Download Vignette-Based Psychiatry Review

Psychiatry Vignette-Based
Review Questions
Adapted from the practice question pdf posted to learn@uw
“INS 2016 Psychiatry Practice Questions”
Format
3-step review:
① Vignette-Style Question
② Discussion: Answer and Explanation
③ High yield follow-up review
(Follow-up for most, not all questions)
Some pertinent animations.
See the notes under the slides for additional info.
Correspondence to [email protected]
1. An 18yow presents to the ED because of increasing depression
and hopelessness for several months. She has had great difficulty
adjusting to life in college, and has fallen behind on her
schoolwork. She has recently felt that life is not worth living.
Today, she is considering killing herself, though she is not sure how
she would do so. She does not have access to a gun and does not
keep any medications or knives in her dorm room. In your
documentation of the MSE, how would you describe her SI?
A. Active SI, with intent and plan to harm herself
B. Active SI, with intent, plan and means to harm
herself
C. Active SI, with intent to harm herself
D. No SI
E. Passive SI
1. Answer & Explanation
• C. Pt considers “killing herself” (active SI, with
intent) but has no plan or access to means.
Passive vs. Active SI:
– Passive SI: “belief that life is not worth living or
wish that (s)he would be dead”
– Active SI: includes at least “an intent to harm
oneself”
1. High yield f/u: Suicide risk factors
1. Gender:
– Men 4x more likely to complete
– Women 3x more to attempt
2. Marital status:
– Single/divorced/widowed/separated men (2-5x)
3. Age (see next slide)
4. FH: first-degree relative (3.5x)
5. Mental illness: psychiatric Hx in 95% suicide
deaths
– MDD, BP d/o, SUDs, Anxiety d/o, Schizophrenia, BPD
– Q: Most important risk for completion in MDD?
Suicide by Age*Gender
1. High yield f/u: suicide risk factors
(cont’d)
6. Other medical illnesses:
- HIV/AIDS, HD, cancer, TBI, seizures, SC injury
7. Suicidal ideation:
*Note: Hx prior attempt far greater predictive value
8. Mental status:
- Anxiety, agitation, despair, hopelessness
- Feelings of loss of control, shame, and anger
9. Social and environmental stressors:
- Loss/lack of social support
- Q: Protective factors?
10. Biological factors:
- Lower serotonin
2. A 21yow presents to your clinic with a six-month history of
depression. She reports that these symptoms began after she
started graduate school, which was much more difficulty than she
had anticipated. She has no past psychiatric or medical history. She
has a strong FH of mood and anxiety disorders, and reports having
been physically abused as a child. What genetic finding is this
patient most likely to have?
A. Autosomal dominant mutation of amyloid
precursor protein
B. CAG trinucleotide repeat
C. Deletion of q11 region of chromosome 22
D. E4 allele of apolipoprotein E
E. Short allele of serotonin transporter
2. Answer & Explanation
• E. Well established gene-environment interaction in depression:
short allele of the SE transporter gene (5-HTTPR) and childhood
maltreatment predicts higher risk of depression.
Rule out the other options:
• The autosomal dominant mutation of APP is found in rare
familial versions of AD.
• An expansion of the CAG trinucleotide repeat is found in HD.
• Deletion of the q11 region of chromosome 22 causes
velocardiofacial syndrome (DiGeorge syndrome), which can have
symptoms similar to schizophrenia.
• The most common polymorphism associated with AD is the e4
allele of apoE; carrying one e4 allele doubles the risk of AD.
3. A 67yom presents to your clinic with a 2-year history of anxiety.
He says that he was always a “worrier,” but this has become worse
since he retired. He finds it difficult to control his worries, and this
in turns has led to insomnia. His wife, who is present, notes that
seems to get upset much more easily. On MSE, he is restless and
has a hard time sitting still; his cognitive testing is normal, with a
SLUMS of 30/30. His PMH includes only HTN, which is well
controlled with atenolol. A recent TSH was normal. What
medication would you recommend?
A.
B.
C.
D.
E.
Bupropion
Diazepam
Methylphenidate
Quetiapine
Sertraline
3. Answer & Explanation
• E. First step is Dx = GAD. Normal SLUMS = r/o cognitive
disorder. Normal TSH = r/o thyroid disorder. EBT’s for GAD =
SSRIs, SNRIs, buspirone, and CBT. Thus, the SSRI sertraline is
the most correct choice on the list. SSRIs are first-line
(efficacy, safety, tolerability).
• BZDs used less commonly (concerns for tolerance and
withdrawal). BZD use is limited to short periods and when
anxiety is severe. Can prescribe an SSRI with a BZD, and stop
the BZD once the SSRI has taken effect. Q: What is this SSRI
property called?
3. Answer & Explanation (cont’d)
Rule out the other options:
• Bupropion is one of the few antidepressants that is not
helpful for anxiety – it may cause or exacerbate anxiety.
• BZDs such as diazepam may be useful in the short-term
treatment of severe anxiety disorders (not first line).
• Methylphenidate is a psychostimulant and would
therefore not be indicated for an anxiety disorder.
• Atypical antipsychotics such as quetiapine are
sometimes used for severe or treatment-refractory
anxiety disorders, but they have too ADRs to be first-line.
3. High yield f/u: GAD Mnemonic
“Worry WARTS”
Worry that is difficult to control, feeling wound-up
or irritable
Absentmindedness or having difficulty
concentrating
Restlessness, feeling tired
Muscle Tension
Sleep disturbance
4. A 21yom with schizophrenia is referred to your clinic for
treatment. A trial of the antipsychotic ziprasidone was not
effective. His brother, who accompanies to him to the visit,
wonders about a trial of haloperidol. What side effect is
haloperidol more likely to cause than an atypical antipsychotic?
A.
B.
C.
D.
E.
Agranulocytosis
Dyslipidemia
Hyperglycemia
Tardive dyskinesia
Weight gain
4. Answer & Explanation
• D. Two main categories of antipsychotics: typicals (older;
MOA = D2 mesocorticolimbic blockade) and atypicals
(newer; variety of MOAs).
• The classic side effects of typicals (i.e., EPS) are due to DA
blockade: tremor, bradykinesia, akathisia, dystonia, TD.
Rule out the other options:
• Atypicals are less likely to cause EPS, and more likely to
cause metabolic side effects, e.g., dyslipidemia,
hyperglycemia, and weight gain.
• Agranulocytosis is a rare but potentially fatal complication
of treatment with the atypical antipsychotic clozapine.
– This is a high-yield association!
4. High yield f/u: EPS & EPS Tx
-EPS: acute dystonia (spasms of tongue, face, neck, back),
parkinsonism (i.e., bradykinesia, tremors, shuffling gait),
akathisia (uncontrollable urge to be in motion: pacing,
restlessness), perioral tremor ("rabbit syndrome”: involuntary,
fine, rhythmic motions of the mouth).
-Treatment: anticholinergic agents, why? In the striatum, there is
an ACh-DA balance. With decreased DA function, ACh starts to
run away unchecked. By administering an anticholinergic, excess
Ach is blocked, ACh-DA balance is restored.
*Note: Tardive dyskinesia: most significant EPS (worm-like
twisting movements of tongue, mouth, face). Has no reliable tx,
often irreversible, even w/ DC of the drug.
5. A 72yom presents to your clinic for evaluation of depression. He
reports that, for the last 5 years, his symptoms have been worse in
the winter; his depression remits in the spring. He has never been
suicidal, and the depression has only moderately affected his
functioning. What treatment has the best balance of risk and
benefit?
A.
B.
C.
D.
E.
Deep Brain Stimulation
Electroconvulsive Therapy
Lithium
Phototherapy
Transcranial Magnetic Stimulation
5. Answer & Explanation
• D. First step = Dx = seasonal depression, where episodes
typically begin in fall or winter and remit in spring.
• Seasonal depression: uniquely responsive to phototherapy
Rule out other options:
• DBS of the PFC is an experimental procedure that may be
effective for treatment-refractory depression.
• ECT is the most effective treatment for severe depression and
psychotic depression.
• Lithium is a useful augmentation agent.
• TMS also has a limited role in the treatment of depression.
5. High yield f/u: MDD subtypes
-Psychotic: ~20% of severely depressed pts experience psychotic
depression; often requires hospitalization and treatment with
med combinations (antidepressant plus antipsychotic) or ECT.
-Seasonal: AKA “Seasonal Affective Disorder.” Typical symptoms:
include low energy, hypersomnia, overeating, craving for
carbohydrates, and weight gain. Women, younger persons, and
those living at higher latitudes are at increased risk.
-Peripartum: NOT “Baby blues,” or transient, low-level mood
changes within 10 days of the birth of a child. Peripartum
depression is a full MDE that begins during pregnancy OR within
one month of delivery.
6. A 72yom presents to your clinic with a four-month history of
severe depression, his first episode ever. He is eating poorly, and
has lost 20 pounds. He is having difficulty caring for himself. He has
command auditory hallucinations telling him to harm himself. He is
currently taking sertraline and quetiapine, which have not been
effective and have caused many side effects. What treatment
would you recommend next?
A.
B.
C.
D.
E.
Deep Brain Stimulation
Electroconvulsive Therapy
Lithium
Phototherapy
Transcranial Magnetic Stimulation
6. Answer & Explanation
• B. Vignette = severe depression with psychotic features
(among most severe forms of depression). High suicide risk
because of the command AH. Thus, a highly effective and
rapid treatment is indicated, namely ECT.
Rule out other options:
• DBS could be an option for severe depression in the future.
• Adding lithium would be a reasonable, but will not work as
quickly as ECT and may be difficult for a 72yo pt to tolerate.
• Phototherapy can work for non-seasonal depression, but
ECT is likely more effective and more rapidly effective.
• TMS is likely not as effective as ECT.
7. A 32yom presents to your clinic with panic attacks of increasing
severity and frequency (at least twice daily). He has never been on
medications, but would now like to try something because the
panic attacks are affecting his work and his relationship with his
partner. He has trouble sleeping because he ruminates about
going to work the next day. What advantage does a selective
serotonin reuptake inhibitor (SSRI) have over a benzodiazepine?
A. Less likely to cause physiologic dependence
B. More likely to be sedating and therefore help
with insomnia
C. More rapid onset of anxiolytic effect
D. Three-times-a-day dosing results in more
consistent effect
7. Answer & Explanation
• A. First step = Dx = Panic d/o, which includes recurrent
unexpected panic attacks. First-line txs include SSRIs,
SNRIs and CBT. BZDs can be effective in preventing panic
attacks, but because of tolerance and withdrawal concerns,
their use is limited to short periods of time. SSRIs are less
likely than BZDs to cause physiological dependence.
Rule out the other options:
• BZDs are more sedating than SSRIs.
• BZDs are more immediately effective than SSRIs (hours to
days, rather than weeks).
• No SSRIs require more than once-daily dosing (other than
the rarely used fluvoxamine).
7. High yield f/u: MOA BZDs vs.
Barbiturates (BBs)
-While both enhance GABA-mediated neuronal inhibition, BBs & BZDs have
different binding sites on the GABAA receptor, thus, different MOAs.
-BZD "agonists" are positive modulators; they increase the affinity of the
GABAA receptor for GABA and increase the frequency of GABA-induced Clchannel openings; do not directly activate GABAA receptor.
*Note: *Because they are positive modulators, in the absence of GABA, BZDs have NO
EFFECT! Nomenclature "agonist" really isn't correct.
-BBs are true agonists; they increase the duration of GABA-induced channel
openings and, at high concentrations, directly activate the GABAA receptor.
-SUMMARY: The effects of both classes of drugs on Cl- flux result in the
neuron becoming hyperpolarized and therefore less excitable. I.e., both make
the neuron LESS LIKE TO FIRE via hyperpolarization.
8. A 23yow with newly diagnosed bipolar disorder presents to your
clinic to discuss treatment options. Which of the following has the
LEAST evidence supporting its efficacy in bipolar disorder?
A.
B.
C.
D.
E.
Lamotrigine
Modafanil
Oxcarbazepine
Risperidone
Valproic acid
8. Answer & Explanation
• B. All of the agents except Modafanil have been shown
to be effective in various phases of BP d/o.
Rule out the other options:
• Lamotrigine has antidepressant properties and thus
may be effective in BP depression and in preventing
depressive episodes.
• Oxcarbazepine and valproic acid are anticonvulsants
effective for manic and mixed episodes.
• Risperidone (like other atypical antipsychotics) is
effective for mania, mixed episodes, depression, and
maintenance treatment.
8. High yield f/u: BP d/o tx
9. An 82yom with his first episode of MDD presents to your clinic.
He has never been treated with an antidepressant. He has stable
coronary artery disease (for which he takes aspirin and betablocker), but is otherwise healthy. Which of the following is the
patient LEAST likely to tolerate?
A.
B.
C.
D.
E.
Bupropion
Citalopram
Duloxetine
Nortriptyline
Sertraline
9. Answer & Explanation
• D. Older adults are more sensitive to ADRs. The most
concerning medication on the list is nortriptyline, a
TCA. TCAs can increase the risk of cardiac arrhythmias,
in particular in pts with cardiac disease. The
anticholinergic side effects include constipation,
urinary retention, sedation, and confusion. Thus,
nortriptyline should be avoided.
Rule out the other options:
• The other medications can also cause significant ADRs
in older adults, but less frequently than TCAs.
Monoamine Hypothesis
9a. High yield f/u: MDD
(1) Pts treated with reserpine for
HTN became very depressed.
Reserpine blocks the VMAT, which
normally acts to transport MAs into
vesicles, which release the NTs into
synapses. Thus, reserpine decreased
MA release, connecting decreased
MAs with depressive symptoms.
Thinking became: if not enough MA
led to depression, perhaps boosting
MA can lessen/treat depression.
(2) Genetic variation 5-HTT (SERT)
(3) People given a diet deficient in
tryptophan (precursor of MA
biosynthesis) tend to have a
recurrence of depressive symptoms,
especially pts that respond well to
SSRIs.
Neurotrophic Hypothesis
9b. High yield f/u: MDD
Nerve growth factors (e.g., BDNF)
are critical in neural plasticity.
Evidence suggests depression is
associated with the loss of
neurogenesis, and effective
antidepressant therapies increase
synaptic connectivity (e.g., in the
hippocampus):
(1) Stress and pain are associated
with a drop in BDNF, contributing to
hippocampal atrophy.
(2) MDD is associated with 5-10%
loss of hippocampal volume.
(3) Human studies: depression
appears to be associated with a
drop in BDNF levels (i.e., in CSF and
serum). Conversely, antidepressants
increase BDNF levels in clinical trials
and may be associated with an
increase in hippocampal volume.
10. A 27yo veteran of the Iraq war presents with severe anxiety
and insomnia. You suspect a diagnosis of post-traumatic stress
disorder. Which of the following is NOT required to make this
diagnosis?
A.
B.
C.
D.
E.
Avoidance behavior
Psychotic symptoms
Exposure to a traumatic event
Hyperarousal symptoms
Intrusive symptoms
10. Answer & Explanation
• B. PTSD requires exposure to trauma and
includes 4 major criteria:
– re-experiencing symptoms (e.g., flashbacks)
– avoidance of stimuli associated with the trauma
– negative alterations in cognitions and mood
– hyperarousal (e.g., hypervigilance)
• Psychotic symptoms are not part of PTSD.
10. High yield f/u: PTSD Psychotherapy
Prolonged Exposure Therapy (PET) Theory: people learn to
fear thoughts, feelings, and situations that remind them of
past trauma. Practice: By talking about the trauma repeatedly,
the pt learns not to fear the memories and to change how
they react to these memories.
Cognitive processing therapy (CPT) Theory: PTSD affects how
people think about and interpret subsequent events in their
lives. Practice: Written exposure in which pts write about the
impact of trauma and how they think differently about safety,
trust, esteem, power/control, and intimacy. Therapist
challenges pt’s interpretations, helps identify “cognitive
distortions,” and replace them with accurate interpretations.
11. A 51yow with chronic and severe depression presents to your
clinic. She has reported intermittent SI. What is most likely to
reduce her risk of suicide?
A. Implanting a deep brain stimulator
B. Involving her support systems
C. Prescribing a benzodiazepine
D. Reminding her that suicides go to hell
11. Answer & Explanation
• B. Modifiable suicide risk factors include mental symptoms
(depression, anxiety, agitation, despair, hopelessness,
feelings of loss of control, shame, and anger), lack of social
supports, and access to means of suicide (guns, pills, etc.).
Rule out the other options:
• DBS is an experimental procedure for severe depression; its
effect on suicide risk is not yet known.
• A BZD could relieve anxiety, but would not address her
depression, and could be used in a suicide attempt.
• Pts sometimes indicate they would not commit suicide
because of religious beliefs; it would be unethical and
possibly culturally inappropriate to invoke this.
11. High yield f/u: Meds for suicide
prevention?
Same question, but this time, a list of
medications for answer options. What would
you pick?
Lithium: FDA approved for BP d/o, but also used
in unipolar depression augmentation for
suicidality.
12. A 56yow presents to your clinic for follow-up of MDD. She has
been successfully treated with deep brain stimulation. What CNS
structure is this treatment directed toward?
A.
B.
C.
D.
E.
Amygdala
Hippocampus
Medial temporal cortex
Prefrontal cortex
Parietal cortex
12. Answer & Explanation
• D. DBS is directed towards the PFC (specifically,
subgenual PFC). Critical point: PFC is involved in MDD
pathophysiology and is thus an intervention target.
Rule out the other options:
• The amygdala is involved primarily in fear responses.
• The hippocampus and the medial temporal cortex
encode new memories and link memory with emotion.
• Parietal cortex has a variety of functions related to
attention, visuospatial processing, and self-awareness.
Subgenual PFC: Extremely rich in 5-HT transporters; influences changes
in appetite and sleep, mood and anxiety, memory formation, and selfesteem. This region is particularly implicated in the normal processing of
sadness.
12. High yield f/u: MDD neurocircuitry review
“Although depressed mood is normal in response to adversity in
all individuals, what distinguishes those vulnerable to MDD is
their inability to effectively regulate negative mood… During an
effortful affective-reappraisal task…these findings indicate that a
key feature underlying the pathophysiology of MDD is lack of
engagement of left lateral vmPFC circuitry important for the
down-regulation of amygdala responses to negative stimuli.
13. A 26yow presents to your clinic because of fatigue and
insomnia for the last 8 months. She also complains of difficulty
concentrating, irritability and worrying all the time. As a result, she
has been having trouble at work. She denies palpitations and
weight change. Her PMH is unremarkable, vital signs are within
normal limits, and her PE shows no focal abnormalities, but she is
quite restless. What is the most likely diagnosis?
A. Anxious temperament
B. Attention-deficit/hyperactivity disorder
C. Generalized anxiety disorder
D. Hyperthyroidism
E. Social phobia
13. Answer & Explanation
• C. Classic symptoms of GAD (Recall, “Worry WARTS” in #3).
Rule out the other options:
• AT is not a diagnosis, but a risk factor for anxiety disorders.
• Both GAD and ADHD present with difficulties concentrating.
But this pt does not have the other sxs of ADHD.
• Hyperthyroidism is on the DDx of GAD and Panic d/o, but she
does not have other hyperthyroidism sxs (palpitations, weight
loss, heat intolerance). It may remain prudent to check TSH.
• Social phobia is a “strong, persisting fear of situations in
which embarrassment can occur.” Is not this presentation.
13. High yield f/u: Distinguishing
similar presentations
MDD (2 weeks)
• Depressed mood/irritability
• Anhedonia
• Δ weight/appetite
• Sleep disturbance
• Psychomotor
agitation/retardation
• Fatigue/energy loss
• Worthlessness/guilt
• Difficulty
concentrating/indecisivenes
s
• SI
GAD (6 months)
• Anxiety/worry
• Difficulty to control worry
• ^Associated with:
–
–
–
–
–
–
Restlessness
Fatigue
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance
*DSM-5: both cause clinically significant distress/impairment; must rule out
substance-induction, and other mental disorders & medical conditions
13. High yield f/u (cont’d): Buspirone
vs. SSRI for GAD
Dr. Walaszek: For GAD pts, buspirone won't work
as well as an SSRI, which are simply more
effective. Buspirone can be used for pts with
moderate anxiety because it tends to be better
tolerated compared to an SSRI.
14. A 44yow with schizophrenia is admitted to an inpatient
psychiatric unit. She is adamant that she is married to the New
Zealand pop sensation, Lorde. When others point out to her that
she is not married to Lorde, she scoffs and says that they are “just
jealous.” Her behavior is otherwise not influenced by this belief.
What is the name of this MSE finding?
A.
B.
C.
D.
E.
Amnesia
Anhedonia
Delusion
Hallucination
Obsession
14. Answer & Explanation
• C. A delusion is a “fixed false belief that cannot be
explained on the basis of the pt’s cultural or spiritual
background.” The pt’s belief that she is married to Lorde is
false and does not respond to evidence to the contrary (i.e.,
it is fixed).
Rule out the other options:
• Amnesia is an impairment in storing/retrieving memories.
• Anhedonia is the loss of interest or enjoyment in activities.
• A hallucination is a sensory perception in the absence of a
stimulus.
• An obsession is a recurrent, persistent idea, thought,
impulse or image.
15. A 45yom who has received long-term treatment for
schizophrenia has recently been noted to display involuntary
movements that include lateral deviations of the jaw and “flycatching” motions with his tongue. Which of the following agents
is the most likely cause of his involuntary movements?
A.
B.
C.
D.
E.
Clozapine
Haloperidol
Lithium
Quetiapine
Selegiline
15. Answer & Explanation
• B. Key: recognize involuntary movements as TD,
“a usually irreversible neurological side effect that
includes abnormal movements of the mouth,
trunk and limbs.” TD is most associated with the
class of typical antipsychotics, to which
haloperidol belongs.
Rule out the other options:
• The atypical antipsychotics quetiapine and
clozapine are much less likely to cause TD.
• TD is a rare side effect of lithium and a very rare
side effect of selegiline.
15. High yield f/u: Typical vs. Atypical
Antipsychotics
How are all atypicals different from typicals?
While all effective antipsychotics reduce
dopaminergic D2 neurotransmission, all
atypicals also block 5-HT2A receptors, and are
more potent antagonists at 5-HT2A receptors
than at D2 receptors.
16. A 35yom with a history of depression presents to the ED with
flushing, diarrhea, sweating & muscle rigidity. He says that he
began seeing a new psychiatrist because sertraline was not
working for him. His new doctor gave him a different medication,
but he decided to use both medications to “really get rid of this
depression.” Which medication, in combination with sertraline, is
most likely to cause these symptoms?
A.
B.
C.
D.
E.
Citalopram
Lithium
Nortriptyline
Tranylcypramine
Trazodone
16. Answer & Explanation
• D. Key: Recognize pt has serotonin syndrome
(SS). The classic combination of meds causing
SS is an SSRI plus an MAO inhibitor. Thus, the
correct answer is tranylcypramine (an MAOi),
which the pt took with sertraline (an SSRI).
• Neuroleptic malignant syndrome is on the
DDx, but is more commonly associated with
antipsychotics (“neuroleptics”).
16. High yield f/u: SS v NMS
16. High yield f/u: ADRs
17. A 28yow presents to the ED because of persistent sore throat
and fevers. Her speech is difficult to follow, since she is continually
shifting conversation topics, talking about being from Mars, and
claiming she is the President of the U.S. Her affect is flat. She
reports that her doctor recently prescribed a new medication to
“help her mind.” Which antipsychotic medication is most likely to
be implicated in the etiology of the sore throat and fevers?
A.
B.
C.
D.
E.
Aripiprazole
Clozapine
Haloperidol
Risperidone
Ziprasidone
17. Answer & Explanation
• B. First, think Dx: Given her delusions and
disorganized speech, this patient is most likely
suffering from a psychotic disorder. Next, think
Tx: Most common txs are antipsychotics. The
combination of sore throat and fever is a rare
side effect of antipsychotics, with one important
exception: agranulocytosis due to clozapine
(MOA: agranulocytosis diminishes the immune
system, increasing susceptibility for infection and
sequalae like sore throat and fever).
17. High yield f/u: Clozapine ANC
Monitoring
Patients on clozapine must have weekly
monitoring of hematologic tests (ANC: absolute
neutrophil count) for the first six months of
treatment, followed by monitoring every other
week for six months, followed by monthly
monitoring for life.
18. A 7yo boy is brought to his pediatrician by his mother after a
troubling parent-teacher conference. The teacher informed the
mother that the child is disruptive in class and generally does not
finish his homework. The mother reports that the child’s room is
always messy and that he has difficulty completing chores in a
timely fashion. In the office, the child is restless and interrupts his
mother often. What is the most likely diagnosis?
A. Antisocial personality disorder
B. Anxious temperament
C. Attention-deficit/hyperactivity disorder
D. Autism spectrum disorder
E. Bipolar disorder
18. Answer & Explanation
• C. The pt’s symptoms include being disruptive in class, not
finishing homework, not completing chores, being
disorganized, restlessness and interrupting others. This
cluster of symptoms is most consistent with ADHD.
Rule out the other options:
• ASPD cannot be diagnosed in a 7yo.
• AT is a risk factor for anxiety disorders, not a disorder itself.
• ASD classic triad includes problems with communication,
repetitive behavior, and impaired social skills.
• A child with BP d/o may have similar sxs, but with waxing and
waning; pediatric BP d/o is far less common.
18. High yield f/u: ADHD Tx
Pharmacological treatments:
-First-line (stimulants): methylphenidate and amphetamine
-Second-line (non-stimulant): atomoxetine; not as effective
*Recall, Modafinil is NOT approved for the tx of ADHD
Psychosocial interventions and accommodations in school can
increase levels of attention and functioning:
• Structure classroom environment to minimize distraction,
increased assistance with organizational skills, and emphasis
on the development of appropriate study skills.
• Interventions to improve social functioning, including social
skills training.
19. A 15yo girl is brought to the ED by her mother after
experiencing her first seizure. The thin-appearing girl has a heart
rate of 55, signs suggestive of dehydration, and fine, velvety hair
covering her arms and legs. Her BMI is 16. When the patient’s
mother leaves the room, the patient admits that she has been
depressed lately, and that for the past week she has been taking
one of her friend’s antidepressant medications. Which
antidepressant is most likely to have caused the seizure?
A.
B.
C.
D.
E.
Bupropion
Citalopram
Fluoxetine
Mirtazapine
Selegiline
19. Answer & Explanation
• A. First step = Dx: combination of very low weight,
bradycardia, dehydration and lanugo (fine, soft hair)
suggests anorexia nervosa. Bupropion in general has a
higher risk of causing seizures than other
antidepressants. Pts with eating disorders, perhaps
because of associated electrolyte disturbances, are
even more likely to get seizures with bupropion.
Rule out the other options:
• The other antidepressants on the list can also cause
seizures, but less so than bupropion.
20. A 72yom presents to your clinic with a 3-month history of
difficulty concentrating, poor memory and inability to make
decisions. You recommend treatment with an antidepressant.
What condition do you suspect?
A.
B.
C.
D.
E.
Attention-deficit/hyperactivity disorder
Bipolar disorder
Dysthymic disorder
Major depressive disorder
Substance-induced mood disorder
20. Answer & Explanation
• D. Key issue: “In older adults, depression may cause such
severe impairment as to make the pt appear to have
dementia” aka “pseudodementia.”
Rule out other options:
• Treating BP d/o with an antidepressant could induce mania.
• Treatment of substance-induced mood disorder begins with
removing the offending substance.
• ADHD does not arise this late in life.
• Dysthymic disorder requires 2+ years of symptoms.
21. A 10yo girl presents to your clinic after a recent
diagnosis of ADHD. Her 11yo brother also has ADHD,
successfully treated with methylphenidate. Which is the
most accurate statement about her prognosis?
A. Depression and anxiety will make her ADHD symptoms more
likely to persist
B. Distractibility is the first symptom to remit, while hyperactivity
is the last to remit
C. Little is known about the natural history of ADHD, making
prognosis difficult
D. The fact that her brother also has ADHD has no impact on her
prognosis
E. There is an 80% chance that her symptoms will spontaneously
remit before age 12
21. Answer & Explanation
• A. “ADHD sxs may persist into adolescence and
adulthood, but they also can remit after puberty.
Hyperactivity is the first symptom to remit, with
distractibility being the last to remit. Persistence
is predicted by FH of ADHD, negative life events,
and comorbidity with conduct disorder,
depression, or anxiety symptoms. If sxs do remit,
remission generally occurs between ages 12-20.
In 15-20% of children with ADHD, symptoms
persist into adulthood.”
22. A 58yom presents to your clinic, accompanied by his distressed
wife. Over the last year, he has had a marked decline in his ability
to care for himself and had to stop working. He has become
apathetic, and has started making inappropriate comments to
neighbors. Prior to one year ago, he had no medical problems. He
does not drink alcohol or use illicit drugs. Which diagnosis is most
likely?
A. Alzheimer’s disease
B. Frontotemporal dementia
C. Huntington’s disease
D. Lewy body disease
E. Vascular dementia
22. Answer & Explanation
• B. The combination of functional decline and change in
behavior suggests dementia. Most common dementia is AD,
but in this relatively young patient (< 65 yo), FTD is more
likely. The inappropriate comments (disinhibition) suggest an
impairment of frontal lobe function, consistent with FTD.
Rule out the other options:
• Vascular dementia is a possibility, but the progression is
usually step-wise and the age range is typically 65-75yo.
• HD could present this way, but is rarer; would also expect FH.
• LBD typically presents with the combination parkinsonism,
visual hallucinations, a fluctuating levels of consciousness.
– This is the LBD triad
23. A 10yo boy presents to your clinic for the treatment
of ADHD. You recommend to his parents that he be
prescribed methylphenidate. Which of the following
statements about methylphenidate is most accurate?
A. Causes about a ten percent decrease in the
height that the child will attain in adulthood.
B. Decreases hyperactivity in ADHD by inducing a
slight degree of drowsiness.
C. Increases attention span and decreases
impulsivity in patients with ADHD.
D. Increases the risk of cocaine abuse after the child
becomes an adult.
23. Answer & Explanation
• C.
Rule out the other options:
• Psychostimulants can affect height and weight, but not
to the extent described in option A.
• Psychostimulants are generally not associated with
drowsiness.
• While amphetamine and methylphenidate can be
reinforcing, appropriate use of stimulants in children
has not been found to increase risk of cocaine abuse
later in life.
23. High yield f/u: MOA, ADRs
Psychostimulants
MOA: increase monoamine (MA) function through (i) inhibiting MA
uptake and (ii) evoking transporter-mediated MA release.
ADRs:
-CNS: insomnia, restlessness, anorexia
-CV: tachycardia, angina
-Overdose may produce anxiety, agitation, biting, delirium,
hallucinations, paranoia, psychosis, tremor, diaphoresis, flushing,
pallor, hyperthermia, labile BP and HR (hypotension or HTN),
palpitations, tachypnea, mydriasis, blurred vision
Methylphenidate: More central DA uptake blockage than
catecholamine releasing activity; thus, more mild ADR profile vs.
amphetamine.
24. To assist teachers with identifying children who may
have ADHD, you partner with the local school to create a
checklist of symptoms. Which combination of symptoms
would be consistent with a diagnosis of ADHD?
A. Being easily distracted, constantly worrying, being
afraid to go to school, feeling irritable, problems falling
asleep, feeling tense
B. Depressed mood, difficulties concentrating, difficult
sustaining attention, decreased interest in activities,
problems falling asleep, losing weight
C. Fidgeting and squirming, feeling irritable, decreased
need for sleep, interrupting others, rapid shifts in affect,
restlessness
D. Making careless mistakes, being easily distracted,
having difficulty organizing tasks, being forgetful in daily
activities, not following instructions, losing things
24. Answer & Explanation
• D.
Rule out the other options:
• The cluster in A is most consistent with GAD.
• The cluster in B is most consistent with MDD.
• The cluster in C is consistent with a
hypomanic or manic episode.
25. A 25yom who is addicted to heroin presents to your
clinic for treatment. Which neurotransmitter is most
likely to be involved in the persistence of this disorder
even after successful detoxification from heroin?
A.
B.
C.
D.
E.
Acetylcholine
Dopamine
Endorphin
Norepinephrine
Serotonin
25. Answer & Explanation
• B. All of the NTs listed, except perhaps ACh, may
be involved in addiction. Because this pt is
addicted to heroin, the endogenous opioid
system (including endorphins) would certainly be
implicated, especially in the acute euphoria and
in withdrawal. However, DA has been implicated
in the long-term risk of relapse. DA may be
responsible for the “wanting” (or craving) of
drugs (incentive-sensitization hypothesis) and for
the overlearning of behaviors and stimuli
associated with drug use (reward-learning
hypothesis).
25. High yield f/u: Striatal mediumspiny neurons
• Integrates top-down
glutamate information
from the cortex and
bottom-up DA
information from the
midbrain.
• The medium-spiny
neurons (the
"integrators") are
GABAergic neurons, i.e.,
information leaving the
striatum is expressed via
GABA neurotransmission.
25. High yield f/u (cont’d): “Wanting”
vs. “Liking”
• The term ‘reward’ perhaps too broad to be meaningful
• 2 distinct reward processes: "Wanting" and "Liking”
– “Wanting” process: mediated by DA transmission in the
Nucleus accumbens; process of identifying which goals
(i.e., salient reinforcers) to pursue and energizing
behaviors to achieve these goals.
– “Liking” process: the subjective emotional experience of
reward (i.e., pleasure) upon interacting with the
reinforcer. *Seems to be DA-insensitive. Nucleus
accumbens is still relevant for liking, but it appears that
the relevant chemical is not DA, but instead, opioids.
•
E.g., If you have a rat eating tasty foods (e.g., our equivalent of a
chocolate cake), and you inject opioid receptor blockers, you
greatly reduce the palatable food intake.
26. A 40yom presents to your clinic after an occupational
accident wherein he sustained damage to the prefrontal
cortex. Which of the following memory deficits is he
most likely to have?
A. Anterograde amnesia
B. A reduction in long-term potentiation
C. Confabulation, but no true memory problem
D. Deficits in the strategic retrieval of
information from long-term memory
26. Answer & Explanation
• D. Damage to the PFC can result in impaired retrieval and
recall of memories due to ineffective strategies being used.
Rule out the other options:
• Anterograde amnesia is more likely due to damage to
structures in the medial temporal lobe, including the
hippocampus, and is the core symptom of AD.
• An LTP deficit would not be localized to a particular
structure, as LTP is a process that takes place globally at the
cellular level. LTP underlies the formation of memory.
• Confabulation, the unconscious fabrication of memories, is
a classic finding in thiamine deficiency due to severe
alcohol use (i.e., Wernicke-Korsakoff syndrome).
26. High yield f/u: Patient H.M.
• Intractable epilepsy
• Bilateral medial
temporal removal
– Seizure free, but…
– Long-term memory
consequences
• Anterograde amnesia
26. High yield f/u (cont’d): H.M.
26. High yield f/u (cont’d): H.M.
27. A 38yow presents with a several day history of excessive
energy and altered mood. You suspect she has bipolar disorder,
and you wish to determine whether she has a hypomanic or manic
episode. Which of the following features is characteristic of a
hypomanic episode, but not a manic episode?
A. Decreased need for sleep
B. Elevated, expansive or irritable mood
C. Increased goal-directed activity
D. Functioning remains intact
E. Not caused by a medical problem
27. Answer & Explanation
• D. Almost all psychiatric disorders cause
functional impairment and/or emotional distress.
Hypomania can be an exception to this. Many
pts with hypomania feel “better than normal”
and enjoy increased productivity – i.e., their
functioning remains intact or even gets
transiently better.
• *The downside is that hypomania may lead to
mania, which does result in functional
impairment, sometimes quite severe.
27. High yield f/u: Bipolar I vs. II
28. A 32yow with bipolar disorder experiences total
sleep deprivation for one night due to international
travel. What is the most likely result?
A. Enhanced memory and attention
B. Exacerbation of depressive symptoms
C. Increased side effects from lithium therapy
D. Induction of an episode of mania
E. Transient suicidal ideation
28. Answer & Explanation
• D. Maintaining regular sleep-wake cycles is critical in the prevention
of mood episodes in patients with BP d/o. “BP d/o is particularly
sensitive to sleep disturbance. Sleep deprivation and travel-related
time-zone changes have been associated with the onset of mania.”
Rule out the other options:
• Worsening depression and suicidal ideation are less likely.
• If the pt develops hypomania rather than mania, it is conceivable
she could have enhanced cognitive function (but the effects of
sleep deprivation would likely offset any benefit).
• It is possible that a pt who gets dehydrated on a long flight could
experience lithium toxicity, but this would not necessarily be
related to sleep deprivation.
29. A 21yow presents to the college health clinic for treatment of
abnormal eating patterns. In a patient with binge-eating and
purging behaviors, which of the following symptoms is more
consistent with bulimia nervosa than with anorexia nervosa?
A. Excessive exercise
B. Misuse of laxatives
C. Normal body weight
D. Self-induced vomiting
29. Answer & Explanation
• C. A hallmark of anorexia nervosa is “refusal to
maintain body weight at or above a minimally
normal weight,” whereas many pts with
bulimia nervosa have normal or higher weight.
• Pts with anorexia or bulimia may misuse
laxatives or induce vomiting to control weight.
29. High yield f/u: Anorexia nervosa
DSM-5 subtypes
Restricting type: During the last 3 months, the
individual has not engaged in recurrent episodes of
binge eating or purging behavior. This subtype
describes presentations in which weight loss is
accomplished primarily through dieting, fasting,
and/or excessive exercise.
Binge-eating/purging type: During the last 3
months, the individual has engaged in recurrent
episodes of binge eating or purging behavior (i.e.,
self-induced vomiting or the misuse of laxatives,
diuretics, or enemas).
30. A 38yom presents to your clinic with a complaint of
chronic insomnia. You would like to teach him the
principles of sleep hygiene. Which of the following is NOT
part of sleep hygiene?
A. Get regular exercise each morning or early afternoon
B. Develop a relaxing routine before bedtime
C. Increase exposure bright light during the day
D. Minimize or avoid the use of caffeine, alcohol and
nicotine
E. Use of laptop computer in bed is allowed, as long as it’s
not stressful
30. Answer & Explanation
• E. Exposure to light at bedtime, including from a
computer screen, will impair sleep.
Rule out the other options:
• The elements of sleep hygiene include daily
exercise (preferably earlier in the day), keeping
the bedroom dark, quiet and set to a comfortable
temperature, and avoiding stimulants and alcohol
around bedtime. Exposure to bright light during
the day can reset circadian rhythms and thus
improve sleep.
31. A 30yow presents to your clinic because of excess
sleepiness. You suspect a disorder that is due to loss of
hypocretin function in the hypothalamus. What disorder
do you suspect?
A. Delayed sleep phase disorder
B. Narcolepsy
C. REM sleep behavior disorder
D. Restless legs syndrome
E. Sleep apnea
31. Answer & Explanation
• B. All of the disorders on the list could cause
excess daytime sleepiness. However,
narcolepsy is the only one linked to
hypocretin: narcolepsy is caused by the loss of
hypocretin-producing cells in the
hypothalamus.
32. A 32yom presents to your clinic with 6 months of increased
anxiety. He finds himself to be restless, irritable and tense. He has
difficulty falling asleep because he worries so much about his job,
and as a result he has been drinking more to help fall asleep. He
would like treatment for his anxiety, and is not interested in
medications. How would you describe how psychotherapy works
to this patient?
A. By helping the pt to find a stable and safe place to live.
B. By providing the pt a set of guiding principles outlining a
course of action for recovery from addiction, compulsion,
or other behavioral problems.
C. By teaching the pt strategies and giving him tools to deal
with stress and unhealthy thoughts and behaviors.
D. By using the pt’s relationship to the content of books and
poetry and other written words as therapy.
32. Answer & Explanation
• C. Pt meets criteria for GAD, and may have a SUD,
too. The psychotherapeutic treatment of choice
for GAD is CBT, which includes analyzing and
changing thoughts, emotions, and behaviors.
Rule out the other options:
• The other approaches listed are psychosocial
rehabilitation for schizophrenia (A), 12-step
programs for SUDs (B) which the pt may
eventually need, and bibliotherapy (D).
33. A 72yom presents to your clinic for treatment of
long-standing difficulties with falling asleep. Which of the
following behavioral changes would be LEAST likely to
address insomnia?
A.
B.
C.
D.
Exercise each morning.
Go to bed only when sleepy.
Have one drink of alcohol at bedtime.
Keep the bedroom dark, quiet and set to a
comfortable temperature.
E. Limit the time spent in bed to actual sleep time.
33. Answer & Explanation
• C. Alcohol is likely to have negative effects on
sleep quality.
Rule out the other options:
• The treatment of choice for chronic insomnia
includes psychotherapeutic approaches, such
as sleep hygiene. These include regular
exercise, going to bed only when sleepy,
keeping the room dark and comfortable, and
limiting time spent in bed to actual sleep time.
34. The parents of a 4yo girl bring her to you for an evaluation of
her hearing. Over the last year, she has not been as responsive to
others as she used to be, and her speech is delayed relative to
other children in the neighborhood. She is not interested in
listening to stories at bedtime. Her parents describe her as “shy,”
since she displays little interest in playing with others. She spends
much of the day playing with light switches and doorknobs around
the house. What is the most likely diagnosis?
A. Absence seizures
B. Attention-deficit hyperactivity disorder
C. Autism spectrum disorder
D. Cerebral palsy
E. Generalized anxiety disorder
34. Answer & Explanation
• C. This patient demonstrates the classic features of an
ASD, namely impairments in communication and
social interactions, and repetitive behaviors.
Rule out the other options:
• GAD could explain the pt being “shy,” but would not
account for the other behaviors.
• Absence seizures typically present with more episodic
findings, rather than persistent behaviors.
• Though autism may be comorbid with either ADHD or
cerebral palsy, there is no evidence here to support
the latter two diagnoses.
34. High yield f/u: “Delayed”
“Is this normal?” Every developmental skill has a
mean, and ±1-2 SDs, just like any lab.
• “Delayed” means > 2 SDs below the mean
• The rate of development is important, not the
number of months. E.g., a 6-month-old with
skills of a 3-month-old is NOT “3 months
behind” but rather “50% delayed.”
• Delayed does not imply eventual “catch up”!
35. You care for a 28yom with MDD. His depression symptoms
remitted one month ago with the combination of psychotherapy
and sertraline. Today, his very concerned wife calls to report that
for the last week he has been acting erratically. He is up all night
working on projects in his workshop; he has made a number of
extravagant purchases; he has been driving recklessly and nearly
caused a car accident. What is the most likely cause of his
symptoms?
A. Caffeinism
B. Generalized anxiety disorder
C. Antidepressant-induced mania
D. Serotonin syndrome
E. SSRI discontinuation syndrome
35. Answer & Explanation
• C. The symptoms of decreased need for sleep
and impulsivity (making extravagant
purchases, driving recklessly) lasting for a
week or more are consistent with a manic
episode. Whenever a person treated with
antidepressants develops a manic episode,
concern arises for the possibility of
antidepressant-induced mania, which
necessitates stopping the antidepressant.
35. High yield f/u: Tx for depressive
phase of BP disorder
36. A 53yom presents to your clinic for an evaluation of
long-standing anxiety. You suspect a diagnosis of OCD.
Which of the following cluster of symptoms is most
consistent with this diagnosis?
A. Discrete episodes of intense fear, palpitations, sweating, and
fear of dying
B. Excessive worry, restlessness, irritability, muscle tension,
insomnia
C. Low mood, restlessness, loss of interest, low energy, insomnia
D. Recurrent and intrusive thoughts, accompanied by repetitive
behaviors
E. Traumatic event followed by hyperarousal, re-experiencing and
avoidance
36. Answer & Explanation
• D. The core symptoms of OCD are obsessions (intrusive thoughts
that cause anxiety, e.g., fear of contamination) and compulsions
(repetitive behaviors that are meant to allay anxiety, e.g., frequent
hand washing).
Rule out the other options:
• Discrete episodes of intense fear, palpitations, sweating, and fear of
dying (Panic disorder)
• Excessive worry, restlessness, irritability, muscle tension, insomnia
(GAD)
• Low mood, restlessness, loss of interest, low energy, insomnia
(MDD)
• Traumatic event followed by hyperarousal, re-experiencing and
avoidance (PTSD)
36. High yield f/u: OCD Tx
• Exposure and response prevention = effectiveness to SSRIs.
• Pharmacotherapy: SSRIs are first-line. Some clinicians
regard clomipramine, a potently serotonergic TCA as the
gold-standard. However, its ADRs usually result in SSRIs
being tried first. Effective OCD tx often requires higher
doses of SSRIs given for longer periods of time.
• Psychotherapy: OCD also responds very well to CBT. The
classic CBT approach to OCD is called exposure and
response prevention. In this tx, the pt is exposed to a
feared situation, event, or stimulus and then prevented
from engaging in the corresponding compulsion. Family
therapy can also be important for OCD.
37. A 34yow presents to your clinic for an evaluation of
stress. She relates to you recent stressful events in her
life, such as the death of her cat, losing her job, and
facing eviction. You notice that she laughs quite a bit,
and does not appear disturbed or upset by these events.
How would you describe her affect?
A.
B.
C.
D.
E.
Apathetic
Flat
Incongruent
Labile
Perseverative
37. Answer & Explanation
• C. Incongruent – The content of her discussion
is stressful and depressing, but her outward
appearance is unconcerned or even jovial.
37. High yield f/u: Affect vs. Mood
• Affect: outward appearance of the pt’s
emotional state (how we see their mood)
• Mood: pt’s own experience of their emotional
state (it is what the pt tells you it is)
– Alexithymia: Inability to describe own
emotional state