc. Washington, D.C. -
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.
Hales RF, Yudofsky SC, Gabbard GO (eds). (2019) The American Psychiatric Publishing Textbook of
Psychiatry: 7th ed. American Psychiatric Publishing, Inc. Washington, DC.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry. Lippincott Williams & Wilkins. Philadelphia.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.
Hales RF, Yudofsky SC, Gabbard GO (eds). (2019) The American Psychiatric Publishing Textbook of
Psychiatry: 7th ed. American Psychiatric Publishing, Inc. Washington, DC.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry. Lippincott Williams & Wilkins. Philadelphia. -
Question 29 of 200
29. Question
A 27 –year-old female with borderline personality disorder presents with rejection sensitivity, and outbursts of anger that are intense and difficult for her to control. She also describes frequent “mood crashes” in which she rapidly becomes depressed. According to the APA Practice Guidelines, which would be the first line medication trial?
Correct
According to the APA practice guidelines for treating Borderline Personality Disorder, the initial medication
treatment for patients who have symptoms of affective dysregulation (mood lability, inappropriate intense
anger, depressive mood crashes, or outbursts of temper), is an SSRI or similar antidepressant. In the
recommended treatment algorithm, the next step would be to try a different SSRI or other related
antidepressant. If this continues to be ineffective or only partially effective, then a low dose of neuroleptic
should be added for symptoms of anger, and or clonazepam for anxiety. If the patient is still symptomatic, then
a trial of an MAOI should be utilized. The last step in the algorithm, if the patient remains symptomatic, is a
trial of a mood stabilizer.
Limandri BJ. (2018). Psychopharmacology for borderline personality disorder. J Psychosoc Nurs Ment Health
Serv, 56(4);8-11.Incorrect
According to the APA practice guidelines for treating Borderline Personality Disorder, the initial medication
treatment for patients who have symptoms of affective dysregulation (mood lability, inappropriate intense
anger, depressive mood crashes, or outbursts of temper), is an SSRI or similar antidepressant. In the
recommended treatment algorithm, the next step would be to try a different SSRI or other related
antidepressant. If this continues to be ineffective or only partially effective, then a low dose of neuroleptic
should be added for symptoms of anger, and or clonazepam for anxiety. If the patient is still symptomatic, then
a trial of an MAOI should be utilized. The last step in the algorithm, if the patient remains symptomatic, is a
trial of a mood stabilizer.
Limandri BJ. (2018). Psychopharmacology for borderline personality disorder. J Psychosoc Nurs Ment Health
Serv, 56(4);8-11. -
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) instead. You will discontinue the fluoxetine today. How long must you wait until you start the MAOI?
Correct
Due to its long half-life, when switching from fluoxetine to an MAOI, a 5-week washout period is advised, in
order 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. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric
Publishing, Inc. Washington, D.C.Incorrect
Due to its long half-life, when switching from fluoxetine to an MAOI, a 5-week washout period is advised, in
order 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. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric
Publishing, Inc. Washington, D.C. -
Question 31 of 200
31. Question
Which is the most common method used to complete suicide in the United States?
Correct
According to data published in 2017 by the American Association of Suicidology, firearms account for 51.6%
of completed suicides. Suffocation or hanging accounts for 22.6% and poisoning resulted in 17.9 % of
suicides. However worldwide, hanging is cited as the most common method of suicide.
Hales RF, Yudofsky SC, Gabbard GO (eds). (2014) The American Psychiatric Publishing Textbook of
Psychiatry. American Psychiatric Publishing, Inc. Washington, DC.Incorrect
According to data published in 2017 by the American Association of Suicidology, firearms account for 51.6%
of completed suicides. Suffocation or hanging accounts for 22.6% and poisoning resulted in 17.9 % of
suicides. However worldwide, hanging is cited as the most common method of suicide.
Hales RF, Yudofsky SC, Gabbard GO (eds). (2014) The American Psychiatric Publishing Textbook of
Psychiatry. American Psychiatric Publishing, Inc. Washington, DC. -
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 101, and was shivering and diaphoretic. She was noted to be mildly agitated and confused. PE was notable for hyperactive bowel sounds, hyperreflexia and bilateral myoclonus of her lower extremities. Her lithium level was 0.7. 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. The neuromuscular
findings of hyperreflexia, myoclonus, and tremor are highly suggestive of the disorder, in a patient who has
recently received serotonergic agents, or has had a dosage adjustment. Other symptoms 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 0.7. In neuroleptic malignant
syndrome, symptoms of 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.
Volpi-Abadie J, Kaye AM, Kaye AD. (2013). Serotonin syndrome. The Ochsner journal, 13(4);533–540.Incorrect
Serotonin syndrome can present with a wide array of symptoms that vary in severity. The neuromuscular
findings of hyperreflexia, myoclonus, and tremor are highly suggestive of the disorder, in a patient who has
recently received serotonergic agents, or has had a dosage adjustment. Other symptoms 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 0.7. In neuroleptic malignant
syndrome, symptoms of 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.
Volpi-Abadie J, Kaye AM, Kaye AD. (2013). Serotonin syndrome. The Ochsner journal, 13(4);533–540. -
Question 33 of 200
33. Question
Which of the following medications is most likely to increase the levels of lamotrigine, if coadministered?
Correct
Valproic acid can double serum levels of lamotrigine. This 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 the
beginning of Steven’s Johnson syndrome, a potentially fatal reaction. Lamotrigine should be discontinued in
any patient who develops a rash. 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. . Paroxetine, a 2D6 inhibitor does not affect lamotrigine levels, nor does
iloperidone.
Schatzberg AF, DeBattista C. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric
Publishing, Inc. Washington, D.C.Incorrect
Valproic acid can double serum levels of lamotrigine. This 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 the
beginning of Steven’s Johnson syndrome, a potentially fatal reaction. Lamotrigine should be discontinued in
any patient who develops a rash. 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. . Paroxetine, a 2D6 inhibitor does not affect lamotrigine levels, nor does
iloperidone.
Schatzberg AF, DeBattista C. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric
Publishing, Inc. Washington, D.C. -
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 delirium or coma. 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.
Saddock B, Saddock V, Sussman N. (2011). Pocket Handbook of Psychiatric Drug Treatment 5th ed. Lippincott
Williams &Wilkins. Philadelphia.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 delirium or coma. 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.
Saddock B, Saddock V, Sussman N. (2011). Pocket Handbook of Psychiatric Drug Treatment 5th ed. Lippincott
Williams &Wilkins. Philadelphia. -
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 be
helpful in decreasing 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.
Citrome LL.(2020). Medication Options and Clinical Strategies for Treating Tardive Dyskinesia. J Clin
Psychiatry, 81(2);TV18059BR2C.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology.
American Psychiatric Publishing. Philadelphia.
Kaufman D, Milstein M, Geyer HL. (2017). Kaufman’s Clinical Neurology for Psychiatrists. 8th edition,
Elsevier, Philadelphia.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 be
helpful in decreasing 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.
Citrome LL.(2020). Medication Options and Clinical Strategies for Treating Tardive Dyskinesia. J Clin
Psychiatry, 81(2);TV18059BR2C.
Schatzberg AF, Nemeroff CB. (2017). The American Psychiatric Publishing Textbook of Psychopharmacology.
American Psychiatric Publishing. Philadelphia.
Kaufman D, Milstein M, Geyer HL. (2017). Kaufman’s Clinical Neurology for Psychiatrists. 8th edition,
Elsevier, Philadelphia. -
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, providing some of the support for the concept that schizoptypal 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.
Hales RF, Yudofsky SC, Gabbard GO (eds). (2014) The American Psychiatric Publishing Textbook of
Psychiatry. American Psychiatric Publishing, Inc. Washington, DC.Incorrect
There is an increased risk of schizotypal personality disorder in the relatives of people diagnosed with
schizophrenia, providing some of the support for the concept that schizoptypal 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.
Hales RF, Yudofsky SC, Gabbard GO (eds). (2014) The American Psychiatric Publishing Textbook of
Psychiatry. American Psychiatric Publishing, Inc. Washington, DC. -
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, and can induce its own metabolism,
leading to decreased plasma levels, even though dosing remains constant.
Schatzberg AF, DeBattista C. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric
Publishing, Inc. Washington, D.C.Incorrect
Carbamazepine is both a substrate and an inducer at CYP 450 3A4, and can induce its own metabolism,
leading to decreased plasma levels, even though dosing remains constant.
Schatzberg AF, DeBattista C. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric
Publishing, Inc. Washington, D.C. -
Question 38 of 200
38. Question
A patient recently diagnosed with schizophrenia is treated on the inpatient unit with risperidone 4 mg. per day. His auditory hallucinations resolve and he is discharged without side effects. Several weeks later, his outpatient psychiatrist adds an antidepressant to treat symptoms of depression. Three days later the patient complains of stiffness in his arms and legs. Which medication was most likely prescribed?
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 may lead to
toxic plasma risperidone concentrations and increased Parkinsonian and EPS symptoms. In addition to careful
clinical observation, monitoring plasma risperidone levels may be of value in patients given adjunctive therapy
with fluoxetine.
Kennedy WK, Jann MW, Kutscher EC. (2013). Clinically significant drug interactions with atypical antipsychotics. CNS Drugs, 27(12);1021-48.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 may lead to
toxic plasma risperidone concentrations and increased Parkinsonian and EPS symptoms. In addition to careful
clinical observation, monitoring plasma risperidone levels may be of value in patients given adjunctive therapy
with fluoxetine.
Kennedy WK, Jann MW, Kutscher EC. (2013). Clinically significant drug interactions with atypical antipsychotics. CNS Drugs, 27(12);1021-48. -
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 events associated with trazodone use.
Schatzberg AF, DeBattista C. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric
Publishing, Inc. Washington, D.C.Incorrect
Sedation is the most common side effect of trazodone. Orthostatic hypotension and dizziness also frequently
occur. Priapism and cardiac arrhythmias are uncommon events associated with trazodone use.
Schatzberg AF, DeBattista C. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric
Publishing, Inc. Washington, D.C. -
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 experiencing a manic episode but not in 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 former.
American Psychiatric Association. (2013). APA Diagnostic and Statistical Manual of Mental Disorders 5th
ed. American Psychiatric Publishing. Philadelphia.Incorrect
Psychotic symptoms are seen in patients experiencing a manic episode but not in 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 former.
American Psychiatric Association. (2013). APA Diagnostic and Statistical Manual of Mental Disorders 5th
ed. American Psychiatric Publishing. Philadelphia. -
Question 41 of 200
41. Question
What is considered to be the most common acquired cause of mild-moderate intellectual disability?
Correct
Fetal Alcohol Syndrome, caused by maternal excessive alcohol consumption, is considered to be the most
common acquired, therefore potentially preventable, cause of intellectual disability. Fetal Alcohol Syndrome is
caused by excessive alcohol consumption late in pregnancy (3>2>1 trimester). Down’s syndrome is the most
common genetic cause of intellectual disability but is not heritable, as it is not present in either parent. Fragile
X is probably the most common heritable rather than acquired cause of intellectual disability. The mutation is
often present in parents, but in small enough size that symptoms occur but in milder forms. When the
mutation, and number of trinucleotide repeats, increase, children are at risk for the full-blown illness. Autism
(DSMIVTR) is associated in 65-70% of cases with intellectual disability but is not a cause of intellectual
disability.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry. Lippincott Williams & Wilkins. Philadelphia.
Roussotte FF, Sulik KK, Mattson SN, et al. (2012). Regional brain volume reductions relate to facial
dysmorphology and neurocognitive function in fetal alcohol spectrum disorders. Human Brain Mapping,
33(4);920-937.Incorrect
Fetal Alcohol Syndrome, caused by maternal excessive alcohol consumption, is considered to be the most
common acquired, therefore potentially preventable, cause of intellectual disability. Fetal Alcohol Syndrome is
caused by excessive alcohol consumption late in pregnancy (3>2>1 trimester). Down’s syndrome is the most
common genetic cause of intellectual disability but is not heritable, as it is not present in either parent. Fragile
X is probably the most common heritable rather than acquired cause of intellectual disability. The mutation is
often present in parents, but in small enough size that symptoms occur but in milder forms. When the
mutation, and number of trinucleotide repeats, increase, children are at risk for the full-blown illness. Autism
(DSMIVTR) is associated in 65-70% of cases with intellectual disability but is not a cause of intellectual
disability.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry. Lippincott Williams & Wilkins. Philadelphia.
Roussotte FF, Sulik KK, Mattson SN, et al. (2012). Regional brain volume reductions relate to facial
dysmorphology and neurocognitive function in fetal alcohol spectrum disorders. Human Brain Mapping,
33(4);920-937. -
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, and is particularly well-known for
representing a genetic risk for schizophrenia. 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 the disorder.
VCFS is also associated with autism, ADHD, mood disorders and phobias. In the very young, management is
related to treatment of heart, immune, palatal difficulties along with developmental delays. In the school years,
cognitive difficulties are prominent. In young adulthood, psychiatric difficulties may develop. Answer a refers
to tuberous sclerosis, which presents with nodules seen on the malar surface of the face, progressive
intellectual disability and is associated with autism, epilepsy and cerebral tumors. VCFS is not a sex-linked
condition; it is caused by a micro-deletion at 22.11.2. The microdeletion syndromes at 15Q are Prader-Willi
(paternal deletion) and Angelman (maternal). In general, abnormal sex chromosomes produce physical
findings and not necessarily intellectual dysfunction, whereas abnormal autosomal chromosomes are usually
associated with intellectual disability.
Kates WR, Antshel KM, Faraone SV, et al. (2011). Neuroanatomic predictors to prodromal psychosis in velocardio-facial syndrome (22q11.2 deletion syndrome): a longitudinal study. Biol Psychiatry, 69;945-52. Hacıhamdioğlu B, Hacıhamdioğlu D, Delil K. (2015). 22q11 deletion syndrome: current perspective. App Clin
Genet, 8;123–132.Incorrect
VCFS is best known for its association with psychiatric disorders, and is particularly well-known for
representing a genetic risk for schizophrenia. 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 the disorder.
VCFS is also associated with autism, ADHD, mood disorders and phobias. In the very young, management is
related to treatment of heart, immune, palatal difficulties along with developmental delays. In the school years,
cognitive difficulties are prominent. In young adulthood, psychiatric difficulties may develop. Answer a refers
to tuberous sclerosis, which presents with nodules seen on the malar surface of the face, progressive
intellectual disability and is associated with autism, epilepsy and cerebral tumors. VCFS is not a sex-linked
condition; it is caused by a micro-deletion at 22.11.2. The microdeletion syndromes at 15Q are Prader-Willi
(paternal deletion) and Angelman (maternal). In general, abnormal sex chromosomes produce physical
findings and not necessarily intellectual dysfunction, whereas abnormal autosomal chromosomes are usually
associated with intellectual disability.
Kates WR, Antshel KM, Faraone SV, et al. (2011). Neuroanatomic predictors to prodromal psychosis in velocardio-facial syndrome (22q11.2 deletion syndrome): a longitudinal study. Biol Psychiatry, 69;945-52. Hacıhamdioğlu B, Hacıhamdioğlu D, Delil K. (2015). 22q11 deletion syndrome: current perspective. App Clin
Genet, 8;123–132. -
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, etc., also almost always occurs in men.
95% of pedophiles are heterosexual. Most pedophiles also have engaged in voyeurism, exhibitionism and rape.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical
Psychiatry. Lippincott Williams & Wilkins. Philadelphia.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, etc., also almost always occurs in men.
95% of pedophiles are heterosexual. Most pedophiles also have engaged in voyeurism, exhibitionism and rape.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical
Psychiatry. Lippincott Williams & Wilkins. Philadelphia. -
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 heritable, but is present
exclusively in girls (and XXY boys) so this is incorrect as a diagnosis. Young girls with Rett have
characteristic hand stereotypies and they do have microcephaly but not bursts of laughter and ataxia. PraderWilli is a heritable cause of intellectual disability (paternal deletion at 15q) but classically has hyperphagia,
obesity, nonfood-related obsessions and severe behavior problems. In Williams one sees “elfin” facies and
“cocktail party chatter” and some level of intellectual disability.
Sadock BJ Kaplan HI Sadock VA: Kaplan & Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s
Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. Lippincott Williams & Wilkins.
Philadelphia.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 heritable, but is present
exclusively in girls (and XXY boys) so this is incorrect as a diagnosis. Young girls with Rett have
characteristic hand stereotypies and they do have microcephaly but not bursts of laughter and ataxia. PraderWilli is a heritable cause of intellectual disability (paternal deletion at 15q) but classically has hyperphagia,
obesity, nonfood-related obsessions and severe behavior problems. In Williams one sees “elfin” facies and
“cocktail party chatter” and some level of intellectual disability.
Sadock BJ Kaplan HI Sadock VA: Kaplan & Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s
Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. Lippincott Williams & Wilkins.
Philadelphia. -
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 (and can cause insomnia.) Lithium is known to cause increased thirst. SSRIs and
antipsychotics are known to increase appetite (stimulants typically decrease appetite.)
Storebø 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 (and can cause insomnia.) Lithium is known to cause increased thirst. SSRIs and
antipsychotics are known to increase appetite (stimulants typically decrease appetite.)
Storebø 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. -
Question 46 of 200
46. Question
A 24 y.o. female 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. B-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. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric
Publishing, Inc. Washington, D.C.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. B-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. (2015). Manual of clinical psychopharmacology, 8th ed. American Psychiatric
Publishing, Inc. Washington, D.C. -
Question 47 of 200
47. Question
Which is not 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. Increased urination is seen with
lithium treatment, not guanfacine.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: BIncorrect
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. Increased urination is seen with
lithium treatment, not guanfacine.
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: B -
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 can 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 dose should not exceed 450 mg. as dose
dependent seizures can occur when this level is exceeded. Because it facilitates dopamine transmission, it may
be a good choice for use in patients with Parkinson’s disease.
Hales RF, Yudofsky SC, Gabbard GO (eds). (2019) The American Psychiatric Publishing Textbook of
Psychiatry: 7th ed. American Psychiatric Publishing, Inc. Washington, DC
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry. Lippincott Williams & Wilkins. Philadelphia.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 can 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 dose should not exceed 450 mg. as dose
dependent seizures can occur when this level is exceeded. Because it facilitates dopamine transmission, it may
be a good choice for use in patients with Parkinson’s disease.
Hales RF, Yudofsky SC, Gabbard GO (eds). (2019) The American Psychiatric Publishing Textbook of
Psychiatry: 7th ed. American Psychiatric Publishing, Inc. Washington, DC
Saddock BJ, Kaplan VA. (2014). Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry. Lippincott Williams & Wilkins. Philadelphia. -
Question 49 of 200
49. Question
Which medication has not been approved by the FDA for 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). Venlafaxine is also an SNRI, but has not been
FDA-approved for fibromyalgia. Tricyclic antidepressants have been shown to be helpful as well.
Arnold LM, Clauw DJ. (2017). Challenges of impIncorrect
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). Venlafaxine is also an SNRI, but has not been
FDA-approved for fibromyalgia. Tricyclic antidepressants have been shown to be helpful as well.
Arnold LM, Clauw DJ. (2017). Challenges of imp -
Question 50 of 200
50. Question
A 71 yr old male develops confusion after a CABG. What is the primary cardiac concern with the use of antipsychotics?
Correct
The use of antipsychotics have 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. Leonard
CE, Freeman CP, Newcomb CW, et al: antipsychotics and the risks of sudden cardiac death and all-cause
death: Cohort studies in Medicaid and dually-eligible Medicaid-Medicare beneficiaries of five states
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 have 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. Leonard
CE, Freeman CP, Newcomb CW, et al: antipsychotics and the risks of sudden cardiac death and all-cause
death: Cohort studies in Medicaid and dually-eligible Medicaid-Medicare beneficiaries of five states
Beach SR, Celano CM, Sugrue AM. (2018). QT Prolongation, Torsades de Pointes, and Psychotropic
Medications: A 5-Year Update. Psychosomatics, 59(2);105–122. -
Question 51 of 200
51. Question
A 45 year old woman admitted to the hospital with Crohn’s disease was treated with steroids 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.
Bancos I, Hahner S, Tomlinson J. (2015). Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol, 3(3);216–226
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.
Bancos I, Hahner S, Tomlinson J. (2015). Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol, 3(3);216–226
-
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. Philadelphia.
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. Philadelphia.
-
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.
Mehler PS, Brown C. (2015). Anorexia nervosa – medical complications. J Eat Disord, 3(1);1–8.
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.
Mehler PS, Brown C. (2015). Anorexia nervosa – medical complications. J Eat Disord, 3(1);1–8.
-
Question 54 of 200
54. Question
A 40 year old male 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 to the mail room at work last month (he used to be a delivery truck driver), 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) is common occurring in up to 17% of men. OSA can lead to symptoms that mimic depression: fatigue, lack of energy, and poor concentration. Sufferers are more likely to be involved in car accidents. 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 in patients with OSA. 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.
Myers KA, Mrkobrada M, Simel DL. (2013). Does this patient have obstructive sleep apnea? the rational clinical examination systematic review. JAMA, 310(7);731-741.
Incorrect
Obstructive sleep apnea (OSA) is common occurring in up to 17% of men. OSA can lead to symptoms that mimic depression: fatigue, lack of energy, and poor concentration. Sufferers are more likely to be involved in car accidents. 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 in patients with OSA. 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.
Myers KA, Mrkobrada M, Simel DL. (2013). Does this patient have obstructive sleep apnea? the rational clinical examination systematic review. JAMA, 310(7);731-741.
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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. Philadelphia.
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. Philadelphia.
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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 trigger factors include psychological stress, physical trauma, infections, certain drugs (lithium, antimalarials, interferon, β-blockers), 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. Philadelphia.
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 trigger factors include psychological stress, physical trauma, infections, certain drugs (lithium, antimalarials, interferon, β-blockers), 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. Philadelphia.
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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 those under 60 years of age. Risk factors include higher viral load, lower educational level, anemia, older age and female sex. The incidence of HAD has decreased significantly since the advent of antiretroviral medication, including zidovudine.
Hoogland ICM, Portegies P. (2014). HIV-associated dementia: Prompt response to zidovudine. Neurology: Clin Pract, 4(3);263–265
Incorrect
HIV-associated dementia (HAD) is one of the leading causes of dementia in those under 60 years of age. Risk factors include higher viral load, lower educational level, anemia, older age and female sex. The incidence of HAD has decreased significantly since the advent of antiretroviral medication, including zidovudine.
Hoogland ICM, Portegies P. (2014). HIV-associated dementia: Prompt response to zidovudine. Neurology: Clin Pract, 4(3);263–265
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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
Medications that are FDA approved 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.
Galanter M, Kleber HD (eds). (2008). The American Psychiatric Press Textbook of Substance Abuse Treatment. APA Press. Washington, D.C.
Incorrect
Medications that are FDA approved 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.
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 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 the hypertension and hyperthermia that can lead to cardiovascular collapse. The other drugs do not produce this combination of symptoms.
Hoffman R. (2020). MDMA (ecstasy) intoxication. UpToDate. Wellesley.
Incorrect
The most likely cause of her delirium is MDMA (Ecstasy, Molly), which can cause agitation and paranoia; however, the greatest concern is the hypertension and hyperthermia that can lead to cardiovascular collapse. The other drugs do not produce this combination of symptoms.
Hoffman R. (2020). MDMA (ecstasy) intoxication. UpToDate. Wellesley.
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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 used in patients with cirrhosis, those with shorter half-lives and without active metabolites like lorazepam and oxazepam are preferred. Benzodiazepines which undergo oxidative metabolism in the liver, can accumulate to toxic levels in patients with cirrhosis. Despite its short half-life, levels of alprazolam, which also undergoes oxidation, can accumulate to dangerous levels in a patients with a cirrhotic liver.
Sadock BJ, Sussman N, Sadock VA. (2019). Kaplan & Sadock’s Pocket Handbook of Psychiatric Drug Treatment (7th ed.). Wolters Kluwer. Philadelphia.
Incorrect
When benzodiazepines are used in patients with cirrhosis, those with shorter half-lives and without active metabolites like lorazepam and oxazepam are preferred. Benzodiazepines which undergo oxidative metabolism in the liver, can accumulate to toxic levels in patients with cirrhosis. Despite its short half-life, levels of alprazolam, which also undergoes oxidation, can accumulate to dangerous levels in a patients with a cirrhotic liver.
Sadock BJ, Sussman N, Sadock VA. (2019). Kaplan & Sadock’s Pocket Handbook of Psychiatric Drug Treatment (7th ed.). Wolters Kluwer. Philadelphia.
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Question 61 of 200
61. Question
Which of the following is the co-occurring psychiatric disorder most likely to be associated with development of 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.
Erskine HE, Norman RE, Ferrari AJ. (2016). Long-term outcomes of attention-deficit/hyperactivity disorder and conduct disorder: a systematic review and meta-analysis. J Amer Acad Child Adol Psychiatry, 55(10);841–850
Incorrect
Conduct disorder both precedes and predicts substance abuse in adolescents. Its risk is greater than for ADHD, PTSD and Bipolar Disorder.
Erskine HE, Norman RE, Ferrari AJ. (2016). Long-term outcomes of attention-deficit/hyperactivity disorder and conduct disorder: a systematic review and meta-analysis. J Amer Acad Child Adol Psychiatry, 55(10);841–850
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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.
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.
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 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.
Olney N, Spina S, Miller B. (2017). Frontotemporal dementia. Neurol Clin, 35(2);339–374.
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 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.
Olney N, Spina S, Miller B. (2017). Frontotemporal dementia. Neurol Clin, 35(2);339–374.
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Question 67 of 200
67. Question
Each of the following somatoform disorders is more common in women except:
Correct
There is a large body of literature on the gender differences in the somatoform disorder. The evidence points to a higher prevalence of these diagnoses in women except for hypochondriasis which is found equally in men and women.
Barsky AJ, Peekna HM, Borus JF. (2001). Somatic symptom reporting in women and men. J Gen Int Med, 16;266-275
Incorrect
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Question 68 of 200
68. Question
Which of the following is true regarding trisomy 21?
Correct
Trisomy chromosome 21, also known as Down syndrome, includes intellectual disability of mild- moderate level, characteristic physical findings including stunted growth, low tone, small genitalia and facial dysmorphia and risk of dementia in later life. This risk is of more concern now that people with Down’s have a greater life expectancy. The intellectual decline in the 40s and 50’s is associated with an excess of beta amyloid. Down’s syndrome is negatively associated with autism. Prader-Willi is caused by a paternally- inherited translocation at 15Q. It is comprised of hyperphagia, non-food-related compulsive behavior and borderline-moderate intellectual disability. Fragile X is caused by a mutation at the “fragile” site of the X chromosome (Xq27.3). Fragile X is the most common inherited cause of intellectual disability, causes moderate to severe disability and, besides a long face and large ears, is also associated with macro-orchidism, ADHD, autism and social anxiety.
Nelson LD, Siddarth P, Kepe V. (2011). Positron emission tomography of brain beta-amyloid and tau levels in adults with Down syndrome. Arch Neurol, 68;768–74
Car J. (2012). Six weeks to 45 years: a longitudinal study of a population with Down syndrome. J Applied Res Intellect Disabil, 25;414-422
Incorrect
Trisomy chromosome 21, also known as Down syndrome, includes intellectual disability of mild- moderate level, characteristic physical findings including stunted growth, low tone, small genitalia and facial dysmorphia and risk of dementia in later life. This risk is of more concern now that people with Down’s have a greater life expectancy. The intellectual decline in the 40s and 50’s is associated with an excess of beta amyloid. Down’s syndrome is negatively associated with autism. Prader-Willi is caused by a paternally- inherited translocation at 15Q. It is comprised of hyperphagia, non-food-related compulsive behavior and borderline-moderate intellectual disability. Fragile X is caused by a mutation at the “fragile” site of the X chromosome (Xq27.3). Fragile X is the most common inherited cause of intellectual disability, causes moderate to severe disability and, besides a long face and large ears, is also associated with macro-orchidism, ADHD, autism and social anxiety.
Nelson LD, Siddarth P, Kepe V. (2011). Positron emission tomography of brain beta-amyloid and tau levels in adults with Down syndrome. Arch Neurol, 68;768–74
Car J. (2012). Six weeks to 45 years: a longitudinal study of a population with Down syndrome. J Applied Res Intellect Disabil, 25;414-422
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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 is an example of the concept of operational thought described by Piaget and typically emerging 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.
Ginsburg H, Opper S. (1988). Piagets theory of intellectual development. Prentice-Hall. Englewood-Cliffs.
Incorrect
This is an example of the concept of operational thought described by Piaget and typically emerging 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.
Ginsburg H, Opper S. (1988). Piagets theory of intellectual development. Prentice-Hall. Englewood-Cliffs.
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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, while 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) as well as weight gain and sedation (mediated by histamine and alpha adrenergic receptors). Perphenazine and thiothixene are both midrange in potency, and less likely to cause anticholinergic side effects.
Sadock BJ, Sussman N, Sadock VA. (2019). Kaplan & Sadock’s Pocket Handbook of Psychiatric Drug Treatment (7th ed.). Wolters Kluwer. Philadelphia.
Incorrect
High potency conventional antipsychotics, like haloperidol, are most likely to cause extrapyramidal side effects, while 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) as well as weight gain and sedation (mediated by histamine and alpha adrenergic receptors). Perphenazine and thiothixene are both midrange in potency, and less likely to cause anticholinergic side effects.
Sadock BJ, Sussman N, Sadock VA. (2019). Kaplan & Sadock’s Pocket Handbook of Psychiatric Drug Treatment (7th ed.). Wolters Kluwer. Philadelphia.
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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.