Mood Disorders — MCQs

Q: A 45-year-old man comes to the physician for a routine health maintenance examination. He is asymptomatic. He reports that he recently found out that his wife had an affair with her personal trainer and that she now left him for her new partner. The patient is alone with their two children now. To be able to care for them, he had to reduce his working hours and to give up playing tennis twice a week. When asked about his feeling towards his wife and the situation, he reports that he has read several books about human emotion recently. He says, “Falling in love has neurological effects similar to those of amphetamines. I suppose, my wife was just seeking stimulation.” Which of the following defense mechanisms best describes this patient's reaction?

Intellectualization. ***Intellectualization*** - The patient demonstrates **intellectualization** by focusing on the abstract, theoretical aspects of his personal crisis, discussing neurology and human emotions rather than expressing his feelings of loss or betrayal. - This defense mechanism allows him to avoid confronting the painful emotional reality of his wife leaving him by engaging in **rational, cognitive thought** about the situation. *Sublimation* - **Sublimation** involves channeling unacceptable impulses or emotions into socially acceptable and constructive behaviors; for instance, expressing aggression through competitive sports. - While the patient has had to reduce his tennis playing, there is no evidence he is diverting his distress into new, positive, and productive activities sanctioned by society. *Rationalization* - **Rationalization** is creating logical but false explanations for one's own unacceptable feelings, behaviors, or motives to avoid self-blame or shame. - The patient's statements about his wife seeking stimulation are more about abstractly analyzing her actions rather than fabricating an excuse for his own behavior or feelings. *Humor* - **Humor** as a defense mechanism involves expressing uncomfortable feelings or thoughts in a way that is amusing or ironic, without necessarily diminishing the underlying emotion. - The patient's statement, while analytical, does not involve any comedic or lighthearted expression of his distress. *Externalization* - **Externalization** (often seen in projection) attributes one's own unacceptable thoughts or feelings to another person or object. - The patient is not projecting his own internal feelings onto his wife; rather, he is attempting to explain her actions through a detached, academic lens.

Q: A mother brings in her 7-year-old son because she is worried about his behavior after his teacher called. The patient’s mother says she was told that he has not been doing his assignments and frequently tells his teachers that he forgets about them. In addition, he tends to have a difficult time sitting still in class and frequently disrupts the other children. This behavior has been going on for about 8 months, but recently it worsened prompting his teacher to bring it to his mother’s attention. The patient’s mother was surprised to hear about these issues; however, she admits that she needs to repeat herself several times when asking her son to complete his chores. He also has trouble sitting still when doing homework. Which of the following is the most likely diagnosis in this patient?

Attention deficit hyperactivity disorder. ***Attention deficit hyperactivity disorder*** - The patient exhibits core symptoms of **inattention** (difficulty completing assignments, forgetting tasks, needing reminders for chores) and **hyperactivity/impulsivity** (difficulty sitting still, disrupting others). - These symptoms are present in multiple settings (school and home), have persisted for at least 6 months, and began before age 12, fulfilling the **DSM-5 criteria for ADHD**. *Conduct disorder* - This is characterized by a persistent pattern of behavior that violates the **basic rights of others** or major **age-appropriate societal norms or rules**. - Symptoms include aggression to people and animals, destruction of property, deceitfulness or theft, and serious rule violations, none of which are described in this patient. *Antisocial personality disorder* - This diagnosis requires individuals to be at least 18 years old and exhibit a pervasive pattern of **disregard for, and violation of, the rights of others** occurring since age 15. - The patient is only 7 years old and does not display the characteristic pattern of deceit, impulsivity, irritability, or lack of remorse associated with this disorder. *Oppositional defiant disorder* - Typically involves a pattern of **angry/irritable mood**, **argumentative/defiant behavior**, or **vindictiveness** directed towards authority figures. - While the patient may have some defiant traits by not doing chores, the primary issues are inattention and hyperactivity rather than active defiance or vindictive behavior. *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 indication that the patient is socially isolated, prefers solitary activities, or shows a lack of interest in others, making this diagnosis unlikely.

Q: You are a sleep physician comparing the results of several hypnograms taken in the sleep lab the prior night. You examine one chart which shows decreased REM sleep, less total time sleeping, and more frequent nocturnal awakenings. Which of these patients most likely exhibits this pattern?

A healthy 75-year-old male. ***A healthy 75-year-old male*** - As individuals **age**, changes in sleep architecture commonly include **decreased REM sleep**, reduced total sleep time, and more frequent **nocturnal awakenings**. - These normative age-related changes are due to alterations in **circadian rhythm regulation** and a decrease in the intensity of sleep-promoting mechanisms. *A healthy 9-month-old female* - **Infants** typically have a significantly **higher proportion of REM sleep** (around 50%) and **more total sleep time** than adults. - While they have frequent awakenings, their overall sleep pattern is not characterized by decreased REM sleep or less total sleep time. *A healthy 40-year-old male* - A healthy middle-aged adult generally exhibits a relatively **stable sleep architecture**, with typical percentages of REM and non-REM sleep. - Significant decreases in REM sleep, total sleep time, and frequent awakenings are **uncommon** in healthy individuals of this age without underlying pathology. *A healthy 3-year-old male* - **Young children** still exhibit a relatively **high percentage of REM sleep** and require a substantial amount of total sleep. - While night awakenings can occur, the overall sleep pattern is not usually characterized by the marked reduction in REM and total sleep seen in the described hypnogram. *A healthy 20-year-old female* - **Young adults** generally have a relatively **robust sleep architecture**, with a higher proportion of **slow-wave sleep** (deep sleep) and stable REM sleep percentages. - The described pattern of decreased REM and total sleep, along with frequent awakenings, is **atypical** for a healthy young adult.

A 21-year-old woman is brought to the emergency room 1 hour after she ingested 12 pills of acetaminophen. She had a fight with her boyfriend immediately prior to the ingestion, during which she threatened to kill herself if he broke up with her. She has been hospitalized 4 times for overdoses in the past 3 years following breakups with her partners. On the way to the hospital, she screamed and then assaulted the paramedic who attempted to take her temperature. Physical examination shows multiple rows of well-healed scars bilaterally on the wrists. This patient is most likely to display which of the following defense mechanisms?

A 48-year-old man and his wife present to a psychologist's office for a therapy session. He was encouraged to visit the psychiatrist 6 months ago by his wife and they have been meeting with the psychologist several times a month ever since. Initially, she was concerned about behavioral changes she observed after he was passed up for a promotion at work. She felt he was taking on a new personality and was acting like his coworker, who actually did get the promotion. He would also talk about his coworker and praise his intelligence and strategic character. Over the course of several months, the patient bought new clothes that looked like the other man's clothes. He changed his hairstyle and started using phrases that were similar to his coworker. Today, they both seem well. The patient still does not seem to think there is a problem and requests to stop therapy. His wife was frustrated because her husband recently bought a new car of the exact make and model of his coworker. Which of the following defense mechanisms best describes this patient's condition?

A 45-year-old man comes to the physician for a routine health maintenance examination. He is asymptomatic. He reports that he recently found out that his wife had an affair with her personal trainer and that she now left him for her new partner. The patient is alone with their two children now. To be able to care for them, he had to reduce his working hours and to give up playing tennis twice a week. When asked about his feeling towards his wife and the situation, he reports that he has read several books about human emotion recently. He says, “Falling in love has neurological effects similar to those of amphetamines. I suppose, my wife was just seeking stimulation.” Which of the following defense mechanisms best describes this patient's reaction?

A parent-teacher conference is called to discuss the behavior of a 9-year-old boy. According to the boy's teacher, he has become progressively more disruptive during class. He is performing poorly in school and has trouble focusing. He is destructive to classroom property, tore a classmate's art project, and takes other children's lunches regularly. He is avoided by his classmates. His mother reports that her son can "sometimes be difficult." Recently he placed a rubber band around the cats tail, resulting in gangrene. What is the most likely diagnosis?

A mother brings in her 7-year-old son because she is worried about his behavior after his teacher called. The patient’s mother says she was told that he has not been doing his assignments and frequently tells his teachers that he forgets about them. In addition, he tends to have a difficult time sitting still in class and frequently disrupts the other children. This behavior has been going on for about 8 months, but recently it worsened prompting his teacher to bring it to his mother’s attention. The patient’s mother was surprised to hear about these issues; however, she admits that she needs to repeat herself several times when asking her son to complete his chores. He also has trouble sitting still when doing homework. Which of the following is the most likely diagnosis in this patient?

A 33-year-old man comes into the ED after getting into a fight at a bar. He tells the physician that he was punched in the face for no reason. In the ED, he declares multiple times that he is incredibly angry and upset that he was beaten up. The patient's mood rapidly shifts between anger and sadness. He is wearing a multi-colored top with bright yellow pants, and he makes broad gestures while speaking. Before the paramedics left, they told the doctor that multiple bystanders at the bar reported the patient was flirting with numerous women. He began to touch one of them inappropriately, and she shoved him away. Upset, he demanded to be taken to the ED. The doctor begins to suspect the patient has a personality disorder. Which one is most likely?

In your outpatient clinic you are seeing a 22-year-old female for her annual check-up. She has a past medical history significant for sexual abuse in her teens. Currently she has no complaints. She reports that her last menstrual period was 1 week ago. Her temperature is 98.5 deg F (36.9 deg C), pulse is 65/min, blood pressure is 110/75 mmHg, respirations are 11/min. Physical exam is notable only for dry mucous membranes with multiple dental carries and calluses on the dorsum of her right hand. Her BMI is 17. What is the most likely diagnosis?

A 19-year-old man presents to the emergency room after a suicidal gesture following a fight with his new girlfriend. He tearfully tells you that she is “definitely the one," unlike his numerous previous girlfriends, who were "all mean and selfish” and with whom he frequently fought. During this fight, his current girlfriend suggested that they spend time apart, so he opened a window and threatened to jump unless she promised to never leave him. You gather that his other relationships have ended in similar ways. He endorses impulsive behaviors and describes his moods as “intense” and rapidly changing in response to people around him. He often feels “depressed” for one day and then elated the next. You notice several superficial cuts and scars on the patient’s arms and wrists, and he admits to cutting his wrists in order to “feel something other than my emptiness.” Which of the following is the most likely diagnosis for this patient?

A 38-year-old male presents for counseling by a psychologist mandated by the court. The patient explains that he does not mean to hit his wife when they are arguing, but something just comes over him that he cannot control. Upon further discussion, the patient reveals that his father was incarcerated several times for physically abusing his mother. Which of the following best describes the behavior seen in this patient?

Q10

You are a sleep physician comparing the results of several hypnograms taken in the sleep lab the prior night. You examine one chart which shows decreased REM sleep, less total time sleeping, and more frequent nocturnal awakenings. Which of these patients most likely exhibits this pattern?

Mood Disorders US Medical PG Practice Questions and MCQs

Question 1: A 21-year-old woman is brought to the emergency room 1 hour after she ingested 12 pills of acetaminophen. She had a fight with her boyfriend immediately prior to the ingestion, during which she threatened to kill herself if he broke up with her. She has been hospitalized 4 times for overdoses in the past 3 years following breakups with her partners. On the way to the hospital, she screamed and then assaulted the paramedic who attempted to take her temperature. Physical examination shows multiple rows of well-healed scars bilaterally on the wrists. This patient is most likely to display which of the following defense mechanisms?

A. Fantasy
B. Controlling
C. Displacement
D. Splitting (Correct Answer)
E. Sublimation

Explanation: ***Splitting*** - Splitting describes **inability to integrate positive and negative qualities** of self and others into a cohesive whole, leading to abrupt, alternating shifts between idealization and devaluation. This is characteristic of **borderline personality disorder (BPD)**, which is strongly suggested by the patient's history of impulsive acts (overdoses, assault, self-harm), unstable relationships, and suicidal threats. - The patient's immediate shift from threatening suicide to assaulting a paramedic, along with the history of repeated overdoses after relationship breakups, indicates an extreme "all good" or "all bad" perception of situations and people, a hallmark of splitting. *Fantasy* - Fantasy involves retreating into a **private mental world** to escape uncomfortable thoughts, feelings, or situations. While the patient may use fantasy at times, it is not the primary defense mechanism explaining her overt behaviors like assault and repeated overdose threats in real-life situations. - It often manifests as **daydreaming** or imaginatively creating alternative realities, which is not depicted as the leading defense in this scenario. *Controlling* - Controlling is a defense mechanism involving the **attempt to manage or regulate events or others** to minimize discomfort or anxiety. While the patient's behaviors might seem manipulative or an attempt to control her relationships, "controlling" in this context is a broader concept that is less specific than "splitting" for explaining the abrupt shifts in her perceptions and actions. - While aspects of her behavior may appear controlling (e.g., threatening suicide to prevent a breakup), it doesn't capture the underlying psychological mechanism of idealization and devaluation as effectively as splitting does. *Displacement* - Displacement involves redirecting an **emotion or impulse from its original source to a safer, more acceptable target**. While assaulting the paramedic could be seen as displacement of anger from her boyfriend, the broader pattern of her behavior (repeated overdoses, suicidal threats, and the "all good"/"all bad" framework) points more strongly to splitting. - The primary emotion (anger at her boyfriend) is redirected, but this single act doesn't explain the full spectrum of her unstable relationships and self-harm, which are characteristic of splitting. *Sublimation* - Sublimation is a **mature defense mechanism** where unacceptable impulses are transformed into socially acceptable and productive behaviors. This patient's actions, such as repeated overdoses, self-harm, and assault, are clearly maladaptive and destructive, not socially acceptable or constructive. - It involves channeling urges into creative or beneficial activities, which is the opposite of the impulsive and destructive behaviors exhibited by the patient.

Question 2: A 48-year-old man and his wife present to a psychologist's office for a therapy session. He was encouraged to visit the psychiatrist 6 months ago by his wife and they have been meeting with the psychologist several times a month ever since. Initially, she was concerned about behavioral changes she observed after he was passed up for a promotion at work. She felt he was taking on a new personality and was acting like his coworker, who actually did get the promotion. He would also talk about his coworker and praise his intelligence and strategic character. Over the course of several months, the patient bought new clothes that looked like the other man's clothes. He changed his hairstyle and started using phrases that were similar to his coworker. Today, they both seem well. The patient still does not seem to think there is a problem and requests to stop therapy. His wife was frustrated because her husband recently bought a new car of the exact make and model of his coworker. Which of the following defense mechanisms best describes this patient's condition?

A. Sublimation
B. Conversion
C. Regression
D. Splitting
E. Introjection (Correct Answer)

Explanation: ***Introjection*** - **Introjection** (also known as identification in some classification systems) is a defense mechanism where an individual unconsciously adopts the characteristics, attitudes, or behaviors of another person, particularly someone perceived as successful or threatening. - In this case, the patient responds to feelings of inadequacy after being passed over for promotion by adopting his coworker's external characteristics—clothes, hairstyle, speech patterns, and even purchasing the same car model. - This represents an attempt to cope with envy and feelings of inferiority by incorporating the perceived superior qualities of the coworker into his own identity. - **Clinical note**: Some classification systems distinguish between "identification" (behavioral imitation) and "introjection" (deeper internalization of values), though these terms are often used interchangeably in defense mechanism literature. *Sublimation* - **Sublimation** is a mature defense mechanism where unacceptable impulses or feelings are redirected into socially acceptable and productive behaviors (e.g., channeling aggressive urges into competitive sports). - The patient's behavior does not involve transforming an unacceptable urge into a constructive outlet; rather, it involves adopting another person's characteristics. *Conversion* - **Conversion disorder** (Functional Neurological Symptom Disorder) involves psychological distress manifesting as neurological symptoms without an identifiable medical cause, such as paralysis, blindness, or seizures. - The patient's presentation involves behavioral and personality changes, not the development of physical or neurological symptoms. *Regression* - **Regression** is a defense mechanism where an individual reverts to behaviors characteristic of an earlier developmental stage in response to stress (e.g., thumb-sucking, tantrums, excessive dependence). - The patient's behavior does not represent a return to childhood patterns but rather emulation of another successful adult. *Splitting* - **Splitting** is a primitive defense mechanism, commonly seen in borderline personality disorder, where individuals view people or situations as entirely good or entirely bad, unable to integrate both positive and negative qualities. - The patient's actions do not involve dichotomous thinking about people but rather an attempt to model himself after someone he perceives as successful.

Question 3: A 45-year-old man comes to the physician for a routine health maintenance examination. He is asymptomatic. He reports that he recently found out that his wife had an affair with her personal trainer and that she now left him for her new partner. The patient is alone with their two children now. To be able to care for them, he had to reduce his working hours and to give up playing tennis twice a week. When asked about his feeling towards his wife and the situation, he reports that he has read several books about human emotion recently. He says, “Falling in love has neurological effects similar to those of amphetamines. I suppose, my wife was just seeking stimulation.” Which of the following defense mechanisms best describes this patient's reaction?

A. Sublimation
B. Intellectualization (Correct Answer)
C. Rationalization
D. Humor
E. Externalization

Explanation: ***Intellectualization*** - The patient demonstrates **intellectualization** by focusing on the abstract, theoretical aspects of his personal crisis, discussing neurology and human emotions rather than expressing his feelings of loss or betrayal. - This defense mechanism allows him to avoid confronting the painful emotional reality of his wife leaving him by engaging in **rational, cognitive thought** about the situation. *Sublimation* - **Sublimation** involves channeling unacceptable impulses or emotions into socially acceptable and constructive behaviors; for instance, expressing aggression through competitive sports. - While the patient has had to reduce his tennis playing, there is no evidence he is diverting his distress into new, positive, and productive activities sanctioned by society. *Rationalization* - **Rationalization** is creating logical but false explanations for one's own unacceptable feelings, behaviors, or motives to avoid self-blame or shame. - The patient's statements about his wife seeking stimulation are more about abstractly analyzing her actions rather than fabricating an excuse for his own behavior or feelings. *Humor* - **Humor** as a defense mechanism involves expressing uncomfortable feelings or thoughts in a way that is amusing or ironic, without necessarily diminishing the underlying emotion. - The patient's statement, while analytical, does not involve any comedic or lighthearted expression of his distress. *Externalization* - **Externalization** (often seen in projection) attributes one's own unacceptable thoughts or feelings to another person or object. - The patient is not projecting his own internal feelings onto his wife; rather, he is attempting to explain her actions through a detached, academic lens.

Question 4: A parent-teacher conference is called to discuss the behavior of a 9-year-old boy. According to the boy's teacher, he has become progressively more disruptive during class. He is performing poorly in school and has trouble focusing. He is destructive to classroom property, tore a classmate's art project, and takes other children's lunches regularly. He is avoided by his classmates. His mother reports that her son can "sometimes be difficult." Recently he placed a rubber band around the cats tail, resulting in gangrene. What is the most likely diagnosis?

A. Oppositional defiant disorder
B. Conduct disorder (Correct Answer)
C. Antisocial personality disorder
D. Attention deficit disorder
E. Separation anxiety disorder

Explanation: **Conduct disorder** - The child's behaviors, such as **aggression towards people and animals** (harming the cat), **destruction of property** (tearing art project), **deceitfulness or theft** (taking lunches), and **serious rule violations** (extreme disruptiveness), are hallmark symptoms of conduct disorder. - The persistence and variety of these behaviors, causing significant impairment in social and academic functioning, align with the diagnostic criteria for conduct disorder, especially given the child's age. *Oppositional defiant disorder* - This disorder involves a pattern of **angry/irritable mood, argumentative/defiant behavior, or vindictiveness**, but typically does not include the more severe behaviors like aggression towards people or animals, destruction of property, or theft. - The child's actions (e.g., harming the cat, stealing lunches, destroying property) go beyond mere defiance and indicate a more pervasive pattern of aggression and rule-breaking. *Antisocial personality disorder* - Antisocial personality disorder cannot be diagnosed before the age of 18; however, evidence often indicates the presence of **conduct disorder** with onset before age 15. - While the symptoms described are consistent with precursors to antisocial personality disorder, the current age of the child (9 years old) makes this diagnosis inappropriate. *Attention deficit disorder* - While the child has trouble focusing and is disruptive, these are only some of the symptoms described; the prominent features are **aggression, destruction, and deceitfulness**, which are not core to ADHD. - ADHD primarily involves **inattention, hyperactivity, and impulsivity**, without the deliberate harmful intent or persistent violation of others' rights seen in this case. *Separation anxiety disorder* - This disorder is characterized by **excessive anxiety concerning separation** from attachment figures, often manifesting as refusal to go to school, nightmares about separation, or physical symptoms when anticipating separation. - The symptoms presented in the vignette (aggression, destruction, theft, and disruptive behavior) bear no resemblance to the diagnostic criteria for separation anxiety disorder.

Question 5: A mother brings in her 7-year-old son because she is worried about his behavior after his teacher called. The patient’s mother says she was told that he has not been doing his assignments and frequently tells his teachers that he forgets about them. In addition, he tends to have a difficult time sitting still in class and frequently disrupts the other children. This behavior has been going on for about 8 months, but recently it worsened prompting his teacher to bring it to his mother’s attention. The patient’s mother was surprised to hear about these issues; however, she admits that she needs to repeat herself several times when asking her son to complete his chores. He also has trouble sitting still when doing homework. Which of the following is the most likely diagnosis in this patient?

A. Conduct disorder
B. Antisocial personality disorder
C. Oppositional defiant disorder
D. Attention deficit hyperactivity disorder (Correct Answer)
E. Schizoid personality disorder

Explanation: ***Attention deficit hyperactivity disorder*** - The patient exhibits core symptoms of **inattention** (difficulty completing assignments, forgetting tasks, needing reminders for chores) and **hyperactivity/impulsivity** (difficulty sitting still, disrupting others). - These symptoms are present in multiple settings (school and home), have persisted for at least 6 months, and began before age 12, fulfilling the **DSM-5 criteria for ADHD**. *Conduct disorder* - This is characterized by a persistent pattern of behavior that violates the **basic rights of others** or major **age-appropriate societal norms or rules**. - Symptoms include aggression to people and animals, destruction of property, deceitfulness or theft, and serious rule violations, none of which are described in this patient. *Antisocial personality disorder* - This diagnosis requires individuals to be at least 18 years old and exhibit a pervasive pattern of **disregard for, and violation of, the rights of others** occurring since age 15. - The patient is only 7 years old and does not display the characteristic pattern of deceit, impulsivity, irritability, or lack of remorse associated with this disorder. *Oppositional defiant disorder* - Typically involves a pattern of **angry/irritable mood**, **argumentative/defiant behavior**, or **vindictiveness** directed towards authority figures. - While the patient may have some defiant traits by not doing chores, the primary issues are inattention and hyperactivity rather than active defiance or vindictive behavior. *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 indication that the patient is socially isolated, prefers solitary activities, or shows a lack of interest in others, making this diagnosis unlikely.

Question 6: A 33-year-old man comes into the ED after getting into a fight at a bar. He tells the physician that he was punched in the face for no reason. In the ED, he declares multiple times that he is incredibly angry and upset that he was beaten up. The patient's mood rapidly shifts between anger and sadness. He is wearing a multi-colored top with bright yellow pants, and he makes broad gestures while speaking. Before the paramedics left, they told the doctor that multiple bystanders at the bar reported the patient was flirting with numerous women. He began to touch one of them inappropriately, and she shoved him away. Upset, he demanded to be taken to the ED. The doctor begins to suspect the patient has a personality disorder. Which one is most likely?

A. Histrionic personality disorder (Correct Answer)
B. Borderline personality disorder
C. Schizotypal personality disorder
D. Narcissistic personality disorder
E. Antisocial personality disorder

Explanation: ***Histrionic personality disorder*** - Patients with **histrionic personality disorder** exhibit a pervasive pattern of excessive emotionality and attention-seeking behavior, often displayed through theatrical speech, provocative dress, and exaggerated gestures. - The rapid shifts in mood between anger and sadness, combined with **inappropriate flirtation** and demanding behavior after being rejected, are characteristic features. *Borderline personality disorder* - While mood lability is present in borderline personality disorder, it is typically accompanied by a pattern of **unstable relationships**, fear of abandonment, and identity disturbance, which are not explicitly highlighted in this presentation. - Patients with borderline personality disorder often engage in **self-harm** or suicidal gestures, which is not mentioned here. *Schizotypal personality disorder* - This disorder is characterized by **eccentric behavior**, peculiar thought patterns, and discomfort with close relationships, often involving magical thinking or unusual perceptual experiences. - The patient's presentation does not describe any **paranoid ideation** or odd beliefs typical of schizotypal personality disorder. *Narcissistic personality disorder* - Individuals with narcissistic personality disorder display a pervasive pattern of **grandiosity**, a need for admiration, and a lack of empathy, often exploiting others for personal gain. - While the patient might feel entitled, the primary presentation emphasizes **attention-seeking** and emotional volatility rather than an inflated sense of self-importance or exploitative behavior. *Antisocial personality disorder* - This disorder is marked by a pervasive pattern of **disregard for and violation of the rights of others**, often involving deceit, impulsivity, irritability, and a lack of remorse. - Although the patient's actions led to a physical altercation, the emphasis on **emotionality** and attention-seeking rather than a consistent pattern of antisocial acts makes this less likely.

Question 7: In your outpatient clinic you are seeing a 22-year-old female for her annual check-up. She has a past medical history significant for sexual abuse in her teens. Currently she has no complaints. She reports that her last menstrual period was 1 week ago. Her temperature is 98.5 deg F (36.9 deg C), pulse is 65/min, blood pressure is 110/75 mmHg, respirations are 11/min. Physical exam is notable only for dry mucous membranes with multiple dental carries and calluses on the dorsum of her right hand. Her BMI is 17. What is the most likely diagnosis?

A. Anorexia nervosa - restrictive type
B. Obsessive compulsive disorder
C. Bulimia nervosa
D. Eating disorder not otherwise specified
E. Anorexia nervosa - purging type (Correct Answer)

Explanation: ***Anorexia nervosa - purging type*** - This patient's **low BMI (17)**, **dental caries**, and **calluses on the dorsum of her right hand** (Russell's sign) are highly suggestive of **anorexia nervosa with purging behaviors**. The history of sexual abuse is also a risk factor for eating disorders. - While she states her last menstrual period was 1 week ago, **amenorrhea is not a required diagnostic criterion** for anorexia nervosa in DSM-5, and purging can complicate the menstrual cycle regardless of weight. *Anorexia nervosa - restrictive type* - While the **low BMI** is consistent with anorexia nervosa, the presence of **dental caries** and **Russell's sign** indicates **purging behaviors**, which are not characteristic of the restrictive type. - The restrictive type exclusively involves **restricting calorie intake**, excessive exercise, or fasting, without regular purging. *Obsessive compulsive disorder* - **OCD** is characterized by **obsessions and compulsions**, which might impact eating habits, but it does not directly explain the specific physical findings of **low BMI**, **dental caries**, and **Russell's sign**. - While there can be comorbidity, the primary presentation points to an eating disorder, not OCD. *Bulimia nervosa* - **Bulimia nervosa** is characterized by **recurrent episodes of binge eating** followed by compensatory behaviors like purging, and it also presents with **dental caries** and **Russell's sign**. - However, for a diagnosis of bulimia nervosa, the individual must maintain a **body weight within or above the normal range**, which contradicts this patient's **BMI of 17**. *Eating disorder not otherwise specified* - This category is used when symptoms cause significant distress or impairment but do not meet the full criteria for specific eating disorders. - Given the clear presentation of **low BMI** along with **purging behaviors** and associated physical signs, the criteria for anorexia nervosa, purging type, are met, making this diagnosis more specific.

Question 8: A 19-year-old man presents to the emergency room after a suicidal gesture following a fight with his new girlfriend. He tearfully tells you that she is “definitely the one," unlike his numerous previous girlfriends, who were "all mean and selfish” and with whom he frequently fought. During this fight, his current girlfriend suggested that they spend time apart, so he opened a window and threatened to jump unless she promised to never leave him. You gather that his other relationships have ended in similar ways. He endorses impulsive behaviors and describes his moods as “intense” and rapidly changing in response to people around him. He often feels “depressed” for one day and then elated the next. You notice several superficial cuts and scars on the patient’s arms and wrists, and he admits to cutting his wrists in order to “feel something other than my emptiness.” Which of the following is the most likely diagnosis for this patient?

A. Bipolar I disorder
B. Major depressive disorder
C. Borderline personality disorder (Correct Answer)
D. Bipolar II disorder
E. Histrionic personality disorder

Explanation: ***Borderline personality disorder*** - This patient exhibits characteristic features of **borderline personality disorder (BPD)**, including a pattern of **unstable relationships** marked by idealization ("definitely the one") and devaluation ("all mean and selfish"). - Other key features are **impulsivity** (suicidal gesture, cutting), **affective instability** ("intense" and rapidly changing moods), chronic feelings of **emptiness**, and a history of **self-harm** (superficial cuts and scars). *Bipolar I disorder* - While the patient describes rapidly changing and "intense" moods, the rapid shifts over days and reactivity to others are more characteristic of **mood lability** in BPD than distinct **manic or hypomanic episodes** lasting several days or longer, which define bipolar disorder. - The suicidal gesture stemming from interpersonal conflict and fear of abandonment, combined with chronic self-harm, points strongly away from a primary mood disorder. *Major depressive disorder* - Although the patient reports feeling "depressed," the predominant features are not a persistent depressed mood or anhedonia but rather **unstable relationships**, **impulsivity**, and **affective dysregulation** beyond typical depressive symptoms. - The "elated" periods described are also inconsistent with unipolar depression. *Bipolar II disorder* - This diagnosis requires a history of at least one **major depressive episode** and at least one **hypomanic episode**. While the patient describes mood shifts, they are described as "rapidly changing in response to people around him" and lasting for a day, which is more consistent with **affective instability** seen in BPD rather than sustained hypomanic episodes. - The prominent features of self-harm and unstable relationships are not central to Bipolar II disorder. *Histrionic personality disorder* - Patients with **histrionic personality disorder** typically display excessive emotionality and attention-seeking behavior, often with a theatrical presentation. - While there may be some overlap in attention-seeking aspects (suicidal gesture), the profound **instability of mood**, chronic **emptiness**, self-harm, and intense **fear of abandonment** are core to BPD and less characteristic of histrionic traits.

Question 9: A 38-year-old male presents for counseling by a psychologist mandated by the court. The patient explains that he does not mean to hit his wife when they are arguing, but something just comes over him that he cannot control. Upon further discussion, the patient reveals that his father was incarcerated several times for physically abusing his mother. Which of the following best describes the behavior seen in this patient?

A. Acting out (Correct Answer)
B. Reaction formation
C. Splitting
D. Dissociation
E. Identification

Explanation: ***Acting out*** - **Acting out** is the defense mechanism where unconscious emotional conflicts or impulses are expressed through actions rather than being consciously felt or verbalized. - The patient's violent behavior toward his wife represents the direct expression of aggressive impulses through physical action without conscious emotional processing or reflection. - The key phrase "something just comes over him that he cannot control" demonstrates the hallmark of acting out—expressing feelings through action rather than words or conscious awareness. - This is a primitive defense mechanism commonly seen in individuals with poor impulse control who cannot tolerate uncomfortable feelings. *Identification* - **Identification** involves unconsciously adopting the characteristics, behaviors, or attitudes of another person, typically to reduce anxiety. - While the patient has a history of witnessing his father's abuse, the question doesn't indicate he is consciously or unconsciously trying to become like his father or modeling himself after him. - The core issue here is impulsive action (acting out), not identification with the father figure. *Reaction formation* - **Reaction formation** occurs when an individual replaces an unacceptable impulse with its opposite behavior. - This is not present here, as the patient is directly expressing aggression, not replacing it with an opposite behavior like excessive kindness. *Splitting* - **Splitting** is viewing people or situations in extreme all-good or all-bad terms, without integrating positive and negative qualities. - This scenario describes a behavioral pattern, not a distortion in how the patient perceives others. *Dissociation* - **Dissociation** involves disruption in consciousness, memory, identity, or perception, with detachment from reality. - While the patient feels he "cannot control" himself, this describes impulsive acting out rather than true dissociation with memory gaps or detachment from identity.

Question 10: You are a sleep physician comparing the results of several hypnograms taken in the sleep lab the prior night. You examine one chart which shows decreased REM sleep, less total time sleeping, and more frequent nocturnal awakenings. Which of these patients most likely exhibits this pattern?

A. A healthy 9-month-old female
B. A healthy 40-year-old male
C. A healthy 75-year-old male (Correct Answer)
D. A healthy 3-year-old male
E. A healthy 20-year-old female

Explanation: ***A healthy 75-year-old male*** - As individuals **age**, changes in sleep architecture commonly include **decreased REM sleep**, reduced total sleep time, and more frequent **nocturnal awakenings**. - These normative age-related changes are due to alterations in **circadian rhythm regulation** and a decrease in the intensity of sleep-promoting mechanisms. *A healthy 9-month-old female* - **Infants** typically have a significantly **higher proportion of REM sleep** (around 50%) and **more total sleep time** than adults. - While they have frequent awakenings, their overall sleep pattern is not characterized by decreased REM sleep or less total sleep time. *A healthy 40-year-old male* - A healthy middle-aged adult generally exhibits a relatively **stable sleep architecture**, with typical percentages of REM and non-REM sleep. - Significant decreases in REM sleep, total sleep time, and frequent awakenings are **uncommon** in healthy individuals of this age without underlying pathology. *A healthy 3-year-old male* - **Young children** still exhibit a relatively **high percentage of REM sleep** and require a substantial amount of total sleep. - While night awakenings can occur, the overall sleep pattern is not usually characterized by the marked reduction in REM and total sleep seen in the described hypnogram. *A healthy 20-year-old female* - **Young adults** generally have a relatively **robust sleep architecture**, with a higher proportion of **slow-wave sleep** (deep sleep) and stable REM sleep percentages. - The described pattern of decreased REM and total sleep, along with frequent awakenings, is **atypical** for a healthy young adult.

Question 11: A 18-year-old woman presents to her primary care physician reporting that she has not experienced her first menses. She is accompanied by her mother who states that she personally experienced menstruation at age 12 and that the patient's sister started menstruating at the age of 11 years. The patient is not sexually-active and denies taking any medications. On physical examination, the patient appears thin and has fine hair covering her arms. Her height is 62 inches (157.48 cm) and her weight is 85 pounds (38.5 kg). The patient does not make eye contact and only answers in one word responses. The mother is asked to step out of the room and the interview resumes. After establishing some trust, the patient admits that she does not have an appetite. She has had difficulty sleeping and some feels guilty for worrying her mother. She also admits to occasional cocaine use. She switches between binge-eating and vomiting. She is constantly fatigued but she also goes to the gym three times daily, often without her parents’ knowledge. Which of the following is the most likely diagnosis in this patient?

A. Binge-eating disorder
B. Anorexia nervosa (Correct Answer)
C. Bulimia nervosa
D. Major depressive disorder
E. Illicit substance use

Explanation: ***Anorexia nervosa*** - The patient presents with **amenorrhea**, significantly low body weight (BMI of 15.6 kg/m$^2$), and a strong fear of gaining weight, evidenced by excessive exercise and restricted eating. The **lanugo hair** on her arms is a common sign of severe malnutrition. - The reported **binge-eating and vomiting** episodes are often part of the **binge-eating/purging type** of anorexia nervosa, and her social withdrawal, guilt, and fatigue are consistent with the psychological distress seen in this disorder. *Binge-eating disorder* - This disorder is characterized by recurrent episodes of **binge eating** without compensatory behaviors, which contradicts the patient's reported vomiting and excessive exercise. - Patients with binge-eating disorder typically **do not exhibit low body weight**, and often they are overweight or obese, which is not the case here. *Bulimia nervosa* - While bulimia nervosa involves **binge-eating and compensatory behaviors** (like vomiting and excessive exercise), it is primarily diagnosed when these behaviors occur in individuals of **normal weight or overweight/obese**, not in those with significantly low body weight. - The patient's **amenorrhea** and **emaciation** strongly point away from typical bulimia nervosa and towards anorexia nervosa. *Major depressive disorder* - While the patient exhibits symptoms like **fatigue, guilt, insomnia, and social withdrawal** which can be seen in major depressive disorder, these are often secondary to the severe eating disorder and nutritional deficiencies. - The presence of specific eating disorder behaviors (extreme weight loss efforts, body image distortion, binge-purging cycles) makes an eating disorder a more comprehensive and primary diagnosis. *Illicit substance use* - Although the patient admits to occasional **cocaine use**, this is unlikely to be the primary diagnosis explaining the constellation of symptoms including **severe weight loss, amenorrhea, excessive exercise, and body image disturbance**. - Substance use can co-occur with eating disorders, but it does not account for the core features of the patient's presentation.

Question 12: A 27-year-old woman presents to your office complaining of right arm numbness and weakness. Her past medical history is unremarkable. Her family history, however, is significant for the unexpected death of both her parents at age 59 in a motor vehicle accident last week. On physical exam, her bicep, brachioradialis, and patellar reflexes are 2+ bilaterally. CNS imaging shows no abnormalities. Which of the following is the most likely diagnosis?

A. Amyotrophic lateral sclerosis
B. Multiple sclerosis
C. Conversion disorder (Correct Answer)
D. Arnold-Chiari malformation
E. Vitamin B12 deficiency

Explanation: ***Conversion disorder*** - The patient's presentation of **numbness and weakness** following a significant **psychological stressor** (parents' deaths) with a normal neurological exam and imaging is classic for conversion disorder. - In conversion disorder, neurological symptoms are inconsistent with known neurological pathways or conditions, and symptoms are often out of patient's conscious control. *Amyotrophic lateral sclerosis* - This condition involves both **upper and lower motor neuron signs**, such as **spasticity, hyperreflexia**, and muscle atrophy, which are not described in this patient's presentation. - ALS typically progresses over time, and the patient's symptoms are acute and without objective neurological findings. *Multiple sclerosis* - MS is characterized by **demyelinating lesions in the CNS** leading to various neurological deficits, which would be visible on CNS imaging. - The patient's normal CNS imaging and unremarkable medical history make MS less likely. *Arnold-Chiari malformation* - This is a structural defect in the cerebellum and brainstem that can cause a range of neurological symptoms, often present from birth or early childhood. - However, typical MRI findings for Chiari malformation would be present, and the acute onset after psychological stress is not characteristic. *Vitamin B12 deficiency* - Can cause **neurological symptoms** such as **paresthesias, weakness, and ataxia**, but it would likely present with other systemic effects like anemia and would typically involve abnormal neurological findings or lab values. - The acute, localized symptoms following stress, absence of other signs, and normal imaging make this diagnosis unlikely.

Question 13: An 8-year-old girl presents to the psychiatrist to discuss the recent divorce of her parents. The girl explains that her mother is the most caring and loving mother anyone could ever have and that she will be spending the majority of her time with her mother. On the other hand, she exclaims that her father is an evil person and hates him. Which of the following ego defenses is best demonstrated by this girl?

A. Splitting (Correct Answer)
B. Projection
C. Denial
D. Regression
E. Acting out

Explanation: ***Splitting*** - **Splitting** is an ego defense mechanism where an individual views people or situations in **all-or-nothing terms**, categorizing them as either entirely good or entirely bad, without acknowledging any integration of positive and negative qualities. - The girl demonstrates splitting by idealizing her mother as "the most caring and loving" while completely devaluing her father as "evil" and expressing hatred, indicating a failure to integrate both positive and negative aspects of her parents. *Projection* - **Projection** involves attributing one's own unacceptable thoughts, feelings, or impulses to another person. - The girl is expressing her own feelings towards her parents, not attributing her own internal states to them. *Denial* - **Denial** is a defense mechanism where an individual refuses to acknowledge a painful or anxiety-provoking reality. - The girl is actively acknowledging and expressing her feelings about her parents and their divorce, rather than denying the situation. *Regression* - **Regression** is a return to an earlier or less mature stage of development when faced with stress or anxiety. - While the stress of divorce could lead to regression, the described behavior specifically involves categorizing her parents rather than exhibiting younger behaviors like thumb-sucking or bedwetting. *Acting out* - **Acting out** involves expressing forbidden or unconscious impulses through action, often in a self-destructive or attention-seeking manner, instead of verbally or emotionally processing them. - The girl is verbally articulating her feelings and perceptions, not engaging in impulsive or destructive behaviors.

Question 14: A 13-year-old boy is brought to the physician by his parents for the evaluation of multiple behavioral problems. The parents report that their son has been bullying several classmates at school over the past year. During this period, he has been accused twice of stealing items from a local store. He has also beaten up the neighbor's son for no obvious reason. The parents state that they had to give up their dog for adoption after finding out that their son was torturing him. There is no personal or family history of serious illness. He attends a local middle school and his performance at school is poor compared to his classmates. He often forgets to do his homework and argues with his teachers. He was also caught smoking cigarettes. Vital signs are within normal limits. Physical examination shows no abnormalities. He has poor attention and does not answer some of the questions. For questions he answers affirmatively about his actions, he sometimes replies, “So what?.” Which of the following conditions is this patient most likely to develop?

A. Early-onset dementia
B. Antisocial personality disorder (Correct Answer)
C. Major depressive disorder
D. Bipolar disorder
E. Obsessive-compulsive disorder

Explanation: ***Antisocial personality disorder*** - The patient's history of **repeated bullying**, stealing, physical aggression, animal cruelty, and lack of remorse ("So what?") are all characteristic behaviors of **Conduct Disorder**. - **Conduct Disorder**, if left untreated and symptoms persist into adulthood (age 18 and older), frequently progresses to **Antisocial Personality Disorder**. *Early-onset dementia* - **Dementia** involves a significant decline in cognitive function, such as memory and executive function, which is not indicated by the presented behavioral issues. - While the patient has poor attention and academic performance, these are more aligned with behavioral difficulties and learning problems rather than a neurodegenerative process. *Major depressive disorder* - **Major depressive disorder** (MDD) symptoms include persistent low mood, anhedonia, changes in appetite or sleep, and feelings of worthlessness or guilt. - The patient's presentation primarily involves **externalizing behaviors** (aggression, stealing) and a lack of remorse, which contradicts the internalizing symptoms typically seen in MDD. *Bipolar disorder* - **Bipolar disorder** is characterized by episodes of both depression and elevated mood (mania or hypomania), which is not described. - While periods of irritability can occur in bipolar disorder, the chronic pattern of **deliberate rule-breaking**, aggression, and lack of empathy is not typical of its presentation. *Obsessive-compulsive disorder* - **Obsessive-compulsive disorder** (OCD) involves recurrent, intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) performed to reduce anxiety. - The patient's behaviors, such as bullying, stealing, and aggression, are not consistent with the anxiety-driven, ritualistic patterns seen in OCD.

Question 15: A 24-year-old woman visits her psychiatrist a week after she delivered a baby. She is holding her baby and crying as she waits for her appointment. She tells her physician that a day or so after her delivery, she has been finding it difficult to contain her feelings. She is often sad and unable to contain her tears. She is embarrassed and often starts crying without any reason in front of people. She is also anxious that she will not be a good mother and will make mistakes. She hasn’t slept much since the delivery and is often stressed about her baby getting hurt. She makes excessive attempts to keep the baby safe and avoid any mishaps. She does not report any loss of interest in her activities and denies any suicidal tendencies. Which of the following is best course of management for this patient?

A. Get admitted immediately
B. Come back for a follow-up in 2 weeks (Correct Answer)
C. Start on a small dose of fluoxetine daily
D. Give her child to child protective services
E. Schedule an appointment for electroconvulsive therapy

Explanation: ***Come back for a follow-up in 2 weeks*** - This patient presents with symptoms highly suggestive of **postpartum blues**, which typically resolve spontaneously within two weeks after delivery. - Reassurance, emotional support, and monitoring her symptoms with a follow-up appointment are the most appropriate initial steps. *Get admitted immediately* - Immediate admission is generally reserved for more severe conditions like **postpartum psychosis**, characterized by delusions, hallucinations, or severe disorganization, which are not described here. - Her symptoms, though distressing, do not indicate a level of impairment or danger requiring urgent inpatient care. *Start on a small dose of fluoxetine daily* - **Antidepressant medication** like fluoxetine is typically considered for **postpartum depression** if symptoms persist beyond two weeks or are severe from the outset. - Given the transient nature of postpartum blues, medication is not the first-line treatment. *Give her child to child protective services* - This action is extreme and entirely unwarranted, as there is no indication of **child abuse, neglect, or harm** from the mother. - Her increased anxiety about the baby's safety indicates concern, not a risk to the child's well-being. *Schedule an appointment for electroconvulsive therapy* - **Electroconvulsive therapy (ECT)** is a highly effective, but usually last-resort, treatment reserved for severe, treatment-refractory depression or psychosis, especially when rapid response is critical. - Her symptoms do not currently warrant such an intensive intervention.

Question 16: A 13-year-old boy is brought to the physician by his mother because she is concerned about her son's behavior. She reports that he has been wearing her dresses at home and asks to be called Lilly. He also stopped going to swim class because he “doesn't feel comfortable in swim trunks.” Since starting puberty about a year ago, he has not had any friends and the teachers report he is consistently being bullied at school. His academic performance has been poor for the last year even though he had maintained an A average the year before. The mother further reports that her son has had mainly female friends since preschool. She also mentions that as a child her son never enjoyed playing with typical boy toys like cars and instead preferred dressing up dolls. The patient was raised by his single mother from the age of 8 because his father left the family due to financial issues. He appears shy. Physical examination shows normal male external genitalia. There is scarce coarse, dark axillary and pubic hair. Upon questioning, the patient reports that he would rather be a girl. Which of the following is the most likely diagnosis?

A. Sexual aversion
B. Gender nonconformity
C. Gender dysphoria (Correct Answer)
D. Fetishistic disorder
E. Body dysmorphic disorder

Explanation: ***Gender dysphoria*** - This patient exhibits a marked incongruence between his **assigned sex at birth** (male) and his **experienced gender** (female), accompanied by significant distress and impairment in social and academic functioning. - Key indicators include wanting to be called by a female name (**Lilly**), wearing female clothing, discomfort with male secondary sex characteristics (swim trunks), and explicitly stating a wish to be a girl. *Sexual aversion* - This involves a strong and persistent aversion to **sexual activity** or specific aspects of sexual activity, which is not the primary issue described in the patient's presentation. - The patient's distress is related to his gender identity, not an aversion to sexual contact. *Gender nonconformity* - Refers to behaviors that are not typical for a person's assigned gender (e.g., a boy playing with dolls), but it does not necessarily cause **distress** or impairment in functioning. - In this case, the patient's strong desire to be a girl and the associated distress from puberty and bullying go beyond simple nonconformity. *Fetishistic disorder* - Characterized by recurrent, intense **sexual arousal** from fantasies, urges, or behaviors involving inanimate objects or non-genital body parts. - The patient's desire to wear dresses and identify as a girl is related to his gender identity, not a paraphilic sexual interest. *Body dysmorphic disorder* - Involves preoccupation with a perceived **flaw in physical appearance** that is not observable or appears slight to others, leading to significant distress or impairment. - The patient's discomfort is with his entire physical sex and gender, not a specific perceived flaw in his body or appearance.

Question 17: A 15-year-old boy is referred to a child psychologist because of worsening behavior and constant disruption in class. He has received multiple reprimands in the past 6 months for not doing the homework his teacher assigned, and he refuses to listen to the classroom instructions. Additionally, his teachers say he is very argumentative and blames other children for not letting him do his work. He was previously well behaved and one of the top students in his class. He denies any recent major life events or changes at home. His past medical history is noncontributory. His vital signs are all within normal limits. Which of the following is the most likely diagnosis?

A. Attention deficit hyperactivity disorder
B. Antisocial personality disorder
C. Conduct disorder
D. Oppositional defiant disorder (Correct Answer)
E. Major depressive disorder

Explanation: ***Oppositional defiant disorder*** - This patient's symptoms of **argumentativeness**, **defiance**, and **blaming others**, combined with his previous good behavior and denial of major life events, are classic signs of **oppositional defiant disorder (ODD)**. - ODD involves a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months, clearly distinguishing it from a temporary behavioral issue. *Attention deficit hyperactivity disorder* - While **ADHD** can cause inattention and difficulty following instructions, it typically presents earlier in childhood and is characterized by **hyperactivity**, **impulsivity**, and **inattention** that would have likely been prominent before recently. - The patient's primary symptoms here are an argumentative and defiant attitude rather than core symptoms of inattention or hyperactivity that began recently. *Antisocial personality disorder* - This disorder is typically diagnosed in **adulthood (18 years or older)**, although symptoms of **conduct disorder** must be present before age 15. The patient is currently 15. - **Antisocial personality disorder** involves a pervasive pattern of disregard for and violation of the rights of others, which is more severe than the defiance seen in this case. *Conduct disorder* - **Conduct disorder** involves a more severe pattern of behavior, including aggression towards people or animals, destruction of property, deceitfulness or theft, and serious violations of rules, which is not described in this patient. - The behaviors in this patient (argumentativeness, defiance) are less severe than the behaviors associated with conduct disorder. *Major depressive disorder* - Although behavioral changes can occur in **depression**, this patient does not exhibit other common symptoms such as **anhedonia**, changes in sleep or appetite, or persistent sadness, which would be expected with **major depressive disorder**. - His behaviors are primarily externalizing and defiant rather than indicating an internal state of sadness or loss of interest.

Question 18: A 29-year-old man presents to his primary care provider complaining of not being able to get enough rest at night. He goes to bed early enough and has otherwise good sleep hygiene but feels drained the next day. He feels he is unable to perform optimally at work, but he is still a valued employee and able to complete his share of the work. About a month ago his wife of 5 years asked for a divorce and quickly moved out. He has cut out coffee after 12 pm and stopped drinking alcohol. He also exercises 3 days per week. Today, his blood pressure is 120/80 mm Hg, heart rate is 95/min, respiratory rate is 25/min, and temperature is 37.0°C (98.6°F ). On physical exam, his heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. A CMP, CBC, and thyroid test are negative. Which of the following statements best describes this patient’s condition?

A. Symptoms are usually self-limited and may persist for 2 years
B. Symptoms typically resolve within 6 months after the stressor ends (Correct Answer)
C. Symptoms develop within 3 months of the stressor
D. Symptoms may be persistent if the stressor is chronic
E. Symptoms represent a maladaptive response to an identifiable stressor

Explanation: ***Symptoms typically resolve within 6 months after the stressor ends*** - This statement accurately describes the **temporal criterion for adjustment disorder** according to DSM-5. Once the stressor or its consequences have terminated, symptoms should resolve within 6 months. - This patient experienced a clear stressor (divorce and wife moving out ~1 month ago) and developed symptoms in response. The diagnosis of adjustment disorder requires that these symptoms resolve within 6 months of the stressor's termination. - His symptoms (poor sleep, feeling drained, suboptimal performance) represent a significant but not incapacitating response, consistent with adjustment disorder. Normal labs rule out medical causes. - This temporal criterion distinguishes adjustment disorder from more chronic conditions and helps guide prognosis and treatment planning. *Symptoms are usually self-limited and may persist for 2 years* - Adjustment disorder symptoms should resolve within **6 months**, not 2 years, after the stressor or its consequences have ended. - If symptoms persist beyond 6 months, this suggests either ongoing stressor consequences, a persistent subtype (for chronic stressors), or an alternative diagnosis should be considered. *Symptoms develop within 3 months of the stressor* - While this is a **correct diagnostic criterion** (symptoms must develop within 3 months of stressor onset), it only addresses timing of onset, not the complete picture. - The question asks for the statement that "best describes" the condition, and the resolution timeline is more distinctive and prognostically important than onset timing alone. *Symptoms may be persistent if the stressor is chronic* - This describes the **persistent specifier** in DSM-5, which applies when the stressor or its consequences are ongoing (chronic stressor or enduring consequences). - However, in this case, the stressor appears to be acute (wife moved out), not chronic, making this less applicable to the specific clinical scenario presented. *Symptoms represent a maladaptive response to an identifiable stressor* - This is a **core defining feature** of adjustment disorder - the development of emotional/behavioral symptoms in response to an identifiable stressor with marked distress or impairment. - While accurate, this is a general characteristic shared across the definition and doesn't capture the specific **temporal criteria** (resolution within 6 months) that is most distinctive for adjustment disorder diagnosis and prognosis.

Question 19: A 21-year-old man presents to the clinic complaining of feeling tired during the day. He is concerned as his grades in school have worsened and he does not want to lose his scholarship. Upon further questioning, the patient describes frequently experiencing a dreamlike state before falling asleep and after waking up. He also has frequent nighttime awakenings where he finds himself unable to move. He denies snoring. The patient does not drink alcohol or abuse any other drugs. The patient's BMI is 21 kg/m2, and his vital signs are all within normal limits. What is this patient's diagnosis?

A. Obstructive sleep apnea (OSA)
B. Insomnia
C. Alcohol withdrawal
D. Delayed sleep phase syndrome (DSPS)
E. Narcolepsy (Correct Answer)

Explanation: ***Narcolepsy*** - The patient's symptoms of **excessive daytime sleepiness**, **hypnagogic/hypnopompic hallucinations** (dreamlike state before falling asleep and after waking up), and **sleep paralysis** (unable to move during nighttime awakenings) are the **classic tetrad of narcolepsy** (cataplexy is the 4th feature, not present here). - The absence of snoring, normal BMI, and lack of alcohol/drug use rule out other common causes of sleep disturbances, supporting the diagnosis of narcolepsy. - Narcolepsy is a **chronic sleep-wake disorder** caused by hypothalamic hypocretin (orexin) deficiency. *Obstructive sleep apnea (OSA)* - While OSA also causes **daytime sleepiness**, a key feature is **snoring**, which this patient denies. - OSA is often associated with obesity, but this patient has a **normal BMI of 21 kg/m²**. - OSA would not explain the hypnagogic hallucinations or sleep paralysis. *Insomnia* - Insomnia primarily involves difficulty initiating or maintaining sleep, leading to **insufficient sleep quantity or quality**. - This patient's symptoms are more specific, including episodes of sleep paralysis and vivid dreamlike states, rather than just general difficulty sleeping. - The hallmark features of narcolepsy distinguish this from simple insomnia. *Alcohol withdrawal* - Alcohol withdrawal can cause **sleep disturbances**, but it is typically accompanied by other symptoms like tremors, anxiety, autonomic hyperactivity, and potentially seizures, none of which are present. - The patient **explicitly denies drinking alcohol**, making this diagnosis highly unlikely. *Delayed sleep phase syndrome (DSPS)* - DSPS is a **circadian rhythm disorder** characterized by a delayed sleep-wake cycle, where individuals fall asleep and wake up later than desired. - While it can cause daytime fatigue if individuals are forced to wake up early, it does **not** involve the specific symptoms of hypnagogic/hypnopompic hallucinations or sleep paralysis seen in this patient. - DSPS is primarily a timing issue, not a neurological sleep disorder.

Question 20: A 40-year-old man is brought into the emergency department because he was involved in a bar fight and sustained an injury to the head. The next day, as requested by the patient, the psychiatry team is called to address some of the concerns he has regarding his drinking habits. He admits that he got irate last night at the bar because his driver’s license was recently taken away and his wife had taken his children to live with her parents because of his drinking problem. He drinks 4–6 beers on a weeknight and more on the weekends. He wants to know if there is anything that could help him at this point. Which stage of overcoming his addiction is this patient currently in?

A. Action
B. Precontemplation
C. Maintenance
D. Contemplation (Correct Answer)
E. Preparation

Explanation: ***Contemplation*** - The patient acknowledges his drinking problem and its serious consequences (loss of driver's license, family separation), demonstrating awareness that change is needed. - He actively requests psychiatric consultation and asks "if there is anything that could help him," indicating he is **exploring options and gathering information** about change. - However, he has not yet made a firm commitment to take action or developed a specific plan, which distinguishes contemplation from preparation. - The **contemplation stage** is characterized by recognition of the problem and consideration of change, with typical ambivalence about taking action—this patient is in this exploratory phase. *Preparation* - The **preparation stage** requires a clear commitment and intent to take action in the immediate future (typically within 30 days), often with a specific plan in place. - This patient is asking exploratory questions rather than stating he is ready to start treatment or outlining steps he will take. - Simply requesting information does not constitute preparation; there must be demonstrated readiness to act. *Precontemplation* - In the **precontemplation stage**, individuals deny having a problem or have no intention of changing their behavior. - This patient clearly acknowledges his drinking problem and recognizes the negative consequences, moving him well beyond precontemplation. *Action* - The **action stage** involves actively modifying behavior and implementing specific strategies to overcome the addiction. - This patient has not yet begun any treatment or behavioral changes related to his drinking. *Maintenance* - The **maintenance stage** occurs after sustained behavior change for at least six months, focusing on preventing relapse. - This patient has not yet initiated any changes to maintain.

Question 21: A 24-year-old man comes to the physician with a wound on his forearm. He says that he injured himself by absentmindedly walking into a glass door. He does not have health insurance. He has had 5 jobs in the past 8 months. He quit each job after 3–4 weeks because he found the work beneath him. He was imprisoned 6 years ago for credit card fraud. He was released from prison on parole a year ago. He was expelled from school at the age of 13 years for stealing school property and threatening to assault a teacher. He has fathered 6 children with 4 women. He says that he does not provide child support because he needs the money for his own personal expenses. The patient's vital signs are within normal limits. Examination of the forearm shows a 6 cm long, 0.5 cm deep wound with neat edges on the dorsal surface of the left forearm. There are bruises on the left shoulder, back, and the proximal phalanges of the right hand. On mental status examination, the patient is alert and calm. His mood is described as cheerful. His thought process, thought content, and speech are normal. Which of the following is the most likely diagnosis?

A. Antisocial personality disorder (Correct Answer)
B. Intermittent explosive disorder
C. Oppositional defiant disorder
D. Narcissistic personality disorder
E. Conduct disorder

Explanation: **Antisocial personality disorder** - The patient exhibits a pervasive pattern of **disregard for and violation of the rights of others**, including impulsive behavior, chronic unemployment, criminal history (**credit card fraud, parole violation**), and lack of remorse for not supporting his children. These behaviors are hallmarks of **antisocial personality disorder**. - The history of behavioral problems starting at age 13 with **stealing and threatening a teacher** (a pattern consistent with childhood conduct disorder transforming into antisocial personality disorder in adulthood) further supports this diagnosis. *Intermittent explosive disorder* - Characterized by recurrent behavioral outbursts representing a failure to control aggressive impulses, often involving verbal aggression or physical aggression toward property, animals, or other individuals. - While the patient has a history of aggression (threatening a teacher), the primary features in the vignette are more consistent with a pervasive pattern of disregard for others' rights and law-breaking, not solely explosive outbursts. *Oppositional defiant disorder* - Characterized by a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months, typically seen in childhood and adolescence. - The patient's behaviors, such as credit card fraud, chronic unemployment, multiple children with different partners, and lack of child support, extend far beyond just oppositional defiance and involve serious violations of societal norms and laws. *Narcissistic personality disorder* - Involves a pervasive pattern of grandiosity, a need for admiration, and a lack of empathy; the patient's statement about work being "beneath him" hints at grandiosity. - However, the prominent features of **criminality, impulsivity, and disregard for others' rights** are more consistent with antisocial personality disorder than narcissistic personality disorder. *Conduct disorder* - This is a diagnostic category for persistent patterns of behavior in childhood and adolescence where the basic rights of others or major age-appropriate societal norms or rules are violated. - While the patient's history at age 13 (stealing, threatening a teacher) would likely meet criteria for **conduct disorder**, this diagnosis is for individuals under 18. At 24 years old, the adult equivalent is antisocial personality disorder.

Question 22: A 17-year-old girl presents to the clinic on her own, complaining of fatigue and feeling cold all the time. She is also very concerned about several minor medical conditions she has developed over the last year or so. Her past medical history is noncontributory. Menarche was at age 11 and her last menstrual period was 3 months ago. Her mother has hypothyroidism and she is concerned that she has it too. She proudly describes her “healthy” routine that consists of 2 grapefruits a day for breakfast and lunch and no dinner and that she runs 6 miles 4 times a week. She reports having good grades in school and that she tries very hard to fit in with the popular girls. She is also concerned that she has trouble losing weight and persistently asks for a prescription for weight loss medication. Her temperature is 36.9°C (98.5°F), blood pressure is 110/70 mm Hg, pulse is 60/min, and respirations are 13/min. Physical examination reveals a thin girl with pale mucosa and lanugo on her arms and back. Urine hCG is negative. Which of the following will most likely be detected in this patient?

A. Pressured speech
B. Increased hemoglobin
C. Normal serum iron levels
D. BMI less than 17 (Correct Answer)
E. Moist, supple skin

Explanation: ***BMI less than 17*** - The patient's presentation with significant **weight loss efforts**, specific dietary restrictions ("2 grapefruits a day for breakfast and lunch, no dinner"), **amenorrhea**, and physical signs like being "thin," "pale mucosa," and **lanugo** strongly points to **anorexia nervosa**. - A body mass index (BMI) of less than 17 kg/m² for adults (or below the 15th percentile for age and sex in adolescents) is a diagnostic criterion for **anorexia nervosa**, reflecting severe underweight. *Pressured speech* - **Pressured speech** is characteristic of **mania** or **hypomania**, where individuals talk rapidly and incessantly, often interrupting or being difficult to interrupt. - This symptom is not typical of anorexia nervosa, and the patient's concern for grades and fitting in, along with fatigue, suggests a more depressive or anxious state rather than elevated mood. *Increased hemoglobin* - Patients with anorexia nervosa often experience **malnutrition**, which can lead to **anemia** due to deficiencies in iron, folate, or vitamin B12. - Thus, **decreased hemoglobin** would be a more likely finding, rather than increased hemoglobin. *Normal serum iron levels* - Due to the severe dietary restrictions and potential for **malabsorption** or **nutritional deficiencies** in anorexia nervosa, patients are prone to developing **iron deficiency**. - Therefore, **low serum iron levels** would be a more expected finding, contributing to her reported fatigue and pale mucosa. *Moist, supple skin* - In anorexia nervosa, dehydration and poor nutritional status often lead to **dry, scaly skin**. - The presence of **lanugo** (fine, downy hair) is a common finding, indicating the body's attempt to conserve heat due to lack of subcutaneous fat, rather than moist, supple skin.

Question 23: A 60-year-old man is brought to the emergency department after a fall. He has been seen by the triage nurse but has not been evaluated by a physician. He is heard yelling down the hallway, requesting to speak to “whoever is in charge.” He refuses to talk to the emergency resident and insists on talking to the attending physician despite being informed that the attending is currently resuscitating a patient who was in a car accident. He says that he deserves better treatment because he has made numerous contributions to the field of medicine. When asked about his work, he mentions that he was a medical device salesman. He is accompanied by his wife, who appears embarrassed. She claims that her husband frequently makes a scene and apologizes for her husband's behavior. On mental status examination, the patient is oriented to person, place, and time. He appears agitated and speaks in short, pressured sentences. There is no disorder of thought process or content. Which of the following is the most likely diagnosis?

A. Acute stress disorder
B. Bipolar disorder
C. Histrionic personality disorder
D. Narcissistic personality disorder (Correct Answer)
E. Obsessive compulsive personality disorder

Explanation: ***Narcissistic personality disorder*** - The patient's exaggerated sense of importance, belief that he deserves special treatment, and grandiosity (claiming to have made "numerous contributions to the field of medicine" despite being a medical device salesman) are classic signs of **narcissistic personality disorder**. - His refusal to speak to a resident and insistence on seeing an attending, along with his agitated, pressured speech without formal thought disorder, further support this diagnosis, illustrating his need for **admiration** and disdain for perceived inferiors. *Acute stress disorder* - This disorder typically develops **immediately after a traumatic event** and involves symptoms like dissociation, intrusive memories, and hyperarousal. - The patient's presentation of grandiosity and sense of entitlement is not characteristic of acute stress disorder, and his symptoms are not directly linked to the fall as a recent trauma. *Bipolar disorder* - While the patient exhibits agitation and pressured speech (which can be seen in mania), the **chronic, stable pattern** of behavior described by his wife points away from bipolar disorder, which involves **episodic mood disturbances** with distinct periods of mania/hypomania and depression. - There is no mention of other DSM-5 manic criteria such as decreased need for sleep, flight of ideas, increased goal-directed activity, or risky behavior, and the grandiosity appears to be a **pervasive personality trait** rather than an episodic mood state. *Histrionic personality disorder* - Individuals with **histrionic personality disorder** seek attention, but they tend to do so through dramatic, theatrical, and often sexually provocative behavior with excessive emotionality. - While this patient is seeking attention, his behavior is more driven by a sense of superiority and entitlement rather than a desire to be the center of attention through emotional display. *Obsessive compulsive personality disorder* - **Obsessive-compulsive personality disorder** is characterized by a preoccupation with orderliness, perfectionism, and control, often at the expense of flexibility and efficiency. - The patient's behavior is impulsive, arrogant, and attention-demanding, which is inconsistent with the traits of rigidity and meticulousness seen in OCPD.

Question 24: A 15-year-old boy is brought to the physician by his parents for evaluation of his “weird” behavior. The parents report that their son tortured their cat to death two weeks ago. Over the past year, he has been accused of stealing a car and setting a fire at his school. He has no history of serious illness. He attends a local high school, and his performance at school is very poor compared to his classmates. He often loses his temper and argues with his teachers. He has smoked one pack of cigarettes daily for 2 years. He does not drink alcohol. His mother has a 10-year history of schizophrenia controlled with medication. On mental status examination, he is oriented to person, place, and time. The pupils are equal and reactive to light. His speech is normal in rate and rhythm, and his thought process is organized. Short- and long-term memory are intact. Attention and concentration are poor. Which of the following is the most likely diagnosis?

A. Autism spectrum disorder
B. Oppositional defiant disorder
C. Antisocial personality disorder
D. Disruptive mood dysregulation disorder
E. Conduct disorder (Correct Answer)

Explanation: ***Conduct disorder*** - The patient's history of **torturing an animal**, **stealing**, and **arson** demonstrates a persistent pattern of behavior that violates the basic rights of others and major age-appropriate societal norms, which is characteristic of conduct disorder. - While he displays some behaviors indicative of **oppositional defiant disorder** (losing temper, arguing), the severity and nature of his actions (e.g., animal cruelty, serious criminal acts) go beyond mere defiance and instead point to conduct disorder. *Autism spectrum disorder* - This diagnosis is characterized by **deficits in social communication and interaction** and **restricted, repetitive patterns of behavior, interests, or activities**. These core features are not described in the patient's presentation. - While the patient might have some social difficulties (e.g., poor school performance, arguing), the primary concerns are related to his **aggressive and destructive behaviors**, not autistic traits. *Oppositional defiant disorder* - This disorder involves a pattern of **angry/irritable mood, argumentative/defiant behavior, or vindictiveness** lasting at least 6 months. - Although the patient exhibits some of these behaviors (losing temper, arguing), his more serious actions like **animal cruelty, theft, and arson** are inconsistent with ODD and are indicative of the more severe diagnosis of conduct disorder. *Antisocial personality disorder* - This diagnosis is characterized by a pervasive pattern of **disregard for and violation of the rights of others** occurring since age 15 years. - However, the criteria for antisocial personality disorder cannot be met before **age 18**, even if the symptoms of conduct disorder are present. Therefore, conduct disorder is the appropriate diagnosis for this 15-year-old. *Disruptive mood dysregulation disorder* - This diagnosis is characterized by **persistent irritability** and frequent, severe temper outbursts that are developmentally inappropriate. - While the patient loses his temper, the defining feature of his presentation is not primarily **mood dysregulation** but rather a pattern of severe rule-breaking, aggression, and violation of others' rights.

Question 25: A 9-year-old girl is brought to the pediatrician for a wellness checkup. The girl's past medical history is non-contributory, and she has met all her developmental milestones. Her parents were recently called into the office as the girl was found touching the genitals of one of her classmates. She was trying to insert a toy into her classmate's genitals. The girl is asked what has happened and what she thinks is going on but she is too shy to reply to the physician. The girl and her mother recently moved in with a family member. They live in low-income housing subsidized by the government and are currently on food stamps. The mother states that her daughter has been particularly argumentative lately and that they have gotten into arguments in which her daughter screamed at her and locked herself in the bathroom. Which of the following is the most likely diagnosis?

A. Adjustment disorder
B. Normal variant of development
C. Attention deficit hyperactivity disorder
D. Precocious puberty
E. Sexual abuse (Correct Answer)

Explanation: ***Sexual abuse*** - The girl's recent behavioral changes, including **argumentativeness**, locking herself in the bathroom, and the incident of inappropriately touching a classmate's genitals, are strong indicators of potential sexual abuse. - Inappropriate sexualized behaviors, especially when coupled with sudden behavioral shifts and exposure to stressful living conditions (like moving and low-income housing), warrant a thorough investigation for **sexual abuse**. *Adjustment disorder* - This diagnosis involves **emotional or behavioral symptoms** in response to an identifiable stressor, but the specific sexualized behavior observed here points to a more specific and severe underlying issue. - While the girl is experiencing stressors (like moving and financial difficulties), an adjustment disorder alone does not fully explain the **sexualized behavior** and aggression. *Normal variant of development* - **Touching a classmate's genitals** and attempting to insert a toy is **not a normal variant of childhood development** at age 9; it is an atypical and concerning sexualized behavior. - Normal developmental curiosity about bodies typically does not involve such actions, especially when accompanied by other disruptive behaviors. *Attention deficit hyperactivity disorder* - This disorder is characterized by persistent patterns of **inattention and/or hyperactivity-impulsivity**, which are not fully described in this case, although some difficulties with impulse control may be present. - While the girl may be argumentative, ADHD alone does not explain the **sexually inappropriate behavior** or the sudden onset of these specific issues. *Precocious puberty* - **Precocious puberty** involves the early onset of physical pubertal signs (e.g., breast development, pubic hair, menstruation) before age 8 in girls, which are not mentioned in this case. - While hormonal changes can influence behavior, precocious puberty does not directly account for **sexualized behavior toward others** or the described aggressive outbursts.

Question 26: A 60-year-old woman is brought into the office by her son. Her son states that the patient has been acting inappropriately over the last few years. She has been taking off her clothes in front of visitors and putting objects in her mouth. She has had no emotional response to the death of one of her close friends and was laughing at her funeral. She has almost no memory issues, but sometimes forgets how to use objects such as a telephone. She has no other medical issues and takes no medications. On exam, she has no focal neurological deficits and her mini-mental status exam is 25/30. What is the most likely diagnosis?

A. Alzheimer's dementia
B. Pick's disease (Correct Answer)
C. Normal aging
D. Vascular dementia
E. Lewy body dementia

Explanation: ***Pick's disease*** - The patient's presentation with **disinhibition**, **inappropriate social behavior**, putting objects in her mouth (hyperorality), and **emotional blunting** with preserved memory are classic signs of **frontotemporal dementia (FTD)**, of which Pick's disease is a subtype. - The relative preservation of memory and visuospatial skills, as indicated by a mini-mental status exam score of 25/30, further supports an FTD diagnosis over Alzheimer's. *Alzheimer's dementia* - This typically presents with **prominent memory impairment** (especially **episodic memory**) as an early and defining feature, which is not the case here. - Behavioral changes in Alzheimer's dementia usually occur later in the disease progression, unlike the early and severe **disinhibition** seen in this patient. *Normal aging* - While some cognitive changes can occur with normal aging, such as mild slowing of processing speed or occasional word-finding difficulties, they do not include severe **disinhibition**, **hyperorality**, or marked personality changes. - Normal aging does not cause significant impairment in daily functioning or inappropriate social behavior. *Vascular dementia* - This type of dementia is characterized by a **stepwise decline** in cognitive function, often associated with a history of **strokes** or **cardiovascular risk factors**. - Its presentation is typically focal neurological deficits and cognitive deficits that correlate with the location of vascular lesions, which are not described in this patient. *Lewy body dementia* - Hallmarks of Lewy body dementia include **fluctuating cognition**, **recurrent visual hallucinations**, and **parkinsonism**, none of which are detailed in the patient's presentation. - While behavioral disturbances can occur, the prominent and early disinhibition and hyperorality seen here are more indicative of frontotemporal dementia.

Question 27: A 25-year-old man is brought to the emergency department by police for aggressive behavior. The patient is combative and shouts sexually aggressive remarks at the nursing staff. While obtaining the patient’s vitals, it is noted that he has markedly dilated pupils. His temperature is 98.2°F (36.8°C), pulse is 112/min, blood pressure is 130/70 mmHg, respirations are 18/min, and oxygen saturation is 98% on room air. Urine toxicology is obtained and sent off. Physical exam is notable for an energetic patient with dilated pupils and increased sweating. The patient spends the night in the emergency department. In the morning the patient is withdrawn and has a notable depressed affect. He apologizes for his behavior the previous night and states that he is concerned about his problem and wants help. Which of the following is appropriate management of this patient?

A. Medical detoxification program
B. Motivational interviewing session
C. Discharge with outpatient follow-up
D. Psychiatric evaluation and assessment
E. Referral to substance abuse treatment program (Correct Answer)

Explanation: ***Referral to substance abuse treatment program*** - The patient exhibits classic features of **stimulant intoxication** (aggression, dilated pupils, tachycardia, sweating) followed by the typical **"crash" phase** with withdrawal and depressed affect, most consistent with cocaine or amphetamine use. - Most importantly, the patient **expresses desire for help** the next morning—this represents a **critical window of opportunity** for intervention while motivation is high. - **Stimulant withdrawal is not medically dangerous** and does not require medical detoxification (unlike alcohol or benzodiazepine withdrawal), so the patient can be directly referred to a substance abuse treatment program. - **Immediate referral** is the standard of care to capitalize on the patient's readiness for change, as delaying treatment risks losing motivation and potential relapse. *Medical detoxification program* - Medical detoxification is **not indicated for stimulant use disorder** because stimulant withdrawal, while uncomfortable (fatigue, depression, increased appetite, vivid dreams), is **not medically dangerous** and has no life-threatening complications. - Unlike alcohol or benzodiazepine withdrawal, there are **no medications required** for stimulant withdrawal management, and symptoms are self-limited. - The patient is already past the acute intoxication phase and does not require medical detoxification before entering treatment. *Motivational interviewing session* - While motivational interviewing is a valuable evidence-based technique to enhance intrinsic motivation for behavior change, it is typically **a component within a comprehensive treatment program** rather than standalone definitive management. - The patient has **already expressed motivation** ("concerned about his problem and wants help"), so the priority is to act on this motivation with immediate treatment referral rather than further motivational work. *Discharge with outpatient follow-up* - Simply discharging with outpatient follow-up is **insufficient** and risks losing the patient during this critical window of motivation. - Patients with substance use disorders often have **poor follow-up rates** when not immediately connected to treatment, and motivation can wane quickly after the acute consequences resolve. - More structured and immediate intervention is needed given the severity of the presentation and expressed desire for help. *Psychiatric evaluation and assessment* - While psychiatric comorbidities are common in patients with substance use disorders and should eventually be assessed, this is **not the immediate priority** when a patient is requesting help for substance abuse. - Comprehensive psychiatric evaluation can be performed **within the substance abuse treatment program** where co-occurring disorders can be addressed simultaneously. - The primary presenting problem is substance use, and immediate treatment engagement takes precedence.

Question 28: A 23-year-old woman is brought to the emergency department by her boyfriend 10 minutes after ingesting at least 15 acetaminophen tablets. She has been admitted to the hospital several times in the past few months after attempted self-harm. She claims that her boyfriend is “extremely selfish” and “does not care for her.” She says she feels lonely and wants her boyfriend to pay attention to her. Her boyfriend says that they have broken up 10 times in the past year because she is prone to outbursts of physical aggression as well as mood swings. He says that these mood swings last a few hours and can vary from states of “exuberance and affection” to states of “depression.” On examination, the patient appears well-dressed and calm. She has normal speech, thought processes, and thought content. Which of the following is the most likely diagnosis?

A. Dependent personality disorder
B. Borderline personality disorder (Correct Answer)
C. Bipolar II disorder
D. Cyclothymic disorder
E. Narcissistic personality disorder

Explanation: ***Borderline personality disorder*** - Patients with **borderline personality disorder** often exhibit a pattern of **unstable relationships**, impulsive behaviors (like self-harm attempts), intense mood swings lasting hours, and efforts to avoid abandonment, consistent with this patient's presentation. - The patient's description of her boyfriend, her history of self-harm attempts, and her rapid, fluctuating mood states ("exuberance and affection" to "depression") are characteristic features. *Dependent personality disorder* - This disorder is characterized by an excessive need to be cared for, leading to **submissive and clinging behavior**, and fears of separation. While she fears abandonment, the **mood swings** and **aggressiveness** point away from this diagnosis. - Patients with dependent personality disorder rarely exhibit the **impulsive self-harm** and dramatic, aggressive outbursts described. *Bipolar II disorder* - Bipolar II disorder involves episodes of **hypomania** and **major depression**, with mood episodes typically lasting days to weeks, not just "a few hours" as described here. - The prominent features of **unstable relationships**, impulsivity, and chronic feelings of emptiness are more characteristic of a personality disorder than bipolar II. *Cyclothymic disorder* - Cyclothymic disorder involves chronic, fluctuating moods with numerous periods of **hypomanic symptoms** and **depressive symptoms** over at least two years, but these symptoms are less severe and do not meet criteria for full hypomanic or major depressive episodes. - While there are mood fluctuations, the **intensity**, **self-harm behavior**, and **interpersonal instability** observed are more typical of borderline personality disorder. *Narcissistic personality disorder* - Narcissistic personality disorder is characterized by a pervasive pattern of **grandiosity**, a need for admiration, and a lack of empathy. - While the patient blames her boyfriend, her primary motivation appears to be a fear of abandonment and a desire for attention, rather than a sense of entitlement or inflated self-importance.

Question 29: A 19-year-old woman is brought to the emergency department by ambulance 30 minutes after her neighbor found her unconscious on a running trail. Her neighbor reports that she has been training for a marathon since the beginning of the summer. She is alert and oriented but becomes irritable when realizing that she is at a hospital and refuses to answer questions. She appears tired. She is 174 cm (5 ft 7 in) tall and weighs 51 kg (112 lb). Her temperature is 35.5°C (96°F), pulse is 44/min, respirations are 20/min, and blood pressure is 84/48 mm Hg. Examination shows dry, scaly skin and dry mucous membranes. Cardiopulmonary examination shows a high-frequency, mid-to-late systolic murmur that is heard best at the apex. Her hemoglobin concentration is 11.9 g/dL. Which of the following is the most likely diagnosis?

A. Heat exhaustion
B. Hypertrophic obstructive cardiomyopathy
C. Hypothyroidism
D. Amphetamine use
E. Anorexia nervosa (Correct Answer)

Explanation: ***Anorexia nervosa*** - The patient's **low BMI** (16.9 kg/m^2), **bradycardia**, **hypotension**, **hypothermia**, and **dry, scaly skin** are classic signs of anorexia nervosa, exacerbated by intense exercise (marathon training). - The **mid-to-late systolic murmur** heard best at the apex is likely due to **mitral valve prolapse**, a common cardiac finding in patients with severe anorexia nervosa due to decreased ventricular size and structural changes. *Heat exhaustion* - Although the patient was exercising, her **temperature is low (96°F)**, which contradicts the expected elevated temperature in heat exhaustion. - Heat exhaustion typically presents with profuse sweating, not **dry mucous membranes** or **dry, scaly skin**. *Hypertrophic obstructive cardiomyopathy* - While it can cause a **systolic murmur** and exercise-induced syncope, it usually presents with a **loud S4**, and the patient's other symptoms like **hypothermia**, **bradycardia**, and severe **cachexia** are not typical. - It would not explain the **low body weight**, **dry skin**, or **hypotension** as primary symptoms. *Hypothyroidism* - Hypothyroidism can cause **fatigue**, **bradycardia**, **hypothermia**, and **dry skin**, but it does not typically lead to such extreme **weight loss** or **hypotension** in a young, active individual. - It doesn't explain the specific cardiac murmur described or the history of intense marathon training contributing to the presentation. *Amphetamine use* - Amphetamine use typically causes **tachycardia**, **hypertension**, **dilation of pupils**, and **hyperthermia**, which are opposite to this patient's presentation of bradycardia, hypotension, and hypothermia. - The patient's **cachectic appearance** could be associated with stimulant use, but the vital signs and overall clinical picture strongly contradict it.

Question 30: A 71-year-old man is brought in by his daughter for forgetfulness. The daughter finds herself repeating things she has already told him. She also reports that the patient recently missed a lunch date they had scheduled. She is worried that he may have Alzheimer's disease because her mother had it, and this is how it started. The patient states that he sometimes forgets where he puts his glasses, but this is not new. He also admits to missing appointments if he doesn't write them in his planner, but he states “I always remember birthdays.” Since his wife passed, the patient has been responsible for all the finances, and the daughter confirms that he pays the bills on time. He cooks for himself, though sometimes he is “lazy” and will order fast food. The patient’s medical history is significant for hypertension, atherosclerosis, and rheumatoid arthritis. His medications include aspirin, lisinopril, atorvastatin, and methotrexate. He was also treated for depression for the first year following his wife's death, which was 3 years ago. He currently denies feelings of depression or suicidal ideation, but admits that he has been thinking more about death since some of his weekly golfing buddies have passed away. He drinks a beer every night with dinner and smokes cigars socially. A physical examination reveals ulnar deviation of the fingers, decreased grip strength, and a slow, steady gait. The patient is able to spell a 5-letter word backwards and remembers 3/3 items after 5 minutes. Which of the following diagnoses most likely explains the patient’s symptoms?

A. Vascular dementia
B. Alzheimer disease
C. Frontotemporal dementia
D. Normal aging (Correct Answer)
E. Major depressive disorder

Explanation: ***Normal aging*** - The patient exhibits age-associated memory impairment, such as occasional forgetfulness (e.g., misplacing glasses, missing an appointment if not written down), but his **activities of daily living** (ADLs) and instrumental ADLs (IADLs) like managing finances and cooking are **intact**. - His cognitive function, evidenced by recalling 3/3 items after 5 minutes and spelling a 5-letter word backward, is **normal for his age**, and there's no significant decline affecting his overall function. *Vascular dementia* - This dementia type typically presents with a **step-wise decline** in cognitive function and often has **focal neurological deficits** corresponding to ischemic events. - The patient's history of **hypertension and atherosclerosis** are risk factors, but his current symptoms do not suggest a significant, progressive decline or focal neurological signs indicative of vascular dementia. *Alzheimer disease* - Characterized by **progressive memory decline** that significantly impacts ADLs and IADLs, often starting with difficulty learning and recalling new information, which is not evident here. - While familial history is a risk factor, the patient's ability to manage finances, cook, and perform well on short cognitive tests makes Alzheimer's less likely at this stage. *Frontotemporal dementia* - Primarily affects **personality, behavior, and language** earlier than memory, often leading to disinhibition, apathy, or language difficulties. - The patient's presentation does not describe significant changes in personality or behavior, distinguishing it from frontotemporal dementia. *Major depressive disorder* - Although the patient had a history of depression and mentions thinking about death (contextually appropriate given friends' recent deaths), he **denies current feelings of depression or suicidal ideation**. - His forgetfulness is mild and does not show features of **pseudodementia** (depression-related cognitive impairment), which typically presents with more prominent subjective complaints, poor effort on testing, and greater functional impairment than objective findings suggest. - His **normal performance** on cognitive testing (3/3 recall) further argues against depression-related cognitive dysfunction.

Question 31: A 15-year-old boy is brought to the clinic by his father for difficulty in school. He reports that his son has been suspended several times over his high school career for instigating fights. Per the patient, he has always had trouble controlling his anger and would feel especially frustrated at school since he has difficulty “keeping up.” His past medical history is unremarkable and he is up-to-date on all his vaccinations. A physical examination demonstrates a 6-foot tall teenage boy with severe acne vulgaris throughout his face and back. He is later worked up to have a chromosomal abnormality. What is the most likely explanation for this patient’s presentation?

A. Klinefelter syndrome
B. Down syndrome
C. Fragile X syndrome
D. Conduct disorder
E. XYY syndrome (Correct Answer)

Explanation: ***XYY syndrome*** - The patient's presentation of **tall stature**, severe **acne vulgaris**, learning difficulties, and behavioral problems like aggression and anger issues are characteristic features of **XYY syndrome**. - This syndrome is due to the presence of an **extra Y chromosome**, often leading to increased testosterone levels and associated physical and behavioral phenotypes. *Klinefelter syndrome* - Characterized by **XXY karyotype**, leading to features like **tall stature**, small testes, **gynecomastia**, and often learning difficulties, but typically not severe acne or markedly aggressive behavior as the primary concern. - Individuals with Klinefelter syndrome often have reduced fertility and hormonal imbalances that differ from those seen in XYY syndrome. *Down syndrome* - Caused by **trisomy 21** and presents with distinct facial features (**epicanthic folds**, flat nasal bridge), intellectual disability, and congenital heart defects, which are not described in this patient. - Patients with Down syndrome are not typically known for excessive height or severe acne. *Fragile X syndrome* - This is an **X-linked genetic disorder** causing intellectual disability, characteristic long face, large ears, and macroorchidism, which are not mentioned in this patient's presentation. - While behavioral issues can occur, the combination of tall stature and severe acne is not typical of Fragile X syndrome. *Conduct disorder* - This is a **behavioral disorder** characterized by a persistent pattern of violating the rights of others or major age-appropriate societal norms, fitting the description of instigating fights and difficulty in school. - However, conduct disorder is a **diagnosis of exclusion** and does not account for the physical findings of tall stature, severe acne, or the underlying chromosomal abnormality that was later identified.

Question 32: An 8-year-old girl is brought to the physician by her parents because they are concerned with her behavior. She has temper outbursts six or seven times per week, which last anywhere between 5 minutes to half an hour or until she becomes tired. According to her father, she screams at others and throws things in anger “when things don't go her way.” He says these outbursts started when she was 6 and a half years old and even between the outbursts, she is constantly irritable. She had been suspended from school three times in the past year for physical aggression, but her grades have remained unaffected. She appears agitated and restless. Physical examination shows no abnormalities. During the mental status examination, she is uncooperative and refuses to answer questions. What is the most likely diagnosis in this child?

A. Pediatric bipolar disorder
B. Conduct disorder
C. Intermittent explosive disorder
D. Oppositional defiant disorder
E. Disruptive mood dysregulation disorder (Correct Answer)

Explanation: ***Disruptive mood dysregulation disorder*** - This diagnosis is characterized by **frequent, severe temper outbursts** that are out of proportion to the situation, along with persistent **irritable or angry mood** between outbursts, lasting for at least 12 months. The girl's symptoms, including frequent outbursts starting before age 10 and chronic irritability, fit these criteria. - The onset of symptoms occurred at 6.5 years of age, and the child is currently 8-years-old, which falls within the diagnostic age range (onset before age 10, diagnosis between 6 and 18 years). *Pediatric bipolar disorder* - This typically involves distinct periods of **elevated or expansive mood** and increased energy (mania or hypomania) that last for at least several days, which are not described in this case. - While irritability can be a feature of pediatric bipolar disorder, the primary feature here is persistent irritability and temper outbursts without clear episodes of mood elevation. *Conduct disorder* - Conduct disorder involves a pervasive pattern of **disregard for the rights of others** and societal norms, including aggression towards people and animals, destruction of property, deceitfulness or theft, and serious rule violations. - While the girl shows aggression, there is no evidence of the broader pattern of repetitive and persistent rule-breaking or delinquent behaviors characteristic of conduct disorder. *Intermittent explosive disorder* - This is characterized by recurrent behavioral outbursts representing a **failure to control aggressive impulses**, often leading to assaultive acts or destruction of property. However, the outbursts are typically episodic, and the mood between episodes is generally normal. - The key differentiating factor here is the girl's **persistent irritability or angry mood** between outbursts, which is a hallmark of disruptive mood dysregulation disorder, not intermittent explosive disorder. *Oppositional defiant disorder* - Oppositional defiant disorder involves a pattern of **angry/irritable mood, argumentative/defiant behavior**, or vindictiveness lasting at least six months. - While there is overlap, the **severity and frequency of the temper outbursts experienced by this child** go beyond what is typically seen in ODD, making DMDD a more appropriate diagnosis. Temper outbursts in ODD are generally less severe and less chronic than those in DMDD.

Question 33: A 9-year-old boy is brought to the psychiatrist due to unusual behavior over the past several months. His mother reports that he has started to blink more frequently than usual. His parents initially attributed this behavior to attention-seeking but he has not stopped despite multiple disciplinary efforts and behavioral therapy from a clinical psychologist. He previously performed well in school but has recently become more disruptive and inattentive in class. He has not been sick recently and denies any drug use. His parents report multiple episodes in the past in which the child seemed overly elated and hyperactive for several days followed by periods in which he felt sad and withdrawn. On examination, he is a well-appearing boy in no acute distress. He is alert and oriented with a normal affect but gets distracted easily throughout the exam. He blinks both eyes several times throughout the examination. Strength, sensation, and gait are all normal. Which of the following medications is most appropriate for this patient?

A. Fluoxetine
B. Guanfacine
C. Amitriptyline
D. Venlafaxine
E. Lithium (Correct Answer)

Explanation: ***Lithium*** - This patient presents with **episodic mood disturbances** including periods of being "overly elated and hyperactive for several days followed by periods in which he felt sad and withdrawn," which is highly suggestive of **pediatric bipolar disorder**. - While he also displays **inattention, disruptive behavior, and motor tics** (eye blinking), the prominent **cyclical mood episodes** indicate that the primary diagnosis is a **mood disorder** that requires stabilization before addressing comorbid ADHD or tic symptoms. - **Lithium** is a **first-line mood stabilizer** for bipolar disorder in children and adolescents. Stabilizing the mood is critical before treating ADHD symptoms, as stimulants or even non-stimulant ADHD medications can exacerbate manic symptoms. - Lithium requires monitoring of blood levels and thyroid/renal function, but it remains the most appropriate choice for this presentation. *Guanfacine* - **Guanfacine** is a **selective alpha-2 adrenergic agonist** used for ADHD and can help with comorbid tics. While this patient has ADHD-like symptoms and a motor tic, the more pressing concern is the **cyclical mood episodes** described. - Treating ADHD without first addressing the underlying mood disorder in pediatric bipolar disorder can worsen mood instability and manic symptoms. - Guanfacine would be appropriate as an **adjunct** after mood stabilization is achieved. *Fluoxetine* - **Fluoxetine** is an **SSRI** used for depression and anxiety. In a child with bipolar disorder, antidepressants can precipitate **manic or hypomanic episodes** and worsen mood cycling. - SSRIs should generally be avoided or used with extreme caution (alongside a mood stabilizer) in pediatric bipolar disorder. *Venlafaxine* - **Venlafaxine** is an **SNRI** used for depression and anxiety. Similar to SSRIs, SNRIs can trigger **mood destabilization** and mania in patients with bipolar disorder. - It is not appropriate as monotherapy in a child with suspected bipolar disorder and could worsen the clinical picture. *Amitriptyline* - **Amitriptyline** is a **tricyclic antidepressant** with significant anticholinergic side effects and a less favorable safety profile in children. - Like other antidepressants, it can induce **mania or mood cycling** in bipolar disorder and is not a first-line treatment for this presentation. - TCAs are generally avoided in pediatric psychiatry due to safety concerns and the availability of better-tolerated alternatives.

Question 34: A 12-year-old boy is referred to a pediatric neurologist because of repetitive motions such as blinking or tilting his head. He is brought in by his mother who says that he also clears his throat and hums repeatedly. These actions have been happening for the past year and his mother is concerned. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccinations and is meeting all developmental milestones. On physical exam, he shows no focal neurological deficits and is cognitively normal for his age. He occasionally sharply jerks his head to one side during the physical exam and utters obscene words. Which of the following is a characteristic feature of this condition?

A. Coprolalia (Correct Answer)
B. X-linked MECP2 mutation with female predominance
C. Severe atrophy of the caudate and putamen
D. 3 Hz spike-wave pattern on EEG
E. CAG repeat on the short arm of chromosome 4

Explanation: ***Coprolalia*** - The boy's symptoms, including **multiple motor tics** (blinking, head tilting, head jerking) and **vocal tics** (throat clearing, humming, uttering obscene words), are classic for **Tourette syndrome**. - **Coprolalia**, the involuntary utterance of obscene words, is a characteristic, albeit uncommon, feature of Tourette syndrome, clearly demonstrated in the clinical presentation. *X-linked MECP2 mutation with female predominance* - This describes **Rett syndrome**, a neurodevelopmental disorder almost exclusively affecting females due to its X-linked dominant inheritance pattern. - Rett syndrome presents with **developmental regression**, loss of purposeful hand skills, and stereotypical hand movements, which are not seen in this boy who is meeting developmental milestones. *Severe atrophy of the caudate and putamen* - This is a hallmark pathological finding in **Huntington's disease**, a neurodegenerative disorder. - Huntington's disease typically presents in adulthood with **progressive chorea**, cognitive decline, and psychiatric symptoms, which are distinct from the tics described. *3 Hz spike-wave pattern on EEG* - This characteristic EEG finding is pathognomonic for **absence seizures**, a type of generalized epilepsy. - Absence seizures manifest as brief episodes of **staring spells** with impaired consciousness, not the complex motor and vocal tics described. *CAG repeat on the short arm of chromosome 4* - This genetic abnormality is the cause of **Huntington's disease**. - As mentioned, Huntington's disease has a different clinical presentation and age of onset compared to the boy's symptoms.

Question 35: A 25-year-old woman comes to the physician because of headache and difficulty sleeping for the past 2 days. She states that she has had similar symptoms over the past several months and that they occur every month around the same time. The episodes are also frequently accompanied by decreased concentration, angry feelings, and cravings for sweet foods. She says that during these episodes she is unable to work efficiently, and often has many arguments with her colleagues and friends. Menses occur at regular 26-day intervals and last 5 days. Her last menstrual period started about 3 weeks ago. She has smoked one pack of cigarettes daily for the last 8 years. She takes no medications. She appears irritable. The patient is oriented to person, place, and time. Physical examination shows no abnormalities. Which of the following is the most appropriate treatment?

A. Naproxen
B. Avoidance of nicotine
C. Cognitive behavioral therapy
D. Bilateral oophorectomy
E. Fluoxetine (Correct Answer)

Explanation: ***Fluoxetine*** - The patient's symptoms (headache, difficulty sleeping, decreased concentration, angry feelings, food cravings, irritability) occurring monthly around her menstrual cycle, significantly impacting her functioning and relationships, are highly suggestive of **Premenstrual Dysphoric Disorder (PMDD)**. - **Selective serotonin reuptake inhibitors (SSRIs)** like fluoxetine are considered first-line pharmacological treatment for PMDD due to their efficacy in reducing both psychological and physical symptoms. *Naproxen* - **Naproxen**, a nonsteroidal anti-inflammatory drug (NSAID), is primarily used for pain relief and inflammation, such as menstrual cramps (dysmenorrhea). - While it might help with headaches or other pain, it does not address the **psychological and emotional symptoms** characteristic of PMDD. *Avoidance of nicotine* - **Smoking cessation** is crucial for overall health and can reduce the severity of some premenstrual symptoms. - However, it is a lifestyle modification that would be an adjunctive recommendation, not the **most appropriate primary treatment** for the cyclical, severe symptoms described, which highly suggest PMDD. *Cognitive behavioral therapy* - **Cognitive behavioral therapy (CBT)** is an effective non-pharmacological treatment for PMDD, helping patients manage stress, mood swings, and coping mechanisms. - While recommended, given the severity and impact of her symptoms on her daily life, **pharmacological intervention** (like an SSRI) is often considered the most appropriate initial treatment, potentially in conjunction with CBT. *Bilateral oophorectomy* - **Bilateral oophorectomy** (surgical removal of both ovaries) induces menopause and permanently stops the ovarian hormone fluctuations that trigger PMDD. - This is a **radical, irreversible surgical intervention** reserved for extremely severe and refractory cases of PMDD where all other medical treatments have failed, not a first-line treatment.

Question 36: A 55-year-old man presents to his primary care physician with complaints of fluctuating mood for the past 2 years. He feels great and full of energy for some months when he is very creative with tons of ideas just racing through his mind. He is noted to be very talkative and distracted by his different ideas. During these times, he is very productive and able to accomplish much at work and home. However, these periods are frequently followed by a prolonged depressed mood. During this time, he has low energy, poor concentration, and low self-esteem. The accompanying feeling of hopelessness from these cycling “ups” and “downs” have him eating and sleeping more during the “downs.” He does not remember a period within the last 2 years where he felt “normal.” What is the most likely diagnosis?

A. Dysthymic disorder
B. Bipolar II disorder
C. Persistent depressive disorder
D. Bipolar I disorder
E. Cyclothymic disorder (Correct Answer)

Explanation: ***Cyclothymic disorder*** - The patient experiences chronic **fluctuating moods**, with numerous periods of **hypomanic symptoms** (elevated energy, racing thoughts, increased productivity) and numerous periods of **depressive symptoms** (low energy, poor concentration, hopelessness) over at least 2 years. - The symptoms are not severe enough to meet full criteria for a **manic episode**, **hypomanic episode**, or **major depressive episode**, and there has been no period longer than 2 months without symptoms. *Dysthymic disorder* - This is the **DSM-IV term** for what is now called **persistent depressive disorder** in DSM-5, involving a **chronic depressed mood** that lasts for at least 2 years. - It does not include periods of significant elevated mood or hypomania. - The patient's presentation includes distinct periods of **elevated mood and energy**, which are not characteristic of dysthymic disorder. *Bipolar II disorder* - Bipolar II disorder requires at least one **major depressive episode** and at least one **hypomanic episode**. - While the patient exhibits hypomanic and depressive symptoms, the periods of depression do not meet the full criteria for a **major depressive episode** (e.g., duration, number of symptoms) and the hypomanic symptoms are subsyndromal. *Persistent depressive disorder* - This is the **DSM-5 term** for chronic low-grade depression (formerly called dysthymic disorder), characterized by depressed mood for at least 2 years without manic or hypomanic symptoms. - The patient's history of elevated mood and energy precludes this diagnosis. *Bipolar I disorder* - Bipolar I disorder requires at least one **manic episode**, which is characterized by a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and causing significant impairment. - The patient's "ups" are described as productive and not causing significant impairment or involving psychotic features, indicating **hypomanic symptoms** rather than full mania.

Question 37: A 65-year-old woman comes to the physician for the evaluation of several episodes of urinary incontinence over the past several months. She reports that she was not able to get to the bathroom in time. During the past 6 months, her husband has noticed that she is starting to forget important appointments and family meetings. She has type 2 diabetes mellitus treated with metformin. The patient had smoked a pack of cigarettes daily for 45 years. Her vital signs are within normal limits. On mental status examination, she is confused and has short-term memory deficits. She walks slowly taking short, wide steps. Muscle strength is normal. Deep tendon reflexes are 2+ bilaterally. Which of the following is the most likely underlying cause of this patient's urinary incontinence?

A. Bacterial infection of the urinary tract
B. Normal pressure hydrocephalus (Correct Answer)
C. Detrusor-sphincter dyssynergia
D. Impaired detrusor contractility
E. Loss of sphincter function

Explanation: ***Normal pressure hydrocephalus*** - The patient's presentation with **urinary incontinence**, **memory deficits/dementia**, and an **ataxic gait** (slow, short, wide steps) represents the classic triad of **Normal Pressure Hydrocephalus (NPH)**. - While the incontinence itself is urge-type (not getting to the bathroom in time), the constellation of symptoms points to NPH as the underlying neurological cause. *Bacterial infection of the urinary tract* - Although urinary tract infections can cause **acute urinary incontinence**, especially in the elderly, they do not explain the accompanying **memory loss** and **gait disturbance**. - There are no symptoms typical of infection such as **dysuria**, **frequency**, or **fever** mentioned in the vignette. *Detrusor-sphincter dyssynergia* - This condition involves involuntary contraction of the urethral sphincter during detrusor contraction, typically seen in **spinal cord injury** patients, and is characterized by **incomplete bladder emptying**, not primarily urge incontinence alone. - It does not account for the **cognitive decline** or **gait abnormalities** presented. *Impaired detrusor contractility* - **Impaired detrusor contractility** (underactive bladder) typically leads to **overflow incontinence** with incomplete emptying, characterized by a constant dribble and difficulty initiating urination, which contrasts with the presented urge incontinence. - This condition does not explain the patient's **dementia** or **gait disturbance**. *Loss of sphincter function* - **Loss of sphincter function** (stress incontinence) typically causes urine leakage with increased intra-abdominal pressure (e.g., coughing, sneezing, lifting), which is different from the patient's report of not making it to the bathroom in time which points towards urge incontinence. - This condition also does not explain the neurological symptoms of **dementia** and **gait ataxia**.

Question 38: A 25-year-old woman is brought to the emergency department by her boyfriend after she cut her forearms with a knife. She has had multiple visits to the emergency department in the past few months for self-inflicted wounds. She claims that her boyfriend is the worst person in the world. She and her boyfriend have broken up 20 times in the past 6 months. She says she cut herself not because she wants to kill herself; she feels alone and empty and wants her boyfriend to take care of her. Her boyfriend claims that she is prone to outbursts of physical aggression as well as mood swings. He says that these mood swings last a few hours and vary from states of exuberance and self-confidence to states of self-doubt and melancholy. On examination, the patient appears well-dressed and calm. She has normal speech, thought processes, and thought content. Which of the following is the most likely diagnosis?

A. Dependent personality disorder
B. Borderline personality disorder (Correct Answer)
C. Bipolar II disorder
D. Cyclothymic disorder
E. Histrionic personality disorder

Explanation: ***Borderline personality disorder*** - This patient exhibits characteristic features of **borderline personality disorder**, including **impulsivity** (self-harm), **unstable relationships** (frequent breakups, idealization/devaluation of boyfriend), **affective instability** (rapid mood swings lasting hours), and feelings of **emptiness** and **abandonment**. - **Self-harm** in BPD is often a coping mechanism for intense emotional pain or a way to elicit care, rather than a genuine suicide attempt, as stated by the patient. *Dependent personality disorder* - Characterized by an **excessive need to be cared for**, leading to submissive and clinging behavior and fears of separation, which is not the primary presentation here. - While there is a desire for care, the prominent features of **impulsivity**, **affective instability**, and **unstable relationships** are not typical of dependent personality disorder. *Bipolar II disorder* - Involves episodes of **hypomania** and **major depression**, with mood swings typically lasting for at least **four days** (hypomania) or **two weeks** (major depression), much longer than the hours described here. - The patient's presentation emphasizes **interpersonal instability** and **self-harm** more than episodic mood disturbances. *Cyclothymic disorder* - Involves **numerous periods of hypomanic symptoms** and numerous periods of **depressive symptoms** for at least two years, but these symptoms are less severe than full-blown hypomanic or major depressive episodes. - The rapid mood shifts within hours and the intensity of **interpersonal dysfunction** and **self-harm** are more indicative of borderline personality disorder. *Histrionic personality disorder* - Characterized by **excessive emotionality** and **attention-seeking behavior**, often sexually provocative, and using physical appearance to draw attention. - While emotionality is present, the **self-harm**, **emptiness**, and **rapid mood shifts** are not core features of histrionic personality disorder.

Question 39: A 23-year-old woman presents to the emergency room for a self-inflicted laceration of her distal volar forearm. The patient states that she knew her husband was having sexual thoughts about the woman from the grocery store, prompting her decision to cut her own wrist. In the emergency department the bleeding is stopped and the patient is currently medically stable. When interviewing the patient, she is teary and apologizes for her behavior. She is grateful to you for her care and regrets her actions. Of note, the patient has presented to the emergency department before for a similar reason when she was struggling with online dating. The patient states that she struggles with her romantic relationship though she deeply desires them. On physical exam you note a frightened young woman who is wearing a revealing dress that prominently displays her breasts. You tell the patient that she will have to stay in the psychiatric emergency department for the night which makes her furious. Which of the following personality disorders is the most likely diagnosis?

A. Borderline (Correct Answer)
B. Dependent
C. Antisocial
D. Histrionic
E. Avoidant

Explanation: ***Borderline*** - The patient exhibits **impulsivity** (self-harm), **unstable relationships**, fear of abandonment (husband's "sexual thoughts"), and rapid mood shifts (tearful apology followed by fury), which are characteristic of Borderline Personality Disorder. - Recurrent self-harm and previous presentations for similar reasons (struggling with online dating) highlight a pattern of **unstable self-image** and coping mechanisms. *Dependent* - While individuals with Dependent Personality Disorder desire relationships, their primary feature is an excessive need to be cared for, leading to **submissive behavior** and fear of separation, rather than the dramatic impulsivity and anger seen in the patient. - The patient's fury and self-harm suggest a more volatile and emotionally dysregulated presentation than typically associated with dependency. *Antisocial* - Antisocial Personality Disorder involves a pervasive pattern of **disregard for and violation of the rights of others**, often involving deceitfulness, impulsivity, and lack of remorse. The patient's apology and regret for her actions are inconsistent with this diagnosis. - There is no evidence of habitual law-breaking, exploitation of others, or a general callous disregard for others' feelings, which are core features of antisocial personality. *Histrionic* - Histrionic Personality Disorder is characterized by excessive **emotionality** and **attention-seeking behavior**, often through provocative actions (like dressing revealingly). However, the patient's severe self-harm, unstable relationships, intense abandonment fears, and rapid mood swings are more indicative of borderline personality. - While the revealing dress might suggest some histrionic traits, the overarching presentation of chronic relationship instability, impulsivity, and self-mutilation points more strongly to Borderline Personality Disorder. *Avoidant* - Avoidant Personality Disorder involves extreme **social inhibition**, feelings of inadequacy, and hypersensitivity to negative evaluation, leading to avoidance of social interactions despite a desire for intimacy. - The patient's active pursuit of relationships, even if unstable, and her dramatic, impulsive behaviors are inconsistent with the core features of social avoidance and timidity seen in Avoidant Personality Disorder.

Question 40: An 11-year-old boy’s parents brought him to a psychologist upon referral from the boy’s school teacher. The boy frequently bullies his younger classmates despite having been punished several times for this. His mother also reported that a year prior, she received complaints that the boy shoplifted from local shops in his neighborhood. The boy frequently stays out at night despite strict instructions by his parents to return home by 10 PM. Detailed history reveals that apart from such behavior, he is usually not angry or irritable. Although his abnormal behavior continues despite warnings and punishments, he neither argues with his parents nor teachers and does not display verbal or physical aggression. Which of the following is the most likely diagnosis?

A. Attention-deficit/hyperactivity disorder, hyperactivity-impulsivity type
B. Disruptive mood dysregulation disorder
C. Intermittent explosive disorder
D. Conduct disorder (Correct Answer)
E. Oppositional defiant disorder

Explanation: ***Conduct disorder*** - The boy's behaviors, including **bullying**, **shoplifting**, and **violating rules** (staying out past curfew), represent a persistent pattern of behavior that violates the basic rights of others or major age-appropriate societal norms, which are core features of **conduct disorder**. - The history indicates these behaviors have been ongoing for at least a year and are not just isolated incidents, fulfilling the diagnostic criteria for **duration and pervasiveness**. *Attention-deficit/hyperactivity disorder, hyperactivity-impulsivity type* - While ADHD involves **hyperactivity** and **impulsivity**, it does not typically manifest with deliberate violations of others' rights or societal norms like **bullying** and **shoplifting**. - There is no mention of symptoms such as **difficulty sustaining attention**, **fidgeting**, or **excessive talking** which are characteristic of ADHD. *Disruptive mood dysregulation disorder* - This disorder is characterized by **severe recurrent temper outbursts** and persistent **irritable or angry mood** between outbursts. - The case explicitly states the boy is "not angry or irritable" and "neither argues with his parents nor teachers," ruling out this diagnosis. *Intermittent explosive disorder* - This disorder involves recurrent behavioral outbursts representing a failure to control aggressive impulses, often with verbal aggression or physical aggression toward property, animals, or other individuals. - The boy does not display verbal or physical aggression and is not noted to have anger or irritability, which are central to this diagnosis. *Oppositional defiant disorder* - ODD involves a pattern of **angry/irritable mood**, **argumentative/defiant behavior**, or **vindictiveness**. - While violating rules is present, **bullying** and **shoplifting** (which violate the basic rights of others) are more severe behaviors that go beyond the scope of ODD and are characteristic of conduct disorder.

Question 41: A 21-year-old woman has frequent sexual fantasies about female coworkers. When she is with her friends in public, she never misses an opportunity to make derogatory comments about same-sex couples she sees. Which of the following psychological defense mechanisms is she demonstrating?

A. Acting out
B. Reaction formation (Correct Answer)
C. Sublimation
D. Sexualization
E. Intellectualization

Explanation: ***Reaction formation*** - The woman's derogatory comments about same-sex couples are a classic example of **reaction formation**, where an unacceptable impulse (sexual fantasies about female coworkers) is transformed into its opposite. - This defense mechanism allows her to hide her true feelings from herself and others by outwardly expressing feelings that are completely contrary to her unconscious desires. *Acting out* - **Acting out** involves expressing unconscious emotional conflicts or stressors through actions rather than words. - This typically manifests as destructive or maladaptive behaviors, not verbal expressions that contradict internal desires. *Sublimation* - **Sublimation** is a mature defense mechanism where unacceptable impulses are channeled into socially acceptable or even highly productive activities. - Her comments are derogatory and not a productive or socially acceptable channeling of her impulses. *Sexualization* - **Sexualization** involves endowing an object or function with sexual significance, which is not the primary defense being used here. - While her fantasies involve sexual themes, her public behavior is a defensive response to those themes, not a direct sexualizing of situations. *Intellectualization* - **Intellectualization** involves using excessive abstract thinking or reasoning to avoid confronting unpleasant emotions or conflicts. - Her behavior involves active expression of an opposing viewpoint, rather than detaching emotionally through abstract thought.

Question 42: An 11-year-old boy is brought to the clinic by his parents for poor academic performance. The patient’s parents say that his teacher told them that he may have to repeat a grade because of his lack of progress, as he does not pay attention to the lessons, tends to fidget about in his seat, and often blurts out comments when it is someone else’s turn to speak. Furthermore, his after-school karate coach says the patient no longer listens to instructions and has a hard time focusing on the activity at hand. The patient has no significant past medical history and is currently not on any medications. The patient has no known learning disabilities and has been meeting all developmental milestones. The parents are vehemently opposed to using any medication with a potential for addiction. Which of the following medications is the best course of treatment for this patient?

A. Sertraline
B. Diazepam
C. Olanzapine
D. Methylphenidate
E. Atomoxetine (Correct Answer)

Explanation: ***Atomoxetine*** - This medication is a **non-stimulant** selective norepinephrine reuptake inhibitor. It is a good choice for **ADHD patients** whose parents are opposed to any medication with a potential for addiction because it does not have the same addictive potential as stimulants. - It works by increasing the levels of **norepinephrine** in the brain, improving attention and hyperactivity symptoms typically seen in ADHD. *Sertraline* - This is a **selective serotonin reuptake inhibitor (SSRI)** and is primarily used to treat depression, anxiety disorders, and obsessive-compulsive disorder. - Sertraline would not be effective for ADHD symptoms like inattention and hyperactivity. *Diazepam* - This is a **benzodiazepine** primarily used for anxiety, seizures, and muscle spasms due to its sedative and anxiolytic properties. - It would likely worsen the patient's inattention and academic performance due to its **sedative effects** and has a significant potential for addiction. *Olanzapine* - This is an **atypical antipsychotic** medication used to treat conditions like schizophrenia and bipolar disorder. - Olanzapine is not indicated for ADHD and could cause severe side effects like **sedation, weight gain, and metabolic issues**. *Methylphenidate* - This is a **stimulant medication** commonly used to treat ADHD and is highly effective in improving attention and reducing hyperactivity. - While effective, methylphenidate has a **potential for abuse and addiction**, which the patient's parents are explicitly against.

Question 43: A 5-year-old boy is brought to the physician by his mother because he claims to have spoken to his recently-deceased grandfather. The grandfather, who lived with the family and frequently watched the boy for his parents, died 2 months ago. The boy was taken out of preschool for 3 days after his grandfather's death but has since returned. His teachers report that the boy is currently doing well, completing his assignments, and engaging in play with other children. When asked about how he feels, the boy becomes tearful and says, “I miss my grandpa. I sometimes talk to him when my mom is not around.” Which of the following is the most likely diagnosis?

A. Normal grief (Correct Answer)
B. Major depressive disorder
C. Brief psychotic disorder
D. Adjustment disorder
E. Schizophreniform disorder

Explanation: ***Normal grief*** - The boy's reaction, including talking to his deceased grandfather and expressing sadness, is a **common and normal part of the grief process in children**, especially given his close relationship with his grandfather and the recent timing of the death. - His continued functioning at school, engaging with peers, and the absence of significant functional impairment indicate that these are likely **age-appropriate coping mechanisms** rather than a pathological condition. *Major depressive disorder* - This diagnosis typically involves **persistent sadness, anhedonia, significant changes in appetite or sleep, fatigue, feelings of worthlessness, or recurrent thoughts of death**, lasting for at least two weeks. - The boy's ability to engage in play and complete schoolwork, along with the episodic nature of his sadness, suggests he does not meet the criteria for **major depressive disorder**. *Brief psychotic disorder* - This disorder is characterized by the sudden onset of **psychotic symptoms** such as delusions, hallucinations, disorganized speech, or grossly disorganized behavior, lasting from one day to one month. - While the boy reports "speaking" to his grandfather, this is more indicative of a **grief-related fantasy or coping mechanism** rather than a true hallucination, especially since he understands his grandfather is deceased and it does not impair his daily functioning. *Adjustment disorder* - This involves **emotional or behavioral symptoms** that develop within three months of an identifiable stressor and cause significant distress or functional impairment. - Although there is a stressor (grandfather's death), the boy's symptoms are part of a **normal grieving process** and do not appear to cause significant impairment in his social or academic functioning. *Schizophreniform disorder* - This is a psychotic disorder with symptoms similar to **schizophrenia** (delusions, hallucinations, disorganized speech, negative symptoms) but lasting between one and six months. - The boy's claims of speaking to his grandfather are more consistent with **grief-induced fantasy** rather than a true psychotic symptom, and he lacks other hallmark features of a psychotic disorder.

Question 44: A 14-year-old boy is brought to the clinic by his mother for temper tantrums for the past year. She is concerned as he gets abnormally irritated and angry towards the smallest things. After asking the mother to leave the room, the patient reports that he is simply annoyed by his mother's constant nagging. He denies any violent tendencies, suicidal ideations, depressive symptoms, or intention to hurt others. The patient states he finds the physician irritating and that he reminds him of his mother in his mannerisms and demeanor. Without provocation, the patient shouts at the physician saying that he does not understand or really care about him and he never would. What is the likely explanation for this patient's behavior toward the physician?

A. Passive aggression
B. Transference (Correct Answer)
C. Displacement
D. Projection
E. Acting out

Explanation: ***Transference*** - **Transference** occurs when a patient unconsciously redirects feelings and attitudes from a significant past relationship (e.g., with a parent) onto the physician. The patient explicitly states the physician reminds him of his mother in mannerisms and demeanor, triggering a hostile outburst. - The patient's anger towards the physician "without provocation" and his declaration that the physician "doesn't understand or care" mirrors his expressed annoyance with his mother's "constant nagging," which he perceives as a lack of understanding or validation. *Passive aggression* - **Passive aggression** involves indirect resistance to the demands of others and an avoidance of direct confrontation, often through procrastination, stubbornness, or intentional inefficiency. - The patient's behavior is a direct, overt verbal outburst, not an indirect form of aggression. *Displacement* - **Displacement** is a defense mechanism where hostile or aggressive impulses are redirected from the original source of the frustration (mother) to a less threatening target (the physician). - While there is redirection of feelings, the key for transference is the *perception* that the physician *reminds* him of the original target, rather than just being a convenient, safer target for displaced feelings. The prompt explicitly states the patient sees the physician as his mother. *Projection* - **Projection** is a defense mechanism where undesirable thoughts, feelings, or qualities are attributed to another person. - The patient is expressing his own feelings of annoyance and anger, not attributing his own *unacceptable* feelings to the physician. He is responding to the physician as if the physician *is* his mother. *Acting out* - **Acting out** refers to the expression of unconscious emotional conflicts or impulses through behavior, rather than through verbal expression or introspection. It's often impulsive and can be self-destructive or defiant. - While the patient is expressing emotions through behavior (shouting), the specific underlying mechanism described (physician reminding him of his mother) points more directly to transference as the primary defense.

Question 45: A 43-year-old female presents to the ED with a severe case of left leg cellulitis. She is admitted for IV antibiotics. After 24 hours, the area of erythema has receded approximately 30%. The following day she is being prepared for discharge when she suddenly begins to complain of nausea and abdominal pain. On physical exam, she is febrile and has mydriasis and piloerection. What is the most likely cause of these new findings?

A. The patient's bacterial infection is no longer responding to the antibiotic regimen and she is showing signs of sepsis
B. The patient has acquired a nosocomial enteritis, as a result of her hospitalization and her antibiotic regimen
C. The patient is most likely withdrawing from an opiate that she uses chronically (Correct Answer)
D. The patient is having an allergic reaction to the antibiotic regimen
E. The patient is now showing signs of a pulmonary embolism as a result of a deep vein thrombosis

Explanation: ***The patient is most likely withdrawing from an opiate that she uses chronically*** - The constellation of **nausea**, **abdominal pain**, **fever**, **mydriasis** (dilated pupils), and **piloerection** (goosebumps) is highly characteristic of **opiate withdrawal syndrome**. - Opiate withdrawal symptoms typically manifest when a chronic user stops or significantly reduces their opiate intake, which could occur during hospitalization if their usual supply is interrupted or not continued. *The patient's bacterial infection is no longer responding to the antibiotic regimen and she is showing signs of sepsis* - While sepsis can present with fever and abdominal pain, **mydriasis** and **piloerection** are not typical signs of sepsis; these point more strongly to autonomic nervous system dysregulation seen in withdrawal. - The initial cellulitis was improving ("erythema has receded approximately 30%"), making worsening sepsis less likely as the primary driver of these *new* and distinct symptoms. *The patient has acquired a nosocomial enteritis, as a result of her hospitalization and her antibiotic regimen* - **Nosocomial enteritis** might cause nausea and abdominal pain, but it would typically involve **diarrhea** and would not explain the prominent findings of **mydriasis** and **piloerection**. - While antibiotics can cause gastrointestinal upset, these specific autonomic signs are not typical for antibiotic-associated enteritis. *The patient is having an allergic reaction to the antibiotic regimen* - An **allergic reaction** would typically present with symptoms like **rash**, **hives**, **pruritus**, **angioedema**, or **bronchospasm**, which are not described. - While fever can occur with drug reactions, the specific combination of pupillary changes and piloerection is not characteristic of an allergic response. *The patient is now showing signs of a pulmonary embolism as a result of a deep vein thrombosis* - A **pulmonary embolism (PE)** characteristically presents with **dyspnea**, **chest pain**, **tachycardia**, and potentially **hypoxia**. - **Nausea**, **abdominal pain**, **mydriasis**, and **piloerection** are not typical symptoms of a PE.

Question 46: A 33-year-old man is brought to a psychiatric emergency room in St. Louis by policemen who report that they found him loitering at the main bus station. The patient is unable to recall why he was at the bus station, but he does have a bus ticket in his pocket from Chicago to St. Louis. When asked what his name is, he replies “I don’t know.” He has no source of identification and cannot recall his own past medical history or medications. His temperature is 98.8°F (37.1°C), blood pressure is 130/75 mmHg, pulse is 85/min, and respirations are 20/min. On examination, the patient is alert but is not oriented to person, place, or time. He appears anxious and upset but is appropriately conversant and cooperative with the examination. His pupils are equally round and reactive to light. The rest of the examination is normal. A urine toxicology screen is negative. A family member of the patient contacts the hospital the next morning and reports that the patient is a soldier who recently returned from a deployment in Afghanistan. He was last seen at his home in Chicago. Which of the following is most consistent with this patient’s condition?

A. Depersonalization disorder
B. Bipolar I disorder
C. Dissociative fugue disorder (Correct Answer)
D. Dissociative identity disorder
E. Post-traumatic stress disorder

Explanation: ***Dissociative fugue disorder*** - The patient exhibits sudden, unexpected **travel away from home** or one's customary workplace, coupled with **amnesia for identity** or other important autobiographical information, which are core features of dissociative fugue. - The history of being a soldier recently returned from deployment suggests a possible **stressor** that could precipitate a dissociative episode. *Depersonalization disorder* - This involves persistent or recurrent experiences of feeling **detached from one's mental processes or body**, as if one is an outside observer. - The patient's inability to recall identity, place, and time, along with travel, goes beyond mere feelings of detachment. *Bipolar I disorder* - Characterized by episodes of **mania and depression**, which are primarily mood disturbances. - The patient's symptoms are focused on **memory loss and identity confusion**, not elevated or depressed mood primarily. *Dissociative identity disorder* - Involves the presence of **two or more distinct personality states** or an experience of possession, which is not described. - While there is memory loss, it's typically for everyday events or important personal information associated with different identities, not a complete loss of personal identity and travel. *Post-traumatic stress disorder* - Involves symptoms like **intrusive thoughts, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity** following a traumatic event. - While the patient's military service and trauma could be an underlying factor, the primary presentation of **identity amnesia and travel** is more consistent with dissociative fugue than the immediate symptoms of PTSD itself.

Question 47: A mother brings her 3-year-old son to the doctor because she is worried that he might be harming himself by constantly banging his head on the wall. He has been exhibiting this behavior for a few months. She is also worried because he has started to speak less than he used to and does not respond when his name is called. He seems aloof during playtime with other children and seems to have lost interest in most of his toys. What is the most likely diagnosis?

A. Autism spectrum disorder (Correct Answer)
B. Attention deficit hyperactivity disorder
C. Generalized anxiety disorder
D. Bipolar disorder
E. Obsessive-compulsive disorder

Explanation: ***Autism spectrum disorder*** - The child's symptoms of **head banging** (a repetitive, self-stimulatory behavior), **decreased speech**, **lack of response to his name**, **social aloofness**, and **loss of interest in toys** are classic indicators of **Autism Spectrum Disorder (ASD)**. - ASD involves persistent deficits in **social communication and interaction** across multiple contexts, as well as **restricted, repetitive patterns of behavior, interests, or activities**. *Attention deficit hyperactivity disorder* - **ADHD** is characterized primarily by **inattention, hyperactivity, and impulsivity**, which are not the prominent or primary concerns described in this case. - While children with ADHD may have social difficulties, their core symptoms do not typically include severe **social aloofness, communication regression**, or **self-injurious repetitive behaviors** like head banging. *Generalized anxiety disorder* - **Generalized anxiety disorder (GAD)** in children typically presents with excessive worry about multiple events or activities, often accompanied by **physical symptoms of anxiety** such as restlessness, fatigue, and difficulty concentrating. - It does not explain the **communication regression, social deficits**, or **stereotypical behaviors** like head banging observed in this child. *Bipolar disorder* - **Bipolar disorder** in children often manifests with severe mood dysregulation, including distinct periods of **elevated or irritable mood (mania/hypomania)** and depression. - The symptoms described, such as social withdrawal and communication difficulties, are not characteristic of the primary presentations of bipolar disorder. *Obsessive-compulsive disorder* - **OCD** is characterized by the presence of **obsessions (recurrent, persistent thoughts, urges, or images)** and/or **compulsions (repetitive behaviors or mental acts)**. - While head banging can be a repetitive behavior, the broader constellation of symptoms, including social and communication deficits, is not typical of primary OCD in young children.

Question 48: A previously healthy 21-year-old woman is brought to the physician because of weight loss and fatigue. Over the past 12 months she has lost 10.5 kg (23.1 lb). She feels tired almost every day and says that she has to go running for 2 hours every morning to wake up. She had been a vegetarian for 2 years but decided to become a vegan 6 months ago. She lives with her mother, who has obsessive-compulsive disorder. The mother reports that her daughter refuses to eat with the family and only eats food that she has prepared herself. When asked about her weight, the patient says that despite her weight loss, she still feels “chubby”. She is 160 cm (5 ft 3 in) tall and weighs 42 kg (92.6 lb); BMI is 16.4 kg/m2. Her temperature is 35.7°C (96.3°F), pulse is 39/min, and blood pressure is 100/50 mm Hg. Physical examination shows emaciation. There is dry skin, covered by fine, soft hair all over the body. On mental status examination, she is oriented to person, place, and time. Serum studies show: Na+ 142 mEq/L Cl 103 mEq/L K+ 4.0 mEq/L Urea nitrogen 10 mg/dL Creatinine 1.0 mg/dL Glucose 65 mg/dL Which of the following is the most appropriate next step in management?

A. Hospitalization and topiramate therapy
B. Hospitalization and fluoxetine therapy
C. Food diary and outpatient follow-up
D. Inpatient nutritional rehabilitation (Correct Answer)
E. Outpatient psychodynamic psychotherapy

Explanation: ***Inpatient nutritional rehabilitation*** - This patient exhibits severe **anorexia nervosa** with a **BMI of 16.4 kg/m²**, **bradycardia (39/min)**, **hypothermia (35.7°C)**, **hypotension (100/50 mm Hg)**, and **emaciation with lanugo hair**. These symptoms indicate an urgent need for medical stabilization. - Inpatient nutritional rehabilitation is crucial for safe **weight restoration**, correction of electrolyte imbalances, and medical monitoring to prevent serious complications like **refeeding syndrome**. *Hospitalization and topiramate therapy* - While hospitalization is indicated, **topiramate** is an anticonvulsant sometimes used for binge-eating disorder or bulimia nervosa, but it is **contraindicated** in anorexia nervosa due to its potential to cause **further weight loss**. - **Hospitalization** alone without a clear plan for nutritional rehabilitation and weight restoration is insufficient for a patient with severe anorexia nervosa. *Hospitalization and fluoxetine therapy* - **Fluoxetine** (an SSRI) is generally **not effective** for weight restoration in the acute phase of anorexia nervosa and is typically reserved for comorbid depression or anxiety **after significant weight restoration** has occurred. - Starting fluoxetine during severe malnutrition can be ineffective and may even carry risks without addressing the primary need for nutritional rehabilitation. *Food diary and outpatient follow-up* - This option is **inappropriate** given the patient's critically low BMI, significant bradycardia, hypothermia, and hypotension, which are all signs of medical instability requiring **immediate inpatient care**. - **Outpatient management** would be insufficient and potentially dangerous for a patient with such severe signs of malnutrition and organ compromise. *Outpatient psychodynamic psychotherapy* - While **psychotherapy** is a cornerstone of long-term treatment for anorexia nervosa, **outpatient psychodynamic psychotherapy** is not the appropriate first step for a patient with significant medical instability. - Medical stabilization and weight restoration through **inpatient nutritional rehabilitation** must precede or occur concurrently with intensive psychotherapy for optimal and safe recovery.

Question 49: A 40-year-old woman presents with an acute loss of vision in her right eye. Past medical history is significant for depression diagnosed 2 years ago and well-managed medically. Further history reveals that the patient recently came to know that her trusted neighbor was sexually abusing her younger daughter. Physical examination is unremarkable and reveals no abnormality that can explain her acute unilateral blindness. Which of the following features is most characteristic of this patient’s condition?

A. Pseudologia fantastica
B. Hyperactive insula
C. Seeking tangible reward
D. Desire for the sick-role
E. La belle indifférence (Correct Answer)

Explanation: ***La belle indifférence*** - This term describes a patient's **lack of concern** or emotional response toward their significant and unexplained physical symptoms, which is characteristic of **conversion disorder**. - In this case, the patient presents with acute, unexplained blindness following a severe psychosocial stressor, and if she reacted with calmness or disinterest regarding her sudden loss of vision, it would strongly suggest this phenomenon. *Pseudologia fantastica* - This refers to a tendency to **fabricate elaborate and fantastical lies** that the individual often comes to believe themselves. - It is more commonly associated with conditions like **factitious disorder** or certain personality disorders, not the presentation described. *Hyperactive insula* - An overactive insula is implicated in conditions involving heightened emotional processing and body awareness, such as **anxiety disorders** and **somatic symptom disorder**. - It does not specifically characterize conversion disorder, where neurological symptoms are often inconsistent with known pathways. *Seeking tangible reward* - This is a hallmark of **malingering**, where individuals consciously feign illness for **external incentives** like financial gain, avoiding work, or obtaining drugs. - In conversion disorder, the symptoms are not consciously produced for such rewards. *Desire for the sick-role* - While individuals with **factitious disorder** often exhibit a strong desire to assume the "sick role" and gain attention from healthcare providers, this is driven by an unconscious psychological need. - This is distinct from conversion disorder, where symptoms arise as an unconscious coping mechanism for stress, without the primary goal of the sick role.

Question 50: A 30-year-old man is brought to the emergency department by the police after starting a fight at a local bar. He has several minor bruises and he appears agitated. He talks incessantly about his future plans. He reports that he has no history of disease and that he is "super healthy" and "never felt better". His temperature is 38.0°C (100.4°F), pulse is 110/min, respirations are 16/min, and blood pressure is 155/80 mm Hg. On physical examination reveals a euphoric and diaphoretic man with slightly dilated pupils. An electrocardiogram is obtained and shows tachycardia with normal sinus rhythm. A urine toxicology screen is positive for cocaine. The patient is held in the ED for observation. Which of the following symptoms can the patient expect to experience as he begins to withdraw from cocaine?

A. Psychosis
B. Seizures
C. Lacrimation
D. Increased appetite (Correct Answer)
E. Increased sympathetic stimulation

Explanation: ***Increased appetite*** - **Cocaine withdrawal** is characterized by a "crash" phase, which includes severe fatigue, **dysphoria**, and increased appetite, often leading to binge eating as the body attempts to replenish depleted neurotransmitters. - This symptom, combined with **hypersomnia** and a reduction in pleasure, represents a rebound effect from the intense stimulation caused by cocaine use. *Psychosis* - While acute cocaine intoxication can induce **psychotic symptoms** like paranoia and hallucinations, psychosis is not a typical feature of the *withdrawal* phase. - Instead, the withdrawal period is often marked by a decrease in stimulation, leading to symptoms like depression and anhedonia rather than further agitation or psychosis. *Seizures* - **Seizures** are a potential complication of acute cocaine intoxication due to its stimulant effects on the central nervous system, but they are generally not a primary symptom of uncomplicated **cocaine withdrawal**. - Withdrawal is more commonly associated with a state of brain hyperexcitability that manifests as cravings and dysphoria, not typically grand mal seizures. *Lacrimation* - **Lacrimation** (tearing) is a common symptom of **opioid withdrawal**, often accompanied by rhinorrhea, muscle aches, and piloerection. - These **cholinergic rebound** symptoms are not characteristic of cocaine withdrawal, which primarily involves dopaminergic and noradrenergic system dysregulation. *Increased sympathetic stimulation* - Acute cocaine use directly causes increased sympathetic stimulation, resulting in **tachycardia**, **hypertension**, and dilated pupils, as seen in this patient. - **Cocaine withdrawal**, conversely, leads to a *decrease* in sympathetic tone, often accompanied by fatigue, bradycardia, and a general depressive state, as the body rebounds from overstimulation.

Question 51: An 81-year-old woman presents to your office accompanied by her husband. She has been doing well except for occasional word finding difficulty. Her husband is concerned that her memory is worsening over the past year. Recently, she got lost twice on her way home from her daughter’s house, was unable to remember her neighbor’s name, and could not pay the bills like she usually did. She has a history of hypertension and arthritis. She has no significant family history. Her medications include a daily multivitamin, hydrochlorothiazide, and ibuprofen as needed. Physical exam is unremarkable. Which of the following is associated with an increased risk of this patient’s disease?

A. Presenilin-2
B. ApoE2
C. ApoE4 (Correct Answer)
D. Female gender
E. Advanced age (>85 years)

Explanation: ***Correct: ApoE4*** - The patient's symptoms (progressive memory loss, getting lost on familiar routes, difficulty with routine tasks like paying bills) in an 81-year-old suggest **Alzheimer's disease**. - The **ApoE4 allele** is a well-established genetic risk factor for **late-onset Alzheimer's disease**, significantly increasing the likelihood (3-fold increased risk for one allele, 12-fold for two alleles) and often lowering the age of onset. - ApoE4 is the **most specific and discriminating risk factor** among the options provided. *Incorrect: Presenilin-2* - **Presenilin-2** mutations are associated with **early-onset familial Alzheimer's disease**, which typically manifests before age 65 and often has a strong family history. - This patient is 81 years old and has no significant family history, making early-onset familial AD unlikely. *Incorrect: ApoE2* - The **ApoE2 allele** is actually associated with a **decreased risk** of Alzheimer's disease. - It is thought to be protective due to its more efficient clearance of amyloid beta peptides from the brain. *Incorrect: Female gender* - While **female gender** is indeed a risk factor for Alzheimer's disease (women have approximately 2:1 higher lifetime risk even after adjusting for longevity), it is less specific than ApoE4 as a discriminating answer. - All patients have a biological sex, but only some carry the ApoE4 allele, making ApoE4 a more useful clinical and epidemiological marker. *Incorrect: Advanced age (>85 years)* - **Advanced age** is actually the strongest non-modifiable risk factor for Alzheimer's disease, with incidence doubling every 5 years after age 65. - However, in the context of this question, **ApoE4 is the better answer** because it represents a specific genetic risk factor that can be tested and is directly associated with disease pathogenesis, whereas advanced age is a universal demographic factor that applies to all individuals who live long enough.

Question 52: A 24-year-old woman comes to her physician because of fatigue. She has been coming to the office multiple times a month for various minor problems over the past six months. During the appointments, she insists on a first name basis and flirts with her physician. She always dresses very fashionably. When his assistant enters the room, she tends to start fidgeting and interrupt their conversation. When the physician tells her politely that her behavior is inappropriate, she begins to cry, complaining that no one understands her and that if people only listened to her, she would not be so exhausted. She then quickly gathers herself and states that she will just have to keep looking for a physician who can help her, although she has doubts she will ever find the right physician. She does not have a history of self harm or suicidal ideation. Which of the following is the most likely diagnosis?

A. Schizotypal personality disorder
B. Dependent personality disorder
C. Schizoid personality disorder
D. Histrionic personality disorder (Correct Answer)
E. Borderline personality disorder

Explanation: ***Histrionic personality disorder*** - This patient exhibits classic features of **Histrionic Personality Disorder**, including **attention-seeking behavior**, **inappropriate sexually provocative interactions** (flirting), rapidly shifting and shallow emotions, and using physical appearance to draw attention. - Her excessive emotionality, self-dramatization ("no one understands her"), and perceiving relationships as more intimate than they are fit the diagnostic criteria. *Schizotypal personality disorder* - Characterized by **magical thinking**, **peculiar speech or behavior**, and **social anxiety** due to paranoid fears, none of which are primarily displayed here. - While there is social awkwardness, it's not driven by paranoid ideation but rather a need for attention. *Dependent personality disorder* - Individuals with dependent personality disorder exhibit an excessive need to be cared for, leading to **submissive and clinging behavior** and an **intense fear of separation**. This patient's behavior is assertive and attention-seeking, not submissive. - They often have difficulty making everyday decisions without excessive reassurance and may go to great lengths to obtain nurturance and support from others. *Schizoid personality disorder* - This disorder is characterized by a **pervasive pattern of detachment from social relationships** and a restricted range of emotional expression. This patient actively seeks interaction and attention. - Individuals with schizoid personality disorder typically prefer solitude and show **indifference to praise or criticism**. *Borderline personality disorder* - While there might be some overlap in emotional intensity, borderline personality disorder is primarily characterized by **instability in relationships, self-image, affects, and impulsivity**, often including **recurrent suicidal behavior or self-mutilating acts**. - The patient's presentation lacks the significant impulsivity, chronic feelings of emptiness, or history of self-harm/suicidal ideation typically seen in Borderline Personality Disorder.

Question 53: A 25-year-old woman presents to her primary care physician with a chief complaint of diffuse muscle aches and pains. She states that she has trouble doing everyday tasks such as showering, cooking, and cleaning due to the pain. The patient has a past medical history of anxiety and bulimia nervosa and is currently not taking any medications. Upon further questioning, the patient states that her symptoms started last week when her boyfriend left her for another individual. The patient was quite upset, as she states she always had tended to all his needs and never argued with him. Since he has left, she has been unable to decide what she should do with herself during the day. The patient has been living with her mother for the past day and states that has helped greatly, as her mother helps her plan her days and gives her chores to do. Regardless, the patient states that her pain persists. The physician sets up a referral for the patient to work with a psychiatrist. Upon hearing this, the patient becomes visually bothered and questions if the physician is actually trying to help her. Which of the following personality disorder does this patient most likely suffer from?

A. Paranoid
B. Borderline
C. Avoidant
D. Histrionic
E. Dependent (Correct Answer)

Explanation: ***Dependent*** - The patient exhibits strong **submissiveness** and a pervasive need to be taken care of, as evidenced by her inability to make decisions and relying on her mother to plan her days and give her chores. - She shows a fear of **separation** and an urgent search for a new relationship or support system, highlighted by her difficulty functioning after her boyfriend left and her extreme devotion to his needs. *Paranoid* - Characterized by a pervasive **distrust and suspiciousness of others**, interpreting their motives as malevolent. - This patient does not display these features; her discomfort with the referral is more about fear of abandonment and lack of self-reliance, not suspicion. *Borderline* - Involves instability in relationships, self-image, affects, and marked **impulsivity**, often with frantic efforts to avoid real or imagined abandonment. - While there is a fear of abandonment, the patient's primary presentation is submissiveness and need for care, rather than the characteristic impulsivity, emotional lability, and unstable self-image seen in borderline personality disorder. *Avoidant* - Marked by **social inhibition**, feelings of inadequacy, and hypersensitivity to negative evaluation, leading to avoidance of social interaction. - This patient seeks close relationships and relies on others, which is opposite to the social withdrawal and avoidance characteristic of avoidant personality disorder. *Histrionic* - Characterized by excessive **emotionality** and attention-seeking behavior, often dramatic and theatrical. - While the patient might seek attention in her relationship, her core issue of submissiveness and reliance on others for decision-making does not align with the overtly dramatic and exhibitionistic traits of histrionic personality disorder.

Question 54: A 19-year-old woman comes to the physician because of a 2-day history of difficulty sleeping. She worries that the lack of sleep will ruin her career prospects as a model. She has been coming to the physician multiple times over the past year for minor problems. She is dressed very extravagantly and flirts with the receptionist. When she is asked to sit down in the waiting room, she begins to cry and says that no one listens to her. When she is called to the examination room, she moves close to the physician, repeatedly intends to touch his cheek, and makes inappropriate comments. She does not have a history of self-harm or suicidal ideation. Which of the following is the most likely diagnosis?

A. Schizotypal personality disorder
B. Borderline personality disorder
C. Dependent personality disorder
D. Narcissistic personality disorder
E. Histrionic personality disorder (Correct Answer)

Explanation: ***Histrionic personality disorder*** - This patient displays classic features of **histrionic personality disorder**, including **attention-seeking behaviors** (flirting, extravagant dress, dramatic crying), **inappropriate sexually seductive behavior** toward the physician, and **rapidly shifting and shallow emotions** (cries that no one listens to her, then attempts to touch the physician). - Her excessive emotionality and constant need to be the center of attention, coupled with a tendency to use physical appearance to draw attention to herself, align well with the diagnostic criteria. *Schizotypal personality disorder* - Characterized by a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as by **cognitive or perceptual distortions** and eccentricities of behavior. - This patient does not exhibit evidence of odd beliefs, magical thinking, unusual perceptual experiences, or paranoid ideation typical of schizotypal personality disorder. *Borderline personality disorder* - Marked by a pervasive pattern of **instability of interpersonal relationships, self-image, and affects**, and marked impulsivity. Patients often exhibit intense fears of abandonment, chronic feelings of emptiness, and self-harming behaviors. - While there is some emotional dysregulation and intense relationships, the patient does not report **self-harm, suicidal ideation**, or the severe identity disturbance common in borderline personality disorder. *Dependent personality disorder* - Individuals with dependent personality disorder exhibit an excessive need to be cared for, leading to **submissive and clinging behavior** and fears of separation. They often have difficulty making everyday decisions without excessive reassurance. - This patient's behaviors are geared towards attracting attention and being the center of it, rather than seeking reassurance or exhibiting submissive behavior. *Narcissistic personality disorder* - Characterized by a pervasive pattern of **grandiosity, a need for admiration**, and a lack of empathy. Patients often believe they are special and unique and expect to be recognized as superior. - While this patient seeks attention, her behavior is more about being dramatic and emotionally expressive rather than a sense of inflated self-importance or a deep need for admiration stemming from grandiosity.

Question 55: A 14-year-old male is brought to your psychiatric clinic after he was caught stealing his peers’ belongings multiple times by his teacher. He is a straight-A student with many friends and is an outstanding football player. He describes his family as very loving and gets along with his older siblings. He also states that he has no ill will towards anyone he stole from in class. Although never caught, he admits that he would often steal things in stores or locker rooms when no one was looking in order to satisfy an intense impulse. Which of the following is the best diagnosis for this patient?

A. Kleptomania (Correct Answer)
B. Antisocial Personality Disorder
C. Conduct disorder
D. Schizophrenia
E. Manic episode

Explanation: ***Kleptomania*** - The patient's presentation of stealing for an **intense impulse** rather than for financial gain or to express anger, along with an absence of other behavioral issues, aligns with the diagnostic criteria for **kleptomania**. - The patient describes feeling no ill will towards those he stole from, suggesting the stealing is driven by a compulsive urge rather than malicious intent or antisocial behavior. *Antisocial Personality Disorder* - This disorder is characterized by a pervasive pattern of **disregard for and violation of the rights of others**, beginning in childhood or early adolescence, and extending into adulthood. - The patient's good academic standing, many friends, loving family, and lack of ill will towards his victims do not fit the typical pattern of deceitfulness, impulsivity, irritability, or aggression seen in **antisocial personality disorder**. *Conduct disorder* - **Conduct disorder** involves a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. - While stealing is a feature, a diagnosis of conduct disorder requires a broader pattern of aggressive, destructive, deceitful, or rule-violating behaviors, which are not present in this patient's otherwise well-adjusted life (e.g., good student, many friends, loving family). *Schizophrenia* - **Schizophrenia** is a severe mental disorder characterized by thought disorders, delusions, hallucinations, and grossly disorganized behavior, which are not present in this patient. - The patient's symptoms are solely focused on impulse-driven stealing and do not include any psychotic features. *Manic episode* - A **manic episode** involves a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy. - While impulsivity can be a feature of mania, the patient's presentation lacks other hallmark symptoms such as decreased need for sleep, grandiosity, flight of ideas, or increased talkativeness, and the stealing is described as an isolated intense impulse rather than part of a broader mood disturbance.

Question 56: A 35-year-old woman is brought to the emergency department by her coworkers after a sudden onset of vision loss. She is a lawyer and lost 3 cases in the past week. Yesterday, she experienced weakness and paralysis of her left wrist. Past medical history is significant for acid reflux. Physical examination reveals 2/4 in reflexes and 5/5 in muscular strength in all extremities. She appears indifferent to her current situation and presents with a flat affect. Slurring of words is absent. CT without contrast and MRI of the brain are unremarkable. Which of the following is the most likely diagnosis?

A. Conversion disorder (Correct Answer)
B. Transient ischemic attack
C. Factitious disorder
D. Major depressive disorder
E. Somatization disorder

Explanation: ***Conversion disorder*** - The sudden onset of **neurological symptoms** (vision loss, wrist paralysis) without a medical explanation, particularly in the context of psychological stress (**losing cases**), is characteristic of conversion disorder. - The patient's **indifference** to her symptoms (**la belle indifférence**) further supports this diagnosis, as does the normal neurological examination and imaging. *Transient ischemic attack* - While TIAs can cause sudden neurological deficits, they typically involve a **brief, full recovery** of symptoms within 24 hours, and are often associated with vascular risk factors. - The patient's symptoms are sustained, and her physical examination is unremarkable, which is inconsistent with acute ischemia. *Factitious disorder* - In factitious disorder, individuals **intentionally feign or induce symptoms** for the primary purpose of assuming the sick role. - This patient presents with real, albeit psychologically-driven, symptoms and does not appear to be consciously fabricating illness. *Major depressive disorder* - While the patient is experiencing stress, the primary features of depression are persistent sadness, anhedonia, and other mood disturbances, not **acute neurological deficits** as the presenting complaint. - Her flat affect could be a symptom, but the core issue is unexplained neurological dysfunction. *Somatization disorder* - Somatization disorder (now part of **somatic symptom disorder**) involves multiple, chronic, and often vague physical complaints across various body systems that are not adequately explained by medical conditions. - This patient presents with acute, specific neurological symptoms, not a chronic and diffuse pattern of complaints.

Question 57: A 25-year-old woman with a history of moderate persistent asthma presents to the emergency department with tachypnea, shortness of breath, and cough. She also mentions that she has recently started to notice red flecks in the sputum that she coughs up. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 26/min. Her physical examination is significant for moderate bilateral wheezes and poor air movement. The forced expiratory volume-1 (FEV-1) is less than 50% of the predicted value, and she is found to have a concurrent upper respiratory tract infection. She is given oxygen, albuterol, and corticosteroids for her exacerbation, and she starts to feel better after a few hours of monitoring in the emergency department. She is ultimately discharged home on a 14-day prednisone taper. Which of the following is a side effect she could experience on this short course of steroids?

A. Impaired wound healing
B. Amenorrhea
C. Fat deposits in the face
D. Emotional instability (Correct Answer)
E. Cushing’s syndrome

Explanation: ***Emotional instability*** - A short course of corticosteroids can significantly impact **mood and cognition**, leading to symptoms like **anxiety**, **irritability**, **insomnia**, or even an acute psychotic episode. - These psychiatric side effects are relatively common, even with short-term use, due to the direct effects of glucocorticoids on the **central nervous system**. *Impaired wound healing* - While chronic corticosteroid use can impair wound healing by inhibiting **collagen synthesis** and **fibroblast proliferation**, it is less likely to be a prominent side effect with a short, 14-day taper. - Significant wound healing issues are typically seen with **prolonged high-dose therapy**. *Amenorrhea* - **Menstrual irregularities** and amenorrhea are usually associated with **long-term steroid use**, leading to suppression of the hypothalamic-pituitary-gonadal axis. - A short, 14-day course is unlikely to cause a significant or lasting impact on the **menstrual cycle**. *Fat deposits in the face* - The development of **"moon face"** (fat deposits in the face) is a characteristic feature of **Cushing's syndrome** resulting from **chronic, high-dose corticosteroid use**. - This symptom primarily develops over **weeks to months** of continuous exposure, not from a short-term taper. *Cushing’s syndrome* - **Cushing's syndrome** is a constellation of symptoms resulting from **prolonged exposure to high levels of cortisol**, endogenous or exogenous. - A 14-day prednisone taper is **insufficient duration** to induce the full clinical picture of Cushing's syndrome.

Question 58: A 27-year-old woman is brought to the physician by her parents because they are concerned about her mood. They say that she has “not been herself” since the death of her friend, who was killed 3 weeks ago when the fighter jet he piloted was shot down overseas. She says that since the incident, she feels sad and alone. She reports having repeated nightmares about her friend's death. Her appetite has decreased, but she is still eating regularly and is otherwise able to take care of herself. She does not leave her home for any social activities and avoids visits from friends. She went back to work after taking 1 week off after the incident. Her vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, she appears sad, has a full range of affect, and is cooperative. In addition to taking measures to evaluate this patient's anxiety, which of the following is the most appropriate statement by the physician at this time?

A. I can see that you have gone through a lot recently, but I think that your reaction is especially severe and has persisted for longer than normal. Would you be open to therapy or medication to help you manage better?
B. I am worried that you may be having an abnormally severe reaction to what is an understandably stressful event. I recommend attending behavioral therapy sessions to help you deal with this challenge.
C. Your grief over the loss of your friend appears to have a negative effect on your social and functional capabilities. I recommend starting antidepressants to help you deal with this challenge.
D. I'm so sorry, but the loss of loved ones is a part of life. Let's try to find better ways for you to deal with this event.
E. I understand that the sudden loss of your friend has affected you deeply. Sometimes in situations like yours, people have thoughts that life is not worth living; have you had such thoughts? (Correct Answer)

Explanation: ***I understand that the sudden loss of your friend has affected you deeply. Sometimes in situations like yours, people have thoughts that life is not worth living; have you had such thoughts?*** - This statement empathetically acknowledges the patient's grief while **directly assessing for suicidal ideation**, which is crucial in any evaluation of a patient experiencing significant emotional distress, especially after a recent loss. - The patient's presentation, including sadness, social withdrawal, decreased appetite, and nightmares, is consistent with **grief**, but the physician must rule out more severe conditions like **major depressive disorder (MDD)**, for which suicidal thoughts are a key diagnostic criterion and safety concern. *I can see that you have gone through a lot recently, but I think that your reaction is especially severe and has persisted for longer than normal. Would you be open to therapy or medication to help you manage better?* - This statement is somewhat judgmental ("especially severe and has persisted for longer than normal") for a patient only three weeks out from a traumatic loss, which could invalidate her feelings. - While therapy or medication might be considered, it's generally too early to classify her normal grief response as an abnormal or prolonged reaction without first screening for immediate safety concerns like suicidal ideation. *I am worried that you may be having an abnormally severe reaction to what is an understandably stressful event. I recommend attending behavioral therapy sessions to help you deal with this challenge.* - Similar to the previous option, labeling her reaction as "abnormally severe" at this early stage (3 weeks post-loss) can be perceived as invalidating and may make the patient less open to further discussion or treatment. - Recommending therapy without first assessing for suicidal ideation or a more comprehensive diagnostic evaluation is premature and misses a critical screening step. *Your grief over the loss of your friend appears to have a negative effect on your social and functional capabilities. I recommend starting antidepressants to help you deal with this challenge.* - While her social and functional capabilities are affected, grief is a normal human response, and recommending antidepressants after only 3 weeks post-loss, without a full psychiatric evaluation or ruling out suicidal ideation, is often premature. - **Antidepressants** are typically considered for **MDD** or **prolonged grief disorder**, usually after a longer period (e.g., 6 months for adults) or if symptoms are markedly severe and debilitating, especially with an immediate safety concern. *I'm so sorry, but the loss of loved ones is a part of life. Let's try to find better ways for you to deal with this event.* - This statement, particularly "the loss of loved ones is a part of life," can come across as dismissive and insensitive to the patient's individual pain and trauma. - It minimizes her experience and does not create an empathetic environment necessary for a patient to open up about potentially sensitive topics, such as suicidal thoughts.

Question 59: A 34-year-old female presents to a counselor at the urging of her parents because they are concerned that she might be depressed. After recently breaking up with her long-term boyfriend, she moved back in with her parents because she could not handle making decisions alone. Soon after their breakup, she started going on 5–7 dates a week. She has been unemployed for 3 years, as her boyfriend took care of all the bills. In the past year, she thought of looking for a job but never felt confident enough to start the process. Her mom arranges her doctor's appointments and handles her car maintenance. She describes feeling uneasy when she is alone. She has hypothyroidism treated with levothyroxine. She does not smoke or drink alcohol. Vital signs are normal. Mental status exam shows a neutral affect. Neurologic examination shows no focal findings. Which of the following is the most likely diagnosis?

A. Avoidant personality disorder
B. Histrionic personality disorder
C. Borderline personality disorder
D. Separation anxiety disorder
E. Dependent personality disorder (Correct Answer)

Explanation: ***Dependent personality disorder*** - The patient exhibits a pervasive and excessive need to be cared for, leading to **submissive and clinging behavior** and fears of separation, as evidenced by her inability to make decisions, reliance on parents, and discomfort when alone. - Her history of unemployment and reliance on her boyfriend, followed by moving back with parents and having her mom handle appointments and car maintenance, strongly supports an inability to function independently and an excessive need for reassurance and support, characteristic of **dependent personality disorder**. *Avoidant personality disorder* - This disorder is characterized by a pervasive pattern of **social inhibition**, feelings of inadequacy, and hypersensitivity to negative evaluation, which are not the primary features here. - While she may lack confidence in looking for a job, her constant search for new relationships (5-7 dates a week) and reliance on others for decision-making point away from the **social avoidance** central to this diagnosis. *Histrionic personality disorder* - This disorder is marked by **excessive emotionality** and **attention-seeking behavior**, often through seductive or provocative means. - Although she is actively dating, the core issue appears to be her need for care and support rather than a desire to be the center of attention or dramatize her emotions. *Borderline personality disorder* - Characterized by a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity, such as **frantic efforts to avoid abandonment** or **recurrent suicidal behavior**. - While she might fear abandonment (expressed as uneasiness when alone), the overall clinical picture lacks the impulsivity, mood swings, self-harm, or intense anger typically seen in borderline personality disorder. *Separation anxiety disorder* - This disorder typically manifests with excessive fear or anxiety concerning separation from attachment figures, often seen in childhood, but can occur in adults. - While she expresses **uneasiness when alone**, the pervasive pattern of **submissive behavior**, difficulty making decisions, and chronic dependency on others for all aspects of life points more towards a personality disorder rather than an anxiety disorder primarily focused on separation.

Question 60: A 71-year-old woman comes to her doctor because she is having trouble staying awake in the evening. Over the past year, she has noticed that she gets tired unusually early in the evenings and has trouble staying awake through dinner. She also experiences increased daytime sleepiness, fatigue, and difficulty concentrating. She typically goes to bed around 9 PM and gets out of bed between 2 and 3 AM. She does not have any trouble falling asleep. She takes 30-minute to 1-hour daytime naps approximately 3 times per week. She has no history of severe illness and does not take any medication. Which of the following is the most likely diagnosis?

A. Non-REM sleep arousal disorder
B. Depressive disorder
C. Delayed sleep phase disorder
D. Advanced sleep phase disorder (Correct Answer)
E. Insomnia disorder

Explanation: ***Advanced sleep phase disorder*** - The patient's early evening fatigue, difficulty staying awake through dinner, and habitual bedtime of 9 PM with waking between 2-3 AM are classic symptoms of **advanced sleep phase disorder**. - This condition involves a consistent advance of the **major sleep episode**, occurring significantly earlier than desired and resulting in early morning awakening. *Non-REM sleep arousal disorder* - This disorder is characterized by recurrent episodes of **incomplete awakening** from sleep, often accompanied by behaviors like sleepwalking or sleep terrors. - The patient's symptoms are primarily related to timing of sleep, not **arousals** from sleep. *Depressive disorder* - While **sleep disturbance** (insomnia or hypersomnia) is common in depression, the specific pattern of early sleep onset and early morning awakening without difficulty falling asleep points away from a primary depressive disorder here. - The patient does not describe other critical symptoms of depression such as anhedonia, low mood, or feelings of worthlessness. *Delayed sleep phase disorder* - This disorder involves a **delay** in the timing of the major sleep episode, meaning individuals go to bed and wake up much later than conventional times. - The patient's symptoms are the **opposite** of delayed sleep phase disorder, as she is going to bed and waking up earlier. *Insomnia disorder* - Characterized by **difficulty falling asleep**, staying asleep, or early morning awakenings with inability to return to sleep, leading to significant distress or impairment. - The patient explicitly states she has **no trouble falling asleep**, which rules out primary insomnia as the main issue.

Question 61: The prison doctor sees a 25-year-old man for some minor injuries sustained during a recent lunchroom brawl. The patient has a long history of getting into trouble. During his interview, he seems very charming and carefully deflects all responsibility to others and gets irritable and hostile once probed on the issues. He is married and has 2 young children for whom he does not pay child support. Which of the following details is most critical for diagnosing this patient’s condition?

A. Criminal record
B. History of substance abuse
C. Family history
D. Evidence of lack of remorse
E. Childhood history (Correct Answer)

Explanation: ***Childhood history*** - A diagnosis of **Antisocial Personality Disorder (ASPD)** requires evidence of **conduct disorder** symptoms beginning before age 15. The childhood history provides insight into the chronicity and developmental pattern of pervasive disregard and violation of the rights of others. - The patient's current presentation of deceitfulness, impulsivity, irritability, and irresponsibility, along with a "long history of getting into trouble," aligns with ASPD criteria, which must be contextualized by their early onset of behavioral problems. *Criminal record* - While a criminal record often accompanies ASPD, it is a consequence of the disorder rather than a diagnostic criterion in itself. Many individuals with ASPD engage in criminal behavior, but the diagnosis focuses on a broader pattern of *disregard for the rights of others*, not just legal infractions. - While it supports the pattern of antisocial behavior, it doesn't provide the crucial developmental information (onset before age 15) required for diagnosis. *History of substance abuse* - **Substance abuse** is highly comorbid with ASPD, often used as a coping mechanism or as a direct consequence of impulsive and risky behaviors. However, it is not a direct criterion for ASPD itself. - While relevant to the patient's overall clinical picture and management, it does not directly contribute to the diagnostic criteria for ASPD. *Family history* - A family history of mental health disorders, including personality disorders, can increase the risk of developing ASPD, indicating a genetic predisposition. However, it is not a diagnostic criterion. - While useful for understanding risk factors, family history does not provide specific information about the patient's individual behavioral patterns or the onset of symptoms crucial for diagnosis. *Evidence of lack of remorse* - **Lack of remorse** is an important diagnostic criterion for ASPD, demonstrating a profound deficit in empathy and moral reasoning. It's evident in the patient's deflection of responsibility. - While a critical symptom, it's one of several criteria. Without evidence of a conduct disorder in childhood, even significant interpersonal impairment and lack of remorse in adulthood may not lead to an ASPD diagnosis.

Question 62: A 60-year-old man presents with severe chronic neck pain. 6 months ago, the patient was in a motor vehicle accident where he sustained a severe whiplash injury. Initial radiographs were negative for fractures, and he was treated with cyclobenzaprine and tramadol and discharged with outpatient follow-up. He says that despite being compliant with his medication, the pain is not going away. It keeps him up at night and prevents him from focusing at work or at home. He also feels that none of the other doctors can help him. Past medical history includes hypertension, hyperlipidemia, and gout for which he takes chlorthalidone, atorvastatin, and allopurinol. He has no family and lives alone. He has never attempted to take his life but thinks that it might be better than living in pain forever. He has a gun at home and plans to commit suicide in the near future. Which of the following is the single best initial treatment option for this patient’s condition?

A. Treat the patient with outpatient psychotherapy only
B. Treat the patient with outpatient pharmacotherapy only
C. Treat the patient with outpatient pharmacotherapy and psychotherapy only
D. Work with local police to confiscate the gun and release the patient home
E. Admission into the hospital (Correct Answer)

Explanation: ***Admission into the hospital*** - This patient expresses a **clear intent to commit suicide** ("plans to commit suicide in the near future") and has access to a lethal means (**a gun at home**). This represents an **imminent risk** requiring immediate inpatient psychiatric hospitalization to ensure safety. - The patient's profound, intractable pain, feelings of helplessness ("none of the other doctors can help him"), social isolation ("no family and lives alone"), and significant functional impairment further contribute to a **high-risk profile** that cannot be managed safely in an outpatient setting. *Treat the patient with outpatient psychotherapy only* - While psychotherapy is an important component of treating chronic pain and depression, it is **insufficient for immediate safety** given the patient's expressed suicidal intent and access to a firearm. - Outpatient therapy does not provide the **24-hour supervision and structured environment** necessary to prevent a suicide attempt in a high-risk individual. *Treat the patient with outpatient pharmacotherapy only* - Initiating or adjusting pharmacotherapy in an outpatient setting would take time to be effective and would **not address the immediate danger** posed by the patient's suicidal ideation and access to a weapon. - This approach fails to prioritize **patient safety** in a crisis situation. *Treat the patient with outpatient pharmacotherapy and psychotherapy only* - Similar to the above, even a combined outpatient approach **cannot guarantee immediate safety** when there is a stated plan and means for suicide. - The severity of the patient's symptoms and the high risk of self-harm necessitate a **more restrictive and supervised environment**. *Work with local police to confiscate the gun and release the patient home* - Confiscating the gun addresses one aspect of safety but does **not mitigate the underlying suicidal ideation** or the patient's overall risk. - Releasing him home, despite the removal of a specific lethal means, still leaves him in a situation of **high social isolation and distress** without adequate immediate support or supervision, potentially leading to other methods of self-harm.

Question 63: A 35-year-old woman is brought into the emergency room by her boyfriend with a superficial cut to the wrist. Her vital signs are normal. On physical examination, the laceration is superficial and bleeding has stopped. She says that the injury was self-inflicted because her boyfriend canceled a dinner date due to his mother being unexpectedly hospitalized. She had tried to call, email, and text him to make sure he kept the date, but he eventually stopped replying to her messages. She loves her boyfriend and says she cannot live without him. However, she was worried that he might be cheating on her and using his mother as an excuse. She admits, however, that he actually has never cheated on her in the past. While she says that she usually feels emotionally empty, she is furious during the interview as she describes how much she hates her boyfriend. Which of the following defense mechanisms is this patient exhibiting?

A. Transference
B. Splitting (Correct Answer)
C. Suppression
D. Repression
E. Regression

Explanation: ***Splitting*** - **Splitting** is apparent in her rapid shift from "loving" her boyfriend to "hating" him, as well as her conflicting thoughts ("cannot live without him" yet "he might be cheating"). - This defense mechanism involves viewing people or situations as either all good or all bad, without integrating positive and negative qualities, often seen in **borderline personality disorder**. *Transference* - **Transference** involves redirecting feelings and desires, especially those unconsciously retained from childhood, toward a new object or person. - While she has intense feelings toward her boyfriend, there's no indication that she is displacing feelings from a past significant relationship onto him. *Suppression* - **Suppression** is a conscious effort to push unwanted thoughts or feelings out of awareness. - The patient is actively expressing her strong emotions and thoughts, not consciously trying to avoid them. *Repression* - **Repression** is an unconscious mechanism where unacceptable thoughts, feelings, or memories are excluded from conscious awareness. - The patient is fully aware of her feelings and actions, even if they are contradictory, indicating this is not an unconscious process. *Regression* - **Regression** involves reverting to childlike behaviors or earlier developmental stages in response to stress. - While her actions are impulsive and emotionally driven, there's no specific indication of a return to a more primitive or immature behavior pattern characteristic of regression.

Question 64: A 4-year-old girl is brought to the physician because her mother is concerned that she has been talking to an imaginary friend for 2 months. The child calls her friend 'Lucy' and says “Lucy is my best friend”. The child has multiple conversation and plays with the 'Lucy' throughout the day. The girl attends preschool regularly. She can copy a circle, tells stories, and can hop on one foot. Her maternal uncle has schizophrenia. Her parents are currently divorcing. The child's father has a history of illicit drug use. Physical examination shows no abnormalities. The mother is concerned about whether the child is acting out because of the divorce. Which of the following is the most appropriate next best step in management?

A. Reassure the mother (Correct Answer)
B. Perform MRI of the brain
C. Schedule psychiatry consult
D. Inform Child Protective Services
E. Screen urine for drugs

Explanation: ***Reassure the mother*** - Imaginary friends are a **normal developmental phenomenon** in preschool-aged children, often associated with creativity and good social skills. - The child's developmental milestones (copying a circle, hopping, telling stories) are appropriate for her age, indicating **healthy cognitive and motor development**. *Perform MRI of the brain* - There are **no neurological symptoms** or concerning signs in this case that would warrant an MRI of the brain. - Imaginary friends are not indicative of a brain abnormality or neurological disorder. *Schedule psychiatry consult* - A psychiatry consult is **not indicated** as the child's behavior is developmentally appropriate. - While there is a family history of schizophrenia and parental stress, the child is exhibiting typical childhood play and not symptoms of a mental health disorder. *Inform Child Protective Services* - There is **no evidence of child abuse or neglect** in the provided information. - Although the parents are divorcing and the father has a history of drug use, there are no specific concerns raised about the child's safety or well-being that would require CPS involvement. *Screen urine for drugs* - A drug screen is **not relevant** to the child's behavior or a concern for drug use by the child. - While the father has a history of illicit drug use, this does not automatically imply the child is being exposed to drugs, and the child's symptoms are unrelated to drug exposure.

Question 65: 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

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.

Question 66: A 23-year-old woman is brought to the emergency room by her mother after she is found to have cut both of her wrists with razor blades. The patient admits to a history of self-mutilation and attributed this incident to a recent breakup with a man she had been seeing for the previous 2 weeks. On morning rounds, the patient reports that the nurses are incompetent but the doctors are some of the best in the world. The patient's vitals are stable and her wrist lacerations are very superficial requiring only simple dressings without sutures. The patient is discharged a few days later and she feels well. Which of the following is the most appropriate initial treatment for this patient?

A. Amitriptyline
B. Fluoxetine
C. Dialectical behavior therapy (Correct Answer)
D. Cognitive behavioral therapy
E. Lithium

Explanation: ***Dialectical behavior therapy*** - The patient's presentation with **recurrent self-harm**, **mood instability** following a brief relationship, and **splitting** ("nurses are incompetent but doctors are the best") are classic features of **borderline personality disorder (BPD)**. - **Dialectical behavior therapy (DBT)** is the gold-standard and most effective initial treatment for BPD, specifically targeting **emotional dysregulation**, self-harm, and suicidal behaviors. *Amitriptyline* - **Amitriptyline** is a **tricyclic antidepressant (TCA)**, primarily used for depression and chronic pain. - While antidepressants might be used *adjunctively* for comorbid mood symptoms in BPD, they are not the primary or most appropriate *initial* treatment for the core features of BPD itself, and TCAs have a high overdose risk. *Fluoxetine* - **Fluoxetine** is a **selective serotonin reuptake inhibitor (SSRI)**, commonly used for depression, anxiety disorders, and some eating disorders. - Similar to other antidepressants, SSRIs may treat comorbid depressive or anxiety symptoms in BPD but do not address the fundamental **personality organization issues** or behavioral patterns like self-harm and splitting characteristic of BPD. *Cognitive behavioral therapy* - **Cognitive behavioral therapy (CBT)** is effective for a wide range of mental health conditions, including depression and anxiety, by focusing on changing negative thought patterns and behaviors. - While elements of CBT are incorporated into DBT, **DBT is specifically adapted and more effective for BPD** due to its emphasis on **emotion regulation**, distress tolerance, and interpersonal effectiveness skills, which are crucial for this patient's presentation. *Lithium* - **Lithium** is a mood stabilizer primarily used to treat **bipolar disorder**. - Although there can be some overlap in symptoms (e.g., mood swings), the patient's presentation is more indicative of BPD due to the **recurrent self-harm, interpersonal instability**, and **splitting**, rather than the distinct mood episodes seen in bipolar disorder.

Question 67: A 24-year-old woman with no past medical history is post operative day 2 from a cesarean section that resulted in the birth of her first child. She begins to cry when she's told that today's lunch will be gluten-free. Although the patient feels "exhausted" and has had trouble sleeping, she deeply desires to return home and take care of her newborn. The patient denies any changes in concentration or suicidal thoughts now or during the pregnancy. What is the diagnosis and likely outcome?

A. Major depressive episode; this patient is at high risk of recurrence
B. Postpartum depression; the patient will likely remain depressed for at least six more months
C. Postpartum psychosis; symptoms will resolve in time, but she needs treatment with antipsychotics, lithium, and/or antidepressants
D. Postpartum bipolar disorder; this patient will likely have future bipolar episodes
E. Postpartum "blues"; her symptoms are likely self-limited (Correct Answer)

Explanation: ***Postpartum "blues"; her symptoms are likely self-limited*** - The patient exhibits mild, transient mood lability (crying over gluten-free lunch) and fatigue, which are characteristic of **postpartum blues**. - Symptoms typically begin within 2-3 days postpartum and resolve spontaneously within **two weeks**, without significant impairment in functioning, making them self-limited. *Major depressive episode; this patient is at high risk of recurrence* - While she has some symptoms like fatigue and sleep disturbance, she denies changes in concentration or suicidal ideation, and expresses a desire to care for her child, which argues against a **major depressive episode**. - A diagnosis of major depressive episode requires five or more symptoms for at least two weeks, including either **depressed mood** or **anhedonia**, which are not fully met here. *Postpartum depression; the patient will likely remain depressed for at least six more months* - This patient's symptoms are mild and have only been present for two days, making **postpartum depression** (which typically lasts longer and is more severe) less likely. - Postpartum depression involves persistent symptoms that significantly impair functioning and often require intervention; these symptoms are not yet severe or prolonged enough. *Postpartum psychosis; symptoms will resolve in time, but she needs treatment with antipsychotics, lithium, and/or antidepressants* - There is no mention of **hallucinations, delusions, severe confusion, or disorganized behavior**, which are hallmarks of postpartum psychosis. - Postpartum psychosis is a severe psychiatric emergency requiring immediate inpatient treatment and does not resolve simply with time without significant intervention. *Postpartum bipolar disorder; this patient will likely have future bipolar episodes* - While **sleep disturbance** is present, there are no classic manic or hypomanic symptoms such as **euphoria, grandiosity, increased goal-directed activity, or racing thoughts**. - A single, acute presentation like this, without a history of bipolar disorder or clear manic symptoms, does not typically lead to a diagnosis of postpartum bipolar disorder.

Question 68: A 21-year-old female was brought to the emergency room after losing large amounts of blood from slicing her wrists longitudinally. A few days later, she was interviewed by the psychiatrist and discussed with him why she had tried to kill herself. "My evil boyfriend of 2 months left me because I never let him leave my side for fear that he would cheat on me and leave me...now I feel so empty without him." Which of the following personality disorders does this female most likely have?

A. Avoidant
B. Dependent
C. Borderline (Correct Answer)
D. Paranoid
E. Histrionic

Explanation: ***Borderline*** - The patient exhibits core features of **borderline personality disorder (BPD)**, including **impulsivity** (suicide attempt via wrist-slicing), **unstable relationships** marked by fear of abandonment, and intense feelings of **emptiness**. - Her statement about her boyfriend refusing to let him leave her side reflects classic BPD traits of **frantic efforts to avoid abandonment** and a **pattern of intense and unstable interpersonal relationships**. *Avoidant* - Individuals with **avoidant personality disorder** are characterized by **social inhibition**, feelings of inadequacy, and hypersensitivity to negative evaluation, which are not the primary features presented in this scenario. - They tend to *avoid* social interactions due to fear of criticism, rather than engaging in intense, unstable relationships and dramatic self-harm as described. *Dependent* - While a **dependent personality disorder** involves a pervasive and excessive need to be cared for, leading to submissive and clinging behavior, it typically doesn't manifest with the same level of **impulsivity**, **self-harm**, or extreme relationship instability seen here. - The "fear that he would cheat on me and leave me" relates more to the **frantic efforts to avoid abandonment** characteristic of borderline personality, rather than general clinginess and submission. *Paranoid* - **Paranoid personality disorder** is characterized by pervasive distrust and suspiciousness of others, often interpreting their motives as malevolent. - The patient's behaviors (suicide attempt, fear of abandonment in a short-term relationship, feeling empty) do not align with the prominent **distrust and suspiciousness** of paranoid personality. *Histrionic* - **Histrionic personality disorder** involves excessive emotionality and attention-seeking behavior. While the suicide attempt might be seen as attention-seeking, the underlying **fear of abandonment**, **feelings of emptiness**, and extremely rapid relationship deterioration are more indicative of borderline personality. - Histrionic individuals tend to be dramatic and theatrical, using physical appearance to draw attention, which is not emphasized in this clinical picture.

Question 69: A 16-year-old boy is brought to a psychotherapist for counseling because he was physically abused by his father. During the first therapy session, the patient recounts the numerous encounters that he had with his abuser. At the end of the session, the therapist, who lost her own son in a car accident when he was 15 years old, refuses to let the patient take the bus back alone to his custodial guardian's home. She offers to take him back in her own car instead, saying, “This way, I will rest assured that you have reached home safely”. The therapist's behavior can be best described as an instance of which of the following?

A. Countertransference (Correct Answer)
B. Sublimation
C. Identification
D. Isolation
E. Displacement

Explanation: ***Countertransference*** - **Countertransference** occurs when a therapist’s past experiences and unresolved emotional issues unconsciously influence their perceptions and reactions to a patient. - In this scenario, the therapist's overprotective behavior stems from her own grief regarding her deceased son, causing her to project her personal feelings onto the patient. *Sublimation* - **Sublimation** is a mature defense mechanism where unacceptable urges or impulses are transformed into socially acceptable behaviors. - The therapist's actions, while well-intentioned, are driven by an emotional reaction rather than a healthy redirection of impulses, and they cross ethical boundaries. *Identification* - **Identification** is a defense mechanism where an individual unconsciously adopts the characteristics, attitudes, or behaviors of another person, often in response to fear or admiration. - While the therapist might empathize with the patient, her behavior is more about her own unresolved issues (grief) being projected onto the patient, rather than adopting the patient's characteristics. *Isolation* - **Isolation** is a defense mechanism where an individual separates a thought or memory from the emotion associated with it. - The therapist's behavior shows an emotional response, not an attempt to detach emotion from a situation. *Displacement* - **Displacement** is a defense mechanism where emotions, usually negative ones like anger, are redirected from the original source to a less threatening target. - The therapist is not redirecting a negative emotion; instead, she is acting out her unresolved grief and anxiety related to her son on the patient.

Question 70: An 8-year-old girl is brought to the physician by her parents for a 10-month history of disturbing dreams and daytime sleepiness. She has difficulty falling asleep and says she sometimes sees ghosts just before falling asleep at night. She has had a 7-kg (15-lb) weight gain during this period despite no changes in appetite. She is alert and oriented, and neurologic examination is unremarkable. During physical examination, she spontaneously collapses after the physician drops a heavy book, producing a loud noise. She remains conscious after the collapse. Polysomnography with electroencephalogram is most likely to show which of the following?

A. Slow spike-wave pattern
B. Periodic sharp waves
C. Decreased delta wave sleep duration
D. Diffuse slowing of waves
E. Rapid onset of REM sleep (Correct Answer)

Explanation: ***Rapid onset of REM sleep*** - The patient's symptoms of **daytime sleepiness**, **hallucinations** (seeing ghosts before sleep, i.e., **hypnagogic hallucinations**), **sleep-onset difficulty**, and the spontaneous collapse (likely **cataplexy** triggered by strong emotion/surprise) are characteristic of **narcolepsy**. - **Narcolepsy** is often associated with a disinhibition of REM sleep, leading to its occurrence at sleep onset or within 15 minutes of falling asleep, which would be detected by **polysomnography** with **EEG**. *Slow spike-wave pattern* - This pattern is characteristic of **absence seizures** (petit mal seizures), which involve brief staring spells and loss of consciousness, not the constellation of sleep disturbances and cataplexy seen here. - Absence seizures typically do not cause significant **daytime sleepiness** or **hallucinations**. *Periodic sharp waves* - **Periodic sharp wave complexes** are pathognomonic for **Creutzfeldt-Jakob disease** (CJD), a rapidly progressive neurodegenerative disorder. - CJD presents with dementia, myoclonus, and other neurological signs, which are distinct from the patient's symptoms. *Decreased delta wave sleep duration* - **Delta wave sleep** (slow-wave sleep or N3 sleep) is a stage of deep non-REM sleep, which is important for restorative sleep. - While sleep architecture can be disturbed in various sleep disorders, a primary decrease in delta wave sleep duration is not the most specific or hallmark finding for narcolepsy; rather, narcolepsy is defined by its REM sleep abnormalities. *Diffuse slowing of waves* - **Diffuse slowing of brain waves** on EEG is a non-specific finding often associated with **encephalopathy**, metabolic disturbances, or diffuse brain dysfunction. - It does not specifically account for the unique constellation of symptoms seen in this patient, particularly the abrupt onset of sleep-related phenomena and **cataplexy**.

Question 71: A 9-year-old boy is brought to a pediatric psychologist by his mother because of poor academic performance. The patient’s mother mentions that his academic performance was excellent in kindergarten and first grade, but his second and third-grade teachers complain that he is extremely talkative, does not complete schoolwork, and frequently makes careless mistakes. They also complain that he frequently looks at other students or outside the window during the class and is often lost during the lessons. At home, he is very talkative and disorganized. When the pediatrician asks the boy his name, he replies promptly. He was born at full term by spontaneous vaginal delivery. He is up-to-date on all vaccinations and has met all developmental milestones on time. A recent IQ test scored him at 95. His physical examination is completely normal. When he is asked to read from an age-appropriate children’s book, he reads it fluently and correctly. Which of the following is the most likely diagnosis in this patient?

A. Intellectual disability
B. Autism spectrum disorder
C. Dyslexia
D. Persistent depressive disorder
E. Attention-deficit/hyperactivity disorder (Correct Answer)

Explanation: **Attention-deficit/hyperactivity disorder** * The child's symptoms of being **extremely talkative**, not completing schoolwork, making **careless mistakes**, and being easily distracted and disorganized are classic signs of **ADHD (Attention-deficit/hyperactivity disorder)**. * His normal IQ, early developmental milestones, and reading fluency rule out other neurological or intellectual disabilities, while his persistent inattention and hyperactivity across settings support ADHD. * *Intellectual disability* * **Intellectual disability** is characterized by significant limitations in both intellectual functioning (IQ below 70) and adaptive behavior, which is contradicted by this patient's **IQ of 95** and normal developmental milestones. * Patients with intellectual disability would typically struggle with academic performance from the start and would not have had "excellent" performance in kindergarten and first grade. * *Autism spectrum disorder* * **Autism spectrum disorder** involves persistent deficits in **social communication and interaction** and **restricted, repetitive patterns of behavior, interests, or activities**. This child's prompt response to his name and ability to read fluently do not align with common autistic features. * While some social difficulties might arise from inattention, the primary symptoms do not point to core deficits in social reciprocity or communication typical of ASD. * *Dyslexia* * **Dyslexia** is a **specific learning disorder** primarily characterized by difficulties with **accurate and/or fluent word recognition, poor decoding, and poor spelling abilities**, despite normal intelligence. * This patient can **read fluently and correctly from an age-appropriate children’s book**, making dyslexia an unlikely diagnosis. * *Persistent depressive disorder* * **Persistent depressive disorder** (dysthymia) involves a **chronically depressed mood** for at least one year in children and adolescents, often accompanied by symptoms such as low energy, poor concentration, sleep disturbance, and feelings of hopelessness. * While poor academic performance and some difficulty concentrating could be present, the prominent symptoms of **hyperactivity** (talkativeness) and impulsivity (careless mistakes) are not typical features of depression, and a depressed mood is not reported.

Question 72: A 26-year-old woman presents to the clinic complaining of a headache, runny nose, and malaise. A few minutes into the interview, she mentions that she recently started her job and is glad to work long hours despite the toll on her health. However, she admits that she is finding it difficult to keep up with the workload. She has numerous pending papers to correct. When advised to seek help from other teachers, she exclaims that it needs to be done in a particular way, and only she can do it the right way. This is causing her to perform poorly at work, and she is at risk of being asked to quit her very first job. Which of the following is the most likely diagnosis in this patient?

A. Ego-dystonic obsessive-compulsive disorder
B. Ego-dystonic obsessive-compulsive personality disorder
C. Ego-syntonic obsessive-compulsive personality disorder (Correct Answer)
D. Ego-syntonic obsessive-compulsive disorder
E. Personality disorder not otherwise specified

Explanation: ***Ego-syntonic obsessive-compulsive personality disorder*** - Patients with **OCPD** are characterized by a pervasive pattern of **preoccupation with orderliness, perfectionism, and mental and interpersonal control**, at the expense of flexibility, openness, and efficiency. This perfectionism can lead to indecisiveness and an inability to complete tasks. - The patient's belief that "only she can do it the right way" and her *inability to delegate tasks* despite the negative impact on her work performance are hallmarks of **ego-syntonic** traits, meaning she views her behaviors and thoughts as reasonable and appropriate. Even though these traits cause significant distress and functional impairment, she doesn't perceive them as problematic in themselves. *Ego-dystonic obsessive-compulsive disorder* - In **OCD**, obsessions and compulsions are typically **ego-dystonic**, meaning the individual recognizes them as irrational, intrusive, and unwanted, causing significant distress. - The patient in the scenario does not express distress about the *nature* of her meticulous and controlling behavior, but rather about the consequences (poor performance), indicating her traits are *syntonic*. *Ego-dystonic obsessive-compulsive personality disorder* - This term is a contradiction in terms; **personality disorders** are, by definition, generally **ego-syntonic**. If obsessive-compulsive symptoms were ego-dystonic, it would point towards OCD. - The core diagnostic feature of a personality disorder is that the problematic patterns are congruent with the individual's self-image and experienced as characteristic parts of themselves. *Ego-syntonic obsessive-compulsive disorder* - **OCD** is characterized by *recurrent, persistent thoughts, urges, or images (obsessions)* and *repetitive behaviors or mental acts (compulsions)* that are typically **ego-dystonic** (i.e., not aligned with one's self-perception and often distressing). - The patient's description focuses on a *pervasive personality style* rather than specific discrete obsessions or compulsions that she would find distressing or irrational. *Personality disorder not otherwise specified* - While this category exists for cases that don't meet full criteria for a specific personality disorder, the patient's symptoms **clearly align with the diagnostic criteria for Obsessive-Compulsive Personality Disorder**. - There is enough specific information provided to make a more precise diagnosis, rendering "not otherwise specified" less appropriate here.

Question 73: A 24-year-old woman comes to the physician because she feels sad and has had frequent, brief episodes of crying for the last month. During this period, she sleeps in every morning and spends most of her time in bed playing video games or reading. She has not been spending time with friends but still attends a weekly book club and continues to plan her annual family reunion. She stopped going to the gym, eats more, and has gained 4 kg (8.8 lb) over the past 4 weeks. Three weeks ago, she also started to smoke marijuana a few times a week. She drinks one glass of wine daily and does not smoke cigarettes. She is currently unemployed; she lost her job as a physical therapist 3 months ago. Her vital signs are within normal limits. On mental status examination, she is calm, alert, and oriented to person, place, and time. Her mood is depressed; her speech is organized, logical, and coherent. She denies suicidal thoughts. Which of the following is the most likely diagnosis?

A. Bipolar disorder
B. Substance use disorder
C. Major depressive disorder
D. Adjustment disorder (Correct Answer)
E. Persistent Depressive Disorder (Dysthymia)

Explanation: ***Adjustment disorder*** - This diagnosis is characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor (such as losing a job) occurring within **3 months** of the onset of the stressor. - The patient exhibits depressive symptoms (sadness, crying, increased sleep, anhedonia, weight gain) that do not meet the full criteria for a major depressive episode and do not significantly impair social/occupational functioning, as evidenced by her continued participation in a book club and planning her family reunion. *Bipolar disorder* - This disorder typically involves episodes of **mania or hypomania** along with depressive episodes, neither of which are described in the patient's presentation. - Her symptoms are consistently depressive in nature and linked to a specific stressor, without periods of elevated mood, increased energy, or decreased need for sleep. *Substance use disorder* - While the patient has recently started smoking marijuana and drinks alcohol, these behaviors developed *after* the onset of her depressive symptoms and a known stressor. - Her marijuana use is still relatively recent ("a few times a week") and not yet described as causing significant impairment or dependence that would typically define a substance use disorder as the primary diagnosis. *Major depressive disorder* - This diagnosis requires a severe and pervasive depressive episode that lasts for at least **2 weeks** and significantly impairs functioning in multiple areas of life. - Although she has several depressive symptoms, her continued ability to engage in some social activities (book club) and plan events (family reunion) suggests that the impairment is not as severe or pervasive as typically seen in MDD. Additionally, her symptoms are clearly linked to a recent life stressor, which points away from MDD as the primary diagnosis. *Persistent Depressive Disorder (Dysthymia)* - This disorder is characterized by a chronically depressed mood that lasts for at least **2 years** (or 1 year in children/adolescents), with symptoms that are generally milder than major depression but more persistent. - The patient's symptoms have only been present for one month, which is far too short a duration to meet the diagnostic criteria for persistent depressive disorder.

Question 74: A 77-year-old Caucasian woman presents to her primary care provider for a general checkup. The patient is with her daughter who brought her to this appointment. The patient states that she is doing well and has some minor joint pain in both hips. She states that sometimes she is sad because her husband recently died. She lives alone and follows a vegan diet. The patient's daughter states that she has noticed her mother struggling with day to day life. It started 2 years ago with her forgetting simple instructions or having difficulty running errands. Now the patient has gotten to the point where she can no longer pay her bills. Sometimes the patient forgets how to get home. The patient has a past medical history of obesity, hypertension, gastroesophageal reflux disease (GERD) controlled with pantoprazole, and diabetes mellitus. Her temperature is 99.5°F (37.5°C), blood pressure is 158/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Which of the following will most likely help with this patient's presentation?

A. Vitamin B12 and discontinue pantoprazole
B. No intervention needed
C. Donepezil (Correct Answer)
D. Fluoxetine and cognitive behavioral therapy
E. Lisinopril and metoprolol

Explanation: ***Correct: Donepezil*** - This patient presents with **progressive dementia**, most consistent with **Alzheimer's disease**: gradual cognitive decline over 2 years, short-term memory loss (forgetting instructions), executive dysfunction (unable to pay bills), impaired navigation (getting lost), and functional decline in activities of daily living (ADLs). - **Donepezil**, an **acetylcholinesterase inhibitor**, is first-line pharmacotherapy for mild-to-moderate Alzheimer's disease, improving cognitive function by increasing acetylcholine availability in the brain. - Key differentiator: The **progressive, global cognitive impairment** with functional decline over years distinguishes this from reversible causes or mood disorders. *Incorrect: Vitamin B12 and discontinue pantoprazole* - While **vitamin B12 deficiency** can cause cognitive impairment and this patient has risk factors (vegan diet, chronic PPI use with pantoprazole), the **severity, duration, and progressive nature** of her symptoms indicate a **neurodegenerative process** rather than a reversible nutritional deficiency. - B12 deficiency typically presents with more prominent neurological signs (peripheral neuropathy, subacute combined degeneration) and would be expected to show improvement with supplementation. - Though checking B12 levels would be part of the dementia workup, it would not be the **primary treatment** for this presentation. *Incorrect: No intervention needed* - This patient has **significant functional impairment** with safety concerns (getting lost, inability to manage finances), requiring immediate intervention. - Progressive cognitive decline causing loss of independence in ADLs is never "normal aging" and always warrants medical evaluation and treatment. - Failure to intervene risks patient safety and further deterioration. *Incorrect: Fluoxetine and cognitive behavioral therapy* - While the patient reports sadness related to her husband's death (suggesting **grief** or possible **depression**), her **predominant symptoms are cognitive and functional**, not primarily mood-related. - **Key differentiation**: Depression can cause "pseudodementia" with cognitive complaints, but true dementia shows objective functional decline (inability to pay bills, getting lost) that progresses regardless of mood, whereas depression-related cognitive symptoms typically improve with mood treatment. - The **2-year progressive course** with worsening executive function points to **organic dementia**, not a primary mood disorder. - Fluoxetine and CBT target depression but would not address the underlying neurodegenerative process. *Incorrect: Lisinopril and metoprolol* - The patient's blood pressure is elevated (158/108 mmHg), indicating uncontrolled **hypertension** that should be managed. - While controlling vascular risk factors is important in dementia management (to prevent vascular dementia progression), treating hypertension would not address her **current cognitive symptoms** or provide symptomatic relief. - The **primary issue** is dementia requiring acetylcholinesterase inhibitor therapy; blood pressure management is secondary.

Question 75: A 4-year-old girl is brought to the pediatrician by her parents after her mother recently noticed that other girls of similar age talk much more than her daughter. Her mother reports that her language development has been abnormal and she was able to use only 5–6 words at the age of 2 years. Detailed history reveals that she has never used her index finger to indicate her interest in something. She does not enjoy going to birthday parties and does not play with other children in her neighborhood. The mother reports that her favorite “game” is to repetitively flex and extend the neck of a doll, which she always keeps with her. She is sensitive to loud sounds and starts screaming excessively when exposed to them. There is no history of delayed motor development, seizures, or any other major illness; perinatal history is normal. When she enters the doctor’s office, the doctor observes that she does not look at him. When he gently calls her by her name, she does not respond to him and continues to look at her doll. When the doctor asks her to look at a toy on his table by pointing a finger at the toy, she looks at neither his finger nor the toy. The doctor also notes that she keeps rocking her body while in the office. Which of the following is an epidemiological characteristic of the condition the girl is suffering from?

A. There has been a steady decline in prevalence in the United States over the last decade.
B. There is an increased risk if the mother smoked during pregnancy.
C. There is an increased risk with low prenatal maternal serum vitamin D level.
D. There is an increased incidence if the mother gives birth before 25 years of age.
E. This condition is 4 times more common in boys than girls. (Correct Answer)

Explanation: **_This condition is 4 times more common in boys than girls._** - The clinical presentation, including **impaired social interaction** (not looking at the doctor, not responding to her name, not playing with other children, not enjoying parties), **communication deficits** (delayed language, lack of pointing), **repetitive behaviors** (flexing doll's neck, body rocking) and **sensory sensitivities** (screaming at loud sounds), is highly suggestive of **Autism Spectrum Disorder (ASD)**. - **ASD** is indeed diagnosed approximately four times more often in boys than in girls, making this a characteristic epidemiological feature. *There has been a steady decline in prevalence in the United States over the last decade.* - The **prevalence of ASD** has actually been **steadily increasing** in the United States and globally over the last few decades, partly due to increased awareness, improved diagnostic criteria, and better screening. - This statement is contrary to current epidemiological trends for **ASD**. *There is an increased risk if the mother smoked during pregnancy.* - While maternal smoking during pregnancy is linked to other developmental issues like **ADHD** and **premature birth**, a definitive, strong, and consistent causal link to a significantly increased risk of **ASD** has not been established. - Research on environmental risk factors for **ASD** is ongoing, but maternal smoking is not a primary, well-established epidemiological characteristic. *There is an increased risk with low prenatal maternal serum vitamin D level.* - Some studies suggest a potential association between low prenatal maternal vitamin D levels and an increased risk of **ASD**, but this link is **not yet definitively established** and requires further research to confirm causation. - It is considered a potential risk factor, but not a widely accepted or strong epidemiological characteristic for the condition. *There is an increased incidence if the mother gives birth before 25 years of age.* - The risk of **ASD** has been more consistently associated with **advanced parental age** (both maternal and paternal), not with younger maternal age. - Studies generally indicate a **higher risk for children born to older parents**, making this statement inaccurate.

Question 76: A 73-year-old woman is brought to the physician by her son because of increasing forgetfulness over the past 2 years. Initially, she used to misplace keys and forget her dog's name or her phone number. Now, she often forgets about what she has seen on television or read about the day before. She used to go for a walk every morning but stopped one month ago after she became lost on her way back home. Her son has prevented her from cooking because she has had episodes of leaving the gas stove on after making a meal. She becomes agitated when asked questions directly but is unconcerned when her son reports her history and says he is overprotective of her. She has hypertension, coronary artery disease, and hypercholesterolemia. Current medications include aspirin, enalapril, carvedilol, and atorvastatin. She is alert and oriented to place and person but not to time. Vital signs are within normal limits. Short- and long-term memory deficits are present. Her speech rhythm is normal but is frequently interrupted as she thinks of words to frame her sentences. She makes multiple errors while performing serial sevens. Her clock drawing is impaired and she draws 14 numbers. Which of the following is the most likely diagnosis?

A. Lewy-body dementia
B. Alzheimer disease (Correct Answer)
C. Frontotemporal dementia
D. Normal pressure hydrocephalus
E. Creutzfeldt-Jakob disease

Explanation: **Alzheimer disease** - The patient's presentation with **progressive memory impairment** (misplacing keys, forgetting recent events), **executive dysfunction** (getting lost, leaving stove on, impaired clock drawing), and **language difficulties** (word-finding pauses) over 2 years is highly characteristic of Alzheimer disease. - The **insidious onset** and gradual cognitive decline affecting multiple domains, along with relative preservation of motor function initially, are key diagnostic features. *Lewy-body dementia* - This condition is often characterized by **fluctuating cognition**, **visual hallucinations**, and **parkinsonism**, none of which are prominent in this patient's presentation. - While memory impairment can occur, the core features of Lewy body dementia are not described here. *Frontotemporal dementia* - **Early behavioral changes** (e.g., disinhibition, apathy) or **prominent language deficits** (e.g., aphasia without initial memory problems) are common in frontotemporal dementia. - This patient's primary complaint is memory loss, and behavioral changes are reactive rather than disinhibited, making frontotemporal dementia less likely. *Normal pressure hydrocephalus* - The classic triad for normal pressure hydrocephalus includes **gait disturbance**, **urinary incontinence**, and **dementia**. - While dementia is present, there is no mention of gait abnormalities or urinary issues in this patient. *Creutzfeldt-Jakob disease* - This is a rapidly progressive and fatal neurodegenerative disorder with a typical course of **weeks to months**, not 2 years. - It usually presents with **myoclonus**, **ataxia**, and **rapidly progressive dementia**, which are not seen in this case.

Question 77: An 84-year-old woman with Alzheimer's disease is brought to the physician by her son for a follow-up examination. The patient lives with her son, who is her primary caregiver. He reports that it is becoming gradually more difficult to care for her. She occasionally has tantrums and there are times when she does not recognize him. She sleeps 6–8 hours throughout the day and is increasingly agitated and confused at night. When the phone, television, or oven beeps she thinks she is at the dentist's office and becomes very anxious. She eats 2–3 meals a day and has a good appetite. She has not fallen. She has not left the home in weeks except for short walks. She has a history of hypertension, hyperlipidemia, atrial fibrillation, and hypothyroidism. She takes levothyroxine, aspirin, warfarin, donepezil, verapamil, lisinopril, atorvastatin, and a multivitamin daily. Her temperature is 37°C (98.4°F), pulse is 66/min, respirations are 13/min, and blood pressure is 126/82 mm Hg. Physical examination shows no abnormalities. It is important to the family that the patient continues her care in the home. Which of the following recommendations is most appropriate at this time?

A. Start quetiapine daily
B. Start lorazepam as needed
C. Frequently play classical music
D. Adhere to a regular sleep schedule (Correct Answer)
E. Schedule frequent travel

Explanation: ***Adhere to a regular sleep schedule*** - The patient exhibits **sundowning**, characterized by increased confusion and agitation in the evening, along with fragmented sleep patterns (sleeping 6-8 hours during the day). Establishing a **regular sleep-wake cycle** can significantly alleviate these symptoms. - This is a **non-pharmacological intervention** that respects the family's desire for continued home care and addresses a key behavioral disturbance in Alzheimer's patients. *Start quetiapine daily* - **Antipsychotics** like quetiapine should be used with extreme caution in elderly patients with dementia due to increased risk of **mortality**, cardiovascular events, and stroke. - They are typically reserved for severe, intractable agitation or psychosis after non-pharmacological methods have failed. *Start lorazepam as needed* - **Benzodiazepines** like lorazepam can worsen cognitive impairment, increase the risk of falls, and cause paradoxical agitation in elderly patients with dementia. - Their use should be limited, especially given the patient's existing confusion and agitation. *Frequently play classical music* - While music therapy can be beneficial for mood and anxiety in some dementia patients, it's a **complementary therapy** that may not directly address the primary issue of **sundowning and sleep disturbance** as effectively as a strict sleep schedule. - There is no indication that music directly addresses the root cause of her specific agitation related to misinterpreting sounds. *Schedule frequent travel* - **Frequent travel** would likely cause increased disorientation, anxiety, and agitation in a patient with Alzheimer's disease, especially given her current confusion and misinterpretation of everyday sounds. - Maintaining a **familiar and stable environment** is crucial for individuals with dementia.

Question 78: A 15-year-old boy is brought to the physician by his mother because of 4 months of strange behavior. She says that during this period, he has had episodic mood swings. She has sometimes found him in his room “seemingly drunk” and with slurred speech. These episodes usually last for approximately 15 minutes, after which he becomes irritable. He has had decreased appetite, and his eyes occasionally appear red. He has trouble keeping up with his schoolwork, and his grades have worsened. Physical examination shows an eczematous rash between the upper lip and nostrils. Neurologic examination shows a delay in performing alternating palm movements. Use of which of the following is the most likely cause of this patient's condition?

A. Inhalants (Correct Answer)
B. Phencyclidine
C. Alcohol
D. Cocaine
E. Marijuana

Explanation: ***Inhalants*** - The patient's presentation with acute, transient episodes of altered mental status ("seemingly drunk," slurred speech, irritability), decreased appetite, red eyes, and declining school performance are classic signs of inhalant abuse. The **eczematous rash between the upper lip and nostrils** (a condition known as **"huffer's rash"** or **"glue sniffer's rash"**) is a highly specific dermatological sign of chronic inhalant use. - Neurological signs such as difficulty with **alternating palm movements** (dysdiadochokinesia) indicate cerebellar dysfunction, which can be a consequence of inhalant neurotoxicity, particularly from toluene and other solvents. *Phencyclidine* - While phencyclidine (PCP) can cause acute behavioral changes, aggression, and psychotic symptoms, it typically results in a more profound and prolonged dissociative state, often with **nystagmus**, rather than brief, "drunk-like" episodes. - PCP intoxication does not typically cause a specific perioral rash or red eyes in the same manner as inhalants. *Alcohol* - Although the patient's "drunk-like" appearance and slurred speech are consistent with alcohol intoxication, the very brief 15-minute duration of these episodes is highly unusual for significant alcohol consumption. - Alcohol intoxication does not cause a specific eczematous rash between the upper lip and nostrils. *Cocaine* - Cocaine use typically manifests as stimulant effects like **euphoria**, increased energy, dilated pupils, and tachycardia, followed by a "crash" with depression or irritability. - It does not present with "drunk-like" behavior, slurred speech, or the characteristic perioral rash described. *Marijuana* - Marijuana use can cause red eyes and decreased motivation (leading to declining school performance), but the "seemingly drunk" appearance, slurred speech, and acute irritable mood swings are less characteristic. - Marijuana does not cause a specific perioral eczematous rash or cerebellar signs like dysdiadochokinesia.

Question 79: A 68-year-old man seeks evaluation by a physician with complaints of worsening forgetfulness and confusion for 1 year. According to his wife, he has always been in good health and is generally very happy; however, he has started to forget important things. He recently had his driving license revoked because of multiple tickets, but he cannot recall having done anything wrong. This morning, he neglected to put on his socks and was quite agitated when she pointed this out to him. He denies having a depressed mood, sleep problems, or loss of interest. He occasionally has a glass of wine with dinner and has never smoked or used recreational drugs. His medical history and family medical history are unremarkable. His pulse is 68/min, respirations are 14/min, and blood pressure is 130/84 mm Hg. Except for a mini-mental state examination (MMSE) score of 20/30, the remainder of the physical examination is unremarkable. Imaging studies, including a chest X-ray and CT of the brain, reveal no pathologic findings. An electrocardiogram (ECG) is also normal. Laboratory testing showed the following: Serum glucose (fasting) 76 mg/dL Serum electrolytes: Sodium 140 mEq/L Potassium 4.1 mEq/L Chloride 100 mEq/L Serum creatinine 0.9 mg/dL Blood urea nitrogen 11 mg/dL Cholesterol, total: 180 mg/dL HDL-cholesterol 45 mg/dL LDL-cholesterol 75 mg/dL Triglycerides 135 mg/dL Hemoglobin (Hb%) 16 g/dL Mean corpuscular volume (MCV) 85 fL Reticulocyte count 0.9% Erythrocyte count 5 million/mm³ Thyroid-stimulating hormone 3.5 µU/mL Urinalysis Glucose Negative Ketones Negative Leucocytes Negative Nitrite Negative RBCs Negative Casts Negative Which of the following is the most likely diagnosis?

A. Alzheimer’s dementia (Correct Answer)
B. Creutzfeldt-Jakob disease
C. Lewy body dementia
D. Parkinson’s disease
E. Vascular dementia

Explanation: ***Alzheimer’s dementia*** - The patient presents with **progressive memory loss** and **confusion** that has worsened over a year, along with **agitational behavior** and difficulty with daily tasks (neglecting to put on socks), which are classic symptoms of Alzheimer's dementia. - The **MMSE score of 20/30** indicates cognitive impairment, and the absence of other neurological findings or clear vascular risk factors supports this diagnosis. *Creutzfeldt-Jakob disease* - This is a rare, rapidly progressive, and fatal neurodegenerative disease that typically presents with **rapidly progressive dementia**, **myoclonus**, and other neurological signs, which are not described in this case. - The patient's symptoms have progressed over a year, which is not as rapid as the typical course of CJD. *Lewy body dementia* - Characterized by **fluctuating cognition**, **recurrent visual hallucinations**, and **spontaneous parkinsonism**, which are not reported in this patient. - While agitation can occur, the core features of Lewy body dementia are absent. *Parkinson’s disease* - Primarily a **movement disorder** characterized by **bradykinesia**, **rigidity**, **tremor**, and **postural instability**. While dementia can occur in later stages (Parkinson's disease dementia), the initial presentation in this patient is predominantly cognitive decline without prominent motor symptoms. - The patient's physical examination is "unremarkable," suggesting an absence of parkinsonian motor signs. *Vascular dementia* - Typically associated with a history of **stroke** or significant **vascular risk factors** (e.g., uncontrolled hypertension, diabetes) and often presents with a **step-wise decline** in cognitive function. - This patient has a largely unremarkable medical history, controlled blood pressure, and normal cholesterol, and a CT scan showed no pathological findings (e.g., infarcts), making vascular dementia less likely.

Question 80: An 8-year-old boy is brought to the clinic by his father for an annual well-check. His dad reports that he has been "difficult to handle" as he would not listen and follow instructions at home. "Telling him to sit still and do something is just so hard," the father says. His teacher also reports difficulties in the classroom where the child would talk out of turn and interrupt the class intermittently by doing something else. His grades have been suffering as a result. Otherwise, the patient has been healthy and up to date on his immunizations. What is the best course of management for this patient?

A. Haloperidol
B. Methylphenidate (Correct Answer)
C. Reassurance
D. Family therapy
E. Psychodynamic therapy

Explanation: ***Methylphenidate*** - The patient's symptoms are highly suggestive of **Attention-Deficit/Hyperactivity Disorder (ADHD)**, including **inattention** (difficulty following instructions), **hyperactivity** (cannot sit still), and **impulsivity** (talking out of turn, interrupting). - According to **AAP Clinical Practice Guidelines**, school-age children (6-11 years) with ADHD should be treated with **FDA-approved ADHD medication** (stimulants like methylphenidate or amphetamines) **AND/OR behavioral therapy**. - **Methylphenidate** (e.g., Ritalin, Concerta) is a first-line stimulant medication that effectively reduces core ADHD symptoms and is appropriate for this 8-year-old with significant functional impairment affecting **academic performance** and **home/school behavior**. - While behavioral interventions are also important, the question asks for the "best course of management," and pharmacotherapy is an evidence-based first-line treatment for school-age children with clear ADHD symptomatology. *Family therapy* - While **behavioral interventions** and **parent training** are important components of ADHD management and can be used alone or in combination with medication, **family therapy** specifically is not the primary evidence-based intervention for ADHD. - Behavioral parent training programs that teach specific strategies for managing ADHD behaviors are more targeted than general family therapy. - For school-age children with significant impairment, medication is typically indicated and should not necessarily be delayed pending completion of family therapy alone. *Haloperidol* - **Haloperidol** is an antipsychotic medication primarily used to treat psychotic disorders (e.g., schizophrenia) or severe tics in Tourette's syndrome. - It is **not indicated** for ADHD symptoms and carries significant risks of **extrapyramidal side effects** (dystonia, akathisia, tardive dyskinesia), making it inappropriate for this presentation. *Reassurance* - Simply offering **reassurance** is insufficient for a child with significant behavioral difficulties causing **academic decline** and impairment in multiple settings (home and school). - The symptoms meet criteria for likely **ADHD**, which requires active intervention, not just reassurance. *Psychodynamic therapy* - **Psychodynamic therapy** explores unconscious processes and past experiences, which is **not an evidence-based treatment** for ADHD. - It may be useful for certain emotional or personality issues but does not address the core neurobiological deficits underlying ADHD symptoms like inattention, hyperactivity, and impulsivity.

Question 81: An 11-year-old boy is brought to the doctor by his father because his father is worried about the boy's performance in school and his lack of a social life. His father is also worried about the ongoing bullying his son is experiencing due to swearing outbursts the boy has exhibited for several years. During these outbursts, the boy contorts his face, blinks repeatedly, and grunts. His father is worried that the bullying will worsen and would like to see if there is a medication that can help his son. Which of the following medications is most likely to be beneficial?

A. Clonazepam
B. Valproic acid
C. Lithium
D. Lamotrigine
E. Risperidone (Correct Answer)

Explanation: ***Risperidone*** - The patient's symptoms are highly suggestive of **Tourette syndrome**, characterized by multiple motor and at least one vocal tic, with symptoms beginning before age 18 and lasting for more than one year. These tics cause significant distress or impairment. - **Risperidone**, an **atypical antipsychotic**, is a well-established first-line treatment for Tourette syndrome due to its ability to block dopamine D2 receptors, which are implicated in tic generation. *Clonazepam* - Clonazepam is a **benzodiazepine** primarily used for anxiety, panic disorder, and seizure disorders. - While it can have a sedating effect that might reduce tic severity indirectly, it is **not a first-line agent** for Tourette syndrome and carries risks of dependence and withdrawal. *Valproic acid* - **Valproic acid** is an **anticonvulsant** and **mood stabilizer** used for epilepsy and bipolar disorder. - It is **not indicated** for Tourette syndrome and does not directly address the underlying neurobiology of tics. *Lithium* - **Lithium** is primarily used as a **mood stabilizer** for bipolar disorder. - It has **no established role or efficacy** in the treatment of Tourette syndrome. *Lamotrigine* - **Lamotrigine** is an **anticonvulsant** used for epilepsy and bipolar disorder. - It is **not considered a treatment option** for Tourette syndrome and would not effectively manage tics.

Question 82: A 50-year-old female radiologist who is interviewing for a night shift position states that she was fired from her past 3 previous positions because she had difficulty working with others. She states that she is perfect for this job however, as she likes to work on her own and be left alone. She emphasizes that she does not have any distractions or meaningful relationships, and therefore she is always punctual and never calls in sick. She is not an emotional individual. Which of the following personality disorders best fits this female?

A. Schizotypal
B. Schizoid (Correct Answer)
C. Obsessive-Compulsive Personality Disorder
D. Antisocial
E. Borderline

Explanation: ***Schizoid*** - The patient's preference for **solitude**, lack of meaningful relationships, and disinterest in social interactions are classic features of **schizoid personality disorder**. - Their statement about not being an emotional individual further supports schizoid personality, as they demonstrate an apparent indifference to praise or criticism and a **restricted range of emotional expression**. *Schizotypal* - Characterized by **eccentric behavior**, odd beliefs, and magical thinking, which are not described in the patient's presentation. - While they share social isolation with schizoid personality, schizotypal individuals often experience **paranoid ideation** or unusual perceptual experiences. *Obsessive-Compulsive Personality Disorder* - Defined by **preoccupation with orderliness, perfectionism**, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. - While the patient is punctual and reliable, her core difficulties stem from social detachment rather than **over-conscientiousness** or rigidity. *Antisocial* - Involves a pervasive pattern of **disregard for and violation of the rights of others**, including deceitfulness, impulsivity, and lack of remorse. - The patient's difficulties are related to social isolation rather than exploitative or **criminal behavior**. *Borderline* - Characterized by **instability in interpersonal relationships**, self-image, affects, and impulsivity, often marked by frantic efforts to avoid abandonment. - The patient's description of preferring to be left alone and having no meaningful relationships directly contradicts the **intense and unstable relationship patterns** typical of borderline personality.

Question 83: A 53-year-old man is brought to the clinic by his son for the evaluation of unusual behavior. He is a shopkeeper by profession and sometimes behaves very rudely to the customers. Recently, he accused one of the customers of using black magic over his shop. He has been increasingly irritable, forgetting things, and having problems managing his finances over the past 8 months. He is also having difficulty finding words and recalling the names of objects during the conversation. There is no history of recent head trauma, fever, hallucinations, or abnormal limb movements. Past medical history is significant for a well-controlled type 2 diabetes mellitus. Family history is unremarkable. He does not smoke or use illicit drugs. Vital signs are stable with a blood pressure of 134/76 mm Hg, a heart rate of 88/min, and a temperature of 37.0°C (98.6°F). On physical examination, he has problems naming objects and planning tasks. Mini-mental state examination (MMSE) score is 26/30. Cranial nerve examination is normal. Muscle strength is normal in all 4 limbs with normal muscle tone and deep tendon reflexes. Sensory examination is also normal. What is the most likely diagnosis?

A. Huntington’s disease
B. Pick’s disease (Correct Answer)
C. Creutzfeldt–Jakob disease
D. Lewy body dementia
E. Alzheimer’s disease

Explanation: ***Pick’s disease*** * This patient presents with prominent **behavioral changes** (rudeness, irritability, accusation of black magic) and **language difficulties** (finding words, recalling names of objects), along with impaired financial management—these are characteristic features of **frontotemporal dementia (FTD)**, of which Pick's disease is a subtype. * The early onset of behavioral symptoms and language deficits, with relative preservation of memory in the initial stages (MMSE 26/30), points towards FTD rather than Alzheimer's. *Huntington’s disease* * This condition is primarily characterized by **chorea** (involuntary jerky movements) and **psychiatric symptoms** often preceding motor dysfunction, which are not described in the patient. * While dementia can occur, it typically manifests later in the disease course and is often overshadowed by prominent motor symptoms. *Creutzfeldt–Jakob disease* * This rapidly progressive neurodegenerative disorder presents with quickly worsening dementia, often accompanied by **myoclonus**, ataxia, and other neurological signs, which are absent in this patient's slower progression and symptoms. * The patient's symptoms have been ongoing for 8 months without the rapid global decline typical of CJD. *Lewy body dementia* * Key features of Lewy body dementia include **fluctuating cognition**, recurrent **visual hallucinations**, and **parkinsonism** (rigidity, bradykinesia), none of which are reported in this case. * Psychiatric symptoms are common, but the specific type of behavioral disinhibition and language deficits presented here are less typical. *Alzheimer’s disease* * **Memory impairment** is typically the most prominent early symptom in Alzheimer's disease, whereas this patient's presentation is dominated by **behavioral changes** and **language difficulties**. * While severe behavior changes can occur, they usually manifest in later stages; significant executive dysfunction and language problems without prominent initial memory loss are more indicative of frontotemporal dementia.

Question 84: A 37-year-old woman is brought to the physician for worsening depressive mood and irritability. Her mood changes began several months ago. Her husband has also noticed shaky movements of her limbs and trunk for the past year. The patient has no suicidal ideation. She has no history of serious illness and takes no medications. Her father died by suicide at the age of 45 years. Her temperature is 37°C (98.6°F), pulse is 76/min, and blood pressure is 128/72 mm Hg. She speaks slowly and quietly and only looks at the floor. She registers 3/3 words but can recall only one word 5 minutes later. Examination shows irregular movements of the arms and legs at rest. Extraocular eye movements are normal. Muscle strength is 5/5 throughout, and deep tendon reflexes are 2+ bilaterally. Further evaluation is most likely to show which of the following?

A. Oligoclonal bands on lumbar puncture
B. Positive Babinski sign on physical examination
C. Mitral vegetations on echocardiogram
D. Poor performance on an IQ test
E. Caudate nucleus atrophy on MRI (Correct Answer)

Explanation: ***Caudate nucleus atrophy on MRI*** - The patient's presentation with **chorea** (shaky movements of limbs and trunk), **depressive mood**, **irritability**, and a **family history of suicide** in her father (suggesting an inherited condition) is highly indicative of **Huntington disease**. - Huntington disease is characterized by progressive neurodegeneration, with prominent **atrophy of the caudate nuclei** and putamen, which can be visualized on MRI. *Oligoclonal bands on lumbar puncture* - **Oligoclonal bands** in cerebrospinal fluid are a hallmark of **multiple sclerosis** and other inflammatory CNS conditions. - This patient's symptoms (chorea, mood changes) are not consistent with typical MS presentation. *Positive Babinski sign on physical examination* - A **positive Babinski sign** indicates an **upper motor neuron lesion** or pyramidal tract dysfunction. - While some neurological conditions can cause this, it is not a primary or characteristic finding in Huntington disease, which primarily affects the basal ganglia. *Mitral vegetations on echocardiogram* - **Mitral vegetations** are associated with **infective endocarditis** or non-bacterial thrombotic endocarditis, and can lead to embolic stroke or systemic complications. - There is no clinical evidence to suggest endocarditis or embolic phenomena in this patient. *Poor performance on an IQ test* - While **cognitive decline** and **dementia** are features of Huntington disease, leading to poor performance on IQ tests, this is a general consequence of the neurological degeneration, not the most specific or primary structural finding. - **Caudate atrophy** is a more direct and specific pathological finding for Huntington disease seen on imaging.

Question 85: A 66-year-old man comes to the physician for a follow-up examination after a below-knee amputation of the right lower leg. Three weeks ago, he had an acute arterial embolism that could not be revascularized in time to save the leg. He now reports episodic hot, shooting, and tingling pain in the right lower leg that began shortly after the amputation. He has type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for the past 30 years. His current medications are metformin and prophylactic subcutaneous heparin. His temperature is 37.1°C (98.8°F), pulse is 78/min, and blood pressure is 135/88 mm Hg. Physical examination shows a slightly erythematous stump with clean sutures. The skin overlying the stump is warm and well-perfused. Muscle strength and sensation are normal throughout the remaining extremity and the left lower extremity. Which of the following is the most likely diagnosis?

A. Osteomyelitis
B. Reinfarction
C. Foreign body reaction
D. Phantom limb pain (Correct Answer)
E. Diabetic neuropathy

Explanation: ***Phantom limb pain*** - The patient's description of **episodic hot, shooting, and tingling pain** in the *amputated* right lower leg, starting shortly after surgery, is characteristic of **phantom limb sensation** that has become painful. - This neuropathic pain is an expected complication after an amputation, regardless of the stump's physical appearance or the presence of other comorbidities. *Osteomyelitis* - **Osteomyelitis** would typically present with more overt signs of infection at the stump site, such as **fever, severe localized pain, purulent discharge**, and significant erythema or warmth. - The physical exam notes a **slightly erythematous stump with clean sutures**, indicating a healing wound without signs of bone infection, and the patient **lacks systemic signs of infection**. *Reinfarction* - A **reinfarction** or new arterial embolism in the remaining limb would manifest with signs of **acute limb ischemia**, such as **severe pain, pallor, pulselessness, paresthesias, and paralysis**, primarily in the *remaining* limb—not the phantom limb. - The patient's symptoms are localized to the *amputated* limb, and the remaining limb shows **normal muscle strength and sensation**, ruling out reinfarction. *Foreign body reaction* - A **foreign body reaction** would typically cause localized **inflammation, swelling, pain, and potentially drainage or granuloma formation** at the surgical site, usually related to non-absorbable sutures or surgical material. - The patient's pain is described as **neuropathic** ("shooting, tingling") and affects the *phantom limb*, not a localized inflammatory reaction at the stump. *Diabetic neuropathy* - While the patient has **type 2 diabetes**, **diabetic neuropathy** typically presents as bilateral **paresthesias, numbness, or burning pain**, often in a **stocking-glove distribution**, gradually worsening over time. - The pain described is specific to the *amputated limb*, is episodic, and has a distinctive **hot, shooting, tingling** quality that is more indicative of post-amputation neuropathic pain than generalized diabetic neuropathy.

Question 86: An 8-year-old boy is brought to the physician by his foster mother because of complaints from his teachers regarding poor performance at school for the past 8 months. He does not listen to their instructions, often talks during class, and rarely completes his school assignments. He does not sit in his seat in the classroom and often cuts in line at the cafeteria. His foster mother reports that he runs around a lot inside the house and refuses to help his sister with chores and errands. He frequently interrupts his foster mother's conversations with others and talks excessively. She has found him trying to climb on the roof on multiple occasions. He was placed in foster care because of neglect by his biological parents 3 years ago. Physical examination shows no abnormalities. Neurologic examination shows no focal findings. Mental status examination shows a neutral affect. Which of the following is the most likely diagnosis?

A. Attention-deficit/hyperactivity disorder (Correct Answer)
B. Oppositional defiant disorder
C. Conduct disorder
D. Hearing impairment
E. Age-appropriate behavior

Explanation: ***Attention-deficit/hyperactivity disorder*** - This boy exhibits classic symptoms of **ADHD combined presentation** with both inattention (difficulty following instructions, not completing assignments) and hyperactivity-impulsivity (frequent talking, not staying seated, interrupting, excessive physical activity including running around and climbing). - **DSM-5 criteria are met**: Symptoms present for >6 months (8 months documented), occurring in multiple settings (school and home), with onset before age 12, and causing functional impairment (poor school performance). - The **history of early childhood neglect** is a significant risk factor for ADHD, making this diagnosis even more likely. *Oppositional defiant disorder* - While some behaviors (refusing chores, cutting in line, interrupting) might suggest defiance, the **predominant pattern is inattention and hyperactivity-impulsivity**, not the angry/irritable mood, argumentative/defiant behavior, and vindictiveness characteristic of ODD. - ODD can be comorbid with ADHD, but the primary diagnosis here is ADHD based on the symptom constellation. *Conduct disorder* - This diagnosis requires **serious violations of rules and rights of others**, including aggression toward people/animals, property destruction, deceitfulness/theft, or major rule violations. - The boy's behaviors, while disruptive, represent **impulsivity and poor impulse control (ADHD features)** rather than the deliberate antisocial acts seen in conduct disorder. *Hearing impairment* - While hearing impairment could explain difficulty following instructions and poor school performance, it would **not account for hyperactivity, impulsivity, excessive talking, climbing behavior, or interrupting**. - The **normal physical and neurologic examination** makes an organic sensory deficit unlikely as the primary cause. *Age-appropriate behavior* - Some restlessness and impulsivity can be normal in children, but the **severity, pervasiveness across settings, duration (8 months), and significant functional impairment** clearly exceed age-appropriate behavior for an 8-year-old. - The impact on academic performance and daily functioning indicates pathological rather than developmental behavior.

Question 87: A 13-year-old boy has been suspended 5 times this year for arguing with teachers. He has presented a pattern of negativism and hostility that has lasted for about 8 months. When asked about the suspensions, he admits that he loses his temper easily and often blames the principal for not being fair to him. He usually finds an argument before finishing his homework. At home, he goes out of his way to annoy his siblings. He gets furious if his legal guardian finds out about it and confiscates his smartphone. Which of the following is the primary behavior characteristic of this patient's most likely diagnosis?

A. Destruction of property and theft
B. Hostile and disobedient behavior towards authority (Correct Answer)
C. Physical aggression
D. Violating the rights of others
E. Killing and/or harming small animals

Explanation: ***Hostile and disobedient behavior towards authority*** - This is the **primary characteristic of Oppositional Defiant Disorder (ODD)**, which best fits this clinical presentation - The patient demonstrates a **pattern of angry/irritable mood, argumentative/defiant behavior** lasting 8 months with significant functional impairment (5 suspensions) - Key ODD features present: **loses temper easily, argues with authority figures (teachers), deliberately annoys others (siblings), blames others** for his mistakes - ODD is defined by a pattern of **negativistic, hostile, and defiant behavior** toward authority figures, not physical aggression *Physical aggression* - Physical aggression is **NOT a primary feature of ODD** - it would suggest **Conduct Disorder** instead - The vignette describes **verbal defiance, arguing, and annoying behaviors**, but **no physical violence** or aggression toward people - The anger described (getting furious) represents emotional dysregulation, not physical acting out *Destruction of property and theft* - These are characteristic behaviors of **Conduct Disorder**, a more severe diagnosis involving violation of societal norms - The patient shows **oppositional behavior without property destruction or stealing** - ODD may progress to Conduct Disorder if untreated, but this patient hasn't crossed that threshold *Violating the rights of others* - This is a core feature of **Conduct Disorder**, including behaviors like **bullying, intimidation, theft, or forced sexual activity** - While the patient annoys siblings, this **doesn't constitute serious violation of basic rights** seen in Conduct Disorder - The behavior is better characterized as **oppositional and defiant rather than rights-violating** *Killing and/or harming small animals* - Animal cruelty is a **serious red flag for Conduct Disorder** and potentially future antisocial behavior - This represents **severe lack of empathy and callousness** not present in this case - No evidence in the vignette suggests the patient engages in animal harm

Question 88: A 46-year-old woman comes to the physician for a cognitive evaluation. She is an office manager. She has had increasing difficulties with multitasking and reports that her job performance has declined over the past 1 year. On mental status examination, short-term memory is impaired and long-term memory is intact. Laboratory studies, including thyroid-stimulating hormone and vitamin B12, are within the reference range. An MRI of the brain shows generalized atrophy, most pronounced in the bilateral medial temporal lobes and hippocampi. If this patient's condition has a genetic etiology, which of the following alterations is most likely to be found on genetic testing?

A. Mutation in presenilin 1 (Correct Answer)
B. Presence of ApoE ε4 allele
C. Noncoding hexanucleotide repeats
D. Deletion of chromosome 21q
E. Expansion of CAG trinucleotide repeat

Explanation: ***Mutation in presenilin 1*** - The patient presents with **early-onset dementia** (46 years old) with marked **medial temporal lobe and hippocampal atrophy** on MRI, which is highly suggestive of **early-onset Alzheimer's disease**. - Mutations in **presenilin 1 (PSEN1)**, *presenilin 2 (PSEN2)*, and **amyloid precursor protein (APP)** are associated with **autosomal dominant early-onset Alzheimer's disease**. *Presence of ApoE ε4 allele* - The **ApoE ε4 allele** is a significant genetic risk factor for **late-onset Alzheimer's disease**, typically presenting after age 65. - While it increases risk, it is not determinative, and the patient's early age of onset points more strongly towards an autosomal dominant form with mutations like PSEN1. *Noncoding hexanucleotide repeats* - **Noncoding hexanucleotide repeat expansions** are characteristic of **amyotrophic lateral sclerosis (ALS)** and **frontotemporal dementia (FTD)**, particularly in the *C9ORF72 gene*. - This patient's symptoms of initial memory impairment and specific atrophy pattern are more consistent with Alzheimer's than FTD or ALS. *Deletion of chromosome 21q* - **Deletion of chromosome 21q** is associated with conditions like **DiGeorge syndrome** if it involves specific regions, but is not typically linked to early-onset Alzheimer's disease. - While **trisomy 21 (Down syndrome)** has a high risk of developing Alzheimer's pathology due to an extra APP gene, a deletion is not the correct association. *Expansion of CAG trinucleotide repeat* - **CAG trinucleotide repeat expansions** are the genetic hallmark of **Huntington's disease**, which presents with a triad of **motor dysfunction**, **cognitive decline**, and **psychiatric symptoms**. - The patient's primary complaint of memory impairment and MRI findings are not typical for Huntington's disease, which often involves preferential atrophy of the caudate and putamen.

Question 89: A 10-year-old child is sent to the school psychologist in May because he refuses to comply with the class rules. His teacher says this has been going on since school started back in August. He gets upset at the teacher regularly when he is told to complete a homework assignment in class. Sometimes he refuses to complete them altogether. Several of his teachers have reported that he intentionally creates noises in class to interrupt the class. He tells the psychologist that the teacher and his classmates are at fault. What is the most appropriate treatment?

A. Cognitive-behavioral therapy (Correct Answer)
B. Interpersonal therapy
C. Administration of lithium
D. Motivational interviewing
E. Administration of clozapine

Explanation: ***Cognitive-behavioral therapy*** - This child exhibits symptoms consistent with **Oppositional Defiant Disorder (ODD)**, including persistent refusal to comply with rules, anger outbursts, and blaming others. **CBT** is a highly effective treatment for ODD, teaching children coping skills, anger management, and problem-solving. - CBT helps children identify and change **maladaptive thought patterns** and behaviors, which is crucial for managing the defiant and argumentative behaviors seen in ODD. *Interpersonal therapy* - **Interpersonal therapy (IPT)** primarily focuses on improving interpersonal relationships and communication patterns, often used for depression or eating disorders. - While improved relationships might be a secondary benefit, IPT does not directly target the core **defiant behaviors** and **anger management** issues central to ODD. *Administration of lithium* - **Lithium** is a mood stabilizer primarily used in the treatment of **bipolar disorder** and severe mood dysregulation. - There is no indication from the provided symptoms (defiance, anger, blaming others) that the child is experiencing a mood disorder that would warrant lithium. *Motivational interviewing* - **Motivational interviewing** is a counseling approach that helps individuals resolve ambivalence to change, often used in substance abuse or health behavior change. - While it can be useful in encouraging willingness to engage in therapy, it is not a direct therapeutic modality for addressing the specific **behavioral challenges** and **underlying cognitive distortions** of ODD. *Administration of clozapine* - **Clozapine** is an antipsychotic medication reserved for severe mental illnesses like **treatment-resistant schizophrenia** due to its significant side effects. - The child's symptoms of defiance and rule-breaking are not indicative of a psychotic disorder requiring antipsychotic medication.

Question 90: A 23-year-old woman is admitted to the inpatient psychiatry unit after her boyfriend reported she was “acting funny and refusing to talk.” The patient’s boyfriend states that he came home from work and found the patient sitting up in bed staring at the wall. When he said her name or waved his hand in front of her, she did not respond. When he tried to move her, she would remain in whatever position she was placed. The patient’s temperature is 99°F (37.2°C), blood pressure is 122/79 mmHg, pulse is 68/min, and respirations are 12/min with an oxygen saturation of 98% O2 on room air. During the physical exam, the patient is lying on the bed with her left arm raised and pointing at the ceiling. She resists any attempt to change her position. The patient remains mute and ignores any external stimuli. The patient’s medical history is significant for depression. She was recently switched from phenelzine to fluoxetine. Which of the following is the best initial therapy?

A. Electroconvulsive therapy
B. Lorazepam (Correct Answer)
C. Haloperidol
D. Cyproheptadine
E. Benztropine

Explanation: **Lorazepam** - The patient presents with classic symptoms of **catatonia**, including **mutism**, **waxy flexibility**, and **posturing**, following a medication change from phenelzine (MAOI) to fluoxetine (SSRI), which could potentially precipitate catatonia or serotonin syndrome. - **Benzodiazepines**, particularly lorazepam, are the **first-line treatment** for catatonia, often showing a rapid and dramatic response. *Electroconvulsive therapy* - While **ECT** is a highly effective treatment for severe catatonia, especially when unresponsive to benzodiazepines, it is typically considered a **second-line intervention** or for cases involving medical instability. - Given the strong initial efficacy and safety profile of benzodiazepines, they are preferred as the first step before proceeding to ECT. *Haloperidol* - **Antipsychotics** like haloperidol are generally **contraindicated** in catatonia, as they can sometimes worsen the symptoms or even induce **neuroleptic malignant syndrome (NMS)**, which shares some features with severe catatonia. - NMS is a serious condition with high mortality, and introducing an antipsychotic in a catatonic patient could be dangerous. *Cyproheptadine* - **Cyproheptadine** is a **serotonin antagonist** used primarily in the treatment of **serotonin syndrome**, which involves symptoms like hyperthermia, agitation, and hyperreflexia. - While the medication change could raise suspicion for serotonin syndrome, the clinical picture of **waxy flexibility, mutism, and posturing** is much more indicative of catatonia, for which cyproheptadine is not an effective treatment. *Benztropine* - **Benztropine** is an **anticholinergic medication** primarily used to treat **extrapyramidal symptoms (EPS)** caused by antipsychotics, such as **dystonia** or **parkinsonism**. - The patient's symptoms are not indicative of EPS, and benztropine has no role in the treatment of catatonia.

Question 91: A 29-year-old woman is hospitalized due to depression and suicidal ideation. She has a 5-year history of chaotic relationships that last only a few short weeks or months. Each relationship has left her feeling abandoned, empty, and extremely upset. During these periods, the patient confesses to shopping and making big purchases on impulse. She says she gets bored easily and moves on to the next adventure. The patient denies any changes in appetite, energy level, or concentration. On examination, multiple linear lacerations of varying phases of healing were noted on her forearms and trunk. Following consultation, she praises physicians to be ‘the best people on the planet’, but when the nurse came in to take her blood, she furiously stated that ‘all nurses are incompetent and cruel’. Which of the following is the most likely diagnosis?

A. Borderline personality disorder (Correct Answer)
B. Histrionic personality disorder
C. Major depressive disorder (MDD)
D. Bipolar I disorder
E. Factitious disorder

Explanation: ***Borderline personality disorder*** - This condition is characterized by a pervasive pattern of **instability in interpersonal relationships**, **self-image**, and **affects**, along with marked impulsivity, as evidenced by chaotic relationships, feelings of abandonment, and impulsive shopping. - The patient's rapid shift from idealizing physicians to devaluing nurses (the "best people" to "incompetent and cruel") is characteristic of **splitting**, a common defense mechanism in borderline personality disorder, and the self-inflicted lacerations indicate **self-harm**, another hallmark feature. *Histrionic personality disorder* - Characterized by **excessive emotionality** and **attention-seeking behavior**, often through dramatic and sexually provocative means. - While there may be some superficial overlap in relationship instability, the primary symptoms of splitting, impulsivity (shopping), and self-harm are less prominent here than in borderline personality disorder. *Major depressive disorder (MDD)* - While the patient exhibits **depression and suicidal ideation**, MDD typically involves core symptoms like persistent sadness, anhedonia, and changes in appetite, sleep, and energy, which the patient denies ("denies any changes in appetite, energy level, or concentration"). - The long-standing pattern of chaotic relationships, impulsivity, and splitting points away from MDD as the primary diagnosis, suggesting a more pervasive personality difficulty. *Bipolar I disorder* - This disorder is characterized by distinct periods of **mania or hypomania** alternating with depressive episodes. - While impulsivity can be seen in hypomanic/manic states, the patient's symptoms are described as persistent emotional instability and chaotic relationships present for five years, rather than episodic changes in mood and energy, and she denies changes in appetite or energy. *Factitious disorder* - Involves **falsification of physical or psychological signs or symptoms**, or induction of injury or disease, associated with identified deception, to assume the sick role. - Although the patient has self-inflicted lacerations, this behavior is more consistent with **self-harm** seen in borderline personality disorder as a coping mechanism for emotional distress, rather than a deliberate attempt to deceive medical professionals for secondary gain.

Question 92: A 14-year-old boy is brought to a child psychiatry office by his father, who is concerned about his grades and teachers’ comments that he has “problems focusing.” He has a B- average. The boy's teachers in math, social studies, and English say that he often appears to not be listening in class, instead talking to classmates, making jokes, and blurting out incorrect answers. He typically turns in his homework late or not at all. During other classes (band and science, which he enjoys), none of these behaviors are observed. At home, he enjoys playing chess and reads comic and fiction books for hours without pause. His father describes him as calm and organized at home. Formal testing reveals an intelligence quotient (IQ) of 102. Which of the following is the most likely explanation for this patient’s grades?

A. Mood disorder
B. Attention deficit hyperactivity disorder (ADHD)
C. Absence seizures
D. Intellectual disability
E. Specific Learning Disorder (Correct Answer)

Explanation: ***Specific Learning Disorder*** - This patient demonstrates **selective academic difficulties** in math, social studies, and English, while performing well in band and science (subjects he enjoys). - The key feature is that his problems are **context-dependent and motivation-based** rather than representing a true learning disorder, but among the given options, this is the most fitting explanation for his grades. - His **normal IQ (102)** and ability to focus for extended periods on preferred activities (chess, reading) suggest this is more likely **underachievement due to lack of interest** rather than a true pathological condition. - True specific learning disorders typically show persistent difficulties in specific academic skills regardless of interest level, making this diagnosis imperfect but the best option available. *Intellectual disability* - A diagnosis of intellectual disability requires an **IQ below 70-75**, which is not present here as the patient's IQ is 102 (normal range). - Additionally, significant deficits in **adaptive functioning across multiple domains** (conceptual, social, practical) during the developmental period are necessary for diagnosis. - This patient shows **normal functioning at home** and in preferred activities, ruling out intellectual disability. *Mood disorder* - While mood disorders can affect concentration and academic performance, the patient's **selective inattentiveness** (present only in certain classes) and ability to focus for hours on enjoyable activities make this unlikely. - There are **no reported symptoms** of depression (persistent sadness, anhedonia, sleep/appetite changes) or mania (elevated mood, grandiosity, decreased need for sleep). *Attention deficit hyperactivity disorder (ADHD)* - ADHD symptoms are typically **pervasive across settings** and are not dependent on whether the activity is enjoyable. - The patient's ability to **focus for hours on chess and reading**, and his calm, organized behavior at home, **contradict the diagnostic criteria** for ADHD. - ADHD requires significant impairment in multiple domains, which is not observed here. *Absence seizures* - Absence seizures are characterized by **brief episodes of staring spells** with impaired consciousness, typically lasting only seconds. - These episodes involve **sudden cessation of activity** and are **not associated with purposeful behaviors** like talking to classmates, making jokes, or blurting out answers.

Question 93: An 18-year-old male is seen for a routine physical prior to starting college. He will be moving from Ohio to California, away from his family for the first time. His temperature is 36.8 deg C (98.2 deg F), pulse is 74/min, and blood pressure is 122/68 mmHg. BMI is 24. On questioning, he reveals that he has a habit of binge eating during times of stress, particularly during exams. He then feels guilty about his behavior and attempts to compensate by going to the gym, sometimes for 4+ hours per day. He is disturbed by this behavior and feels out of control. He denies ever vomiting as a means of losing weight. What is the most likely diagnosis?

A. Normal behavior variant
B. Hypomania
C. Body dysmorphic disorder
D. Anorexia nervosa
E. Bulimia nervosa (Correct Answer)

Explanation: ***Bulimia nervosa*** - This patient exhibits characteristic symptoms of **bulimia nervosa**, including recurrent episodes of **binge eating** followed by inappropriate compensatory behaviors (excessive exercise) to prevent weight gain. - While he denies vomiting, other compensatory behaviors like **excessive exercise** are common and validate the diagnosis, coupled with feelings of lack of control and guilt. *Normal behavior variant* - The described pattern of recurrent binge eating, lack of control, and extreme compensatory behaviors is **not within the range of normal eating behavior** or coping mechanisms. - The distress and impairment associated with these behaviors differentiate it from typical stress-related eating patterns. *Hypomania* - **Hypomania** involves elevated mood, increased energy, decreased need for sleep, and impulsivity, but it does not typically involve specific patterns of binge eating and compensatory behaviors. - The patient's reported distress about his eating habits also contradicts the usually euphoric or irritable mood seen in hypomania. *Body dysmorphic disorder* - **Body dysmorphic disorder** is characterized by preoccupation with perceived flaws in physical appearance, leading to repetitive behaviors like mirror checking or excessive grooming. - While body image concerns can co-occur with eating disorders, the primary issue described here is the cycle of binge eating and compensatory behaviors, not preoccupation with a specific physical defect. *Anorexia nervosa* - **Anorexia nervosa** is characterized by a significant **restriction of energy intake** leading to a significantly low body weight, intense fear of gaining weight, and disturbance in the way one's body weight or shape is experienced. - This patient's **BMI is normal**, and he does not show evidence of being underweight, which is a core diagnostic criterion for anorexia nervosa.

Question 94: A 78-year-old man is brought to the physician by his daughter for a follow-up examination. The daughter noticed that he has gradually become more forgetful and withdrawn over the last year. He frequently misplaces his car keys and forgets the names of his neighbors, whom he has known for 30 years. He has difficulty recalling his address and telephone number. He recently had an episode of urinary and fecal incontinence. Last week, his neighbor found him wandering the parking lot of the grocery store. He has hypertension and hyperlipidemia. He had smoked one pack of cigarettes daily for 40 years but quit 18 years ago. His current medications include hydrochlorothiazide and atorvastatin. He appears healthy; BMI is 23 kg/m2. His temperature is 37.2°C (99.0°F), pulse is 86/min, respirations are 14/min, and blood pressure is 136/84 mm Hg. Mini-mental state examination score is 19/30. He is not bothered by his forgetfulness. Cranial nerves II–XII are intact. He has 5/5 strength and full sensation to light touch in all extremities. His patellar, Achilles, and biceps reflexes are 2+ bilaterally. His gait is steady. MRI scan of the brain shows ventriculomegaly and prominent cerebral sulci. Which of the following is the most appropriate pharmacotherapy?

A. Acetazolamide
B. Sertraline
C. Memantine
D. Thiamine
E. Donepezil (Correct Answer)

Explanation: ***Donepezil*** - The patient exhibits features consistent with **Alzheimer's disease**, including gradual memory loss, difficulty with daily tasks, episodes of incontinence, and a Mini-Mental State Examination (MMSE) score of 19/30. Donepezil, a **cholinesterase inhibitor**, is a first-line treatment for mild to moderate Alzheimer's to slow cognitive decline. - The MRI findings of **ventriculomegaly and prominent cerebral sulci** are consistent with general cerebral atrophy often seen in Alzheimer's disease, not hydrocephalus requiring shunting or other specific brain pathologies (normal pressure hydrocephalus would have gait disturbance as a prominent feature, which is absent here). *Acetazolamide* - **Acetazolamide** is a **carbonic anhydrase inhibitor** used to treat conditions like glaucoma, altitude sickness, and idiopathic intracranial hypertension. - There is no indication of elevated intracranial pressure or hydrocephalus that would warrant the use of acetazolamide in this patient. *Sertraline* - **Sertraline** is a **selective serotonin reuptake inhibitor (SSRI)** primarily used to treat depression, anxiety disorders, and obsessive-compulsive disorder. - While depression can coexist with dementia, the primary cognitive symptoms described here are not primarily depressive; therefore, an antidepressant is not the most appropriate initial pharmacotherapy for cognitive decline. *Memantine* - **Memantine** is an **NMDA receptor antagonist** used in moderate to severe Alzheimer's disease, often in combination with cholinesterase inhibitors or when cholinesterase inhibitors are not tolerated. - While appropriate for moderate to severe Alzheimer's, **cholinesterase inhibitors** are typically the initial treatment for mild to moderate stages, and the patient's MMSE score of 19/30 often falls into the mild-moderate category where donepezil is usually favored first. *Thiamine* - **Thiamine** (vitamin B1) supplementation is primarily used to treat **Wernicke-Korsakoff syndrome**, which is associated with chronic alcohol abuse and presents with ataxia, ophthalmoplegia, and confusion, none of which are the primary presenting symptoms here. - There is no evidence of **nutritional deficiency** or alcohol abuse in this patient to suggest thiamine deficiency as the cause of his cognitive decline.

Question 95: A 31-year-old male comedian presents to your mental health clinic for a psychotherapy appointment. He is undergoing psychodynamic psychotherapy for depressive symptoms. During the therapy session, you discuss his job as a successful comedian and identify ways that he channels his emotions about his abusive childhood into comedy routines. Though he enjoys his job overall and idolizes some of his coworkers, he complains about most of them being "totally incompetent." When you attempt to shift the discussion back to his childhood, he avoids eye contact and he tells you he "doesn't want to talk about it anymore." Which of the following is a primitive defense mechanism exhibited by this patient?

A. Humor
B. Denial
C. Suppression
D. Splitting (Correct Answer)
E. Reaction formation

Explanation: ***Splitting*** - The patient exhibits **splitting** by describing coworkers as "totally incompetent" while simultaneously idealizing others, demonstrating an inability to integrate positive and negative qualities of himself or others. - This defense mechanism leads to black-and-white thinking, where individuals or situations are perceived as either all good or all bad. *Humor* - **Humor** is typically considered a mature defense mechanism used to express uncomfortable feelings or thoughts in a socially acceptable way, as seen with his comedy routines. - While he channels emotions into comedy, this specific act of avoiding deep discussion and categorizing coworkers is not humor. *Denial* - **Denial** involves refusing to acknowledge a painful reality, which isn't explicitly demonstrated by his statement "doesn't want to talk about it anymore" regarding his childhood, but rather an avoidance of the topic itself. - Although he avoids the topic, it does not mean he denies the reality of his childhood. *Suppression* - **Suppression** is a conscious decision to delay paying attention to an emotion or need, which differs from his outright refusal to discuss his childhood further. - He explicitly states he "doesn't want to talk about it anymore," indicating a more forceful push away than merely postponing. *Reaction formation* - **Reaction formation** involves transforming an unacceptable impulse or feeling into its opposite, which is not evident in his complaints about incompetent coworkers or avoidance of discussing his childhood. - There is no indication that his complaints or avoidance are actually masked versions of opposite feelings or thoughts.

Question 96: A 61-year-old woman presents to her primary care doctor with her son who reports that his mother is not acting like herself. She has gotten lost while driving several times in the past 2 months and appears to be talking to herself frequently. Of note, the patient’s husband died from a stroke 4 months ago. The patient reports feeling sad and guilty for causing so much trouble for her son. Her appetite has decreased since her husband died. On examination, she is oriented to person, place, and time. She is inattentive, and her speech is disorganized. She shakes her hand throughout the exam without realizing it. Her gait is slow and appears unstable. This patient’s condition would most likely benefit from which of the following medications?

A. Bromocriptine
B. Rivastigmine (Correct Answer)
C. Reserpine
D. Selegiline
E. Levodopa

Explanation: ***Rivastigmine*** - The patient's symptoms of progressive cognitive decline (getting lost while driving, talking to herself), inattention, disorganized speech, and motor symptoms (hand tremor, unstable gait) suggest **Dementia with Lewy Bodies (DLB)**. - Key features supporting DLB over depression with pseudodementia: **involuntary hand tremor**, **unstable gait**, **visual hallucinations** (talking to herself), and **disorganized speech** occurring with cognitive decline. - **Rivastigmine**, a cholinesterase inhibitor, is a first-line treatment for the cognitive and behavioral symptoms in DLB and is FDA-approved for this indication. - While bereavement-related depression is present, the prominent motor and cognitive features indicate an underlying neurodegenerative process. *Bromocriptine* - This is a **dopamine agonist** typically used for Parkinson's disease, hyperprolactinemia, and acromegaly. - While Parkinsonian features are present in DLB, dopamine agonists can worsen **psychotic symptoms** (hallucinations) common in DLB, making them unsuitable as first-line treatment. *Reserpine* - **Reserpine** depletes catecholamines and serotonin and is primarily used as an antihypertensive. - Its use in dementia is not indicated and could exacerbate mood, cognitive issues, and Parkinsonian symptoms due to its dopamine-depleting effects. - This medication is rarely used in modern practice. *Selegiline* - **Selegiline** is a **monoamine oxidase-B (MAO-B) inhibitor** used in Parkinson's disease to reduce dopamine breakdown. - While it may help with motor symptoms, its benefit in DLB is less established compared to cholinesterase inhibitors. - The prominent **cognitive and behavioral symptoms** in this patient make cholinesterase inhibition the priority. *Levodopa* - **Levodopa** is a dopamine precursor and the most effective medication for motor symptoms of Parkinson's disease. - In DLB, while it can improve motor symptoms, it can significantly worsen **psychotic symptoms** (hallucinations, delusions) and cognitive fluctuations. - Given the prominent non-motor symptoms and existing hallucinations, levodopa is not first-line therapy for this patient.

Question 97: A 15-year-old girl is brought into her pediatrician's office by her mother because the mother thinks her daughter has attention issues. The mother explains that her daughter started high school four months ago and had lackluster grades in a recent progress report despite having earned consistent top marks in middle school. The mother complains that her daughter never talks to her at home anymore. The patient yells at her mother in the exam room, and the mother is escorted out of the room. The patient scoffs that her mother is so overbearing, ruining her good days with criticism. She begins to chew gum and states that she hates hanging out with the girls on the cheerleading squad. She denies experiencing physical abuse from anyone or having a sexual partner. She has seen kids smoke marijuana underneath the football field bleachers, but does not go near them and denies smoking cigarettes. She denies any intention to harm herself or others, thinks her grades went down because her teachers are not as good as her middle school teachers, and states she thinks she learns best by watching explanations through online videos. What is the most likely diagnosis?

A. Attention deficit hyperactivity disorder
B. Conduct disorder
C. Oppositional defiant disorder
D. Antisocial personality disorder
E. Normal behavior (Correct Answer)

Explanation: ***Normal behavior*** - The patient exhibits behaviors typical of **adolescent development**, including increased desire for independence, conflicts with parents, and shifting social interests. - While academic performance has declined, her explanation about learning preferences and criticisms of school staff is consistent with a normal rebellious phase and does not indicate a mental health disorder. *Attention deficit hyperactivity disorder* - ADHD is characterized by persistent patterns of **inattention**, **hyperactivity**, and **impulsivity** that interfere with functioning or development. - The patient's explanation for poor grades and lack of other ADHD symptoms makes this diagnosis less likely; her academic decline is recent and attributed to external factors. *Conduct disorder* - Conduct disorder involves a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, such as **aggression to people and animals**, **destruction of property**, **deceitfulness or theft**, or **serious violation of rules**. - The patient's behaviors, while defiant, do not meet criteria for significant rule-breaking, aggression, or deceit. *Oppositional defiant disorder* - This disorder involves a pattern of **angry/irritable mood**, **argumentative/defiant behavior**, or **vindictiveness** lasting at least 6 months, often directed at an authority figure. - While the patient shows some defiant behavior towards her mother, it is limited to this particular interaction, and not a pervasive pattern that meets the frequency and severity for ODD, especially considering her age and developmental stage. *Antisocial personality disorder* - Antisocial personality disorder cannot be diagnosed before age 18 and requires a history of **conduct disorder** symptoms before age 15. - The patient does not display the pervasive disregard for the rights of others, deceit, or criminal behavior characteristic of antisocial personality disorder.

Question 98: A 55-year-old man is brought to the physician because of inappropriate behavior for the past 6 months. He has been making inappropriate comments and jokes while talking to friends and family members. He was arrested 3 weeks ago while trying to kiss strangers on the street. He has no interest in talking to his daughter or playing with his grandchildren. During this period, he has developed a strong desire for chocolate pudding and potato chips and has gained 10 kg (22 lb). He appears unkempt. Vital signs are within normal limits. Physical examination is unremarkable. Mental status examination shows apathy and a blunt affect. He avoids answering questions and instead comments on the individuals he saw in the waiting room. Mini-Mental State Examination score is 28/30. A complete blood count and serum concentrations of glucose, creatinine, and electrolytes are within the reference range. Which of the following is the most likely diagnosis?

A. Parkinson disease
B. Normal pressure hydrocephalus
C. Amyotrophic lateral sclerosis
D. Wilson disease
E. Frontotemporal dementia (Correct Answer)

Explanation: ***Frontotemporal dementia*** - This patient's presentation with **inappropriate behavior**, **disinhibition**, **apathy**, **dietary changes** (sweet cravings, weight gain), and **lack of insight** are classic features of the **behavioral variant of frontotemporal dementia (bvFTD)**. - The **Mini-Mental State Examination (MMSE) score of 28/30** indicates relatively preserved memory and visuospatial skills, which is typical in early bvFTD as cognitive deficits often appear later. *Parkinson disease* - While Parkinson's can present with **cognitive and behavioral changes** in later stages (Parkinson's disease dementia), the *initial* presentation is typically dominated by **motor symptoms** such as **bradykinesia, tremor, and rigidity**, which are absent here. - The prominent behavioral disinhibition and early dietary changes are less characteristic of Parkinson's disease. *Normal pressure hydrocephalus* - Characterized by the classic triad of **gait disturbance**, **urinary incontinence**, and **dementia (subcortical)**. - While some behavioral changes can occur, the prominent disinhibition, hyperorality, and specific dietary cravings seen here are not typical primary symptoms. *Amyotrophic lateral sclerosis* - This is a **motor neuron disease** characterized by progressive **muscle weakness, atrophy, and fasciculations**, affecting both upper and lower motor neurons. - While approximately 15% of ALS patients can develop FTD, the primary presentation is invariably motor, and there are no motor symptoms described in this patient. *Wilson disease* - A **rare genetic disorder** leading to **copper accumulation**, affecting the **liver** and **brain**. - Presents with a combination of **hepatic symptoms** (e.g., cirrhosis), **neurological symptoms** (e.g., tremor, dystonia, dysarthria), and **psychiatric symptoms** (e.g., depression, psychosis), often with **Kayser-Fleischer rings** in the cornea. The patient has none of these characteristic findings.

Question 99: A 15-year-old girl presents to her primary care physician, accompanied by her mother, for 4 days of abdominal pain. She describes the pain as diffuse, dull, and constant. She also endorses constipation over this time. The patient's mother says the patient has become increasingly self-conscious of her appearance since starting high school this year and has increasingly isolated herself to her room, rarely spending time with or eating meals with the rest of the family. Her temperature is 98.0°F (36.7°C), blood pressure is 100/70 mmHg, pulse is 55/min, and respirations are 19/min. Body mass index (BMI) is at the 4th percentile for age and gender. Physical exam reveals dental caries, mild abdominal distension, and diffuse, fine body hair. Basic labs are most likely to reveal which of the following?

A. Hyperkalemia
B. Hyperphosphatemia
C. Hypocalcemia
D. Hypokalemia (Correct Answer)
E. Hypercalcemia

Explanation: ***Hypokalemia*** - The patient's clinical presentation, including low BMI, dental caries, abdominal pain, constipation, diffuse fine body hair (**lanugo**), and **bradycardia**, is highly suggestive of **anorexia nervosa** with possible **bulimic features** (dental caries suggest purging). - **Hypokalemia** is a common electrolyte abnormality in patients with bulimia nervosa or anorexia nervosa with purging behaviors due to **vomiting** (loss of gastric acid and subsequent renal potassium wasting) or **laxative abuse**. *Hyperkalemia* - **Hyperkalemia** is unlikely given the history of suspected purging behavior (vomiting/laxative abuse), which typically leads to potassium loss. - While some conditions affecting renal function can cause hyperkalemia, there is no information to suggest such issues in this patient. *Hyperphosphatemia* - **Hyperphosphatemia** is not a typical finding in eating disorders; rather, **hypophosphatemia** can occur, especially during refeeding syndrome. - There are no clinical signs or symptoms in this patient's presentation that would suggest hyperphosphatemia. *Hypocalcemia* - **Hypocalcemia** is not a primary or common electrolyte disturbance directly related to the purging behaviors seen in anorexia or bulimia nervosa. - While chronic malnutrition might affect calcium balance over time, it's not the most immediate or characteristic electrolyte imbalance in this acute presentation. *Hypercalcemia* - **Hypercalcemia** is rare in eating disorders and is usually associated with conditions like **hyperparathyroidism** or certain malignancies, which are not indicated here. - There are no symptoms presented that would point towards this electrolyte imbalance.

Question 100: A 53-year-old man is brought to the physician by his wife because of strange behavior and emotional outbursts for the past 6 months. He was previously healthy and physically active, but he recently started binge-eating candy and stopped exercising. He was fired from his job for inappropriate behavior after he undressed in the office and made lewd remarks to several female coworkers. He claims there is nothing wrong with his behavior. On mental status examination, he is alert and irritable but cooperative. Short-term recall is normal but he has some word-finding difficulties. Babinski reflex is positive bilaterally. This patient's symptoms are most likely due to a degenerative process in which of the following regions of the brain?

A. Frontal cortex (Correct Answer)
B. Corona radiata
C. Hippocampus
D. Caudate nucleus
E. Substantia nigra

Explanation: ***Frontal cortex*** - This patient's symptoms, including **behavioral disinhibition** (inappropriate sexual behavior, emotional outbursts, undressing in the office), **changes in eating habits** (binge-eating candy), **loss of empathy**, and **lack of insight**, are classic presentations of **frontotemporal dementia (FTD)**. - **Word-finding difficulties** and the **positive Babinski reflex** bilaterally further support a neurodegenerative process affecting the **frontal lobes**, which are crucial for executive function, social conduct, and language. *Corona radiata* - The **corona radiata** consists of white matter tracts connecting the cerebral cortex to the brainstem and spinal cord. - While damage here can cause motor and sensory deficits, it is **less directly involved in the primary behavioral and personality changes** seen in this patient compared to the frontal cortex. *Hippocampus* - The **hippocampus** is primarily involved in **memory formation**, particularly **short-term and declarative memory**. - This patient's **short-term recall is normal**, making the hippocampus an unlikely primary site of degeneration for the presented symptoms. *Caudate nucleus* - The **caudate nucleus** is part of the **basal ganglia** and is involved in motor control, learning, and cognitive functions. - While atrophy can occur in some neurodegenerative diseases like Huntington's disease, the predominant symptoms here are **behavioral and executive dysfunction**, not typical of isolated caudate pathology. *Substantia nigra* - The **substantia nigra** is a midbrain structure crucial for **motor control** due to its role in dopamine production. - Degeneration of the substantia nigra is characteristic of **Parkinson's disease**, leading to bradykinesia, rigidity, and tremor, which are not the primary features described here.

Question 101: A parent-teacher conference is called to discuss the behavior of a 9 year-old boy. According to the boy's teacher, he has become progressively more disruptive during class. When asked to help clean up or read out-loud, he replies with "You're not the boss of me." or "You can't make me." He refuses to participate in gym class, but will play the same games during recess. He gets along with and is well-liked by his peers. His mother reports that her son can "sometimes be difficult," but he is helpful around the house and is very good playing with his 7-year-old sister. What is the most likely diagnosis?

A. Conduct disorder
B. Attention deficit disorder
C. Separation anxiety disorder
D. Oppositional defiant disorder (Correct Answer)
E. Antisocial personality disorder

Explanation: ***Oppositional defiant disorder*** - The boy exhibits a pattern of **defiant and disobedient behavior** towards authority figures (teacher) but a generally good relationship with peers and family, which is characteristic of ODD. - His refusal to participate in formal class activities while still engaging in informal play highlights a specific defiance towards structured rules rather than a general aversion to activity. *Conduct disorder* - This disorder involves a more severe pattern of **aggression, destruction of property, deceitfulness, or serious rule violations**, which are not described in the boy's behavior. - The boy's ability to get along with peers and be helpful at home suggests he does not meet the criteria for significant social impairment or callousness seen in conduct disorder. *Attention deficit disorder* - This disorder is characterized by **inattention, hyperactivity, and impulsivity**, which are not the primary symptoms described here. - While defiance might be a secondary issue, the core problem is not difficulty sustaining attention or controlling impulsive behaviors. *Separation anxiety disorder* - This involves **excessive fear or anxiety concerning separation from home or attachment figures**, which is not indicated by any of the behavioral descriptions. - The boy's issues are related to defiance and authority, not fear of separation. *Antisocial personality disorder* - This diagnosis can only be made in individuals **18 years or older** and requires a pervasive pattern of disregard for and violation of the rights of others. - The boy's age (9 years old) and his reported positive relationships with peers and family rule out this diagnosis.

Question 102: A 25-year-old man presents to his primary care physician for trouble with focus and concentration. The patient states that he has lived at home with his parents his entire life but recently was able to get a job at a local factory. Ever since the patient has started working, he has had trouble focusing at his job. He is unable to stay focused on any task. His boss often observes him "daydreaming" with a blank stare off into space. His boss will have to yell at him to startle him back to work. The patient states that he feels fatigued all the time and sometimes will suddenly fall asleep while operating equipment. He has tried going to bed early for the past month but is unable to fall asleep until two hours prior to his alarm. The patient fears that if this continues he will lose his job. Which of the following is the best initial step in management?

A. Zolpidem
B. Ethosuximide
C. Modafinil
D. Polysomnography (Correct Answer)
E. Bright light therapy

Explanation: ***Polysomnography*** - The patient's symptoms of excessive daytime sleepiness, sudden sleep attacks (possibly **cataplexy**), and difficulty maintaining sleep, along with the "daydreaming" spells, are highly suggestive of **narcolepsy**. - **Polysomnography** is the gold standard diagnostic test for narcolepsy and other sleep disorders, confirming the diagnosis and ruling out other causes of excessive somnolence. *Zolpidem* - **Zolpidem** is a sedative-hypnotic primarily used for treating **insomnia** by helping to initiate and maintain sleep. - While the patient has difficulty falling asleep, addressing the underlying cause of his **excessive daytime sleepiness** is the priority before symptomatic treatment of insomnia. *Ethosuximide* - **Ethosuximide** is an anti-epileptic drug specifically used to treat **absence seizures** (petit mal seizures). - Although the patient's "daydreaming" spells might resemble absence seizures, the combination with profound daytime sleepiness and sudden sleep attacks points away from epilepsy and towards a primary sleep disorder. *Modafinil* - **Modafinil** is a stimulant used to promote wakefulness in patients with excessive daytime sleepiness associated with narcolepsy, obstructive sleep apnea, and shift work sleep disorder. - While it might be a potential treatment, it is usually initiated *after* a definitive diagnosis is established through **polysomnography** and other sleep studies. *Bright light therapy* - **Bright light therapy** is primarily used to treat **seasonal affective disorder** and **circadian rhythm sleep disorders**, such as delayed sleep phase syndrome. - The patient's symptoms are more severe and complex than typical circadian rhythm issues and include sudden sleep attacks, making this an inappropriate initial intervention without a proper diagnosis.

Question 103: A 9-year-old boy is brought to a psychologist by his mother because his teachers frequently complain about his behavioral problems at school. The patient’s mother reports that his concerning behavior started at a young age. She says he is disrespectful to family members and to his teachers at school. He also talks back to everyone. Grounding him and limiting his freedom has not improved his behavior. His grades have never been very good, and he is quite isolated at school. After a further review of the patient’s medical history and a thorough physical exam, the physician confirms the diagnosis of oppositional defiant disorder. Which of the following additional symptoms would most likely present in this patient?

A. Fights at school
B. Staying out of home at nights despite restrictions
C. History of deliberately damaging furniture
D. Frequently leaving his seat during class despite instructions by the teacher
E. Blaming others for his own misbehavior (Correct Answer)

Explanation: ***Blaming others for his own misbehavior*** - **Oppositional Defiant Disorder (ODD)** is characterized by a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness, often including **blaming others for their mistakes or misbehavior**. - The patient's established pattern of disrespect and talking back aligns with the argumentative and defiant nature of ODD, making blaming others a highly consistent additional symptom. *Fights at school* - While fighting can occur in children with ODD, **physical aggression is more characteristic of Conduct Disorder (CD)**. - ODD primarily involves verbal defiance and non-compliance, not necessarily direct physical altercations. *Staying out of home at nights despite restrictions* - **Running away from home or staying out despite parental rules is a feature of Conduct Disorder (CD)**, not typically ODD. - ODD is focused on defiance within established settings, whereas CD involves more severe violations of societal norms and rules. *History of deliberately damaging furniture* - **Deliberate destruction of property is a core symptom of Conduct Disorder (CD)**. - ODD involves defiance and an irritable mood, but usually stops short of actively damaging property. *Frequently leaving his seat during class despite instructions by the teacher* - This symptom is more indicative of **Attention-Deficit/Hyperactivity Disorder (ADHD)**, specifically the hyperactive-impulsive presentation. - While comorbidity with ODD is common, this specific behavior is not a defining characteristic of ODD itself.

Question 104: A 13-year-old teenage girl was brought to the emergency department by her mom after she collapsed. Her mom reports that she was at a birthday party when all of a sudden she fell. She reported left foot weakness and has been limping ever since. The patient has been healthy and had an uncomplicated birth history, though her mom reports that she just recovered from a cold. She currently lives with her younger sister and mother as her parents recently divorced. She does well in school and has a handful of good friends. Her physical exam demonstrated normal bulk and tone, 5/5 strength in all motions, 2+ and symmetric reflexes at biceps, triceps and knees. She had 1+ ankle reflex on left. What is the most likely explanation for her symptoms?

A. Guillain-Barre syndrome
B. Cerebral vascular accident
C. Conversion disorder (Correct Answer)
D. Multiple sclerosis
E. Myasthenia gravis

Explanation: ***Conversion disorder*** - The patient's presentation with acute onset of neurological symptoms (left foot weakness, limping) following a stressful event (parents' divorce) and a recent illness, coupled with a **neurological exam that is inconsistent with true organic disease** (reported weakness but 5/5 strength on exam), is highly suggestive of a **conversion disorder**. - **Conversion disorder**, also known as **functional neurological symptom disorder**, involves neurological symptoms lacking a compatible neurological or medical explanation, often triggered by psychological stress. *Guillain-Barre syndrome* - This is an **acute demyelinating polyneuropathy** characterized by **ascending paralysis** and **areflexia**, typically following an infection. - The physical exam findings of normal strength and only a slightly diminished ankle reflex on one side are not consistent with the widespread weakness and **loss of reflexes** seen in Guillain-Barré syndrome. *Cerebral vascular accident* - A stroke (**CVA**) in a 13-year-old girl is rare without predisposing factors and would typically present with more definitive and consistent neurological deficits, such as **hemiparesis**, **facial droop**, or **aphasia**, which are absent here. - The neurological exam showing normal strength and tone throughout, despite reported weakness, does not align with the **focal neurological deficits** expected from a CVA. *Multiple sclerosis* - **Multiple sclerosis** is a demyelinating disease of the central nervous system that typically presents with fluctuating neurological symptoms over time, often involving **sensory disturbances**, **visual changes**, or **motor weakness**. - While an acute onset is possible, the reported weakness with an otherwise normal neurological exam and the single, isolated symptom without other characteristic features make MS less likely. *Myasthenia gravis* - **Myasthenia gravis** is an autoimmune disorder characterized by **fluctuating muscle weakness** that **worsens with activity** and improves with rest, often affecting ocular, bulbar, and limb muscles. - The patient's reported weakness being constant and her normal strength on examination, without the typical fluctuating fatigue or specific muscle group involvement, argues against myasthenia gravis.

Question 105: A 28-year-old woman is brought into the clinic by her husband with concerns that she might be depressed. She delivered a healthy newborn a week and a half ago without any complications. Since then, she has been having trouble sleeping, eating poorly, and has stopped playing with the baby. The patient says she feels like she is drained all the time and feels guilty for not doing more for the baby. Which of the following is the best course of treatment for this patient?

A. Reassurance
B. Fluoxetine (Correct Answer)
C. Risperidone
D. Amitriptyline
E. No treatment

Explanation: ***Fluoxetine*** - This patient's symptoms (trouble sleeping, poor appetite, guilt, and anhedonia towards the baby) occurring 10 days postpartum are highly suggestive of **postpartum depression**. **SSRIs** like fluoxetine are first-line pharmacological treatments for this condition. - Fluoxetine is a **selective serotonin reuptake inhibitor (SSRI)** that helps regulate mood by increasing serotonin levels in the brain. It is generally considered safe during breastfeeding, with a relatively low infant exposure compared to other antidepressants. *Reassurance* - Reassurance alone may be appropriate for **postpartum blues**, which are milder and self-limiting, typically resolving within two weeks. - This patient's symptoms are more severe and persistent, lasting beyond typical postpartum blues and significantly impacting her functioning, indicating a need for more substantial intervention. *Risperidone* - Risperidone is an **atypical antipsychotic** primarily used to treat conditions like schizophrenia or bipolar disorder, or as an adjunct for severe refractory depression with psychotic features. - There is no indication of psychosis in this patient's presentation, and the use of an antipsychotic would be disproportionate and carry unnecessary side effects. *Amitriptyline* - Amitriptyline is a **tricyclic antidepressant (TCA)**. While effective for depression, TCAs are generally not first-line due to a less favorable side effect profile (e.g., anticholinergic effects, cardiac conductivity issues) compared to SSRIs. - SSRIs like fluoxetine are preferred for initial treatment of postpartum depression due to their better tolerability and safety profile. *No treatment* - This patient exhibits clear symptoms of **postpartum depression**, which is a serious condition that can worsen without intervention and impact both the mother's and infant's well-being. - Untreated depression can lead to significant functional impairment, chronic suffering, and in severe cases, harm to oneself or the baby.

Question 106: A 23-year-old woman is seen by her primary care physician. The patient has a several year history of excessive daytime sleepiness. She also reports episodes where she suddenly falls to the floor after her knees become weak, often during a laughing spell. She has no other significant past medical history. Her primary care physician refers her for a sleep study, which confirms the suspected diagnosis. Which of the following laboratory findings would also be expected in this patient?

A. Increased serum ESR
B. Undetectable CSF hypocretin-1 (Correct Answer)
C. Reduced serum hemoglobin
D. Increased serum methemoglobin
E. Increased CSF oligoclonal bands

Explanation: ***Undetectable CSF hypocretin-1*** - The patient's symptoms of excessive daytime sleepiness and **cataplexy** (suddenly falling after knees become weak during laughing spells) are classic for **narcolepsy with cataplexy**. - **Narcolepsy with cataplexy** is associated with the destruction of **hypocretin-producing neurons** in the hypothalamus, leading to undetectable levels of **hypocretin-1 (orexin A)** in the cerebrospinal fluid. *Increased serum ESR* - An **elevated erythrocyte sedimentation rate (ESR)** is a non-specific marker of inflammation and is not typically associated with narcolepsy. - Inflammatory conditions such as **autoimmune diseases** or **infections** would cause an increased ESR. *Reduced serum hemoglobin* - **Reduced serum hemoglobin** indicates **anemia**, which is not a characteristic finding in narcolepsy with cataplexy. - Anemia can cause fatigue but does not explain the episodes of cataplexy. *Increased serum methemoglobin* - **Methemoglobin** is an abnormal form of hemoglobin, and its increase (methemoglobinemia) is typically caused by exposure to certain **drugs or toxins**, not narcolepsy. - It would lead to **cyanosis** and reduced oxygen carrying capacity, unrelated to the patient's symptoms. *Increased CSF oligoclonal bands* - **Oligoclonal bands in CSF** are indicative of **intrathecal immunoglobulin production** and are a hallmark finding in **multiple sclerosis (MS)**. - While MS can cause fatigue, the specific presentation of cataplexy and excessive daytime sleepiness points away from MS as the primary diagnosis.

Question 107: A 12-year-old boy is brought in by his parents as they are concerned about his behavior. He is constantly arguing with his parents and blatantly defying their every request. In school, he is known for being intentionally tardy and for defying his teachers. Upon further questioning of the patient you learn about some of his recent behaviors such as beginning smoking to bother his parents. You also notice that he is disrespectful towards you. You then learn that he has also gotten into weekly fights with his peers at school with no apparent cause. In addition, last week he was seen hitting one of the local neighborhood cats with a baseball bat trying to kill it. The patient lives at home with his two parents in a pre-World War II house that was recently renovated. Physical exam is unremarkable. Laboratory values are as follows: Na: 140 mmol/L K: 4.5 mmol/L Cl: 100 mmol/L Glucose: 80 mg/dL Ca: 10 mmol/L Mg: 3 mEq/L Cr: 0.8 mg/dL BUN: 10 mg/dL Serum lead: < .01 µg/dL Hb: 15 g/dL Hct: 45% MCV: 95 Urine toxicology: negative As the patient leaves the office you notice him stealing all of the candy from the office candy bowl. The patient seems unconcerned about his behavior overall. Which of the following statements is most likely to be true in this patient?

A. This patient will likely function normally despite continuing to defy authority figures
B. Environmental exposures are likely causing this patient's behavior
C. The patient's symptoms could progress to antisocial personality disorder (Correct Answer)
D. This patient is suffering from antisocial personality disorder and will likely be incarcerated in adulthood
E. Strong D2 antagonists are first-line pharmacotherapy

Explanation: ***The patient's symptoms could progress to antisocial personality disorder*** - The patient's pattern of **aggression towards people and animals**, **deceitfulness or theft**, and **serious violations of rules** (e.g., truancy, defying authority) are all diagnostic criteria for **conduct disorder**. - If conduct disorder symptoms persist into adulthood (age 18 or older), it can lead to a diagnosis of **antisocial personality disorder (ASPD)**, as ASPD requires evidence of conduct disorder before age 15. *This patient will likely function normally despite continuing to defy authority figures* - The described behaviors go beyond simple defiance; they include **aggression, severe rule violations, and lack of remorse**. These are significant indicators of a **conduct disorder**, which is associated with poor long-term outcomes and functional impairment, not normal functioning. - Undiagnosed and untreated conduct disorder can lead to **academic difficulties, substance abuse, legal problems, and inability to maintain relationships**, making normal functioning unlikely. *Environmental exposures are likely causing this patient's behavior* - While environmental factors can contribute, the **severity and widespread nature** of the behaviors (at home, school, with peers, and animals), coupled with the **lack of remorse and intentional malice**, point more strongly to an underlying psychiatric diagnosis like conduct disorder rather than solely environmental causes. - The provided lab results rule out common environmental toxins like **lead poisoning**, and the recent house renovation doesn't provide direct evidence of a toxic exposure causing these specific behavioral manifestations. *This patient is suffering from antisocial personality disorder and will likely be incarcerated in adulthood* - **Antisocial personality disorder (ASPD)** cannot be diagnosed before age 18. This patient is 12 years old, making ASPD an incorrect diagnosis at this stage, although his current behaviors are consistent with **conduct disorder**, which is a precursor. - While there is an increased risk of incarceration for individuals with ASPD, stating it as a **definitive outcome** or that he "will likely be incarcerated" is deterministic and not universally true, as interventions can impact outcomes. *Strong D2 antagonists are first-line pharmacotherapy* - **First-line treatment for conduct disorder** typically involves **psychosocial interventions**, such as parent management training, cognitive behavioral therapy, and multisystemic therapy. - While **D2 antagonists** (antipsychotics) may be used in severe cases, particularly for **aggression and impulsivity** when other treatments fail or if there are comorbid conditions, they are not considered **first-line pharmacotherapy** for conduct disorder itself.

Question 108: A 37-year-old patient is being evaluated for involuntary movements, difficulty swallowing food, and personality change. He has entered a clinical trial that is studying the interaction of certain neuromediators in patients with similar (CAG) n trinucleotide repeat disorders. The laboratory results of 1 of the candidates for the clinical trial are presented below: Acetylcholine ↓ Dopamine ↑ Gamma-aminobutyric acid (GABA) ↓ Norepinephrine unchanged Serotonin unchanged Which trinucleotide disorder most likely represents the diagnosis of this patient?

A. Huntington's disease (Correct Answer)
B. Fragile X syndrome
C. Spinobulbar muscular atrophy
D. Friedreich's ataxia
E. Myotonic dystrophy

Explanation: ***Huntington's disease*** - The constellation of **involuntary movements** (**chorea**), **dysphagia**, and **personality changes** is classic for Huntington's disease, a **neurodegenerative disorder**. - The specific pattern of neurotransmitter changes—**decreased acetylcholine and GABA**, with **increased dopamine**—is characteristic of the basal ganglia dysfunction seen in Huntington's, caused by a **CAG trinucleotide repeat expansion** in the huntingtin gene. *Fragile X syndrome* - This is a common cause of **inherited intellectual disability**, typically presenting with **developmental delay**, **macro-orchidism**, and characteristic facial features. - It is caused by a **CGG trinucleotide repeat expansion** in the FMR1 gene, not a CAG repeat, and does not typically present with the described motor and psychological symptoms or the specific neurotransmitter profile. *Spinobulbar muscular atrophy* - Also known as **Kennedy's disease**, this is an **X-linked recessive disorder** characterized by **progressive muscle weakness** and **atrophy**, especially in bulbar and limb muscles. - It is caused by a **CAG trinucleotide repeat expansion** in the androgen receptor gene, but its clinical presentation primarily involves motor neuron dysfunction, not the prominent chorea and psychiatric features described. *Friedreich's ataxia* - This is an **autosomal recessive ataxia** characterized by progressive gait and limb **ataxia**, **dysarthria**, and often **scoliosis** and **cardiomyopathy**. - It is caused by a **GAA trinucleotide repeat expansion** in the FXN gene, mainly affecting cerebellar and spinal cord tracts, and its clinical features and neurotransmitter profile differ from the patient's presentation. *Myotonic dystrophy* - This is an **autosomal dominant disorder** characterized by **myotonia** (delayed muscle relaxation), **progressive muscle weakness** and wasting, cataracts, and cardiac conduction abnormalities. - It is caused by a **CTG trinucleotide repeat expansion** in the DMPK gene (Type 1) or a CCTG repeat (Type 2) and does not typically present with involuntary choreiform movements or the described specific neurotransmitter alterations.

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