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?
Q42
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?
Q43
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?
Q44
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?
Q45
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?
Q46
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?
Q47
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?
Q48
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?
Q49
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?
Q50
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?
Psychotic Disorders US Medical PG Practice Questions and MCQs
Question 41: 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 42: 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 43: 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 44: 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 45: 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 46: 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 47: 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 48: 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 49: 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 50: 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.
