Psychotic Disorders — MCQs

Q: A 45-year-old male presents to your office following a diagnosis of an autosomal dominant disease. He has started therapy and has a strong family support system. He endorses a decrease in appetite over the last two weeks that he attributes to sadness surrounding his diagnosis and a depressed mood but denies any suicidal ideation. He continues to enjoy working in the yard and playing with his children. On physical examination you notice involuntary quick jerky movements of his hands and feet. Which of the following would you expect to see in this patient?

Caudate and putamen atrophy. ***Caudate and putamen atrophy*** - The patient's presentation with **involuntary quick jerky movements (chorea)**, mood changes, and autosomal dominant inheritance is highly characteristic of **Huntington's disease**. - **Huntington's disease** is pathologically defined by significant **atrophy of the caudate nucleus and putamen**. *Depigmentation of the substantia nigra pars compacta* - This finding is characteristic of **Parkinson's disease**, which involves the degeneration of **dopaminergic neurons** in the substantia nigra. - Parkinson's disease typically presents with **bradykinesia, rigidity, tremor**, and postural instability, not choreiform movements. *Lesion in the vermis* - A lesion in the **cerebellar vermis** would typically cause **truncal ataxia** and other deficits related to balance and coordination. - It does not explain the choreiform movements or other symptoms seen in this patient. *Caudate overactivity* - While basal ganglia dysfunction is central to Huntington's, the issue is **neuronal degeneration and atrophy**, leading to disinhibition of movement rather than simple overactivity of the caudate. - The atrophy results in a loss of the **indirect pathway's inhibitory output**, contributing to chorea. *Atrophy of the subthalamic nucleus* - Atrophy of the **subthalamic nucleus** is more commonly associated with conditions like **hemiballismus**, which involves large-amplitude, flinging movements. - While it's part of the basal ganglia circuit, it's not the primary or characteristic finding in Huntington's disease, which is caudate and putamen atrophy.

Q: A 24-year-old woman presents to the emergency department when she was found yelling and screaming outside a bowling alley. The patient was found smoking marijuana and eating pizza while stating “if I'm going to die I'm going to die happy.” She was brought in by police and has been compliant since her arrival. Upon questioning, the patient states that she has had technology implanted in her for quite a while now, and she knows she will die soon. Any attempts to obtain further history are not helpful. The patient’s parents are contacted who provide additional history. They state that the patient recently started college 3 months ago. Two months ago, the patient began complaining about “technology” and seemed at times to converse with inanimate objects. On physical exam, you note a healthy young woman whose neurological exam is within normal limits. The patient is fixated on her original story and does not offer any information about her past medical history or current medications. Which of the following is the most likely diagnosis?

Schizophreniform disorder. ***Schizophreniform disorder*** - The patient exhibits **psychotic symptoms** (delusions about implanted technology, conversing with inanimate objects) for a duration of **more than one month but less than six months**, which is characteristic of schizophreniform disorder. - The recent onset in a young adult, often precipitated by a stressor like starting college, is consistent with this diagnosis. *Bipolar disorder* - While **psychotic features** can occur in the manic phase of bipolar disorder, the patient's presentation lacks the defining **euphoria, grandiosity, decreased need for sleep, or rapid cycling** typically seen in bipolar mania. - The **persistent paranoid delusions** about technology and the duration of symptoms are more indicative of a primary psychotic disorder. *Schizophrenia* - Schizophrenia requires the continuous presence of symptoms for at least **six months**, including at least one month of active-phase symptoms. - Since the patient's symptoms only started two months ago, she has not yet met the **duration criterion** for schizophrenia. *Brief psychotic disorder* - Brief psychotic disorder involves psychotic symptoms lasting for **at least one day but less than one month**, with eventual full return to premorbid functioning. - This patient's symptoms have persisted for **two months**, exceeding the time limit for brief psychotic disorder. *Major depression with psychotic features* - This diagnosis would require a primary **depressive episode** (e.g., persistent sadness, anhedonia, changes in sleep/appetite) occurring concurrently with or preceding the psychotic symptoms. - The patient's presentation is dominated by **psychotic symptoms** without clear evidence of a mood disorder preceding or accompanying them.

Q: A 64-year-old man is admitted with a history of altered mental status. He was in his usual state of health until a few days ago when he has started to become confused, lethargic, forgetful, and repeating the same questions. Over the last few days, he sometimes appears perfectly normal, and, at other times, he has difficulty recognizing his family members. Yesterday, he was screaming that the room was filled with snakes. Past medical history is significant for type 2 diabetes mellitus, managed medically, and chronic kidney disease, for which he undergoes regular hemodialysis on alternate days. There is no history of smoking, alcohol use, or illicit drug use. His vitals include: blood pressure 129/88 mm Hg, pulse 112/min, temperature 38.2°C (100.8°F), and respiratory rate 20/min. The patient is oriented only to person and place. His mini-mental state examination (MMSE) score is 18/30, where he had difficulty performing basic arithmetic calculations and recalled only 1 out of 3 objects. Nuchal rigidity is absent. Muscle strength is 5/5 bilaterally. Which of the following is the most likely diagnosis in this patient?

Delirium. ***Delirium*** - The patient's **acute onset** of fluctuating mental status, inattention, disorientation, and hallucinations, especially in the context of recent medical procedures (hemodialysis) and multiple comorbidities (CKD, diabetes), is highly characteristic of **delirium**. - His **fever** and elevated pulse suggest an underlying infection, a common precipitant of delirium in vulnerable patients. *Wernicke’s aphasia* - This condition primarily involves comprehension and production of **language deficits**, presenting as fluent but meaningless speech with poor comprehension. - It does not explain the **fluctuating global cognitive impairment**, hallucinations, or acute onset seen in this patient. *Schizophrenia* - Schizophrenia is a **chronic psychiatric disorder** typically presenting in early adulthood with persistent positive (hallucinations, delusions) and negative symptoms, which is not consistent with the acute, fluctuating presentation in an elderly man. - The patient's presentation with an **acute change in mental status** and clear underlying medical conditions points away from a primary psychiatric disorder. *Transient global amnesia* - This condition involves sudden, **temporary anterograde and retrograde amnesia**, where patients have difficulty forming new memories and recalling recent events, but without other significant cognitive impairments. - It resolves within 24 hours and does not include the **hallucinations**, disorientation, and **fluctuating level of consciousness** observed here. *Dementia* - Dementia is a **progressive, chronic decline** in multiple cognitive domains, developing gradually over months to years, which is inconsistent with the patient's acute and fluctuating presentation. - While patients with dementia can experience acute confusion, the rapid onset and **fluctuating nature of the symptoms** strongly suggest delirium rather than uncomplicated dementia.

Q: Two days after undergoing hemicolectomy for colon cancer, a 78-year-old man is found agitated and confused in his room. He says that a burglar broke in. The patient points at one corner of the room and says “There he is, doctor!” Closer inspection reveals that the patient is pointing to his bathrobe, which is hanging on the wall. The patient has type 2 diabetes mellitus and arterial hypertension. Current medications include insulin and hydrochlorothiazide. His temperature is 36.9°C (98.4°F), pulse is 89/min, respirations are 15/min, and blood pressure is 145/98 mm Hg. Physical examination shows a nontender, nonerythematous midline abdominal wound. On mental status examination, the patient is agitated and oriented only to person. Which of the following best describes this patient's perception?

Illusion. ***Illusion*** - An **illusion** is a **misinterpretation of an actual external stimulus**, as seen when the patient perceives his bathrobe as a burglar. - This symptom, combined with **agitation**, **confusion**, and **recent surgery**, is highly suggestive of **delirium**. *Hallucination* - A **hallucination** is a **perception in the absence of an external stimulus**, meaning the patient would see or hear something that is not there at all. - The patient here is clearly reacting to an existing object (the bathrobe), albeit misinterpreting it. *Loose association* - **Loose association** refers to a **thought disorder** where ideas shift from one subject to another in a way that is unrelated or minimally related, making the speech difficult to follow. - This describes a pattern of thought, not a perceptual disturbance involving an external object. *Delusion* - A **delusion** is a **fixed, false belief** that is not amenable to change in light of conflicting evidence and is not in keeping with the individual's cultural background. - While the patient believes a burglar is present, this belief arises from a direct misinterpretation of an object rather than a fixed, unfounded belief. *External attribution* - **External attribution** is a psychological concept where individuals ascribe responsibility for events or outcomes to **external factors** rather than internal ones. - This term describes a cognitive bias in explaining causality, not a perceptual disturbance.

A 40-year-old sexually active woman with type 2 diabetes mellitus is admitted to a hospital 2 weeks after an uncomplicated cholecystectomy for pain, itching, and erythema at the incision site. Labs show a hemoglobin A1c of 6.5%, and wound cultures reveal mixed enteric bacteria. She is treated with appropriate antibiotics and discharged after her symptoms resolve. One week later, she is re-admitted with identical signs and symptoms. While in the hospital, the patient eats very little but is social and enjoys spending time with the staff. She repeatedly checks her own temperature and alerts the nursing staff when it is elevated. One morning, you notice her placing the thermometer in hot tea before doing so. What is the most likely cause of this patient’s recurrent infection and/or poor wound healing?

A 45-year-old male presents to your office following a diagnosis of an autosomal dominant disease. He has started therapy and has a strong family support system. He endorses a decrease in appetite over the last two weeks that he attributes to sadness surrounding his diagnosis and a depressed mood but denies any suicidal ideation. He continues to enjoy working in the yard and playing with his children. On physical examination you notice involuntary quick jerky movements of his hands and feet. Which of the following would you expect to see in this patient?

A 5-year-old girl is brought to the physician by her parents because of difficulty at school. She does not listen to her teachers or complete assignments as requested. She does not play or interact with her peers. The girl also ignores her parents. Throughout the visit, she draws circles repeatedly and avoids eye contact. Physical and neurological examination shows no abnormalities. Which of the following is the most likely diagnosis?

A 68-year-old man, accompanied by his wife, presents to his physician with cognitive decline and hallucinations. The patient’s wife tells that his cognitive impairment progressed gradually over the past 6 years, and first began with problems counting and attention. The hallucinations began approximately a year ago. The patient describes them as realistic and non-frightening; most often, he sees his cat accompanying him everywhere he goes. The patient’s wife also notes frequent episodes of staring spells in her husband and prolonged daytime napping. The blood pressure is 130/80 mm Hg with the orthostatic change to 110/60 mm Hg, heart rate is 75/min, respiratory rate is 13/min, and the temperature is 36.6°C (97.8°F). The patient is alert and responsive, but he is disoriented to time and place. He is pale and hypomimic. The cardiac, lung, and abdominal examinations are within normal limits for the patient’s age. The neurological examination is significant for a bilateral symmetrical cogwheel rigidity in the upper extremities. What would you most likely see on additional radiological investigations?

A 24-year-old woman presents to the emergency department when she was found yelling and screaming outside a bowling alley. The patient was found smoking marijuana and eating pizza while stating “if I'm going to die I'm going to die happy.” She was brought in by police and has been compliant since her arrival. Upon questioning, the patient states that she has had technology implanted in her for quite a while now, and she knows she will die soon. Any attempts to obtain further history are not helpful. The patient’s parents are contacted who provide additional history. They state that the patient recently started college 3 months ago. Two months ago, the patient began complaining about “technology” and seemed at times to converse with inanimate objects. On physical exam, you note a healthy young woman whose neurological exam is within normal limits. The patient is fixated on her original story and does not offer any information about her past medical history or current medications. Which of the following is the most likely diagnosis?

A 10-year-old boy is brought to the physician by his parents because they are concerned about his “strange behavior”. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. The parents state that he has always been a solitary child without many friends, but that recently, he has been having behavioral problems that seem to be unprovoked and are occurring more frequently. The child will throw a tantrum for no reason and does not respond to punishment or reward. He also has a 'strange obsession' with collecting rocks that he finds on his way to and from school, so much so that his room is filled with rocks. His teachers say he “daydreams a lot” and is very good at art, being able to recreate his favorite cartoon characters in great detail. On assessment, the patient does not make eye contact with the physician but talks incessantly about his rock collection. The child’s grammar and vocabulary seem normal, but his speech is slightly labored. Which of the following is the most likely diagnosis?

A 64-year-old man is admitted with a history of altered mental status. He was in his usual state of health until a few days ago when he has started to become confused, lethargic, forgetful, and repeating the same questions. Over the last few days, he sometimes appears perfectly normal, and, at other times, he has difficulty recognizing his family members. Yesterday, he was screaming that the room was filled with snakes. Past medical history is significant for type 2 diabetes mellitus, managed medically, and chronic kidney disease, for which he undergoes regular hemodialysis on alternate days. There is no history of smoking, alcohol use, or illicit drug use. His vitals include: blood pressure 129/88 mm Hg, pulse 112/min, temperature 38.2°C (100.8°F), and respiratory rate 20/min. The patient is oriented only to person and place. His mini-mental state examination (MMSE) score is 18/30, where he had difficulty performing basic arithmetic calculations and recalled only 1 out of 3 objects. Nuchal rigidity is absent. Muscle strength is 5/5 bilaterally. Which of the following is the most likely diagnosis in this patient?

Two days after undergoing hemicolectomy for colon cancer, a 78-year-old man is found agitated and confused in his room. He says that a burglar broke in. The patient points at one corner of the room and says “There he is, doctor!” Closer inspection reveals that the patient is pointing to his bathrobe, which is hanging on the wall. The patient has type 2 diabetes mellitus and arterial hypertension. Current medications include insulin and hydrochlorothiazide. His temperature is 36.9°C (98.4°F), pulse is 89/min, respirations are 15/min, and blood pressure is 145/98 mm Hg. Physical examination shows a nontender, nonerythematous midline abdominal wound. On mental status examination, the patient is agitated and oriented only to person. Which of the following best describes this patient's perception?

A 57-year-old man is brought to the emergency department by the police after he was found running around a local park naked and screaming late at night. During intake, the patient talks non-stop about the government spying on him and his family, but provides little useful information besides his name and date of birth. Occasionally he refers to himself in the third person. He refuses to eat anything and will only drink clear fluids because he is afraid of being poisoned. A medical records search reveals that the patient has been treated for psychotic behavior and occasional bouts of severe depression for several years. Today, his heart rate is 90/min, respiratory rate is 19/min, blood pressure is 135/85 mm Hg, and temperature is 37.0°C (98.6°F). On physical exam, he appears gaunt and anxious. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. CMP, CBC, and TSH are normal. A urine toxicology test is negative. What is the most likely diagnosis?

Q10

A 4-year-old boy is brought to the physician by his parents because of concerns about his behavior during the past year. His parents report that he often fails to answer when they call him and has regular unprovoked episodes of crying and screaming. At kindergarten, he can follow and participate in group activities, but does not follow his teacher's instructions when these are given to him directly. He is otherwise cheerful and maintains eye contact when spoken to but does not respond when engaged in play. He gets along well with friends and family. He started walking at the age of 11 months and can speak in two-to-three-word phrases. He often mispronounces words. Which of the following is the most likely diagnosis?

Psychotic Disorders US Medical PG Practice Questions and MCQs

Question 1: A 40-year-old sexually active woman with type 2 diabetes mellitus is admitted to a hospital 2 weeks after an uncomplicated cholecystectomy for pain, itching, and erythema at the incision site. Labs show a hemoglobin A1c of 6.5%, and wound cultures reveal mixed enteric bacteria. She is treated with appropriate antibiotics and discharged after her symptoms resolve. One week later, she is re-admitted with identical signs and symptoms. While in the hospital, the patient eats very little but is social and enjoys spending time with the staff. She repeatedly checks her own temperature and alerts the nursing staff when it is elevated. One morning, you notice her placing the thermometer in hot tea before doing so. What is the most likely cause of this patient’s recurrent infection and/or poor wound healing?

A. Colonization with methicillin-resistant Staphylococcus aureus (MRSA)
B. Self-inflicted wound contamination with fecal matter (Correct Answer)
C. Poor wound healing due to uncontrolled diabetes mellitus
D. Poor wound healing due to vitamin C deficiency
E. Recurrent infections due to an immune deficiency syndrome

Explanation: ***Self-inflicted wound contamination with fecal matter*** - The patient's behaviors, such as **feigning fever** by putting a thermometer in hot tea and enjoying attention from staff, are highly suggestive of **factitious disorder**, potentially leading to self-inflicted wound contamination. - The isolation of **mixed enteric bacteria** from the wound culture strongly supports the idea of fecal contamination, as these bacteria are typically found in the gastrointestinal tract. *Colonization with methicillin-resistant Staphylococcus aureus (MRSA)* - While MRSA can cause recurrent wound infections, the wound cultures revealed **mixed enteric bacteria**, not *Staphylococcus aureus*. - There is no mention of prior MRSA history or exposure, making this less likely than self-contamination given the behavioral cues. *Poor wound healing due to uncontrolled diabetes mellitus* - An **HbA1c of 6.5%** indicates well-controlled diabetes in this patient, which is unlikely to significantly impair wound healing to the extent of causing recurrent infections without other factors. - While diabetes can impair wound healing, the specific behavioral findings and the type of bacteria isolated point away from this being the primary cause of recurrent infections. *Poor wound healing due to vitamin C deficiency* - **Vitamin C deficiency (scurvy)** can cause impaired wound healing, but it is typically associated with widespread symptoms like **gingival bleeding**, **petechiae**, and constitutional symptoms, none of which are described. - This deficiency would not explain the presence of mixed enteric bacteria in the wound or the patient's suspicious behaviors. *Recurrent infections due to an immune deficiency syndrome* - The patient's history does not suggest any underlying immune deficiency, and recurrent infections due to such syndromes would typically manifest in various body sites, not just a surgical wound. - The specific context of the "recurrent infection" being localized to a surgical site with enteric flora, combined with clear behavioral indicators, makes an immune deficiency syndrome less probable.

Question 2: A 45-year-old male presents to your office following a diagnosis of an autosomal dominant disease. He has started therapy and has a strong family support system. He endorses a decrease in appetite over the last two weeks that he attributes to sadness surrounding his diagnosis and a depressed mood but denies any suicidal ideation. He continues to enjoy working in the yard and playing with his children. On physical examination you notice involuntary quick jerky movements of his hands and feet. Which of the following would you expect to see in this patient?

A. Depigmentation of the substantia nigra pars compacta
B. Lesion in the vermis
C. Caudate overactivity
D. Caudate and putamen atrophy (Correct Answer)
E. Atrophy of the subthalamic nucleus

Explanation: ***Caudate and putamen atrophy*** - The patient's presentation with **involuntary quick jerky movements (chorea)**, mood changes, and autosomal dominant inheritance is highly characteristic of **Huntington's disease**. - **Huntington's disease** is pathologically defined by significant **atrophy of the caudate nucleus and putamen**. *Depigmentation of the substantia nigra pars compacta* - This finding is characteristic of **Parkinson's disease**, which involves the degeneration of **dopaminergic neurons** in the substantia nigra. - Parkinson's disease typically presents with **bradykinesia, rigidity, tremor**, and postural instability, not choreiform movements. *Lesion in the vermis* - A lesion in the **cerebellar vermis** would typically cause **truncal ataxia** and other deficits related to balance and coordination. - It does not explain the choreiform movements or other symptoms seen in this patient. *Caudate overactivity* - While basal ganglia dysfunction is central to Huntington's, the issue is **neuronal degeneration and atrophy**, leading to disinhibition of movement rather than simple overactivity of the caudate. - The atrophy results in a loss of the **indirect pathway's inhibitory output**, contributing to chorea. *Atrophy of the subthalamic nucleus* - Atrophy of the **subthalamic nucleus** is more commonly associated with conditions like **hemiballismus**, which involves large-amplitude, flinging movements. - While it's part of the basal ganglia circuit, it's not the primary or characteristic finding in Huntington's disease, which is caudate and putamen atrophy.

Question 3: A 5-year-old girl is brought to the physician by her parents because of difficulty at school. She does not listen to her teachers or complete assignments as requested. She does not play or interact with her peers. The girl also ignores her parents. Throughout the visit, she draws circles repeatedly and avoids eye contact. Physical and neurological examination shows no abnormalities. Which of the following is the most likely diagnosis?

A. Rett syndrome
B. Attention-deficit/hyperactivity disorder
C. Autism spectrum disorder (Correct Answer)
D. Oppositional defiant disorder
E. Childhood disintegrative disorder

Explanation: ***Autism spectrum disorder*** - The child's **social communication deficits**, including ignoring teachers and parents and avoiding eye contact, along with **restricted repetitive behaviors** (drawing circles repeatedly), are classic features aligning with the diagnostic criteria for **autism spectrum disorder (ASD)**. - ASD is characterized by persistent deficits in social communication and social interaction across multiple contexts, and restricted, repetitive patterns of behavior, interests, or activities. *Rett syndrome* - This is a neurodevelopmental disorder almost exclusively affecting **girls**, characterized by normal early development followed by a period of regression, microcephaly, and **stereotypic hand wringing**. - While it shares some features like social withdrawal, the **absence of typical hand stereotypies** and the child being 5 years old (regression usually occurs between 6-18 months) makes it less likely. *Attention-deficit/hyperactivity disorder* - Characterized by persistent patterns of **inattention** and/or **hyperactivity-impulsivity** that interfere with functioning or development. - While the child has difficulty listening at school, the **pronounced social deficits** and **repetitive behaviors** are not primary features of ADHD. *Oppositional defiant disorder* - Involves a pattern of **angry/irritable mood, argumentative/defiant behavior**, or vindictiveness lasting at least 6 months. - This diagnosis primarily focuses on **defiance toward authority figures** and does not typically include the social interaction difficulties or repetitive behaviors described. *Childhood disintegrative disorder* - This is a rare disorder characterized by a significant **regression in multiple areas of functioning** after at least 2 years of normal development. - The onset is typically later than in this case (often between 3 and 4 years of age), and it involves a more **global loss of acquired skills**, which is not clearly indicated here beyond social difficulties.

Question 4: A 68-year-old man, accompanied by his wife, presents to his physician with cognitive decline and hallucinations. The patient’s wife tells that his cognitive impairment progressed gradually over the past 6 years, and first began with problems counting and attention. The hallucinations began approximately a year ago. The patient describes them as realistic and non-frightening; most often, he sees his cat accompanying him everywhere he goes. The patient’s wife also notes frequent episodes of staring spells in her husband and prolonged daytime napping. The blood pressure is 130/80 mm Hg with the orthostatic change to 110/60 mm Hg, heart rate is 75/min, respiratory rate is 13/min, and the temperature is 36.6°C (97.8°F). The patient is alert and responsive, but he is disoriented to time and place. He is pale and hypomimic. The cardiac, lung, and abdominal examinations are within normal limits for the patient’s age. The neurological examination is significant for a bilateral symmetrical cogwheel rigidity in the upper extremities. What would you most likely see on additional radiological investigations?

A. Multiple lacunar infarcts on MRI
B. Marked hippocampal atrophy on MRI
C. Hypoperfusion and hypometabolism in frontal lobes on SPECT
D. Decreased perfusion and dopaminergic activity in occipital lobes on PET (Correct Answer)
E. Pontine 'hot-cross bun' sign on MRI

Explanation: ***Decreased perfusion and dopaminergic activity in occipital lobes on PET*** - This finding is characteristic of **dementia with Lewy bodies (DLB)**, which is strongly suggested by the patient's presentation with **cognitive fluctuations**, **visual hallucinations** (non-frightening, realistic), **parkinsonism** (cogwheel rigidity), and **REM sleep behavior disorder** (daytime napping/staring spells could be a manifestation). PET scans in DLB often show reduced occipital lobe uptake. - The combination of **parkinsonism** (cogwheel rigidity) and **visual hallucinations** preceding or appearing early in the course of cognitive decline is a hallmark of DLB, which differentiates it from other dementias. *Multiple lacunar infarcts on MRI* - While lacunar infarcts can cause cognitive decline (**vascular dementia**), the clinical picture of prominent, well-formed visual hallucinations, parkinsonism, and cognitive fluctuations is less typical for purely vascular dementia. - Vascular dementia usually presents with a step-wise decline in cognition and focal neurological deficits, which are not the primary features here. *Marked hippocampal atrophy on MRI* - **Hippocampal atrophy** is a hallmark of **Alzheimer's disease**, which typically presents with insidious memory loss as the primary symptom. - The prominent early visual hallucinations and parkinsonism are not typical initial features of Alzheimer's disease. *Hypoperfusion and hypometabolism in frontal lobes on SPECT* - **Frontal lobe hypoperfusion/hypometabolism** on SPECT/PET is characteristic of **frontotemporal dementia (FTD)**. - FTD typically presents with early behavioral changes or language deficits, not prominent visual hallucinations, parkinsonism, or significant cognitive fluctuations in the way seen in this patient. *Pontine 'hot-cross bun' sign on MRI* - The **'hot-cross bun' sign** on MRI is pathognomonic for **multiple system atrophy (MSA)**, specifically the **MSA-C subtype (cerebellar)**. - While MSA can cause parkinsonism and autonomic dysfunction, it typically does not feature prominent visual hallucinations or significant cognitive decline as early and striking features as seen in this patient.

Question 5: A 24-year-old woman presents to the emergency department when she was found yelling and screaming outside a bowling alley. The patient was found smoking marijuana and eating pizza while stating “if I'm going to die I'm going to die happy.” She was brought in by police and has been compliant since her arrival. Upon questioning, the patient states that she has had technology implanted in her for quite a while now, and she knows she will die soon. Any attempts to obtain further history are not helpful. The patient’s parents are contacted who provide additional history. They state that the patient recently started college 3 months ago. Two months ago, the patient began complaining about “technology” and seemed at times to converse with inanimate objects. On physical exam, you note a healthy young woman whose neurological exam is within normal limits. The patient is fixated on her original story and does not offer any information about her past medical history or current medications. Which of the following is the most likely diagnosis?

A. Bipolar disorder
B. Schizophrenia
C. Schizophreniform disorder (Correct Answer)
D. Brief psychotic disorder
E. Major depression with psychotic features

Explanation: ***Schizophreniform disorder*** - The patient exhibits **psychotic symptoms** (delusions about implanted technology, conversing with inanimate objects) for a duration of **more than one month but less than six months**, which is characteristic of schizophreniform disorder. - The recent onset in a young adult, often precipitated by a stressor like starting college, is consistent with this diagnosis. *Bipolar disorder* - While **psychotic features** can occur in the manic phase of bipolar disorder, the patient's presentation lacks the defining **euphoria, grandiosity, decreased need for sleep, or rapid cycling** typically seen in bipolar mania. - The **persistent paranoid delusions** about technology and the duration of symptoms are more indicative of a primary psychotic disorder. *Schizophrenia* - Schizophrenia requires the continuous presence of symptoms for at least **six months**, including at least one month of active-phase symptoms. - Since the patient's symptoms only started two months ago, she has not yet met the **duration criterion** for schizophrenia. *Brief psychotic disorder* - Brief psychotic disorder involves psychotic symptoms lasting for **at least one day but less than one month**, with eventual full return to premorbid functioning. - This patient's symptoms have persisted for **two months**, exceeding the time limit for brief psychotic disorder. *Major depression with psychotic features* - This diagnosis would require a primary **depressive episode** (e.g., persistent sadness, anhedonia, changes in sleep/appetite) occurring concurrently with or preceding the psychotic symptoms. - The patient's presentation is dominated by **psychotic symptoms** without clear evidence of a mood disorder preceding or accompanying them.

Question 6: A 10-year-old boy is brought to the physician by his parents because they are concerned about his “strange behavior”. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. The parents state that he has always been a solitary child without many friends, but that recently, he has been having behavioral problems that seem to be unprovoked and are occurring more frequently. The child will throw a tantrum for no reason and does not respond to punishment or reward. He also has a 'strange obsession' with collecting rocks that he finds on his way to and from school, so much so that his room is filled with rocks. His teachers say he “daydreams a lot” and is very good at art, being able to recreate his favorite cartoon characters in great detail. On assessment, the patient does not make eye contact with the physician but talks incessantly about his rock collection. The child’s grammar and vocabulary seem normal, but his speech is slightly labored. Which of the following is the most likely diagnosis?

A. Autism spectrum disorder, level 1 (Correct Answer)
B. Pick’s disease
C. Autism spectrum disorder, level 3
D. Tourette’s syndrome
E. Obsessive compulsive disorder

Explanation: ***Autism spectrum disorder, level 1*** - The child's **social communication deficits**, including difficulty making friends, lack of eye contact, and talking incessantly about a specific interest despite others' disinterest, are characteristic of autism spectrum disorder. - His **restricted, repetitive behaviors**, such as the intense rock collection, unprovoked tantrums, and difficulty with punishment/reward, along with his high artistic skill and normal grammar, align with **Level 1 ASD** (requiring support). *Pick’s disease* - This is a neurodegenerative disorder primarily affecting the **frontal and temporal lobes**, typically presenting in **middle to late adulthood**, with prominent behavioral and language changes. - It is extremely rare in children and would not account for the developmental history of social difficulties and restricted interests present since childhood. *Autism spectrum disorder, level 3* - **Level 3 ASD** involves **very substantial support** due to severe deficits in verbal and nonverbal social communication skills and highly inflexible, restrictive, repetitive behaviors. - This child's normal grammar and vocabulary, high artistic skill, and ability to meet developmental milestones prior to recent behavioral escalations suggest that his needs for support are not as substantial as described in Level 3. *Tourette’s syndrome* - Characterized by the presence of **multiple motor tics** and at least **one vocal tic** (e.g., grunting, barking), often fluctuating in severity. - The symptoms described, such as social communication challenges, restricted interests, and unprovoked tantrums, do not include tics and are not consistent with Tourette's syndrome. *Obsessive compulsive disorder* - OCD involves **unwanted, intrusive thoughts (obsessions)** and/or **repetitive behaviors (compulsions)** performed in response to obsessions or according to rigid rules. - While collecting rocks might seem compulsive, the broader pattern of social communication deficits, lack of eye contact, difficulties with reciprocity, and general rigidity points more strongly to autism spectrum disorder.

Question 7: A 64-year-old man is admitted with a history of altered mental status. He was in his usual state of health until a few days ago when he has started to become confused, lethargic, forgetful, and repeating the same questions. Over the last few days, he sometimes appears perfectly normal, and, at other times, he has difficulty recognizing his family members. Yesterday, he was screaming that the room was filled with snakes. Past medical history is significant for type 2 diabetes mellitus, managed medically, and chronic kidney disease, for which he undergoes regular hemodialysis on alternate days. There is no history of smoking, alcohol use, or illicit drug use. His vitals include: blood pressure 129/88 mm Hg, pulse 112/min, temperature 38.2°C (100.8°F), and respiratory rate 20/min. The patient is oriented only to person and place. His mini-mental state examination (MMSE) score is 18/30, where he had difficulty performing basic arithmetic calculations and recalled only 1 out of 3 objects. Nuchal rigidity is absent. Muscle strength is 5/5 bilaterally. Which of the following is the most likely diagnosis in this patient?

A. Delirium (Correct Answer)
B. Wernicke’s aphasia
C. Schizophrenia
D. Transient global amnesia
E. Dementia

Explanation: ***Delirium*** - The patient's **acute onset** of fluctuating mental status, inattention, disorientation, and hallucinations, especially in the context of recent medical procedures (hemodialysis) and multiple comorbidities (CKD, diabetes), is highly characteristic of **delirium**. - His **fever** and elevated pulse suggest an underlying infection, a common precipitant of delirium in vulnerable patients. *Wernicke’s aphasia* - This condition primarily involves comprehension and production of **language deficits**, presenting as fluent but meaningless speech with poor comprehension. - It does not explain the **fluctuating global cognitive impairment**, hallucinations, or acute onset seen in this patient. *Schizophrenia* - Schizophrenia is a **chronic psychiatric disorder** typically presenting in early adulthood with persistent positive (hallucinations, delusions) and negative symptoms, which is not consistent with the acute, fluctuating presentation in an elderly man. - The patient's presentation with an **acute change in mental status** and clear underlying medical conditions points away from a primary psychiatric disorder. *Transient global amnesia* - This condition involves sudden, **temporary anterograde and retrograde amnesia**, where patients have difficulty forming new memories and recalling recent events, but without other significant cognitive impairments. - It resolves within 24 hours and does not include the **hallucinations**, disorientation, and **fluctuating level of consciousness** observed here. *Dementia* - Dementia is a **progressive, chronic decline** in multiple cognitive domains, developing gradually over months to years, which is inconsistent with the patient's acute and fluctuating presentation. - While patients with dementia can experience acute confusion, the rapid onset and **fluctuating nature of the symptoms** strongly suggest delirium rather than uncomplicated dementia.

Question 8: Two days after undergoing hemicolectomy for colon cancer, a 78-year-old man is found agitated and confused in his room. He says that a burglar broke in. The patient points at one corner of the room and says “There he is, doctor!” Closer inspection reveals that the patient is pointing to his bathrobe, which is hanging on the wall. The patient has type 2 diabetes mellitus and arterial hypertension. Current medications include insulin and hydrochlorothiazide. His temperature is 36.9°C (98.4°F), pulse is 89/min, respirations are 15/min, and blood pressure is 145/98 mm Hg. Physical examination shows a nontender, nonerythematous midline abdominal wound. On mental status examination, the patient is agitated and oriented only to person. Which of the following best describes this patient's perception?

A. Hallucination
B. Illusion (Correct Answer)
C. Loose association
D. Delusion
E. External attribution

Explanation: ***Illusion*** - An **illusion** is a **misinterpretation of an actual external stimulus**, as seen when the patient perceives his bathrobe as a burglar. - This symptom, combined with **agitation**, **confusion**, and **recent surgery**, is highly suggestive of **delirium**. *Hallucination* - A **hallucination** is a **perception in the absence of an external stimulus**, meaning the patient would see or hear something that is not there at all. - The patient here is clearly reacting to an existing object (the bathrobe), albeit misinterpreting it. *Loose association* - **Loose association** refers to a **thought disorder** where ideas shift from one subject to another in a way that is unrelated or minimally related, making the speech difficult to follow. - This describes a pattern of thought, not a perceptual disturbance involving an external object. *Delusion* - A **delusion** is a **fixed, false belief** that is not amenable to change in light of conflicting evidence and is not in keeping with the individual's cultural background. - While the patient believes a burglar is present, this belief arises from a direct misinterpretation of an object rather than a fixed, unfounded belief. *External attribution* - **External attribution** is a psychological concept where individuals ascribe responsibility for events or outcomes to **external factors** rather than internal ones. - This term describes a cognitive bias in explaining causality, not a perceptual disturbance.

Question 9: A 57-year-old man is brought to the emergency department by the police after he was found running around a local park naked and screaming late at night. During intake, the patient talks non-stop about the government spying on him and his family, but provides little useful information besides his name and date of birth. Occasionally he refers to himself in the third person. He refuses to eat anything and will only drink clear fluids because he is afraid of being poisoned. A medical records search reveals that the patient has been treated for psychotic behavior and occasional bouts of severe depression for several years. Today, his heart rate is 90/min, respiratory rate is 19/min, blood pressure is 135/85 mm Hg, and temperature is 37.0°C (98.6°F). On physical exam, he appears gaunt and anxious. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. CMP, CBC, and TSH are normal. A urine toxicology test is negative. What is the most likely diagnosis?

A. Schizophrenia
B. Major depressive disorder
C. Schizoaffective disorder (Correct Answer)
D. Brief psychotic disorder
E. Bipolar 1 disorder

Explanation: ***Schizoaffective disorder*** - The patient exhibits features of both a **mood disorder** (severe depression) and a **psychotic disorder** (delusions, disorganized behavior, referring to himself in the third person), which are key characteristics of schizoaffective disorder. - The history of **psychotic behavior** and **severe depression** over several years, with current presentation involving both prominent mood symptoms (agitation, gaunt appearance suggesting poor self-care due to mood) and psychotic features (paranoia, disorganized speech), supports this diagnosis over other psychotic or mood disorders. *Schizophrenia* - While the patient exhibits **psychotic symptoms** (delusions, disorganization), the history of "occasional bouts of severe depression" suggests a more prominent and recurring mood component than typically seen in schizophrenia. - In schizophrenia, mood symptoms are often confined to brief periods relative to the duration of the psychotic illness or are not a prominent and defining feature. *Major depressive disorder* - This diagnosis is incorrect because the patient displays clear and pervasive **psychotic symptoms** such as paranoia, disorganized speech, and bizarre behavior (running naked, screaming), which are beyond what is typically seen in major depressive disorder with psychotic features (where psychosis is congruent with the depressive theme). - The historical pattern of **psychotic behavior** occurring separately from or alongside depressive episodes points away from a primary diagnosis of major depressive disorder. *Brief psychotic disorder* - This diagnosis is characterized by psychotic symptoms lasting **less than one month**, with an eventual full return to premorbid functioning. - The patient's history of **several years** of psychotic behavior and severe depression rules out this acute and time-limited condition. *Bipolar 1 disorder* - While bipolar 1 disorder can feature **psychotic symptoms** during manic or depressive episodes, the presentation here emphasizes persistent psychotic features (delusions of being spied on, fear of poisoning) that are not always directly tied to mood episodes or are more enduring than typical for bipolar disorder. - The long-standing history of both **psychotic and depressive episodes** suggests a more integrated condition of mood and psychosis rather than distinct episodes as seen in bipolar 1 disorder.

Question 10: A 4-year-old boy is brought to the physician by his parents because of concerns about his behavior during the past year. His parents report that he often fails to answer when they call him and has regular unprovoked episodes of crying and screaming. At kindergarten, he can follow and participate in group activities, but does not follow his teacher's instructions when these are given to him directly. He is otherwise cheerful and maintains eye contact when spoken to but does not respond when engaged in play. He gets along well with friends and family. He started walking at the age of 11 months and can speak in two-to-three-word phrases. He often mispronounces words. Which of the following is the most likely diagnosis?

A. Selective mutism
B. Hearing impairment (Correct Answer)
C. Conduct disorder
D. Specific-learning disorder
E. Autistic spectrum disorder

Explanation: ***Hearing impairment*** - The child's inconsistent response to being called, failure to follow direct instructions, and unprovoked crying and screaming, despite maintaining eye contact and having normal social interactions, are all suggestive of a **hearing impairment**. - His delayed and unusual speech patterns (two-to-three-word phrases, mispronouncing words) for his age further points to **auditory processing difficulties** due to hearing loss. *Selective mutism* - This condition involves a consistent failure to speak in specific social situations where speaking is expected, despite speaking in other situations. The child's issue is with comprehending and responding to speech, not with speaking itself. - The behavior observed (not responding to calls or direct instructions) is more indicative of an inability to hear rather than a choice not to speak. *Conduct disorder* - Conduct disorder is characterized by a persistent pattern of behavior that violates the rights of others and major societal norms appropriate for the individual's age. - The child's symptoms do not include aggression, destruction of property, deceitfulness, or serious rule violations and he gets along well with friends and family. *Specific-learning disorder* - A specific learning disorder involves difficulties with academic skills, despite normal intelligence. While he has speech difficulties, he can participate in group activities, and there is no information about his academic performance. - The primary concern here is his inability to respond to auditory input, which precedes and likely causes any potential learning difficulties rather than being a learning disorder itself. *Autistic spectrum disorder* - Autism spectrum disorder is characterized by persistent deficits in social communication and social interaction across multiple contexts, and restricted, repetitive patterns of behavior, interests, or activities. - This child maintains eye contact, is cheerful, gets along well with friends and family, and can participate in group activities, which argues against significant **social communication deficits** typical of autism.

Question 11: A 48-year-old man is brought to the emergency department after he was found in a stuporous state with a small cut on his forehead on a cold night in front of his apartment. Non-contrast head CT is normal, and he is monitored in the emergency department. Twelve hours later, he yells for help because he hears the wallpaper threatening his family. He also has a headache. The patient started drinking regularly 10 years ago and consumed a pint of vodka prior to admission. He occasionally smokes marijuana and uses cocaine. His vital signs are within normal limits. On mental status examination, the patient is alert and oriented. He appears markedly distressed and is diaphoretic. A fine digital tremor on his right hand is noted. The remainder of the neurological exam shows no abnormalities. Urine toxicologic screening is pending. Which of the following is the most likely diagnosis?

A. Delirium tremens
B. Alcoholic hallucinosis (Correct Answer)
C. Cocaine intoxication
D. Brief psychotic disorder
E. Phencyclidine intoxication

Explanation: ***Alcoholic hallucinosis*** - The patient's history of **heavy alcohol use**, followed by the development of **hallucinations** (hearing wallpaper threatening his family) within 12-48 hours of reduced or cessation of alcohol intake, is classic for alcoholic hallucinosis. - Unlike delirium tremens, **alcoholic hallucinosis** primarily involves prominent **auditory and visual hallucinations** without significant disorientation or vital sign instability. *Delirium tremens* - Delirium tremens typically presents later, usually **48-96 hours after alcohol cessation**, and is characterized by a more severe clinical picture including **global disorientation**, marked autonomic instability (fever, tachycardia, hypertension), and severe agitation. - While the patient is agitated and diaphoretic, the absence of significant disorientation, fever, or tachycardia makes delirium tremens less likely at this early stage. *Cocaine intoxication* - Cocaine intoxication would typically present with symptoms such as **tachycardia**, **hypertension**, **pupillary dilation**, **psychomotor agitation**, and potentially paranoia or hallucinations, but these would occur **acutely after cocaine use**, rather than 12 hours after being found in a stuporous state. - The patient's vital signs are noted to be normal, which argues against acute cocaine intoxication as the primary cause of his current symptoms. *Brief psychotic disorder* - Brief psychotic disorder is characterized by the sudden onset of psychotic symptoms (delusions, hallucinations, disorganized speech or behavior) lasting more than one day but less than one month, followed by full return to premorbid functioning. - While the patient exhibits hallucinations, the strong temporal link to **alcohol use and withdrawal** makes a substance-induced psychotic disorder, such as alcoholic hallucinosis, a more specific and likely diagnosis. *Phencyclidine intoxication* - PCP intoxication is associated with symptoms such as **nystagmus**, **ataxia**, **hypertension**, **tachycardia**, **violence**, and *dissociative symptoms*, along with hallucinations and delusions. - The patient does not exhibit the characteristic nystagmus, ataxia, or typical behavioral aggression associated with PCP intoxication.

Question 12: A 21-year-old nurse starts to feel ill during his evening shift. Earlier this evening, he started his shift in his normal state of health. Past medical history is significant for multiple admissions to the hospital under strange circumstances. One time he presented to the emergency department complaining of severe abdominal pain and gallstones, though no stones were identified and he was discharged after a full workup. Another time he was admitted for recurrent vomiting episodes and he was discharged after an EGD and several rounds of antiemetics. He has also visited an outpatient clinic for back pain and knee pain, though no findings were ever identified. He takes a multivitamin every day. His mother developed breast cancer at 47 and his father is healthy. Today, his blood pressure is 120/80 mm Hg, heart rate is 105/min, respiratory rate is 17/min, and temperature is 36.9°C (98.4°F). On physical exam, he appears thin and anxious. He is diaphoretic with clammy hands. His heart is tachycardic with an irregular rhythm and his lungs are clear to auscultation bilaterally. A urine toxicology test and EKG are negative. Random blood sugar is 45 mg/dL. The nurse is admitted and treated appropriately. After a thorough review of his medical records, the hospitalist assigned to this patient consults with psychiatry because she is concerned the patient may have factitious disorder. Which of the following would confirm a diagnosis of the factitious disorder in this patient?

A. Elevated troponin I and CK-MB levels
B. Presence of norepinephrine and vanillylmandelic acid in the urine
C. Increased c-peptide levels
D. Low c-peptide levels (Correct Answer)
E. Increased anion gap

Explanation: ***Low c-peptide levels*** - The patient presents with **hypoglycemia** (blood sugar 45 mg/dL) and symptoms like anxiety, diaphoresis, and tachycardia that suggest an acute insulin-induced event. - **Low C-peptide levels** in the presence of hypoglycemia indicate that the insulin is exogenous (injected) rather than naturally produced by the body, as C-peptide is co-secreted with endogenous insulin. This manipulation for secondary gain is characteristic of **factitious disorder**. *Elevated troponin I and CK-MB levels* - These markers are indicative of **myocardial injury** or **ischemia**, which is not directly suggested by the patient's presentation or typical for factitious disorder unless used as an elaborate means to feign a heart attack. - While the patient has tachycardia and an irregular rhythm, a negative EKG makes acute cardiac injury less likely as the primary concern for diagnosing factitious disorder in this scenario. *Presence of norepinephrine and vanillylmandelic acid in the urine* - Elevated levels of these catecholamine metabolites would suggest a **pheochromocytoma**, a tumor of the adrenal medulla causing excessive catecholamine release. - The patient's symptoms (tachycardia, anxiety, diaphoresis) could overlap with pheochromocytoma, but the primary acute finding of **hypoglycemia** is not characteristic of this condition. *Increased c-peptide levels* - **High C-peptide levels** in the presence of hypoglycemia would indicate **endogenous hyperinsulinism**, such as from an insulinoma or sulfonylurea overdose. - While this suggests an internal cause of excess insulin production, it would contradict the hypothesis of injected insulin for factitious disorder, making it an unlikely finding in this context. *Increased anion gap* - An **increased anion gap** is typically seen in metabolic acidosis, caused by conditions like lactic acidosis, diabetic ketoacidosis, or toxic ingestions (e.g., methanol, ethylene glycol). - Although the patient is acutely ill, an increased anion gap is not directly implicated in the diagnosis of factitious disorder related to insulin administration.

Question 13: A 21-year-old woman is brought to the clinic for evaluation by her brother. The patient’s brother says that, 3 days ago, the patient had put on her best pantsuit and makeup and insisted that she was returning to work and driving to Seattle to take over for the CEO of the Amazon Corporation. He says this was especially odd because her husband was just killed in an automobile accident in a different city 2 days ago. Today, the patient’s brother says she was saddened, wearing grey jogging pants. The patient says she does not recall acting odd and does remember that her husband is dead. Her vital signs include: blood pressure 132/84 mm Hg, pulse 92/min, respiratory rate 16/min, temperature 37.4°C (99.4°F). Upon physical examination, the patient’s affect is saddened but her speech rate and volume are normal. There is no hallucinations, mania, interruptive speech, depressive symptoms, or loss of interest in activities once enjoyed. Results of urine drug screen are provided below: Amphetamine negative Benzodiazepine negative Cocaine negative GHB negative Ketamine negative LSD negative Marijuana negative Opioids negative PCP negative Which of the following best describes the patient’s state?

A. Schizoaffective disorder
B. Brief psychotic disorder (Correct Answer)
C. Schizoid personality disorder
D. Schizotypal personality disorder
E. Borderline personality disorder

Explanation: ***Brief psychotic disorder*** - The patient experienced a sudden, short-lived period of **psychotic symptoms** (delusions about taking over Amazon CEO) immediately following a significant stressor (husband's death). - Her current state shows resolution of these symptoms and lack of criteria for other mood or psychotic disorders, consistent with the definition of **brief psychotic disorder** (symptoms lasting less than 1 month). *Schizoaffective disorder* - This disorder involves a continuous period where an individual experiences both a **major mood episode (depressive or manic)** and **psychotic symptoms** (e.g., delusions, hallucinations) simultaneously. - The patient's psychotic episode was brief and resolved, and she does not currently exhibit criteria for a major mood episode or ongoing psychotic symptoms. *Schizoid personality disorder* - Characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of expression of emotions in interpersonal settings. - This patient's acute, short-lived psychotic symptoms, followed by recovery, do not align with the chronic, pervasive nature of a personality disorder. *Schizotypal personality disorder* - Involves a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as **cognitive or perceptual distortions** and eccentricities of behavior. - The patient's presentation was an acute, time-limited psychotic episode, not a persistent pattern of odd thoughts, behaviors, and social deficits characteristic of schizotypal personality disorder. *Borderline personality disorder* - Defined by a pervasive pattern of **instability of interpersonal relationships, self-image, and affects**, and marked impulsivity. - While individuals with borderline personality disorder can experience transient, stress-related psychotic-like symptoms, the primary features of severe mood dysregulation, unstable relationships, and identity disturbance are not described.

Question 14: A mother brings her 4-year-old son to his pediatrician. Over the last eight months, her son has been exhibiting several "odd" behaviors. Most importantly, he repeatedly says that he is playing games with a friend named "Steven," though she is certain that he does not exist. She has often found him acting out magical scenarios as though someone else is present, when no one is there. What is the most likely diagnosis in this patient?

A. Schizophreniform disorder
B. Schizophrenia
C. Developmental delay
D. Schizoid personality disorder
E. Normal development (Correct Answer)

Explanation: ***Normal development*** - It is **normal for children** between the ages of 3-7 to have **imaginary friends** or engage in imaginary play, which supports **creativity** and **social development**. - There is no indication of distress, functional impairment, or other diagnostic criteria for a mental disorder, making this a typical developmental phenomenon. *Schizophreniform disorder* - This disorder is characterized by symptoms of schizophrenia lasting **between 1 and 6 months**; the child's age makes a diagnosis of schizophrenia or schizophreniform disorder highly unlikely. - While it involves psychotic symptoms such as **hallucinations** or **delusions**, the described behaviors of an imaginary friend and magical thinking are not psychotic in a 4-year-old. *Schizophrenia* - Schizophrenia is rare in children and typically involves more pervasive and severe symptoms such as **prominent delusions**, **frank hallucinations**, **disorganized speech**, and **negative symptoms** causing significant functional impairment. - The behavior described is consistent with a normal developmental stage, not the severe and persistent psychotic symptoms required for a schizophrenia diagnosis. *Developmental delay* - Developmental delay implies a significant lag in reaching developmental milestones across various domains (e.g., cognitive, social, motor). - The child's behaviors are within the range of **typical development** for imaginary play, and there is no information to suggest a global delay in other areas. *Schizoid personality disorder* - This is a personality disorder typically diagnosed in **adulthood**, characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression. - This child's behavior of having an imaginary friend suggests active engagement in a form of social interaction and creativity, which contradicts the features of social detachment seen in schizoid personality disorder.

Question 15: A 45-year-old man presents to a psychiatrist by his wife with recent behavioral and emotional changes. The patient’s wife says that her husband’s personality has completely changed over the last year. She also says that he often complains of unpleasant odors when actually there is no discernible odor present. The patient mentions that he is depressed at times while on other occasions, he feels like he is ‘the most powerful man in the world.’ The psychiatrist takes a detailed history from this patient and concludes that he is most likely suffering from a psychotic disorder. However, before prescribing an antipsychotic medication, he recommends that the patient undergoes brain imaging to rule out a brain neoplasm. Based on the presence of which of the following clinical signs or symptoms in this patient is the psychiatrist most likely recommending this imaging test?

A. Olfactory hallucinations (Correct Answer)
B. Echolalia
C. Anhedonia
D. Delusions of grandeur
E. Thought broadcasting

Explanation: ***Olfactory hallucinations*** - The presence of **olfactory hallucinations** ("unpleasant odors when actually there is no discernible odor present") in the context of new-onset psychotic symptoms and personality changes, particularly in a middle-aged adult, raises suspicion for an underlying **structural brain lesion**, such as a **frontal or temporal lobe tumor**. - Brain neoplasms in these regions can irritate cortical areas, leading to atypical psychotic symptoms and these specific types of hallucinations, making imaging crucial before initiating antipsychotic therapy. *Echolalia* - **Echolalia** is the involuntary repetition of words or phrases spoken by another person, often associated with conditions like **autism spectrum disorder**, **Tourette's syndrome**, or severe **psychotic disorders**, particularly **schizophrenia**. - While it can be a feature of psychiatric illness, it is not a red flag for structural brain pathology in the same manner as new-onset olfactory hallucinations. *Anhedonia* - **Anhedonia** is the inability to experience pleasure from activities usually found enjoyable, a prominent symptom of **major depressive disorder** and other mood disorders, as well as some psychotic disorders. - Although the patient reports feeling "depressed at times," anhedonia is a common psychiatric symptom and does not specifically point to a need for urgent brain imaging in the absence of other alarming features. *Delusions of grandeur* - **Delusions of grandeur** are false beliefs that one is much greater or more powerful than they truly are, as described by the patient feeling like "the most powerful man in the world." This symptom is characteristic of **bipolar disorder (manic episodes)** or some **psychotic disorders**. - While present in this patient, grandiose delusions are part of the core symptomatology of many psychiatric conditions and, by themselves, do not typically necessitate brain imaging to rule out a tumor. *Thought broadcasting* - **Thought broadcasting** is the belief that one's thoughts are being transmitted into the minds of others, a classic **first-rank symptom of schizophrenia**. - This symptom is indicative of a severe thought disorder within the spectrum of psychotic illnesses but does not specifically raise the suspicion of an underlying brain lesion requiring neuroimaging.

Question 16: A 23-year-old man is brought to the emergency department by his girlfriend because of acute agitation and bizarre behavior. The girlfriend reports that, over the past 3 months, the patient has become withdrawn and stopped pursuing hobbies that he used to enjoy. One month ago, he lost his job because he stopped going to work. During this time, he has barely left his apartment because he believes that the FBI is spying on him and controlling his mind. He used to smoke marijuana occasionally in high school but quit 5 years ago. Physical and neurologic examinations show no abnormalities. On mental status examination, he is confused and suspicious with marked psychomotor agitation. His speech is disorganized and his affect is labile. Which of the following is the most likely diagnosis?

A. Schizophreniform disorder (Correct Answer)
B. Schizoid personality disorder
C. Delusional disorder
D. Schizoaffective disorder
E. Brief psychotic disorder

Explanation: **Correct: Schizophreniform disorder** - This patient presents with ***psychotic symptoms*** (delusions, disorganized speech, agitation) and ***negative symptoms*** (withdrawal, anhedonia, loss of job), which have been present for approximately ***3 months***. - The ***duration of symptoms (1-6 months)*** is the key differentiating factor for schizophreniform disorder compared to brief psychotic disorder (<1 month) or schizophrenia (>6 months). - Meets DSM-5 criteria: psychotic symptoms with functional impairment lasting between 1 and 6 months. *Incorrect: Schizoid personality disorder* - Characterized by a pervasive pattern of ***detachment from social relationships*** and a restricted range of emotional expression, which are ***ego-syntonic*** and typically stable over time. - This is a personality disorder with chronic traits, not an acute psychotic disorder. - Does not include acute psychotic symptoms like delusions or disorganized speech. *Incorrect: Delusional disorder* - Defined by the presence of ***non-bizarre delusions*** for at least one month, without other significant psychotic symptoms or major functional impairment. - This patient has ***bizarre delusions*** (FBI controlling his mind), ***disorganized speech***, ***psychomotor agitation***, and ***marked functional impairment***, which exceed the criteria for delusional disorder. *Incorrect: Schizoaffective disorder* - Requires the presence of a ***major mood episode*** (depressive or manic) concurrent with symptoms of schizophrenia, AND ***delusions or hallucinations for at least 2 weeks*** in the absence of a major mood episode. - While the patient exhibits labile affect, there is no evidence of a distinct, prolonged major mood episode (major depression or mania) as required for schizoaffective disorder. *Incorrect: Brief psychotic disorder* - Characterized by the sudden onset of psychotic symptoms (delusions, hallucinations, disorganized speech or behavior) that last for ***at least one day but less than one month***, followed by full return to premorbid functioning. - The patient's symptoms have been ongoing for approximately ***3 months***, which exceeds the duration criteria for brief psychotic disorder.

Question 17: A 21-year-old man is brought to the office by his parents due to concerns about his behavior. They describe their son as aloof and a loner who earns average to below average grades in school. Today, his heart rate is 90/min, respiratory rate is 17/min, blood pressure is 110/65 mm Hg, and temperature is 36.8°C (98.2°F). On physical examination, he appears gaunt and anxious. His heart has a regular rhythm, and his lungs are clear to auscultation bilaterally. CMP, CBC, and TSH are normal. A urine toxicology test is negative. During the examination, he avoids eye contact and appears detached. When asked about his social life, he claims that he does not care about making friends and prefers to be alone. He says he enjoys going to the movies, but he enjoys doing this alone. He has not had a romantic partner before and takes little pleasure in intimacy. He denies experiencing hallucinations or delusions. Which of the following is the most likely diagnosis?

A. Avoidant personality disorder
B. Schizoid personality disorder (Correct Answer)
C. Major depressive disorder
D. Autism spectrum disorder
E. Schizotypal personality disorder

Explanation: ***Schizoid personality disorder*** - The patient's **detachment from social relationships**, **restricted range of emotional expression**, and indifference to praise or criticism are characteristic features. He actively *prefers* to be alone and "does not care about making friends." - His lack of desire for intimacy, preference for solitary activities like going to movies alone, and reports of taking **little pleasure in intimacy**, align with the diagnostic criteria. *Avoidant personality disorder* - Individuals with avoidant personality disorder *desire* social connections but **avoid them due to fear of rejection** or criticism, which is not described in this patient. - This patient explicitly states he "does not care about making friends" and "prefers to be alone," indicating a lack of desire rather than fear. *Major depressive disorder* - While **anhedonia** (loss of pleasure) can be a symptom of depression, the chronic and pervasive nature of his social detachment and emotional blunting, starting in adolescence, points away from an episodic mood disorder. - There are no other common symptoms of depression such as changes in sleep, appetite, energy, or feelings of worthlessness, nor does he report dysphoria. *Autism spectrum disorder* - Although there is some overlap in symptoms like **social aloofness** and restricted interests, autism spectrum disorder typically involves **deficits in nonverbal communication** and often repetitive behaviors or highly restricted, fixated interests. - The patient's social presentation primarily revolves around a *lack of desire* for social connection rather than an *impairment in capacity* for social interaction. *Schizotypal personality disorder* - Schizotypal personality disorder involves **eccentric behavior**, **peculiar thought patterns**, and perceptual distortions (e.g., magical thinking, ideas of reference), and often odd speech. - The patient denies experiencing hallucinations or delusions, and his presentation does not include the characteristic cognitive or perceptual distortions seen in schizotypal personality disorder.

Question 18: A 27-year-old female is brought to the Emergency Department by Fire Rescue after participating in a physical altercation with several commuters on the subway. She appears to be responding to hallucinations and is diaphoretic. Her vitals are as follows: T 100.5F (38C), HR 115, BP 155/90, RR 17. Her past medical history is notable for a previous ED visit for phencyclidine-related agitation. Which of the following physical findings would most strongly suggest the same diagnosis?

A. Conjunctival injection
B. Dilated, minimally responsive pupils
C. Prominent vertical nystagmus (Correct Answer)
D. Constricted but responsive pupils
E. Conjunctival pallor

Explanation: ***Prominent vertical nystagmus*** - **Vertical nystagmus** is a classic and highly suggestive finding in **phencyclidine (PCP) intoxication**, distinguishing it from other stimulant or hallucinogenic drug effects. - PCP directly affects the cerebellar and vestibular systems, leading to unique oculomotor disturbances including both horizontal and vertical forms of nystagmus, though vertical is particularly indicative. *Conjunctival injection* - While sometimes seen in drug intoxication, **conjunctival injection** is more commonly associated with **cannabis use** or other irritants and is not specific to PCP. - This finding does not provide strong diagnostic evidence for PCP, as it can occur in various conditions. *Dilated, minimally responsive pupils* - **Mydriasis (dilated pupils)** can be observed with various stimulant and hallucinogenic drugs, including PCP, due to sympathetic nervous system activation. - However, the descriptor "minimally responsive" is less specific to PCP and could be seen in other severe intoxications or neurological impairments. *Constricted but responsive pupils* - **Constricted pupils (miosis)** are typically associated with **opioid intoxication** or certain cholinergic agents, not PCP. - This finding would strongly argue against PCP use. *Conjunctival pallor* - **Conjunctival pallor** suggests **anemia** or reduced blood flow, and is not a common or specific finding in drug intoxications. - It would not support a diagnosis of PCP intoxication in this context.

Question 19: A 35-year-old male with a history of repeated arrests for assault, robbery, and arson displays a callous disregard for the safety of others and a lack of remorse, as evidenced by smiling when questioned about burning down his ex-girlfriend's apartment. Considering a diagnosis of antisocial personality disorder, which of the following behaviors was most likely present during his childhood?

A. Fear of abandonment
B. Bed-wetting
C. Odd beliefs
D. Conduct disorder behaviors (Correct Answer)
E. Perfectionist

Explanation: ***Conduct disorder behaviors*** - A diagnosis of **antisocial personality disorder** in adulthood requires a history of **conduct disorder** onset before age 15. - Behaviors such as **aggression towards people and animals**, **destruction of property**, **deceitfulness or theft**, and **serious violations of rules** are characteristic of conduct disorder and often precede ASPD. *Fear of abandonment* - This symptom is characteristic of **borderline personality disorder**, which involves instability in relationships, self-image, and emotions, and is not typically associated with ASPD. - Individuals with borderline personality disorder often engage in frantic efforts to avoid real or imagined abandonment. *Bed-wetting* - While sometimes associated with childhood trauma or psychological distress, **enuresis (bed-wetting)** is not a specific diagnostic criterion or a strong predictor of antisocial personality disorder. - It does not directly reflect the core patterns of disregard for others or rule-breaking that define the developmental trajectory of ASPD. *Odd beliefs* - **Odd beliefs** are more indicative of **schizotypal personality disorder**, which involves eccentric behavior, cognitive or perceptual distortions, and discomfort with close relationships. - These beliefs are not a typical feature in the developmental history of antisocial personality disorder. *Perfectionist* - **Perfectionism** is a central characteristic of **obsessive-compulsive personality disorder (OCPD)**, marked by a preoccupation with orderliness, control, and details to the extent of rigid and inflexible behavior. - This trait is contrary to the impulsive and disregardful nature seen in individuals with antisocial personality disorder.

Question 20: A 26-year-old woman is brought to the emergency department by her husband due to her disturbing behavior over the past 24 hours. Her husband says that he has noticed his wife talking to herself and staying in a corner of a room throughout the day without eating or drinking anything. She gave birth to their son 2 weeks ago but has not seen or even acknowledged her baby’s presence ever since he was born. He says that he didn’t think much of it because she seemed overwhelmed during her pregnancy and he considered that she was probably unable to cope with being a new mother; however, last night, he says, his wife told him that their child was the son of the devil and they ought to get rid of him as soon as possible. Which of the following describes this patient’s abnormal reaction to her child?

A. Brief psychotic disorder
B. Schizoaffective disorder
C. Postpartum psychosis (Correct Answer)
D. Major depressive disorder
E. Postpartum blues

Explanation: **Postpartum psychosis** - This patient exhibits **psychotic symptoms** (delusions about the child, hallucinations like talking to herself) and **severe disorganization** (staying in a corner, not eating/drinking, neglecting her baby) within two weeks postpartum. - This severe and acute onset of psychosis in the **postpartum period** is characteristic of postpartum psychosis, which is a medical emergency requiring immediate intervention. *Brief psychotic disorder* - While it involves psychotic symptoms of acute onset and short duration (less than one month), this diagnosis typically applies when symptoms are not directly attributable to a specific precipitating factor like childbirth. - The clear temporal association with childbirth in this case makes postpartum psychosis a more specific and accurate diagnosis. *Schizoaffective disorder* - This disorder typically involves a combination of **mood symptoms** (depressive or manic) and **psychotic symptoms**, where psychotic symptoms are present for at least two weeks in the absence of a major mood episode. - The sudden onset and direct link to the postpartum period distinguish this case from schizoaffective disorder, which usually has a more chronic or episodic course. *Major depressive disorder* - Although the patient shows signs of severe withdrawal and neglect, the presence of **frank psychotic symptoms** (delusions about the child being the "son of the devil") goes beyond the typical presentation of major depressive disorder, even with psychotic features. - While depression can coexist, the predominant and acute psychotic features point more directly to postpartum psychosis. *Postpartum blues* - Postpartum blues are **mild and transient mood disturbances** (tearfulness, irritability, anxiety) occurring in the first few days to two weeks postpartum, typically resolving on their own. - The patient's symptoms are far more severe, involving **psychotic delusions and severe functional impairment**, making postpartum blues an inadequate diagnosis.

Question 21: A 28-year-old G1P1 woman is brought into the clinic by her concerned husband. The husband has noted that his wife is not behaving normally. She no longer enjoys his company or is not particularly happy around their newborn. The newborn was delivered 3 weeks ago via normal vaginal delivery with no complications. He also notes that his wife seems to be off in some other world with her thoughts. Overall, she appears to be drained, and her movements and speech seem slow. The patient complains that the newborn is sucking the lifeforce from her when she breastfeeds. She has thus stopped eating to save herself from this parasite. Which of the following statements is true regarding this patient’s most likely condition?

A. Risk for this patient’s condition increases with each pregnancy
B. Ziprasidone is the first-line pharmacotherapy recommended for this patient’s condition
C. This patient’s condition is self-limited
D. Electroconvulsive therapy is the first-line therapy for this patient’s condition
E. If symptoms present within a month after delivery and treatment occurs promptly, the prognosis is good (Correct Answer)

Explanation: ***If symptoms present within a month after delivery and treatment occurs promptly, the prognosis is good*** - This patient presents with symptoms highly suggestive of **postpartum psychosis**, including **delusions** (**newborn sucking lifeforce**), **disorganized thoughts**, **psychomotor retardation**, and **mood lability**, which developed rapidly after childbirth. Prompt identification and treatment of postpartum psychosis, especially when symptoms manifest early, leads to a **good prognosis** for recovery. - Early intervention significantly reduces the risk of harm to the mother or infant and improves long-term outcomes, with many women achieving full remission. *Risk for this patient’s condition increases with each pregnancy* - The risk of **postpartum psychosis** is primarily associated with a **history of bipolar disorder** or a previous episode of postpartum psychosis, not simply the number of pregnancies. - While it can recur, it does not inherently increase with each subsequent pregnancy in the absence of other risk factors. *Ziprasidone is the first-line pharmacotherapy recommended for this patient’s condition* - While **antipsychotics** like ziprasidone are part of the treatment for postpartum psychosis, **lithium** is often considered a first-line agent, particularly when there is a significant mood component or history of bipolar disorder. - The initial management often involves hospitalization, mood stabilizers, and antipsychotics, with the choice of medication tailored to the individual's symptoms and history. *This patient’s condition is self-limited* - **Postpartum psychosis** is a severe psychiatric emergency that is **not self-limited** and requires urgent medical intervention. - Without treatment, it carries a significant risk of harm to both the mother and the infant, including infanticide or suicide. *Electroconvulsive therapy is the first-line therapy for this patient’s condition* - **Electroconvulsive therapy (ECT)** is a highly effective treatment for severe postpartum psychosis, especially in cases of **catatonia**, severe mood symptoms, or when there is an inadequate response to medication, but it is typically reserved for **severe or refractory cases** rather than being the absolute first-line therapy. - Initial treatment usually involves pharmacotherapy (e.g., antipsychotics and mood stabilizers) and often hospitalization for safety reasons.

Question 22: A 20-year-old woman is brought to the physician by her mother because she has been worried about her daughter's strange behavior for the past 2 years. She does not have any friends and spends most of her time alone in her room. She usually wears a long, black, hooded cloak. She is anxious at college because she is uncomfortable around other people, and her academic performance is poor. She collects rare crystals and says that they support her “sixth sense.” Mental status examination shows slow, hesitant speech, and she avoids eye contact. Which of the following is the most likely diagnosis?

A. Schizophrenia
B. Social anxiety disorder
C. Schizoid personality disorder
D. Schizotypal personality disorder (Correct Answer)
E. Paranoid personality disorder

Explanation: ***Schizotypal personality disorder*** - This disorder is characterized by **peculiar behaviors**, **odd beliefs (e.g., "sixth sense" and crystals)**, and **social anxiety** with discomfort in close relationships. - The patient's social isolation, eccentric dress, and anxious behavior are consistent with **schizotypal traits**, which can include magical thinking and perceptual distortions. *Schizophrenia* - This condition involves significant **psychotic symptoms** such as **hallucinations, delusions**, and disorganized thought/speech, which are not explicitly described here. - While schizotypal personality disorder can be a precursor, the patient's symptoms do not yet meet the full criteria for a psychotic episode. *Social anxiety disorder* - This disorder primarily involves an intense fear of social situations due to concerns about being judged or embarrassed. - While social anxiety is present, the additional features of **odd beliefs** and **peculiar behaviors** are not typical of social anxiety disorder. *Schizoid personality disorder* - Individuals with schizoid personality disorder exhibit **detachment from social relationships** and a restricted range of emotional expression. - However, they typically lack the **odd beliefs, eccentric behavior**, and social anxiety seen in schizotypal personality disorder. *Paranoid personality disorder* - Characterized by pervasive **distrust and suspiciousness of others**, often interpreting others' motives as malicious. - This patient does not show evidence of paranoia or suspiciousness; her withdrawal is due to discomfort rather than mistrust.

Question 23: A 20-year-old male is involuntarily admitted to the county psychiatric unit for psychotic behavior over the past three months. The patient's mother explained to the psychiatrist that her son had withdrawn from family and friends, appeared to have no emotions, and had delusions that he was working for the CIA. When he spoke, his sentences did not always seem to have any connection with each other. The mother finally decided to admit her son after he began stating that he "revealed too much information to her and was going to be eliminated by the CIA." Which of the following diagnoses best fits this patient's presentation?

A. Schizophrenia
B. Brief psychotic disorder
C. Schizophreniform disorder (Correct Answer)
D. Schizoid personality disorder
E. Schizotypal personality disorder

Explanation: ***Schizophreniform disorder*** - The patient exhibits classic symptoms of **psychosis**, including delusions, disorganized speech, flat affect, and social withdrawal, which are characteristic of schizophrenia spectrum disorders. - The duration of symptoms (3 months) fits the criteria for **schizophreniform disorder**, which is when psychotic symptoms last between 1 month and 6 months. *Schizophrenia* - Schizophrenia requires symptoms to be present for at least **6 months**, including at least 1 month of active-phase symptoms. - While this patient's symptoms are consistent with psychotic disorder, the **duration criteria** for schizophrenia have not yet been met. *Brief psychotic disorder* - Brief psychotic disorder is characterized by symptoms lasting from **1 day to 1 month**, with eventual full return to premorbid functioning. - The patient's symptoms have persisted for **3 months**, exceeding the maximum duration for brief psychotic disorder. *Schizoid personality disorder* - This disorder is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression. - While the patient exhibits social withdrawal, the presence of **delusions, disorganized speech, and flat affect** indicates a psychotic disorder, not merely a personality disorder. *Schizotypal personality disorder* - Schizotypal personality disorder involves pervasive social and interpersonal deficits with **cognitive or perceptual distortions** and eccentric behaviors. - While it can involve odd beliefs, it does not typically include the prominent, fixed, and systematized **delusions and disorganized speech** seen in this patient's presentation.

Question 24: A 14-year-old boy is brought to the office by his step-parents because he was recently caught beating a stray cat in an alley near his home. He has a police record which includes vandalism, shoplifting, and running away on two occasions. He has also received several detentions and threats of expulsion from school due to bullying and being too aggressive with the younger students. Past medical history is significant for a history of ADHD previously treated with methylphenidate, but now he does not take anything. His biological family placed him and his sister into the foster care system. His step-parents try to provide support and nurturing home life but the patient is very resistant and often acts out. What is the most likely diagnosis for this patient?

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

Explanation: ***Conduct disorder*** - This patient exhibits a persistent pattern of behavior that **violates the basic rights of others** and **major age-appropriate societal norms**, including aggression to people and animals (beating a stray cat), destruction of property (vandalism), deceitfulness or theft (shoplifting), and serious violations of rules (running away, truancy due to bullying). - The onset of these behaviors is before age 15, which is consistent with the diagnosis of **childhood-onset type conduct disorder**. *Schizoid personality disorder* - Characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression. - This patient's behaviors, such as aggression and bullying, are indicative of active engagement with others (albeit negative), rather than social detachment. *Antisocial personality disorder* - This diagnosis requires the individual to be at least **18 years old** and to have a history of symptoms of conduct disorder before age 15. - While the patient's behaviors are consistent with antisocial traits, he is currently **14 years old**, making antisocial personality disorder an inappropriate diagnosis at this time. *Oppositional defiant disorder* - Primarily involves a pattern of **angry/irritable mood**, **argumentative/defiant behavior**, or **vindictiveness**. - While some features overlap, this patient's actions, such as beating an animal, vandalism, and shoplifting, go beyond mere defiance and constitute **serious violations of the rights of others** and major societal norms, which are characteristic of conduct disorder. *Attention deficit hyperactivity disorder* - Characterized by persistent patterns of **inattention**, **hyperactivity**, or **impulsivity**. - While the patient has a history of ADHD, his current severe behaviors (e.g., animal cruelty, vandalism) signify a more pervasive disturbance involving aggression and rule-breaking, which are not core features of ADHD itself, but rather common comorbidities or a separate, more severe diagnosis like conduct disorder.

Question 25: At a counseling session, a 15-year-old boy recounts his childhood. He explained that his father was an angry, violent man who physically abused him and his younger brother every time he was drunk - which was almost every night. The boy said that the only way he could escape the situation was to believe that he himself was a superhero that would fight crime. Which of the following best describes the ego defense of this male?

A. Denial
B. Dissociation
C. Isolation of affect
D. Splitting
E. Fantasy (Correct Answer)

Explanation: ***Fantasy*** - This defense mechanism involves retreating into an **imaginary world** or scenario to escape from an unpleasant or difficult reality, as seen with the boy imagining himself as a superhero to cope with abuse. - It allows an individual to avoid the pain and stress of their current situation by creating a more desirable internal experience. *Denial* - **Denial** involves refusing to acknowledge or accept a distressing reality, memory, or feeling. - The boy is acknowledging the abuse but altering his perception of it, rather than flat-out denying it. *Dissociation* - **Dissociation** is a detachment from one's immediate surroundings, thoughts, memories, or identity, often in response to trauma. - While he is escaping reality, his imaginative coping mechanism is more specifically "fantasy," which involves actively creating an imaginary world rather than a general detachment. *Isolation of affect* - This defense mechanism separates an unwanted thought or memory from the **emotion** associated with it, allowing the thought to remain conscious but without its painful emotional impact. - The boy is not just isolating the feeling but is actively constructing an alternative reality. *Splitting* - **Splitting** involves viewing people or situations in extremes of all good or all bad, without integrating positive and negative qualities. - This defense is not applicable here as the boy isn't dichotomizing his father or situation in an all-good/all-bad manner, but rather escaping the reality of the situation.

Question 26: A 27-year-old man is brought to the emergency department after he was found locked in a bathroom at a local gas station. The patient states that he was being followed. The patient is unable to reveal additional medical history due to his condition. The patient’s sister is contacted and states that he has trouble taking care of himself and has observed him maintaining a dialogue with what appears to be no one on several occasions. The patient’s temperature is 99.5°F (37.5°C), pulse is 90/min, blood pressure is 120/70 mmHg, respirations are 14/min, oxygen saturation is 98% on room air, and BMI is 22 kg/m^2. The patient is medicated and transferred to the inpatient psychiatric unit. The patient is kept there for three weeks and maintained on his medication regimen. Towards the end of his hospitalization, the patient is grooming himself properly, denies hearing voices, and no longer believes he is being followed. The patient’s temperature is 99.5°F (37.5°C), pulse is 80/min, blood pressure is 130/75 mmHg, respirations are 15/min, oxygen saturation is 98% on room air, and BMI is 24 kg/m^2. Which of the following medications was this patient most likely started on?

A. Ziprasidone
B. Risperidone
C. Olanzapine (Correct Answer)
D. Fluphenazine
E. Haloperidol

Explanation: ***Olanzapine*** - **Olanzapine** is associated with significant **weight gain**, which is reflected in the patient's BMI increase from 22 to 24 kg/m^2 over three weeks. This adverse effect is a key differentiator among antipsychotics. - It is an **atypical antipsychotic** effective in treating positive symptoms (e.g., hallucinations, delusions) and negative symptoms of psychosis, as observed in the patient's improved condition. *Ziprasidone* - **Ziprasidone** is generally considered to be **weight-neutral** or associated with minimal weight gain, which contradicts the observed increase in the patient's BMI. - It has a risk of **QT prolongation**, which is not indicated as a primary concern or differentiating factor in this case. *Risperidone* - While **risperidone** can cause weight gain, it is typically less pronounced in the short term compared to olanzapine. Its main distinguishing side effect is often **hyperprolactinemia**. - It is also an effective antipsychotic but does not fit the rapid, significant weight gain pattern as strongly as olanzapine. *Fluphenazine* - **Fluphenazine** is a **first-generation (typical) antipsychotic** known for a higher risk of **extrapyramidal symptoms** (EPS) and less for significant weight gain, although some weight gain can occur. - The patient's presentation does not strongly suggest an initial choice of a typical antipsychotic over an atypical one, given the potential for more severe side effects like EPS. *Haloperidol* - **Haloperidol** is another powerful **first-generation antipsychotic** often used for acute psychosis, notorious for its high incidence of **extrapyramidal symptoms** (e.g., dystonia, parkinsonism, akathisia). - While it can cause some weight gain, it is less consistently associated with the substantial short-term weight gain observed in this patient compared to olanzapine.

Question 27: A 31-year-old woman is brought to the emergency department by EMS, activated by a bystander who found her wandering in the street. She provides short, vague answers to interview questions and frequently stops mid-sentence and stares at an empty corner of the room, appearing distracted. Her affect is odd but euthymic. Past medical history is notable for obesity and pre-diabetes. Collateral information from her brother reveals that she left home 3 days ago because she thought her family was poisoning her and has since been listed as a missing person. He also describes a progressive 2-year decline in her social interactions and self-care. The patient has no history of substance use and has never been prescribed psychiatric medications before but is amenable to starting a medication now. Which of the following would be the most appropriate as a first line medication for her?

A. Risperidone (Correct Answer)
B. Trazodone
C. Clomipramine
D. Olanzapine
E. Clozapine

Explanation: ***Risperidone*** - This patient presents with symptoms highly suggestive of **schizophrenia**, including **paranoid delusions** (family poisoning her), **disorganized thinking** (vague answers, stopping mid-sentence), **social withdrawal**, and decline in **self-care**. **Risperidone** is a **second-generation antipsychotic** and a common first-line treatment for schizophrenia due to its efficacy against both positive and negative symptoms. - It is the **best choice among first-line antipsychotics** for this patient given her **obesity and pre-diabetes**, as it has a **lower risk of metabolic side effects** compared to olanzapine, while still maintaining excellent antipsychotic efficacy. - The patient's **amenability to medication** and lack of prior treatment history make risperidone an ideal initial choice. *Trazodone* - **Trazodone** is an **antidepressant** primarily used for **major depressive disorder** and **insomnia**. - It does not have significant **antipsychotic effects** and would not be effective in treating the delusions and disorganized thought processes seen in this patient. *Clomipramine* - **Clomipramine** is a **tricyclic antidepressant (TCA)** mainly used for **obsessive-compulsive disorder (OCD)** and severe depression. - It is not indicated for psychotic disorders like schizophrenia and would not address the patient's **psychotic symptoms**. *Olanzapine* - While **olanzapine** is also a **second-generation antipsychotic** very effective for schizophrenia and considered first-line, the patient's history of **obesity** and **pre-diabetes** makes it a less ideal choice compared to risperidone. - **Olanzapine** is associated with the **highest risk of metabolic side effects** among second-generation antipsychotics, including **weight gain**, **dyslipidemia**, and **new-onset diabetes**, which could significantly exacerbate her pre-existing conditions. *Clozapine* - **Clozapine** is a highly effective **antipsychotic**, but it is typically reserved for **treatment-resistant schizophrenia** due to its potentially severe side effects, including **agranulocytosis** and **myocarditis**. - It requires **frequent blood monitoring** and is not considered a first-line agent, especially in a patient who has never received prior antipsychotic treatment.

Question 28: An 8-year-old boy is brought in by his mother who is concerned about her child’s behavior. She says his teachers have complained about him bullying other students at school, starting fights, and stealing other children’s lunch money. She also says that a neighbor down the street called her 6 months ago and reported that the patient had entered her yard and started viciously kicking her dog. He has no significant past medical history. He is in the 90th percentile for height and weight and has been meeting all developmental milestones. The patient is afebrile and his vital signs are within normal limits. Which of the following adult personality disorders does this patient’s diagnosis most likely predict?

A. Paranoid personality disorder
B. Schizotypal personality disorder
C. Schizoid personality disorder
D. Avoidant personality disorder
E. Antisocial personality disorder (Correct Answer)

Explanation: ***Antisocial personality disorder*** - The patient's presentation with a consistent pattern of violating the rights of others, including **bullying**, **fighting**, **stealing**, and **animal cruelty**, is highly indicative of **conduct disorder**. - **Conduct disorder** in childhood is the most common precursor to developing **antisocial personality disorder** in adulthood. *Paranoid personality disorder* - This disorder is characterized by a pervasive **distrust and suspicion of others**, interpreting their motives as malicious, which is not indicated by the patient's behavior. - While they may be hostile, their actions typically stem from perceived threats rather than direct aggression or disregard for others' rights as seen here. *Schizotypal personality disorder* - Individuals with schizotypal personality disorder exhibit **odd beliefs**, **magical thinking**, and **eccentric behavior** or appearance. - They also tend to have **social anxiety** and difficulty forming close relationships, which doesn't align with the presented externalizing behaviors. *Schizoid personality disorder* - This disorder is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression. - There is no evidence of social withdrawal or uninterest in relationships; instead, the patient is actively engaging in harmful social interactions. *Avoidant personality disorder* - This disorder involves extreme **social inhibition**, feelings of inadequacy, and hypersensitivity to **negative evaluation**. - The patient’s aggressive and non-compliant behaviors are contrary to the withdrawn and fearful nature seen in avoidant personality disorder.

Question 29: A 57-year-old man is brought to the physician for worsening mental status over the past 2 months. His wife reports he was initially experiencing lapses in memory and over the past 3 weeks he has begun having difficulties performing activities of daily living. Yesterday, he became lost heading to the post office down the street. He has hypertension treated with lisinopril and hydrochlorothiazide. Vital signs are within normal limits. He is alert but verbally uncommunicative. Muscle strength is normal. Reflexes are 2+ in bilateral upper and lower extremities. He has diffuse involuntary muscle jerking that can be provoked by loud noises. Mental status examination shows a blunt affect. 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's disease
B. Creutzfeldt-Jakob disease (Correct Answer)
C. Alzheimer's disease
D. Normal pressure hydrocephalus
E. Huntington's disease

Explanation: ***Creutzfeldt-Jakob disease*** - The rapid progression of **dementia**, combined with **myoclonus** (involuntary muscle jerking provoked by loud noises, also known as **startle myoclonus**), is highly characteristic of Creutzfeldt-Jakob disease (CJD). - CJD is a **prion disease** that causes spongiform encephalopathy, leading to rapidly progressive neurologic decline over weeks to months, typically fatal within a year. *Parkinson's disease* - Characterized by a classic triad of **bradykinesia**, **rigidity**, and **resting tremor**, none of which are prominently described in this patient. - While dementia can occur in later stages of Parkinson's, the **rapid progression** and presence of **myoclonus** are atypical. *Alzheimer's disease* - Presents with a **gradual onset** and **slow progression** of memory loss and cognitive decline, typically over many years, which contrasts with this patient's **2-month rapid deterioration**. - **Myoclonus** is not a common early feature and the rate of progression is inconsistent with Alzheimer's. *Normal pressure hydrocephalus* - Classically presents with a triad of **gait disturbance**, **urinary incontinence**, and **dementia**; while dementia is present, the other two key features are not mentioned, and the progression is faster than typically seen. - The characteristic **myoclonus** is not a feature of normal pressure hydrocephalus. *Huntington's disease* - Genetically inherited disorder characterized by **chorea** (involuntary, jerky movements) and psychiatric symptoms, followed by dementia. - The onset is typically earlier (30s-40s) and the primary motor symptom is chorea, not the **startle myoclonus with rapid progression** observed here.

Question 30: A 10-year-old boy is brought to the physician by his parents because they are concerned about his “strange behavior”. The parents state that he has always been a lonely kid without many friends, but recently he has been having behavioral problems that seem to be unprovoked and are occurring more frequently. The child throws tantrums for no reason and does not respond to punishment or reward. He also has a “strange obsession” with collecting rocks that he finds on his way to and from school to the point where his room is filled with rocks. He plays alone in his room, lining the rocks up, organizing them by size, shape, or color, and he will randomly bark or make high-pitched noises without provocation. His teachers say he daydreams a lot and is very good at art, being able to recreate his favorite cartoon characters in great detail. On physical assessment, the patient does not make eye contact with the physician but talks incessantly about his rock collection. The child’s grammar and vocabulary seem normal but his speech is slightly labored, and he can’t seem to tell that the physician is not really interested in hearing about his rock collection. Which of the following is the most likely diagnosis?

A. Autism spectrum disorder (Correct Answer)
B. Obsessive-compulsive disorder
C. Tourette’s syndrome
D. Pick disease
E. Attention deficit hyperactivity disorder

Explanation: ***Autism spectrum disorder*** - This case presents classic features of **autism spectrum disorder (ASD)**, including **social deficits** (lonely, no friends, no eye contact, lack of awareness of others' interest), **repetitive behaviors and fixated interests** (rock collection, lining them up, organizing), and **stereotyped movements/vocalizations** (random barking, high-pitched noises). - The child's excellent artistic skills and normal grammar/vocabulary despite other communication difficulties are also consistent with the varying presentations within the **autism spectrum**, which can include areas of exceptional talent alongside core deficits. *Obsessive-compulsive disorder* - While the rock collection and organizing might resemble an **obsession/compulsion**, OCD typically involves **intrusive thoughts (obsessions)** causing distress and **repetitive behaviors (compulsions)** performed to alleviate that distress. - The presented social deficits, communication difficulties, and stereotyped movements are not characteristic of OCD alone. *Tourette’s syndrome* - **Tourette's syndrome** is characterized by **multiple motor tics** and **one or more vocal tics**. The barking and high-pitched noises could be tics, but Tourette's does not explain the profound social impairments, repetitive behaviors/interests, and communication difficulties described. - The global pattern of symptoms points beyond Tourette's. *Pick disease* - **Pick disease** is a rare form of **frontotemporal dementia** that primarily affects adults, typically presenting with **personality changes**, **behavioral disinhibition**, and **language difficulties**. - It is an adult-onset neurodegenerative disorder and would not be diagnosed in a 10-year-old child presenting with developmental differences. *Attention deficit hyperactivity disorder* - **ADHD** is characterized by **persistent patterns of inattention** and/or **hyperactivity-impulsivity**. While "daydreaming" could suggest inattention, the core features of social impairment, repetitive behaviors, and specific vocalizations are not typical of ADHD. - The child's "strange obsession" and social isolation point away from a primary diagnosis of ADHD.

Question 31: A 21-year-old man presents to an outpatient psychiatrist with chief complaints of fatigue and “hearing voices.” He describes multiple voices which sometimes call his name or say nonsensical things to him before he falls asleep at night. He occasionally awakes to see “strange people” in his room, which frighten him but then disappear. The patient is particularly worried by this because his uncle developed schizophrenia when he was in his 20s. The patient also thinks he had a seizure a few days ago, saying he suddenly fell to the ground without warning, though he remembers the episode and denied any abnormal movements during it. He is in his 3rd year of college and used to be a top student, but has been getting C and D grades over the last year, as he has had trouble concentrating and fallen asleep during exams numerous times. He denies changes in mood and has continued to sleep 8 hours per night and eat 3 meals per day recently. Which of the following medications will be most beneficial for this patient?

A. Haloperidol
B. Valproic acid
C. Risperidone
D. Modafinil (Correct Answer)
E. Levetiracetam

Explanation: ***Modafinil*** - This patient presents with **narcolepsy**, characterized by the **classic tetrad**: excessive daytime sleepiness (falling asleep during exams), **cataplexy** (sudden fall without loss of consciousness or abnormal movements), **hypnagogic hallucinations** (hearing voices before sleep), and **hypnopompic hallucinations** (seeing people upon awakening). - The hallucinations are **not true psychotic symptoms** but rather dream-like phenomena occurring at sleep-wake transitions, which are common in narcolepsy. - **Modafinil** is a first-line **wakefulness-promoting agent** that treats the excessive daytime sleepiness and improves alertness, addressing the primary pathology. - The patient's family history of schizophrenia is a red herring; his symptoms are explained by narcolepsy, not a primary psychotic disorder. *Risperidone* - Risperidone is an **atypical antipsychotic** used for schizophrenia and other psychotic disorders. - This patient does **not have a primary psychotic disorder**—the hallucinations are hypnagogic/hypnopompic phenomena associated with narcolepsy, not true psychotic hallucinations. - Using an antipsychotic would be inappropriate and could **worsen daytime sleepiness** due to sedating effects, exacerbating the patient's core problem. *Haloperidol* - Haloperidol is a **first-generation antipsychotic** with significant risk of **extrapyramidal side effects**. - Like risperidone, it would be inappropriate here as the patient does not have a psychotic disorder, and it would worsen sedation and daytime sleepiness. *Valproic acid* - Valproic acid is a **mood stabilizer and anticonvulsant** used for bipolar disorder and seizure disorders. - The described "seizure" event is actually **cataplexy** (preserved consciousness, no abnormal movements), not a true seizure, so an anticonvulsant is not indicated. - It would not address the narcolepsy symptoms and can cause sedation. *Levetiracetam* - Levetiracetam is an **anticonvulsant** medication. - The patient's description (remembering the episode, no abnormal movements) is inconsistent with a seizure and consistent with **cataplexy**, which is treated by addressing the underlying narcolepsy, not with anticonvulsants.

Question 32: A 27-year-old man is brought into the emergency department by ambulance. The patient was at an appointment to receive welfare when he began acting abnormally. The patient was denied welfare. Shortly afterwards, he no longer responded to questions and stared blankly off into space, not responding to verbal stimuli. Other than odd lip-smacking behavior, he was motionless. Several minutes later, he became responsive but seemed confused. The patient has a past medical history of drug abuse and homelessness and is not currently taking any medications. His temperature is 98.9°F (37.2°C), blood pressure is 124/78 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals cranial nerves II-XII as grossly intact with 5/5 strength in the upper and lower extremities and a stable gait. The patient seems confused when answering questions and has trouble remembering the episode. Which of the following is the most likely diagnosis?

A. Absence seizure
B. Malingering
C. Focal impaired awareness seizure (Correct Answer)
D. Transient ischemic attack
E. Generalized seizure

Explanation: ***Focal impaired awareness seizure*** - The patient's presentation with a period of **unresponsiveness**, **staring blankly**, repetitive **lip-smacking automatisms**, and subsequent **postictal confusion** and **amnesia of the event** are highly characteristic of a focal impaired awareness seizure (formerly called complex partial seizure). - This seizure type originates from a **focal area of the brain** (often temporal lobe) and involves **impaired consciousness** during the episode. - The context of significant stress (welfare denial) can sometimes precipitate seizures in susceptible individuals, although it is not a direct cause. - **Automatisms** (repetitive purposeless movements like lip-smacking) are a hallmark feature. *Absence seizure* - Absence seizures are typically **brief (seconds)**, characterized by a sudden **cessation of activity and blank stares**, without automatisms like lip-smacking. - Patients usually have **no postictal confusion** or memory loss of the event, which contradicts this patient's presentation. - More common in **children** rather than adults. *Malingering* - Malingering involves the **intentional feigning of symptoms** for secondary gain, but the presence of automatisms like lip-smacking and the postictal state are objective neurological signs not easily faked. - The lack of responsiveness to verbal stimuli and subsequent confusion are clinical features inconsistent with volitional control. *Transient ischemic attack* - TIAs present with **focal neurological deficits** (e.g., weakness, speech disturbance, visual loss) that resolve completely within 24 hours, often without confusion. - The symptoms described (staring, lip-smacking, generalized unresponsiveness, and confusion) are not typical of a TIA. - More common in **older patients** with vascular risk factors. *Generalized seizure* - A generalized seizure, such as a tonic-clonic seizure, would involve **loss of consciousness** with **tonic and clonic movements** of the extremities, which are not described here. - While postictal confusion is common, the focal automatisms and lack of widespread motor activity point away from a primary generalized seizure. - Generalized seizures involve **both hemispheres** from onset, unlike this focal presentation.

Question 33: Five days after undergoing surgical repair of a hip fracture, a 71-year-old man is agitated and confused. Last night, he had to be restrained multiple times after attempting to leave his room. His overnight nurse reported that at times he would be resting, but shortly afterward he would become agitated again for no clear reason. He has hypertension and COPD. He had smoked one pack of cigarettes daily for 50 years but quit 10 years ago. He drinks 1 glass of whiskey per day. His current medications include oxycodone, hydrochlorothiazide, albuterol, and ipratropium. He appears agitated. His temperature is 37°C (98.6°F), pulse is 72/min, and blood pressure is 141/84 mm Hg. Pulmonary examination shows a prolonged expiratory phase but no other abnormalities. Neurologic examination shows inattentiveness and no focal findings. He is oriented to person but not to place or time. During the examination, the patient attempts to leave the room after pulling out his intravenous line and becomes violent. He is unable to be verbally redirected and is placed on soft restraints. Laboratory studies show: Hemoglobin 14.5 g/dL Leukocyte count 8,000/mm3 Platelet count 245,000/mm3 Serum Na+ 142 mEq/L K+ 3.5 mEq/L Cl- 101 mEq/L HCO3- 24 mEq/L Urea nitrogen 14 mg/dL Creatinine 1.1 mg/dL Urine dipstick shows no abnormalities. Which of the following is the most appropriate next step in management?

A. Obtain CT scan of the head
B. Obtain urine culture
C. Administer lorazepam
D. Administer haloperidol (Correct Answer)
E. Obtain x-ray of the chest

Explanation: ***Administer haloperidol*** - The patient is exhibiting acute **delirium**, characterized by **agitation**, **confusion**, inattentiveness, and fluctuating mental status in a post-surgical setting. - Given his **violent behavior**, inability to be verbally redirected, and **immediate danger to self/others** (pulling IV line, requiring restraints), pharmacological intervention is necessary for acute safety management. - **Haloperidol** (a typical antipsychotic) has historically been used for severe agitation in delirium when the patient poses imminent danger, though current guidelines emphasize it should be used at the **lowest effective dose for the shortest duration** while underlying causes are addressed. - Note: Antipsychotics do not treat the underlying delirium but manage dangerous agitation; concurrent evaluation for reversible causes (pain, infection, medications, alcohol withdrawal) remains essential. *Obtain CT scan of the head* - While a CT scan may be indicated in delirium workup to rule out **structural lesions** or **intracranial hemorrhage**, there are no focal neurological deficits, head trauma, or signs of increased intracranial pressure here. - His delirium is likely multifactorial (postoperative state, opioid use, possible pain, stress), and CT would not address the immediate safety concern. - Neuroimaging can be pursued after acute agitation is controlled. *Obtain urine culture* - **Urinary tract infections (UTIs)** are common delirium triggers in elderly patients, but the **urine dipstick is unremarkable** (no leukocyte esterase, nitrites, or WBCs), making UTI less likely. - While a culture could be ordered as part of comprehensive workup, it does not address the immediate violent behavior. *Obtain x-ray of the chest* - A chest x-ray would be appropriate if there were signs of **pneumonia** (fever, cough, hypoxia, new lung sounds), but examination shows only a **prolonged expiratory phase** consistent with his known COPD. - Pneumonia can cause delirium, but without acute respiratory symptoms, this is not the immediate priority over managing dangerous agitation. *Administer lorazepam* - **Benzodiazepines** like lorazepam are **contraindicated** in delirium unless the cause is alcohol or benzodiazepine withdrawal, as they can **worsen confusion**, cause paradoxical agitation, and increase fall risk in elderly patients. - While the patient drinks 1 glass of whiskey daily, this level of consumption makes severe alcohol withdrawal less likely (though should still be assessed), and benzodiazepines carry significant risks of respiratory depression given his COPD. - Antipsychotics are preferred for non-withdrawal delirium when pharmacological management is necessary.

Question 34: A 3-year-old boy is brought in by his mother because she is concerned that he has been “acting differently recently”. She says he no longer seems interested in playing with his friends from preschool, and she has noticed that he has stopped making eye contact with others. In addition, she says he flaps his hands when excited or angry and only seems to enjoy playing with objects that he can place in rows or rigid patterns. Despite these behaviors, he is meeting his language goals for his age (single word use). The patient has no significant past medical history. He is at the 90th percentile for height and weight for his age. He is afebrile and his vital signs are within normal limits. A physical examination is unremarkable. Which of the following is the most likely diagnosis in this patient?

A. Pervasive developmental disorder, not otherwise specified
B. Autism spectrum disorder (Correct Answer)
C. Rett’s disorder
D. Childhood disintegrative disorder
E. Asperger’s disorder

Explanation: ***Autism spectrum disorder*** - This patient exhibits **persistent deficits in social communication and social interaction** (e.g., lack of interest in friends, poor eye contact) and **restricted, repetitive patterns of behavior, interests, or activities** (e.g., hand flapping, lining up objects). These are the core diagnostic criteria for **autism spectrum disorder (ASD)**. - The symptoms are presenting in **early childhood** (age 3) and are causing **clinically significant impairment** in social, occupational, or other important areas of current functioning, consistent with an ASD diagnosis. *Pervasive developmental disorder, not otherwise specified* - This diagnosis was previously used when a child met some, but not all, criteria for autistic disorder or when there was atypical presentation. However, under **DSM-5**, these conditions are now unified under the single diagnosis of **Autism Spectrum Disorder**. - Its usage has been largely superseded by the broader diagnosis of **Autism Spectrum Disorder** in the DSM-5. *Rett’s disorder* - **Rett's disorder** primarily affects **females** and is characterized by a period of normal development followed by a loss of acquired hand skills, severe intellectual disability, and characteristic hand-wringing movements. This patient is a male and does not exhibit these specific features. - Patients typically experience **regression** in language and motor skills after normal early development, which is not described in this case, and they develop **microcephaly**. *Childhood disintegrative disorder* - This diagnosis involves a **marked regression** in multiple areas of functioning (social, communication, motor) after at least **2 years of normal development**. - The patient's mother notes recent changes, but there is no indication of previous normal development followed by significant loss of skills across multiple domains after age 2, which differentiates it from the insidious onset of ASD symptoms. *Asperger’s disorder* - **Asperger’s disorder** was characterized by **significant difficulties in social interaction** and **restricted, repetitive patterns of behavior**, but with **no clinically significant delay in language or cognitive development**. - In **DSM-5**, Asperger's disorder is no longer a distinct diagnosis and is now subsumed under the umbrella of **Autism Spectrum Disorder**, which better reflects the spectrum of symptom severity.

Question 35: A 29-year-old woman presents to the clinic regularly with her young daughter and complains that ever since her last delivery 5 years ago, she has been having intermittent light vaginal bleeding. She has seen several doctors so far and even some ‘specialist doctors.’ Her menstrual history also appears to be variable. Physical examination is within normal limits. Her urine analysis always seems to have > 10 RBCs/hpf. Which of the following is the most likely diagnosis?

A. Somatic symptom disorder
B. Malingering
C. Illness anxiety disorder
D. Factitious disorder imposed on another
E. Factitious disorder (Correct Answer)

Explanation: ***Factitious disorder*** - This is characterized by the **intentional falsification of physical or psychological symptoms** with the primary motivation being to assume the sick role, without obvious external rewards. The patient in the vignette consistently presents with ambiguous symptoms (intermittent light vaginal bleeding, variable menstrual history, unexplained hematuria) that are not substantiated by objective findings, and seeks multiple consultations (doctor shopping). - The patient's presentation with her daughter, the history of multiple doctor visits, and the lack of clear medical explanation despite persistent symptoms are all consistent with a desire to maintain the **"sick role"**, which is the defining feature of factitious disorder. - Key features include: normal physical exam, persistent symptom reporting, healthcare utilization pattern, and absence of external incentives. *Somatic symptom disorder* - In **somatic symptom disorder**, patients experience genuine distress and anxiety about their symptoms and truly believe they are ill, rather than consciously fabricating or inducing symptoms. - While these patients may also seek multiple medical opinions, they are not intentionally producing symptoms—they genuinely perceive their symptoms as real medical problems. *Malingering* - **Malingering** involves the intentional production of false or grossly exaggerated physical or psychological symptoms, but the motivation is explicitly for **external incentives** (e.g., avoiding work or military duty, obtaining financial compensation, evading criminal prosecution, or acquiring drugs). - The vignette does not suggest any tangible external benefits that the patient is trying to obtain, making malingering less likely. - Malingering is not considered a psychiatric disorder but rather a V-code/Z-code condition. *Factitious disorder imposed on another* - **Factitious disorder imposed on another** (formerly Munchausen syndrome by proxy) involves a caregiver (usually a parent) fabricating or inducing illness in another person (typically a child) to indirectly assume the sick role or gain attention for themselves. - In this case, the patient is fabricating her own illness, not the illness of her daughter, so this diagnosis is incorrect. *Illness anxiety disorder* - In **illness anxiety disorder** (formerly hypochondriasis), patients have excessive worry about having or acquiring a serious illness, with minimal or no somatic symptoms present. - These patients are not intentionally producing symptoms; rather, they misinterpret normal bodily sensations as signs of serious disease. - The presence of fabricated physical findings (hematuria) and the pattern of doctor shopping without genuine anxiety about disease make this diagnosis less likely.

Question 36: A 23-year-old man presents to the emergency department with a chief complaint of being assaulted on the street. The patient claims that he has been followed by the government for quite some time and that he was assaulted by a government agent but was able to escape. He often hears voices telling him to hide. The patient has an unknown past medical history and admits to smoking marijuana frequently. On physical exam, the patient has no signs of trauma. When interviewing the patient, he is seen conversing with an external party that is not apparent to you. The patient states that he is afraid for his life and that agents are currently pursuing him. What is the best initial response to this patient’s statement?

A. I think you are safe from the agents here.
B. You have a mental disorder but don’t worry we will help you.
C. I don’t think any agents are pursuing you.
D. What medications are you currently taking?
E. It sounds like you have been going through some tough experiences lately. (Correct Answer)

Explanation: ***It sounds like you have been going through some tough experiences lately.*** - This response **acknowledges the patient's distress** and experience without validating or refuting their delusional beliefs. - It helps establish **rapport** and encourages the patient to share more about their symptoms, which is crucial for assessment in a psychiatric emergency. *I think you are safe from the agents here.* - While intended to reassure, directly addressing the delusion can be perceived as dismissive and may **escalate the patient's paranoia** or agitation. - It does not validate their *feelings* of fear, which are real to them, even if the source is delusional. *You have a mental disorder but don’t worry we will help you.* - This statement is **confrontational** and judgmental, labeling the patient immediately with a diagnosis. - This approach can cause the patient to become defensive, shut down, or feel stigmatized, making further assessment and trust-building very difficult in the **initial interaction**. *I don’t think any agents are pursuing you.* - Directly **challenging a patient's delusion** is generally unhelpful in acute settings and can lead to increased agitation. - It invalidates their subjective reality and can make them feel misunderstood or distrustful of the healthcare provider. *What medications are you currently taking?* - While important information, asking about medications is too premature as an *initial response* to a patient expressing severe paranoia and fear. - This question comes across as dismissive of their current emotional state and **prioritizes medical history over emotional support** and rapport-building.

Question 37: A 35-year-old computer programmer presents to the psychiatrist at the request of his mother for his oddities. He explains that he wears an aluminum foil cap while he works because he does not want extraterrestrial life to steal his thoughts. He spends his free time building a radio transmitter to contact distant planets. He denies any delusions or hallucinations. He claims that nothing is wrong with his eccentricities and is happy the way his life is. Which of the following personality disorders does this male most likely have?

A. Schizotypal (Correct Answer)
B. Schizoid
C. Narcissistic
D. Borderline
E. Paranoid

Explanation: ***Schizotypal*** - This patient exhibits **eccentric behavior**, **odd beliefs** (aliens stealing thoughts), and **magical thinking** (radio transmitter for distant planets) without reaching the level of frank delusions or hallucinations. - The patient's lack of concern about his "eccentricities" and satisfaction with his life are consistent with the **ego-syntonic nature** often seen in personality disorders. *Schizoid* - Characterized by a **detachment from social relationships** and a restricted range of emotional expression, often preferring solitary activities. - While they may display some oddities, their primary feature is a **lack of interest in social interaction**, which is not the prominent feature described here. *Narcissistic* - Individuals with narcissistic personality disorder display a **pervasive pattern of grandiosity**, a need for admiration, and a lack of empathy. - Their behaviors are typically driven by a need for **external validation** and a sense of superiority, which are absent in this case. *Borderline* - Marked by **instability in interpersonal relationships**, self-image, affects, and impulsivity; traits like fear of abandonment, unstable identity, and self-harm are common. - The patient's presentation does not align with the **emotional dysregulation and interpersonal chaos** characteristic of borderline personality disorder. *Paranoid* - Characterized by a **pervasive distrust and suspiciousness of others**, interpreting their motives as malevolent. - While the patient has unusual beliefs, his primary concern is about alien intervention, not **suspicion of human intentions** or behaviors.

Question 38: A 60-year-old man who was admitted for a fractured hip and is awaiting surgery presents with acute onset altered mental status. The patient is noted by the nurses to be shouting and screaming profanities and has already pulled out his IV and urine catheter. He says he believes he is being kept against his will and does not recall falling or fracturing his hip. The patient must be restrained by the staff to prevent him from getting out of bed. He is refusing a physical exam. Initial examination reveals an agitated elderly man with a trickle of blood flowing down his left arm. He is screaming and swinging his fists at the staff. The patient is oriented x 1. Which of the following is the next, best step in the management of this patient?

A. Order 24-hour restraints
B. Change his medication
C. Order CMP and CBC (Correct Answer)
D. Repair the fractured hip
E. Administer an Antipsychotic

Explanation: ***Order CMP and CBC*** - The patient is exhibiting **acute delirium**, characterized by altered mental status, disorientation, and agitation, especially common in elderly patients post-surgery or with underlying medical issues. - Initial management involves identifying and addressing potential underlying medical causes such as **electrolyte imbalances**, **infection**, or **anemia** (evaluated by CMP and CBC). *Order 24-hour restraints* - While restraints might be necessary for patient safety in the short term, ordering 24-hour restraints without investigating the cause is not the **next best step**. - Restraints should be used as a last resort, minimized in duration, and not as a primary management strategy for **delirium**. *Change his medication* - Changing medication without a clear understanding of the underlying cause of delirium could exacerbate the situation or introduce new complications. - A thorough investigation to **identify the etiology** of his altered mental status is crucial before adjusting pharmacotherapy. *Repair the fractured hip* - The patient's acute delirium makes him an unstable candidate for surgery due to the increased risk of complications and difficulty with consent. - Addressing the **acute medical instability** (delirium) takes precedence over elective or semi-elective surgical procedures. *Administer an Antipsychotic* - **Antipsychotics** can be used to manage severe agitation in delirium, but they are a symptomatic treatment and not the initial **diagnostic step**. - Without identifying the underlying cause, administering medication could mask symptoms or have adverse effects, especially in an **elderly patient**.

Question 39: A 19-year-old man presents to a psychiatrist for the management of substance abuse. He reports that he started using the substance 2 years ago and that he smokes it after sprinkling it on his cigarette. He describes that after smoking the substance, he feels excited and as if he does not belong to himself. He also reports that when he is in his room, he sees vivid colors on the walls after using the substance; if he listens to his favorite music, he clearly sees colors and shapes in front of his eyes. There is no history of alcohol or nicotine abuse. The psychiatrist goes through his medical records and notes that he had presented with acute substance intoxication 1 month prior. At that point, his clinical features included delusions, amnesia, generalized erythema of his skin, tachycardia, hypertension, dilated pupils, dysarthria, and ataxia. Which of the following signs is also most likely to have been present on physical examination while the man was intoxicated with the substance?

A. Increased sensitivity to pain
B. Excessive perspiration
C. Hyporeflexia
D. Generalized hypotonia
E. Nystagmus (Correct Answer)

Explanation: ***Nystagmus*** - The patient's symptoms of **dissociation** ("feels as if he does not belong to himself"), **visual hallucinations** (seeing vivid colors and shapes), delusions, amnesia, tachycardia, hypertension, dilated pupils, dysarthria, and ataxia are highly characteristic of **phencyclidine (PCP) intoxication**. - **Nystagmus**, particularly **horizontal and vertical nystagmus**, is a classic and frequently observed sign in PCP intoxication due to its effects on the **cerebellum** and vestibular system. *Increased sensitivity to pain* - PCP is known for its **analgesic** and **anesthetic** properties, leading to **decreased sensitivity to pain**, not increased. - This effect contributes to the potential for self-injurious behavior during intoxication. *Excessive perspiration* - While other stimulants can cause diaphoresis, PCP intoxication more typically presents with **dry skin** or normal perspiration despite **hyperthermia** as it interferes with cholinergic thermoregulation. - The described **generalized erythema** suggests **vasodilation**, but **dry skin** is more often associated with the anticholinergic effects that can accompany PCP. *Hyporeflexia* - PCP intoxication commonly causes **hyperreflexia** and **spasticity**, not hyporeflexia, due to its excitatory effects on the **central nervous system**. - **Muscle rigidity** and **seizures** are also possible, further indicating CNS excitation. *Generalized hypotonia* - PCP typically leads to **increased muscle tone** and **rigidity**, not generalized hypotonia. - The patient's presentation with **ataxia** and **dysarthria** suggests cerebellar involvement, but this usually manifests with motor incoordination rather than widespread flaccidity.

Question 40: A 24-year-old man presents to the emergency department after a suicide attempt. He is admitted to the hospital and diagnosed with schizoaffective disorder. A review of medical records reveals a history of illicit drug use, particularly cocaine and amphetamines. He is started on aripiprazole, paroxetine, and trazodone. At the time of discharge, he appeared more coherent and with a marked improvement in positive symptoms of hallucinations and delusions but still with a flat effect. During the patient’s first follow-up visit, his mother reports he has become increasingly agitated and restless despite compliance with his medications. She reports that her son’s hallucinations and delusions have stopped and he does not have suicidal ideations, but he cannot sit still and continuously taps his feet, wiggles his fingers, and paces in his room. When asked if anything is troubling him, he stands up and paces around the room. He says, “I cannot sit still. Something is happening to me.” A urine drug screen is negative. What is the next best step in the management of this patient?

A. Add propranolol (Correct Answer)
B. Increase the aripiprazole dose
C. Stop aripiprazole and switch to clozapine
D. Add lithium
E. Stop paroxetine

Explanation: ***Add propranolol*** - The patient's symptoms of **agitation**, **restlessness**, inability to sit still, **foot tapping**, and **finger wiggling** are highly suggestive of **akathisia**, a common extrapyramidal side effect of antipsychotic medications, particularly **aripiprazole**. - **Beta-blockers**, such as **propranolol**, are the **first-line treatment** for akathisia due to their ability to provide symptomatic relief by reducing the adrenergic hyperactivity associated with this condition. *Increase the aripiprazole dose* - Increasing the dose of **aripiprazole** would likely **worsen** the akathisia, as it is a dose-dependent side effect of **antipsychotic medications**. - The patient's positive symptoms are already controlled, so increasing the dose is not indicated and could cause more harm. *Stop aripiprazole and switch to clozapine* - While switching antipsychotics is an option for persistent side effects, abruptly stopping an effective medication like **aripiprazole** could lead to a **relapse of psychotic symptoms**. - **Clozapine** is typically reserved for **treatment-resistant schizophrenia** and carries risks of severe side effects like **agranulocytosis**, making it an inappropriate first step for akathisia. *Add lithium* - **Lithium** is primarily used as a **mood stabilizer** for bipolar disorder and in augmenting antidepressants; it is not indicated for treating **akathisia**. - While some cases of akathisia might be mistaken for mood episodes, the classic motor restlessness points to an **extrapyramidal side effect**. *Stop paroxetine* - **Paroxetine**, an **SSRI**, is less likely to cause severe akathisia compared to antipsychotics, and discontinuing it would not address the most probable cause of the patient's symptoms, which is the **aripiprazole**. - Stopping the antidepressant could also exacerbate the patient's **mood symptoms**, given his history of **schizoaffective disorder** and prior suicide attempt.

Question 41: A 24-year-old woman is brought to the hospital by her mother because she has "not been herself" for the past 3 months. The patient says she hears voices in her head. The mother said that when she is talking to her daughter she can’t seem to make out what she is saying; it is as if her thoughts are disorganized. When talking with the patient, you notice a lack of energy and an apathetic affect. Which of the following is the most likely diagnosis for this patient?

A. Major depressive disorder
B. Schizophrenia
C. Brief psychotic disorder
D. Schizotypal disorder
E. Schizophreniform disorder (Correct Answer)

Explanation: ***Schizophreniform disorder*** - The patient exhibits core **psychotic symptoms** (hearing voices, disorganized thoughts) for a duration of **3 months**, which is characteristic of schizophreniform disorder (symptoms lasting **1 to 6 months**). - Her **lack of energy** and **apathetic affect** align with the negative symptoms commonly seen in psychotic disorders. *Major depressive disorder* - While **lack of energy** and **apathetic affect** can be present, the prominent **hallucinations** (hearing voices) and **disorganized thoughts** are not primary features of major depressive disorder. - A diagnosis of depression alone would not fully account for her psychotic symptoms. *Schizophrenia* - Schizophrenia requires symptoms to be present for **at least 6 months**, including at least one month of **active phase symptoms**. This patient's symptoms have only been present for 3 months. - While the symptoms are consistent with schizophrenia, the **duration criterion** has not yet been met. *Brief psychotic disorder* - Brief psychotic disorder is characterized by psychotic symptoms lasting **less than 1 month**. This patient's symptoms have been ongoing for 3 months. - The chronicity of symptoms makes this diagnosis unlikely. *Schizotypal disorder* - Schizotypal disorder is a **personality disorder** characterized by peculiar thoughts and behaviors, but typically **without overt psychotic episodes** or pronounced disorganized speech/hallucinations as described. - While there may be odd beliefs or ideas of reference, the clear **auditory hallucinations** and **thought disorder** in this case point to a more severe psychotic condition.

Question 42: A 31-year-old man comes to the emergency department because of chest pain for the last 3 hours. He describes the pain as a sharp, substernal chest pain that radiates to the right shoulder; he says “Please help me. I'm having a heart attack.” He has been admitted to the hospital twice over the past week for evaluation of shortness of breath and abdominal pain but left the hospital the following day on both occasions. The patient does not smoke or drink alcohol but is a known user of intravenous heroin. He has been living in a homeless shelter for the past 2 weeks after being evicted from his apartment for failure to pay rent. His temperature is 37.6°C (99.6°F), pulse is 90/min, respirations are 18/min, and blood pressure is 125/85 mm Hg. The patient seems anxious and refuses a physical examination of his chest. His cardiac troponin I concentration is 0.01 ng/mL (N = 0–0.01). An ECG shows a normal sinus rhythm with nonspecific ST-T wave changes. While the physician is planning to discharge the patient, the patient reports numbness in his arm and insists on being admitted to the ward. On the following day, the patient leaves the hospital without informing the physician or the nursing staff. Which of the following is the most likely diagnosis?

A. Malingering (Correct Answer)
B. Factitious disorder
C. Somatic symptom disorder
D. Conversion disorder
E. Illness anxiety disorder

Explanation: ***Malingering*** - The patient exhibits several signs of **malingering**, including the claim of severe symptoms ("Please help me. I'm having a heart attack."), inconsistent presentation (refusing physical exam, insisting on admission after normal findings, then leaving AMA), and a clear external incentive (access to shelter, food, or drugs, as suggested by his homelessness and IV drug use). - His normal vital signs, **negative troponin**, and nonspecific ECG changes despite dramatized symptoms further support that his complaints are not genuinely medical. Additionally, his repeated hospital visits and abrupt departure suggest a pattern of utilizing healthcare for secondary gain rather than actual illness. *Factitious disorder* - In **factitious disorder**, individuals *intentionally produce or feign* symptoms but lack a clear external incentive for their behavior, driven instead by an internal psychological need to assume the sick role or gain attention. - This patient's history of homelessness and IV drug use suggests a strong **external incentive** (e.g., shelter, food, access to drugs), making malingering a more likely diagnosis. *Somatic symptom disorder* - **Somatic symptom disorder** involves genuine distress and preoccupation with physical symptoms, but these symptoms are *not intentionally produced or feigned*. The patient believes they are truly ill. - This patient's behavior—dramatizing symptoms, refusing examination, and leaving quickly—suggests an **intentional deception** rather than a deeply held conviction of illness without an observable cause. *Conversion disorder* - **Conversion disorder** (functional neurological symptom disorder) involves neurological symptoms (e.g., numbness, paralysis, blindness) that are *not intentionally produced* and are incompatible with known neurological pathways, often precipitated by psychological stress. - While the patient's report of numbness could be superficial, the overall pattern of behavior, including the seeking of admission and rapid departure, points away from an unconscious manifestation of psychological distress towards **conscious deception for gain.** *Illness anxiety disorder* - **Illness anxiety disorder** (formerly hypochondriasis) is characterized by a preoccupation with having or acquiring a serious illness, with minimal or no somatic symptoms, and a high level of anxiety about health despite medical reassurance. - This patient's behavior is inconsistent with a genuine preoccupation with illness; instead, he appears to be **manipulating the system for immediate benefit**, rather than genuinely fearing a specific disease.

Question 43: A 69-year-old male presents to his primary care physician for a checkup. He has not seen a doctor in 15 years and thought he may need an exam. The patient’s past medical history is unknown and he is not currently taking any medications. The patient lives on a rural farm alone and has since he was 27 years of age. The patient works as a farmer and never comes into town as he has all his supplies delivered to him. The patient is oddly adorned in an all-denim ensemble, rarely makes eye contact with the physician, and his responses are very curt. A physical exam is performed and is notable for an obese man with a S3 heart sound on cardiac exam. The patient is informed that further diagnostic testing may be necessary and that it is recommended that he begin taking lisinopril and hydrochlorothiazide for his blood pressure of 155/95 mmHg. Which of the following is the most likely personality disorder that this patient suffers from?

A. Avoidant
B. Schizoid (Correct Answer)
C. Paranoid
D. Schizotypal
E. Antisocial

Explanation: ***Schizoid*** - The patient exhibits traits consistent with schizoid personality disorder, including **social isolation** (lives alone on a farm, rarely comes to town), **detachment from social relationships**, and **restricted emotional expression** (rarely makes eye contact, curt responses). - His lack of interest in personal relationships and preference for solitary activities are key features. *Avoidant* - Individuals with avoidant personality disorder desire social interaction but are held back by an **intense fear of rejection** or criticism, leading them to avoid social situations. - This patient, however, seems genuinely indifferent to social contact, preferring to be alone rather than fearing negative evaluation. *Paranoid* - Patients with paranoid personality disorder are characterized by **pervasive distrust and suspiciousness of others**, interpreting their motives as malevolent. - While this patient is reserved, there is no evidence of paranoia or unjustified suspicion towards the physician or others in the scenario. *Schizotypal* - Schizotypal personality disorder involves a pattern of **acute discomfort with, and reduced capacity for, close relationships**, alongside **cognitive or perceptual distortions** and eccentricities of behavior. - While this patient is eccentric (all-denim ensemble, social isolation), there is no mention of odd beliefs, magical thinking, or unusual perceptual experiences that are hallmarks of schizotypal disorder. *Antisocial* - Antisocial personality disorder is marked by a **disregard for and violation of the rights of others**, often involving deceit, impulsivity, and a lack of remorse. - None of the patient's behaviors described (social withdrawal, curt responses) suggest a history of criminal acts, manipulation, or aggression characteristic of antisocial personality disorder.

Question 44: A 55-year-old male was picked up by police in the public library for harassing the patrons and for public nudity. He displayed disorganized speech and believed that the books were the only way to his salvation. Identification was found on the man and his sister was called to provide more information. She described that he recently lost his house and got divorced within the same week although he seemed fine three days ago. The man was sedated with diazepam and chlorpromazine because he was very agitated. His labs returned normal and within three days, he appeared normal, had no recollection of the past several days, and discussed in detail how stressful the past two weeks of his life were. He was discharged the next day. Which of the following is the most appropriate diagnosis for this male?

A. Brief psychotic disorder (Correct Answer)
B. Schizotypal personality disorder
C. Schizophreniform disorder
D. Schizophrenia
E. Schizoid personality disorder

Explanation: ***Brief psychotic disorder*** - This patient exhibited characteristic symptoms such as **sudden onset of psychotic symptoms** (disorganized speech, delusions, public nudity) that lasted **less than one month** and were preceded by a **severe psychosocial stressor** (loss of house, divorce). - The **full return to premorbid functioning** and lack of recollection after the episode further support brief psychotic disorder, distinguishing it from other chronic psychotic disorders. *Schizotypal personality disorder* - Characterized by a pervasive pattern of **social and interpersonal deficits**, cognitive or perceptual distortions, and eccentricities of behavior, which are usually **long-standing** and not episodic. - While there may be odd beliefs or magical thinking, the dramatic and time-limited psychotic episode in the scenario is not typical of schizotypal personality disorder. *Schizophreniform disorder* - This disorder is diagnosed when psychotic symptoms (like those seen in schizophrenia) are present for **at least one month but less than six months**. - Although the patient presented with psychotic symptoms, their rapid resolution within three days makes a diagnosis of schizophreniform disorder unlikely. *Schizophrenia* - Requires continuous signs of disturbance for **at least six months**, including at least one month of active-phase symptoms, along with significant impairment in social or occupational functioning. - The rapid resolution of symptoms and return to baseline within days in this case immediately rules out schizophrenia, which is a chronic condition. *Schizoid personality disorder* - Characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of expression of emotions in interpersonal settings. - This disorder does not involve psychotic symptoms, disorganized speech, or delusions of the intensity described in the patient's presentation.

Question 45: A 63-year-old woman is brought to the clinic by her husband with complaints of cognitive decline. The patient's husband says that she has had intermittent problems with her memory for the past few years. He says she has occasional 'bad days' where her memory deteriorates to the point where she cannot perform activities of daily living. She is also sometimes found conversing in an empty room and, when inquired, she confirms that she is talking to a friend. There have also been some recent falls. There is no history of fever, recent head trauma, loss of consciousness, or illicit drug use. Past medical history is significant for bronchial asthma and osteoarthritis, both managed medically. Her mother died due to metastatic breast cancer at age 71 and her father was diagnosed with Alzheimer's disease at age 65. The patient is afebrile and her vital signs are within normal limits. Physical examination reveals a tremor present in both her hands that attenuates with voluntary movement. Deep tendon reflexes are 2+ bilaterally. Romberg's sign is negative. She has a slow gait with a mild stooped posture. Her laboratory findings are significant for the following: Hemoglobin 12.9 g/dL White cell count 8,520/mm³ Platelets 295,000/mm³ Serum creatinine 1.0 mg/dL Glucose 94 mg/dL Sodium 141 mEq/L Potassium 3.9 mEq/L Calcium 92 mg/dL Ferritin 125 ng/mL Serum B12 305 ng/L TSH 2.1 µU/mL Ceruloplasmin 45 mg/dL Which of the following is the most appropriate management for this patient?

A. Escitalopram
B. Penicillamine
C. Haloperidol
D. Ropinirole
E. Rivastigmine (Correct Answer)

Explanation: ***Rivastigmine*** - The patient exhibits classic symptoms of **dementia with Lewy bodies (DLB)**, including cognitive fluctuations, visual hallucinations (conversing in an empty room), and parkinsonism (tremor, slow gait, stooped posture, and falls). **Cholinesterase inhibitors** like **rivastigmine** are the first-line treatment for cognitive and neuropsychiatric symptoms in DLB as they can help improve cognitive function and reduce hallucinations. - While Parkinson's disease itself is not the primary diagnosis, the presence of **parkinsonian features** and cognitive decline with hallucinations makes DLB a strong consideration. Rivastigmine increases the availability of **acetylcholine** in the brain, improving cognitive function and behavioral symptoms in DLB. *Escitalopram* - **Escitalopram** is an **SSRI antidepressant** and would be appropriate if the patient's primary symptoms were **depression or anxiety**. - While depression can coexist with dementia, the described symptoms of cognitive fluctuations, hallucinations, and parkinsonism are not primarily indicative of depression. *Penicillamine* - **Penicillamine** is a **chelating agent** used primarily in the treatment of **Wilson's disease**, which is characterized by copper accumulation. - The patient's **ceruloplasmin levels are normal**, making Wilson's disease unlikely, and the clinical presentation does not align with typical Wilson's disease symptoms. *Haloperidol* - **Haloperidol** is a **first-generation antipsychotic** that could be used for severe behavioral disturbances or psychosis. - However, in patients with **dementia with Lewy bodies (DLB)**, antipsychotics, particularly typical ones like haloperidol, can significantly worsen parkinsonian symptoms and cognitive function due to **extreme sensitivity to neuroleptics**. *Ropinirole* - **Ropinirole** is a **dopamine agonist** primarily used in the treatment of **Parkinson's disease** to manage motor symptoms. - While the patient has parkinsonian features, the prominent cognitive fluctuations and visual hallucinations point more towards **Dementia with Lewy Bodies (DLB)**, where dopamine agonists can sometimes exacerbate hallucinations and other neuropsychiatric symptoms.

Question 46: A 19-year-old male is brought to the emergency department by his roommate for 'strange' behavior over the last 48 hours. The patient states that he is hearing voices speak to him, giving him secret messages and instructions to carry out. He believes that the FBI is following him and spying on his conversations. The patient is concerned that they are listening to these messages and will find out his secrets. The patient's friend does not believe the patient ingested any substance or used any recreational drugs prior to this episode. A negative drug screen is obtained and confirms this. Physical examination does not reveal any abnormalities. Which of the following treatments might best target this patient's symptoms?

A. Risperidone (Correct Answer)
B. Psychotherapy
C. Haloperidol
D. Chlorpromazine
E. Sertraline

Explanation: ***Risperidone*** - The patient presents with **auditory hallucinations** and **paranoid delusions**, suggesting an acute psychotic episode, likely the first presentation of **schizophrenia** or a related psychotic disorder. - **Risperidone** is a second-generation (atypical) antipsychotic, an appropriate first-line treatment for acute psychosis due to its efficacy against both positive and some negative symptoms, with a generally favorable side effect profile compared to first-generation agents. *Psychotherapy* - While psychotherapy is a crucial component in the long-term management of psychotic disorders, it is **not sufficient as a monotherapy** for acute psychotic symptoms like prominent hallucinations and delusions, especially in the initial phase. - Psychotherapy alone would not adequately address the **neurotransmitter imbalances** (e.g., dopamine dysregulation) believed to underlie acute psychosis. *Haloperidol* - **Haloperidol** is a first-generation (typical) antipsychotic that is very effective for acute psychosis and severe agitation, primarily by blocking **dopamine D2 receptors**. - However, first-generation antipsychotics like haloperidol have a **higher risk of extrapyramidal side effects (EPS)**, such as dystonia, akathisia, and parkinsonism, compared to second-generation agents like risperidone, making them generally less preferred for initial treatment unless rapid tranquilization is the main concern or other options are ineffective. *Chlorpromazine* - **Chlorpromazine** is another first-generation antipsychotic known for its strong sedative effects and efficacy in treating acute psychosis. - Similar to haloperidol, it carries a **higher risk of severe side effects**, including **orthostatic hypotension**, sedation, and EPS, making it less favorable as a first-line choice compared to atypical antipsychotics in many acute presentations. *Sertraline* - **Sertraline** is a **selective serotonin reuptake inhibitor (SSRI)**, primarily used to treat depression, anxiety disorders, and obsessive-compulsive disorder. - It has **no significant antipsychotic properties** and would not be effective in treating the patient's acute psychotic symptoms such as hallucinations and delusions.

Question 47: A 20-year-old college student presents to her college's mental health services department because her dean has been concerned about her academic performance. She was previously a straight A student; however, she has been barely passing her exams since the death of her younger brother in an accident 5 months ago. She reveals that she feels guilty for not spending more time with him in the years leading up to his death. Furthermore, she has been experiencing abdominal pain when she thinks about him. Additional questioning reveals that she is convinced that her brother simply went missing and will return again despite her being at his funeral. Finally, she says that she saw a vision of her brother in his childhood bedroom when she went home for winter break. Which of the following symptoms indicates that this patient's grief is pathologic?

A. Somatic symptoms
B. Hallucinations about her brother
C. Feelings of guilt
D. Duration of the grief
E. Delusions about her brother (Correct Answer)

Explanation: ***Delusions about her brother*** - The patient's conviction that her brother simply went missing and will return, despite having attended his funeral, represents a fixed, false belief that is characteristic of a **delusion**. - Such **persistent denial of reality** regarding the death is a strong indicator of **pathologic grief**, moving beyond typical mourning into a distorted perception of reality. *Somatic symptoms* - Experiencing **abdominal pain** when thinking about the deceased is a common physical manifestation of **stress and grief**, which can be part of normal grieving processes. - While uncomfortable, **psychosomatic symptoms** do not inherently signify pathologic grief unless they are severely debilitating or contribute to a delusional framework. *Hallucinations about her brother* - Seeing a **vision of her brother** (a vivid sensory experience without external stimulus) can be a part of normal grief, especially in the context of recent loss where the deceased may feel physically present. - These are typically understood by the grieving individual as not being truly real and are distinct from the fixed, false beliefs seen in **delusions**. *Feelings of guilt* - Feeling **guilt for not spending more time** with the deceased is a very common and understandable emotional component of grief, reflecting a natural human tendency to re-evaluate past interactions after a loss. - This emotion, while painful, is not indicative of path-ologic grief unless it becomes pervasive, irrational, and leads to severe self-blame that impairs functioning, which is not the primary issue here. *Duration of the grief* - The grief having lasted **5 months** is within a typical range for processing a significant loss, especially that of a close family member. - While prolonged grief (which typically extends beyond 6-12 months for many diagnostic criteria) can be pathologic, the duration alone in this case does not make it the most indicative symptom compared to the presence of delusions.

Question 48: A 20-year-old student is referred to his college's student health department because his roommates are concerned about his recent behavior. He rarely leaves his room, has not showered in several days, appears to be praying constantly even though he is not religious, and has not been studying despite previously being an extremely good student. After evaluating this patient, a physician decides to recommend initiation of pharmacological treatment. The patient's family is concerned because they heard that the drug being recommended may be associated with heart problems. Which of the following characteristics is a property of the most likely drug that was prescribed in this case?

A. May cause weight gain and metabolic changes
B. Lower risk of extrapyramidal symptoms
C. High affinity for serotonin 5-HT2A receptors
D. Prolongs the QT interval (Correct Answer)
E. Generally less sedating than older antipsychotics

Explanation: ***Prolongs the QT interval*** - The patient presents with **first-episode psychosis** (social withdrawal, poor hygiene, bizarre behavior, academic decline in a previously high-functioning young adult) - The family's specific concern about **"heart problems"** is the key clue pointing to **QT interval prolongation** - Among antipsychotics used for first-episode psychosis, **ziprasidone** is most notably associated with QT prolongation and carries an FDA warning about this cardiac effect - While other antipsychotics may also prolong QT to varying degrees, ziprasidone's association with this adverse effect is well-established and would prompt specific family counseling about cardiac risks - QT prolongation increases risk of **torsades de pointes**, a potentially fatal arrhythmia *May cause weight gain and metabolic changes* - **Weight gain and metabolic syndrome** (hyperglycemia, dyslipidemia) are common adverse effects of many **atypical antipsychotics**, particularly olanzapine and clozapine - While these are serious long-term concerns, they would typically be described as "weight" or "diabetes" problems rather than acute "heart problems" - This is not the distinguishing feature being emphasized by the family's concern *Lower risk of extrapyramidal symptoms* - **Lower EPS risk** is a characteristic feature of **atypical (second-generation) antipsychotics** compared to typical (first-generation) agents - This is actually a therapeutic advantage and would not be a concern for the family - This property applies to most atypical antipsychotics, not specifically to the one causing family concern about cardiac effects *High affinity for serotonin 5-HT2A receptors* - **5-HT2A receptor antagonism** is a defining pharmacological property of **atypical antipsychotics** that contributes to their lower EPS risk and efficacy for negative symptoms - This mechanism applies broadly to the atypical antipsychotic class - It does not explain the specific family concern about "heart problems" *Generally less sedating than older antipsychotics* - Sedation profiles vary widely among antipsychotics; some atypicals (quetiapine) are quite sedating while others (aripiprazole, ziprasidone) are less so - Sedation is not typically characterized as a "heart problem" - This does not address the cardiac safety concern highlighted in the question

Question 49: A 24-year-old man is brought to your emergency department under arrest by the local police. The patient was found naked at a busy intersection jumping up and down on top of a car. Interviewing the patient, you discover that he has not slept in 2 days because he does not feel tired. He reports hearing voices. The patient was previously hospitalized 1 year ago with auditory hallucinations, paranoia, and a normal mood. What is the most likely diagnosis?

A. Schizophrenia
B. Bipolar disorder
C. Brief psychotic disorder
D. Schizotypal disorder
E. Schizoaffective disorder (Correct Answer)

Explanation: ***Schizoaffective disorder*** - This patient demonstrates the **hallmark feature** of schizoaffective disorder: **psychotic symptoms occurring both during AND independent of mood episodes**. - **Current presentation**: Clear **manic episode** (decreased need for sleep, grandiose/disinhibited behavior, psychomotor agitation) with psychotic features (auditory hallucinations). - **Previous hospitalization**: **Psychotic symptoms (hallucinations, paranoia) in the absence of a mood episode** ("normal mood"), requiring hospitalization for at least 2 weeks - this is the **key diagnostic criterion** for schizoaffective disorder. - The diagnosis requires an **uninterrupted period of illness** with both psychotic symptoms (meeting Criterion A for schizophrenia) and a major mood episode, PLUS psychotic symptoms for **≥2 weeks without prominent mood symptoms**. *Bipolar disorder* - In bipolar disorder with psychotic features, psychotic symptoms occur **exclusively during mood episodes** (manic, hypomanic, or depressive). - This patient's previous hospitalization with psychosis but **"normal mood"** indicates psychotic symptoms independent of mood episodes, which **rules out** bipolar disorder and points to schizoaffective disorder. - While the current presentation shows mania with psychosis, the longitudinal course is critical for diagnosis. *Schizophrenia* - Schizophrenia involves **continuous psychotic symptoms** without prominent mood episodes dominating the clinical picture. - This patient has **prominent manic symptoms** (decreased sleep, grandiose behavior, agitation) that are central to the current presentation, making schizophrenia less likely. - The presence of full mood episodes that occupy a **substantial portion** of the illness duration favors schizoaffective disorder over schizophrenia. *Brief psychotic disorder* - Brief psychotic disorder involves psychotic symptoms lasting **<1 month** with full return to baseline functioning. - This patient has a **recurrent course** with hospitalization 1 year ago, indicating a chronic/recurring condition rather than a brief, self-limited episode. *Schizotypal disorder* - This is a **personality disorder** characterized by social deficits, cognitive/perceptual distortions, and eccentric behavior, but **NOT overt psychotic episodes**. - Does not involve acute psychotic breaks with severe symptoms like hallucinations requiring hospitalization or manic episodes.

Question 50: A 23-year-old man is brought to the emergency department by the police after attempting to assault a waiter with a broom. The patient states that the FBI has been following him his entire life and that this man was an agent spying on him. The patient has a past medical history of irritable bowel syndrome. His temperature is 98.0°F (36.7°C), blood pressure is 137/68 mmHg, pulse is 110/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is deferred due to patient combativeness. The patient is given haloperidol and diphenhydramine. The patient is later seen in his room still agitated. Intraosseous access is obtained. Which of the following is the best next step in management?

A. Complete blood count
B. Urine toxicology (Correct Answer)
C. Thyroid stimulating hormone level
D. Assess for suicidal ideation
E. Syphilis screening

Explanation: ***Urine toxicology*** - A definitive diagnosis of **substance-induced psychosis** or **agitation** can be made through a urine toxicology screen, which is crucial given the patient's acute agitated state and paranoid delusions. - Identification of specific substances helps guide further management, as some intoxicants or withdrawal states require targeted interventions. *Complete blood count* - While a CBC assesses for infection or anemia, it is unlikely to reveal the primary cause of acute **agitation** and **paranoid delusions** in this context. - This diagnostic test would be more relevant if there were signs of infection (e.g., fever, localized pain) or significant blood loss. *Thyroid stimulating hormone level* - Although **thyroid dysfunction** can cause psychiatric symptoms, it typically manifests more gradually and rarely presents with such an acute onset of severe **agitation** and **paranoia**. - Other clinical signs of thyroid dysfunction, such as weight changes or altered energy levels, are also absent. *Assess for suicidal ideation* - While important in any psychiatric evaluation, assessing for **suicidal ideation** is a part of mental status examination. Given the patient's current severe agitation and combativeness, obtaining a reliable assessment of suicidal ideation is extremely difficult and secondary to managing the acute behavioral crisis and identifying immediate medical causes. - The immediate priority is to understand the etiology of his acute behavioral disturbance and ensure safety, before a full psychiatric history can be reliably obtained. *Syphilis screening* - **Neurosyphilis** can cause neuropsychiatric symptoms, including psychosis, but it is typically a chronic condition with a more insidious onset. - In an acutely agitated patient with sudden onset of paranoid delusions, syphilis is a less likely immediate cause compared to substance use.

Question 51: A 20-year-old male is brought to a psychiatrist by his parents for bizarre behavior. His parents report that over the past two semesters in school, his personality and behavior have changed noticeably. He refuses to leave his room because he believes people are spying on him. He hears voices that are persecutory and is convinced that people at school have chips implanted in their brains to spy on him. Screenings for depression and mania are negative. His past medical history is unremarkable. His family history is notable for a maternal uncle with bipolar disorder. He does not drink alcohol or smoke. His temperature is 98.8°F (37.1°C), blood pressure is 115/70 mmHg, pulse is 85/min, and respirations are 18/min. On examination, he appears to be responding to internal stimuli. Which of the following pathways is primarily responsible for these symptoms?

A. Papez circuit
B. Mesocortical pathway
C. Nigrostriatal pathway
D. Tuberoinfundibular pathway
E. Mesolimbic pathway (Correct Answer)

Explanation: ***Mesolimbic pathway*** - The **mesolimbic pathway** is primarily associated with the **positive symptoms of psychosis**, such as **hallucinations and delusions**, due to **dopamine hyperactivity**. - The patient's **persecutory delusions, auditory hallucinations, and paranoia** are hallmark positive symptoms seen in conditions like schizophrenia, which are mediated by this pathway. *Papez circuit* - The **Papez circuit** is involved in **emotion and memory**, connecting structures like the hippocampus and cingulate gyrus. - Dysregulation of this circuit would more likely manifest as deficits in memory or emotional regulation rather than the prominent psychotic features described. *Mesocortical pathway* - The **mesocortical pathway** projects to the **prefrontal cortex** and is implicated in **negative symptoms** (e.g., apathy, flat affect) and **cognitive deficits** (e.g., executive dysfunction) of psychosis, often due to **dopamine hypoactivity**. - While cognitive and negative symptoms can co-occur in psychotic disorders, they are not the primary, most striking symptoms described here. *Nigrostriatal pathway* - The **nigrostriatal pathway** is crucial for **motor control**, connecting the substantia nigra to the striatum. - Dysfunction in this pathway leads to **extrapyramidal symptoms** (e.g., tremors, rigidity, dyskinesia), which are not present in this patient's presentation. *Tuberoinfundibular pathway* - The **tuberoinfundibular pathway** connects the hypothalamus to the pituitary gland and regulates **prolactin secretion**. - Its primary role is in neuroendocrine function, and its dysfunction would lead to **hyperprolactinemia** and related symptoms, not the psychotic features described.

Question 52: A 35-year-old male is brought to the physician by his wife who is concerned because he has begun to demonstrate odd behavior which has worsened over the past several months. She states that he has become very aggressive and at times will have sudden, jerky movements which he is unable to control. The patient states that his father had the same problem which he died of at age 69. The patient had a recent cold with fevers, chills and throat pain which resolved on its own some time ago. Which of the following is true of this disease?

A. A mutation in ATP7B on chromosome 13 is responsible
B. Erythema marginatum is a complication associated with this disease
C. Overactivity of dopamine in the mesolimbic pathway is the underlying pathology
D. It demonstrates anticipation (Correct Answer)
E. Underactivity of dopamine in the nigrostriatal pathway is the underlying pathology

Explanation: ***It demonstrates anticipation*** - This patient presents with symptoms characteristic of **Huntington's disease**, including **choreiform movements** and **behavioral changes** (aggression). The family history of the father having the same condition and dying at a younger age than expected for a neurodegenerative disease suggests **anticipation**. - **Anticipation** in Huntington's disease refers to the phenomenon where successive generations experience an earlier onset of symptoms and increased severity due to the expansion of the **CAG trinucleotide repeat** in the Huntingtin gene. *A mutation in ATP7B on chromosome 13 is responsible* - A mutation in the **ATP7B gene on chromosome 13** is responsible for **Wilson's disease**, an autosomal recessive disorder of copper metabolism. - Wilson's disease presents with neurological and psychiatric symptoms, but typically includes **Kayser-Fleischer rings** and liver disease, and does not commonly manifest with the pronounced chorea and anticipation seen in Huntington's. *Underactivity of dopamine in the nigrostriatal cortex is the underlying pathology* - **Underactivity of dopamine in the nigrostriatal cortex** is the primary pathology in **Parkinson's disease**, characterized by **bradykinesia**, rigidity, tremor, and postural instability. - Huntington's disease, however, is associated with the **degeneration of GABAergic neurons** in the striatum, leading to an effective overactivity of dopamine relative to acetylcholine. *Erythema marginatum is a complication associated with this disease* - **Erythema marginatum** is a characteristic skin rash associated with **acute rheumatic fever**, an inflammatory condition that can occur after a Group A Streptococcus infection, and can lead to **Sydenham's chorea**. - While Sydenham's chorea presents with jerky movements, it typically follows streptococcal infection and resolves, unlike the progressive neurodegeneration and anticipation seen in Huntington's disease. *Overactivity of dopamine in the mesolimbic pathway is the underlying pathology* - **Overactivity of dopamine in the mesolimbic pathway** is often implicated in **psychotic disorders** like schizophrenia, contributing to positive symptoms. - While Huntington's disease involves a relative dopaminergic overactivity leading to chorea, the core pathology lies in the degeneration of specific striatal neurons rather than solely mesolimbic pathway dysfunction, and it's not the primary underlying mechanism for the entire spectrum of its symptoms.

Question 53: A 5-year-old girl is brought to the physician because her mother has found her to be inattentive at home and has received multiple complaints from her teachers at school. She does not complete her assignments and does not listen to her teachers' instructions. She refuses to talk to her parents or peers. Her mother says, “She ignores everything I say to her!” She prefers playing alone, and her mother reports that she likes playing with 5 red toy cars, repeatedly arranging them in a straight line. She avoids eye contact with her mother and the physician throughout the visit. Physical and neurological examination shows no abnormalities. Which of the following is the most likely diagnosis?

A. Rett syndrome
B. Conduct disorder
C. Oppositional defiant disorder
D. Attention deficit hyperactivity disorder
E. Autism spectrum disorder (Correct Answer)

Explanation: ***Autism spectrum disorder*** - The child exhibits core features of **autism spectrum disorder (ASD)**, including **social communication deficits** (refuses to talk, ignores parents, avoids eye contact) and **restricted, repetitive patterns of behavior** (playing with 5 red toy cars, repeatedly arranging them in a straight line). - Her inattention and difficulty following instructions are also common in ASD, often related to focus on their specific interests rather than external demands, and **sensory processing differences** or **executive dysfunction**. *Rett syndrome* - This is a neurodevelopmental disorder almost exclusively affecting **females** and typically presents with a period of normal development followed by **regression of acquired skills**, especially **language and motor skills**. - Key features include **stereotypic hand movements** (hand-wringing, squeezing), **gait abnormalities**, and **deceleration of head growth**, none of which are described in the patient. *Conduct disorder* - Characterized by a **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, and serious rule violations. - The presented symptoms of social communication deficits and repetitive behaviors are not indicative of conduct disorder. *Oppositional defiant disorder* - Involves a pattern of **angry/irritable mood, argumentative/defiant behavior**, or **vindictiveness** lasting at least 6 months, often directed at authority figures. - While the child may appear defiant by not listening, the broader constellation of **social communication deficits** and **repetitive behaviors** points away from ODD as the primary diagnosis. *Attention deficit hyperactivity disorder* - Presents with a persistent pattern of **inattention and/or hyperactivity-impulsivity** that interferes with functioning or development. - Although the child is inattentive, the presence of **social communication difficulties** and **restricted, repetitive behaviors** are not characteristic of ADHD and are better explained by ASD.

Question 54: A 34-year-old woman presents with recurrent panic attacks that have been worsening over the past 5 weeks. She also says she has been seeing things that are not present in reality and is significantly bothered by a short attention span which has badly affected her job in the past 6 months. No significant past medical history. No current medications. The patient is afebrile and vital signs are within normal limits. Her BMI is 34 kg/m2. Physical examination is unremarkable. The patient is prescribed antipsychotic medication. She expresses concerns about any effects of the new medication on her weight. Which of the following medications would be the best course of treatment in this patient?

A. Ziprasidone (Correct Answer)
B. Clozapine
C. Chlorpromazine
D. Olanzapine
E. Clonazepam

Explanation: ***Ziprasidone*** - **Ziprasidone** causes minimal **weight gain** and has a lower risk of metabolic side effects compared to other antipsychotics, making it a good choice for a patient concerned about weight, especially with a BMI of 34 kg/m2. - It treats psychotic symptoms like hallucinations and can help manage anxiety associated with panic attacks. *Clozapine* - **Clozapine** is known for causing significant **weight gain** and metabolic disturbances, which would be a concern for this patient. - It is typically reserved for treatment-resistant schizophrenia due to its potential for serious side effects like **agranulocytosis**. *Chlorpromazine* - **Chlorpromazine** is a first-generation antipsychotic associated with a high risk of **extrapyramidal symptoms** (EPS) and sedation. - It can also lead to moderate **weight gain** and is generally not preferred as a first-line treatment if metabolic concerns are present. *Olanzapine* - **Olanzapine** is associated with a high risk of **weight gain** and metabolic syndrome, which would exacerbate the patient's existing weight concerns. - While effective for psychosis, its metabolic side effect profile makes it a less suitable choice in this scenario. *Clonazepam* - **Clonazepam** is a **benzodiazepine** primarily used for anxiety and panic attacks, but it is not an antipsychotic. - It would not address the patient's psychotic symptoms (seeing things not present in reality), which require an antipsychotic medication.

Question 55: A 3-year-old girl is brought in by her parents to her pediatrician for concerns about their child’s behavior. Since the parents started taking their child to daycare, they have become concerned that their daughter has not been behaving like other children her age. Most notably, she seldom responds when her name is called at home or at daycare. Additionally, she has been getting in trouble with the day care staff for not following directions but instead demanding to play with the train set at all times. She has been asked numerous times to share the toys, but the patient does not play with the other children. The parents state that the patient was born vaginally following a normal pregnancy, and the patient had been meeting developmental milestones all along. While she does not speak much, she is able to construct sentences up to 4-5 words. On exam, the patient’s temperature is 98.2°F (36.8°C), blood pressure is 106/60 mmHg, pulse is 76/min, and respirations are 14/min. The patient does not cooperate with gross or fine motor testing, but she appears to have no trouble running around the room and draws very detailed trains with crayons. While drawing and standing, she frequently makes flapping motions with her hands. The patient has ample vocabulary, but speaks in a singsong voice mostly to herself and does not engage during the exam. Which of the following is the most likely diagnosis?

A. Rett syndrome
B. Normal development
C. Tourette syndrome
D. Attention-deficit hyperactivity disorder
E. Autism spectrum disorder (Correct Answer)

Explanation: ***Autism spectrum disorder*** - The patient exhibits core features of **autism spectrum disorder (ASD)**, including **deficits in social-emotional reciprocity** (seldom responds to name, does not play with other children, does not engage during exam) and **restricted, repetitive patterns of behavior, interests, or activities** (demands to play with train set, flapping motions with hands, detailed train drawings). - Her **normal developmental milestones** initially, followed by the emergence of these behaviors by age 3, and her peculiar speech patterns (singsong voice, speaking mostly to herself) further support this diagnosis. *Rett syndrome* - This genetic disorder primarily affects girls and is characterized by **normal early development followed by regression** of communication and motor skills, as well as **stereotypic hand movements**. - However, key differentiating features such as **loss of purposeful hand skills** and **severe intellectual disability** are not prominent in this case, and the patient has some communicative abilities. *Normal development* - While some variations in child behavior are normal, the described combination of **persistent social communication deficits** and **restricted, repetitive behaviors** significantly deviates from typical development for a 3-year-old. - The child's lack of response to her name, inability to play with peers, and intense focus on a single activity are **red flags for developmental concerns**. *Tourette syndrome* - This disorder is characterized by **multiple motor tics and one or more vocal tics** that are sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations. - While the patient has flapping motions, these are more consistent with **stereotyped movements** seen in ASD rather than the characteristic tics of Tourette syndrome, and vocal tics are not mentioned. *Attention-deficit hyperactivity disorder* - This condition is characterized by **persistent patterns of inattention and/or hyperactivity-impulsivity** that interfere with functioning or development. - While hyperactivity might be present (running around the room), the primary concern in this patient is the profound **social communication deficits** and **restricted, repetitive behaviors**, which are not central to ADHD.

Question 56: A 60-year-old man is brought to the emergency department by police officers because he was seen acting strangely in public. The patient was found talking nonsensically to the characters on cereal boxes in a grocery store. Past medical history is significant for multiple hospitalizations for alcohol-related injuries and alcohol withdrawal seizures. Vital signs are within normal limits. On physical examination, the patient is disheveled and oriented x1. Neurologic examination shows horizontal nystagmus and severe ataxia. It is noted that after interviewing the patient, he forgets the faces of persons and the questions asked shortly after he walks out the door. He, however, remembers events from his distant past quite well. Which of the following is the most likely diagnosis in this patient?

A. Dementia
B. Delirium
C. Korsakoff amnesia (Correct Answer)
D. Delirium tremens
E. Schizophrenia

Explanation: ***Korsakoff amnesia*** - This patient presents with **anterograde amnesia** (inability to form new memories, forgetting faces/questions after a short time) and **retrograde amnesia** for recent events, while **remote memory remains intact**. These are classic features of Korsakoff amnesia, also known as **Korsakoff syndrome**, which stems from **thiamine deficiency**, common in chronic alcoholics. - The history of **chronic alcoholism** and previous **alcohol withdrawal seizures** strongly supports a diagnosis of thiamine deficiency. The earlier symptoms of horizontal nystagmus and ataxia could point to a preceding Wernicke encephalopathy, which can progress to Korsakoff syndrome if untreated. *Dementia* - **Dementia** is a progressive decline in cognitive function, including memory, over time, but it typically affects both recent and remote memories and is usually not characterized by a sudden onset after alcohol-related issues. - While dementia can be caused by chronic alcoholism, the specific constellation of symptoms, including intact remote memory and prominent anterograde amnesia, alongside acute neurological signs, is more characteristic of Korsakoff amnesia. *Delirium* - **Delirium** is characterized by an **acute onset of fluctuating attention** and **altered consciousness**, often accompanied by hallucinations and disorientation. While this patient has disorientation and strange behavior, the **specific memory deficits** (intact remote memory, severe anterograde amnesia) and the history of chronic alcoholism point to a more specific chronic condition. - Although the patient's acute presentation in the ED might seem like delirium, the persistent and specific memory deficits and neurological signs suggest a more underlying chronic problem than just an acute confusional state. *Delirium tremens* - **Delirium tremens** is a severe form of **alcohol withdrawal** characterized by hallucinations, severe disorientation, tremors, and autonomic instability. It typically presents with a more acute and agitated course and **does not primarily manifest with the selective memory deficits** seen in this patient (intact remote memory with severe anterograde amnesia). - The patient's vital signs are noted as "within normal limits," which would be unlikely during a severe episode of delirium tremens, which often involves significant **autonomic hyperactivity** (e.g., tachycardia, hypertension, fever). *Schizophrenia* - **Schizophrenia** is a chronic mental disorder characterized by **psychosis**, disorganized thought, hallucinations, and delusions, typically developing in early adulthood. While the patient is acting "strangely" and "talking nonsensically," the **neurological signs** (nystagmus, ataxia) and specific patterns of **memory loss** are not typical features of schizophrenia. - The acute presentation in an older patient with a history of severe alcoholism strongly points away from schizophrenia as the primary diagnosis.

Question 57: A 9-year-old boy is brought to the emergency room by his mother for weakness, diaphoresis, and syncope. His mother says that he has never been diagnosed with any medical conditions but has been having “fainting spells” over the past month. Routine lab work reveals a glucose level of 25 mg/dL. The patient is promptly given glucagon and intravenous dextrose and admitted to the hospital for observation. The patient’s mother stays with him during his hospitalization. The patient is successfully watched overnight and his blood glucose levels normalize on his morning levels. The care team discusses a possible discharge during morning rounds. One hour later the nurse is called in for a repeat fainting episode. A c-peptide level is drawn and shown to be low. The patient appears ill, diaphoretic, and is barely arousable. Which of the following is the most likely diagnosis in this child?

A. Conversion disorder
B. Somatic symptom disorder
C. Munchausen syndrome
D. Insulinoma
E. Munchausen syndrome by proxy (Correct Answer)

Explanation: ***Munchausen syndrome by proxy*** - The repeated **hypoglycemic episodes**, particularly after initial recovery and in the presence of the mother, suggest that the symptoms are **induced by a caregiver**. - A **low C-peptide** level during hypoglycemia indicates exogenous insulin administration, a typical finding in factitious hypoglycemia induced by a caregiver. *Conversion disorder* - This involves neurological symptoms **without a clear medical explanation**, often triggered by psychological stress. - However, the **severe hypoglycemia** and **low C-peptide** provide clear physiological evidence that rules out a purely psychological conversion. *Somatic symptom disorder* - Characterized by one or more **somatic symptoms that are distressing** or result in significant disruption of daily life, without a medical explanation. - The **objective finding of severe hypoglycemia** and **low C-peptide** indicates a real physiological disturbance, not just perceived symptoms. *Munchausen syndrome* - This involves an individual **falsifying or inducing illness in themselves** for attention or sympathy. - The patient is a 9-year-old boy, and the context points to **caregiver involvement** in inducing the illness, making **Munchausen by proxy** more likely. *Insulinoma* - An **insulinoma** is an insulin-producing tumor that would cause **high insulin** and **high C-peptide** levels during hypoglycemia. - The presented case explicitly states a **low C-peptide** level, which rules out an insulinoma as the cause.

Question 58: A 17-year-old boy with behavioral changes is brought in by his concerned parents. The patient’s parents say that he has been acting very odd and having difficulty academically for the past 4 months. The patient says that he has been worried and distracted because he is certain the government is secretly recording him although he cannot provide a reason why. He mentions that he does feel depressed sometimes and no longer gets joy out of playing the guitar and his other previous activities. He has no significant past medical history. The patient denies any history of smoking, alcohol consumption, or recreational drug use. He is afebrile, and his vital signs are within normal limits. Physical examination is unremarkable. On mental status examination, the patient is slightly disheveled and unkempt. He has a disorganized monotonous speech pattern. He expresses tangential thinking and has a flat affect. During the exam, it is clear that he suffers from auditory hallucinations. Which of the following is the most likely diagnosis in this patient?

A. Schizophreniform disorder (Correct Answer)
B. Schizophrenia
C. Schizoaffective disorder
D. Schizotypal personality disorder
E. Brief psychotic disorder

Explanation: ***Schizophreniform disorder*** - This patient presents with **psychotic symptoms** including delusions (government recording him), auditory hallucinations, disorganized speech, flat affect, and behavioral changes, which have been present for **4 months**. - The duration of symptoms (1 to 6 months) is the key criterion for diagnosing **schizophreniform disorder**, differentiating it from brief psychotic disorder (less than 1 month) and schizophrenia (greater than 6 months). *Schizophrenia* - While the patient exhibits many symptoms consistent with schizophrenia, the duration of his symptoms (4 months) is **less than the 6 months** required for a diagnosis of schizophrenia. - Schizophrenia requires at least 6 months of continuous signs of disturbance, including at least 1 month of active-phase symptoms. *Schizoaffective disorder* - This disorder requires a significant mood episode (major depressive or manic) to be present concurrently with the psychotic symptoms for most of the illness duration. - Although the patient mentions feeling depressed sometimes and having anhedonia, there is no indication of a full-blown **major depressive or manic episode** meeting diagnostic criteria, nor is it explicitly stated that mood symptoms are present for a majority of the illness. *Schizotypal personality disorder* - This is a personality disorder characterized by pervasive patterns of social and interpersonal deficits, accompanied by **cognitive or perceptual distortions** and eccentric behaviors. - While some features like odd beliefs might overlap, the patient's presentation with clear-cut delusions and hallucinations indicates a **psychotic disorder**, not primarily a personality disorder. *Brief psychotic disorder* - Brief psychotic disorder is characterized by the sudden onset of psychotic symptoms that last for **less than 1 month**. - This patient's symptoms have been ongoing for **4 months**, exceeding the duration criteria for brief psychotic disorder.

Question 59: A 28-year-old man presents to his psychiatrist for continuing cognitive behavioral therapy for bipolar disorder. At this session, he reveals that he has had fantasies of killing his boss because he feels he is not treated fairly at work. He says that he has been stalking his boss and has made detailed plans for how to kill him in about a week. He then asks his psychiatrist not to reveal this information and says that he shared it only because he knew these therapy sessions would remain confidential. Which of the following actions should the psychiatrist take in this scenario?

A. Respect patient confidentiality and do not write down this information
B. Ask for the patient's permission to share this information and share only if granted
C. Contact the police to warn them about this threat against the patient's wishes (Correct Answer)
D. Refer the patient to the ethics board of the hospital that meets in 1 week
E. Write the information in the note but do not contact the police

Explanation: ***Correct: Contact the police to warn them about this threat against the patient's wishes*** * This scenario directly invokes the **duty to warn** (or the **Tarasoff duty**), which legally obligates psychiatrists to breach confidentiality when a patient poses a serious and imminent threat of violence to an identifiable victim. * The patient has expressed clear intent, a specific victim (the boss), and a detailed plan with an imminent timeline (about a week), making the threat credible and requiring immediate action to protect the potential victim. * Contacting the police is an appropriate way to fulfill this duty. The psychiatrist may also directly warn the intended victim (the boss) or take both actions depending on the circumstances and jurisdiction. *Incorrect: Respect patient confidentiality and do not write down this information* * While patient confidentiality is paramount in psychiatry, it is not absolute when there is a **serious and imminent threat of harm** to an identifiable person. * Failing to act on a credible threat of violence could result in harm to the intended victim and expose the psychiatrist to **legal liability** for failure to warn. *Incorrect: Ask for the patient's permission to share this information and share only if granted* * In situations involving a clear and imminent threat to a third party, gaining the patient's permission is not required and waiting for it could delay necessary protective actions. * The duty to warn takes precedence over patient autonomy in these specific circumstances to prevent serious harm. *Incorrect: Refer the patient to the ethics board of the hospital that meets in 1 week* * Referring to an ethics board would involve a **significant delay**, which is unacceptable given the imminent nature of the threat (to occur in "about a week"). * This approach would not fulfill the psychiatrist's immediate legal and ethical obligation to protect the potential victim from harm. *Incorrect: Write the information in the note but do not contact the police* * While documenting the threat is important for the medical record, simply writing it down without taking action to warn the victim or authorities would fail to mitigate the imminent danger. * This action alone would not fulfill the **duty to warn** and could result in preventable harm, making the psychiatrist potentially liable for failure to protect.

Question 60: A 3-year-old girl is brought to the pediatrician by her parents who are concerned that she is not developing normally. They say she does not talk and avoids eye contact. She prefers to sit and play with blocks by herself rather than engaging with other children. They also note that she will occasionally have violent outbursts in inappropriate situations. She is otherwise healthy. In the office, the patient sits quietly in the corner of the room stacking and unstacking blocks. Examination of the patient shows a well-developed female with no physical abnormalities. Which of the following is the most likely diagnosis in this patient?

A. Autism spectrum disorder (Correct Answer)
B. Fragile X syndrome
C. Cri-du-chat syndrome
D. Oppositional defiant disorder
E. Rett syndrome

Explanation: **Autism spectrum disorder** - The patient's presentation with **impaired social interaction** (avoiding eye contact, playing alone), **communication deficits** (not talking), **repetitive behaviors** (stacking/unstacking blocks), and **restricted interests/activities** (violent outbursts in inappropriate situations) are classic diagnostic criteria for **autism spectrum disorder**. - ASD has a **strong genetic component** (heritability 60-90%), though the absence of physical abnormalities helps distinguish it from syndromic forms like Fragile X syndrome. *Fragile X syndrome* - While **intellectual disability** and **autism-like features** can occur, Fragile X syndrome is typically associated with specific physical findings such as a **long face, large ears, and macroorchidism** in males, which are not mentioned here. - It is a **genetic condition** and often presents with more significant cognitive impairment than described. *Cri-du-chat syndrome* - This syndrome is characterized by a **distinctive high-pitched cry** resembling a cat's meow, **microcephaly**, and **severe intellectual disability**, none of which are noted in the patient's presentation. - Children with Cri-du-chat syndrome often have significant **developmental delays** and physical abnormalities that are not described. *Oppositional defiant disorder* - This disorder is characterized by a pattern of **angry/irritable mood, argumentative/defiant behavior, or vindictiveness** towards authority figures, but it does not fully explain the social and communication deficits, or the repetitive behaviors observed. - While violent outbursts could be a symptom, the overall clinical picture of **social avoidance and communication delay** is more indicative of a pervasive developmental disorder. *Rett syndrome* - Rett syndrome is a **neurodevelopmental disorder** that primarily affects girls, characterized by a period of normal development followed by regression, loss of acquired hand skills, and **stereotypic hand movements**. - The patient's presentation does not describe a period of regression or the characteristic hand stereotypies, which typically emerge between 6-18 months of age.

Question 61: An 81-year-old man is brought to the physician by his daughter after being found wandering on the street. His daughter says that over the past several months he has been more aggressive towards friends and family. She also reports several episodes in which he claimed to see two strangers in her apartment. He sometimes stares blankly for several minutes and does not react when addressed. He has hypertension, hyperlipidemia, and was diagnosed with Parkinson disease 10 months ago. His current medications include carbidopa-levodopa, hydrochlorothiazide, and atorvastatin. His temperature is 37°C (98.6°F), pulse is 99/min, and blood pressure is 150/85 mm Hg. He is confused and oriented to person and place but not to time. There is a resting tremor in his right upper extremities. There is muscle rigidity in the upper and lower extremities. He is able to walk without assistance but has a slow gait with short steps. Mental status examination shows short-term memory deficits. Which of the following is the most likely underlying cause of this patient's condition?

A. Impaired CSF absorption
B. Thiamine deficiency
C. Vascular infarcts
D. Lewy body deposition (Correct Answer)
E. Frontotemporal lobe atrophy

Explanation: ***Lewy body deposition*** - The patient's history of **Parkinson disease** along with the development of **visual hallucinations** (seeing strangers), waxing and waning cognition (staring blankly, not reacting), parkinsonism, and fluctuations in alertness strongly suggest **Lewy body dementia (LBD)**. - LBD is characterized by the abnormal deposition of **alpha-synuclein proteins** (Lewy bodies) in neurons, affecting both cortical and subcortical areas. *Impaired CSF absorption* - This usually leads to **normal pressure hydrocephalus (NPH)**, characterized by a triad of **gait disturbance**, **urinary incontinence**, and **dementia**. While gait issues and cognitive decline are present, visual hallucinations and fluctuating cognition are not typical features. - NPH lacks the prominent **parkinsonian features** and **visual hallucinations** seen in this patient. *Thiamine deficiency* - **Thiamine deficiency** (Wernicke-Korsakoff syndrome) typically presents with **ataxia**, **ophthalmoplegia**, and **confusion**, which can progress to **memory deficits** (Korsakoff psychosis). - It is commonly associated with **alcoholism** or severe malnutrition, and the patient's symptoms, particularly the visual hallucinations and parkinsonism, do not fit this profile. *Frontotemporal lobe atrophy* - **Frontotemporal dementia** (FTD) is characterized by prominent changes in **personality, behavior**, or **language skills**, with relatively preserved memory in early stages. While behavioral changes are noted, the vivid visual hallucinations, fluctuating cognition, and predominant parkinsonism are not characteristic of FTD. - FTD often involves specific **aphasic or behavioral variants** that differ from the diffuse cognitive and perceptual disturbances seen here. *Vascular infarcts* - **Vascular dementia** typically presents with a **step-wise decline** in cognitive function, often associated with a history of strokes or vascular risk factors (hypertension, hyperlipidemia). While this patient has vascular risks, the prominent visual hallucinations and fluctuating cognition are less characteristic. - The **parkinsonian features** and **visual hallucinations** point more strongly towards Lewy body pathology than vascular changes.

Question 62: A 25-year-old woman is brought to a psychiatrist's office by her husband who states that he is worried about her recent behavior, as it has become more violent. The patient's husband states that his family drove across the country to visit them and that his wife 'threatened his parents with a knife' at dinner last night. Police had to be called to calm her down. He states that she has been acting 'really crazy' for the last 9 months, and the initial behavior that caused him alarm was her admission that his deceased sister was talking to her through a decorative piece of ceramic art in the living room. Initially, he thought she was joking, but soon realized her complaints of 'hearing ghosts' talking to her throughout the house were persisting and 'getting worse'. Over the past 9 months, she has experienced multiple periods of profound sadness, with persistent insomnia and an unintentional weight loss of 12 pounds over several months. She has been complaining of feeling 'worthless' and has had markedly diminished interest in activities for much of this time period. Her general hygiene has also suffered from her recent lack of motivation and she insists that the 'ghosts' are asking her to kill as many people as she can so they won't be alone in the house. Her husband is extremely concerned that she may harm herself or someone else. He states that she currently does not take any medications or illicit drugs as far as he knows. She does not smoke or drink alcohol. The patient herself does not make eye contact or want to speak to the psychiatrist, allowing her husband to speak on her behalf. Which of the following is the most likely diagnosis in this patient?

A. Schizophreniform disorder
B. Schizophrenia
C. Delusional disorder
D. Schizoaffective disorder (Correct Answer)
E. Brief psychotic disorder

Explanation: ***Schizoaffective disorder*** - This patient exhibits symptoms of both a **major depressive disorder** (multiple periods of profound **sadness**, persistent **insomnia**, **weight loss** over several months, feelings of **worthlessness**, and markedly **diminished interest in activities**) and a **psychotic disorder** (auditory **hallucinations**, command hallucinations, **delusions**, violent behavior). - The total symptom duration is **9 months**, with **mood symptoms present for the majority of this period**, meeting the key DSM-5 criterion for schizoaffective disorder. - The patient also demonstrates **psychotic symptoms (hallucinations) that persist throughout**, including periods when mood symptoms may fluctuate, satisfying the requirement for delusions or hallucinations for ≥2 weeks in the absence of a major mood episode. - The combination of prominent mood episodes concurrent with schizophrenia-spectrum symptoms, with mood symptoms present for the majority of the illness duration, confirms schizoaffective disorder. *Schizophreniform disorder* - This disorder involves symptoms characteristic of **schizophrenia** lasting **between 1 and 6 months**. - The patient's symptoms have been present for **9 months**, exceeding the maximum duration for schizophreniform disorder. *Schizophrenia* - Schizophrenia requires persistent psychotic symptoms lasting **at least 6 months**, with at least one month of active-phase symptoms. - While this patient has psychotic symptoms for 9 months, the **prominent and prolonged depressive symptoms** that are present for the **majority of the illness duration** distinguish this from schizophrenia. - In schizophrenia, mood symptoms, if present, are **brief relative to the total duration** of the psychotic illness, which is not the case here. *Delusional disorder* - Delusional disorder is characterized by **non-bizarre delusions** for at least 1 month, without other prominent psychotic symptoms. - This patient experiences prominent **auditory hallucinations** ("hearing ghosts," "deceased sister talking to her") and **command hallucinations**, which are not features of delusional disorder. - The presence of hallucinations rules out this diagnosis. *Brief psychotic disorder* - This diagnosis involves sudden onset of psychotic symptoms lasting **more than 1 day but less than 1 month**, with eventual full recovery. - The patient's symptoms have persisted for **9 months**, far exceeding the duration criterion for brief psychotic disorder.

Question 63: A 14-year-old girl presents to her pediatrician with complaints of repeated jerking of her neck for the past 2 years. Initially, her parents considered it a sign of discomfort in her neck, but later they noticed that the jerking was more frequent when she was under emotional stress or when she was fatigued. The patient says she can voluntarily control the jerking in some social situations, but when she is under stress, she feels the urge to jerk her neck and she feels better after that. The parents also report occasional throat clearing and brief vocal sounds that seem involuntary. During the past year, there have been a few weeks when the frequency of both the neck jerking and vocal sounds decreased drastically, only to increase again afterwards. On physical examination, she is a physically healthy female with normal vital signs. Her neurologic examination is normal. The pediatrician also notes that when he makes certain movements, the patient partially imitates these movements. The parents are very concerned about her abnormal movements and insist on a complete diagnostic work-up. After a detailed history, physical examination, and laboratory investigations, the pediatrician confirms the diagnosis of Tourette syndrome. The presence of which of the following findings is most likely to confirm the pediatrician's diagnosis?

A. Decreased caudate volumes in magnetic resonance imaging (MRI) of the brain
B. Rigidity and bradykinesia
C. History of repeated bouts of unprovoked obscene speech over the past year (Correct Answer)
D. Increased activity in frontal subcortical regions in positron-emission tomography (PET) study
E. Low serum ceruloplasmin level

Explanation: ***History of repeated bouts of unprovoked obscene speech over the past year*** - **Coprolalia** (involuntary obscene speech) is a **complex vocal tic** that, when present, is **highly specific for Tourette syndrome** and strongly supports the diagnosis. - While coprolalia is **NOT required for diagnosis** (present in only 10-15% of Tourette patients), its presence in the context of motor and vocal tics is **highly characteristic** and distinguishes Tourette syndrome from other tic disorders. - The clinical vignette already demonstrates the **DSM-5 diagnostic criteria**: multiple motor tics plus vocal tics for >1 year with onset before age 18, making coprolalia an **additional supportive feature** rather than necessary for diagnosis. - Among the options provided, coprolalia is the **most clinically relevant finding** that would further support the Tourette syndrome diagnosis. *Decreased caudate volumes in magnetic resonance imaging (MRI) of the brain* - While structural brain changes including **reduced caudate volumes** have been observed in research studies of Tourette syndrome, these findings are **not diagnostic** or consistently present across all patients. - Neuroimaging is typically used to **rule out secondary causes** of tics (e.g., structural lesions, stroke) rather than to confirm Tourette syndrome, which remains a **clinical diagnosis**. *Rigidity and bradykinesia* - **Rigidity and bradykinesia** are cardinal features of **Parkinson's disease** and other parkinsonian syndromes, not Tourette syndrome. - Tourette syndrome involves **tics** (sudden, rapid, recurrent, non-rhythmic movements or vocalizations), which are phenomenologically distinct from parkinsonian features. *Increased activity in frontal subcortical regions in positron-emission tomography (PET) study* - Functional neuroimaging may show abnormalities in **basal ganglia-thalamocortical circuits** in Tourette syndrome, but these are **research findings** not used in clinical practice. - PET scans are **not part of diagnostic criteria** and lack the specificity needed to confirm Tourette syndrome, which is diagnosed based on clinical history and examination. *Low serum ceruloplasmin level* - A **low serum ceruloplasmin level** is diagnostic of **Wilson's disease**, a genetic disorder of copper metabolism that can present with neuropsychiatric symptoms and movement disorders. - Wilson's disease typically presents with tremor, dystonia, and parkinsonian features—not the tic pattern described in this case—and usually includes hepatic involvement.

Question 64: An 83-year-old man is being seen in the hospital for confusion. The patient was admitted 4 days ago for pneumonia. He has been improving on ceftriaxone and azithromycin. Then 2 nights ago he had an episode of confusion. He was unsure where he was and attempted to leave. He was calmed down by nurses with redirection. He had a chest radiograph that was stable from admission, a normal EKG, and a normal urinalysis. This morning he was alert and oriented. Then this evening he became confused and agitated again. The patient has a history of benign prostatic hyperplasia, severe dementia, and osteoarthritis. He takes tamsulosin in addition to the newly started antibiotics. Upon physical examination, the patient is alert but orientated only to name. He tries to get up, falls back onto the bed, and grabs his right knee. He states, “I need to get to work. My boss is waiting, but my knee hurts.” He tries to walk again, threatens the nurse who stops him, and throws a plate at the wall. In addition to reorientation, which of the following is the next best step in management?

A. Morphine
B. Lorazepam
C. Haloperidol (Correct Answer)
D. Rivastigmine
E. Physical restraints

Explanation: ***Haloperidol*** - The patient exhibits **delirium** with acute agitation, threatening behavior, and violent actions (throwing objects), representing an **imminent safety risk** to himself and staff. - After **non-pharmacological interventions** (reorientation) have failed, **low-dose haloperidol** is appropriate for managing **severe agitation** in delirium when there is risk of harm. - While antipsychotics have an FDA black box warning for increased mortality in elderly patients with dementia and recent evidence questions their efficacy in delirium, they remain indicated for **acute agitation with safety concerns** as a short-term intervention. - Haloperidol is preferred over atypical antipsychotics in acute hospital settings due to availability in parenteral forms and lower anticholinergic burden. *Morphine* - While the patient mentions knee pain (likely from osteoarthritis), his **primary issue** is acute agitation and delirium, not pain management. - **Opioids** can worsen delirium and confusion in elderly patients through anticholinergic effects and sedation. - Pain should be addressed, but not as the primary intervention for violent, agitated behavior. *Lorazepam* - **Benzodiazepines** are generally **contraindicated in delirium** as they worsen confusion, increase fall risk, and can cause paradoxical agitation in elderly patients. - The **only exceptions** are delirium from alcohol or benzodiazepine withdrawal, or seizures—none of which apply to this patient. - Lorazepam would likely exacerbate rather than improve this patient's mental status. *Rivastigmine* - **Rivastigmine** is an acetylcholinesterase inhibitor for chronic management of **dementia symptoms**, not acute delirium. - It has **no role** in managing acute behavioral disturbances and takes weeks to show any effect. - Studies have not shown benefit of cholinesterase inhibitors in preventing or treating delirium. *Physical restraints* - Physical restraints should be used only as a **last resort** when pharmacological and non-pharmacological interventions have failed and there is immediate, serious risk of harm. - Restraints can **increase agitation**, cause injuries, lead to delirium worsening, and are associated with increased morbidity and mortality. - They do not address the underlying cause and should be avoided when other options are available.

Question 65: A 21-year-old male college student is brought to the emergency department by the campus police after he was found yelling at a bookshelf in the library. His roommate does not know of any prior episodes similar to this. His vital signs are within normal limits. The patient appears unkempt. On mental status examination, he talks very fast with occasional abrupt interruptions. He is agitated. He is disoriented to time and repeatedly tells the physician, “I hear the sun telling me that I was chosen to save the universe.” Urine toxicology screen is negative. Which of the following is the most appropriate pharmacotherapy?

A. Alprazolam
B. Valproic acid
C. Dexmedetomidine
D. Haloperidol (Correct Answer)
E. Ziprasidone

Explanation: ***Haloperidol*** - This patient presents with acute **psychosis** characterized by **auditory hallucinations**, **disorganized speech**, and **agitation**, making an **antipsychotic** the most appropriate initial treatment. - **Haloperidol** is a potent **first-generation antipsychotic** effective for rapid tranquilization in acute psychotic episodes due to its fast onset of action and available parenteral formulation. - It remains a widely used option for acute agitation with psychosis, particularly when rapid control is needed. *Alprazolam* - **Alprazolam** is a **benzodiazepine** primarily used for anxiety and panic disorders, acting as a CNS depressant. - While it can reduce agitation, it does not directly address the underlying psychotic symptoms (hallucinations, delusions) and could exacerbate disorientation in a psychotic patient. *Valproic acid* - **Valproic acid** is a **mood stabilizer** and anticonvulsant, primarily used for bipolar disorder and epilepsy. - It is not an appropriate first-line treatment for acute psychosis or agitation when the primary issue is psychotic symptoms, as its onset of action is slower for acute behavioral control. *Dexmedetomidine* - **Dexmedetomidine** is an alpha-2 adrenergic agonist used for sedation, particularly in ICU settings, that provides sedation without significant respiratory depression. - While it could sedate this agitated patient, it does not treat the underlying psychosis and is generally not the first choice for agitation in acute psychiatric emergencies due to its primary action as a sedative rather than an antipsychotic. *Ziprasidone* - **Ziprasidone** is a **second-generation antipsychotic** that effectively treats psychosis and is available in both oral and IM formulations. - While ziprasidone IM has rapid onset and is commonly used for acute agitation with psychosis, **haloperidol** has longer historical use and more extensive clinical experience in emergency settings for rapid tranquilization, though both are appropriate choices. - Ziprasidone may cause QT prolongation, requiring ECG monitoring in some patients.

Question 66: A 17-year-old boy is brought to the physician by his parents who are concerned about his bizarre behavior. Over the past three months, he has become withdrawn from his friends and less interested in his classes and extracurricular activities. On several occasions, he has torn apart rooms in their home looking for “bugs” and states that the President is spying on him because aliens have told the government that he is a threat. Although he has always been quite clean in the past, his father notes that the patient’s room is now malodorous with clothes and dishes strewn about haphazardly. He also says that sometimes he can hear the devil speaking to him from inside his head. He has no medical problems, does not drink alcohol or use any drugs. Physical examination of the boy reveals no abnormalities. On mental status examination, the boy is oriented to person, place and time. He avoids eye contact and replies mostly with monosyllabic responses. He appears distracted, and confirms that he is hearing whispering voices in his head. What is the most appropriate diagnosis for this patient?

A. Schizophrenia
B. Schizoid personality type
C. Brief psychotic disorder
D. Schizophreniform disorder (Correct Answer)
E. Schizoaffective disorder

Explanation: ***Schizophreniform disorder*** - The patient exhibits core **psychotic symptoms** (delusions, hallucinations, disorganized thinking) for at least three months, but the duration is less than six months. - The presence of social and occupational dysfunction, along with prominent psychotic features like **paranoid delusions** and **auditory hallucinations**, is consistent with this diagnosis. *Schizophrenia* - Requires continuous signs of the disturbance for at least **six months**, including at least one month of active-phase symptoms. - While the symptoms are consistent with schizophrenia, the **duration criterion** of six months has not yet been met. *Schizoid personality type* - Characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression. - This patient's symptoms are primarily **psychotic** (delusions, hallucinations) and represent a significant change in functioning, not merely a personality style. *Brief psychotic disorder* - Characterized by the sudden onset of **psychotic symptoms** that last at least one day but **less than one month**. - The patient's symptoms have been ongoing for **three months**, exceeding the criteria for brief psychotic disorder. *Schizoaffective disorder* - Involves a period of illness during which there is an uninterrupted major mood episode (depressive or manic) concurrent with Criterion A of schizophrenia. - There is no mention of concurrent **major mood episodes** (mania or severe depression) in this patient's presentation.

Question 67: A 26-year-old man is brought to the emergency department by his wife because of bizarre and agitated behavior for the last 6 weeks. He thinks that the NSA is spying on him and controlling his mind. His wife reports that the patient has become withdrawn and at times depressed for the past 3 months. He lost his job because he stopped going to work 4 weeks ago. Since then, he has been working on an invention that will block people from being able to control his mind. Physical and neurologic examinations show no abnormalities. On mental status examination, he is confused and suspicious with marked psychomotor agitation. His speech is disorganized and his affect is labile. Which of the following is the most likely diagnosis?

A. Brief psychotic disorder
B. Schizophreniform disorder (Correct Answer)
C. Schizotypal personality disorder
D. Schizophrenia
E. Delusional disorder

Explanation: ***Schizophreniform disorder*** - The patient's symptoms, including **delusions** (fixed false beliefs that the NSA is spying and controlling his mind), **disorganized speech**, and **agitated behavior**, are consistent with a psychotic disorder. - The duration of active psychotic symptoms (6 weeks), which is more than 1 month but less than 6 months, fits the diagnostic criteria for **schizophreniform disorder**. - The prodromal phase (withdrawn and depressed for 3 months) plus the active phase does not yet meet the 6-month requirement for schizophrenia. *Brief psychotic disorder* - This disorder is characterized by a sudden onset of psychotic symptoms lasting less than 1 month, followed by a full return to premorbid functioning. - The patient's active psychotic symptoms have persisted for 6 weeks, exceeding the maximum duration for brief psychotic disorder. *Schizotypal personality disorder* - This disorder primarily involves a pervasive pattern of social and interpersonal deficits marked by acute discomfort with close relationships, as well as cognitive or perceptual distortions and eccentricities. - While there might be odd beliefs or magical thinking, it does not typically involve the persistent and severe delusions and disorganized speech seen in this case. - This is a personality disorder, not a psychotic disorder. *Schizophrenia* - Schizophrenia requires continuous signs of disturbance for at least 6 months, which includes at least 1 month of active-phase symptoms (delusions, hallucinations, disorganized speech). - The patient's total duration of illness (3 months of prodromal symptoms plus 6 weeks of active symptoms) totals approximately 4.5 months, which is less than the 6-month minimum duration required for a diagnosis of schizophrenia. *Delusional disorder* - The primary feature of delusional disorder is the presence of one or more delusions for at least 1 month, without other prominent psychotic symptoms such as disorganized speech or behavior. - This patient exhibits prominent **disorganized speech**, **labile affect**, and **disorganized behavior** (bizarre invention work), which are not characteristic of delusional disorder. - Functioning is more impaired than typically seen in delusional disorder.

Question 68: A 42-year-old woman is brought to the physician by her husband because of a 1-year history of abnormal behavior. During this time she has been irritable, restless, and has had multiple episodes of hearing voices. Over the past month, she has also had difficulty swallowing. She has a 2-year history of depression. She was let go by her employer 6 months ago because she could no longer handle all her tasks and often forgot about assignments. Her father committed suicide at the age of 50. The patient has smoked one pack of cigarettes daily over the past 20 years. She has a history of smoking cocaine for 8 years but stopped 1 year ago. Vital signs are within normal limits. On mental status examination, she is confused and oriented to person and place only. Neurologic examination shows a delayed return to neutral ankle position after triggering the plantar reflex. Physical examination shows irregular, nonrepetitive, and arrhythmic movements of the neck and head. The patient has poor articulation. Which of the following is the most likely diagnosis?

A. Parkinson disease
B. Multiple sclerosis
C. Huntington disease (Correct Answer)
D. Drug-induced chorea
E. Sydenham chorea

Explanation: ***Huntington disease*** - This patient presents with a classic triad of **motor dysfunction (chorea)**, **cognitive decline (dementia)**, and **psychiatric symptoms (irritability, restlessness, hallucinations, depression)**, which is highly characteristic of Huntington disease. - The **family history of suicide** in her father at a relatively young age (50), along with the patient's early onset of symptoms (42 years old), suggests an autosomal dominant inheritance pattern typical of Huntington disease. *Parkinson disease* - Parkinson disease typically presents with **bradykinesia**, **rigidity**, **tremor at rest**, and **postural instability**, which are distinctly different from the choreiform movements described. - While cognitive and psychiatric symptoms can occur, the prominent **chorea** and early onset of **dementia** are not typical primary features. *Multiple sclerosis* - Multiple sclerosis is characterized by **demyelination** in the central nervous system, leading to a variety of neurological symptoms that are often episodic, such as **visual disturbances**, **weakness**, **sensory deficits**, and **ataxia**. - It does not typically present with the progressive chorea, cognitive decline, and psychiatric symptoms seen in this patient. *Drug-induced chorea* - Drug-induced chorea would typically manifest following the initiation or change in dose of certain medications, and usually resolves upon their discontinuation; this patient's chorea has been ongoing for a year without recent drug changes. - While she has a history of cocaine use, she stopped 1 year ago, and the progressive nature of the symptoms, along with cognitive and psychiatric deterioration, points away from acute drug-induced effects. *Sydenham chorea* - Sydenham chorea is associated with **rheumatic fever** and typically presents in childhood or adolescence following a Group A streptococcal infection. - The patient's age (42 years old) and the absence of other symptoms of rheumatic fever make Sydenham chorea unlikely.

Question 69: A 60-year-old man presents to the emergency department with a rapid change in his behavior. The patient recently returned from a vacation in rural Mexico and recovered from several episodes of bloody diarrhea. He has had a notable and rapid decline in his memory which started this morning. His personality has also changed, has not been sleeping, and seems generally apathetic. Brief and involuntary muscle twitches have been noted as well. The patient has a past medical history of hypertension and diabetes. His temperature is 99.8°F (37.7°C), blood pressure is 152/98 mmHg, pulse is 97/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is notable for a confused and apathetic man who is not compliant with the neurological exam. The patient is admitted to the ICU; however, during his hospital course, the patient ultimately dies. Which of the following was most likely to be found in this patient upon initial presentation?

A. Sharp wave complexes on EEG (Correct Answer)
B. Multifocal infarction on MRI
C. Neurofibrillary tangles
D. Tear of a bridging vein
E. Blood in the subarachnoid space

Explanation: ***Sharp wave complexes on EEG*** * The patient's presentation with **rapidly progressive dementia**, personality changes, insomnia, and myoclonus (brief, involuntary muscle twitches) following travel to rural Mexico with bloody diarrhea is highly suggestive of **Creutzfeldt-Jakob disease (CJD)**. * **Sharp wave complexes on EEG** (also known as periodic sharp wave complexes) are a characteristic finding in CJD, often appearing as highly sensitive and specific indicators of the disease. * *Multifocal infarction on MRI* * While **Cerebrovascular accidents** can cause cognitive decline and neurological deficits, the rapid onset and specific constellation of symptoms like myoclonus and personality changes are not typical for multifocal infarction. * An MRI showing multifocal infarction would indicate multiple areas of **ischemic stroke**, which would present differently from the described progressive neurological decline. * *Neurofibrillary tangles* * **Neurofibrillary tangles** are a hallmark pathological feature of **Alzheimer's disease**. * Alzheimer's disease typically presents with a **slowly progressive dementia** over years, not the rapid decline observed in this patient. * *Tear of a bridging vein* * A tear of a bridging vein leads to a **subdural hematoma**, which usually presents with symptoms like headache, confusion, and focal neurological deficits that develop over hours to days. * The patient's history of bloody diarrhea, rapid cognitive decline, and myoclonus does not fit the typical presentation of a subdural hematoma. * *Blood in the subarachnoid space* * **Blood in the subarachnoid space** indicates a **subarachnoid hemorrhage**, which commonly presents as a sudden, severe "thunderclap" headache, often accompanied by neck stiffness, focal neurological deficits, and altered consciousness. * This presentation does not align with the patient's symptoms of progressive dementia, personality changes, and myoclonus.

Question 70: A 22-year-old man is brought to the physician by his mother because of concerns about his recent behavior. Three months ago, the patient first reported hearing loud voices coming from the ceiling of his room. During this time, he has also become increasingly worried that visitors to the house were placing secret surveillance cameras. Mental status examination shows tangential speech with paranoid thoughts. Treatment for this patient's condition predominantly targets which of the following dopaminergic pathways?

A. Mesocortical pathway
B. Thalamocortical pathway
C. Nigrostriatal pathway
D. Corticostriatal pathway
E. Mesolimbic pathway (Correct Answer)

Explanation: ***Mesolimbic pathway*** - The patient's symptoms of **auditory hallucinations** and **paranoid delusions** are **positive symptoms** of psychosis consistent with **schizophrenia**. - **Hyperactivity** of the **mesolimbic dopaminergic pathway** is strongly associated with the positive symptoms of schizophrenia, making it the primary target for antipsychotic treatment. *Mesocortical pathway* - The **mesocortical pathway** is primarily involved in **cognition, motivation, and executive functions**, originating from the ventral tegmental area and projecting to the prefrontal cortex. - **Hypoactivity** in this pathway is thought to contribute to the **negative and cognitive symptoms** of schizophrenia, not the positive symptoms described. *Thalamocortical pathway* - The **thalamocortical pathway** connects the **thalamus to the cerebral cortex** and is crucial for sensory processing, arousal, and consciousness. - While involved in neural circuits, it is not considered a primary dopaminergic pathway targeted for the treatment of positive psychotic symptoms. *Nigrostriatal pathway* - The **nigrostriatal pathway** projects from the **substantia nigra to the striatum** and is primarily involved in **motor control**. - Blocking dopamine receptors in this pathway by antipsychotic medications can cause **extrapyramidal symptoms (EPS)**, but it is not the main pathway responsible for positive psychotic symptoms or their treatment. *Corticostriatal pathway* - The **corticostriatal pathway** is **predominantly a glutamatergic pathway** connecting the **cerebral cortex to the striatum**, playing a role in motor control and habit formation. - This is not a primary dopaminergic pathway and is not directly implicated in the positive symptoms of schizophrenia or their pharmacological treatment.

Question 71: A 34-year-old man presents to the behavioral health clinic for an evaluation after seeing animal-shaped clouds in the form of dogs, cats, and monkeys. The patient says that these symptoms have been present for more than 2 weeks. Past medical history is significant for simple partial seizures for which he takes valproate, but he has not had his medication adjusted in several years. His vital signs include: blood pressure of 124/76 mm Hg, heart rate of 98/min, respiratory rate of 12/min, and temperature of 37.1°C (98.8°F). On physical examination, the patient is alert and oriented to person, time, and place. Affect is not constricted or flat. Speech is of rapid rate and high volume. Pupils are equal and reactive bilaterally. The results of a urine drug screen are as follows: Alcohol positive Amphetamine negative Benzodiazepine negative Cocaine positive GHB negative Ketamine negative LSD negative Marijuana negative Opioids negative PCP negative Which of the following is the most likely diagnosis in this patient?

A. Delusion
B. Alcohol withdrawal
C. Visual hallucination
D. Cocaine intoxication
E. Illusion (Correct Answer)

Explanation: ***Illusion*** - The patient is seeing **animal shapes in the clouds**, which is a misinterpretation of a real external stimulus. This is the definition of an **illusion**. - Unlike hallucinations, illusions involve a distorted perception of an existing object, rather than perceiving something that is not present. *Delusion* - A **delusion** is a **fixed, false belief** that is not amenable to change in light of conflicting evidence, and it is not what is being described here. - The patient is experiencing a perceptual distortion, not a false belief system. *Alcohol withdrawal* - While the patient tests positive for alcohol, the symptoms described are **perceptual distortions** (misinterpretation of clouds), not typical signs of alcohol withdrawal which include tremors, seizures, and delirium tremens. - The timeline of "more than 2 weeks" also makes acute alcohol withdrawal less likely, as withdrawal symptoms typically peak within days. *Visual hallucination* - A **hallucination** is a perception in the absence of an external stimulus; the patient would be seeing animals when no clouds (or other visual stimuli) are present. - The patient is seeing animal shapes *in the clouds*, indicating an existing external stimulus that is being misinterpreted. *Cocaine intoxication* - While cocaine intoxication can cause psychiatric symptoms like paranoia and hallucinations, the specific description of **seeing animal shapes in clouds** (misinterpretation of a real stimulus) points more directly to an illusion rather than a primary effect of cocaine use. - The patient's presentation does not include other common symptoms of acute cocaine intoxication like severe agitation, dilated pupils, or hyperthermia beyond a rapid heart rate.

Question 72: A 58-year-old right-handed man is brought to the emergency department after he was found unconscious in his living room by his wife. She reports that he has never had a similar episode before. The patient has hypertension and consumes multiple alcoholic drinks per day. On arrival, he is confused and oriented only to person. He cannot recall what happened. He has difficulty speaking and his words are slurred. He reports a diffuse headache and muscle pain and appears fatigued. His temperature is 37°C (98.6°F), pulse is 85/min, respirations are 14/min, and blood pressure is 135/70 mm Hg. Examination shows a 2-cm bruise on his right shoulder. Strength is 5/5 throughout, except for 1/5 in the left arm. The remainder of the physical examination shows no abnormalities. An ECG shows left ventricular hypertrophy. A CT scan of the head without contrast shows no abnormalities. Which of the following is the most likely underlying cause of this patient's symptoms?

A. Syncope
B. Seizure (Correct Answer)
C. Transient ischemic attack
D. Stroke
E. Migraine

Explanation: ***Seizure*** - The patient's **postictal confusion**, **slurred speech**, **diffuse headache**, and **muscle pain** following a transient loss of consciousness are highly suggestive of a seizure. The unilateral weakness (**Todd's paralysis**) is also a classic postictal phenomenon. - The **bruise on his shoulder** could indicate a fall during the event, and his alcohol consumption and hypertension are risk factors for seizures. *Syncope* - Syncope is characterized by a **brief loss of consciousness due to global cerebral hypoperfusion**, usually followed by rapid and complete recovery of consciousness and neurological function. - The patient's **prolonged confusion**, **slurred speech**, and **unilateral weakness** after the event are inconsistent with typical syncope. *Transient ischemic attack* - A TIA involves **transient neurological dysfunction caused by focal brain or retinal ischemia**, without acute infarction. Symptoms typically resolve within 24 hours. - While the **slurred speech** and **unilateral weakness** (left arm 1/5 strength) might mimic TIA symptoms, the preceding **loss of consciousness** and subsequent **prolonged postictal state** are not characteristic of a TIA. *Stroke* - A stroke involves **brain tissue damage due to ischemia or hemorrhage**, leading to persistent neurological deficits. - Although he presents with **unilateral weakness** and **slurred speech**, the **head CT without contrast** showed **no abnormalities**, ruling out acute ischemic stroke within the typical detection window for initial CT (within a few hours) and hemorrhagic stroke, and the preceding **loss of consciousness** and **postictal symptoms** point away from a primary stroke. *Migraine* - Migraine is a **primary headache disorder** often accompanied by neurological symptoms (aura) but typically does not involve a complete **loss of consciousness**. - While he has a **diffuse headache**, the **loss of consciousness**, **unilateral weakness**, and **postictal confusion** are inconsistent with migraine.

Question 73: A 23-year-old woman is brought to the emergency department by her boyfriend because of a 4-month history of feeling sad. Her boyfriend says that, during this period, she has slept and eaten very little and has been unable to focus at work. She says that she feels “empty inside” and has been hearing voices telling her that she is worthless. She first heard these voices 7 months ago when they started to make fun of her. She does not drink alcohol or use illicit drugs. Physical and neurological examinations show no abnormalities. On mental status examination, her speech is slow and monotonous; she abruptly stops talking in the middle of sentences and does not finish them. She occasionally directs her attention to the ceiling as if she were listening to someone. Which of the following is the most likely diagnosis?

A. Schizophreniform disorder
B. Schizoaffective disorder (Correct Answer)
C. Schizotypal personality disorder
D. Mood disorder with psychotic features
E. Schizophrenia

Explanation: ***Schizoaffective disorder*** - The patient presents with a **major depressive episode** (sadness, anhedonia, sleep and appetite disturbance, poor concentration, feelings of worthlessness) concurrent with **psychotic symptoms** (auditory hallucinations) for 4 months. - A key diagnostic criterion for schizoaffective disorder is the presence of **psychotic symptoms for at least 2 weeks in the absence of a major mood episode**, which is met by the prolonged duration of voices starting 7 months ago, while the depressive symptoms have been present for 4 months. *Schizophreniform disorder* - This disorder involves a constellation of **psychotic symptoms** lasting at least 1 month but **less than 6 months**. - While she has psychotic symptoms, the prominent and prolonged mood symptoms (sadness, anhedonia, changes in sleep/appetite) suggest a mood component beyond what is typically seen in schizophreniform disorder. *Schizotypal personality disorder* - Characterized by pervasive patterns of social and interpersonal deficits marked by **acute discomfort** with, and **reduced capacity for, close relationships**, as well as **cognitive or perceptual distortions** and eccentric behaviors. - This diagnosis does not account for the prominent mood symptoms (major depressive episode) and the clear psychotic symptoms (persistent auditory hallucinations independent of mood state) described in the patient. *Mood disorder with psychotic features* - In a mood disorder with psychotic features, the **psychotic symptoms occur exclusively during the mood episodes**. - The patient reported hearing voices "7 months ago," while her depressive symptoms started "4 months ago," indicating that the **psychotic features preceded and occurred independently of the major depressive episode** for at least a 3-month period. *Schizophrenia* - Schizophrenia requires at least **6 months of continuous signs of disturbance**, including at least 1 month of **active-phase symptoms** (delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptoms). - While the patient has psychotic symptoms for 7 months, the prominent and lengthy mood symptoms that occurred concurrently and independently of the psychosis point away from a primary diagnosis of schizophrenia.

Question 74: A 12-year-old boy is brought to a psychiatrist by his mother upon referral from his pediatrician. The mother describes that for the past 2 years her son has experienced episodes of repetitive blinking and sudden jerking of the arms. Additionally, she notes that he often clears his throat and occasionally makes grunting noises. These symptoms have waxed and waned in frequency, but they have persisted for the past 2 years since they first developed. The patient is otherwise healthy without any coexisting medical issues. Which of the following agents would be effective at reducing the severity and frequency of this patient's current symptoms?

A. Baclofen
B. Gabapentin
C. Sertraline
D. Fluphenazine (Correct Answer)
E. Valproic acid

Explanation: ***Fluphenazine*** - This patient presents with **motor and vocal tics** that have persisted for over a year, consistent with **Tourette's disorder**. **Fluphenazine**, a **first-generation antipsychotic**, is highly effective in blocking **dopamine D2 receptors** and reducing tic severity and frequency. - **Tourette's disorder management** often involves antipsychotics like fluphenazine when tics are severe and impairing, as they directly address the presumed **dopaminergic hyperactivity** underlying the condition. *Baclofen* - **Baclofen** is a **GABA-B receptor agonist** primarily used as a **muscle relaxant** for spasticity, commonly seen in conditions like multiple sclerosis or spinal cord injuries. - While tics involve muscle movements, they are not primarily spasticity and therefore would not be effectively treated with baclofen. *Gabapentin* - **Gabapentin** is an **anticonvulsant** and neuropathic pain medication that modulates **GABAergic neurotransmission**, but its mechanism is not directly targeting the **dopaminergic pathways** implicated in Tourette's. - It is often used for **neuropathic pain**, **seizures**, and sometimes anxiety, none of which are the primary issue here. *Sertraline* - **Sertraline** is a **selective serotonin reuptake inhibitor (SSRI)** used to treat depression, anxiety disorders, and obsessive-compulsive disorder (OCD). - While OCD can co-occur with Tourette's, sertraline would not directly treat the **tics** themselves, which are primarily related to dopamine dysregulation. *Valproic acid* - **Valproic acid** is a broad-spectrum **anticonvulsant** and **mood stabilizer** used for seizures, bipolar disorder, and migraine prevention. - It works by increasing **GABA levels** and blocking **voltage-gated sodium channels**, but it is not a first-line or primary treatment for the reduction of tics in Tourette's disorder.

Question 75: A 25-year-old man presents to his primary care physician with a chief complaint of "failing health." He states that he typically can converse with animals via telepathy, but is having trouble right now due to the weather. He has begun taking an assortment of Peruvian herbs to little avail. Otherwise he is not currently taking any medications. The patient lives alone and works in a health food store. He states that his symptoms have persisted for the past eight months. On physical exam, you note a healthy young man who is dressed in an all burlap ensemble. When you are obtaining the patient's medical history there are several times he is attempting to telepathically connect with the animals in the vicinity. Which of the following is the most likely diagnosis?

A. Brief psychotic disorder
B. Schizoid personality disorder
C. Schizophrenia
D. Schizophreniform disorder
E. Schizotypal personality disorder (Correct Answer)

Explanation: ***Schizotypal personality disorder*** - This patient exhibits **eccentric behavior**, **magical thinking** (telepathy with animals), and **odd perceptions** that are characteristic of schizotypal personality disorder. - The duration of symptoms (eight months) is consistent with a personality disorder, as these patterns are pervasive and long-standing. *Brief psychotic disorder* - Symptoms of brief psychotic disorder must last for **at least one day but less than one month**, with eventual full return to premorbid functioning. - This patient's symptoms have persisted for eight months, making this diagnosis unlikely. *Schizoid personality disorder* - Characterized by **detachment from social relationships** and a restricted range of emotional expression, with no interest in social interactions. - While this patient lives alone, his primary symptoms are **peculiar thoughts and behaviors**, not primarily a lack of social interest or flattened affect. *Schizophrenia* - Requires continuous signs of disturbance for **at least six months**, including at least one month of **active-phase symptoms** (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms). - While this patient has some peculiar symptoms, they do not meet the full criteria for schizophrenia, lacking clear-cut delusions or hallucinations and having a more pervasive pattern of oddness. *Schizophreniform disorder* - Involves symptoms similar to schizophrenia but with a duration of **at least one month but less than six months**. - This patient's symptoms have lasted eight months, exceeding the maximum duration for schizophreniform disorder.

Question 76: A 60-year-old man is brought to the emergency department by police officers because he was acting strangely in public. The patient was found talking nonsensically to characters on cereal boxes in the store. Past medical history is significant for multiple hospitalizations for alcohol-related injuries and seizures. The patient’s vital signs are within normal limits. Physical examination shows a disheveled male who is oriented to person, but not time or place. Neurologic examination shows nystagmus and severe gait ataxia. A T1/T2 MRI is performed and demonstrates evidence of damage to the mammillary bodies. The patient is given the appropriate treatment for recovering most of his cognitive functions. However, significant short-term memory deficits persist. The patient remembers events from his past such as the school and college he attended, his current job, and the names of family members quite well. Which of the following is the most likely diagnosis in this patient?

A. Schizophrenia
B. Korsakoff's syndrome (Correct Answer)
C. Wernicke encephalopathy
D. Delirium
E. Delirium tremens

Explanation: ***Korsakoff's syndrome*** - The patient's history of **chronic alcohol abuse**, along with **gait ataxia**, **nystagmus**, and most notably, significant **anterograde amnesia** (inability to form new long-term memories) despite preserved remote memory, points to Korsakoff's syndrome. - **Damage to the mammillary bodies** on MRI is a classic finding in Korsakoff's syndrome, a direct result of **thiamine deficiency**. - The patient demonstrates the characteristic pattern: **impaired new memory formation** while retaining memories from his past (school, college, job, family names). *Schizophrenia* - Schizophrenia typically presents with **hallucinations and delusions** (e.g., talking to cereal box characters), but it is not commonly associated with physical signs like **nystagmus** or **gait ataxia**, nor with MRI findings of mammillary body damage. - While the initial presentation of talking to cereal box characters might suggest psychosis, the complete clinical picture, especially the neurological deficits and persistent memory impairment, points away from schizophrenia as the primary diagnosis. *Wernicke encephalopathy* - Wernicke encephalopathy shares symptoms like **nystagmus** and **ataxia** with this patient and is also due to **thiamine deficiency** in alcoholics. - However, Wernicke encephalopathy typically presents with more acute and severe symptoms, including **global confusion** and **ophthalmoplegia**, and represents the acute phase. The dominant chronic **anterograde amnesia** described here is characteristic of Korsakoff's syndrome, which represents the chronic sequela. *Delirium* - Delirium is characterized by an **acute disturbance in attention and cognition**, often with a fluctuating course, and can be seen in alcohol withdrawal. - While the patient shows some disorientation, the chronic nature of the symptoms, the specific neurological deficits (nystagmus, ataxia), and particularly the persistent, isolated **anterograde amnesia** are not typical features of delirium. *Delirium tremens* - Delirium tremens is a severe form of **alcohol withdrawal** characterized by **autonomic hyperactivity**, severe delirium, hallucinations, and seizures. - While the patient has a history of alcohol-related seizures, his current vital signs are normal, and the persistent, chronic memory deficits and specific MRI findings are not hallmarks of acute delirium tremens but rather a chronic neurological complication.

Question 77: A 19-year-old man is brought to the emergency department by the resident assistant of his dormitory for strange behavior. He was found locked out of his room, where the patient admitted to attending a fraternity party before becoming paranoid that the resident assistant would report him to the police. The patient appears anxious. His pulse is 105/min, and blood pressure is 142/85 mm Hg. Examination shows dry mucous membranes and bilateral conjunctival injection. Further evaluation is most likely to show which of the following?

A. Impaired reaction time (Correct Answer)
B. Synesthesia
C. Pupillary constriction
D. Tactile hallucinations
E. Sense of closeness to others

Explanation: ***Impaired reaction time*** - The patient's presentation with **paranoia**, **anxiety**, **tachycardia**, **hypertension**, **dry mucous membranes**, and **conjunctival injection** is highly suggestive of **cannabis intoxication**. - **Cannabis use** is known to **impair reaction time**, cognitive function, and motor coordination. *Synesthesia* - **Synesthesia** is a perceptual phenomenon where stimulation of one sensory or cognitive pathway leads to automatic, involuntary experiences in a second sensory or cognitive pathway (e.g., "seeing sounds" or "tasting words"). - While associated with some hallucinogens such as **LSD**, it is not a typical or expected finding with **cannabis intoxication**. *Pupillary constriction* - **Cannabis use** typically causes **mild to moderate mydriasis** (pupillary dilation) due to its sympathomimetic effects, not pupillary constriction. - **Pupillary constriction** (miosis) is more commonly associated with **opioid intoxication**. *Tactile hallucinations* - While hallucinations can occur with **high doses of cannabis**, **tactile hallucinations** (e.g., feeling bugs crawling on skin) are more characteristic of **stimulant intoxication** (e.g., cocaine, amphetamines) or severe alcohol withdrawal. - Auditory or visual hallucinations with cannabis are typically less organized and less common than with other hallucinogens. *Sense of closeness to others* - While some users report feelings of **euphoria** or **relaxation** with cannabis, a specific "sense of closeness to others" is not a universally reported or diagnostic symptom. - The patient's **paranoid behavior** in this scenario contradicts a feeling of closeness.

Question 78: A 75-year-old woman presents to her primary care physician with her son because she is convinced that people are stealing from her. Her son claims she has been misplacing her medications and money throughout the house. She recently lost her husband to old age and has become reclusive and no longer wants people to visit. Physical examination is unremarkable and the patient is oriented to person, time, and place. A mini-mental status examination (MMSE) is performed and she has difficulty recalling words after 5 minutes and also has problems with serial subtraction. Which of the following is the most likely diagnosis in this patient?

A. Histrionic personality disorder
B. Schizophrenia
C. Delirium
D. Schizoid personality disorder
E. Dementia (Correct Answer)

Explanation: ***Dementia*** - The patient has **primary cognitive impairment** evidenced by MMSE deficits (poor delayed recall, impaired serial subtraction) and functional decline (misplacing items). - Her **delusions of theft are secondary to dementia**, a common behavioral and psychological symptom of dementia (BPSD), particularly in Alzheimer's disease. - The **insidious onset** in a 75-year-old with progressive memory decline points to a neurodegenerative process. - Orientation remains intact in early-to-moderate dementia, which doesn't rule out the diagnosis. - The stressor (husband's death) may have unmasked or accelerated symptom recognition but doesn't explain the cognitive deficits. *Histrionic personality disorder* - Characterized by **excessive emotionality** and **attention-seeking behavior**, which are not evident in this presentation. - Personality disorders are lifelong patterns, not new-onset conditions in elderly patients with cognitive decline. - Does not explain the objective cognitive deficits on MMSE. *Schizophrenia* - Schizophrenia typically has onset in **late adolescence to early adulthood**, not at age 75. - While late-onset schizophrenia exists, the **prominent cognitive impairment** (memory, executive function) as the PRIMARY feature points toward dementia rather than a primary psychotic disorder. - Schizophrenia would show more pervasive psychotic symptoms without the specific pattern of memory and executive dysfunction seen here. *Delirium* - Delirium has **acute onset** (hours to days) with **fluctuating consciousness** and altered attention. - This patient is **oriented to person, time, and place** and has a gradual, progressive course (misplacing items over time). - No mention of acute medical illness, medication changes, or rapid cognitive fluctuation. *Schizoid personality disorder* - A lifelong pattern of **social detachment** and restricted emotional expression, not a new condition in late life. - Does not explain the cognitive impairment, memory deficits, or delusional beliefs. - The patient's reclusiveness is reactive to recent loss and concerns about theft, not a longstanding personality trait.

Question 79: A 77-year-old woman is brought to her primary care provider by her daughter with behavioral changes and an abnormally bad memory for the past few months. The patient’s daughter says she sometimes gets angry and aggressive while at other times she seems lost and stares at her surroundings. Her daughter also reports that she has seen her mother talking to empty chairs. The patient says she sleeps well during the night but still feels sleepy throughout the day. She has no problems getting dressed and maintaining her one bedroom apartment. Past medical history is significant for mild depression and mild osteoporosis. Current medications include escitalopram, alendronic acid, and a multivitamin. The patient is afebrile, and her vital signs are within normal limits. On physical examination, the patient is alert and oriented and sitting comfortably in her chair. A mild left-hand tremor is noted. Muscle strength is 5 out of 5 in the upper and lower extremities bilaterally, but muscle tone is slightly increased. She can perform repetitive alternating movements albeit slowly. She walks with a narrow gait and has mild difficulty turning. Which of the following is the most likely diagnosis in this patient?

A. Lewy body dementia (Correct Answer)
B. Alzheimer's disease
C. Serotonin syndrome
D. Frontotemporal dementia
E. Delirium

Explanation: ***Lewy body dementia*** - This patient exhibits **fluctuating cognition** (being lost and staring, behavioral changes), **recurrent visual hallucinations** (talking to empty chairs), and spontaneous motor features of **parkinsonism** (mild left-hand tremor, increased muscle tone, slow alternating movements, narrow gait, difficulty turning), all core features of Lewy body dementia. - The **insidious onset** and progressive decline over months, along with the symptom triad, fit the diagnostic criteria for Lewy body dementia. *Alzheimer's disease* - While Alzheimer's involves memory loss and cognitive decline, it is not typically associated with **prominent early visual hallucinations** or **parkinsonian features** at presentation. - Alzheimer's disease often presents with **memory impairment as the most prominent early symptom**, often preceding other cognitive deficits by years. *Serotonin syndrome* - This is an acute drug reaction characterized by a triad of **mental status changes**, **autonomic hyperactivity**, and **neuromuscular abnormalities**, usually developing rapidly after medication changes affecting serotonin levels. - The patient's symptoms have been present for months, the vital signs are stable, and her medications (escitalopram) have been stable, making an **acute syndrome** like serotonin syndrome unlikely. *Frontotemporal dementia* - This type of dementia primarily affects personality, behavior, and language, with **prominent disinhibition or apathy**. - While behavioral changes are present, the patient's prominent **visual hallucinations** and **parkinsonian features** are not characteristic of frontotemporal dementia. *Delirium* - Delirium is characterized by an **acute onset** and fluctuating course of attention and awareness, often triggered by an underlying medical condition, medication, or infection. - The patient's symptoms have progressed over **several months**, rather than hours or days, and she is afebrile with stable vital signs, making delirium less likely.

Question 80: A 42-year-old woman is in the hospital recovering from a cholecystectomy performed 3 days ago that was complicated by cholangitis. She is being treated with IV piperacillin-tazobactam. She calls the nurse to her room because she says that her heart is racing. She also demands that someone come in to clean the pile of garbage off of the floor because it is attracting flies. Her pulse is 112/min, respiratory rate is 20/min, temperature is 38.0°C (100.4°F), and blood pressure is 150/90 mm Hg. On physical examination, the patient appears sweaty, distressed, and unable to remain still. She is oriented to person, but not place or time. Palpation of the abdomen shows no tenderness, rebound, or guarding. Which of the following is the most likely diagnosis in this patient?

A. Delirium tremens (Correct Answer)
B. Alcoholic hallucinosis
C. Hepatic encephalopathy
D. Thyroid storm
E. Acute cholangitis

Explanation: ***Delirium tremens*** - The patient's symptoms, including **delirium**, **tachycardia**, **sweating**, **agitation**, and **visual hallucinations** (seeing garbage and flies), are highly indicative of **alcohol withdrawal delirium**, also known as delirium tremens, which typically peaks 48-96 hours after the last drink. - Her recent surgery and hospitalization likely disrupted her usual alcohol intake, precipitating withdrawal. *Alcoholic hallucinosis* - This condition involves **prominent auditory or visual hallucinations** without significant disorientation or global cognitive impairment, whereas the patient presents with disorientation to place and time. - It usually occurs within 12-48 hours after the last drink and typically does not include the significant autonomic instability (tachycardia, diaphoresis) seen in this patient. *Hepatic encephalopathy* - While the patient has a history of cholangitis, a condition that could potentially lead to liver dysfunction, there are no specific signs of **liver failure** such as **asterixis**, **jaundice**, or significantly elevated **ammonia levels** mentioned. - Hepatic encephalopathy typically presents with impaired consciousness, confusion, and asterixis but lacks the intense psychomotor agitation, prominent hallucinations, and severe autonomic hyperactivity characteristic of delirium tremens. *Thyroid storm* - Thyroid storm would also present with tachycardia, fever, and agitation, but it would typically include other signs of **hyperthyroidism** such as **goiter**, **exophthalmos**, and more pronounced fever, which are not described. - While agitation and tachycardia are present, the specific nature of her hallucinations and disorientation, combined with the lack of classic thyroid storm features, makes this less likely. *Acute cholangitis* - The patient is recovering from a cholecystectomy complicated by cholangitis and is on IV antibiotics, but her current symptoms primarily involve **neurological and psychomotor agitation** rather than worsening signs of infection or biliary obstruction. - Although cholangitis can cause fever and tachycardia, it would not explain the prominent disorientation, agitation, and complex visual hallucinations found in this case without significant worsening of her infectious symptoms.

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