60 ABPN Psychiatry Board Exam Practice Questions

Cyproheptadine is the correct answer. This patient presents with serotonin syndrome, which is characterized by hyperthermia, hyperreflexia, hypertension, diaphoresis, and altered mental status caused by excessive serotonergic activity. Serotonin syndrome typically comes on quickly after starting a new serotonergic agent (usually within 24 hours) and is more likely to occur with more serotonergic agents. She is taking 3 serotonergic medications (sertraline, mirtazapine, and tramadol.) Treatment is first to stop the offending agents, then to provide supportive therapy, and then to give cyproheptadine if necessary.

Labetalol is incorrect. Labetalol is used in the management of hypertensive crises in which blood pressure is ? 180/120 mmHg. This patient?s history and examination findings are not consistent with this diagnosis.

Dantrolene is incorrect. Dantrolene is used in the management of malignant hyperthermia, which is characterized by hyperthermia and severe muscle contractions as adverse effects of anesthesia. This patient’s presentation is not consistent with the diagnosis.

Atropine is incorrect. Atropine is used in the management of acetylcholine toxicity, which is characterized by miosis, diarrhea, excessive salivation and lacrimation, vomiting, bronchoconstriction, etc.

Epinephrine is incorrect. Intramuscular epinephrine is used in the management of anaphylaxis, which is a life-threatening allergic reaction characterized by the appearance of skin changes (wheals, hives, etc.) and vascular changes (vasodilation, low blood pressure, etc.).

The discrepancies in the presentation of the child, mother’s history of the child’s condition, and lab reports support a diagnosis of factitious disorder by proxy. Moreover, the history of repeated hospital admissions acts as a possible red flag for factitious disorder by proxy. The underlying motivation is either to assume the sick role indirectly and or to get sympathy from people or to get relieved of the responsibility of caretaking for the child.
Conversion disorder consists of a patient experiencing (usually neurological) symptoms that cannot be explained by or are inconsistent with medical evaluations. Conversion disorder is rare in children, and in this case, the child is not reporting any symptoms or portraying any symptoms; rather, Mom is the only historian reporting illness.
Vesicoureteral reflux can be found in children who suffer from recurrent urinary tract infections (UTIs). However, in this case, the diagnosis of UTI cannot be confirmed due to discrepancies in history (the boy has not had any complaints of symptoms when asked) and labs do not support.
No reported hematuria or physical evidence (such as edema, hypertension).
Children with pyelonephritis are most likely quite ill appearing with pain and fever. This boy demonstrates neither.

There are some notable neurophysiological differences between unipolar and bipolar depression which could explain why treatment is different. There is a reduction in the number of connections between pregenual anterior cingulate cortex, amygdala and dorsomedial thalamus in patients with bipolar depression as compared to unipolar depression.
Decreased amygdala activation is incorrect because there is an increased activation of amygdala in patients with bipolar depression as compared to unipolar depression.
Decreased activation of dorsolateral prefrontal cortex is incorrect. In bipolar depression, the dorsolateral prefrontal cortex is more activated.
Reduced activation of caudate nucleus and putamen is incorrect. There is an increased activation of caudate nucleus and putamen in patients with bipolar depression as compared to unipolar depression.
The corpus callosum cross sectional area is increased in bipolar depression patients relative to unipolar depression patients, and thus the decreased corpus callosum cross sectional area is incorrect.

C-reactive protein (CRP) is correct because it is the most significant inflammatory marker associated with depressive symptoms like change in appetite, sleep disturbance, lack of energy, and tiredness. It is associated with depression, but hasn’t been shown to be causative.

Fibrinogen is incorrect because this inflammatory marker does not positively correlate with any symptom of depression.

Erythrocyte sedimentation rate (ESR) is incorrect because the data is mixed as to whether it correlates with major depressive disorder or not.

Interleukin 5 (IL-5) is incorrect because it does not positively correlate with the development of depressive symptoms. However, interleukin 6 (IL-6) and other interleukins have a positive correlation with symptoms of depression like tiredness, insomnia, and lack of energy.

Ferritin is incorrect because it has no correlation with symptoms of depression.

Clonazepam is correct because it can be used in combination therapy with SSRI drugs to prevent SSRI-induced agitation symptoms. However, benzodiazepines are most helpful during the initial phase of treatment (up to 2 weeks), and continual use is discouraged.

Fluoxetine is incorrect because it is another selective serotonin reuptake inhibitor (SSRI). This patient has SSRI-induced agitation and would not have benefited if fluoxetine was prescribed in combination with paroxetine.

Donepezil is incorrect because it is an acetylcholinesterase inhibitor used to manage patients with Alzheimer’s disease. Therefore, this drug would not benefit this patient if used as combination therapy to combat SSRI symptoms induced agitation.

Bupropion is incorrect because it is not recommended to resolve the symptoms of SSRI-induced agitation. Bupropion is used as add-on therapy to an SSRI for treatment-resistant depression and for other subtypes of depression.

Trazodone is incorrect because it does not resolve the symptoms of SSRI-induced agitation. Trazodone is usually recommended as combination therapy with SSRIs to resolve insomnia symptoms associated with SSRI use. Therefore, the use of this drug would not have prevented the symptoms of SSRI-induced agitation.

Activation syndrome is correct because her symptoms and clinical history both correlate well with a diagnosis of activation syndrome. Selective serotonin reuptake inhibitors (SSRIs) cause restlessness, anxiety, and emotional lability, especially during the first 1-2 weeks of treatment. This patient’s symptoms and symptom duration both strongly suggest a diagnosis of activation syndrome.

Antidepressant discontinuation syndrome is incorrect because this patient has only used antidepressants for a 2 weeks. Symptoms of antidepressant discontinuation usually appear when patients abruptly stop taking their antidepressant medication and can be controlled by restarting their antidepressant therapy. Fluoxetine causes less discontinuation symptoms compared to other selective serotonin reuptake inhibitors since it and its metabolite (norfluoxetine) have long half lives.

Serotonin syndrome is incorrect because this patient’s symptoms and history are not suggestive of serotonin syndrome. Symptoms of serotonin syndrome may vary but include sweating, tremors, and diarrhea, and muscle stiffness. In addition, serotonin syndrome comes on within hours after the addition of a new serotonergic medication, and thus this time course is not consistent with serotonin syndrome.

Neuroleptic malignant syndrome (NMS) is incorrect because it is a reaction that develops in response to the consumption of antipsychotic medications. Symptoms of NMS include fever, muscle rigidity, and autonomic dysfunction. This patient is not taking antipsychotic medication and has no signs consistent with NMS.

Stevens-Johnson syndrome (SJS) is incorrect because SJS is a hypersensitivity reaction characterized by severe mucosal and dermatologic manifestations and is often seen as a reaction to drugs like sulfasalazine, phenytoin, lamotrigine, and carbamazepine. This patient’s symptoms and history do not correlate with SJS.

Lorazepam is correct as it provides rapid relief from panic attacks. This patient’s history of recurrent episodes of nausea, diaphoresis, shortness of breath, racing heart, and anxiety, as well as persistent concern about further attacks, in an otherwise healthy individual, is suggestive of panic disorder.

Buspirone is incorrect as it is indicated in patients with a generalized anxiety disorder. This patient has panic disorder as evident from her panic attacks and persistent fear of future attacks.

Fluoxetine is incorrect as it is a selective serotonin reuptake inhibitor used in the long-term management of panic disorder as it takes weeks to have an effect. Immediate management with benzodiazepines is indicated in this case, although starting fluoxetine would be a long-term solution to her problem.

Exposure therapy is incorrect as it is used in the management of phobias. This patient with a panic disorder may benefit from cognitive-behavioral therapy in the long term, but immediate treatment with a benzodiazepine is required.

Propranolol is incorrect as it is a beta-blocker used in the management of performance anxiety. This patient, with recurrent episodes of panic attacks, cannot benefit from this.

Panic disorder is correct because it presents with recurrent panic attacks that have no specific triggers. The onset of these episodes is unexpected and has no particular triggers. There are intense fear and discomfort that last for several minutes and a feeling of dying and choking. There can also be an overstimulation of the sympathetic system that presents with sweating, palpitations, and other symptoms. There is a constant concern about future panic attacks and a significant change related to the attacks for at least a month.

Generalized anxiety disorder is incorrect because it is a long period of generalized anxiety of at least 6 months and is not linked to any specific situation, object, or person. The anxiety can cause somatic symptoms, but not necessarily panic attacks like in this patient.

Agoraphobia is incorrect because it represents a feeling of fear in a crowded area or an open space where a person deems their surroundings unsafe and finds no easy way to escape it.

Social phobia is incorrect because it represents feelings of unease and nervousness during social interactions.

Obsessive compulsive disorder is incorrect because it involves recurrent and intrusive thoughts that cause severe distress and the need to perform an act repetitively to alleviate anxiety.

Selective mutism is correct because it is a child’s refusal to speak in a specific setting, particularly school, with a particular set of people, while not exhibiting the same nature of speech refusal in other settings. The child does not have any kind of speech disorder. Selective mutism often co-occurs with social anxiety disorder, but that is not the case in this child.

Separation anxiety disorder is incorrect because it is a type of anxiety disorder related to the fear of being away from home and parents and is common in children. This boy displays no difficulties going to school or playing with other children in the neighborhood. His only issue revolves around his inability to speak to adult figures at his school.

Social anxiety disorder is defined by having a marked fear or anxiety about social situations where one could feel judged by others. This oftentimes begins during teenage years when theory of mind is developed more fully. This boy plays well with others and displays no signs of social anxiety at this time.

Agoraphobia is incorrect because it represents a feeling of fear in a crowded area or an open space where a person deems his surroundings unsafe and finds no easy way to escape it.

Acute stress disorder is incorrect because it is characterized by a severe, unpleasant, and emotionally numbing reaction shortly after an intensely stressful event. Starting Kindergarten is a large stressor but this boy is not displaying other symptoms consistent with a trauma-related disorder.

Mirtazapine is correct because the potent anti-histaminic side-effects of mirtazapine make its use desirable as a first-line agent for the management of a major depressive disorder (MDD) patient with significant insomnia. It is rarely associated with cardiac conduction problems.

Trazodone is incorrect because the patient suffers from cardiac conduction disease while Trazodone predisposes to cardiac arrhythmia, mandating extreme caution in the prescription of Trazodone in this scenario.

Phenelzine is incorrect because monoamine oxidase inhibitors are generally not used as first-line agents due to their high risk of adverse effects.

Selegiline is incorrect because, despite adequate efficacy, the high side-effect potential and risk for serious adverse effects associated with monoamine oxidase inhibitor use does not make their use as a first-line agent in MDD management likely.

Nortriptyline is incorrect because the first-line use of tricyclic antidepressants is unlikely due to their greater side effect potential compared to newer antidepressants. Given this patient has cardiac conduction issues this would be a dangerous choice.

Reassurance is correct because the patient presents with mild symptoms following discontinuation of paroxetine. These symptoms require only reassurance that these symptoms will pass within a few days. If her symptoms were interfering with her ability to fulfill her home or work obligations, or if they persisted for an excessive amount of time then doing some intervention (increasing dose or adding fluoxetine) could be considered.

Initiate atropine is incorrect. The patient is suffering from the discontinuation reaction of an SSRI while anticholinergics are indicated for the management of tricyclic withdrawal.

Initiate mirtazapine is incorrect. The patient was originally using paroxetine and in the case of a discontinuation reaction, the original drug or only another of the same class can be administered followed by gradual tapering. Of the SSRIs, paroxetine is one of the more likely agents to cause withdrawal symptoms. Mirtazapine will not be effective in reducing the discontinuation symptoms.

Initiate fluvoxamine is incorrect. This patient in this scenario has presented with mild rather than severe symptoms of discontinuation which does not require the introduction of another SSRI. Fluvoxamine is a short-acting SSRI and like paroxetine is likely to lead to withdrawal symptoms. If another SSRI were given (due to moderate-severe withdrawal symptoms) usually fluoxetine is recommended because it and its metabolites have long half-lives and can auto-taper.

Increase dose of paroxetine is incorrect. Increasing the paroxetine dose increase would only be recommended for more moderate or severe symptoms. Of the SSRIs, paroxetine is one of the more likely agents to cause withdrawal symptoms. This patient is still able to function at home and work and thus her symptoms are considered mild for now. If the goal is to come off paroxetine then increasing the dose of paroxetine will be discouraged because it will only prolong the time to come off of the medication.

Acceptance is the correct answer. Dialectical behavior therapy (DBT) works by incorporating 2 main principles in therapy: acceptance and change. These 2 principles help patients identify their problems or negative ideas and enable them to change for the better. This statement describes accepting the difficulties of childhood, which will then allow the patient to change the problematic patterns they developed as a result.

Dialectical is incorrect. Dialectical explains the idea of bringing the 2 opposite theories of acceptance and change together.

Interpersonal skills is incorrect. Interpersonal skills is an aspect which is essential for establishing an understanding relationship with the patient and those around them; however, it is not reflected in this statement.

Mindfulness is incorrect. Mindfulness is a process whereby all the attention is focused on all that is happening at that moment, including the environment.

Transference is incorrect. Transference is a psychological phenomenon whereby the patient’s feelings toward their family or friends are directed toward the psychologist.

Transference-focused psychotherapy is correct because it focuses on improving interpersonal relations by working with the therapist alone. This does not target past incidents, but the therapist takes up the role of people close to the patient and enables the patient to identify their interactions and improve them. This only involves the patient and the therapist and helps the patient overcome their fear of abandonment, particularly in borderline personality disorder.

Dialectical behavior therapy is incorrect. Dialectical behavior therapy was developed by Marsha Linehan for the treatment of highly suicidal patients and is used frequently with borderline personality disorder patients. Dialectical behavior therapy uses elements from multiple different sources, such as the cognitive and behavioral elements of CBT, mindfulness from Eastern religions, and skills training.

Exposure and relapse prevention (ERP) therapy is incorrect. It works by increasing the patient’s exposure to the source causing anxiety or fear and then avoiding using the typical compulsion used to ameliorate the anxiety/fear. ERP is used with OCD patients.

Eye movement desensitization and reprocessing therapy (EMDR) is incorrect. Eye movement desensitization and reprocessing therapy (EMDR) involves the patient recalling distressing images followed by some sensory inputs, which decreases their response to those images. EMDR is used in the treatment of PTSD and other trauma-related disorders.

Schema therapy is incorrect. Schema therapy works by revealing maladaptive coping mechanisms due to unmet emotional needs during the early years of life.

Medication-induced psychotic disorder is correct because he developed psychotic symptoms (delusions) in response to a medication. The likely mechanism was an increase in dopamine activation in the mesolimbic pathway. It has been shown that patients diagnosed with Parkinson’s disease who are being treated with dopamine agonists can develop delusional jealousy. This can be remedied by lowering the dose of the dopamine agonists or treating the patient with antipsychotics while continuing the dopamine agonists. The antipsychotics should have minimal or no D2 blockade; potential options include quetiapine or pimavanserin.

Delusional disorder is incorrect because it refers to the presence of one or more delusions for a period of one month or longer with the criteria for schizophrenia not being met. The delusions must be present in the absence of any mood or another psychotic disorder and are not brought about due to drugs or illness. These delusions can be erotomaniac, grandiose, jealous type, persecutory type, somatic, mixed, and unspecified. Since these symptoms occurred in response to medication, it is better conceptualized as a medication-induced psychotic disorder.

Schizophrenia is incorrect. In schizophrenia, 2 or more of the following symptoms must be present for a significant portion: delusions, hallucinations, grossly disorganized or catatonic behavior, disorganized speech, and negative symptoms (e.g., diminished emotional expression). Signs of disturbance must be present continuously for at least 6 months. This patient only has experienced the symptoms for 6 weeks, and they are likely due to his medication.

Major neurocognitive disorder with Lewy bodies is incorrect. This patient does not have a major neurocognitive disorder (NCD) because he has no impairment in his functioning at this time (normal ADLs and iADLs) from Parkinson’s disease. Even though he has Lewy bodies from Parkinson’s, he would not qualify for a diagnosis of NCD with Lewy bodies because Parkinson’s symptoms appeared before any cognitive decline. If he were to develop an NCD, then it would be classified as a major or mild neurocognitive disorder due to Parkinson’s disease.

Schizophreniform disorder is incorrect. Schizophreniform disorder involves 2 or more of the following symptoms, with each present for a significant portion of time during a one-month period: delusions, hallucinations, grossly disorganized or catatonic behavior, disorganized speech, and negative symptoms (e.g., diminished emotional expression).

Cognitive behavioral therapy (CBT) is the first-line intervention for patients with a performance-only social anxiety disorder. This patient has a 6-month history of physical symptoms (sweating, palpitations, and flushing) during performance situations resulting in anxious anticipation and avoidance. These features fulfill the criteria for performance-only social anxiety disorder.

Duloxetine may be considered for the treatment of generalized anxiety or social anxiety. However, due to concerns about potential sexual side effects, this may not be the best next treatment option for the patient.

Olanzapine is an antipsychotic that can be used in psychotic disorders or augmentation strategy that can also address insomnia or irritability. It would not be appropriate to start for someone in this situation.

Propranolol does provide short-term benefits for patients with a performance-only social anxiety disorder when used before an anxiety-inducing event. But due to his history of bradycardia and asthma, this drug should be used with caution.

Impairment in excitation-inhibitory balance due to altered NMDA receptor signaling is the correct answer. Schizophrenia has been attributed to a disturbed cellular balance between excitation and inhibition. This disturbance has been associated with altered function of the NMDA receptor.

Decreased expression of brain-derived neurotrophic factor (BDNF) is incorrect. Neuronal atrophy and loss of synaptic connections in cortical and limbic areas are thought to be implicated in depression due to a decreased expression and function of growth factors. These growth factors include BDNF in the pre-frontal cortex and hippocampus.

Long alleles of MAOA-uVNTR promoter polymorphism is incorrect. The MAOA-uVNTR promoter polymorphism has been associated with panic disorder with agoraphobia. It is implicated in fear conditioning and avoidance behavior and affects the effectiveness of cognitive therapy. It has also been documented in aggressive, impulsive behaviors, depression associated with suicide, and major depressive disorder.

Deposition of amyloid plaques is incorrect. The deposition of amyloid plaques in the brain is part of the pathology in Alzheimer’s disease.

Catecholaminergic and cholinergic dysfunction is incorrect. Catecholaminergic disruption is attributed to episodes of mania, whereas cholinergic dysfunction is attributed to episodes of depression.

Haloperidol is the correct answer. The patient’s history is consistent with antipsychotic-induced neuroleptic malignant syndrome. Neuroleptic malignant syndrome (NMS) is characterized by fever, autonomic instability, movement disorder, delirium, and muscular rigidity caused by the use of antipsychotics.

Clozapine is incorrect. Clozapine can cause many different side effects, but due to its weak D2 antagonism, it is unlikely to cause extrapyramidal symptoms or NMS.

Trazodone is incorrect. Trazodone is a 5HT agonist and reuptake inhibitor used to treat insomnia and anxiety disorders. Priapism, dizziness, and orthostatic hypotension are its major side effects.

Lithium is incorrect. Lithium is a mood stabilizer that is not a significant cause of NMS.

Imipramine is incorrect. Imipramine belongs to the class of tricyclic antidepressants (TCAs.) Its major side effects include blurred vision, dry mouth, sedation, orthostatic hypotension, convulsion, and coma.

Agoraphobia is correct as it is characterized by the presence of intense fear or anxiety which is triggered by real or anticipated exposure to at least 2 of the following situations: using public transportation, being in open spaces, being in enclosed spaces, standing in line, being in a crowd, or being outside of the home alone. The individual avoids these places and needs a companion in fear that the escape might be difficult in case the symptoms appear. The symptoms typically last for 6 months or more. The fear is out of proportion to the actual danger and causes significant impairment in important areas of functioning. Often, patients with agoraphobia experience panic attacks, hence, why the specifier is added.

Specific phobia is incorrect as it is characterized by the presence of intense fear of a certain object or situation typically lasting for 6 months or more that almost always provokes anxiety and is actively avoided. This patient’s fear is not a specific object or situation but rather leaving her house or being in enclosed spaces.

Social anxiety disorder is incorrect, as it is characterized by the presence of fear of one or more social situations, which exposes the individual to possible scrutiny by others.

Generalized anxiety disorder is incorrect, as it is characterized by the presence of intense worry about various events for a number of days, but for at least 6 months, and is associated with the presence of at least 3 of the following symptoms form restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbances. This patient’s anxiety is encapsulated by leaving her house and being in open spaces and not with other items.

Panic disorder is incorrect, as it is characterized by the presence of recurrent unexpected panic attacks with an intense fear that reaches a peak within minutes and is associated with 4 of the following symptoms from palpitations, sweating, shaking, shortness of breath, choking, nausea, abdominal pain, feeling dizzy or light-headed, chills or heat sensation, paraesthesias, derealization, fear of losing control, and fear of dying. This patient does not have panic disorder because there is a specific stressor that leads to her panic attacks, and thus, is better described as agoraphobia.

Cognitive behavioral therapy is correct. First-line treatment is either with Cognitive-behavioral therapy (CBT) or with pharmacotherapy such as a selective serotonin reuptake inhibitor (SSRI) or selective serotonin and norepinephrine reuptake inhibitor (SNRI.) Because the patient is pregnant, CBT is preferred.

Paroxetine is a Category D with known risks to the fetus in women of childbearing age.

Electroconvulsive therapy is not indicated as a treatment for social anxiety disorder.

Lamotrigine is an anticonvulsant and mood stabilizer that is not used for social anxiety disorder.

Phenelzine is a non-selective and irreversible monoamine oxidase inhibitor (MAOI) that requires dietary restrictions for use and also, due to its adverse effects, it is usually recommended as a second or third-line treatment.

Amygdala is the correct answer. Anxiety disorders present with elements of fear, aversion, anxiety, obsessive thinking, and exaggerated normal adaptive emotional responses. Amygdala is involved in aversive conditioning by the encoding of fearful memory. It is also involved in acute fear along with locus ceruleus which activates the fight and flight response.

Cingulate gyrus is incorrect, as it is involved in controlling motivation, akinetic mutism, Tourette’s syndrome, and obsessive-compulsive disorders.

Hippocampus is incorrect, as it is involved in long-term explicit or declarative memory, which is the ability to recollect facts and events consciously. The hippocampi have hemispheric laterality, with verbal memories localizing to the left hippocampus and non-verbal memories localizing to the right hippocampus.

Hypothalamus is incorrect, as it is particularly important for maintaining homeostasis using the autonomic and endocrine systems.

Basal ganglia is incorrect, as it is associated with control of voluntary motor movements, procedural learning memory, eye movements, cognition, and emotions.

The patient presents with delusions, hallucinations, and negative symptoms for over 6 months which is consistent with schizophrenia. Negative symptoms such as apathy, flattened affect, lack of energy, social absenteeism, and a lack of expressiveness are associated with a poorer outcome in terms of treatment response, hospitalization time, readmissions, and social functioning. In contrast, prevalent positive symptoms such as delusions and hallucinations are the predictors of a better outcome and respond better to treatment.

Presence of bronchial asthma is incorrect. People with schizophrenia have a higher risk of a number of medical conditions including cardiovascular, metabolic, and respiratory diseases (including bronchial asthma.) Medical pathology or medications used for their control were not shown to affect the outcome.

Female sex is incorrect. Female sex is associated with earlier remission and better response to treatment during the first episode but the difference in long-term prognosis in men and women remains unclear.

Lack of family history of psychiatric illness is incorrect. The lack of family history of psychiatric illness is a good prognostic factor for her future functioning.

Language disorder is correct because it primarily affects the acquisition and use of language due to comprehension or production difficulties, which may co-occur with ASD. Unlike the other conditions listed, a language disorder does not encompass the broad social communication and interaction difficulties characteristic of ASD, making it the least likely to be excluded through a psychosocial history alone.

Schizophrenia with childhood onset is incorrect because it can be differentiated from ASD by the presence of psychotic symptoms, such as hallucinations and delusions, that are not characteristic of ASD. A detailed psychosocial history can help identify these symptoms.

Reactive attachment disorder is incorrect because it is characterized by markedly disturbed and developmentally inappropriate social relatedness that usually stems from grossly negligent care. A comprehensive psychosocial history can reveal these caregiving issues and differentiate reactive attachment disorder from ASD.

Intellectual disability with behavioral symptoms is incorrect because it involves limitations in intellectual functioning and adaptive behavior. While it may coexist with ASD, its distinguishing features, such as the degree of intellectual impairment, can often be clarified through a detailed history.

Social (pragmatic) communication disorder is incorrect because it involves difficulties in the social use of verbal and nonverbal communication. Unlike ASD, it lacks the restricted/repetitive patterns of behavior, interests, or activities. These differences can be discerned through a comprehensive psychosocial history.

Neurocognitive disorder due to frontotemporal lobar degeneration is correct. The combination of memory loss and pronounced personality changes are characteristic of neurocognitive disorder due to frontotemporal lobar degeneration. Due to its involvement in the frontal lobes, it has a more pronounced impact on behavior and language relative to the other dementias. The major subtypes are the behavior variant, semantic variant, and progressive nonfluent aphasia variant.

Alzheimer’s disease is incorrect, the progression seems to be slower and the predominant feature is memory loss, therefore, this does not fit the patient’s profile.

Neurocognitive disorder with Lewy bodies is incorrect. The presentation for neurocognitive disorder with Lewy bodies is typically different in that visual hallucinations are seen along with a fluctuating course. Behavioral changes typically occur later in the disease course.

Neurocognitive disorder due to vascular disease usually shows step-wise progression, and personality changes occur later on in the disease course.

Pseudodementia is the cognitive impairment resulting from major depressive symptoms and does not include marked behavioral changes.

Neurocognitive disorder with Lewy bodies (LBD) is the second most frequent cause of neurocognitive disorder after AD. LBD presents with a significantly faster cognitive and functional decline compared with AD. Psychotic symptoms are often present, including well-formed and detailed visual hallucinations and systematized delusions. Fluctuating cognition with pronounced variations in attention and alertness is also a hallmark of LBD. Patients may develop spontaneous features of Parkinsonism. LBD patients are extremely sensitive to the extrapyramidal motoric side effects of antipsychotic medications.

Vascular neurocognitive disorder is incorrect. Vascular neurocognitive disorder presents with a step-wise deterioration (due to infarcts) of the patient’s cognitive and functional capabilities. These patients are not excessively sensitive to D2 blockade from antipsychotics and do not typically present with sensorium changes or with hallucinations.,

Creutzfeldt-Jakob disease is incorrect. Creutzfeldt-Jakob disease is a prion disease that is incurable and quickly progressive. It presents with mycolonus in most cases. Like LBD, hallucinations and personality changes can be present. This patient most likely doesn’t have Creutzfeldt-Jakob disease because patients don’t typically last more than 1 year after the symptoms are discovered and the deterioration is more rapid.

HIV encephalopathy is incorrect. HIV encephalopathy occurs in patients with HIV who have very low CD4 counts (less than 200.) There is no indication that this patient has HIV, and these patients typically present with depression which is not seen in this patient.

Progressive supranuclear palsy is incorrect. Progressive supranuclear palsy occurs late in life (usually starting in the 7th decade) and presents with supranuclear ophthalmoplegia, dysarthria, poor balance, and falls. Dementia is not seen in all patients but is seen in further progressed cases.

Control of risk factors is the only management among the given options that has been proven beneficial in preventing the progression of cognitive decline in vascular NCD.

Amlodipine is a calcium channel blocker that acts on L-type calcium channels and relaxes vascular smooth muscle, leading to reduced blood pressure. However, the control of all risk factors is superior to controlling only hypertension in the prevention of NCD progression.

Aspirin is a non-steroidal anti-inflammatory drug that irreversibly inhibits cycloogenease (COX1 and COX2); it can be used as an anti-platelet, antipyretic, and anti-inflammatory drug but has no role in treating dementia progression or prevention.

Citalopram is a selective serotonin reuptake inhibitor (SSRI) that is useful in mood disorders and can be used to treat low mood secondary to the disease, but has no proven benefit in slowing dementia progression.

Paroxetine is a selective serotonin reuptake inhibitor (SSRI) that is useful in mood disorders and can be used to treat low mood secondary to the disease, but has no proven benefit in slowing dementia progression.

Substance or medication-induced anxiety disorder is correct. This question describes a patient with steroid-induced anxiety disorder. This disorder is characterized by panic attacks or anxiety in response to the exposure to or the withdrawal from a substance or medication. Steroids such as prednisone can precipitate various psychiatric symptoms including anxiety.

Myocardial infarction is incorrect because cardiac enzyme levels, specifically myoglobin, are anticipated to show elevation within 60 minutes of an ischemic cardiac event.

Panic disorder is incorrect because this patient’s symptoms are most likely secondary to treatment with prednisone. Also, for panic disorder, there needs to be at least 1 month of ongoing anxiety or maladaptive change secondary to the panic attack(s).

Agoraphobia with panic attacks is incorrect. This patient experienced a panic attack, however, it is clear that it was not brought on by agoraphobia. The 5 possible situations that bring on anxiety in agoraphobia patients are: 1) Using public transportation 2) Being in open spaces 3) Being in enclosed spaces 4) Standing in line or being in a crowd 5) Being outside of the home alone.

Unexpected panic attack is incorrect because DSM-5 only permits the term “panic attack” to be used as a specifier for other diagnoses. It should be noted that the panic attack specifier can only be used in conjunction with DMS-5 diagnoses that do not contain panic attacks as part of their diagnostic criterion (for example, generalized anxiety disorder with panic attacks).

Symptoms that a person experiences during benzodiazepine withdrawal may reflect three phenomena: recurrence (backlash of original symptoms), rebound (worsening compared to original symptoms), or true withdrawal (new symptoms experienced). Common symptoms of withdrawal include anxiety, irritability, dysphoria, drowsiness, tachycardia, raised blood pressure, muscle tension, tremor, agitation/motor restlessness, myoclonus, and joint and muscle pain. Visual disturbances and hallucinations may also be experienced by some individuals.

All the given options favor a reduced chance of encountering withdrawal symptoms, except for the short half-life of the benzodiazepine. This is because the longer-acting benzodiazepines (diazepam or chlordiazepoxide) often can self-taper due to the long half-lives of the drug and the active metabolites.

Anxiety due to a general medical disorder is correct. The patient in the given scenario is a young female who presents with complaints of increased irritability, unintentional weight loss, anxiety, increased gastrointestinal motility (diarrhea), and increased sweating (warm or moist skin on touch). These are characteristics that point to anxiety which is secondary to hyperthyroidism.

Generalized anxiety disorder (GAD) is incorrect because the patient needs to have the symptoms for at least 6 months for a diagnosis of GAD to be made. If the medical workup comes up negative and she continues to have the same symptoms for another month, then she will likely fulfill the criteria for GAD at that time.

Obsessive-compulsive disorder (OCD) is incorrect, as the patient’s presentation does not include any intrusive thoughts, nor does she engage in any compulsive behaviors.

Panic disorder is incorrect, as her anxiety episodes are not intense enough to be considered a panic attack.

Major depressive disorder (MDD) is incorrect. She displays some symptoms of a major depressive episode (e.g. insomnia), but she does not fulfill the full criteria at this time.

Escitalopram is a selective serotonin reuptake inhibitor (SSRI). SSRIs are the first line of medication for both depression and anxiety disorders. There is a delayed onset of action of SSRIs, psychotherapy can help equip the patient to deal with his depressed mood and panic attacks during this time.

Buspirone is a non-benzodiazepine anxiolytic medication that binds to serotonin 1a and 2 receptors. It is approved for treating generalized anxiety disorder but not major depression or panic disorder.

Quetiapine is an atypical antipsychotic used to treat psychotic and mood disorders. It is sometimes used off-label for of treatment-resistant anxiety but should not be considered a first-line treatment.

diazepamis not considered a first-line treatment. It can help relieve anxiety symptoms on a short-term basis but does not help treat the disease in the long run. Furthermore, it creates dependence and should never be given for more than a few weeks.

alprazolam is not considered a first-line treatment. It can help relieve anxiety symptoms on a short-term basis but does not help treat the disease in the long run. Furthermore, it creates dependence and should never be given for more than a few weeks.

Continue medication and lifestyle changes for Crohn’s disease along with CBT (cognitive behavioral therapy) is correct. Anxiety disorders are common in patients with inflammatory bowel disease (IBD) and can directly affect the patient’s quality of life, as well as their IBD treatment adherence. IBD tends to be diagnosed between the ages of 15 to 30, which are formative and stressful years. It is possible that the way IBD affects the quality of life can lead to the development of anxiety. Chronic pain, in particular, tends to increase the possibility of developing anxiety. Most important for this patient is to address the poor adherence issues and assure the patient that although there’s no cure for Crohn’s disease, taking the prescribed medication and making lifestyle changes will improve her quality of life. Additionally, CBT (cognitive behavioral therapy) could help ameliorate her anxiety while also improving her treatment adherence.

Counsel the patient to be adherent with her medication and lifestyle changes is incorrect. It will be important to go forward with the lifestyle changes and medication, but CBT will not only help with her comorbid anxiety but also will help with her poor adherence.

Prescribe SSRIs for anxiety is incorrect. CBT treatment more directly focuses on her specific core issues and should be used prior to relying on the other modalities.

Generalized anxiety disorder is characterized by excessive worry on most days for a period of at least six months. The patient is unable to control their worrying and experiences restlessness, easy fatigability, irritability, muscle tension, and sleep disturbances. One of the most effective ways to treat this disorder is through a combination of psychotherapy and pharmacotherapy. In terms of pharmacotherapy, selective serotonin reuptake inhibitors (SSRIs) are the first line of treatment for generalized anxiety disorder. Anxiety peripartum, intrapartum, and postpartum can lead to fetal and maternal complications, as well as problems in fetal-maternal bonding. Anxiety can worsen during pregnancy due to hormonal and physiological changes, as well as due to increased stress. Anxiety during pregnancy can also put the patient at greater risk for postpartum depression. Therefore, a careful weighing of risks and benefits is necessary. SSRIs are considered safe in pregnancy, but nothing is without risk. In this case, since the patient is in remission and will continue therapy, stopping the medication and continuing it would be acceptable treatment choices. The patient should be educated and allowed to make her own decision.

It is incorrect to switch to benzodiazepines since benzodiazepines are not recommended in pregnancy.

Mindfulness-based cognitive therapy has proven to be effective in many mental disorders and is useful in alleviating emotional distress. Mindfulness breaks the habit of looking to the future with fear, as is characteristic of generalized anxiety disorder. It is a useful technique for fighting anxiety during pregnancy. It should be paired with tapering off sertraline instead of immediately discontinuing it.

Immediate discontinuation can lead to discontinuation syndrome, which presents with psychomotor and somatic symptoms. This can reverse the remission of symptoms and can place the patient in a state similar to or even worse than before treatment was started.

Intermittent dosing of sertraline is not recommended.

Low mood, insomnia, feelings of hopelessness for at least 2 years is correct. Persistent depressive disorder, with pure dysthymic syndrome (previously known as dysthymia), is characterized by low mood for most of the day on most days for at least 2 years in addition to at least 2 symptoms from the following list for at least 2 years: poor appetite or overeating, insomnia or hypersomnia, fatigue and low energy, low self-esteem, feelings of hopelessness, and poor concentration.

Low mood, suicidal ideation, diminished interest in pleasurable activities for at least 2 weeks is incorrect. The diagnosis of major depressive order requires the patient to present at least 5 of the following symptoms almost every day for at least 2 weeks: low mood most of the day, loss of energy or easy fatigability, diminished interest in pleasurable activities, weight loss, or weight gain, insomnia or hypersomnia, psychomotor agitation or retardation, feelings of worthlessness, diminished ability to think or concentrate, recurrent thoughts of death and suicidal ideation.

Low mood, irritability, lethargy a week before menses is incorrect. Premenstrual dysphoric disorder is diagnosed when a minimum of 5 symptoms are present from the following: marked affective lability, marked irritability, marked depressed mood, marked anxiety, decreased interest in usual activities, lethargy, overeating, insomnia or hypersomnia, feeling overwhelmed, bloating, and breast tenderness. At least 5 of these symptoms must be present in the week before menses, start improving during menses, and become minimal or absent in the week after menses.

Recurrent panic attacks, palpitations, difficulty breathing, and nausea is incorrect. Panic disorder is characterized by recurrent panic attacks that manifest as palpitations, difficulty breathing, trembling, sweating, nausea, dizziness, chest pain, intense fear of dying or losing control.

Alternating depressive and manic episodes is incorrect. Bipolar disorder is characterized by alternating manic episodes (in bipolar I) or hypomanic episodes (in bipolar II) and major depressive episodes.

HIV and hepatitis B and hepatitis C is correct since they can be transmitted through blood via needle sharing. Hepatitis C is rarely transmitted sexually, but it can occur.

Gonorrhea and chlamydia can only be transmitted through having vaginal, anal, or oral sex with a person who has either of the infections. If there is an indication in the patient’s history and physical examination, then gonorrhea and chlamydia may be tested for as well. The Centers for Disease Control and Prevention (CDC) recommends that health care providers should test patients with high-risk behaviors, such as injection drug users, at least once a year for HIV infection.

Persistent depressive disorder with intermittent major depressive episodes, with current episode is correct. This classification is correct due to the chronic (over 2 years) nature of the symptoms associated with persistent depressive disorder combined with the recent episode of more intense symptoms of mood disturbances as well as indications of decreased appetite, feelings of guilt and psychomotor disturbances.

Cyclothymia is incorrect as it requires periods of elevated mood and the patient cannot meet criteria for a major depressive episode.

Major depressive disorder would fail to capture the chronic nature of depressive symptoms in this patient. This is an important distinction, given that chronic depression coupled with major depressive episode(s) are associated with a poorer prognosis than those with either disorder alone.

Persistent depressive disorder with pure dysthymic syndrome replaced the term dysthymic in the DSM-5. A diagnosis of the persistent depressive disorder with pure dysthymic syndrome would not reflect the more recent symptoms of intensified sadness accompanied by somatic and psychomotor disturbances that meet the criteria for a major depressive episode, this specifier is used if the patient has not met criteria for major depression in the last 2 years.

Bipolar II disorder is incorrect, as this would require symptoms or episodes of hypomania. The sign of psychomotor agitation, pacing, is not sufficient to indicate mania and can occur in forms of depression as well.

Beta hCG is correct because pregnancy must be ruled out prior to starting lithium therapy in women of reproductive age. Lithium is reported to have teratogenic potential and is associated with cardiac malformations in the fetus (Ebstein’s anomaly in particular). This condition results in atrialization of the right ventricle (which means that part of the right ventricle becomes functionally part of the right atrium) due to the apical displacement of the tricuspid valve leaflets. Lithium can also lead to hypothyroidism, diabetes insipidus, gastrointestinal discomfort, psoriasis, tremors, and weight gain. Other baseline investigations before starting lithium include renal function tests (includes serum creatinine and blood urea nitrogen), serum calcium, complete blood count with differential, and thyroid function tests.

Chest x-ray is incorrect because an EKG is needed for cardiac evaluation prior to lithium therapy for patients 40 years and older.

Fasting lipid panel is done prior to starting antipsychotic medications, but is not required before starting lithium. Lithium can cause weight gain and theoretically can increase the risk for hyperlipidemia and thus it could be considered in some patients.

Pulmonary function tests (PFTs) is incorrect because lithium use is not associated with significant pulmonary side effects.

Abdominal ultrasound is incorrect as it is unnecessary in a young patient with no comorbidities or symptoms of abdominal disease.

Bulimia nervosa; cyclothymia is correct and defined by low-grade hypomanic and depressive symptoms associated with significant distress or impairment that has lasted over two years (at least one year for children and adolescents), and is not better explained by substance use. Patients with cyclothymia experience intense and rapid mood fluctuations of opposite polarity leading to interpersonal and behavioral consequences that usually prove to be the most prominent clinical expression of the disorder.

She has never had a manic episode so bipolar I disorder can be ruled out. Cyclothymia is the common factor underlying a wide range of comorbidity and complications including anxiety, suicidality, and drug abuse.

Eating disorders, especially those that include impulsive behaviors towards food, such as bulimia, binging-purging anorexia, binge-eating disorder, and obesity are common comorbidities.

Comorbid disorders are often the reason why patients with cyclothymia require psychiatric intervention rather than for the mood variations that are usually egosyntonic. The patient in this vignette also presents with enlarged parotid glands and poor dentition due to repeated episodes of self-induced vomiting. Her body mass index (BMI) is normal (between 18.5 to 25), which suggests that her most likely diagnosis is bulimia nervosa. The DSM-5 includes updated diagnostic criteria for bulimia nervosa; the criterion for frequency of binge and purge episodes decrease from twice to once per week.

Anorexia nervosa is classified as a restricting type and binge eating/purging type. Both types are associated with significantly low weight (BMI <85% of ideal body weight), and the DSM-5 updated diagnostic criteria by eliminating amenorrhea as a diagnostic criterion.

Activated charcoal (if the patient is awake and gag reflex is present) would be the initial medical treatment if the likelihood of tricyclic antidepressant overdose is high or can be quickly confirmed by history, pill count, or QRS prolongation on ECG. These interventions need to be done quickly, typically within an hour of ingestion.

Flumazenil is used of benzodiazepine overdoses.

Physostigmine (to counteract tricyclic anticholinergic effects with a cholinergic agonist) is controversial because of the potential for serious adverse effects (cardiac toxicity, seizures) and it should only be used when there is life-threatening, treatment-refractory anticholinergic toxicity.

Haloperidol is not an antidote for any overdose.

Naloxone is used for opiate overdoses.

Prazosin is an alpha-1 adrenergic receptor antagonist that has been extensively studied for the use of nightmares in PTSD and is often used off-label. The data for prazosin was largely positive at first, but then a large double-blind RCT was published in 2018 that demonstrated no difference between the prazosin and the placebo groups. Having said that, there is still some data supporting its use, and it is commonly used as an agent to help with nightmares in patients who fail to improve with 1st line PTSD treatments (trauma-focused therapy.)

Clonidine is incorrect. Clonidine is an alpha-2 receptor agonist that has limited data for the treatment of nightmares.

Guanfacine is incorrect because most of the studies show an inconclusive or negative result for its use in treatment, so no PTSD treatment guidelines recommend guanfacine.

Alfuzosin is incorrect. Alfuzosin is an alpha-1 blocker used for the treatment of benign prostatic hyperplasia and has no data supporting its use for PTSD.

Mirtazapine is incorrect. Mirtazapine is an alpha-2 receptor blocker and serotonin receptor blocker considered an atypical antidepressant that is used primarily in the treatment of major depressive disorder.

Incidence of FAS in infants is the correct answer because disease incidence is the number of new cases of a disease that have occurred in a specific time interval divided by the population at risk at the beginning of the time interval.
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Odds ratio of FAS in infants is incorrect. The odds ratio equals the odds that an individual with a disease has been exposed to a risk factor divided by the odds that a control has been exposed.
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Prevalence of FAS in infants is incorrect. Disease point and period prevalence refer to the number of individuals with a disease at a specific point in time or during a particular time, respectively, divided by the population at risk at that point or during that interval of time.
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Relative risk of FAS in infants is incorrect. The relative risk (or risk ratio) is the incidence among individuals exposed to a risk factor divided by the incidence in unexposed individuals.
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Attributable risk of FAS in infants is incorrect. Attributable risk is the difference in the rate of disease between a population exposed to risk factors and an unexposed one.

Neurocognitive disorder with Lewy bodies is correct. Per the Dementia with Lewy bodies (DLB) consortium, neurocognitive disorder with Lewy bodies presents with neurocognitive dysfunction but must also have at least 2 of the following symptoms as well: fluctuating cognition, recurrent visual hallucinations (VHS), rapid eye movement (REM) sleep behavior disorder (RBD), and Parkinson symptoms. The fluctuating cognition could be mistaken for delirium, so careful evaluation is needed. Neurocognitive disorder with Lewy bodies is 1 of the 3 α- Synucleinopathies, the other 2 being multiple system atrophy (MSA) and Parkinson’s disease. The pathogenesis is a buildup of α- Synuclein proteins in neurons and glial cells, which leads to cellular death. The location of the cellular damage will dictate which of the 3 α-Synucleinopathies will present. RBD is commonly a precursor to one of the α- Synucleinopathies.

Neurocognitive disorder due to Alzheimer’s disease typically starts with memory impairments and then progresses to include problems with depressive mood, language, mood regulation, and other cognitive processes. Approximately 60-70% of cases of dementia occur due to Alzheimer’s disease.

Neurocognitive disorder due to Huntington’s disease is an autosomal dominantly inherited condition. A key feature of Huntington’s is the chorea movements.

Frontotemporal neurocognitive disorder typically presents earlier than other neurocognitive disorders, usually before the age of 65. Since it affects the frontal and temporal lobes, language and behavior are affected more than with other neurocognitive disorders.

Vascular neurocognitive disorder demonstrates a stepwise progression based on new infarcts. It often occurs with Alzheimer’s disease, and the features can be mixed.

Vertebral artery dissection is correct. The clinical findings of nystagmus, Horner syndrome, cerebellar abnormalities, and crossed sensory loss suggest a brain stem/cerebellar localization. The acute onset of the deficit is most consistent with an ischemic or hemorrhagic process. The abrupt onset of pain in combination with a focal neurologic process would be most consistent with a vertebral arterial dissection with resultant infarction.

Acute multiple sclerosis is incorrect because a subacute onset is more typical and is not associated with headache.

Complicated migraine is a very unusual cause of cerebral infarction and is more cortically-based when it does occur.

Subarachnoid hemorrhage is incorrect as it usually does not cause the acute onset of focal findings in the brainstem.

Transverse sinus thrombosis is incorrect as it can cause cerebral infarction but not infarction of the brain stem.

GABAergic is correct. GABA (gamma-Aminobutyric acid) is the chief inhibitory neurotransmitter in the central nervous system. The GABA receptor is the main site for the binding of benzodiazepines as well as for non-benzodiazepine hypnotic medications such as the so-called z-drugs. Flumazenil is a competitive inhibitor at the benzodiazepine receptor site on the GABA/benzodiazepine receptor complex and is used for benzodiazepine reversal when used in conscious sedation or general sedation and is also used to treat benzodiazepine overdose.

Acetylcholinergic is incorrect because acetylcholine is a neurotransmitter active at the neuromuscular junction and in the autonomic nervous system. Flumazenil does not bind to this site.

Dopaminergic is incorrect because dopamine is a neurotransmitter that has broad effects throughout the brain. It is not affected by flumazenil.

Glutamatergic is incorrect because glutamate is the main excitatory neurotransmitter in the central nervous system and is not the direct target of flumazenil.

Serotonergic is incorrect because serotonin is a neurotransmitter with broad effects in the CNS and, in psychopharmacology, is commonly associated with mood. It is the target for many antidepressant medications, including selective serotonin reuptake inhibitors, but is not the target of flumazenil.

Dialectical behavior therapy (DBT) is the correct answer. This patient likely presents with borderline personality disorder (BPD.) She presents with a history of unstable relationships, recurrent suicidal behavior, affective instability, inappropriate/intense anger, chronic feelings of emptiness, and frantic efforts to avoid abandonment. Dialectical behavior therapy (DBT) is often viewed as the gold standard treatment for BPD. It is used to help patients with borderline personality disorder to learn to cope with stress and manage emotions.

Hypnotherapy is incorrect. Hypnotherapy is used to create focused attention. It is used to help people quit smoking. This patient has a personality disorder in addition to an addiction to tobacco and alcohol. It is essential to manage the personality disorder first.

Couples therapy is incorrect. Couples use couples therapy to ease tension and discord within the relationship. This patient has had multiple failed relationships recently, but before engaging in couples therapy, she needs to achieve some psychological stabilization first.

Aripiprazole is incorrect. Aripiprazole is an antipsychotic medication that can be used off-label in treating some of the mood lability symptoms in BPD patients. At best, it is an adjunctive therapy (with many adverse effects) and would not be the most appropriate therapy at this time.

Fluoxetine is incorrect. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). It is used as a first-line treatment option for depression and anxiety. Though it may have some value in treating some of this patient’s symptoms, she will need DBT to address her maladaptive and self-injurious behaviors.

Consider electroconvulsive therapy (ECT) is correct. ECT involves electrical stimulation of the brain. This procedure is usually carried out under anesthesia. It is safe to use, even during pregnancy. The few side effects of ECT include retrograde amnesia and adverse effects of anesthesia.

Electroconvulsive therapy (ECT) has different indications for major depressive disorder (MDD) and bipolar disorders. It is indicated in refractory MDD cases in which two antidepressant trials were unsuccessful and in other cases such cases with significant safety concerns. This patient is refractory to medications and poses a significant safety concern; thus, ECT would be the appropriate next step for him.

Start a trial of imipramine is incorrect. Imipramine is a tricyclic antidepressant (TCA), which is an older class of antidepressants. Due to this patient’s history of multiple failed medications, it is unlikely that another antidepressant will be helpful for him. In addition, TCAs have a small therapeutic window and can be a safety risk for someone with ongoing suicidality.

Start a trial of methylphenidate is an incorrect answer. Methylphenidate is a stimulant that is used to treat attention deficit disorder and would not be appropriate for this patient.

Start a trial of olanzapine is an incorrect answer. Olanzapine is an atypical antipsychotic that is used in the management of thought disorders like schizophrenia and would be inappropriate for him at this time.

Start a trial of mirtazapine is incorrect. Mirtazapine is an atypical antidepressant, and like imipramine, is not indicated with this patient due to his history of failed medication trials.

Haloperidol is a typical antipsychotic often used as a treatment in schizophrenia. It can cause extrapyramidal symptoms in patients including acute dystonia, restlessness, Parkinsonism and tardive dyskinesia. This patient’s restlessness, likely akathisia, is caused by haloperidol, so her prescription should be changed to an atypical antipsychotic. Atypical antipsychotics often have a lower incidence of the development of extra-pyramidal symptoms.

Refractory schizophrenia is unresponsive to first-line antipsychotics. This patient’s psychotic symptoms have improved, so her restlessness is not due to refractory schizophrenia.

Bipolar disorder is a mood disorder characterized by alternating episodes of mania and depression not caused by the direct psychological effects of another medication. This patient’s restlessness can not be considered a manic episode as she is taking an antipsychotic for her schizophrenia. She also does not have a history of depression or any other mood disorder, so this option is incorrect.

Generalized anxiety disorder is characterized by persistent and excessive worry about everyday issues. This patient’s restlessness, palpitations, shortness of breath, and chest tightness are not caused by anxiety. She is experiencing the side effects of haloperidol.

Noncompliance with medication is incorrect as her symptoms have improved with the use of medication; this indicates her regular use of medication.

Cognitive behavioral therapy is the correct answer. This patient’s intentional production of symptoms of depression, a false psychological stressor (death of her friend), and the absence of any secondary gain indicate the diagnosis of factitious disorder imposed on self. She is assuming the sick role to gain medical attention as she has previously consulted different physicians for a variety of false complaints. Cognitive-behavioral therapy is the most appropriate treatment option for these patients.

Prescribe antipsychotics is incorrect. The patient does not have signs or symptoms of psychosis (delusions, hallucinations, altered thought processes). As this patient appears to be feigning her illness, this would not be an appropriate treatment.

Start fluoxetine is incorrect. Starting fluoxetine is unlikely to cause any improvement, especially given her previous history and the question if she has any mood/anxiety symptoms.

Electroconvulsive therapy is incorrect. Electroconvulsive therapy (ECT) is used in the management of treatment-resistant psychiatric illnesses. Aside from the fact that the patient appears to be feigning illness, she would need to have failed multiple medication trials before undergoing ECT.

Prescribe tranylcypromine is incorrect. Tranylcypromine is a monoamine oxidase inhibitor (MAOI) that is used to manage treatment-resistant depression. This patient is only feigning symptoms of depression. Therefore, this management option is incorrect.

Iron deficiency is correct because restless leg syndrome, also known as Willis-Ekbom Disease (WED), is associated with iron deficiency. There is a decreased availability of iron in the neuromelanin cells of the substantia nigra, which leads to reduced activity of the enzyme involved in dopamine synthesis or reduced expression of dopamine receptors and transporters.

Vitamin B12 deficiency is incorrect. Restless leg syndrome could potentially be linked to vitamin B12 deficiency, but it is still not viewed as a major cause. Subacute combined degeneration of the spinal cord, also known as Lichtheim’s disease, is associated with vitamin B12 deficiency.

Zinc deficiency is incorrect. Restless leg syndrome is not associated with zinc deficiency.

Vitamin D deficiency is incorrect. Vitamin D deficiency is associated with bone disorders and is not associated with restless leg syndrome.

Vitamin C deficiency is incorrect. Vitamin C deficiency is associated with scurvy and does not cause restless leg syndrome. Despite this, vitamin C supplementation may help relieve restless leg syndrome symptoms.

Increased norepinephrine levels is the correct answer. The above case describes a patient with the most likely diagnosis of post-traumatic stress disorder (PTSD) in that he displays re-experiencing symptoms, avoidance symptoms, negative cognitions, and elevated arousal symptoms that started after the trauma 6 months ago. There is an increase in the levels of norepinephrine in patients with PTSD as it is associated with a heightened state of arousal, startle response, increased heart rate and blood pressure, and response to memories.

Decreased dopamine levels is incorrect. There have been inconsistent results regarding dopamine levels in PTSD patients, but it is unlikely that these levels go down. There is some evidence that dopamine levels do not change, and there is some evidence that dopamine levels go up. Dopamine in the mesolimbic system has been implicated in fear conditioning. When stressors stimulate the mesolimbic system, this releases dopamine, which is involved in the modulation of the hypothalamic-pituitary-adrenal axis responses.

Increased serotonin levels is incorrect. Serotonin plays a role in the regulation of sleep, appetite, aggression, impulsivity, sexual behavior, and modulation of affective and stress responses. There is a decrease in the levels of serotonin in patients with PTSD which leads to increased vigilance and startle, impulsivity, hostility, aggression, depression, and suicide.

Increased GABA levels is incorrect. GABA plays an important role in dampening behavioral and physiological responses to stressors and has profound anxiolytic effects. There is an alteration in the GABA receptor complex due to uncontrollable stress leading to decreased activity and compromised anxiolytic effects in patients with PTSD.

Decreased glutamate levels is incorrect. Glutamate, via binding to N-methyl D-aspartate (NMDA) receptors, is implicated in learning, memory, and synaptic plasticity. Increased exposure to stress leads to increased levels of glutamate, which is excitotoxic to neurons and can lead to neuronal loss in the hippocampus and prefrontal cortex of patients with PTSD, causing derealization and dissociation of memories.

Phenelzine is the correct answer because it is an monoamine oxidase inhibitor (MAOI) that can cause a hypertensive crisis when ingested with tyramine-rich foods. This man presents amid a probable hypertensive crisis, and was most probably taking a MAOI. This class of drugs can cause hypertensive crisis with the ingestion of tyramine-rich foods such as fava beans, and aged food including cheese, fish, wine, tofu, and bean curds. This is because tyramine is also metabolized by monoamine oxidase. Patients who are prescribed an MAOI should be educated about dietary restrictions and the danger signs and symptoms of a hypertensive crisis. They should immediately report to the hospital if they experience severe headaches, palpitations, flushing, profuse sweating, and chest pain.

Fluoxetine is incorrect because it is a selective-serotonin reuptake inhibitor (SSRI) and is not associated with hypertensive crisis.

Mirtazapine is incorrect because it is an alpha2-receptor antagonist that increases norepinephrine release by feedback inhibition of presynaptic adrenergic receptors. It does not inhibit monoamine oxidase inhibitor (MAOI) nor does it cause hypertensive crisis.

Imipramine is a tricyclic antidepressant (TCA) that is not used as much as newer antidepressants due to its higher side effect profile. It does not cause hypertensive crisis.

Bupropion is a norepinephrine and dopamine reuptake inhibitor (NDRI). It does not inhibit monoamine oxidase inhibitor (MAOI) and doesn’t cause hypertensive crisis.

Continue paroxetine for at least 2 years at the same dose is correct because he has had more than 3 depressive episodes in total.

Switch frpm paroxetine to cognitive behavioral therapy (CBT) is incorrect because paroxetine helped the patient achieve remission, so switching therapies at this time is not recommended.

Continue paroxetine therapy for 6 months then discontinue is incorrect because it refers just to the continuation phase of treatment. This is the right approach for patients who have only had one depressive episode and don’t fulfill the criteria for requiring maintenance therapy. This patient, however, has had several depressive episodes and therefore requires a different management approach.

Taper paroxetine over 2 months is incorrect. SSRIs should always be tapered off if they are discontinued, but not right after the acute phase of treatment. Tapering off at this point would be too early in this patient due to his history of recurrent depressive episodes, as it could lead to a recurrence of depressive symptoms.

Add lithium to the current regimen is incorrect. Lithium can be combined with paroxetine in patients with treatment-resistant depression. This patient has responded well to monotherapy, making lithium augmentation unnecessary.

Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that is used in the management of major depressive disorder as well as neuropathic pain. SNRIs like duloxetine (along with SSRIs) are considered to be first-line agents for treating depression. Duloxetine is also FDA-approved to treat neuropathic pain associated with diabetes mellitus. This dual indication makes it the ideal choice for this patient.

Bupropion is incorrect because it is a norepinephrine-dopamine reuptake inhibitor (NDRI) used for the treatment of MDD and smoking cessation. Bupropion could be a good choice for his depression, and many patients find that their pain improves as their depression improves. However, given that bupropion does not effectively treat neuropathic pain, duloxetine is preferred in this case.

Olanzapine is incorrect because it is an antipsychotic medication that is FDA-indicated for use in bipolar disorder. It is used off-label for multiple other disorders, but not as a monotherapy for depression.

Gabapentin is incorrect because it is an anti-epileptic drug that is often used to treat neuropathic pain. Though it is often used off-label for anxiety and alcohol use, it is not an appropriate treatment for depression.

Selegiline is incorrect because it is a monoamine oxidase-B inhibitor that can be used to treat unipolar depressive disorder (transdermal application) and Parkinson’s disease. However, it is typically not used for the initial treatment of depression because of its unfavorable side effect profile.

Light therapy has proven efficacy in major depressive disorder with seasonal pattern and may be effective as an added therapy to major depressive disorder. The light must be 10,000 lux and needs to be used for 30 minutes a day.

Hospital admission is incorrect. The patient has presented with major depressive illness, and the priority of treatment is to ensure patient safety. If the patient is at risk of self-harm or requires treatment that cannot be done as an outpatient, then they would need to be admitted to the hospital. The patient in question does not have any signs or symptoms that would show any predisposition towards self-harm.

Electroconvulsive therapy is the treatment of choice in major depressive illness when either the first line of treatment has failed, when the symptoms are very severe and endanger the person’s life, or if no other treatment is tolerable. Light therapy and pharmacotherapy should be tried first in this case.

Alprazolam is a benzodiazepine and is an anxiolytic, not an antidepressant.

Valproate is used in the treatment of bipolar disorder. This patient has not presented with episodes of elevated mood or mania or hypomania, so bipolar disorder is unlikely; the patient suffers from major depressive disorder with a seasonal pattern, and the use of valproate is not warranted in the management of this disorder.

Premenstrual dysphoric disorder symptoms include, but are not limited to, irritability, interpersonal conflicts, marked depressed mood, being “on edge”, lethargy, and sleep and appetite changes for more than 2 cycles. The patient should keep a record of her day-to-day mood changes and bring the record with her to her consultation.

Premenstrual syndrome is incorrect. Premenstrual syndrome differs from premenstrual dysphoric disorder in that the symptoms are less severe than the former. The diagnosis of premenstrual syndrome does not warrant a minimum of 5 symptoms, and there is no stipulation for affective symptoms. Premenstrual syndrome is more common.

Dysmenorrhea is incorrect. Dysmenorrhea is a syndrome of painful menses, and dysmenorrhea begins with the menstrual cycle, whereas premenstrual dysphoric disorder often begins before the start of menses and may continue into the first few days of menses.

Major depressive disorder due to medication is incorrect. Some patients experience symptoms of premenstrual syndrome while they use hormonal treatments, e.g. birth control. If the symptoms appear after starting the hormonal therapy, the therapy is likely to be the cause of the symptoms, and it would be considered medication-induced depressive disorder. There are no clues of any hormone use in the question.

Bipolar disorder is incorrect. It is the presence of major depressive episodes with episodes of hypomania and/or mania. There are no symptoms or history of mania or hypomania in the question.

Major depressive disorder, single episode is the correct answer. Major depressive episodes contain the following symptoms: low mood for most of the day at least half of the days, loss of interest in activities, feelings of worthlessness/guilt, changes in sleep, changes in appetite, decreased energy, decreased concentration/memory, psychomotor retardation or agitation and suicidal thoughts or thoughts of death. A patient must have at least 5 symptoms, which must include either a depressed mood or loss of interest to have a major depressive episode. These symptoms need to be persistent for over 2 weeks, every day, for most of the day.

Bereavement is incorrect. While sadness is the normal reaction to loss, periods of sadness do not necessarily indicate any mental illness. This patient’s symptoms are more severe than typical bereavement and meet the criteria for major depressive disorder. If the symptoms of bereavement fulfill the criteria for a major depressive episode, then the diagnosis is major depressive disorder. Major depression often has an inciting event, such as the loss of a loved one.

Attention deficit hyperactivity disorder is incorrect. Some symptoms of major depressive disorder overlap those of attention-deficit/hyperactivity disorder, especially in children and adolescents. These symptoms are low frustration tolerance and distractibility. However, in patients with attention deficit disorder, a disturbance in mood will be characterized by irritability rather than sadness or loss of interest.

Adjustment disorder with depressed mood is incorrect. The difference between adjustment disorder with depressed mood and major depressive disorder is that the full criteria for major depression are not met in the former.

Bipolar disorder is incorrect. While it is possible the patient is suffering from bipolar disorder, such a patient would need to have a history of episodes of hypomania or mania. This patient does not endorse any symptoms suggesting a history of mania/hypomania.

Persistent depressive disorder is correct. A diagnosis of persistent depressive disorder (dysthymia) in children and adolescents requires the presence of low mood almost every day or irritability, for more days than not, for over one year. While depressed, the child or adolescent must have at least 2 other symptoms, including feeling hopeless, having a low appetite or overeating, sleep disturbances, low energy, low self-esteem, and poor concentration. These mood changes must considerably affect the patient’s daily activity. This boy has had over 12 months of depressed mood, insomnia, low energy, and low self-esteem.

Attention-deficit/hyperactivity disorder is incorrect. In children and adolescents, the symptoms of attention-deficit/hyperactivity disorder suggest significant problems with focus, hyperactivity, and impulsivity but are not related to a mood disorder.

Major depressive disorder is incorrect. Major depression in children and adolescents requires either irritability or depressed mood for two weeks in addition to 5 or more of the following in the same 2-week period: loss of interest, weight changes, sleep changes, low energy, poor concentration, feeling worthless, suicidal ideation. This boy does not fulfill the criteria of a major depressive episode and thus does not meet the criteria for major depressive disorder.

Substance-induced depressive disorder is incorrect. There is no “clue” in the question that leads to the suspicion that the mood disorder is related to a substance.

Schizophrenia is incorrect. Schizophrenia will present with symptoms of psychosis, including, but not limited to, hallucinations and delusions.

24 hours is the correct answer because, according to the diagnostic criteria of tobacco withdrawal, the symptoms appear within 24 hours after abrupt cessation of tobacco use or decrease in the amount of tobacco use. Tobacco withdrawal presents with at least 4 symptoms from the following, including increased appetite, irritability, frustration, or anger, anxiety, difficulty concentrating, restlessness, depressed mood, and insomnia. Nicotine has a short half-life of approximately 2 hours, and its major metabolite has a half-life of 16 to 18 hours. Therefore, withdrawal effects are mostly seen within 24 hours after cessation or decreased tobacco use.

48 hours is incorrect because the diagnostic criteria for tobacco withdrawal describe the presence of symptoms within 24 hours.

72 hours is incorrect because the diagnostic criteria for tobacco withdrawal describe the presence of symptoms within 24 hours of abrupt cessation or decrease in the use of tobacco.

96 hours is incorrect because the diagnostic criteria for tobacco withdrawal describe the presence of symptoms within 24 hours of abrupt cessation or decreased use of tobacco.

120 hours is incorrect because diagnostic criteria for tobacco withdrawal describe the presence of symptoms within 24 hours.

Intention-to-treat analysis is correct because an intention-to-treat analysis is a statistical method that includes all patients, including those who dropped out of the study. It then analyzes them based on their assigned group. The drop-out rate in this study may have resulted in some selection bias, and the results of this study may be falsely skewed in favor of the new treatment. An intention-to-treat analysis is an appropriate technique to address this bias.

Subgroup analysis is incorrect because it adjusts for effect modifier or confounder. This technique does not minimize selection bias because of the individual’s loss during the study.

Noninferiority trial is incorrect because it is commonly used when placebo control would be unethical. This investigation has a placebo group in place.

Per-protocol analysis is incorrect because this statistical method does not include data from patients who dropped out of the study or did not follow treatment protocol. This technique will not minimize the selection bias.

Crossover trial is incorrect because this type of clinical trial aims to make patients serve as their own control. This study method consists of 2 groups, i.e., experimental and control. Additionally, it is not a method of statistical analysis.

Reassure the patient is highly unlikely to test positive from secondhand smoke is correct. As the patient has not smoked themselves, the cutoff of the SAMSHA-approved tests is too high to return a positive result for secondhand smoke. Thus, a positive test due to secondhand smoke is considered near impossible and the patient can be reassured that the test will be negative.

Suggest the patient wait 2 more weeks for cannabis to clear her system is incorrect. This case describes a patient that has inhaled secondhand smoke of cannabis 2 weeks ago and is now worried about a positive drug screen. Although cannabis (THC) metabolites can be detected in urine for up to 30 days, especially in long-term users, a naïve user that has smoked can expect THC to clear their system within a week.

Refer the patient to an addiction specialist is incorrect. This option can be considered if the patient admits to a history of cannabis use.

Suggest patient use hemp seed oil to enhance metabolism of THC is incorrect. Hemp seed oil or hemp-containing products can return false positives for drug testing and thus the patient should be warned against using them.

Write the patient a doctor’s note explaining the possibility of a false positive from second-hand smoking is incorrect. While this can be valid for medications such as efavirenz, which may lead to false positives in drug testing for cannabis, this would not be recommended in this context.

Add pimavanserin is the correct answer because anti-parkinsonian medications can cause psychosis due to their dopaminergic effects. When the risks of dosage reduction outweigh the benefits, a trial on antipsychotic medication is warranted to offset the adverse effects of the anti-parkinsonian medications. Medications with strong D2 blockade (such as risperidone and haloperidol) are contraindicated, because they will worsen the parkinsonian features. Antipsychotics with minimal to no D2 blockade are recommended. Pimavanserin is FDA indicated for the treatment of psychosis in Parkinson’s disease. Quetiapine and clozapine can also be considered, due to low D2 blockade.

Decrease his dose of carbidopa/levodopa is incorrect because although dosage reduction or discontinuation is an option, it is frequently not possible due to the need to control motor symptoms. In this patient, reducing the dose would risk a return of disabling motor symptoms and increase the risk of injury due to falls.

Add a selective serotonin reuptake inhibitor is incorrect because although this patient has a history of depression, his recent behavioral change is more consistent with psychosis than depression.

Increase his dose of carbidopa-levodopa is incorrect because the patient’s motor symptoms are currently well controlled, and increasing his anti-parkinsonian medication would likely worsen his psychosis.

Add risperidone is incorrect. Antipsychotics with strong D2 receptor antagonism will only worsen the motor symptoms in Parkinson’s disease. Pimavanserin is the recommended 1st line.

Reduce the prednisone dose is the correct answer because this patient’s new onset of mood symptoms is most likely due to corticosteroid use. High doses of prednisone (40 mg/day), often given for allergic, inflammatory, or autoimmune conditions (systemic lupus erythematosus), may cause psychiatric symptoms in a dose-dependent fashion, with or without any history of underlying psychiatric disorders. In addition to mood symptoms, psychosis, and anxiety can also occur. Other neuropsychiatric symptoms seen in patients taking glucocorticoids include sleep disturbances, restlessness, and memory loss.

Add lithium is incorrect. Whenever possible, the first step in the treatment of corticosteroid-induced psychiatric symptoms is dose reduction (or discontinuation if appropriate) of the offending medication. This patient has a family history of bipolar disorder, however there is no evidence that this patient is experiencing a manic episode at this time.

Add bupropion is incorrect. This patient presents with depressive symptoms, and antidepressant therapy could be considered in the future, however the first choice of treatment now would be to minimize the offending substance.

Add duloxetine is incorrect. This patient presents with depressive symptoms, and antidepressant therapy could be considered in the future, however the first choice of treatment now would be to minimize the offending substance.

Begin cognitive behavioral therapy (CBT) is incorrect. CBT is an evidence based treatment that can be used as a monotherapy agent for mild and moderate depressive episodes. Despite the efficacy of CBT, reducing the dose of prednisone makes the most clinical sense at this time.