Violence risk assessment in psychosis US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Violence risk assessment in psychosis. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Violence risk assessment in psychosis US Medical PG Question 1: A 23-year-old man presents to the emergency department with a chief complaint of being assaulted on the street. The patient claims that he has been followed by the government for quite some time and that he was assaulted by a government agent but was able to escape. He often hears voices telling him to hide. The patient has an unknown past medical history and admits to smoking marijuana frequently. On physical exam, the patient has no signs of trauma. When interviewing the patient, he is seen conversing with an external party that is not apparent to you. The patient states that he is afraid for his life and that agents are currently pursuing him. What is the best initial response to this patient’s statement?
- A. I think you are safe from the agents here.
- B. You have a mental disorder but don’t worry we will help you.
- C. I don’t think any agents are pursuing you.
- D. What medications are you currently taking?
- E. It sounds like you have been going through some tough experiences lately. (Correct Answer)
Violence risk assessment in psychosis Explanation: ***It sounds like you have been going through some tough experiences lately.***
- This response **acknowledges the patient's distress** and experience without validating or refuting their delusional beliefs.
- It helps establish **rapport** and encourages the patient to share more about their symptoms, which is crucial for assessment in a psychiatric emergency.
*I think you are safe from the agents here.*
- While intended to reassure, directly addressing the delusion can be perceived as dismissive and may **escalate the patient's paranoia** or agitation.
- It does not validate their *feelings* of fear, which are real to them, even if the source is delusional.
*You have a mental disorder but don’t worry we will help you.*
- This statement is **confrontational** and judgmental, labeling the patient immediately with a diagnosis.
- This approach can cause the patient to become defensive, shut down, or feel stigmatized, making further assessment and trust-building very difficult in the **initial interaction**.
*I don’t think any agents are pursuing you.*
- Directly **challenging a patient's delusion** is generally unhelpful in acute settings and can lead to increased agitation.
- It invalidates their subjective reality and can make them feel misunderstood or distrustful of the healthcare provider.
*What medications are you currently taking?*
- While important information, asking about medications is too premature as an *initial response* to a patient expressing severe paranoia and fear.
- This question comes across as dismissive of their current emotional state and **prioritizes medical history over emotional support** and rapport-building.
Violence risk assessment in psychosis US Medical PG Question 2: An 8-year-old boy is brought in by his mother who is concerned about her child’s behavior. She says his teachers have complained about him bullying other students at school, starting fights, and stealing other children’s lunch money. She also says that a neighbor down the street called her 6 months ago and reported that the patient had entered her yard and started viciously kicking her dog. He has no significant past medical history. He is in the 90th percentile for height and weight and has been meeting all developmental milestones. The patient is afebrile and his vital signs are within normal limits. Which of the following adult personality disorders does this patient’s diagnosis most likely predict?
- A. Paranoid personality disorder
- B. Schizotypal personality disorder
- C. Schizoid personality disorder
- D. Avoidant personality disorder
- E. Antisocial personality disorder (Correct Answer)
Violence risk assessment in psychosis Explanation: ***Antisocial personality disorder***
- The patient's presentation with a consistent pattern of violating the rights of others, including **bullying**, **fighting**, **stealing**, and **animal cruelty**, is highly indicative of **conduct disorder**.
- **Conduct disorder** in childhood is the most common precursor to developing **antisocial personality disorder** in adulthood.
*Paranoid personality disorder*
- This disorder is characterized by a pervasive **distrust and suspicion of others**, interpreting their motives as malicious, which is not indicated by the patient's behavior.
- While they may be hostile, their actions typically stem from perceived threats rather than direct aggression or disregard for others' rights as seen here.
*Schizotypal personality disorder*
- Individuals with schizotypal personality disorder exhibit **odd beliefs**, **magical thinking**, and **eccentric behavior** or appearance.
- They also tend to have **social anxiety** and difficulty forming close relationships, which doesn't align with the presented externalizing behaviors.
*Schizoid personality disorder*
- This disorder is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- There is no evidence of social withdrawal or uninterest in relationships; instead, the patient is actively engaging in harmful social interactions.
*Avoidant personality disorder*
- This disorder involves extreme **social inhibition**, feelings of inadequacy, and hypersensitivity to **negative evaluation**.
- The patient’s aggressive and non-compliant behaviors are contrary to the withdrawn and fearful nature seen in avoidant personality disorder.
Violence risk assessment in psychosis US Medical PG Question 3: A 55-year-old male was picked up by police in the public library for harassing the patrons and for public nudity. He displayed disorganized speech and believed that the books were the only way to his salvation. Identification was found on the man and his sister was called to provide more information. She described that he recently lost his house and got divorced within the same week although he seemed fine three days ago. The man was sedated with diazepam and chlorpromazine because he was very agitated. His labs returned normal and within three days, he appeared normal, had no recollection of the past several days, and discussed in detail how stressful the past two weeks of his life were. He was discharged the next day. Which of the following is the most appropriate diagnosis for this male?
- A. Brief psychotic disorder (Correct Answer)
- B. Schizotypal personality disorder
- C. Schizophreniform disorder
- D. Schizophrenia
- E. Schizoid personality disorder
Violence risk assessment in psychosis Explanation: ***Brief psychotic disorder***
- This patient exhibited characteristic symptoms such as **sudden onset of psychotic symptoms** (disorganized speech, delusions, public nudity) that lasted **less than one month** and were preceded by a **severe psychosocial stressor** (loss of house, divorce).
- The **full return to premorbid functioning** and lack of recollection after the episode further support brief psychotic disorder, distinguishing it from other chronic psychotic disorders.
*Schizotypal personality disorder*
- Characterized by a pervasive pattern of **social and interpersonal deficits**, cognitive or perceptual distortions, and eccentricities of behavior, which are usually **long-standing** and not episodic.
- While there may be odd beliefs or magical thinking, the dramatic and time-limited psychotic episode in the scenario is not typical of schizotypal personality disorder.
*Schizophreniform disorder*
- This disorder is diagnosed when psychotic symptoms (like those seen in schizophrenia) are present for **at least one month but less than six months**.
- Although the patient presented with psychotic symptoms, their rapid resolution within three days makes a diagnosis of schizophreniform disorder unlikely.
*Schizophrenia*
- Requires continuous signs of disturbance for **at least six months**, including at least one month of active-phase symptoms, along with significant impairment in social or occupational functioning.
- The rapid resolution of symptoms and return to baseline within days in this case immediately rules out schizophrenia, which is a chronic condition.
*Schizoid personality disorder*
- Characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of expression of emotions in interpersonal settings.
- This disorder does not involve psychotic symptoms, disorganized speech, or delusions of the intensity described in the patient's presentation.
Violence risk assessment in psychosis US Medical PG Question 4: An 18-year-old man is brought to the emergency department after his mother found him locked in his room stammering about a government conspiracy to brainwash him in subterranean tunnels. His mother says that he has never done this before, but 6 months ago he stopped going to classes and was subsequently suspended from college. She reports that he has become increasingly taciturn over the course of the past month. He drinks one to two beers daily and has smoked one pack of cigarettes daily for 3 years. He occasionally smokes marijuana. His father was diagnosed with schizophrenia at the age of 25 years. The patient has had no friends or social contacts other than his mother since he was suspended. He appears unkempt and aloof. On mental status examination, he is disorganized and shows poverty of speech. He says his mood is "good." He does not hear voices and has no visual or tactile hallucinations. Toxicology screening is negative. Which of the following is an unfavorable prognostic factor for this patient's condition?
- A. Poor premorbid functioning (Correct Answer)
- B. Late onset of illness
- C. Presence of mood symptoms
- D. Good insight into illness
- E. Strong family support
Violence risk assessment in psychosis Explanation: ***Poor premorbid functioning***
- **Poor premorbid functioning** is a well-established **unfavorable prognostic factor** in schizophrenia, associated with worse long-term outcomes and functional recovery.
- This patient demonstrates poor premorbid functioning: he declined from being a college student to being suspended, became increasingly isolated with no friends or social contacts, and presents as unkempt and aloof.
- The insidious deterioration over 6 months with prominent negative symptoms (taciturnity, poverty of speech, social withdrawal) further suggests poor premorbid adjustment.
*Late onset of illness*
- **Late onset** (after age 25-30) is associated with a **better prognosis** because brain development is more complete and there is typically better premorbid functioning.
- This is a **favorable**, not unfavorable, prognostic factor.
*Presence of mood symptoms*
- The presence of **prominent mood symptoms** (depression, mania) in psychotic disorders is associated with a **better prognosis** than pure schizophrenia.
- Schizoaffective disorder generally has better outcomes than schizophrenia.
- This is a **favorable** prognostic factor.
*Good insight into illness*
- **Good insight** is a highly **favorable prognostic factor** as it increases treatment adherence and engagement in recovery.
- This patient lacks insight, demonstrating disorganized thought and delusions without awareness of illness.
*Strong family support*
- **Strong family support** is a crucial **favorable prognostic factor**, improving treatment adherence, recovery, and social reintegration.
- While the mother is involved, the patient's complete social isolation (no friends or contacts besides mother) suggests limited overall support network.
Violence risk assessment in psychosis US Medical PG Question 5: A 60-year-old man who was admitted for a fractured hip and is awaiting surgery presents with acute onset altered mental status. The patient is noted by the nurses to be shouting and screaming profanities and has already pulled out his IV and urine catheter. He says he believes he is being kept against his will and does not recall falling or fracturing his hip. The patient must be restrained by the staff to prevent him from getting out of bed. He is refusing a physical exam. Initial examination reveals an agitated elderly man with a trickle of blood flowing down his left arm. He is screaming and swinging his fists at the staff. The patient is oriented x 1. Which of the following is the next, best step in the management of this patient?
- A. Order 24-hour restraints
- B. Change his medication
- C. Order CMP and CBC (Correct Answer)
- D. Repair the fractured hip
- E. Administer an Antipsychotic
Violence risk assessment in psychosis Explanation: ***Order CMP and CBC***
- The patient is exhibiting **acute delirium**, characterized by altered mental status, disorientation, and agitation, especially common in elderly patients post-surgery or with underlying medical issues.
- Initial management involves identifying and addressing potential underlying medical causes such as **electrolyte imbalances**, **infection**, or **anemia** (evaluated by CMP and CBC).
*Order 24-hour restraints*
- While restraints might be necessary for patient safety in the short term, ordering 24-hour restraints without investigating the cause is not the **next best step**.
- Restraints should be used as a last resort, minimized in duration, and not as a primary management strategy for **delirium**.
*Change his medication*
- Changing medication without a clear understanding of the underlying cause of delirium could exacerbate the situation or introduce new complications.
- A thorough investigation to **identify the etiology** of his altered mental status is crucial before adjusting pharmacotherapy.
*Repair the fractured hip*
- The patient's acute delirium makes him an unstable candidate for surgery due to the increased risk of complications and difficulty with consent.
- Addressing the **acute medical instability** (delirium) takes precedence over elective or semi-elective surgical procedures.
*Administer an Antipsychotic*
- **Antipsychotics** can be used to manage severe agitation in delirium, but they are a symptomatic treatment and not the initial **diagnostic step**.
- Without identifying the underlying cause, administering medication could mask symptoms or have adverse effects, especially in an **elderly patient**.
Violence risk assessment in psychosis US Medical PG Question 6: A 23-year-old woman is brought to the emergency department by her friend because of strange behavior. Two hours ago, she was at a night club where she got involved in a fight with the bartender. Her friend says that she was smoking a cigarette before she became irritable and combative. She repeatedly asked “Why are you pouring blood in my drink?” before hitting the bartender. She has no history of psychiatric illness. Her temperature is 38°C (100.4°F), pulse is 100/min, respirations are 19/min, and blood pressure is 158/95 mm Hg. Examination shows muscle rigidity. She has a reduced degree of facial expression. She has no recollection of her confrontation with the bartender. Which of the following is the most likely primary mechanism responsible for this patient's symptoms?
- A. Stimulation of cannabinoid receptors
- B. Inhibition of NMDA receptors (Correct Answer)
- C. Inhibition of norepinephrine, serotonin, and dopamine reuptake
- D. Stimulation of 5HT2A and dopamine D2 receptors
- E. Inhibition of dopamine D2 receptors
Violence risk assessment in psychosis Explanation: ***Inhibition of NMDA receptors***
- The patient's symptoms, including **combativeness**, **erratic behavior**, **delusions** ("Why are you pouring blood in my drink?"), **hypertension**, **tachycardia**, and **muscle rigidity**, are characteristic of **PCP intoxication**.
- **Phencyclidine (PCP)** acts primarily as an **NMDA receptor antagonist**, blocking calcium channels and leading to these neurotoxic effects.
*Stimulation of cannabinoid receptors*
- **Cannabis intoxication** typically involves **euphoria**, distorted perception, impaired memory, and increased appetite, which are not the primary features described here.
- While agitation can occur, the severe combativeness, delusions, and specific vital sign changes point away from cannabinoid receptor stimulation as the primary mechanism for this presentation.
*Inhibition of norepinephrine, serotonin, and dopamine reuptake*
- This mechanism is characteristic of stimulants like **cocaine** or **amphetamines**. While these drugs can cause agitation, paranoia, hypertension, and tachycardia, they typically do not cause the prominent **muscle rigidity** and **delusional thought** content as described.
- The "smoking a cigarette" context might suggest stimulants, but the overall clinical picture is more consistent with PCP.
*Stimulation of 5HT2A and dopamine D2 receptors*
- Stimulation of **5HT2A receptors** is associated with **hallucinogens** like LSD, causing perceptual distortions and altered consciousness, but typically not the intense combativeness, muscle rigidity, and specific delusions seen here.
- While **dopamine D2 receptor stimulation** can contribute to psychosis, it's not the primary mechanism that brings together all the described symptoms in this acute, severe presentation.
*Inhibition of dopamine D2 receptors*
- **Dopamine D2 receptor inhibition** is the mechanism of action for antipsychotic medications and generally leads to a reduction in psychotic symptoms, not the intense agitation, combativeness, and psychotic features observed in this patient.
- Such inhibition can lead to extrapyramidal symptoms, but not the acute, substance-induced presentation described.
Violence risk assessment in psychosis US Medical PG Question 7: A 17-year-old man is brought by his mother to his pediatrician in order to complete medical clearance forms prior to attending college. During the visit, his mother asks about what health risks he should be aware of in college. Specifically, she recently saw on the news that some college students were killed by a fatal car crash. She therefore asks about causes of death in this population. Which of the following is true about the causes of death in college age individuals?
- A. More of them die from homicide than suicide
- B. More of them die from suicide than injuries
- C. More of them die from cancer than suicide
- D. More of them die from homicide than injuries
- E. More of them die from homicide than cancer (Correct Answer)
Violence risk assessment in psychosis Explanation: ***More of them die from homicide than cancer***
- While relatively rare, **homicide rates** for college-aged individuals (18-24 years) are generally higher than their rates of death due to **cancer**.
- **Cancer** is a leading cause of death in older populations but is much less common in young adults.
*More of them die from homicide than suicide*
- **Suicide** is a significantly more common cause of death than homicide among college-aged individuals.
- Data consistently shows that **suicide** ranks as one of the top causes of death in this demographic, often second only to unintentional injuries.
*More of them die from suicide than injuries*
- **Unintentional injuries** (including motor vehicle accidents, accidental poisoning, and falls) are the leading cause of death in the 18-24 age group.
- **Suicide** is typically the second leading cause, meaning more individuals die from injuries than from suicide.
*More of them die from cancer than suicide*
- As mentioned, **suicide** is a much more prevalent cause of death in young adults than cancer.
- **Cancer deaths** are relatively uncommon in this age group compared to other causes like injuries and suicide.
*More of them die from homicide than injuries*
- **Unintentional injuries** are the leading cause of death among college-aged individuals.
- **Homicide rates** are considerably lower than injury rates in this population.
Violence risk assessment in psychosis US Medical PG Question 8: A 28-year-old woman is brought to a counselor by her father after he found out that she is being physically abused by her husband. The father reports that she refuses to end the relationship with her husband despite the physical abuse. She says that she feels uneasy when her husband is not around. She adds, “I'm worried that if I leave him, my life will only get worse.” She has never been employed since they got married because she is convinced that nobody would hire her. Her husband takes care of most household errands and pays all of the bills. Physical examination shows several bruises on the thighs and back. Which of the following is the most likely diagnosis?
- A. Schizoid personality disorder
- B. Separation anxiety disorder
- C. Avoidant personality disorder
- D. Dependent personality disorder (Correct Answer)
- E. Borderline personality disorder
Violence risk assessment in psychosis Explanation: ***Dependent personality disorder***
- This patient exhibits a pervasive and excessive need to be taken care of, leading to **submissive and clinging behavior, and fears of separation**. Key features include difficulties making decisions, avoiding disagreement due to fear of loss of support, and preoccupation with fears of being left to care for herself.
- Her comments about her life getting worse if she leaves her husband, her inability to seek employment, and her husband managing all household affairs are consistent with her **reluctance to leave an abusive relationship** because of an exaggerated fear of being alone or unable to care for herself.
*Schizoid personality disorder*
- Characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- Individuals with this disorder typically show **little interest in forming close relationships**, in contrast to the patient's clinging behavior.
*Separation anxiety disorder*
- Primarily marked by **excessive anxiety concerning separation from home or from those to whom the individual is attached**, often seen in childhood, but can occur in adults.
- While there is some anxiety about separation, the patient's broader pattern of submissive behavior, difficulty with independent functioning, and belief she cannot care for herself points more strongly to a **personality disorder** rather than an anxiety disorder focused solely on separation.
*Avoidant personality disorder*
- Involves extreme social inhibition, feelings of inadequacy, and **hypersensitivity to negative evaluation**.
- These individuals **desire social connection but avoid it due to fear of rejection**, which contrasts with the patient's clinging and submissive efforts to maintain a relationship.
*Borderline personality disorder*
- Characterized by significant **instability in moods, interpersonal relationships, self-image, and behaviors**.
- While there can be fear of abandonment, this disorder typically involves **impulsivity, intense anger, and frantic efforts to avoid abandonment**, which are not the primary features described in this patient.
Violence risk assessment in psychosis US Medical PG Question 9: 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
Violence risk assessment in psychosis 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.
Violence risk assessment in psychosis US Medical PG Question 10: A 23-year-old man is brought to the emergency department by the police after attempting to assault a waiter with a broom. The patient states that the FBI has been following him his entire life and that this man was an agent spying on him. The patient has a past medical history of irritable bowel syndrome. His temperature is 98.0°F (36.7°C), blood pressure is 137/68 mmHg, pulse is 110/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is deferred due to patient combativeness. The patient is given haloperidol and diphenhydramine. The patient is later seen in his room still agitated. Intraosseous access is obtained. Which of the following is the best next step in management?
- A. Complete blood count
- B. Urine toxicology (Correct Answer)
- C. Thyroid stimulating hormone level
- D. Assess for suicidal ideation
- E. Syphilis screening
Violence risk assessment in psychosis Explanation: ***Urine toxicology***
- A definitive diagnosis of **substance-induced psychosis** or **agitation** can be made through a urine toxicology screen, which is crucial given the patient's acute agitated state and paranoid delusions.
- Identification of specific substances helps guide further management, as some intoxicants or withdrawal states require targeted interventions.
*Complete blood count*
- While a CBC assesses for infection or anemia, it is unlikely to reveal the primary cause of acute **agitation** and **paranoid delusions** in this context.
- This diagnostic test would be more relevant if there were signs of infection (e.g., fever, localized pain) or significant blood loss.
*Thyroid stimulating hormone level*
- Although **thyroid dysfunction** can cause psychiatric symptoms, it typically manifests more gradually and rarely presents with such an acute onset of severe **agitation** and **paranoia**.
- Other clinical signs of thyroid dysfunction, such as weight changes or altered energy levels, are also absent.
*Assess for suicidal ideation*
- While important in any psychiatric evaluation, assessing for **suicidal ideation** is a part of mental status examination. Given the patient's current severe agitation and combativeness, obtaining a reliable assessment of suicidal ideation is extremely difficult and secondary to managing the acute behavioral crisis and identifying immediate medical causes.
- The immediate priority is to understand the etiology of his acute behavioral disturbance and ensure safety, before a full psychiatric history can be reliably obtained.
*Syphilis screening*
- **Neurosyphilis** can cause neuropsychiatric symptoms, including psychosis, but it is typically a chronic condition with a more insidious onset.
- In an acutely agitated patient with sudden onset of paranoid delusions, syphilis is a less likely immediate cause compared to substance use.
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