First-episode psychosis management US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for First-episode psychosis management. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
First-episode psychosis management US Medical PG Question 1: A 26-year-old man is brought to the emergency department by his wife because of bizarre and agitated behavior for the last 6 weeks. He thinks that the NSA is spying on him and controlling his mind. His wife reports that the patient has become withdrawn and at times depressed for the past 3 months. He lost his job because he stopped going to work 4 weeks ago. Since then, he has been working on an invention that will block people from being able to control his mind. Physical and neurologic examinations show no abnormalities. On mental status examination, he is confused and suspicious with marked psychomotor agitation. His speech is disorganized and his affect is labile. Which of the following is the most likely diagnosis?
- A. Brief psychotic disorder
- B. Schizophreniform disorder (Correct Answer)
- C. Schizotypal personality disorder
- D. Schizophrenia
- E. Delusional disorder
First-episode psychosis management Explanation: ***Schizophreniform disorder***
- The patient's symptoms, including **delusions** (fixed false beliefs that the NSA is spying and controlling his mind), **disorganized speech**, and **agitated behavior**, are consistent with a psychotic disorder.
- The duration of active psychotic symptoms (6 weeks), which is more than 1 month but less than 6 months, fits the diagnostic criteria for **schizophreniform disorder**.
- The prodromal phase (withdrawn and depressed for 3 months) plus the active phase does not yet meet the 6-month requirement for schizophrenia.
*Brief psychotic disorder*
- This disorder is characterized by a sudden onset of psychotic symptoms lasting less than 1 month, followed by a full return to premorbid functioning.
- The patient's active psychotic symptoms have persisted for 6 weeks, exceeding the maximum duration for brief psychotic disorder.
*Schizotypal personality disorder*
- This disorder primarily involves a pervasive pattern of social and interpersonal deficits marked by acute discomfort with close relationships, as well as cognitive or perceptual distortions and eccentricities.
- While there might be odd beliefs or magical thinking, it does not typically involve the persistent and severe delusions and disorganized speech seen in this case.
- This is a personality disorder, not a psychotic disorder.
*Schizophrenia*
- Schizophrenia requires continuous signs of disturbance for at least 6 months, which includes at least 1 month of active-phase symptoms (delusions, hallucinations, disorganized speech).
- The patient's total duration of illness (3 months of prodromal symptoms plus 6 weeks of active symptoms) totals approximately 4.5 months, which is less than the 6-month minimum duration required for a diagnosis of schizophrenia.
*Delusional disorder*
- The primary feature of delusional disorder is the presence of one or more delusions for at least 1 month, without other prominent psychotic symptoms such as disorganized speech or behavior.
- This patient exhibits prominent **disorganized speech**, **labile affect**, and **disorganized behavior** (bizarre invention work), which are not characteristic of delusional disorder.
- Functioning is more impaired than typically seen in delusional disorder.
First-episode psychosis management US Medical PG Question 2: A 45-year-old obese man is evaluated in a locked psychiatric facility. He was admitted to the unit after he was caught running through traffic naked while tearing out his hair. His urine toxicology screening was negative for illicit substances and after careful evaluation and additional history, provided by his parents, he was diagnosed with schizophrenia and was treated with aripiprazole. His symptoms did not improve after several dosage adjustments and he was placed on haloperidol, but this left him too lethargic and slow and he was placed on loxapine. After several dosage adjustments today, he is still quite confused. He describes giant spiders and robots that torture him in his room. He describes an incessant voice screaming at him to run away. He also strongly dislikes his current medication and would like to try something else. Which of the following is indicated in this patient?
- A. Haloperidol
- B. Olanzapine
- C. Chlorpromazine
- D. Fluphenazine
- E. Clozapine (Correct Answer)
First-episode psychosis management Explanation: ***Clozapine***
- This patient has **treatment-resistant schizophrenia**, indicated by a lack of response to multiple trials of antipsychotics, including aripiprazole (atypical), haloperidol (typical), and loxapine (atypical).
- **Clozapine** is the only antipsychotic proven effective for treatment-resistant schizophrenia, significantly reducing psychotic symptoms and suicidality.
*Haloperidol*
- Haloperidol is a **first-generation antipsychotic** that the patient has already tried and found to be too sedating and slow.
- Continuing with haloperidol would likely result in persistent side effects and inadequate symptom control given his prior negative experience.
*Olanzapine*
- Olanzapine is a **second-generation atypical antipsychotic**; however, it is not typically indicated as a first-line treatment for treatment-resistant schizophrenia after failure of multiple agents.
- While effective for schizophrenia, it would be less effective than clozapine in a patient who has failed several previous antipsychotic trials.
*Chlorpromazine*
- Chlorpromazine is a **first-generation antipsychotic** that carries a higher risk of sedation, extrapyramidal symptoms, and anticholinergic side effects.
- It is unlikely to be more effective than haloperidol, which the patient already found too sedating and slow, and would not be the preferred choice for treatment-resistant schizophrenia.
*Fluphenazine*
- Fluphenazine is a **first-generation antipsychotic** with potent dopamine D2 receptor blockade, often leading to significant extrapyramidal side effects.
- Like other first-generation antipsychotics, it is not indicated as the next step for treatment-resistant schizophrenia after failure of multiple trials.
First-episode psychosis management US Medical PG Question 3: Two dizygotic twins present to the university clinic because they believe they are being poisoned through the school's cafeteria food. They have brought these concerns up in the past, but no other students or cafeteria staff support this belief. Both of them are average students with strong and weak subject areas as demonstrated by their course grade-books. They have no known medical conditions and are not known to abuse illicit substances. Which statement best describes the condition these patients have?
- A. A trial separation is likely to worsen symptoms.
- B. The disorder is its own disease entity in DSM-5.
- C. Antipsychotic medications are rarely beneficial.
- D. Can affect two or more closely related individuals. (Correct Answer)
- E. Cognitive behavioral therapy is a good first-line.
First-episode psychosis management Explanation: ***Can affect two or more closely related individuals.***
- The shared delusional belief in **folie à deux**, also known as **shared psychotic disorder**, typically occurs in two or more people who are closely associated.
- In this case, the **dizygotic twins** sharing the same delusional belief about being poisoned from cafeteria food fits this pattern.
*A trial separation is likely to worsen symptoms.*
- **Separating the individuals** involved in **folie à deux** is often a crucial step in treatment, as it can help break the cycle of shared delusion and allow for individual therapy.
- Separation typically IMPROVES rather than worsens symptoms by removing the reinforcement of the shared delusion.
*The disorder is its own disease entity in DSM-5.*
- In the **DSM-5**, **folie à deux** is no longer considered a separate diagnostic category.
- Instead, it is classified under **Other Specified Schizophrenia Spectrum and Other Psychotic Disorder** or **Unspecified Schizophrenia Spectrum and Other Psychotic Disorder**, with the specific context of shared delusion noted.
*Antipsychotic medications are rarely beneficial.*
- **Antipsychotics** are actually commonly used in treating folie à deux, particularly for the **primary individual** who initially developed the delusion.
- They can be an important component of treatment, often combined with separation and psychotherapy.
*Cognitive behavioral therapy is a good first-line.*
- **Cognitive Behavioral Therapy (CBT)** can be beneficial, particularly after separation, to help individuals challenge and reframe their delusional beliefs.
- However, the **first-line intervention** for shared psychotic disorder is **separation of the involved individuals**, followed by individual therapy (which may include CBT) and medication as needed.
First-episode psychosis management US Medical PG Question 4: A 20-year-old male is involuntarily admitted to the county psychiatric unit for psychotic behavior over the past three months. The patient's mother explained to the psychiatrist that her son had withdrawn from family and friends, appeared to have no emotions, and had delusions that he was working for the CIA. When he spoke, his sentences did not always seem to have any connection with each other. The mother finally decided to admit her son after he began stating that he "revealed too much information to her and was going to be eliminated by the CIA." Which of the following diagnoses best fits this patient's presentation?
- A. Schizophrenia
- B. Brief psychotic disorder
- C. Schizophreniform disorder (Correct Answer)
- D. Schizoid personality disorder
- E. Schizotypal personality disorder
First-episode psychosis management Explanation: ***Schizophreniform disorder***
- The patient exhibits classic symptoms of **psychosis**, including delusions, disorganized speech, flat affect, and social withdrawal, which are characteristic of schizophrenia spectrum disorders.
- The duration of symptoms (3 months) fits the criteria for **schizophreniform disorder**, which is when psychotic symptoms last between 1 month and 6 months.
*Schizophrenia*
- Schizophrenia requires symptoms to be present for at least **6 months**, including at least 1 month of active-phase symptoms.
- While this patient's symptoms are consistent with psychotic disorder, the **duration criteria** for schizophrenia have not yet been met.
*Brief psychotic disorder*
- Brief psychotic disorder is characterized by symptoms lasting from **1 day to 1 month**, with eventual full return to premorbid functioning.
- The patient's symptoms have persisted for **3 months**, exceeding the maximum duration for brief psychotic disorder.
*Schizoid personality disorder*
- This disorder is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- While the patient exhibits social withdrawal, the presence of **delusions, disorganized speech, and flat affect** indicates a psychotic disorder, not merely a personality disorder.
*Schizotypal personality disorder*
- Schizotypal personality disorder involves pervasive social and interpersonal deficits with **cognitive or perceptual distortions** and eccentric behaviors.
- While it can involve odd beliefs, it does not typically include the prominent, fixed, and systematized **delusions and disorganized speech** seen in this patient's presentation.
First-episode psychosis management US Medical PG Question 5: A 30-year-old man comes to the clinic with complaints of increased frequency of urination, especially at night, for about a month. He has to wake up at least 5-6 times every night to urinate and this is negatively affecting his sleep. He also complains of increased thirst and generalized weakness. Past medical history is significant for bipolar disorder. He is on lithium which he takes regularly. Blood pressure is 150/90 mm Hg, pulse rate is 80/min, respiratory rate is 16/min, and temperature is 36°C (96.8°F). Physical examination is normal. Laboratory studies show:
Na+: 146 mEq/L
K+: 3.8 mEq/L
Serum calcium: 9.5 mg/dL
Creatinine: 0.9 mg/dL
Urine osmolality: 195 mOsm/kg
Serum osmolality: 305 mOsm/kg
Serum fasting glucose: 90 mg/dL
Which of the following is the best initial test for the diagnosis of his condition?
- A. Serum ADH level
- B. MRI scan of brain
- C. CT thorax
- D. Chest X-ray
- E. Water deprivation test (Correct Answer)
First-episode psychosis management Explanation: ***Water deprivation test***
- The patient presents with **polyuria**, **polydipsia**, and **nocturia**, along with elevated **serum osmolality** and low **urine osmolality**, indicating a probable diagnosis of **diabetes insipidus**. The **water deprivation test** is the gold standard for differentiating between central and nephrogenic diabetes insipidus by assessing the kidney's response to fluid restriction and subsequently to desmopressin.
- Given the history of **lithium use**, **nephrogenic diabetes insipidus** is a strong possibility, as lithium can impair the kidney's ability to respond to ADH. The water deprivation test will help clarify the type of diabetes insipidus.
*Serum ADH level*
- While **ADH levels** can be informative, they are often difficult to interpret in isolation and can vary based on hydration status; a single measurement might not be diagnostic.
- The diagnosis of diabetes insipidus is primarily clinical and biochemical, with ADH levels used as an adjunct rather than a primary diagnostic test.
*MRI scan of brain*
- An **MRI of the brain** would be considered if **central diabetes insipidus** is highly suspected, as it could identify structural abnormalities of the hypothalamus or pituitary gland.
- However, since the patient is on **lithium**, which commonly causes nephrogenic diabetes insipidus, evaluating renal response to dehydration and possibly ADH is the more immediate and appropriate next step before imaging.
*CT thorax*
- A **CT thorax** is not indicated in the initial workup for diabetes insipidus, as the patient's symptoms are not suggestive of a pulmonary or thoracic etiology.
- This test would be used to investigate conditions like sarcoidosis or lung cancer, which can rarely cause central diabetes insipidus through ADH suppression or ectopic ADH production, but these are not the primary concerns here.
*Chest X-ray*
- A **chest X-ray** is generally not part of the initial diagnostic workup for diabetes insipidus.
- It would only be considered if there were respiratory symptoms or a suspicion of conditions like **sarcoidosis** or **tuberculosis** that could involve the pituitary, but there are no such indications in this patient.
First-episode psychosis management US Medical PG Question 6: A 34-year-old woman presents with recurrent panic attacks that have been worsening over the past 5 weeks. She also says she has been seeing things that are not present in reality and is significantly bothered by a short attention span which has badly affected her job in the past 6 months. No significant past medical history. No current medications. The patient is afebrile and vital signs are within normal limits. Her BMI is 34 kg/m2. Physical examination is unremarkable. The patient is prescribed antipsychotic medication. She expresses concerns about any effects of the new medication on her weight. Which of the following medications would be the best course of treatment in this patient?
- A. Ziprasidone (Correct Answer)
- B. Clozapine
- C. Chlorpromazine
- D. Olanzapine
- E. Clonazepam
First-episode psychosis management Explanation: ***Ziprasidone***
- **Ziprasidone** causes minimal **weight gain** and has a lower risk of metabolic side effects compared to other antipsychotics, making it a good choice for a patient concerned about weight, especially with a BMI of 34 kg/m2.
- It treats psychotic symptoms like hallucinations and can help manage anxiety associated with panic attacks.
*Clozapine*
- **Clozapine** is known for causing significant **weight gain** and metabolic disturbances, which would be a concern for this patient.
- It is typically reserved for treatment-resistant schizophrenia due to its potential for serious side effects like **agranulocytosis**.
*Chlorpromazine*
- **Chlorpromazine** is a first-generation antipsychotic associated with a high risk of **extrapyramidal symptoms** (EPS) and sedation.
- It can also lead to moderate **weight gain** and is generally not preferred as a first-line treatment if metabolic concerns are present.
*Olanzapine*
- **Olanzapine** is associated with a high risk of **weight gain** and metabolic syndrome, which would exacerbate the patient's existing weight concerns.
- While effective for psychosis, its metabolic side effect profile makes it a less suitable choice in this scenario.
*Clonazepam*
- **Clonazepam** is a **benzodiazepine** primarily used for anxiety and panic attacks, but it is not an antipsychotic.
- It would not address the patient's psychotic symptoms (seeing things not present in reality), which require an antipsychotic medication.
First-episode psychosis management US Medical PG Question 7: A 23-year-old male presents to the emergency department. He was brought in by police for shouting on a subway. The patient claims that little people were trying to kill him, and he was acting within his rights to defend himself. The patient has a past medical history of marijuana and IV drug use as well as multiple suicide attempts. He is currently homeless. While in the ED, the patient is combative and refuses a physical exam. He is given IM haloperidol and diphenhydramine. The patient is transferred to the inpatient psychiatric unit and is continued on haloperidol throughout the next week. Though he is no longer aggressive, he is seen making "armor" out of paper plates and plastic silverware to defend himself. The patient is switched onto risperidone. The following week the patient is still seen gathering utensils, and muttering about people trying to harm him. The patient's risperidone is discontinued. Which of the following is the best next step in management?
- A. Olanzapine
- B. Thioridazine
- C. Clozapine (Correct Answer)
- D. Chlorpromazine
- E. Fluphenazine
First-episode psychosis management Explanation: ***Clozapine***
- This patient has demonstrated **treatment-resistant schizophrenia**, evidenced by persistent positive symptoms despite trials of haloperidol and risperidone, necessitating a trial of clozapine.
- **Clozapine** is an atypical antipsychotic that is uniquely effective for treatment-resistant schizophrenia, especially in patients with a history of **suicidality**.
*Olanzapine*
- While **olanzapine** is an effective atypical antipsychotic, it is generally considered a first-line or second-line agent, and this patient has already failed two antipsychotics (haloperidol and risperidone).
- Its efficacy in **treatment-resistant cases** is not superior to clozapine.
*Thioridazine*
- **Thioridazine** is a first-generation antipsychotic with a high risk of **QT prolongation** and other cardiac side effects, making it a less safe option.
- It is not typically reserved for **treatment-resistant schizophrenia** due to its side effect profile and lack of superior efficacy compared to newer agents.
*Chlorpromazine*
- **Chlorpromazine** is another first-generation antipsychotic that is not indicated for **treatment-resistant schizophrenia** at this stage.
- It carries significant anticholinergic and sedative side effects, similar to thioridazine, and is not significantly more effective than haloperidol for this indication.
*Fluphenazine*
- **Fluphenazine** is a potent first-generation antipsychotic, often available as a **depot injection** for adherence issues.
- However, it is not considered the best next step for **treatment-resistant schizophrenia** after failure of two different classes of antipsychotics.
First-episode psychosis management US Medical PG Question 8: A 20-year-old man comes to the physician because of decreasing academic performance at his college for the past 6 months. He reports a persistent fear of “catching germs” from his fellow students and of contracting a deadly disease. He finds it increasingly difficult to attend classes. He avoids handshakes and close contact with other people. He states that when he tries to think of something else, the fears “keep returning” and that he has to wash himself for at least an hour when he returns home after going outside. Afterwards he cleans the shower and has to apply disinfectant to his body and to the bathroom. He does not drink alcohol. He used to smoke cannabis but stopped one year ago. His vital signs are within normal limits. He appears anxious. On mental status examination, he is oriented to person, place, and time. In addition to starting an SSRI, which of the following is the most appropriate next step in management?
- A. Cognitive-behavioral therapy (Correct Answer)
- B. Psychodynamic psychotherapy
- C. Motivational interviewing
- D. Interpersonal therapy
- E. Group therapy
First-episode psychosis management Explanation: **Cognitive-behavioral therapy**
- **Cognitive-behavioral therapy (CBT)**, specifically **Exposure and Response Prevention (ERP)**, is the most effective psychotherapy for **obsessive-compulsive disorder (OCD)**, which this patient's symptoms strongly suggest.
- CBT helps patients challenge distorted thoughts and gradually expose themselves to feared situations while preventing compulsive rituals, thus breaking the cycle of obsessions and compulsions.
*Psychodynamic psychotherapy*
- This therapy focuses on **unconscious conflicts** and **past experiences** to understand current symptoms.
- While it can be helpful for some mental health conditions, it is generally **less effective** than CBT for the specific, highly ritualized symptoms of OCD.
*Motivational interviewing*
- **Motivational interviewing** is a patient-centered counseling style designed to address **ambivalence about change** and enhance intrinsic motivation.
- It is often used in substance abuse or lifestyle changes, but it does not directly teach coping skills for OCD symptoms or address the underlying thought patterns.
*Interpersonal therapy*
- **Interpersonal therapy (IPT)** focuses on the patient's **current interpersonal relationships** and social functioning.
- While social difficulties can arise from OCD, IPT does not directly target the obsessions and compulsions that are central to the disorder.
*Group therapy*
- **Group therapy** can provide support and a sense of community, but for a severe condition like OCD, **individual therapy** (especially CBT/ERP) is typically recommended first due to the highly individualized nature of obsessions and compulsions.
- It may be a complementary approach, but usually not the most appropriate initial next step given the intensity of the patient's symptoms.
First-episode psychosis management US Medical PG Question 9: A 21-year-old man presents to an outpatient psychiatrist with chief complaints of fatigue and “hearing voices.” He describes multiple voices which sometimes call his name or say nonsensical things to him before he falls asleep at night. He occasionally awakes to see “strange people” in his room, which frighten him but then disappear. The patient is particularly worried by this because his uncle developed schizophrenia when he was in his 20s. The patient also thinks he had a seizure a few days ago, saying he suddenly fell to the ground without warning, though he remembers the episode and denied any abnormal movements during it. He is in his 3rd year of college and used to be a top student, but has been getting C and D grades over the last year, as he has had trouble concentrating and fallen asleep during exams numerous times. He denies changes in mood and has continued to sleep 8 hours per night and eat 3 meals per day recently. Which of the following medications will be most beneficial for this patient?
- A. Haloperidol
- B. Valproic acid
- C. Risperidone
- D. Modafinil (Correct Answer)
- E. Levetiracetam
First-episode psychosis management Explanation: ***Modafinil***
- This patient presents with **narcolepsy**, characterized by the **classic tetrad**: excessive daytime sleepiness (falling asleep during exams), **cataplexy** (sudden fall without loss of consciousness or abnormal movements), **hypnagogic hallucinations** (hearing voices before sleep), and **hypnopompic hallucinations** (seeing people upon awakening).
- The hallucinations are **not true psychotic symptoms** but rather dream-like phenomena occurring at sleep-wake transitions, which are common in narcolepsy.
- **Modafinil** is a first-line **wakefulness-promoting agent** that treats the excessive daytime sleepiness and improves alertness, addressing the primary pathology.
- The patient's family history of schizophrenia is a red herring; his symptoms are explained by narcolepsy, not a primary psychotic disorder.
*Risperidone*
- Risperidone is an **atypical antipsychotic** used for schizophrenia and other psychotic disorders.
- This patient does **not have a primary psychotic disorder**—the hallucinations are hypnagogic/hypnopompic phenomena associated with narcolepsy, not true psychotic hallucinations.
- Using an antipsychotic would be inappropriate and could **worsen daytime sleepiness** due to sedating effects, exacerbating the patient's core problem.
*Haloperidol*
- Haloperidol is a **first-generation antipsychotic** with significant risk of **extrapyramidal side effects**.
- Like risperidone, it would be inappropriate here as the patient does not have a psychotic disorder, and it would worsen sedation and daytime sleepiness.
*Valproic acid*
- Valproic acid is a **mood stabilizer and anticonvulsant** used for bipolar disorder and seizure disorders.
- The described "seizure" event is actually **cataplexy** (preserved consciousness, no abnormal movements), not a true seizure, so an anticonvulsant is not indicated.
- It would not address the narcolepsy symptoms and can cause sedation.
*Levetiracetam*
- Levetiracetam is an **anticonvulsant** medication.
- The patient's description (remembering the episode, no abnormal movements) is inconsistent with a seizure and consistent with **cataplexy**, which is treated by addressing the underlying narcolepsy, not with anticonvulsants.
First-episode psychosis management US Medical PG Question 10: A 23-year-old woman is brought to the physician by her father because of strange behavior for the past 6 months. The father reports that his daughter has increasingly isolated herself in college and received poor grades. She has told her father that aliens are trying to infiltrate her mind and that she has to continuously listen to the radio to monitor these activities. She appears anxious. Her vital signs are within normal limits. Physical examination shows no abnormalities. Neurologic examination shows no focal findings. Mental status examination shows psychomotor agitation. She says: “I can describe how the aliens chase me except for my car which is parked in the garage. You know, the sky is beautiful today. Why does my mother have a cat?” Which of the following best describes this patient's thought process?
- A. Circumstantial speech
- B. Clang associations
- C. Flight of ideas
- D. Thought-blocking
- E. Loose associations (Correct Answer)
First-episode psychosis management Explanation: ***Loose associations***
- This is characterized by a **lack of logical connection** between thoughts or ideas, leading to a disorganized and incoherent flow of speech. The patient's statements about aliens, her car, the sky, and her mother's cat are **unrelated and lack a clear thematic thread**.
- It is a key feature of **thought disorganization** and is commonly seen in psychotic disorders like **schizophrenia**.
*Circumstantial speech*
- This involves including a **multitude of unnecessary details** before finally arriving at the point or answering the question.
- While the patient's speech is disorganized, it does not demonstrate the characteristic meandering yet goal-directed nature of circumstantiality.
*Clang associations*
- This refers to the **association of words based on their sound** rather than their meaning, often involving rhyming or alliteration.
- The patient's statements do not exhibit a pattern of rhyming or sound-based word choices.
*Flight of ideas*
- This is a rapid, continuous progression from one thought to another, with thoughts often **connected by tangential associations** but still having some discernable link.
- Although the patient's thoughts shift rapidly, the connections are not simply tangential; they are largely absent, suggesting a more severe form of disorganization than flight of ideas typically entails.
*Thought-blocking*
- This is an **abrupt cessation of thought or speech** in the middle of a sentence, often followed by a new and unrelated thought.
- The patient's speech flows continuously, albeit incoherently, without sudden stops or breaks.
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