A 28-year-old man comes to the physician because of a 1-year history of chronic back pain. He explains that the pain started after getting a job at a logistics company. He does not recall any trauma and does not have morning stiffness or neurological symptoms. He has been seen by two other physicians for his back pain who did not establish a diagnosis. The patient also has abdominal bloating and a feeling of constipation that started 3 weeks ago. After doing extensive research on the internet, he is concerned that the symptoms might be caused by pancreatic cancer. He would like to undergo a CT scan of his abdomen for reassurance. He has a history of episodic chest pain, for which he underwent medical evaluation with another healthcare provider. Tests showed no pathological results. He does not smoke or drink alcohol. He reports that he is under significant pressure from his superiors due to frequent performance evaluations. He takes daily multivitamins and glucosamine to prevent arthritis. His vital signs are within normal limits. Examination shows a soft, non-tender, non-distended abdomen and mild bilateral paraspinal muscle tenderness. The remainder of the examination, including a neurologic examination, shows no abnormalities. Laboratory studies are within the reference range. An x-ray of the spine shows no abnormalities. Which of the following is the most likely explanation for this patient's symptoms?
Q42
A 20-year-old female college student comes to the student clinic for an annual physical examination. She has no complaints. On further questioning, she admits to having only two friends on campus, which she attributes to her shyness, and has been present for as long as she can remember. She intentionally enrolls in large classes that do not require participation, due to her fear of being criticized. She works part time as a library shelver and has turned down promotions for a front desk job. She lives alone because she is concerned that others will find her unappealing. She turns down invitations to parties and prefers spending time with her cat. She worries that she may not be able to find a boyfriend who thinks she is good enough. The patient most likely has which of the following primary diagnoses?
Q43
A 42-year-old man comes to the emergency department complaining of chest pain. He states that he was at the grocery store when he developed severe, burning chest pain along with palpitations and nausea. He screamed for someone to call an ambulance. He says this has happened before, including at least 4 episodes in the past month that were all in different locations including once at home. He is worried that it could happen at work and affect his employment status. He has no significant past medical history, and reports that he does not like taking medications. He has had trouble in the past with compliance due to side effects. The patient’s temperature is 98.9°F (37.2°C), blood pressure is 133/74 mmHg, pulse is 110/min, and respirations are 20/min with an oxygen saturation of 99% on room air. On physical examination, the patient is tremulous and diaphoretic. He continually asks to be put on oxygen and something for his pain. An electrocardiogram is obtained that shows tachycardia. Initial troponin level is negative. A urine drug screen is negative. Thyroid stimulating hormone and free T4 levels are normal. Which of the following is first line therapy for the patient for long-term management?
Q44
A 28-year-old medical student presents to the student health center with the complaint being unable to sleep. Although he is a very successful student, over the past few months he has become increasingly preoccupied with failing. The patient states that he wakes up 10-15 times per night to check his textbooks for factual recall. He has tried unsuccessfully to suppress these thoughts and actions, and he has become extremely anxious and sleep-deprived. He has no past medical history and family history is significant for a parent with Tourette's syndrome. He is started on cognitive behavioral therapy. He is also started on a first-line medication for his disorder, but after eight weeks of use, it is still ineffective. What drug, if added to his current regimen, may help improve his symptoms?
Q45
A 28-year-old male presents to trauma surgery clinic after undergoing an exploratory laparotomy, femoral intramedullary nail, and femoral artery vascular repair 3 months ago. He suffered multiple gunshot wounds as a victim of a drive-by shooting. He is progressing well with well-healed surgical incisions on examination. He states during his clinic visit that he has been experiencing 6 weeks of nightmares where he "relives the day he was shot." The patient also endorses 6 weeks of flashbacks to "the shooter pointing the gun at him" during the daytime as well. He states that he has had difficulty sleeping and cannot concentrate when performing tasks. Which of the following is the most likely diagnosis?
Q46
A 28-year-old woman is brought to the emergency department after being found in a confused state on an interstate rest area in Florida. She is unable to recall her name, address, or any other information regarding her person. She denies being the woman on a Connecticut driver's license found in her wallet. A telephone call with the police department of her hometown reveals that she had been reported missing three days ago by her husband. When the husband arrives, he reports that his wife has had a great deal of stress at work lately and before she went missing, was anxious to tell her boss that she will not meet the deadline for her current project. She has had two major depressive episodes within the past 4 years that were treated with citalopram. She drinks one to two beers daily and sometimes more on weekends. She does not use illicit drugs. Her vital signs are within normal limits. Physical and neurological examinations show no abnormalities. On mental status exam, she is oriented only to time and place but not to person. Short-term memory is intact; she does not recognize her husband or recall important events of her life. Which of the following is the most likely diagnosis?
Q47
A 47-year-old male presents to a psychiatrist for the first time, explaining that he is tired of living his 'double life.' At church, he preaches vehemently against the sin of drinking alcohol, but at home he gets drunk every night. Which of the following ego defenses best explains his behavior?
Q48
A 39-year-old woman is brought to the emergency room by her husband because of severe dyspnea and dizziness. Her symptoms started suddenly 30 minutes ago. She appears distressed. Arterial blood gas shows a pH of 7.51, pO2 of 100 mm Hg, and a pCO2 of 30 mm Hg. Which of the following is the most likely cause?
Q49
A 23-year-old man presents to an outpatient psychiatrist complaining of anxiety and a persistent feeling that “something terrible will happen to my family.” He describes 1 year of vague, disturbing thoughts about his family members contracting a “horrible disease” or dying in an accident. He believes that he can prevent these outcomes by washing his hands of “the contaminants” any time that he touches something and by performing praying and counting rituals each time that he has unwanted, disturbing thoughts. The thoughts and rituals have become more frequent recently, making it impossible for him to work, and he expresses feeling deeply embarrassed by them. Which of the following is the most effective treatment for this patient's disorder?
Q50
A 13-year-old girl is brought to the physician because she has suddenly withdrawn from her close friends and has been displaying anger and hostility toward her friends at school, as well as toward her parents at home over the past month. She has also begun to skip classes and has been absent from school several times during this time period. Her mother says that she has been making up stories about her new art teacher touching her inappropriately. However, she believes that her daughter's behavior is the result of recent divorce issues in the family. Which of the following is the most appropriate next step in the evaluation of this patient?
Anxiety US Medical PG Practice Questions and MCQs
Question 41: A 28-year-old man comes to the physician because of a 1-year history of chronic back pain. He explains that the pain started after getting a job at a logistics company. He does not recall any trauma and does not have morning stiffness or neurological symptoms. He has been seen by two other physicians for his back pain who did not establish a diagnosis. The patient also has abdominal bloating and a feeling of constipation that started 3 weeks ago. After doing extensive research on the internet, he is concerned that the symptoms might be caused by pancreatic cancer. He would like to undergo a CT scan of his abdomen for reassurance. He has a history of episodic chest pain, for which he underwent medical evaluation with another healthcare provider. Tests showed no pathological results. He does not smoke or drink alcohol. He reports that he is under significant pressure from his superiors due to frequent performance evaluations. He takes daily multivitamins and glucosamine to prevent arthritis. His vital signs are within normal limits. Examination shows a soft, non-tender, non-distended abdomen and mild bilateral paraspinal muscle tenderness. The remainder of the examination, including a neurologic examination, shows no abnormalities. Laboratory studies are within the reference range. An x-ray of the spine shows no abnormalities. Which of the following is the most likely explanation for this patient's symptoms?
A. Somatic symptom disorder (Correct Answer)
B. Acute stress disorder
C. Atypical depression
D. Irritable bowel syndrome
E. Malignant neoplasm
Explanation: ***Somatic symptom disorder***
- The patient presents with multiple unexplained physical symptoms (chronic back pain, abdominal bloating, constipation, episodic chest pain) over an extended period. Despite normal physical examinations, laboratory studies, and imaging, he continues to have significant distress and concern about serious medical conditions (e.g., pancreatic cancer), consistent with **somatic symptom disorder**.
- His history of job-related stress, frequent performance evaluations, and the anxiety leading him to seek reassurance and extensive internet research further support the diagnosis of illness preoccupation and persistent somatic symptoms without a clear medical cause.
*Acute stress disorder*
- This disorder typically develops within **1 month** of exposure to a **traumatic event** and resolves within that timeframe.
- The patient's symptoms are chronic (1 year of back pain), unrelated to a specific traumatic event, and do not fit the time course of acute stress disorder.
*Atypical depression*
- Atypical depression is characterized by mood reactivity (mood improves in response to positive events), increased appetite/weight gain, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity.
- While the patient is under stress, his primary presentation revolves around physical symptoms and health anxiety, not the core features of atypical depression.
*Irritable bowel syndrome*
- Although the patient's abdominal bloating and constipation are consistent with irritable bowel syndrome (IBS), IBS alone would not explain his chronic back pain, episodic chest pain, and the pervasive health anxiety with repeated medical evaluations.
- IBS is a diagnosis of exclusion and a component of a broader picture in this patient, not the sole or primary explanation of all his symptoms.
*Malignant neoplasm*
- The patient's thorough medical evaluations, including normal laboratory studies and an X-ray of the spine, along with a normal physical examination, make a malignant neoplasm highly unlikely.
- His symptoms also lack typical red flags for malignancy, such as unexplained weight loss, fever, or night sweats.
Question 42: A 20-year-old female college student comes to the student clinic for an annual physical examination. She has no complaints. On further questioning, she admits to having only two friends on campus, which she attributes to her shyness, and has been present for as long as she can remember. She intentionally enrolls in large classes that do not require participation, due to her fear of being criticized. She works part time as a library shelver and has turned down promotions for a front desk job. She lives alone because she is concerned that others will find her unappealing. She turns down invitations to parties and prefers spending time with her cat. She worries that she may not be able to find a boyfriend who thinks she is good enough. The patient most likely has which of the following primary diagnoses?
A. Adjustment disorder with depressed mood
B. Avoidant Personality Disorder (Correct Answer)
C. Dependent personality disorder
D. Social anxiety disorder
E. Schizoid personality disorder
Explanation: ***Avoidant Personality Disorder***
- This patient exhibits a pervasive pattern of **social inhibition**, feelings of **inadequacy**, and **hypersensitivity to negative evaluation**, consistent with Avoidant Personality Disorder. Her shyness, fear of criticism, avoidance of social interaction, and belief that others will find her unappealing are key indicators.
- The symptoms are long-standing ("as long as she can remember") and pervasive across different situations (college, work, personal life), meeting the diagnostic criteria for a **personality disorder**.
*Adjustment disorder with depressed mood*
- An **adjustment disorder** typically arises in response to an identifiable stressor and begins within three months of the stressor's onset, resolving once the stressor is removed or a new level of adaptation is achieved.
- The patient's symptoms are chronic and long-standing, not attributable to a recent stressor, and therefore do not fit this diagnosis.
*Dependent personality disorder*
- Individuals with **Dependent Personality Disorder** exhibit an excessive need to be cared for, leading to submissive and clinging behaviors and fears of separation. They often struggle to make decisions and require constant reassurance.
- While the patient expresses worry about not finding a boyfriend who thinks she is good enough, her primary motivation for social avoidance is fear of criticism and inadequacy, not a pervasive need for care or fear of abandonment.
*Social anxiety disorder*
- **Social Anxiety Disorder** (Social Phobia) involves intense fear or anxiety about social situations in which the individual may be scrutinized by others, leading to avoidance or endurance with great distress.
- While there is overlap, Avoidant Personality Disorder is characterized by a more pervasive and deeply ingrained sense of **self-inadequacy** and shame, leading to a broader pattern of social avoidance, whereas social anxiety disorder is primarily driven by performance-related fears in specific social situations. The chronic and pervasive nature of the patient's self-perception aligns more with a personality disorder.
*Schizoid personality disorder*
- **Schizoid Personality Disorder** is characterized by a pervasive pattern of detachment from social relationships and a restricted range of emotional expression. Individuals with schizoid personality disorder typically show no desire for close relationships and are indifferent to the approval or criticism of others.
- This patient desires relationships (expressing worry about finding a boyfriend) but avoids them due to fear of criticism and inadequacy, which is distinct from the lack of desire for relationships seen in **Schizoid Personality Disorder**.
Question 43: A 42-year-old man comes to the emergency department complaining of chest pain. He states that he was at the grocery store when he developed severe, burning chest pain along with palpitations and nausea. He screamed for someone to call an ambulance. He says this has happened before, including at least 4 episodes in the past month that were all in different locations including once at home. He is worried that it could happen at work and affect his employment status. He has no significant past medical history, and reports that he does not like taking medications. He has had trouble in the past with compliance due to side effects. The patient’s temperature is 98.9°F (37.2°C), blood pressure is 133/74 mmHg, pulse is 110/min, and respirations are 20/min with an oxygen saturation of 99% on room air. On physical examination, the patient is tremulous and diaphoretic. He continually asks to be put on oxygen and something for his pain. An electrocardiogram is obtained that shows tachycardia. Initial troponin level is negative. A urine drug screen is negative. Thyroid stimulating hormone and free T4 levels are normal. Which of the following is first line therapy for the patient for long-term management?
A. Cognitive behavioral therapy (Correct Answer)
B. Alprazolam
C. Imipramine
D. Fluoxetine
E. Buspirone
Explanation: ***Cognitive behavioral therapy***
- This patient's symptoms are highly suggestive of **panic disorder**, characterized by recurrent, unexpected panic attacks and persistent worry about future attacks. **Cognitive behavioral therapy (CBT)** is considered **first-line treatment** for panic disorder, especially for long-term management, as it addresses the underlying thought patterns and behaviors.
- CBT, particularly exposure therapy, helps patients **reframe their catastrophic thoughts** and directly confront situations that trigger anxiety, leading to a significant reduction in panic attack frequency and severity. It is a good choice for this patient since he has had problems with medication compliance.
*Alprazolam*
- **Alprazolam** is a **benzodiazepine** that provides rapid symptom relief during acute panic attacks but is generally not recommended as first-line for long-term management due to its **potential for dependence**, tolerance, and withdrawal symptoms.
- Its short half-life can lead to rebound anxiety, and it does not address the underlying cognitive distortions common in panic disorder.
*Imipramine*
- **Imipramine** is a **tricyclic antidepressant (TCA)** that can be effective for panic disorder, but it is **not generally a first-line pharmacotherapy** due to its more significant side effect profile (e.g., anticholinergic effects, cardiac toxicity in overdose) compared to SSRIs.
- The patient's history of medication non-compliance due to side effects makes this a less suitable long-term option compared to CBT.
*Fluoxetine*
- **Fluoxetine** is a **selective serotonin reuptake inhibitor (SSRI)**, which is often considered first-line pharmacotherapy for panic disorder due to its efficacy and generally favorable side effect profile. However, given the patient's strong preference against medication and history of non-compliance, CBT would be the preferred initial long-term strategy.
- While effective, SSRIs generally take several weeks to reach full therapeutic effect, and the patient may still experience initial side effects, further contributing to potential non-compliance.
*Buspirone*
- **Buspirone** is an **anxiolytic** that is effective for generalized anxiety disorder but is **not considered first-line for panic disorder**.
- It has a slower onset of action and is typically less effective in treating the acute, intense symptoms of panic attacks compared to other agents.
Question 44: A 28-year-old medical student presents to the student health center with the complaint being unable to sleep. Although he is a very successful student, over the past few months he has become increasingly preoccupied with failing. The patient states that he wakes up 10-15 times per night to check his textbooks for factual recall. He has tried unsuccessfully to suppress these thoughts and actions, and he has become extremely anxious and sleep-deprived. He has no past medical history and family history is significant for a parent with Tourette's syndrome. He is started on cognitive behavioral therapy. He is also started on a first-line medication for his disorder, but after eight weeks of use, it is still ineffective. What drug, if added to his current regimen, may help improve his symptoms?
A. Risperidone (Correct Answer)
B. Sertraline
C. Propranolol
D. Methylphenidate
E. Phenelzine
Explanation: ***Risperidone***
- The patient presents with classic symptoms of **Obsessive-Compulsive Disorder (OCD)**, including intrusive thoughts (preoccupation with failing) and compulsive behaviors (checking textbooks). When a first-line SSRI is ineffective after an adequate trial (8-12 weeks), **augmentation with an atypical antipsychotic** is the evidence-based next step.
- **Risperidone** (along with aripiprazole) has the strongest evidence for augmenting SSRIs in treatment-resistant OCD. It helps reduce the severity of **obsessive thoughts** and **compulsive actions** by modulating dopamine and serotonin pathways.
- The family history of **Tourette's syndrome** further supports this choice, as both conditions share genetic links and respond to dopamine modulation.
*Sertraline*
- **Sertraline** is a **first-line selective serotonin reuptake inhibitor (SSRI)** for OCD. The patient in the vignette has already been on a first-line medication for eight weeks, implying an initial SSRI was ineffective.
- Adding another SSRI like sertraline when one has already failed is generally not the next step in managing refractory OCD; augmentation with a different class of medication (atypical antipsychotic) is the preferred strategy.
*Propranolol*
- **Propranolol** is a **beta-blocker** primarily used to manage symptoms of anxiety such as **tremors**, **palpitations**, and **social anxiety** by reducing peripheral adrenergic effects.
- It does not directly address the core obsessive thoughts or compulsive behaviors characteristic of OCD and is not considered a primary treatment or augmentation strategy for this disorder.
*Methylphenidate*
- **Methylphenidate** is a **stimulant** medication primarily used to treat **Attention-Deficit/Hyperactivity Disorder (ADHD)** and **narcolepsy**.
- It is not indicated for the treatment of OCD and could potentially exacerbate anxiety or sleep disturbances in this patient.
*Phenelzine*
- **Phenelzine** is a **monoamine oxidase inhibitor (MAOI)**, an older class of antidepressants. While MAOIs can be effective for some anxiety disorders, they are not first-line for OCD due to their significant side effect profile and dietary restrictions (**tyramine-free diet**).
- MAOIs are generally reserved for highly refractory cases of depression or anxiety and are not a standard augmentation strategy when an SSRI has failed for OCD, especially before trying atypical antipsychotics.
Question 45: A 28-year-old male presents to trauma surgery clinic after undergoing an exploratory laparotomy, femoral intramedullary nail, and femoral artery vascular repair 3 months ago. He suffered multiple gunshot wounds as a victim of a drive-by shooting. He is progressing well with well-healed surgical incisions on examination. He states during his clinic visit that he has been experiencing 6 weeks of nightmares where he "relives the day he was shot." The patient also endorses 6 weeks of flashbacks to "the shooter pointing the gun at him" during the daytime as well. He states that he has had difficulty sleeping and cannot concentrate when performing tasks. Which of the following is the most likely diagnosis?
A. Schizophrenia
B. Normal reaction to trauma
C. Acute stress disorder
D. Post-traumatic stress disorder (PTSD) (Correct Answer)
E. Schizophreniform disorder
Explanation: ***Post-traumatic stress disorder (PTSD)***
- The patient's symptoms of **nightmares**, **flashbacks** (re-experiencing the trauma), **difficulty sleeping**, and **impaired concentration** following severe trauma are characteristic of PTSD.
- The symptoms have persisted for **6 weeks** (more than 1 month), meeting the duration criterion for PTSD diagnosis.
*Schizophrenia*
- Schizophrenia is characterized by **psychotic symptoms** such as hallucinations, delusions, and disorganized thought/speech, which are not described in this patient.
- While stress can exacerbate schizophrenia, the patient's symptoms are directly tied to a specific traumatic event, not a chronic psychotic disorder.
*Normal reaction to trauma*
- While some distress is expected after trauma, the presence of **persistent re-experiencing symptoms** (nightmares, flashbacks), and hyperarousal symptoms lasting for **over a month** is beyond a normal, transient reaction.
- These symptoms significantly impair the patient's functioning and indicate a clinically significant disorder.
*Acute stress disorder*
- Acute stress disorder presents with similar symptoms to PTSD, including intrusive thoughts, negative mood, dissociation, avoidance, and arousal.
- However, acute stress disorder is diagnosed when symptoms occur **3 days to 1 month** after trauma exposure; this patient's symptoms have lasted **6 weeks**, exceeding the 1-month threshold for ASD and meeting criteria for PTSD.
*Schizophreniform disorder*
- Schizophreniform disorder involves psychotic symptoms like **hallucinations, delusions, or disorganized speech**, lasting between 1 and 6 months.
- The patient's symptoms are primarily related to trauma re-experiencing and hyperarousal, not psychotic features.
Question 46: A 28-year-old woman is brought to the emergency department after being found in a confused state on an interstate rest area in Florida. She is unable to recall her name, address, or any other information regarding her person. She denies being the woman on a Connecticut driver's license found in her wallet. A telephone call with the police department of her hometown reveals that she had been reported missing three days ago by her husband. When the husband arrives, he reports that his wife has had a great deal of stress at work lately and before she went missing, was anxious to tell her boss that she will not meet the deadline for her current project. She has had two major depressive episodes within the past 4 years that were treated with citalopram. She drinks one to two beers daily and sometimes more on weekends. She does not use illicit drugs. Her vital signs are within normal limits. Physical and neurological examinations show no abnormalities. On mental status exam, she is oriented only to time and place but not to person. Short-term memory is intact; she does not recognize her husband or recall important events of her life. Which of the following is the most likely diagnosis?
A. Dissociative identity disorder
B. Depersonalization/derealization disorder
C. Korsakoff syndrome
D. Delirium
E. Dissociative amnesia with dissociative fugue (Correct Answer)
Explanation: ***Dissociative amnesia with dissociative fugue***
- This diagnosis is strongly suggested by the patient's sudden, unexpected travel away from home accompanied by an inability to recall her past, including her personal identity, and confusion about her new identity or assumption of a new identity. The stress and prior depressive episodes are contributing factors.
- The patient's inability to recognize her husband or recall significant life events, combined with intact short-term memory and normal physical/neurological exams, fits the criteria for **dissociative amnesia**, and the travel indicates **dissociative fugue specifier** (DSM-5 terminology).
*Dissociative identity disorder*
- This disorder is characterized by the presence of two or more distinct personality states (or "alters"), each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self. This patient does not exhibit multiple distinct identities.
- While there is amnesia associated with this disorder, it typically involves switching between alters and their associated memories, which is not described here.
*Depersonalization/derealization disorder*
- This condition involves persistent or recurrent experiences of feeling detached from one's mental processes or body (depersonalization), or experiences of unreality or detachment from one's surroundings (derealization), as if one is an outside observer. The primary symptom here is not detachment but rather a loss of personal identity and memory.
- Patients with depersonalization/derealization disorder typically maintain a sense of personal identity and recall their past, which is contrary to the details of this case.
*Korsakoff syndrome*
- This is a neurological disorder caused by a severe deficiency of **thiamine (vitamin B1)**, often associated with chronic alcohol abuse, leading to severe anterograde and retrograde amnesia, confabulation, and often ataxia and ophthalmoplegia. While the patient drinks, her vital signs and neurological exam are normal, and her acute presentation isn't typical for Korsakoff.
- The primary type of memory loss in Korsakoff is generally chronic and global, particularly affecting the ability to form new memories (**anterograde amnesia**), whereas this patient's short-term memory is noted as intact, and the amnesia is specific to personal identity.
*Delirium*
- Delirium is characterized by an acute, fluctuating disturbance in attention and awareness, along with cognitive changes that develop over a short period. This patient's vital signs are stable, and she lacks the global cognitive disorganization often seen in delirium.
- The absence of a clear medical cause, intoxicant, or withdrawal, along with her ability to be oriented to time and place (albeit not person), makes delirium less likely.
Question 47: A 47-year-old male presents to a psychiatrist for the first time, explaining that he is tired of living his 'double life.' At church, he preaches vehemently against the sin of drinking alcohol, but at home he gets drunk every night. Which of the following ego defenses best explains his behavior?
A. Acting out
B. Projection
C. Rationalization
D. Reaction formation (Correct Answer)
E. Displacement
Explanation: ***Correct: Reaction formation***
- **Reaction formation** involves unconsciously replacing an unacceptable feeling or urge with its directly opposing, more acceptable counterpart.
- The patient's vehement preaching against alcohol (opposite of his secret drinking) is a classic example of this defense mechanism.
- This defense allows him to manage the anxiety from his unacceptable impulse by adopting an extreme opposite public stance.
*Incorrect: Acting out*
- **Acting out** is the expression of an unconscious emotional conflict or impulse through action, often destructive or inappropriate behaviors.
- While his drinking could be considered acting out, the key feature of this case is his public preaching against the very behavior he engages in privately, which is more specific to reaction formation.
*Incorrect: Projection*
- **Projection** is attributing one's own unacceptable thoughts, feelings, or impulses to another person.
- The patient is not attributing his drinking problem to others; he is actively opposing it publicly while engaging in it privately.
*Incorrect: Rationalization*
- **Rationalization** is concocting a seemingly logical reason or excuse for an unacceptable behavior or impulse.
- The patient is not trying to explain away his drinking; rather, he is defending against the impulse by adopting an extreme opposing stance.
*Incorrect: Displacement*
- **Displacement** is redirecting one's feelings (often hostility or anger) from the original target to a less threatening substitute.
- There is no evidence of him redirecting emotions from one target to another in this scenario.
Question 48: A 39-year-old woman is brought to the emergency room by her husband because of severe dyspnea and dizziness. Her symptoms started suddenly 30 minutes ago. She appears distressed. Arterial blood gas shows a pH of 7.51, pO2 of 100 mm Hg, and a pCO2 of 30 mm Hg. Which of the following is the most likely cause?
A. Myasthenia gravis
B. Opioid toxicity
C. Panic attack (Correct Answer)
D. Epiglottitis
E. Pulmonary fibrosis
Explanation: ***Panic attack***
- The sudden onset of **severe dyspnea** and **dizziness** in a distressed patient, along with ABG results indicating **respiratory alkalosis** (pH 7.51, pCO2 30 mm Hg), is highly characteristic of a panic attack with hyperventilation.
- **Hyperventilation** leads to excessive CO2 exhalation, causing the pCO2 to drop and the pH to rise, resulting in symptoms like lightheadedness and dyspnea.
*Myasthenia gravis*
- This is a **neuromuscular disorder** causing muscle weakness, which can lead to respiratory compromise over time, but typically does not present with such acute, sudden dyspnea and dizziness without prior symptoms.
- The ABG findings of respiratory alkalosis are not typical for a primary myasthenic crisis, which would likely show respiratory acidosis if respiratory failure were imminent.
*Opioid toxicity*
- Opioid overdose causes **respiratory depression**, leading to reduced respiratory rate and shallow breathing, which would result in **respiratory acidosis** (increased pCO2 and decreased pH), not alkalosis.
- The patient's pO2 of 100 mm Hg also argues against significant respiratory depression.
*Epiglottitis*
- Epiglottitis presents with a **rapidly worsening sore throat**, difficulty swallowing, drooling, and stridor, indicating upper airway obstruction.
- While it causes severe dyspnea, the ABG would likely show signs of hypoxemia and potentially acidosis due to airway compromise, not hyperventilation-induced alkalosis.
*Pulmonary fibrosis*
- This is a **chronic interstitial lung disease** that causes progressive dyspnea, often with a dry cough.
- The onset of symptoms is typically gradual, over months to years, not sudden within 30 minutes, and ABG would likely show hypoxemia with compensated respiratory alkalosis or acidosis depending on the stage, but not acutely severe hyperventilation-induced alkalosis.
Question 49: A 23-year-old man presents to an outpatient psychiatrist complaining of anxiety and a persistent feeling that “something terrible will happen to my family.” He describes 1 year of vague, disturbing thoughts about his family members contracting a “horrible disease” or dying in an accident. He believes that he can prevent these outcomes by washing his hands of “the contaminants” any time that he touches something and by performing praying and counting rituals each time that he has unwanted, disturbing thoughts. The thoughts and rituals have become more frequent recently, making it impossible for him to work, and he expresses feeling deeply embarrassed by them. Which of the following is the most effective treatment for this patient's disorder?
A. Psychodynamic psychotherapy and citalopram
B. Cognitive behavioral therapy and haloperidol
C. Cognitive behavioral therapy and clonazepam
D. Cognitive behavioral therapy and fluoxetine (Correct Answer)
E. Psychodynamic psychotherapy and aripiprazole
Explanation: ***Cognitive behavioral therapy and fluoxetine***
- This patient presents with symptoms highly suggestive of **obsessive-compulsive disorder (OCD)**, characterized by intrusive, distressing thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) performed to neutralize the anxiety.
- **Cognitive Behavioral Therapy (CBT)**, specifically Exposure and Response Prevention (ERP), is the most effective psychotherapy for OCD, and **SSRIs** like fluoxetine are the first-line pharmacotherapy.
*Psychodynamic psychotherapy and citalopram*
- While citalopram (an SSRI) is an appropriate pharmacological treatment for OCD, **psychodynamic psychotherapy** is generally not considered first-line or most effective for OCD due to its focus on unconscious conflicts rather than direct symptom reduction.
- This approach may not provide the structured, symptom-focused interventions needed to manage obsessions and compulsions effectively.
*Cognitive behavioral therapy and haloperidol*
- **CBT** is an excellent choice, but **haloperidol**, an antipsychotic, is not a first-line treatment for OCD; it is primarily used for psychotic disorders or as an augmentation strategy in severe, treatment-resistant OCD, which is not indicated here.
- Using an antipsychotic as a primary treatment for OCD without a clear indication of psychosis or severe non-response to SSRIs is inappropriate and can lead to unnecessary side effects.
*Cognitive behavioral therapy and clonazepam*
- **CBT** is appropriate, but **clonazepam**, a benzodiazepine, is generally not recommended as a monotherapy or primary adjunctive treatment for OCD due to its *sedative side effects*, *potential for dependence*, and *lack of efficacy* in addressing the core symptoms of OCD.
- Benzodiazepines may be used for short-term anxiety relief but do not treat the underlying obsessive-compulsive processes.
*Psychodynamic psychotherapy and aripiprazole*
- **Psychodynamic psychotherapy** is not the most effective approach for OCD.
- **Aripiprazole**, an atypical antipsychotic, is typically used as an augmentation strategy for *treatment-resistant OCD* when initial SSRI trials have failed, not as a first-line medication, and this patient's case does not describe treatment resistance.
Question 50: A 13-year-old girl is brought to the physician because she has suddenly withdrawn from her close friends and has been displaying anger and hostility toward her friends at school, as well as toward her parents at home over the past month. She has also begun to skip classes and has been absent from school several times during this time period. Her mother says that she has been making up stories about her new art teacher touching her inappropriately. However, she believes that her daughter's behavior is the result of recent divorce issues in the family. Which of the following is the most appropriate next step in the evaluation of this patient?
A. Prescribing oral contraceptive pills
B. Performing a thorough genitourinary exam
C. Obtaining STD screening
D. Referring the patient for confirmation of sexual abuse (Correct Answer)
E. Referring the patient and her parents for family therapy
Explanation: ***Referring the patient for confirmation of sexual abuse***
- The patient's statements about the "new art teacher touching her inappropriately," coupled with a sudden shift in behavior including withdrawal, anger, hostility, and truancy, are **red flags for potential sexual abuse**.
- As a mandatory reporter, the physician has a legal and ethical obligation to investigate these allegations and ensure the child's safety, making a referral for confirmation of abuse the most critical immediate step.
*Prescribing oral contraceptive pills*
- There is **no indication** for contraception in this scenario, as the primary concern is potential abuse, not a request for birth control.
- Addressing the underlying behavioral and safety concerns takes precedence over prescribing medication for which there is no demonstrated need.
*Performing a thorough genitourinary exam*
- While a genitourinary exam might be part of an abuse investigation, it should be performed by a specialist in a **child-friendly, trauma-informed setting** and only after the appropriate referral and assessment for abuse has been initiated.
- Performing it as the *first* step without proper context or preparation could further traumatize the child.
*Obtaining STD screening*
- Similar to the genitourinary exam, STD screening is a component of a comprehensive sexual abuse evaluation but should not be the **initial or primary step**.
- It would follow a referral and confirmed suspicion of abuse, and be part of a coordinated care plan.
*Referring the patient and her parents for family therapy*
- While family therapy may be beneficial in addressing the impact of the parents' divorce or behavioral issues, it is **not the immediate priority** when there are direct allegations and strong indicators of sexual abuse.
- The safety of the child must be ensured first, and family therapy may not be appropriate in an acute abuse situation without prior investigation.
