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DIRECTIONS (Items 1-34): Each of the numbered items or incomplete statements in this section is followed by answers or completions of the statement. Select the ONE lettered answer or completion that is BEST in each case and fill in the circle containing the corresponding letter on the answer sheet. 1. Electroconvulsive treatment is most specifically therapeutic for A. B. C. D. E. 2. B. C. D. E. relaxant may potentiate the convulsive effect patient may constitutionally lack succinylcholinesterase and so stay apneic succinylcholine may precipitate a toxic psychosis muscle relaxant may cause acute hemolysis patient is resistant to the succinylcholine The following is a "absolute" contraindication to ECT A. B. C. D. E. 4. conversion disorder smile dementia major depression schizophrenia, residual type obsessive-compulsive In using the muscle relaxant succinykholine during electroconvulsive therapy, the physician must be alert to the rare complication in which the A. 3. 5. A brain tumor recent myocardial infarction pregnancy recent intracerebral hemorrhage there are no absolute contraindication to ECT The most likely diagnosis is A. B. C. D. E. Medications used right before given ETC should be administered in the following order. A. B. C. D. E. A 38-year old married woman had complained of nervousness since childhood. She also said she was sickly since her youth, with a succession of physical problems doctors often indicated were caused by her nerves or depression. She, however, believed that she had a physical problem that had not yet been discovered by the doctors. Besides nervousness, she had chest pain and had been told by a variety of medical consultants that she had a nervous heart. She also consulted doctors for abdominal pain and had been told she had a spastic colon. She had seen chiropractors and osteopaths for backaches, for pains in her extremities, and for anesthesia of her fingertips. Three months previously, she was vomiting and had chest pain and abdominal pain, and she was admitted to a hospital for a hysterectomy. Since the hysterectomy, she had had repeated anxiety attacks, fainting spells that she claimed were associated with unconsciousness that lasted more than 30 minutes, vomiting, food intolerance, weakness, and fatigue. She had been hospitalized several times for medical workups for vomiting, colitis, vomiting of blood, and chest pain. She had had a surgical procedure for an abscess of the throat. She said she felt depressed, but thought that it was all because her "hormones were not straightened out." She was still looking for a medical explanation for her physical and psychological problems. an ticholinergic, anesthetic, muscle relaxant anesthetic, muscle relaxant, anticholinergic muscle relaxant, anesthetic, anticholinergic anticholinergic, muscle relaxant, anesthetic muscle relaxant, anticholinergic, anesthetic 6. In body dysmorphic disorder A. B. C. D. E. 1 somatization disorder conversion disorder hypochondriasis dysthymic disorder pain disorder plastic surgery is usually beneficial a comorbid diagnosis is unusual anorexia nervosa may also be diagnosed 50% of patients may attempt suicide serotonin-specific drugs are effective in reducing the symptoms 7. A patient with somatbatization disorder A. B. C. D. E. 12. presents the initial physical complaints after age 30 has had physical symptoms for three months has complained of pain, gastrointestinal, sexual, and pseudoneurological symptoms, which are not explained by a know medical condition usually experiences minimal impairment in social or occupational functioning may have a false belief of being pregnant and objective signs of pregnancy, such as decreased menstrual flow or amenorrhea Patients with factitious disorder with predominantly physical signs and symptoms A. B. C. D. E. 13. Factitious disorder with predominantly physical signs and symptoms is A. 8. All the following are classified as somatoform disorders except A. B. C. D. E. 9. B. C. conversion disorder hypochondriasis somatization disorder Munchausen syndrome body dysmorphic disorder D. E. Medical disorders to be considered in a differential diagnosis of somatization disorder include A. B. C. D. E. A B. C. D. E. multiple sclerosis systemic lupus erythematosus acute intermittent porphyria hyperparathyroidism all the above Exhibitionism Fetichism Sexual Aversion Disorder Sexual Sadism None of the above 15. Rubbing up against a fully clothed woman to achieve orgasm, is considered A. B. C. D. E. somatization disorder hypochondriasis antisocial personality disorder malingering all the above 11. Factitious disorder A. B. C. D. E. under voluntary control, but the patient often denies the voluntary production of the illness also known as Munchausen syndrome frequency seen in patients with a family history of serious illness or disability frequently seen in persons employed in health care jobs characterized by all the above 14. Observing people who are naked or engaging in sexual activity is called; 10. The differential diagnosis of a factitious disorder includes A. B. C. D. E. do not usually gain admission to a hospital may take anticoagulants to simulate bleeding disorders are usually easy to manage in the hospital do not display symptoms of pseudologia phantastica usually receive the co-diagnosis of schizotypal personality disorder usually begin in childhood are best treated with psychoactive drug; usually have a good prognosis are synonymous with Ganser's syndrome may occur by proxy 2 an orgasm disorder a paraphilia a gender identity disorder a male erectile disorder none of the above renewed his complaints about “suicidal thoughts" and “hearing voices.” It was the opinion of the ward staff members that the patient was not truly psychotic but merely feigned his symptoms whenever the subject of the disposition of his case came up. They thought that he wanted to remain in the hospital primarily so that he could bully the other patients and be a big man' on the ward. 16. Sexual Aversion Disorder A. B. C. D. E. Is characterized by absence of sexual fantasies and of desire of sexual activity. Is a farm of paraphilias Is all the time associated with homosexuality Is all the time detected in females Is characterized by an aversion to and avoidance of genital sexual contact with a sexual partner The diagnosis of this case should be A. 17. A muscular 24-year-old man presented himself to the admitting office of a state hospital. He told the admitting physician that he had taken thirty 200 mg tablets of chlorpromazine (Thorazine) in the bus on the way over to the hospital. After receiving medical treatment for the "suicide attempt," he was transferred to the inpatient ward. B. C. D. E. Factitious Disorder with Predominantly psychological signs and symptoms Munchausen Syndrome Schizophrenia Paranoid Type Somatization Disorder Somatoform Disorder NOS 18. Male erectile disorder is also called On mental status examination the patient told a fantastic story about his father, a famous surgeon, who had a woman he was operating on die in surgery and who was then killed by the husband of the woman. The patient then stalked his father's murderer several thousand miles across the United States and, when he found him, was prevented from killing him, at the last moment, by the timely arrival of the man's 94-year-old grandmother. He also related several other intriguing stories involving his $64,000 sports car, which had a 12-cylinder diesel engine, and about his children, two sets of identical triplets. AIR those stories had a grandiose tinge, and none of them could be confirmed. The patient claimed that he was hearing voices, as on television or in a dream. He answered affirmatively, to questions about thought control, thought broadcasting, and other Schneiderian first-rank symptoms; he also claimed depression. He was oriented and alert and had a good range of information except that he kept insisting that it was the Germans (not the Russians) who had invaded Afghanistan. There was not evidence of any associated features of mania or depression, and the patient did not seem elated, depressed, or irritable when he related the stories. A. B. C. D. E. Impotence Male orgasmic disorder Frotteurism Partialism none of the above 19. Vaginismus is characterized by A. B. C. D. E. Involuntary muscle constriction of the outer third of the vagina Fantasies involving harm to others Persistent genital pain occurring before, during, or after intercourse Sexual masochism All of the above 20. All of the following is characteristic of the orgasmic phase EXCEPT A. B. C. D. E. On the ward the patient bullied the other patients and took food and cigarettes from them. He was reluctant to be discharged, and, whenever the subject of his discharge was brought up, he 3 The male orgasm is associated with four or five rhythmic spasms of the prostate, seminal vesicles, vas and urethra Involuntary contraction of the internal and external sphincters Hypotension Facial grimacing Carpopedal spasm 21. The following is correct about the resolution phase in the female and male sexual response cycle EXCEPT A. B. C. D. E. 26. A married man with a chief complaint of premature ejaculation is best treated with A. B. C. D. E. After orgasm males do not have refractory periods Refractory period usually does not exist in females Resolution consist of the disgorgement of blood from the genitalia If orgasm occurs, resolution is rapid resolution through orgasm is characterized by a subjective feeling of well-being 27. Premature ejaculation is associated with A. B. C. 22. The following conditions have classified among the gender identity disorders EXCEPT A. B. C. D. E. D. E. Turner's Syndrome Klinefelter's Syndrome Congenital virilizing adrenal hyperplasia Androgen insensitive Syndrome Klismaphilia A. B. C. D. E. Partialism Coprophilia Urophilia Hypoxyphilia Nymphomania C. D. Gender identity disorder in children Gender identity disorder is adolescents and adults Transsexualism Gender identity disorder NOS She left the hospital against medical advice, but was shortly admitted to another hospital with opisthotonos and a history of having been bitten by a sick squirrel. 25. Orgasm is characterized by all the following EXCEPT A. B. C. D. E. usually try to maintain the gender role assigned by biological sex are usually adults usually assert that they will grow up to be members of the opposite sex usually desire sex-change operations usually achieve sexual excitement when cross-dressing 29. A young nursing student was admitted to the hospital for severe headache, nausea, vomiting, stiff neck, and sudden development of a dilated, light fired, right pupil. Eyelid ptosis and extraocular muscle weakness were not present. It was later discovered she had put an anticholinergic drug in her eye and that she had a history of multiple hospitalizations for obscure disorders. At one time, she had caused skin abscesses and bacteremia by injecting urine subcutaneously. 24. In regard to gender identify disorder the DSM IV include the following diagnostical categories EXCEPT A. B. stress negative cultural conditioning more frequency among college-educated men some general medical factors all the above 28. Persons with gender identity disorder 23. Which of the following conditions IS NOT A PARAPHILIA A. B. C. D. E. antianxiety agents psychoanalysis squeeze techniques cognitive therapy none of the above involuntary contractions of the anal sphincter carpopedal spasm absence of contractions of the uterus blood pressure rise slight clouding of consciousness The MOST likely diagnosis is A. B. C. D. E. 4 Somatization disorder NOS Conversion disorder Briquet syndrome Hypochondriasis Factitious disorder with physical symptoms 30. A 46-year-old woman was referred by her husband's psychiatric for consultation. In the course of discussing certain marital conflicts that the husband was having with his wife, he had described attacks of dizziness that his wife experienced and that left her incapacitated, In consultation the wife described being overcome with feelings of extreme dizziness, accompanied by slight nausea, four or five nights a week. During the attacks the room around her would take on a “shimmering” appearance, and she would have the feeling that she was floating and unable to keep her balance. Inexplicably, the attacks almost always occurred at about 4:00 pm. She usually had to lie down on a couch and often did not feel better until 7:00 or 8:00 pm. After recovering, she generally spent the rest of the evening watching television, more often than not, she fell asleep in the living room, not going to bed in the bedroom until 2:00 or 3:00 am. EXAM CONTINUES – NEXT PAGE PLEASE The patient had been pronounced physically fit her internist, a neurologist, and an ear, nose, and throat specialist on more than one occasion. Hypoglycemia had been ruled out by glucose tolerance tests. When asked about her marriage, the pmt described her husband as a tyrant, frequently demanding and verbally abusive of her and their four children. She admitted that she dreaded his arrival home from work each day, knowing that he would comment that the house was a mess and the dinner, if prepared, not to his liking. Since the onset of her attacks, when she was unable to make dinner, he and the four children would go to McDonald's or the local pizza parlor. After that he would settle in to watch a ball game on television in the bedroom, and their conversation was minimal. In spite of their troubles, the patient claimed that she loved and needed her husband very much. The most probable diagnosis in this case should be A. B. C. D. E. Conversion disorder Munchausen's syndrome Ganser's syndrome Briquets syndrome Hypochondriasis 5 31. The patient was a happily married 23-year-old investment counselor who had reluctantly agreed to see a psychiatrist, an old friend of her husband's. She told the psychiatrist that she did not think she needed to see a psychiatrist, because her problem was "these ugly lines on my forehead." The psychiatrist asked, "What lines?" The patient pointed to the frown lines above her nose, which to the psychiatrist seemed no more pronounced than they are on the foreheads of most people her age. The psychiatrist asked about other problems in the patient's life and learned that her concern with her appearance was not affecting her ability to work but that she had started to avoid social situations because she did not want people looking at her blemish. The patient acknowledged being upset and unhappy about her problem but denied having a persistently depressed mood or any associated symptoms of depression. The most likely diagnosis in this case is A. B. C. D. E. The patient continued: "It's horrible, isn't it? I mean, I don't have to be the most gorgeous girl on earth, but I also don't want to be disfigured." Somatization disorder Body dysmorphic disorder Pain disorder Undifferentiated somatoform disorder Somatoform disorder NOS The psychiatrist asked, “What makes you think it looks so awful? Everyone has those lines.” EXAM CONTINUES - NEXT PAGE PLEASE “C’mon. I appreciate your trying to make me feel better, but I can see what I look like.” “What do you look like?” It's horrible. Everybody notices. They make me look so old I'm we my husband is turned off. I don't know what I would ever do if he left me. I have started to wear all this heavy makeup to hide them, but try to hide something like this." Let me ask you this. Most of us are sensitive about our appearance, and sometimes we exaggerate some minor imperfection. Do you think you may be doing that?" The patient sighed. “My husband has been saying the same thing. I think about that, and sometimes I can convince myself that I am too concerned about something that is really very minor. But then I go to the mirror, and there it is. Can't you help me convince my husband and I should see if a plastic surgeon can do something about it?” “Before we get into that, how long have you been bothered by the lines?” “I’m not sure, but I didn't pay any attention to it until a few months ago. A friend at work mentioned that she had seen a doctor for a bad sunburn and told me I had better be mirror and kept noticing the lines.” 6 32. A 39-year. woman was referred for psychiatric evaluation after a brief hospitalization for complaints of intermittent numbness in her arms and the right side of her face. Extensive neurological and neurosurgical evaluation revealed stenosis of the outlets of several cervical vertebrae; intermittently compromised nerve roots were thought to account for the physical symptoms. The patient, an artist who composed large structures from various work materials, was advised by her physicians to stop for the next several months all lifting, reaching, raising her arms, and other strenuous activities requisite to her work. She had felt despondent for more than two months, with episodes of tearfulness, anxiety, and increased irritability. She continued to supervise her assistants but was increasingly uninterested in work She had no sleep or appetite change, but her libido was diminished. She was still able to enjoy music. The patient had no prior personal or familial history of a mood disorder. 33. According to DSM-IV if an individual was expected to weigh 120 lbs. but currently weighs 100 lbs., refuses to eat, fears gaining weight, and binges and purges daily, she would diagnostic criteria for? A. B. C. D. B. 34. teacher health care worker police officer banker waitress EXAM CONTINUES - NEXT PAGE PLEASE The clinical diagnosis in this case should be A. B. C. D. E. A leading predisposing factor in the development of factitious disorder with predominantly physical signs and symptoms is employment as a A. B. C. D. E. The identified stressors in her case were the physical illness and the directive to minimize for an indefinite interval the use of her arms. The net result was to preclude the patient's ability to continue her artistic endeavors, which were crucial to her sense of self. In response, she experienced the emergence of a depressive constellation with less than a fall vegetative set of symptoms. The clinician diagnosed adjustment disorder with depressed mood. Intervention was directed to (1) clarification with the neurosurgeon of the likely course and necessary treatment of the outlet problem and (2) several sessions with the patient to explore her responses to and perceptions of the changes in her life imposed by the neurological problem. bulimia nervosa anorexia nervosa eating disorder NOS Axis III coding all the above Adjustment disorder with depressed mood Pain disorder Conversion disorder Somatization disorder Malingering 7 DIRECTIONS (Items 35.58): The questions below consist of lettered headings followed by a list of numbered words or phrases. For each numbered word or phrase, select the one lettered heading that is most closely associated with it. Each heading may be used once, more than once, or not at all. QUESTIONS 43 - 47 A. B. C. D. Desire phase Excitement phase Orgasm phase Resolution phase 43. Vaginal lubrication QUESTIONS 35 - 38 44. Orgasmic platform A. B. C. Conversion disorder Pain disorder Somatization disorder 45. Testes increase in size by 50 percent 46. Slight clouding of consciousness 35. La belle indifference 47. Detumescence 36. Alexithymia 37. Briquet's syndrome QUESTIONS 48-51 38. Astasia-abasia A. B. C. D. E. QUESTIONS 39 - 42 A. B. C. D. Somataform disorder NOS Undifferentiated somatoform disorder Both Neither Klinefelter's syndrome Turner's syndrome Congenital virilizing adrenal hyperplasia True hermaphroditism Androgen insensitivity syndrome 48. A 17-year-old girl presented to a clinic with primary amenorrhea and no development of secondary sex characteristics. She was short in stature and had a webbed neck 39. Fatigue, loss of appetite, gastrointestinal or urinary complaints 49. A baby was born with ambiguous external genitalia. Further evaluation revealed that both ovaries and testes were present. 40. Pseudocyesis 41. A disorder involving multiple somatic delusions 50. A baby was born with ambiguous external genitalia. Further evaluation revealed that ovaries, a vagina, and a uterus were normal and intact . No tests were found. 42. Symptoms can be fully explained by a known general medical condition 51. A buccal smear from a phenotypically female patient revealed that the patient was XY. A further workup revealed undescended tests. 52. A tall, thin man who presented for infertility problems was found to be XXY. EXAM CONTINUES - NEXT' PAGE PLEASE 8 QUESTIONS 53 - 58 A. B. C. D. 53. Hypochondriasis Somatization disorder Both Neither Is found approximately equal in men and women 54. Peak incidence during the 40's or 50's 55. Chronic debilitating condition 56. Includes disease conviction or disease fear 57. Associated with anhedonia 58. Hallucinations may be present DIRECTIONS (ITEMS 59 - 61): Each of the following statements is either true or false. On the answer sheet, fill in the circle containing A. B. If the statement is True If the statement is False 59. Compared to adolescent onset, adult onset of eating disorders is associated with a history of more negative life events and poorer prognosis. 60. Mitchell (1990) found that a history of substance abuse had no affect on treatment outcome of eating disorder patients at a 2 to 5 year follow-up. 61. According to Beckman & Burns (1990) and Pope & Hudson (1992) there is a strong link between eating disorders and sexual abuse history. END OF EXAM 9 ANSWERS 1. C 2. B 3. E 4. A 5. A 6. E 7. C 8. D 9. E 10. E 11. E 12. B 13. E 14. E 15. B 16. E 17. A 18. A 19. A 20. C 21. A 22. E 23. E 24. C 25. C 26. C 27. E 28. C 29. E 30. A 31. B 32. A 33. B 34. B 35. A 36. B 37. C 38. A 39. B 40. A 41. D 42. D 43. B 44. B 45. B 46. C 47. D 48. B 49. D 50. C 51. E 52. A 53. A 54. D 55. B 56. A 57. 58. 59. 60. 61. 10 C D T T F