Questions
Each of the following questions or incomplete statements is followed by suggested answers or completions. Select the ONE BEST ANSWER in each case.
1. Cognitive therapy involves
A) repetition of negative thoughts that eventually dissipate
B) changing a thought that involves a situation that leads to a change of mood, behavior, or reaction
C) repeated acts of fearful situations that allow adaptation
D) negative reinforcement of harmful activities
E) none of the above
View Answer
Answer and Discussion
The answer is B. Cognitive therapy is a psychological treatment method that helps patients correct false self-beliefs that contribute to certain moods and behaviors. The basic principle behind cognitive therapy is that a thought precedes a mood, and that both are interrelated with a person's environment, physical reaction, and subsequent behavior. Therefore, changing a thought that arises in a given situation changes mood, behavior, and physical reaction. Although it is unclear who benefits most from cognitive therapy, motivated patients who have an internal center of control and the capacity for introspection likely would benefit most.
Ramana R, Paykel ES, Cooper Z, et al. Remission and relapse in major depression: a two-year prospective follow-up study. Psychol Med. 1995;25:1161–1170.
The basic principle behind cognitive therapy is that a thought precedes a mood, and that both are interrelated with a person's environment, physical reaction, and subsequent behavior.
2. The most common side effect of high dose St. John's Wort is
A) transient photosensitivity
B) hoarseness
C) myalgias
D) hypertension
E) tremor
View Answer
Answer and Discussion
The answer is A. Transient photosensitivity is generally the most common side effect of St. John's Wort and occurs more commonly at higher dosages. Other side effects include gastrointestinal upset, increased anxiety, minor palpitations, fatigue, restlessness, dry mouth, headache, and increased depression.
Brockmoller J, Reum T, Bauer S, et al. Hypericin and pseudohypericin: pharmacokinetics and effects on photosensitivity in humans. Pharmacopsychiatry. 1997;30(suppl 2):94–101.
3. Which of the following medications can be affected by the concurrent use of St. John's Wort?
A) Amoxicillin
B) Gabapentin
C) Oral contraceptives
D) Glipizide
E) Hydrochlorothiazide
View Answer
Answer and Discussion
The answer is C. Due to the induction of CYP 3A4, concurrent use of St. John's Wort may reduce the effectiveness of oral contraceptives. Women using oral contraceptives should be counseled regarding possible breakthrough bleeding and might consider a barrier method of contraception when taking St. John's Wort.
Hall SD, Wang Z, Huang SM, et al. The interaction between St. John's Wort and an oral contraceptive. Clin Pharmacol Ther. 2003;74:525–535.
4. Which of the following is the definition of adjustment disorder with depressed mood?
A) Tearfulness related to the death of a loved one 1 year ago.
B) Development of emotional or behavioral symptoms in response to an identifiable stressor that occurs within 3 months of the stressor.
C) Thoughts of death and morbid preoccupation with worthlessness with no prior triggering event.
D) Lifetime obsession with morbid thoughts.
E) Transient, normal depressive responses or mood changes to stress.
View Answer
Answer and Discussion
The answer is B. Adjustment disorder with depressed mood is defined as development of emotional or behavioral symptoms in response to an identifiable stressor that occurs within 3 months of the stressor. Symptoms include depressed mood, tearfulness, and hopelessness, and occur in excess of what would usually be expected from exposure to the stressor and cause significant impairment in social and occupational/academic functioning. Once the stressor (or its consequences) has terminated, the symptoms resolve within 6 months. Acute episodes last for less than 6 months, and chronic episodes last 6 months or more.
Son SE, Kirchner JT. Depression in children and adolescents. Am Fam Physician. 2000;62:2297–2308, 2311–2312.
5. Which of the following medications would be the best selection to treat chronic neuropathic pain in a frail elderly man with a history of cardiac conduction abnormalities?
A) Fluoxitene (Prozac)
B) Amitryptiline (Elavil)
C) Gabapentin (Neurontin)
D) Phenytoin (Dilantin)
E) Cyclobenzaprine (Flexaril)
View Answer
Answer and Discussion
The answer is C. An antiepileptic drug [e.g., gabapentin (Neurontin)] is preferred if the patient cannot tolerate the side effects of tricyclic antidepressants, has cardiac contraindications to the use of tricyclic antidepressants (e.g., conduction abnormalities, recent cardiac event), or is a “frail elder.” Of the second-generation antiepileptic drugs, gabapentin (Neurontin) has the best documented efficacy in the treatment of neuropathic pain.
Son SE, Kirchner JT. Depression in children and adolescents. Am Fam Physician. 2000;62:2297–2308, 2311–2312.
6. Which of the following medications is limited by potentially life-threatening rashes?
A) Phenytoin (Dilantin)
B) Lamotrigine (Lamictal)
C) Carbamazepine (Tegretol)
D) Gabapentin (Neurontin)
E) Tramadol (Ultram)
View Answer
Answer and Discussion
The answer is B. Lamotrigine (Lamictal) has been proved to be modestly effective in patients with trigeminal neuralgia, neuropathy associated with human immunodeficiency virus (HIV) infection, and poststroke pain. The drug is ineffective in patients with unspecified refractory neuropathic pain. The use of lamotrigine is limited by potentially life-threatening rashes.
Son SE, Kirchner JT. Depression in children and adolescents. Am Fam Physician. 2000;62:2297–2308, 2311–2312.
7. Which of the following means is the most common for suicide completion?
A) Firearms
B) Prescription medication overdose
C) Illicit drug overdose
D) Carbon monoxide poisoning
E) Hanging
View Answer
Answer and Discussion
The answer is A. Access to means to attempt suicide is an important precipitating cause. This is true even after controlling for other risk factors such as depression or substance use. Firearms are the most common means for suicide completion. Other means include medications, illicit drugs, toxic chemicals, carbon monoxide, hanging, and cutting. Almost anything can be used as a means to attempt suicide, but access to the most lethal means often is preventable.
Brent DA, Perper JA, Allman CJ. Alcohol, firearms, and suicide among youth. Temporal trends in Allegheny County, Pennsylvania, 1960 to 1983. JAMA. 1987;257:3369.
Brent DA, Perper JA, Allman CJ, et al. The presence and accessibility of firearms in the homes of adolescent suicides. A case-control study. JAMA. 1991;266:2989.
Kennebeck S, Bonin L. Epidemiology and risk factors for suicidal behavior in children and adolescents. Up to Date, version 14.1. Accessed 3/6/06.
8. Which of the following statements is true regarding the use of haloperidol?
A) The drug has been approved for intravenous use.
B) Haloperidol is considered safe in those with a known seizure disorder.
C) The drug can cause prolongation of the QT interval.
D) ECG monitoring is not necessary when the drug is given intravenously.
E) None of the above.
View Answer
Answer and Discussion
The answer is C. Haloperidol has not been approved for intravenous use, although it is commonly used by this route and is generally thought to be safe. The drug may cause prolongation of the QT interval; as a result, electrocardiographic monitoring is necessary. Haloperidol should be avoided if possible in patients with a known seizure disorder.
Fife A, Schreiber J. Psychiatric emergencies: agitation or aggression. Up to Date, version 14.1. Accessed 3/6/06.
9. Domestic violence
A) is higher in gay and lesbian relationships
B) affects males and females equally
C) rarely affects the elderly
D) increases during pregnancy
E) is rarely associated with a spouse
View Answer
Answer and Discussion
The answer is D. Studies show that women are much more likely than men to be the victims of chronic physical abuse. Domestic violence in gay and lesbian relationships appears to be as common as in heterosexual relationships. Domestic violence is also a significant problem among the elderly. Elder abuse is associated with an increase in reports of chronic pain, depression, number of health conditions, and an increased mortality. The abuser is most commonly a relative (usually the spouse). Domestic violence often begins or, if already present, increases during pregnancy and the postpartum period.
Hillard PJ. Physical abuse in pregnancy. Obstet Gynecol. 1985;66:185.
Sillman JS. Diagnosing, screening and counseling for domestic violence. Up to Date, version 14.1. Accessed 3/6/06.
Studies show that women are much more likely than men to be the victims of chronic physical abuse. Domestic violence in gay and lesbian relationships appears to be as common as in heterosexual relationships.
10. When considering light therapy for seasonal affective disorder (SAD), which of the following is not a factor that predicts a positive result?
A) Hypersomnia
B) High number of vegetative symptoms
C) Increased intake of sweet foods in the afternoon
D) History of reactivity to ambient light
E) Positive family history of SAD
View Answer
Answer and Discussion
The answer is E. Light therapy involves exposure to minimum 2,500 lux of visible light. 10,000 lux for 30 minutes/day has been shown to be effective. Factors that have predicted a positive response to light therapy include hypersomnia, high rate of vegetative symptoms, an increased intake of sweet foods in the afternoon, and a history of reactivity to ambient light. A positive family history does not necessarily increase a positive response to light therapy.
Oren DA, Jacobsen FM, Wehr TA, et al. Predictors of response to phototherapy in seasonal affective disorder. Compr Psychiatry. 1992; 33:111.
Saeed SA, Bruce TJ. Seasonal affective disorder. Up to Date, version 14.1. Accessed 3/8/06.
11. Which of the following statements regarding lesbians and health care is true?
A) Approximately 1% of the women in the United States identify themselves as lesbian.
B) Lesbians tend to overutilize health care.
C) Lesbians typically present later for health care than heterosexual women.
D) Lesbian women are usually of higher socioeconomic status than gay men.
E) Lesbian awareness rarely affects their health care.
View Answer
Answer and Discussion
The answer is C. Approximately 4% to 10% of women in the United States identify themselves as lesbians. Lesbians, like other marginalized groups of women, underutilize clinical care services and present later for health care than heterosexual women. Some reasons for these deficiencies are health-care providers who lack awareness of the health issues of lesbians, who discriminate against them, and who create negative experiences. In addition, women are often of lower socioeconomic status than gay men, without spousal or family benefits such as health insurance. Lesbians also use health-care services that focus on contraception and reproduction less frequently; these services are entry points to the health-care system for many women.
Denenberg R. Report on lesbian health. Womens Health Issues. 1995;5:81.
O'Hanlan KA. Lesbian health and homophobia: Perspectives for the treating obstetrician/ gynecologist. Curr Probl Obstet Gynecol Fertil. 1995;18:99.
Carroll NM. Gynecologic and obstetric care for lesbians. Up to Date, version 14.1. Accessed 3/8/06.
12. Risk factors for smoking include all of the following except
A) exposure to secondhand smoke
B) presence of a smoker in the family
C) poor academic performance
D) single parent at home
E) lack of concern over weight and body image, particularly in women
View Answer
Answer and Discussion
The answer is E. Risk factors for smoking include exposure to secondhand smoke, presence of a smoker in the household, comorbid psychiatric disorders, strained relationship with parent and/or single parent at home, low level of expressed self-esteem and self-worth, poor academic performance, increased adolescent perception of parental approval of smoking, affiliation with smoking peers, and availability of cigarettes. An additional risk factor for boys is high levels of aggression and rebelliousness; among girls, preoccupation with weight and body image is a separate risk factor.
Hurt RD, Sachs DPL, Glover ED, et al. A Comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med. 1997;337:1195.
Rennard RI, Daughton DM. Overview of smoking cessation. Up to Date, version 14.1. Accessed 3/8/06.
13. Smoking is associated with an increased risk of all of the following except
A) infertility
B) spontaneous abortion
C) ectopic pregnancy
D) premature menopause
E) multiple births
View Answer
Answer and Discussion
The answer is E. Smoking is associated with infertility, spontaneous abortion, ectopic pregnancy, and premature menopause.
Smoking and infertility. Fertil Steril. 2004;81:1181.
Rennard RI, Daughton DM. Overview of smoking cessation. Up to Date, version 14.1. Accessed 3/8/06.
14. Which of the following has been shown to be beneficial in smoking cessation?
A) Fluoxetine
B) Venlafaxine
C) Bupropion
D) Sertraline
E) Doxepin
View Answer
Answer and Discussion
The answer is C. Bupropion (also marketed as Wellbutrin) has been available for use as an antidepressant in the United States since 1989, and is thought to act by enhancing central nervous system noradrenergic and dopaminergic function. A sustained-release formulation of the drug (Zyban) is licensed as an aid to smoking cessation.
Rennard RI, Daughton DM. Overview of smoking cessation. Up to Date, version 14.1. Accessed 3/8/06.
15. Urges or impulses for repetitive intentional behavior performed in a stereotyped manner in an attempt to relieve anxiety is termed
A) adaptation
B) congruence
C) compulsion
D) obsession
E) transference
View Answer
Answer and Discussion
The answer is C. Obsessions are persistent thoughts, ideas, and images that invade into conscious awareness, are recognized as a product of one's mind, and are perceived as senseless and intrusive. In many cases these obsessions have a theme that an insignificant oversight will result in tremendous catastrophe. Other common themes are contamination, a need for ordering things, aggressive impulses, and sexual imagery. Compulsions are urges or impulses for repetitive intentional behavior performed in a stereotyped manner (e.g., touching, counting, arranging) in an attempt to alleviate the anxiety that most frequently results from the obsessions. Often these behaviors are believed to help defend the patient and others from potential harm.
Ciechanowski P, Katon W. Overview of obsessive-compulsive disorder. Up to Date, version 14.1. Accessed 3/8/06.
16. Which of the following medications is used in the classic treatment of bipolar disorder?
A) Lithium
B) Sertraline
C) Amitriptyline
D) Phenytoin
E) Alprazolam
View Answer
Answer and Discussion
The answer is A. Bipolar disorder is most commonly diagnosed in persons between 18 and 24 years of age. The clinical presentations of this disorder are diverse and include mania, hypomania, and psychosis. Frequently associated conditions include substance abuse and anxiety disorders. Patients with acute mania must be evaluated urgently. Treatment involves the use of mood stabilizers such as lithium, valproic acid, and carbamazepine.
Grisswold KS, Pessar LF. Management of bipolar disorder. Am Fam Physician. 2000;62:1343–1353, 1357–1358.
17. A 21 year old presents with complaints of an inflated self-esteem, decreased need for sleep, and distractibility. The most likely diagnosis is
A) depression
B) hypothymia
C) borderline personality
D) mania
E) antisocial personality
View Answer
Answer and Discussion
The answer is D. The diagnosis of mania consists of at least three of the following:
· Inflated self-esteem or grandiosity
· Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
· More talkative than usual, or pressure to keep talking
· Flight of ideas, or subjective experience that thoughts are racing
· Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
· Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
· Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, foolish business investments)
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association; 2000:327, 332.
18. Which of the following is the greatest risk factor for suicide?
A) Unemployment
B) Single status
C) Low income status
D) Resident of urban area
E) History of admission to a psychiatric hospital
View Answer
Answer and Discussion
The answer is E. Suicide rates were higher in residents of urban areas compared with nonurban residents. The risk of suicide was also increased with unemployment, single status, low income, and receipt of pension or social security benefit. The strongest risk factor concerned admission to a psychiatric hospital. Almost one half of the persons who committed suicide had a history of admission to psychiatric facilities. Regardless of diagnosis, the greatest risk was during hospital admission and in the first week following discharge.
Mortensen PB, Agerboo E, Erikson T. Psychiatric illness and risk factors for suicide in Denmark. Lancet. 2000;355:9–12.
The risk of suicide is increased with unemployment, single status, low income, and receipt of pension or social security benefit. The strongest risk factor is admission to a psychiatric hospital.
19. In a dying patient, which of the following is used to detect depression?
A) Pervasive hopelessness
B) Weight loss
C) Crying
D) Dependency
E) Concern over being a burden
View Answer
Answer and Discussion
The answer is A. A person who is grieving maintains a sense of hope. Hope may change from the hope for a cure to the hope for prolonging life to the hope to live comfortably and without pain for the duration of life, but it is not lost in persons who are dying. Pervasive hopelessness, however, is a hallmark of depression.
Periyakoil VS, Hallenbeck J. Identifying and managing preparatory grief and depression at the end of life. Am Fam Physician. 2002;65:883–890, 897–898.
20. Which of the following electrolyte abnormalities is associated with bulimic patients?
A) Metabolic acidosis
B) Respiratory acidosis
C) Metabolic alkalosis
D) Respiratory alkalosis
E) Normal electrolytes
View Answer
Answer and Discussion
The answer is C. Symptoms and signs of bulimia include reflux esophagitis, abdominal cramping, diarrhea, and rectal bleeding. Electrolyte abnormalities and metabolic alkalosis signal extreme purging habits in a bulimic patient. Patients with anorexia generally have laboratory test results within normal limits until the very late stage of the condition.
Mehler PS. Diagnosis and care of patients with anorexia nervosa in the primary care setting. Ann Intern Med. 2001;134:1048–1059.
21. A 42-year-old man is seen in your office. He has recently seen a psychiatrist and is being treated for severe depression. The patient cannot recall the medication that he is taking, but he remembers that the psychiatrist told him not to eat cheeses or aged meats. Which of the following agents is this patient most likely taking?
A) Tricyclic antidepressant
B) Selective serotonin release inhibitor
C) Monoamine oxidase (MAO) inhibitor
D) Neuroleptic
E) Anxiolytic
View Answer
Answer and Discussion
The answer is C. Antidepressant medications fall into three basic categories:
· Tricyclic antidepressants: These include amitriptyline, imipramine, nortriptyline, and desipramine. Tricyclic antidepressants have been commonly used in the treatment of depression since the mid-1980s. These medications may require 2 to 6 weeks before full therapeutic effect is noted. Many have anticholinergic side effects. Amitriptyline has the most anticholinergic properties, including dry mouth, blurred vision, constipation, ileus, urinary retention, and even delirium. In most cases, these side effects improve with time. Drug selection should depend on the symptoms and the side effect profile of the medication.
· Selective serotonin reuptake inhibitors (SSRIs): These include fluoxetine, paroxetine, citalopram, escitalopram, and sertraline. SSRIs are popular mainly because of their reduced side effect profile and once-a-day dosing. These medications are very effective in the treatment of depression and are associated with a lower incidence of side effects compared with tricyclic antidepressants. The risk of death from overdose is very low with these medications. They are activating and should be given during the day.
· Serotonin modulators: The medications block primarily the 5-HT2 receptor and inhibit reuptake of 5-HT and norepinephrine. The group includes nefazodone, trazadone, and mirtazapine.
· Serotonin-norepinephrine reuptake inhibitors: This group includes venlafaxine and duloxetine. They have dual 5-HT and norepinephrine mechanism of action.
· Dopamine-norepinephrine reuptake inhibitors: The only drug in this class is bupropion.
· MAO inhibitors: These include phenelzine and tranylcypromine. MAO inhibitors are not used as frequently for the treatment of depression because of the potential for severe side effects. Interactions with sympathomimetic medications or tyramine-containing foods (e.g., cheeses, wines, beers, aged meats and fruits, beans, liver, yeast extracts) can lead to a hypertensive crisis. Orthostatic hypotension, nausea, insomnia, and sexual dysfunction are also common.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1708–1709.
22. Which of the following is considered tertiary prevention?
A) Pneumococcal (Pneumovax) immunization
B) Purified protein derivative determination in a patient who is affected with tuberculosis
C) Smoking cessation counseling in a patient who is known to have chronic obstructive pulmonary disease
D) Administration of erythromycin eye drops to neonates
E) Hepatitis A vaccination for travelers
View Answer
Answer and Discussion
The answer is C. The following are three types of prevention:
· Primary prevention: These types of treatments prevent the development of disease. Examples include tetanus, influenza, or pneumovax vaccination and intraocular administration of erythromycin to prevent neonatal chlamydia or gonorrhea.
· Secondary prevention: These are steps taken in the early course of illness and help identify those who are affected. Examples include purified protein derivative determination in patients affected with tuberculosis or Venereal Disease Research Laboratory (VDRL) determination in those with syphilis.
· Tertiary prevention: These are steps that are taken after the development of a condition to help rehabilitate the patient. Examples include counseling a patient with emphysema or chronic bronchitis to stop smoking.
Rakel RE. Textbook of Family Practice, 4th ed. Philadelphia: WB Saunders; 1990:209, 210, 217.
23. A 30-year-old woman presents with fatigue, difficulty with concentration, weight loss, and insomnia. She is an avid equestrian, but recently has not been interested in riding. The most likely diagnosis is
A) somatoform disorder
B) depression
C) anorexia nervosa
D) bulimia
E) cyclothymia
View Answer
Answer and Discussion
The answer is B. Common symptoms that are associated with clinical depression include depressed mood, diminished interest or pleasure, significant appetite or weight change, sleep disturbances, agitation, fatigue, feelings of worthlessness or guilt, difficulty with concentration, or suicidal thoughts. Symptoms must be present for at least 2 weeks before the diagnosis is made. In addition, symptoms must be present almost daily and must represent a change from the patient's previous level of functioning. Other contributing causes must be ruled out. Either a depressed mood or a loss of pleasure in most activities must be present for the diagnosis.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 2000:78.
24. In young women with an eating disorder, at what point would you expect her menstrual periods to resume?
A) 75% of ideal body weight
B) 80% of ideal body weight
C) 90% of ideal body weight
D) 100% of body weight
E) It is unusual for menstrual cycles to resume with any weight gain.
View Answer
Answer and Discussion
The answer is C. Menstruation usually resumes in women affected with anorexia when the patient approaches 90% of ideal body weight.
Mehler PS. Diagnosis and care of patients with anorexia nervosa in the primary care setting. Ann Intern Med. 2001;134:1048–1059.
25. Which of the following behaviors is associated with bulimia?
A) Self-mutilation
B) Anxiety
C) Substance abuse
D) Unprotected sexual activity
E) All of the above
View Answer
Answer and Discussion
The answer is E. Young women with bulimia characteristically have low self-esteem, are depressed and/or anxious, and have poor impulse control. They typically engage in other risky behaviors, such as substance abuse, unprotected sexual activity, self-mutilation, and suicide attempts.
Kaplan A, Seidenfeld ME, Rickert VI. Impact of anorexia, bulimia and obesity on the gynecologic health of adolescents. Am Fam Physician. 2001;64:445–450.
26. Which of the following statements regarding obsessive-compulsive disorder (OCD) is true?
A) Obsessions are repetitive behaviors.
B) Most affected patients have obsessions as well as compulsions.
C) Compulsions are thoughts or ideas that recur.
D) Anxiety is a central feature.
E) Patients are usually unaware of their actions and thoughts and are resistant to them.
View Answer
Answer and Discussion
The answer is D. OCD is characterized by recurrent actions or ideas that interfere with normal daily activities. The patient is usually aware of the actions and thoughts and feels a strong inner resistance toward them. Obsessions are defined as thoughts or ideas that recur, and the patient tries to repress them. Common obsessions include fear of dirt, germs, or contamination; disgust with bodily waste or secretions; fear of harming a family member or friend; concern with order, symmetry (balance), and exactness; worry that a task has been done poorly, even when the person knows this is not true; fear of thinking evil or sinful thoughts; constantly thinking about certain sounds, images, words, or numbers; or a constant need for reassurance. Compulsions are repetitive behaviors that are performed in response to the obsessions. Common compulsions include cleaning and grooming rituals, such as excessive hand-washing, showering, and tooth-brushing; checking rituals involving drawers, door locks, and appliances to be sure they are shut, locked, or turned off; repeating rituals, such as going in and out of a door, sitting down and getting up from a chair, and touching certain objects several times; putting items in a certain order or arrangement; counting over and over to a certain number; saving newspapers, mail, or containers when they are no longer needed; or seeking reassurance and approval. Obsessions and compulsions can have an aggressive or sexual attachment. Fewer than 10% of patients have both obsessions and compulsions; however, individuals may exhibit multiple obsessions or multiple compulsions. Anxiety is a central feature of this disorder, but it is generated by internal thoughts as opposed to external circumstances. The neurosis affects men and women equally and usually is found in those of a higher socioeconomic class with above-average intelligence. The condition usually becomes apparent in childhood. Until recently, OCD has been a difficult illness to treat. However, we now have better medicines. Clomipramine (Anafranil) helps many people with OCD and usually decreases symptoms to mild levels. Si3de effects from this drug, such as dry mouth, constipation and drowsiness, and sometimes an inability to achieve orgasm, are common. Fluoxetine, sertraline, paroxetine, and fluvoxamine (Luvox) can also help some patients with OCD.
American Academy of Family Physicians. Information from your family doctor—Obsessive-compulsive disorder: what it is and how to treat it. Am Fam Physician. 2000;61(5):1537.
27. High fever, tachycardia, tachypnea, diaphoresis, hypertension, and seizures develop in a psychiatric patient who is receiving haloperidol. The most likely diagnosis is
A) malignant hyperthermia
B) rhabdomyolysis
C) neuroleptic malignant syndrome
D) sepsis
E) serotonin syndrome
View Answer
Answer and Discussion
The answer is C. Neuroleptic malignant syndrome is an uncommon idiosyncratic condition that is associated with the use of dopamine antagonist (i.e., antipsychotic medications). Usually associated with the more potent medications, such as haloperidol and piperazine phenothiazines, the symptoms include high fever (102°F to 104°F), tachycardia, tachypnea, diaphoresis, autonomic dysfunction, mental status changes, hypertension and hypotension, tremors, seizures, muscle rigidity, and leukocytosis. Significant elevations of serum creatinine kinase may signal rhabdomyolysis. Other complications include respiratory failure, myocardial infarction, and renal and hepatic failure. Disseminated intravascular coagulopathy may also occur. The treatment involves stopping the antipsychotic, supportive care, and the use of intravenous dantrolene. Bromocriptine, amantadine, and benzodiazepines can also be used. Mortality approaches 30%.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1671.
28. Panic disorder is defined as recurrent attacks that may involve which of the following symptoms?
A) Flight of ideas
B) Hallucinations
C) Feelings of envy
D) Impulsivity
E) Choking
View Answer
Answer and Discussion
The answer is E. As much as 33% of the population may have a panic episode during the year, but far fewer are affected with panic disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV-TR), the diagnosis of panic attack is a discrete period of intense fear or discomfort in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes:
· Shortness of breath
· Dizziness, fainting
· Palpitations or tachycardia
· Shaking
· Diaphoresis
· Choking
· Nausea or abdominal discomfort
· Depersonalization
· Paresthesia
· Flushing or chills
· Chest discomfort
· Fear of dying
· Fear of insanity or doing something uncontrolled
Panic disorder is divided into panic disorder with or without agoraphobia. Criteria consist of
· Recurrent unexpected panic attacks.
· At least one of the attacks has been followed by 1 month (or more) of the following:
o Persistent concern about additional attacks.
o Worry about the implications of the attack or its consequences.
o Significant change in behavior related to the attacks.
· Panic attacks are not due to the direct physiologic effects of a substance (drug abuse, medication).
· Panic attacks are not better accounted for by another mental disorder.
Treatment involves counseling, antidepressants (paroxetine), buspirone, and benzodiazepines (alprazolam).
Saddock BJ, Saddock VA. Kaplan and Saddock's Concise Textbook of Psychiatry, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:216–217.
Panic attacks are not due to the direct physiologic effects of a substance (drug abuse, medication).
29. Which of the following medications is best indicated in a patient with Parkinson's disease who experiences psychosis?
A) Haloperidol (Haldol)
B) Olanzapine (Zyprexa)
C) Quetiapine (Seroquel)
D) Risperidone (Risperdal)
E) Thioridazine (Mellaril)
View Answer
Answer and Discussion
The answer is C. Quetiapine (Seroquel) has shown promise in the treatment of psychosis in elderly patients with Alzheimer's disease and Parkinson's disease. It improves psychosis in patients with Parkinson's disease without exacerbating movement disorders. This feature has led some experts to recommend it as the first-line agent for treatment of psychosis in patients with Parkinson's disease. Haloperidol (Haldol) and thioridazine (Mellaril) can cause drug-induced parkinsonism, akathisia, acute dystonia, and tardive dyskinesia. Risperidone (Risperdal) exacerbates movement disorders in patients with Parkinson's disease. In patients with Parkinson's disease, olanzapine (Zyprexa) was found to increase motor symptoms.
Dewey RB Jr, O'Suilleabhain PE. Treatment of drug-induced psychosis with quetiapine and clozapine in Parkinson's disease. Neurology. 2000;55:1753–1754.
30. Which of the following is a potential side effect of quetiapine (Seroquel)?
A) Agranulocytosis
B) Cataract formation
C) Hepatotoxicity
D) QT interval prolongation
E) Thrombocytopenia
View Answer
Answer and Discussion
The answer is B. Quetiapine should be initiated at a dosage of 12.5 mg at bedtime and titrated every 3 to 5 days until the desired effect is achieved or side effects emerge. Common side effects include sedation, headache, and orthostatic hypotension. Cataract formation was noticed in pre-marketing studies, but a causal relationship has not been found. Screening for cataract formation is recommended at the initiation of therapy and at 6-month intervals thereafter.
Mosby's GenRx: a comprehensive reference for generic and brand prescription drugs, 11th ed. St. Louis: Mosby; 2001.
31. Which of the following statements about fluoxetine (Prozac) is true?
A) Side effects often include dry mouth, urinary retention, and blurred vision.
B) The treatment of panic disorder typically requires higher doses than the recommended starting dose for depression.
C) The mechanism of action involves the reuptake of dopamine at the postsynaptic junction.
D) The drug has significant anticholinergic activity.
E) Treatment of bulimia typically requires higher doses than the recommended starting dose for depression.
View Answer
Answer and Discussion
The answer is E. Fluoxetine (Prozac) is used for the treatment of depression, OCD, and bulimia nervosa. Other uses include the treatment of dysthymic disorder, panic disorder, social phobia, premenstrual syndrome, and bipolar disorder depression. The medication is an SSRI and has advantages when compared with the older tricyclic antidepressants. SSRIs have very little anticholinergic activity (which can cause blurred vision, urinary retention, and dry mouth); thus, they are better tolerated. The starting dose of fluoxetine is usually 10 to 20 mg/day, which is then titered up to 80 mg/day to achieve a clinical response. The full therapeutic response may take up to 4 weeks. Treatment of bulimia and OCD requires a dose of 60 mg/day. The treatment of panic disorder often requires smaller initial doses. Initial doses of 20 mg often precipitate panic attacks and lead to a high discontinuation rate. Side effects include headaches, anxiety, nervousness, excessive sweating, insomnia, anorexia, weight loss, nausea, diarrhea, and rash. Depressed patients should be monitored closely for suicidal thoughts or gestures, especially once their depression starts to improve. In most cases, medication for depression is complemented with counseling and is more effective than medication alone.
Saddock BJ, Saddock VA. Kaplan and Saddock's Concise Textbook of Psychiatry, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:482.
32. The treatment of choice for seasonal affective disorder (SAD) is
A) tricyclic antidepressants
B) electroconvulsive shock treatment
C) psychotherapy
D) intense white light therapy
E) MAO inhibitors
View Answer
Answer and Discussion
The answer is D. SAD is a pattern of major depressive episodes that occur and remit with changes in seasons. Two patterns have been identified. The most often recognized is the fall-onset type, also known as winter depression, in which major depressive episodes begin in the late fall to early winter months and remit during the summer months. Atypical signs and symptoms of depression predominate in cases of winter depression and include the following:
· Increased rather than decreased sleep
· Increased rather than decreased appetite and food intake with carbohydrate craving
· Marked increase in weight
· Irritability
· Interpersonal difficulties (especially rejection sensitivity)
· Leaden paralysis (a heavy, leaden feeling in the arms or legs)
A spring-onset pattern (summer depression) also has been described in which the severe depressive episode begins in late spring to early summer and is characterized by typical vegetative symptoms of depression, such as decreased sleep, weight loss, and poor appetite. Patients with winter depression usually reside in the more northern regions, and symptoms tend to develop when the days become shorter and nighttime is more prolonged. Treatment with intense white light has proved to be successful in controlling symptoms. Light therapy is initiated with a 10,000-lux light box directed toward the patient at a downward slant. The patient's eyes should remain open throughout the treatment session, although staring directly into the light source is unnecessary and is not advised. The patient should start with a single 10- to 15-minute session per day, gradually increasing the session's duration to 30 to 45 minutes. Sessions should be increased to twice a day if symptoms worsen. Ninety minutes a day is the conventional daily maximum duration of therapy, although there is no reason to limit the duration of sessions if side effects are not severe.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:1560, 2554.
33. Which of the following is a characteristic of antisocial personality disorder?
A) Those who are affected suppress their conflicts
B) Symptoms include severe agoraphobia
C) Schizophrenia may coexist
D) Many patients have a record of stealing, fighting, rape, or arson
E) Adolescents under the age of 18 are commonly affected
View Answer
Answer and Discussion
The answer is D. Patients with antisocial personality disorder must be older than 18 years of age and act out their conflicts or go against the rules of social normalcy. They are often impulsive, reckless, and immoral. They often had previous problems concerning truancy, cruelty to animals and other individuals, and initiation of fights and use of weapons with fighting. They usually have a record of stealing, possible rape, arson, and falsifying the truth since childhood. The definition also requires that a pattern of irresponsible behavior must be present since the age of 15, with school suspension, employment problems, poor parenting, lack of monogamy (no monogamous relationship lasting more than 1 year), and failed financial obligations in the absence of schizophrenia or manic episodes. In most cases, those affected lack regard for other people's rights.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 2000:327, 332.
34. Which of the following is not classified as a selective serotonin reuptake inhibitor (SSRI)?
A) Sertraline (Zoloft)
B) Mirtazapine (Remeron)
C) Escitalopram (Lexapro)
D) Paroxetine (Paxil)
E) Fluoxetine (Prozac)
View Answer
Answer and Discussion
The answer is B. Mirtazapine (Remeron) is a tetracyclic antidepressant unrelated to tricyclic antidepressants and SSRIs. It is unique in its action among the currently available antidepressants. It is referred to as a serotonin modulator. Mirtazapine is a presynaptic α2-adrenergic receptor antagonist plus a potent antagonist of postsynaptic 5-HT2 and 5-HT3 receptors. The net outcome of these effects is stimulation of the release of norepinephrine and serotonin. The drug has antidepressant and anxiolytic effects but does not cause sexual dysfunction. It can cause sedation and weight gain.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1709.
35. Which of the following is most likely to cause withdrawal symptoms with abrupt discontinuation?
A) Fluoxetine (Prozac)
B) Sertraline (Zoloft)
C) Paroxetine (Paxil)
D) Citalopram (Celexa)
E) none of the SSRIs cause withdrawal symptoms
View Answer
Answer and Discussion
The answer is C. Studies have shown that when comparing fluoxetine, sertraline, paroxetine, and citalopram, withdrawal from paroxetine was shown to cause more severe symptoms that may occur more quickly, even after the second missed dose. Because of its long half-life, fluoxetine may have the least severe symptoms. Methods to prevent antidepressant discontinuation syndrome include tapering the drug and educating the patient to avoid sudden cessation of the medication. Reintroduction of the medication will usually reverse severe symptoms within 24 hours.
Haddad PM. Antidepressant discontinuation syndromes. Drug Saf. 2001;24:183–197.
Michelson D, Fava M, Amsterdam J, et al. Interruption of selective serotonin reuptake inhibitor treatment: double-blind, placebo-controlled trial. Br J Psychiatry. 2000;176:363–368.
Studies have shown that when comparing fluoxetine, sertraline, paroxetine, and citalopram, withdrawal from paroxetine was shown to cause more severe symptoms that may occur more quickly, even after the second missed dose.
36. A 20-year-old college student presents to her dentist. Her vital signs are normal, and her weight is 120 lb. On examination, extensive upper dental erosion is noted. The most likely diagnosis is
A) obsessive-compulsive disorder
B) anorexia nervosa
C) hypothyroidism
D) bulimia nervosa
E) Crohn's disease
View Answer
Answer and Discussion
The answer is D. Bulimia nervosa is an eating disorder that usually affects young, white, middle- and upper-class women (typically college women). The disorder is characterized by episodes of secret binge eating followed by self-induced vomiting. Other manifestations include excessive exercise and the misuse of diuretics, laxatives, or enemas. Although the etiology of this disorder is unknown, genetic and neurochemical factors have been implicated. Bulimia nervosa is ten times more common in females than in males and affects up to 3% of young women. The condition usually becomes symptomatic between the ages of 13 and 20 years, and it has a chronic, sometimes episodic course. Unlike anorexia nervosa, those affected with bulimia are within 15% of their desirable weight. Menstrual cycles are rarely affected; in anorexia, menstrual cycles are commonly absent or extremely irregular. Most affected individuals have feelings of guilt and depression. Severe cases may result in
· Gastric dilation
· Dental erosions, particularly the upper dentition (the lower dentition is protected by the tongue during vomiting)
· Salivary gland enlargement
· Esophagitis
· Electrolyte abnormalities
· Aspiration
· Pancreatitis
Treatment involves psychotherapy with behavior modification and the use of antidepressants (tricyclic antidepressants and SSRIs, especially fluoxetine). Many patients relapse and require long-term therapy.
Yager J, ed. Treatment of bulimia nervosa and binge eating disorder [Monograph]. University of South Florida College of Medicine. 2003.
37. Which of the following factors is associated with dysthymic disorder?
A) Substance abuse
B) Sleep disturbances
C) Mania
D) Myasthenia gravis
E) Flight of ideas
View Answer
Answer and Discussion
The answer is B. Dysthymia is a condition characterized by depressed mood for at least 2 years with at least two of the following factors:
· Appetite changes
· Sleep disturbances
· Fatigue
· Low self-esteem
· Poor concentration
· Feelings of hopelessness
The symptoms must not have an organic cause and must never be interrupted for more than 2 months. Major depression has many of the same symptoms, but they are more severe. Cyclothymia is dysthymia followed by episodes of mild mania. The diagnosis of dysthymia requires that the patient has no history of substance abuse, mania, hypomania, major depression, or psychotic disorders.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 2000:327, 332.
38. Children who exhibit symptoms of school avoidance with nausea, vomiting, and abdominal pain may benefit from
A) antidepressant medication
B) methylphenidate
C) psychotherapy
D) benzodiazepines
E) mood stabilizers
View Answer
Answer and Discussion
The answer is C. It is a normal developmental response for children to cry when their parents leave the room beginning at approximately 8 months of age and continuing up to 2 years of age. The response varies with each child. Many first-time parents overreact and fear that the child is emotionally harmed by the separation. Reassuring the parents that this is a normal response is appropriate for treatment. Occasionally, a child exhibits symptoms of nausea, vomiting, and abdominal pain, which signal an abnormal response. Separation anxiety disorder affects children under the age of 18 years and consists of developmentally inappropriate and excessive anxiety concerning separation from home or a major attachment figure that lasts for at least 4 weeks. Periods of exacerbations and remissions are typical. These children (in many cases, school-aged children with school avoidance) often have no siblings and come from an extremely close family. Boys and girls are equally affected. Psychotherapy may be necessary for these children. Medication is not recommended.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 2000:327, 332.
39. Which of the following medications is least likely to cause sexual side effects?
A) Fluoxetine (Prozac)
B) Sertraline (Zoloft)
C) Venlafaxine (Effexor)
D) Citalopram (Celexa)
E) Bupropion (Wellbutrin)
View Answer
Answer and Discussion
The answer is E. Sexual side effects, usually delayed ejaculation or anorgasmia, may occur in both men and women who are taking SSRIs and venlafaxine (Effexor). Treatment consists of several options: reducing the dosage, switching to another agent, or adding another agent to overcome the sexual side effects. Sexual dysfunction typically resolves within 1 to 3 days after discontinuation of the antidepressant and returns on reintroduction. Recovery after withdrawal from fluoxetine (Prozac) may occur within 1 to 3 weeks. Studies suggest that the addition of bupropion (Wellbutrin) may decrease sexual side effects.
Ables AZ, Baughman AO III. Antidepressants: update on new agents and indications. Am Fam Physician. 2003;67:547–554.
40. After discontinuing fluoxetine, how long should a clinician wait before prescribing a monoamine oxidase inhibitor (MAOI)?
A) 1 day
B) 3 days
C) 1 week
D) 5 weeks
E) No delay is necessary.
View Answer
Answer and Discussion
The answer is D. Because of its long half-life, patients should allow at least 5 weeks between discontinuation of fluoxetine (Prozac) and commencement of monoamine oxidase inhibitor (MAOI) therapy.
Hines Burnham T, et al., eds. Drug facts and comparisons, 55th ed. St. Louis: Facts and Comparisons; 2001:345.
41. Which of the following statements is associated with adjustment disorder?
A) The patient has an expected reaction to a known stressor.
B) The condition is usually chronic, lasting for several years or more.
C) Depression and anxiety are commonly associated.
D) Medication is usually indicated for treatment.
E) Support groups are rarely of any benefit.
View Answer
Answer and Discussion
The answer is C. An adjustment disorder is defined as an excessive maladaptive reaction to an identifiable psychosocial stressor (e.g., death of a loved one, loss of a job, marital discord, divorce) that has occurred within the previous 3 months. The reaction may affect social relationships or the ability to function effectively at work or school. The disturbance cannot last for more than 6 months, and other mental disorders must be ruled out. In most cases, depression and anxiety are major manifestations. The best treatment is psychosocial support to help enhance the patient's ability to cope and adapt to stressful conditions. In most cases, medication is not necessary; rather, psychotherapy (individual, family, behavioral, and self-help groups) is used in treatment.
Saddock BJ, Saddock VA. Kaplan and Saddock's Concise Textbook of Psychiatry, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:333–334.
42. Which of the following statements about somatization disorder is true?
A) Men are more commonly affected than women.
B) Patients exhibit multiple physical complaints that usually have an identifiable physiologic basis.
C) The condition usually develops after age 50.
D) Symptoms rarely affect the patient's interpersonal relationships.
E) Treatment involves frequent office visits and reassurance to the patient.
View Answer
Answer and Discussion
The answer is E. Somatization disorder is a condition characterized by multiple physical symptoms that have no identifiable physiologic basis or are in excess of any physical findings made. The symptoms are usually defined in vague or exaggerated terms. The condition generally develops in the teen years and always before 30 years of age. Women are more commonly affected than men, and there is usually a positive family history. The symptoms generally interrupt one's job and interpersonal relationships. Suicide can occur in those affected. Currently, eight symptoms are required, which must meet a specific pattern: four different sites of pain, two different gastrointestinal symptoms, one sexual or reproductive system other than pain, and one pseudoneurologic symptom. The subjective severity of the symptoms must be sufficient to lead the patient to consult a physician, take medicine, or make lifestyle changes. It appears that there is no effective treatment; however, reassurance with frequent office visits and sensitivity to the patient's needs is usually beneficial. Costly tests and repeated subspecialty consultations are discouraged unless there are questions with the diagnosis.
Saddock BJ, Saddock VA. Kaplan and Saddock's Concise Textbook of Psychiatry, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:216–217.
43. Which of the following statements about the use of buspirone (Buspar) is true?
A) The drug is used in the treatment of acute anxiety.
B) The drug may cause displacement of tightly bound drugs, such as phenytoin and warfarin, leading to toxicity.
C) Side effects include dizziness, fatigue, nervousness, and headache.
D) The medication is commonly associated with abuse.
E) The drug can be used in combination with MAO inhibitors to treat resistant depression.
View Answer
Answer and Discussion
The answer is C. Buspirone (Buspar) is an antianxiety medication that is used for chronic anxiety. It is not associated with abuse, drowsiness, or functional limitations. Buspirone is not useful in the treatment of acute anxiety, because it often takes several days to weeks (depending on the patient) to produce its therapeutic effect. The drug's mechanism of action involves serotonin, norepinephrine, and dopamine receptors, and it indirectly affects GABA receptors. The medication does not affect other tightly bound drugs, such as warfarin, propranolol, or phenytoin, but may affect less tightly bound drugs, such as digoxin. Patients receiving MAO inhibitors should not use buspirone because of the risk of elevated blood pressure and hypertensive crisis. Side effects reported with the use of buspirone include dizziness, fatigue, nervousness, headache, decreased concentration, palpitations, nausea, and abdominal complaints.
Saddock BJ, Saddock VA. Kaplan and Saddock's Concise Textbook of Psychiatry, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:442–443.
44. Which of the following is rated the greatest problem in children 8 to 15 years of age by children of that age?
A) Racism
B) Pressure to have sex
C) Pressure to drink alcohol
D) Pressure to do drugs
E) Bullying
View Answer
Answer and Discussion
The answer is E. Childhood bullying has been viewed as an inevitable part of growing up. However, recent survey data show that American children 8 to 15 years of age rate bullying as a greater problem than racism or pressure to have sex or use alcohol and other drugs.
Kaiser Family Foundation. Children Now. Talking with kids about tough issues. Accessed online March 12, 2006, at: http://www.childrennow.org/nickelodeon/new-booklet.pdf.
Lyznicki JM, McCaffree MA, Robinowitz CB. Childhood bullying: implications for physicians. Am Fam Physician. 2004;70:1723–1728, 1729–1730.
45. A 42-year-old woman presents to your office. Her life appears chaotic and she transfers many of her dysfunctional feelings and conflicts to you her physician. She is at times paranoid, depressed, and angry. She has a history of multiple unstable interpersonal relationships. The most likely diagnosis is
A) borderline personality disorder
B) antisocial behavior
C) narcissistic disorder
D) histrionic disorder
E) none of the above
View Answer
Answer and Discussion
The answer is A. Treating borderline personality disorder can be difficult and challenging. Because of their instability in the multiple areas of interpersonal relationships, self image, affects, and impulsivity, these affected patients can present with a wide range of symptoms, including depression, anger, paranoia, extreme dependency, self mutilation, and alternating idealization and devaluation of the physician. Their lives tend to be chaotic. They transfer many of their dysfunctional feelings and conflicts to the treating physician and the medical encounter. A detached professional stance and clear limit setting in terms of availability, appointment frequency, appropriate behavior, and medication use are necessary to manage these patients successfully. It is important to monitor one's own feelings, and to refrain from responding inappropriately to verbal attacks and manipulation. The development of a formal behavioral treatment plan and insistence on participation in psychiatric care may be required to establish an effective working relationship.
Ward RK. Assessment and management of personality disorders. Am Fam Physician. 2004;70:1505–1512.
When treating borderline personality disorder a detached professional stance and clear limit setting in terms of availability, appointment frequency, appropriate behavior, and medication use are necessary to manage these patients successfully.
46. A 17-year-old girl is brought to your office by her parents. She has been having hallucinations over the past year and recently experienced a psychotic episode that lasted for 2 weeks. She has been out of school for 3 years and has not been able to hold a job. Her mother reports that the girl often remains in her room. The most likely diagnosis is
A) agoraphobia
B) panic attacks
C) schizophrenia
D) school avoidance
E) major depression
View Answer
Answer and Discussion
The answer is C. Schizophrenia is one of the most common psychiatric disorders and usually has a strong family history. Typically, patients are in the late teens or early 20s when the condition is identified. The definition describes a condition in which there is chronic impairment of functioning that involves disturbances of thinking, feeling, and behavior. Specific criteria involve the following:
· Episodes of psychosis, including delusions, hallucinations, incoherent behavior, and a decrease in social functioning.
· Signs must be present for at least 6 months, with one psychotic episode that lasts at least 1 week.
· Other features include social isolation, difficulties with social functioning or job requirements, peculiar behavior, impaired hygiene, abnormal thought processes, inappropriate affect, and lack of energy or interest.
Treatment involves the use of antipsychotics and psychotherapy. The prognosis in patients with schizophrenia is worsened the longer the duration of psychosis before institution of effective antipsychotic therapy and the greater the number of psychotic relapses. Use of traditional antipsychotic medications has been limited by their side effects and failure to achieve long-term control of symptoms in some cases. New “atypical” antipsychotic drugs (clozapine, risperidone, and olanzapine) are used for the treatment of resistant cases of schizophrenia and improvement in patient tolerance and compliance. These medications have been more successful than traditional antipsychotic drugs in treating the negative symptoms of schizophrenia, such as social withdrawal and apathy. The atypical antipsychotic drugs produce fewer extrapyramidal side effects and no tardive dyskinesia or dystonia. However, they are associated with neuroleptic malignant syndrome, and clozapine can produce fatal agranulocytosis. Use of these medications in selected patients who do not benefit from, or cannot tolerate, traditional agents is an important step in improving the lives of individuals with schizophrenia. Despite advancement in medication, relapses are common, and some patients require institutionalization.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1722–1728.
47. A 7-year-old boy is brought to your office. The parents report that the child has had problems in school for the last 6 months. His teacher reports lack of concentration and excessive fidgeting. The child typically interrupts others and often loses objects. The most appropriate treatment is
A) reassurance
B) stimulant medication
C) antidepressant medication
D) short-acting benzodiazepines
E) strict discipline
View Answer
Answer and Discussion
The answer is B. Attention deficit disorder, also known as hyperactivity, is a condition characterized by a short attention span or distractibility that persists for longer than 6 months. Other symptoms include fidgeting or squirming in one's seat, restlessness, inability to remain seated when required to do so, difficulty in awaiting one's turn, blurting out answers to questions before they are completed, difficulty in completing cognitive tasks (not related to oppositional behavior or lack of comprehension), and excessive talking. Affected children often interrupt others, frequently lose objects, do not listen to instructions, and engage in dangerous activities without consideration of the consequences. Boys are more commonly affected, and the onset typically occurs before 7 years of age. The clinical history is usually all that is needed to determine the diagnosis, although psychological and educational testing may help to support the diagnosis. Treatment is accomplished with stimulants, such as methylphenidate and dextroamphetamine, which have a paradoxical calming effect on young patients. Atomoxetine (Staterra) is a selective norepinephrine reuptake inhibitor that is approved for use in children over age 6. Most children show improvement with medication; drug holidays (at least 2 weeks/year) are important during chronic therapy to see if further medication is necessary. Behavior modification for the child and family counseling may also be helpful.
Ferri FF. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:107–108.
48. Which of the following statements about suicide is true?
A) Males make more suicide attempts.
B) Women are more successful.
C) Anxiety is the most common contributing factor.
D) Most suicides occur during December.
E) Married people have the lowest risk for suicide.
View Answer
Answer and Discussion
The answer is E. Suicide is an ever-increasing problem in the United States. Men tend to be more successful at suicide attempts, whereas women make more attempts. Underlying depression is the most common contributing factor. Persons in the 40- to 50-year age range are at particular risk, as are those with chronic diseases (e.g., acquired immunodeficiency syndrome, cancer, and respiratory illnesses, and patients who require hemodialysis). Groups that are particularly affected include those who feel overwhelmed with their personal problems, those who attempt to control others with their actions, those with severe depression who are overwhelmed by a stressful situation or accusation, and those with underlying psychotic illness. Other risk factors include drug abuse, family history of suicide, previous suicide attempts, lack of social support system, and recent loss of a loved one, particularly in older patients. The number of suicides increases slightly in the spring and summer; however, contrary to popular belief, suicides do not increase in December and holiday periods. Married people have the lowest suicide rates.
Saddock BJ, Saddock VA. Kaplan and Saddock's Concise Textbook of Psychiatry, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:389–395.
49. A 31-year-old woman you are treating is emotional and seductive in her behavior. She is very focused on her appearance to others and wants to be the center of attention. You note she has a difficult time making decisions. The most likely diagnosis is
A) borderline personality disorder
B) antisocial behavior
C) narcissistic disorder
D) histrionic disorder
E) none of the above
View Answer
Answer and Discussion
The answer is D. Histrionic patients are not satisfied if they are not the center of attention. They tend to be emotional and seductive, and use their appearance to attract the attention of others. As a result, the implications of illness and aging may have a profound impact on their psychologic functioning. When faced with these patients the physician should maintain an awareness of the patients' interpersonal style, and be empathetic to their issues, while at the same time avoiding inappropriate emotional or seductive behaviors. Additionally, these patients have difficulties in dealing with facts, details, and decision making. As a result, they may require extra assistance in processing medical information.
Ward RK. Assessment and management of personality disorders. Am Fam Physician. 2004;70:1505–1512.
50. Before the diagnosis of post-traumatic stress disorder (PTSD) is made, symptoms should be present for at least
A) 1 year
B) 6 months
C) 3 months
D) 1 month
E) 1 week
View Answer
Answer and Discussion
The answer is D. PTSD can occur after any major traumatic event. Symptoms include disturbing thoughts and nightmares about the traumatic event, avoidance behavior, numbing of general responsiveness, increased irritability, and hypervigilance. To fulfill the DSM-IV criteria for PTSD, an individual must have been exposed to a traumatic event; have at least one re-experiencing, three avoidance, and two hyperarousal phenomena; have had the symptoms for at least 1 month; and the symptoms must cause clinically important distress or reduced day-to-day functioning. Acute stress disorder occurs within the first month after a major traumatic event and requires the presence of symptoms for at least 2 days. It is similar to PTSD, but dissociative symptoms are required to make the diagnosis. Treatments for PTSD may have similar effects, regardless of the traumatic event that precipitated PTSD. However, caution should be applied when generalizing among types of trauma.
Bisson J. Post-traumatic stress disorder. Clin Evid Concise. 2005;13:306–309.
51. Which of the following agents is the most appropriate treatment for a patient with bipolar disorder?
A) Haloperidol (Haldol)
B) Chlorpromazine (Thorazine)
C) Diazepam (Valium)
D) Lithium (Eskalith)
E) Fluoxetine (Prozac)
View Answer
Answer and Discussion
The answer is D. Bipolar disorder is characterized by episodes of mania (e.g., flight of ideas, excessive spending, aggressive and grandiose behavior, little sleep, activities that are later regretted) followed by major depressive attacks (e.g., anhedonia, inability to concentrate, withdrawal from activities, chronic fatigue, loss of sexual drive, insomnia, anorexia with weight loss). Bipolar I disorder is typically diagnosed when patients are in their early 20s. Manic symptoms can rapidly escalate over a period of days and frequently follow psychosocial stressors. Some patients initially seek treatment for depression. Others may appear irritable, disorganized, or psychotic. Differentiating true mania from mania that results from secondary causes can be challenging. Initially, during the manic phase, these behaviors may attract other people; however, in the long term, they lead to significant interpersonal difficulties and conflicts. The episodes, which begin abruptly and are often precipitated by life stresses, may last for up to several months; manic episodes are typically shorter in duration. Bipolar II disorder typically is brought to medical attention when the patient is depressed. A careful history usually illuminates the diagnosis. Some depressed patients exhibit hypomania when given antidepressants. This variation is sometimes referred to as bipolar III disorder. Spring and summer months tend to be peak times for the development of symptoms. The condition may occur at any age but is most common in the second or third decade of life. The treatment for bipolar disorder is accomplished with lithium (Eskalith). It is important to remember that lithium levels need to be followed, and abnormalities associated with the kidneys and thyroid can be induced with medication. Valproic acid (Depakene) can also be used to treat the manic symptoms. If the patient is psychotic, a neuroleptic medication is also given. Long-acting benzodiazepines can be used for treating agitation. However, in patients with a substance abuse history, benzodiazepines should be used with caution because of the addictive potential of these agents. When the patient with bipolar disorder becomes depressed, an SSRI or bupropion is recommended. The use of tricyclic antidepressants should be avoided because of the possibility of inducing rapid cycling of symptoms.
Griswold KS, Pessar LF. Management of bipolar disorder. Am Fam Physician. 2000;62:1343–1353, 1357–1358.
52. Tardive dyskinesia is associated with
A) use of lithium
B) chronic blockade of dopaminergic receptors
C) use of serotonin reuptake inhibitors
D) short-term use of phenothiazine neuroleptics
E) anti-Parkinson's medications
View Answer
Answer and Discussion
The answer is B. Tardive dyskinesia is a condition characterized by repetitive, involuntary, and purposeless choreiform movements of the extremities and buccal, oral, and lingual structures. Although often considered an extrapyramidal symptom, tardive dyskinesia is a separate, mechanistically distinct phenomenon. The condition is thought to be secondary to chronic blockage of dopamine receptors in the brain. It is usually associated with side effects of long-term use of phenothiazine neuroleptics and anticholinergic medication. Older patients and those with previous brain injury have a higher incidence of tardive dyskinesia. In most cases, the symptoms do not resolve when the medication is discontinued. Treatment with lithium, tricyclic antidepressants, and baclofen has shown some limited benefit.
Gurvich T, Cunningham JA. Appropriate use of psychotropic drugs in nursing homes. Am Fam Physician. 2000;61:1437–1446.
53. Laboratory findings seen in anorexia nervosa include
A) hyperkalemia
B) leukocytosis
C) prolonged QT interval on electrocardiogram
D) metabolic acidosis
E) elevated sedimentation rate
View Answer
Answer and Discussion
The answer is C. Anorexia nervosa is a psychiatric problem that centers on a disturbed sense of body image and extreme fear of obesity. Among women, the lifetime prevalence of anorexia nervosa is 0.5% to 3.7%. Symptoms include self-induced vomiting and extreme exercise routines in the setting of extreme thinness. Women account for 95% of those affected. Onset is usually during adolescence but can occur earlier. Severe cases can be fatal. Most patients are described as being compulsive, intelligent, and meticulous; they are usually high achievers. Physical findings include cachexia (>15% less than ideal weight), amenorrhea, loss of sexual desire, low body temperature, cold intolerance, bradycardia, dental erosions, hypotension, hypothermia, edema, and hirsutism. Depression may also be present. Laboratory findings include electrolyte disorders (e.g., hypokalemia), metabolic alkalosis, increased blood urea nitrogen secondary to dehydration, thrombocytopenia, leukopenia, low or normal erythrocyte sedimentation rate, and prolonged QT interval on electrocardiogram. Short-term treatment involves active intervention to restore weight (which may require hospitalization), correction of electrolytes, and preservation of vital functions; long-term treatment involves psychiatric counseling to restore a healthy body image and to treat possible underlying depression. The goals of treatment for anorexia nervosa are to restore patients to a healthy weight, treat the physical complications, enhance the patient's motivation to cooperate with treatment, and provide education about healthy nutrition and eating habits. Other goals of treatment include correcting maladaptive thoughts, attitudes, and feelings related to the eating disorder; treating associated psychiatric conditions; enlisting family support; and attempting to prevent relapse. Medication should be considered in the treatment of anorexia but should not be the sole or primary treatment.
American Psychiatric Association. Practice guideline for the treatment of patients with eating disorders (revision). Am J Psychiatry. 2000;157[Suppl]:1–39.
54. An 80-year-old man is hospitalized secondary to pneumonia. On day 2 of his hospitalization, the nurse calls and tells you he is confused and calling out from his room. He has made multiple attempts to leave his room. You suspect delirium. He has no history of drug or alcohol abuse. Appropriate medication would include
A) diazepam (Valium)
B) lorazepam (Ativan)
C) haloperidol (Haldol)
D) mirtazapine (Remeron)
E) fluoxetine (Prozac)
View Answer
Answer and Discussion
The answer is C. The management of delirium involves identifying and correcting the underlying medical problem, and symptomatically managing any behavioral or psychiatric symptoms. Low doses of antipsychotic drugs can help to control agitation. The use of benzodiazepines should be avoided except in cases of alcohol or sedative-hypnotic withdrawal. Environmental interventions, including frequent reorientation of patients by nursing staff and education of patients and families, should be instituted in all cases.
Gleason OC. Delirium. Am Fam Physician. 2003;67:1027–1034.
The management of delirium involves identifying and correcting the underlying medical problem, and symptomatically managing any behavioral or psychiatric symptoms.
55. When patients participated in weekly alcoholics anonymous meetings after discharge from a treatment program, the 1-year abstinence rate is
A) 1% to 5 %
B) 10% to 20%
C) 25% to 30%
D) 56% to 60%
E) 80% to 90%
View Answer
Answer and Discussion
The answer is E. The abstinence-based method is commonly used to treat alcohol/drug addiction (95% of programs reviewed). This method utilizes cognitive behavior techniques and referral to 12-step recovery programs, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). One-year abstinence rates of 80% to 90% were accomplished when patients participated in weekly continuing care and/or AA meetings after discharge from the treatment program. Also, 1-year abstinence rates were associated with reduced rates of medical and psychiatric utilization.
Miller NS. Treatment of the Addictions: Applications of Outcome Research for Clinical Management. New York: Haworth; 1995.
56. Which of the following is considered the “date rape” drug?
A) 3,4-Methylenedioxymethamphetamine (MDMA)
B) Flunitrazepam (Rohypnol)
C) Ketamine (Ketalar)
D) Cocaine
E) Cannabis
View Answer
Answer and Discussion
The answer is B. The most widely used club drugs are 3,4-methylenedioxymethamphetamine (MDMA), also known as ecstasy; gamma-hydroxybutyrate (GHB); flunitrazepam (Rohypnol); and ketamine (Ketalar). These drugs are popular because they are inexpensive and are conveniently dispensed as small pills, powders, or liquids. Club drugs usually are taken orally and may be taken in combination with each other, with alcohol, or with other drugs. Adverse effects of MDMA ingestion result from sympathetic overload and include tachycardia, mydriasis, diaphoresis, tremor, hypertension, arrhythmias, parkinsonism, esophoria (tendency for eyes to turn inward), and urinary retention. However, the most dangerous potential outcome of MDMA ingestion is hyperthermia and the associated “serotonin syndrome.” Serotonin syndrome is manifested by grossly elevated core body temperature, rigidity, myoclonus, and autonomic instability; it can result in end-organ damage, rhabdomyolysis and acute renal failure, hepatic failure, adult respiratory distress syndrome, and coagulopathy. GHB produces euphoria, progressing with higher doses to dizziness, hypersalivation, hypotonia, and amnesia. Overdose may result in Cheyne-Stokes respiration, seizures, coma, and death. Coma may be interrupted by agitation, with flailing activity described similar to a drowning swimmer fighting for air. Bradycardia and hypothermia are present in about one third of patients admitted to a hospital for using GHB and appear to be correlated with the level of consciousness. Chronic use of GHB may produce dependence and a withdrawal syndrome that includes anxiety, insomnia, tremor, and in severe cases, treatment-resistant psychoses. In the United States, imported Rohypnol came to prominence in the 1990s as an inexpensive recreational sedative and the “date rape” drug. Effects of rohypnol occur about 30 minutes after ingestion, peak at 2 hours, and may last up to 8 to 12 hours. The effects are much greater with the concurrent ingestion of alcohol or other sedating drugs. Some users experience hypotension, dizziness, confusion, visual disturbances, urinary retention, or aggressive behavior. Ketamine is difficult to develop; therefore, most of the illegal supply is obtained from human and veterinary anesthesia products. Ketamine is distributed in a liquid form that can be ingested or injected. In clubs, it usually is smoked in a powder mixture of marijuana or tobacco, or is taken intranasally. A typical method uses a nasal inhaler, called a “bullet” or “bumper”; an inhalation is called a “bump.” Ketamine often is taken in “trail mixes” of methamphetamine, cocaine, sildenafil citrate (Viagra), or heroin. Effects of ketamine ingestion appear rapidly and last about 30 to 45 minutes, with sensations of floating outside the body, visual hallucinations, and a dream-like state. Along with these “desired” effects, users also commonly experience confusion, anterograde amnesia, and delirium. They also may experience tachycardia, palpitations, hypertension, and respiratory depression with apnea. “Flashbacks” or visual disturbances can be experienced days or weeks after ingestion. Some chronic users become addicted and exhibit severe withdrawal symptoms that require detoxification.
Gahlinger PM. Club Drugs: MDMA, Gamma-hydroxybutyrate (GHB), Rohypnol, and Ketamine. Am Fam Physician. 2004;69:2619–2626, 2627.
57. Galactorrhea is associated with which of the following medications?
A) Benzodiazepines
B) Tricyclic antidepressants
C) MAO inhibitors
D) Antipsychotic medication
E) Dopamine agonist
View Answer
Answer and Discussion
The answer is D. Antipsychotic (neuroleptic) medications are dopamine receptor antagonist and include the following:
· Phenothiazines—chlorpromazine (Thorazine), thioridazine (Mellaril), mesoridazine (Serentil), perphenazine (Trilafon), trifluoperazine (Stelazine), and fluphenazine (Prolixin)
· Thioxanthenes—thiothixene (Navane)
· Butyrophenones—haloperidol (Haldol)
· Dihydroindolones—molindone (Moban)
· Dibenzoxazepine—loxapine (Loxitane)
Side effects of these medications are extensive and include anticholinergic effects such as dry mouth, blurred vision, urinary retention, delayed gastric emptying, acute glaucoma in patients with narrow anterior chamber angles, orthostatic hypotension, sexual dysfunction, cardiac arrhythmias, and endocrine abnormalities (hyperglycemia and hyperprolactinemia with galactorrhea). Extrapyramidal symptoms include akathisias (the desire to be in constant motion), acute dystonias (bizarre muscle spasms of the head, neck, and tongue), drug-induced parkinsonism (pill-rolling tremor, rigidity, and bradykinesia), and tardive dyskinesia (abnormal repetitive movements of the face, tongue, trunk, or limbs). The medications are indicated in the treatment of schizophrenia, psychoses, and mania. The risk for tardive dyskinesia increases with age and the length of administration of the medication. Neuroleptic malignant syndrome is a severe life-threatening side effect of antipsychotics that requires prompt recognition and treatment. Newer atypical antipsychotics have fewer side effects and are dopamine-serotonin antagonists.
Saddock BJ, Saddock VA. Kaplan and Saddock's Concise Textbook of Psychiatry, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:454–455.
58. Good parenting is associated with which of the following?
A) Bargaining
B) Redirecting
C) Dependence
D) Variability
E) Inconsistency
View Answer
Answer and Discussion
The answer is B. The use of positive reinforcement can be a powerful determinate of a child's behavior. Parents need to be instructed that positive reinforcers, such as candy, toys, and increased attention, given to children who disobey only serve to encourage poor behavior. However, failure to reward good behavior discourages further obedience. Therefore, parents should attempt to use positive reinforcers when they are pleased with their child's behavior. Parents must also remain consistent in their parenting practices. Children require reliable standards and expectations that are clearly demonstrated by their parents. Parents must be in agreement with regard to discipline. It is important to foster a sense of independence and responsibility in children. The goal of discipline is to teach children self-control. One good method for infants and toddlers is called redirecting. When one redirects a child, one replaces an unwanted (bad) behavior with an acceptable (good) behavior. For example, if throwing a ball inside the house is not allowed, a parent can take the child outside to throw the ball. For older children, it is important that they see the consequences of their actions and take responsibility for them.
American Academy of Family Physicians. Information from your family doctor—Tips for better parenting. Am Fam Physician. 1999;59(6):1591.
59. A recognized symptom of depression includes which of the following?
A) Sense of entitlement
B) Changes in weight
C) Hallucination
D) Flight of ideas
E) Depersonalization
View Answer
Answer and Discussion
The answer is B. Depression is one of the most common problems seen by family physicians. Women are more affected than men, and the most common age range is 20 to 50 years. DSM-IV requires that at least five of the following symptoms are present for at least 2 weeks. The patient must show anhedonia or dysphoria and
· Depressed or irritable mood, or both (most of the day)
· Diminished interest or pleasure, or both, in most activity
· Significant change in weight or appetite, or both, with no effort
· Insomnia; hypersomnia
· Psychomotor retardation or agitation
· Fatigue; decreased activity
· Feelings of worthlessness or inappropriate guilt
· Poor concentration; indecisiveness
· Recurrent thoughts of death or suicide, or both
The patient must have no evidence of previous psychiatric diagnosis, no organic contributing cause, and no recent emotional loss. Many patients have a family history of depression and substance abuse. Evaluation should be performed to rule out causative factors such as anemia, infections, hypothyroidism, medication-related side effects, and alcohol or illegal drug abuse. Psychotherapy and antidepressant medication are the mainstays of treatment. Electroconvulsive therapy is reserved for severe cases. Hospitalization is indicated if a patient is suicidal.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 2000:327, 332.
60. Which of the following statements is true regarding inhalant abuse?
A) Twenty percent of children in middle school and high school have experimented with inhalants.
B) Inhalant use is not addictive.
C) A comprehensive drug screen can help identify the inhalant used.
D) Reversing agents can assist with recovery from an inhalant toxicity.
E) Hepatic damage is not associated with inhalant abuse because of the lack of enterohepatic circulation of the substance.
View Answer
Answer and Discussion
The answer is A. Inhalant abuse is prevalent in adolescents. Studies show that nearly 20% of children in middle school and high school have experimented with inhalants. The method of delivery is inhalation of a solvent from its container, a soaked rag, or a bag. Solvents include household cleaning agents or propellants, paint thinners, glue, and lighter fluid. Inhalant abuse typically can cause a euphoric feeling and can become addictive. Acute effects include sudden sniffing death syndrome, asphyxia, and serious injuries (e.g., falls, burns, frostbite). Chronic inhalant abuse can cause cardiac, renal, hepatic, and neurologic damage. Inhalant abuse during pregnancy can lead to fetal abnormalities. Diagnosis of inhalant abuse is difficult and relies almost entirely on a thorough history and a high index of suspicion. No specific laboratory tests confirm solvent inhalation. Treatment is generally supportive, because there are no reversal agents for inhalant intoxication.
Anderson CE, Loomis GA. Recognition and prevention of inhalant abuse. Am Fam Physician. 2003;68:869–874, 876.
61. Which of the following is true regarding attention-deficit/hyperactivity disorder (ADHD)?
A) The condition is more common in females.
B) Combining psychosocial therapy with medication has proven to be superior to medication alone.
C) ADHD is best diagnosed using the DSM-IV diagnostic criteria and the Conners' Parent and Teacher Rating Scales.
D) Symptoms tend to increase over time.
E) Other psychiatric co-morbidities are rare.
View Answer
Answer and Discussion
The answer is C. ADHD presents as inappropriate hyperactivity, impulsivity, and inattention in reference to the patient's age. ADHD cannot be easily diagnosed by a specific test or biologic marker, and it is unclear if the disorder is a truly pathologic condition or just one end of the behavioral spectrum. ADHD is more frequently diagnosed in children with behavioral difficulties and academic underachievement. Based on study results the pooled prevalence of ADHD is between 6.8% and 10.3%, with boys having a threefold higher rate. Psychiatric comorbidities, including oppositional-defiant disorder, conduct disorder, depressive disorder, and anxiety disorders are common. The Conners' ADHD Index and symptom scales from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), which are ADHD-specific checklists, have a high sensitivity for identification of children with the disorder. Reviews of the pharmacologic management of ADHD with methylphenidate hydrochloride, dextroamphetamine sulfate, and pemoline show these drugs to be effective. Nonpharmacologic treatments that have some beneficial effect on behavior and academic performance are behavioral modification and intensive contingency management therapy. Combining drug therapy with psychosocial therapy shows no clear advantage when compared to drug therapy alone. However, the addition of behavioral therapies to medication may have some benefit, including reduction of anxiety and improvement in social skills. ADHD is best diagnosed using the DSM-IV diagnostic criteria and the Conners' Parent and Teacher Rating Scales. Other psychiatric comorbidities are common and should be identified and properly managed. The symptoms of ADHD tend to decrease over the long-term but may continue into adolescence and adulthood. The most common treatment is stimulant medication.
Guevara JP. Attention deficit hyperactivity disorder. West J Med. 2001;175:189–192.
Hunt RD, Paquin A, Payton K. An update on assessment and treatment of complex attention-deficit hyperactivity disorder. Pediatr Ann. 2001 30;3:162–172.
62. Chronic alcohol abuse is associated with which of the following?
A) Hyperuricemia
B) Alanine aminotransferase–aspartate aminotransferase ratio of 2:1
C) Decreased mean corpuscular volume
D) Decreased γ-glutamyl transferase
E) Decreased triglycerides
View Answer
Answer and Discussion
The answer is A. Alcohol abuse is usually described as an impairment of social or occupational functioning because of alcohol use. Symptoms include chronic anxiety or tension, insomnia, depression, headaches, legal and marital problems, gastrointestinal discomfort, frequent falls, and minor injuries. Complications include gastritis, peptic ulcer disease, cirrhosis, sexual dysfunction, nutritional deficiencies, neuropathy, and pancreatitis. Laboratory findings may include mild elevations of liver function tests. The aspartate aminotransferase–alanine aminotransferase ratio is often 2:1. A macrocytosis with an elevated mean corpuscular volume is usually the result of folate deficiency. Hypertriglyceridemia, hyperuricemia, and elevations in γ-glutamyl transferase are also seen. Treatment is aimed at abstinence of alcohol, and participation in rehabilitation programs such as Alcoholics Anonymous should be encouraged. Close monitoring, including hospitalization, may be necessary if withdrawal symptoms are anticipated.
Ferri FF. Ferri's Clinical Advisor, Instant Diagnosis and Treatment. Philadelphia: Elsevier/Mosby; 2006:36–38.
63. A patient whose spouse recently died presents to your office complaining of anxiety, insomnia, depressed mood, and anorexia. She reports that she continues to work and remains active playing bridge. The most appropriate treatment is
A) antidepressant medications
B) major tranquilizers
C) frequent office visits to receive biofeedback
D) inpatient psychiatric counseling
E) short-acting sedative to help with sleep
View Answer
Answer and Discussion
The answer is E. Grief or bereavement reaction occurs in response to significant loss or separation. Situations such as the death of a loved one, marital separation, loss of a girlfriend or boyfriend, or a move to a different and unfamiliar location can give rise to the condition. The reaction is a normal process that usually improves with time. Symptoms include anxiety, insomnia, depressed mood, anorexia, and mood swings. Treatment involves frequent, short office visits to allow patients to express their grief. The use of major tranquilizers and antidepressants is unnecessary and may interfere with the normal grieving process. However, nighttime sedatives can be used for patients with insomnia. It is common for relapses to occur after the resolution of the grieving process, especially during the holidays or special events. Patient reassurance is usually all that is needed. In severe cases, in which there is significant functional impairment or psychomotor retardation, antidepressants may become necessary.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2768.
The use of major tranquilizers and antidepressants during a significant loss is unnecessary and may interfere with the normal grieving process.
64. A 28-year-old man is noted to have impairment in social situations and job-related problems because of a pervasive pattern of grandiosity, lack of empathy, and extreme sensitivity to criticism. Coworkers report he frequently takes advantage of others for self-promotion. The most likely diagnosis is
A) borderline personality disorder
B) bipolar disorder
C) narcissistic personality disorder
D) paranoid personality disorder
E) antisocial personality disorder
View Answer
Answer and Discussion
The answer is C. Patients who are affected with narcissistic personality disorder fulfill the following DSM-IV criteria and exhibit impairment in social or job situations with a pervasive pattern of grandiosity, lack of empathy, and extreme sensitivity to the evaluation and judgment of others. They must exhibit at least five of the following behaviors:
· Reacts with rage, shame, or humiliation to criticism by others
· Takes advantage of others for self-promotion
· Requires constant attention and admiration of others
· Lacks empathy toward others
· Obsessed with feelings of envy
· Possesses a sense of entitlement
· Possesses a sense of self-importance
· Remains preoccupied with fantasies of unlimited success
· Believes own problems are unique and only understood by other special people
Patients with narcissistic personality disorder often experience depression and severe bouts of envy toward others. Occasionally, those who are affected become delusional in their thoughts. The treatment is psychoanalytic therapy that emphasizes acceptance of failures and the development of appreciation toward others. Success is limited but can be achieved. The course of this disease is chronic; however, narcissistic symptoms tend to diminish after the age of 40, when pessimism usually develops.
Saddock BJ, Saddock VA. Kaplan and Saddock's Concise Textbook of Psychiatry, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:347.
65. Traditionally, what is the cutoff for a normal score on the Mini-Mental Status Examination in a college graduate?
A) 18
B) 20
C) 24
D) 27
E) 30
View Answer
Answer and Discussion
The answer is C. A total maximal score on the MMSE is 30 points. Generally, a score of <24 points is suggestive of dementia or delirium. Using a cutoff of 24 points, the MMSE had a sensitivity of 87% and a specificity of 82% in a large population–based sample. However, the test is not sensitive for mild dementia, and scores may be influenced by age and education, as well as language, motor, and visual impairments. In one study, for example, the median MMSE score was 29 for individuals with at least 9 years of schooling, 26 for those with 5 to 8 years of schooling, and 22 for those with 4 years of schooling or less. The use of higher cutoff scores on the MMSE improves sensitivity but lowers specificity. The MMSE also has utility in assessing competency in decision making. Studies suggest that high scores (≥23) and low scores (<19) can be highly predictive in discriminating competency from incompetency. Intermediate scores warrant more detailed competency evaluation.
Crum RM, Anthony JC, Bassett SS, et al. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA. 1993;269:2386.
66. Which of the following statements is true regarding Tourette's syndrome?
A) Only 1% of the population is affected.
B) Tourette's syndrome is a familial disorder.
C) Patients with tic disorders rarely have other associated psychological conditions.
D) Tricyclic antidepressants are the treatment of choice.
E) The long-term prognosis for treatment is poor.
View Answer
Answer and Discussion
The answer is B. Tic disorders and Tourette's syndrome are conditions that are rather common in the general population. Up to 20% of children have at least a transient tic disorder at some point. Once thought to be rare, Tourette's syndrome is now known to be a more common disorder that represents the most complex and severe manifestation of the spectrum of tic disorders. Tourette's syndrome is a chronic familial disorder with a fluctuating course; the long-term outcome is generally favorable. Although the exact underlying pathology has yet to be determined, evidence indicates a disorder localized to the frontal-subcortical neural pathways. Tourette's syndrome is associated with attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, behavior problems, and learning disabilities. These associated conditions can make the management of Tourette's syndrome more difficult. Use of antipsychotic medications (resperidone, pimozide, olanzapine, and haloperidol) and clonidine can be effective but may be associated with significant side effects.
Bagheri MM, Kerbeshian J, Burd L. Recognition and management of Tourette's syndrome and tic disorders. Am Fam Physician. 1999;59:2263–2274.
67. Obligatory running is associated with
A) OCD
B) manic-depressive disorder
C) panic disorder
D) antisocial personality disorder
E) borderline personality disorder
View Answer
Answer and Discussion
The answer is A. In some individuals who run on a regular basis, an obsession with running develops. The obsession can lead to a significant disruption in a person's life. Extreme inflexibility, adherence to running schedules, and extreme commitment to running can lead to pathologic behavior. If the patient cannot run, depression, fatigue, insomnia, irritability, and anxiety may occur. As in the alcoholic, interpersonal relationships can also be affected. The disorder has elements of a neurotic obsessive disorder. Psychotherapy may be necessary if symptoms are severe.
Dishman RK. Medical psychology in exercise and sport. Med Clin North Am. 1985;69:123–143.
Mellion MB, ed. Office management of sports injuries and athletic problems. Philadelphia: Hanley & Belfus; 1988:136–137.
68. Which of the following would be the drug of first choice for the treatment of mild Tourette's syndrome?
A) Carbamazepine
B) Phenobarbital
C) Primidone
D) Phenytoin
E) Lorazepam
View Answer
Answer and Discussion
The answer is E. Tourette's syndrome is a genetically transmitted disorder that begins in childhood as a simple tic, progressing to multiple tics as the patient ages. Tics may begin as grunts or barks and progress to involuntary compulsive utterances called coprolalia. These outbursts may become severe and significantly disable the patient from a physical or social standpoint. Tics tend to be more complex than myoclonus but less flowing than choreic movements, from which they must be differentiated. The patient may voluntarily suppress them for seconds or minutes. Simple tics may respond to benzodiazepines. For simple and complex tics, clonidine is effective in some patients. Long-term use of clonidine does not cause tardive dyskinesia; its limiting adverse effect is hypotension. Intermediate-acting benzodiazepines (e.g., lorazepam) may be useful as adjuvant treatment. For more severe cases, antipsychotics, such as haloperidol, olanzapine, resperidone or pimozide, may be required. Side effects of dysphoria, parkinsonism, akathisia, and tardive dyskinesia may limit their use. Antipsychotics should be started cautiously, and patients should be told about potential adverse outcomes.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2379.
69. Which of the following statements about conversion disorder is true?
A) An underlying conflict or need does not have to be present.
B) Symptoms often have a physiologic or pathophysiologic explanation.
C) Men are more commonly affected.
D) Treatment usually involves pharmacotherapy.
E) Those who are affected subject themselves to unnecessary medical testing.
View Answer
Answer and Discussion
The answer is E. Conversion disorder, also known as hysterical neurosis, occurs because of an underlying psychological conflict or need. The symptoms are not voluntarily controlled, and there is no physiologic or pathophysiologic explanation for the symptoms. Reported symptoms include paresis, paralysis, seizures, blindness, abdominal pain, and vomiting. Most patients present with symptoms in adolescence, but the disorder may occur at any age. Women are more commonly affected than men. Episodes may occur over time but may be limited to a single episode. Stress often precipitates the episode. In most cases, the episode is short, and most symptoms resolve quickly. The diagnosis may be difficult initially because the patient believes that the symptoms stem from a physical disorder. Also, physicians are taught almost exclusively to consider (and exclude) physical disorders as the cause of physical symptoms. Commonly, the diagnosis is considered only after extensive physical examinations and laboratory tests fail to reveal a disorder that can fully account for the symptom and its effects. Although ruling out a possible underlying physical disorder is crucial, early consideration of conversion may avoid tests that increase the costs and risks to the patient and that may unduly delay diagnosis. The best clue is that conversion symptoms rarely conform fully to known anatomic and physiologic mechanisms. Most patients, because of their complaints, subject themselves to unnecessary medical tests. Treatment usually involves psychotherapy. Medication is generally not warranted.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1737–1738.
70. Which of the following medications should be monitored in the blood of newborns when treating the mother for postpartum depression?
A) Fluoxetine (Prozac)
B) Sertraline (Zoloft)
C) Bupropion (Wellbutrin)
D) Paroxetine (Paxil)
E) Mirtazapine (Remeron)
View Answer
Answer and Discussion
The answer is A. Because of the long elimination half-life of fluoxetine (Prozac), if a woman who was taking this drug during pregnancy wishes to breast feed while continuing fluoxetine treatment, she should have the infant's blood tested after about 6 weeks of breast-feeding to rule out drug accumulation. In infants exposed to any antidepressant through breast milk, plasma concentrations of the drug should be determined if they are exhibiting persistent unexplained irritability.
Epperson CN. Postpartum major depression: detection and treatment. Am Fam Physician. 1999;59:2247–2259.
71. Which of the following should be used initially in conjunction with benzodiazepines in the treatment of serotonin syndrome?
A) Diphenhydramine
B) Prednisone
C) Cyproheptadine
D) Dantrolene
C) Nitroprusside
View Answer
Answer and Discussion
The answer is C. The initial pharmacologic treatment of serotonin syndrome is with benzodiazepines and cyproheptadine (an antihistamine with serotonin antagonist properties). Other medications may include dantrolene and methysergide. If muscular rigidity and hyperthermia do not respond to these interventions, neuromuscular paralysis with endotracheal intubation is appropriate.
Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352:1112.
72. Which of the following statements is true regarding lithium administration?
A) Hepatotoxicity can develop after 4 weeks of therapy.
B) The drug may affect thyroid function.
C) Renal function can be improved with the use of lithium.
D) Peripheral neuropathy is a possible side effect.
E) Drug levels remain constant and rarely need monitoring.
View Answer
Answer and Discussion
The answer is B. Lithium is used in the treatment of bipolar disorder. In most cases, it takes 1 week before the effects are noted. Side effects of the medication include tremor, polydipsia, polyuria, gastrointestinal irritation, and diarrhea. Hypothyroidism and renal toxicity are other complications of lithium administration. Toxicity is characterized by lethargy, seizures, nephropathy, and coma. Blood levels should be monitored carefully and adjusted as necessary. In addition, serum creatinine and thyroid function tests should be evaluated periodically. Drugs that decrease renal clearance, such as nonsteroidal anti-inflammatory agents, should be used cautiously in patients receiving lithium.
Saddock BJ, Saddock VA. Kaplan and Saddock's Concise Textbook of Psychiatry, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:458–460.
73. A 30-year-old woman makes frequent visits to your office with vague somatic complaints that have no medical justification. In addition, she has frequent mood swings and unstable interpersonal relationships. In the past, she has had problems with alcohol. She is very interested in your personal life and thinks you are a “wonderful doctor.” The most likely diagnosis is
A) borderline personality disorder
B) bipolar disorder
C) schizophrenia
D) dysthymic disorder
E) narcissistic personality disorder
View Answer
Answer and Discussion
The answer is A. Borderline personalities are often encountered in the family physician's office. Characteristics of this disorder include impulsiveness, unstable and intense interpersonal relationships, substance abuse, and self-destructive behavior with accident proneness. Those who are affected lack self-control, lack self-fulfillment, and have identity problems. Their behaviors include aggressive and suicidal actions with frequent mood swings. In many cases, they present with vague, unexplainable somatic complaints; do not follow therapeutic recommendations; and are very frustrating to their physicians. Most affected persons present during adolescence. Treatment involves adequate communication, supportive limit-setting, frequent office visits, and occasionally medication. Acute crisis may require hospitalization. Patients with this disorder have high comorbidity with other psychiatric disorders and high rates of suicidal ideation, and they cause particular treatment difficulties, including hostility toward caregivers and low rates of treatment compliance. The central feature of patients with borderline personality disorder is a morbid fear of abandonment, with consequential pathologic responses to perceived rejection. Such patients may demand inappropriate amounts of time or support from a primary care physician, and they may become hostile and demanding or suicidal if these needs are not met. The family practitioner should be alert to the following “red flags”: a history of doctor shopping; a history of legal suits against physicians or other professionals; a history of suicide attempts; a history of several brief marriages or intimate relationships; an immediate idealization of you as a “wonderful doctor,” especially if the patient compares you with disappointing caregivers of the past; and excessive interest in your personal life, eventually leading to invitations to socialize with you. Behavior of this type implies boundary violations, and its purpose is to cement a relationship with the physician, allaying the patient's ever-present fear of abandonment.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1719.
74. Which of the following drugs has been shown to be beneficial in the treatment of premenstrual dysphoric disorder?
A) Haloperidol
B) Progesterone
C) Fluoxetine
D) Furosemide
E) Lithium
View Answer
Answer and Discussion
The answer is C. Premenstrual dysphoric disorder is associated with mood-related symptoms leading to functional impairment that distinguish it from premenstrual syndrome. Patients must have a symptom-free postmenopausal week, and they typically experience the symptom of being overwhelmed or out of control during the most affected time. The symptoms must be present during the luteal phase of the menstrual cycle (from ovulation to the onset of menses), and there must not be an underlying psychiatric disorder. The most common symptom reported is depressed mood, followed by anxiety or tension, mood swings, and anger or irritability. At least one of these must be present to make the diagnosis. The time of greatest well-being is just before ovulation. The average age of presentation is 36. Many report that their symptoms began when they were in their 20s and worsened over time. Those who are affected are at higher risk for development of a major depressive disorder. Fluoxetine (Sarafem, Prozac) was found to be beneficial in treating symptoms, as was sertraline (Zoloft).
Saddock BJ, Saddock VA. Kaplan and Saddock's Concise Textbook of Psychiatry, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:207–208.
Premenstrual dysphoric disorder is associated with mood-related symptoms leading to functional impairment that distinguish it from premenstrual syndrome.
75. Which of the following is most commonly associated with tricyclic antidepressant toxicity?
A) Third-degree AV block
B) Prolongation of the PR interval
C) Prolongation of the QT interval
D) Widened QRS interval
E) T-wave elevation
View Answer
Answer and Discussion
The answer is C. The tricyclic antidepressants are used less frequently as first-line agents with the development of the SSRIs and other newer antidepressants. This is mainly due to the less benign side-effect profile of the cyclic antidepressants. These drugs interact with a wide variety of brain-receptor types that result in their antidepressant efficacy and side-effect profiles. Most serious is the toxicity of the cyclic antidepressants in overdose. In comparison to the SSRIs, the cyclic antidepressants can be fatal in doses as little as five times the therapeutic dose. The toxicity is usually due to prolongation of the QT interval, leading to arrhythmias.
Ray WA, Meredith S, Thapa PB, et al. Cyclic antidepressants and the risk of sudden cardiac death. Clin Pharmacol Ther. 2004;75:234.
76. Which of the following has the least amount of sexual side effects?
A) Fluoxetine (Prozac)
B) Sertraline (Zoloft)
C) Bupropion (Wellbutrin)
D) Paroxetine (Paxil)
E) Citalopram (Celexa)
View Answer
Answer and Discussion
The answer is C. Bupropion appears to have no or only a limited effect on sexual function.
Zajecka J. Strategies for the treatment of antidepressant-related sexual dysfunction. J Clin Psychiatry. 2001;62 (Suppl) 3:35.
77. A 41 year old presents with feelings of being “choked up.” The symptoms are rather constant and are not made worse with swallowing. He denies that food is stuck in the throat, and he has had no recent weight change. Eating and drinking help to relieve symptoms. The most likely diagnosis is
A) globus hystericus
B) panic attacks
C) Barrett's esophagus
D) reflux esophagitis
E) Zenker's diverticulum
View Answer
Answer and Discussion
The answer is A. Globus hystericus is defined as the subjective sensation of a lump or mass in the throat. No specific cause or mechanism has been determined, although there is some evidence to suggest that increased cricopharyngeal (upper esophageal sphincter) pressures or abnormal hypopharyngeal motility exist during the time of symptoms. The sensation may result from gastroesophageal reflux or from frequent swallowing and drying of the throat associated with anxiety or other emotional states. Although not related to a specific psychiatric disorder, globus may be a symptom of certain mood states. Suppression of sadness is most often implicated. Symptoms resemble the normal sensation of being “choked up.” With globus, symptoms do not become worse during swallowing, food does not stick in the throat, and eating or drinking often provides relief. No pain or weight loss occurs. Chronic symptoms may be experienced during grief reactions and may be relieved by crying. The diagnosis is based on the history and physical examination and is a diagnosis of exclusion. The treatment involves treating the underlying psychological condition.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:69–70.
78. A 7 year old is brought to your office by his parents at the request of his teachers. The child appears to have understanding of spoken language but has a reading disorder that involves single word decoding. The parents report that the father has similar problems that were detected during his schooling. The most likely diagnosis is
A) attention deficit disorder
B) autism
C) dyslexia
D) congenital hearing loss
E) mental retardation
View Answer
Answer and Discussion
The answer is C. The inability to learn derivational rules of printed language is often considered part of dyslexia. Affected children may have difficulty in determining root words or word stems and determining which letters in words follow others and form specific sound-symbol associations, such as vowel patterns, affixes, syllables, and word endings. The cause of dyslexia is unknown, but a strong genetic link has been established. Cerebrovascular accidents, prematurity, and intrauterine complications have been linked to dyslexia. Most experts agree that dyslexia is left hemisphere–related and is associated with deficiencies or dysfunctions in the areas of the brain that are responsible for language association (Wernicke's area) and sound and speech production (Broca's area) and in the interconnection of these areas. Most dyslexics are not identified until kindergarten or first grade, when symbolic learning is taught. However, dyslexia in preschool children may manifest itself as delayed language production, speech articulation problems, and difficulties in remembering the names of letters, numbers, and colors, particularly in children with a family history of reading or learning problems. Many dyslexics confuse letters and words with similar configurations or have difficulty in visually selecting or identifying letter patterns and clusters (sound-symbol association) in words. Reversals or visual confusions tend to be seen frequently during the early school years. Most reading and writing reversals occur because dyslexics forget or confuse the names of letters and words that have similar structures; subsequently, d becomes b, m becomes w, h becomes n, was becomes saw, and on becomes no, for example. Students with a history of delayed language acquisition use or who are not accelerating in word learning by the middle or end of first grade, or who are not reading at the level expected for their verbal or intellectual abilities at any grade level, should be evaluated. Many dyslexics develop functional reading skills with direct instruction, although dyslexia is a lifelong problem, and many dyslexics never reach full literacy. Compensatory approaches, such as taped texts, readers, and scribes, are used to assist the dyslexic with higher-order learning.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2490–2491.
79. Medication for the treatment of premature ejaculation includes
A) finasteride (Proscar)
B) tamsulosin (Flomax)
C) sildenafil (Viagra)
D) sertraline (Zoloft)
E) progesterone (Provera)
View Answer
Answer and Discussion
The answer is D. Premature ejaculation is best defined as persistent or recurrent ejaculation with minimal stimulation before, on, or shortly after penetration and before the sexual partner wishes it. Premature ejaculation is thought to be the most common form of male sexual dysfunction, with an estimated prevalence of up to 40%. Treatment of ejaculatory dysfunction centers on relationship counseling, behavioral therapy, and pharmacologic interventions. Behavioral therapy has been considered the gold standard of treatment. Techniques include the Semen's pause maneuver, the Masters and Johnson pause-squeeze technique, and the Kaplan stop-start method. These techniques are directed at the induction of male sexual arousal to the point of ejaculation followed by relaxation before orgasm is allowed to occur. The methods can be self-applied, although with suboptimal outcomes; hence, involvement of the sexual partner is essential. Because of the limitations of behavioral therapy, pharmacologic interventions are often used to treat premature ejaculation. Anorgasmia and delayed ejaculatory response are well-known side effects of tricyclic antidepressants (clomipramine) and SSRIs. Recent studies have shown that these drugs modify the ejaculatory response in men with premature ejaculation. Results appear better with clomipramine, but sertraline was better tolerated and had a better safety profile.
Epperly TD, Moore KE. Health issues in men (Part I). Common genitourinary disorders. Am Fam Physician. 2000;61:3657–3664.
80. When initiating antidepressants in children, the risk of suicide is maximum during
A) the first hours of medication administration
B) during the first few weeks
C) during the first few months
D) usually a year or more after starting therapy
E) the risk of suicide is not increased
View Answer
Answer and Discussion
The answer is B. The FDA advisory panel concluded there is a small, but real, increased risk of suicidal thoughts or behavior in children taking antidepressants compared to placebo. The risk appears to be greatest in the first few weeks after initiation of therapy.
Hammad TA. Review and evaluation of clinical data. Center for Drug Evaluation and Research, FDA. August 16, 2004. Available at www.fda.gov/ohrms/dockets/ac/04/briefing/2004-4065b1.htm. Accessed on March 17, 2006.
Jick H, Kaye JA, Jick SS. Antidepressants and the risk of suicidal behaviors. JAMA. 2004; 292:338.
81. Which of the following has the best side-effect profile?
A) Amitriptyline
B) Nortriptyline
C) Desipramine
D) Clomipramine
E) Fluoxetine
View Answer
Answer and Discussion
The answer is E. The tricyclic antidepressants are used less frequently as first-line agents with the development of the SSRIs and other newer antidepressants. This is mainly due to the less benign side-effect profile of the cyclic antidepressants.
Ray WA, Meredith S, Thapa PB, et al. Cyclic antidepressants and the risk of sudden cardiac death. Clin Pharmacol Ther. 2004;75:234.
82. Which of the following factors may contribute to an increased risk of domestic violence?
A) More than three children in the home
B) Power differential in the relationship
C) Women with depression
D) Prior divorce
E) One spouse undergoing schooling
View Answer
Answer and Discussion
The answer is B. Studies have not identified any consistent psychiatric diagnoses among abusers, but abusive men share some common characteristics such as rigid sex role stereotypes, low self-esteem, depression, a high need for power and control, a tendency to minimize and deny their problems or the extent of their violence, a tendency to blame others for their behavior, violence in the family of origin (particularly witnessing parental violence), and drug and alcohol abuse (which are not causative but are often associated). Some but not all batterers meet the criteria in the DSM-IV for personality disorders or depression. Men who have alcoholism combined with a major depressive disorder or antisocial personality disorder are more likely to commit domestic violence than are men with either of these conditions alone. Most researchers believe that abusive behavior is the result of multiple factors, including individual characteristics, a family history of violence, and the culturally rooted belief that violence is an acceptable means of solving problems and that violence toward women is acceptable or tolerated. Factors that specifically relate to partner abuse include the following:
· A power differential in the relationship in which one partner is financially or emotionally dependent on the other.
· A temporary or permanent disability (including pregnancy).
· A force orientation––a belief on the part of the perpetrator that violence is an acceptable solution to conflicts and problems.
· A personal or family history of abuse.
Signs that often indicate a need to further assess the risk of abuse include excessive work loss, sleep disturbances, substance abuse, anxiety, sexual dysfunction, depression, frequent injuries, or being “accident prone.” It is imperative to discuss events noted in these records with the patient and to assess any discrepancy between an injury and its reported causative mechanism, because injuries that are related to battering are often attributed to falling on the stairs or some other household accident. In such cases, the patient should be asked to describe the accident in more detail, or the physician should ask about precipitating factors (e.g., “Were you pushed?”). Ancillary tests should be obtained as indicated for the specific injury or infection. The physician should be especially alert for pregnancy complications and sexually transmitted infections, including human immunodeficiency virus infection.
U.S. Preventive Services Task Force. Screening for family and intimate partner violence: recommendation statement. Ann Intern Med. 2004;140:382–386.
83. Which of the following statements regarding the use of psychotropic agents in a nursing home setting is true?
A) Phenobarbital does not require monitoring.
B) Sedative-hypnotics should be used to sedate patients who are at risk for falls.
C) Periodic dose reductions should be performed.
D) The physician is ultimately responsible for drug monitoring.
E) Tranquilizers, regardless of their effectiveness in patients before admission to the nursing home, should not be used.
View Answer
Answer and Discussion
The answer is C. All psychotropic drugs (antidepressants, anxiolytics, sedative-hypnotics, and antipsychotics) are subject to the “unnecessary drug” regulation of the Omnibus Budget Reconciliation Act (OBRA). According to the federal government guidelines, “nursing home residents must be free of unnecessary drugs,” which are defined as those that are duplicative, excessive in dose or duration, or used in the presence of adverse effects or without adequate monitoring or indication. Medical, environmental, and psychosocial causes of behavioral problems must be ruled out, and nonpharmacologic management must be attempted before psychotropic drugs are prescribed to nursing home residents. Because treatment with psychotropic medications is indicated only to maintain or improve functional status, diagnoses and specific target symptoms or behaviors must be documented, and the effectiveness of drug therapy must be monitored. Specific dosage limits must be observed, and periodic dosage reductions or drug discontinuations must be undertaken. Side effects (of antipsychotics in particular) must be monitored. Barbiturates and certain other older tranquilizers may not be prescribed unless they were being used successfully before a patient was admitted to a long-term care facility. Phenobarbital can be used only to control seizures. OBRA restricts the use of antipsychotic drugs only in patients with dementia. None of the OBRA dosage restrictions or monitoring requirements apply in patients with psychotic disorders (e.g., schizophrenia). Each nursing home is surveyed annually. Because facilities that do not meet the federal government's requirements may be denied Medicare reimbursement, physicians who prescribe medications for nursing home residents must document the medical necessity of noncompliance with regulations (e.g., drug prescriptions in excess of OBRA-mandated dosages). In most cases, a local consultant pharmacist reviews all charts monthly and assists with compliance. According to the OBRA strategy, the long-term care facility, rather than the prescribing physician, is accountable for monitoring drug use. Regardless of where final responsibility lies, physicians need to be aware of the federal government's interpretive guidelines for the fulfillment of OBRA requirements.
Gurvich T, Cunningham JA. Appropriate use of psychotropic drugs in nursing homes. Am Fam Physician. 2000;61:1437–1446.
84. Which of the following antidepressant medications has the lowest risk of drug interactions?
A) Fluoxetine (Prozac)
B) Paroxetine (Paxil)
C) Sertraline (Zoloft)
D) Citalopram (Celexa)
E) Amitriptyline (Elavil)
View Answer
Answer and Discussion
The answer is D. Most SSRIs are associated with significant drug interactions. Fluoxetine, paroxetine, and, to a lesser extent, sertraline inhibit the metabolism of warfarin (Coumadin), cisapride (Propulsid), benzodiazepines, quinidine, tricyclic antidepressants, theophylline, and some statins. In patients who are at risk for these interactions, citalopram, an SSRI that is now available in the United States, may offer an advantage. Studies have shown that compared with other SSRIs, citalopram has less of an inhibitory effect on the cytochrome P-450 system. It is as effective as fluoxetine and sertraline in the treatment of depression.
Gurvich T, Cunningham JA. Appropriate use of psychotropic drugs in nursing homes. Am Fam Physician. 2000;61:1437–1446.
Compared with other SSRIs, citalopram has less of an inhibitory effect on the cytochrome P-450 system.
85. A 47-year-old man complains of a depressed mood over the last 3 years. He complains of low energy and low self-esteem. The condition has not prevented him from working nor has it seemed to interfere with his family life. You explain to him he has the diagnosis of
A) major depression
B) dysthymia
C) dissociation disorder
D) attention deficit disorder
E) introvert personality disorder
View Answer
Answer and Discussion
The answer is B. Dysthymia is a more chronic, low-intensity mood disorder. By definition, symptoms must be present for more than 2 years consecutively. It is characterized by anhedonia, low self-esteem, and low energy. It may have a more psychologic than biologic explanation and tends to respond to medication and psychotherapy equally. Long-term psychotherapy is frequently able to establish a permanent change in dysthymic individuals. There are often unrealistic and neurotic expectations stemming from adolescence in this disorder.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 2000:327, 332.
86. Selective serotonin reuptake inhibitors (SSRIs) are
A) associated with GI bleeding in patients taking NSAIDs
B) contraindicated in diabetics
C) not associated with withdrawal symptoms
D) cardiotoxic in doses that approach therapeutic range
E) contraindicated in patients with a history of suicidal attempts
View Answer
Answer and Discussion
The answer is A. Studies have suggested that SSRIs are associated with an increased risk of upper gastrointestinal (UGI) bleeding, particularly in patients taking NSAIDs.
de Abajo FJ, Garcia Rodriguez LA, Montero D. Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: Population-based case-control study. BMJ. 1999;319:1106.
87. Bupropion (Wellbutrin) is structurally related to
A) anxiolytics
B) stimulants
C) barbiturates
D) alcohol
E) antibiotics
View Answer
Answer and Discussion
The answer is B. Bupropion (Wellbutrin, Zyban) is used for the treatment of depression and also in treatment for tobacco abuse. Because bupropion is structurally related to stimulants, bedtime administration should be avoided. The most common adverse reactions include tremor, headaches, rash, and urticaria. Other adverse effects include insomnia and dry mouth. Bupropion in dosages >400 mg/day is associated with seizures.
Gurvich T, Cunningham JA. Appropriate use of psychotropic drugs in nursing homes. Am Fam Physician. 2000;61:1437–1446.
88. Children whose parents divorce are at increased risk for
A) lower academic achievement
B) more conduct problems
C) poorer self-concept
D) more maladjustment problems
E) all of the above
View Answer
Answer and Discussion
The answer is E. Marital conflict and divorce are prevalent in our society. Women who divorce during middle age face age-specific stresses, including loss of long-held social position, the possibility of overdependence on young adult children, a shrinking remarriage pool, socially denigrated body changes, and unfair labor market conditions. In assisting women who are going through divorce, family physicians need to focus initially on the patient's grief and mourning and then emphasize behavior modification and improved coping skills, which can be accomplished with the aid of a therapist. As a group, children (especially boys) of parents who are going through a high-conflict divorce are two to four times more likely to have clinical emotional and behavioral disturbances compared with national norms. Court-ordered joint physical custody and a frequent visitation arrangement in high-conflict divorce tend to be associated with poorer outcomes in children, especially girls. Thus, a child's ultimate adjustment to divorce depends on several factors, including the following:
· The level of interparental conflict that precedes and follows divorce. The number of stressful life events that accompany and follow divorce
· The custodial parent's psychological adjustment and parenting skills
· The amount and quality of contact with the noncustodial parent
· The degree of economic hardship to which children are exposed
After a divorce, children may experience sadness and depression, aggressive behavior, frequent illnesses, abdominal pain, headaches, difficulty in school, eating problems, and sleeping disturbances. Children who experience parental divorce, compared with children in intact two-parent families, exhibit more conduct problems, more symptoms of psychologic maladjustment, lower academic achievement, more social difficulties, and poorer self-concept. Similarly, adults who experienced parental divorce as children, compared with adults raised in continuously intact two-parent families, score lower on a variety of indicators of psychologic, interpersonal, and socioeconomic well-being. However, the overall differences between offspring from divorced and intact families are small, with considerable diversity existing in children's reactions to divorce.
Meurer JR, Meurer LN, Holloway RL. Clinical problems and counseling for single-parent families. Am Fam Physician. 1996;54(3):864.
89. Teen pregnancy is most closely associated with
A) higher birth weight infants
B) improved Apgar scores
C) higher risk of gestational diabetes
D) higher risk of preeclampsia
E) higher risk of deep venous thrombosis
View Answer
Answer and Discussion
The answer is D. Each year, approximately 1 million adolescents become pregnant in the United States, and nearly half of them give birth and become parents. Risk factors that are predictive of early sexual activity and subsequent pregnancy include poverty, poor academic ability and achievement, and a lack of educational goals. Pregnant adolescents are at greater risk than older mothers for nutritional deficiencies, anemia, preeclampsia, and cephalopelvic disproportion, due partly to inadequate prenatal care. In addition, pregnancy increases the teenager's risk of dropping out of school, leading to fewer career opportunities, chronic unemployment, and societal dependence. Infants who are born to adolescents are at high risk for premature birth, low birth weight, and infant death. They experience more illnesses, have more cognitive delays, and perform less well in school than children with more mature parents. The children of adolescent parents are at risk themselves for early sexual activity and teenage pregnancy, thereby perpetuating the cycle.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw-Hill; 2005:281.
90. Which of the following is the primary treatment of schizophrenia?
A) Cognitive therapy
B) Behavioral therapy
C) Interpersonal therapy
D) Psychodynamic psychotherapy
E) Pharmacotherapy
View Answer
Answer and Discussion
The answer is E. Pharmacotherapy is the primary treatment for schizophrenia and other psychotic disorders.
Kopelowicz A, Liberman RP. Psychosocial treatments for schizophrenia. In: Nathan PE, Gorman JM, eds. A guide to treatments that work. New York: Oxford University Press; 1998:190.
91. Which of the following foods is safe to eat if the patient is taking a monoamine oxidase inhibitor (MAOI)?
A) Fermented cheese
B) Soy sauce
C) Bananas
D) Smoked sausage
E) Wheat bread
View Answer
Answer and Discussion
The answer is E. MAO inhibitors are often avoided because of their potential to precipitate enhanced sympathetic activity and severe hypertension with the concomitant ingestion of tyramine containing foods (e.g., fermented cheeses; imported beer; Chianti, champagne, some other wines; soy sauce; avocados; bananas; overripe or spoiled food; and any fermented, smoked, or aged fish or meat).
Paulson RH, Katon W, Ciechenowski P. Treatment of depression in adults. Up to Date, version 14.1. Accessed 3/17/06.
92. Which of the following drugs used in the treatment of attention deficit disorder hyperactivity disorder has been associated with hepatotoxicity?
A) Methylphenidate (Ritalin)
B) Dextroamphetamine (Dexedrine)
C) Pemoline (Cylert)
D) Clonidine (Catapres)
E) Desipramine (Norpramin)
View Answer
Answer and Discussion
The answer is C. Attention deficit hyperactivity disorder is the most common pediatric psychiatric disorder, involving 1 of every 20 children. It is often a disabling condition and is frequently accompanied by high levels of frustration and comorbidity. Diagnosis of attention deficit hyperactivity disorder requires a detailed history from the family and use of rating scales to collect observations from two or more settings. Effective treatment, including behavior management, appropriate educational placement, and stimulant medication, improves academic performance and behavior in most patients. Children in whom initial management fails or for whom the diagnosis is unclear or complicated should be referred to appropriate mental health professionals. Medications that are used for treatment include methylphenidate, dextroamphetamine, and pemoline. Although these medicines have a stimulating effect in most, they have a calming effect in children and adults with attention deficit hyperactivity disorder. Other medications include atomoxetine, clonidine, desipramine, imipramine, and bupropion. Side effects include headaches, gastrointestinal symptoms, anorexia and weight loss, insomnia, and palpitations. Pemoline has been associated with hepatotoxicity and is no longer used. Dosing of medications should be 30 to 45 minutes before meals (breakfast and lunch). Lunchtime doses can be given at school for some children. An alternative is the use of longer-acting preparations. The long-acting form of these medications should not be crushed, broken, or chewed before swallowing. The long-acting forms are dosed (usually) once a day, before breakfast.
Guevara J, Paquin A, Payton K. Attention deficit hyperactivity disorder. West J Med. 2001;175:189–192.
Hunt RD, et al. An update on assessment and treatment of complex attention-deficit hyperactivity disorder. Pediatr Ann. 2001;30(3):162–172.
93. Which of the following side effects is associated with the use of St. John's Wort?
A) Photosensitivity
B) Peripheral neuropathy
C) Hepatotoxicity
D) Renal toxicity
E) Rhabdomyolysis
View Answer
Answer and Discussion
The answer is A. St. John's Wort (Hypericum perforatum) is an herbal medicine that is used for the treatment of depression. Several studies have shown beneficial responses with use of the medication, although criticism of the research exists. St. John's Wort should not be combined with the use of SSRIs. In addition there is concern about the side effect of photosensitivity with prolonged use. Other side effects include delayed hypersensitivity, gastrointestinal tract upset, dizziness, dry mouth, sedation, restlessness, and constipation. No effect on cardiac conduction has been found. Contraindications include pregnancy, lactation, exposure to strong sunlight, and pheochromocytoma. The drug should not be used with MAO inhibitors. A recent review concluded that Hypericum is at least as safe and possibly safer than conventional antidepressant medications.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2732–2733.
94. Kava is included in an herbal remedy that is used in the treatment of
A) depression
B) impotence
C) anxiety
D) memory loss
E) attention deficit disorder
View Answer
Answer and Discussion
The answer is C. The term kava refers to a Pacific Island plant (Piper methysticum) and the beverage that is prepared from it. The drug may be beneficial in the management of anxiety and tension of nonpsychotic origin and does not adversely affect cognitive function, mental acuity, or coordination. Long-term use of high doses has been associated with scaling of the skin on the extremities. Kava may potentiate the action of other centrally mediated agents and interact with alcohol.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2732.
Kava may be beneficial in the management of anxiety and tension of nonpsychotic origin and does not adversely affect cognitive function, mental acuity, or coordination.
95. Which of the following conditions is commonly seen in patients with mental retardation?
A) Hyperthyroidism
B) Hyperparathyroidism
C) Diabetes mellitus
D) Osteoporosis
E) Pernicious anemia
View Answer
Answer and Discussion
The answer is D. Osteoporosis is a common condition seen in patients with mental retardation, particularly among non-weight-bearing patients. It has been estimated that as many as 50% of adults with mental retardation have osteoporosis or osteopenia. Conditions associated with an increased risk of osteoporosis include cerebral palsy, Down syndrome, use of antiepileptics, special diets (e.g., ketogenic diet for seizure control), and hypogonadism. Aggressive evaluation of traumatic injuries with radiographic studies may be justified even when there are few physical findings. Furthermore, osteoporosis and use of antiepileptics may predispose patients to degenerative disk disease with spinal cord compromise, leading to functional decline.
Prater CD, Zylstra RG. Medical care of adults with mental retardation. Am Fam Physician. 2006;73:2175–2183, 2184.
96. Which of the following medications is more likely to have a paradoxical reaction in patients affected with mental retardation?
A) Haloperidol
B) Lorazepam
C) Phenobarbitol
D) Phenytoin
E) Buspirone
P.253
View Answer
Answer and Discussion
The answer is B. In patients affected with mental retardation, many of the most challenging behaviors are caused by the same neuropsychiatric disorders that affect the general population and most respond to the same treatments. One notable exception is benzodiazepine therapy, which can precipitate paradoxical reactions of increased irritability and aggression in 10% to 15% of patients with mental retardation.
Kalachnik JE, Hanzel TE, Sevenich R, et al. Benzodiazepine behavioral side effects: review and implications for individuals with mental retardation. Am J Ment Retard. 2002;107:376–410.
97. Valerian is an herbal remedy that is used for the treatment of
A) sleep disorders
B) mania
C) depression
D) menstrual disorders
E) bulimia
View Answer
Answer and Discussion
The answer is A. Valerian is derived from the perennial herb Valerian officinalis. The herb is used in the treatment of anxiety and sleep disorders. It interacts with the inhibitory neurotransmitter GABA. Valerian may potentiate the effects of other central nervous system depressants. The incidence of adverse side effects with its use appears to be low; however, more research is needed.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2733.
98. Patients with which of the following conditions should use ginkgo biloba with caution?
A) Peptic ulcer disease
B) Peripheral neuropathy
C) Cardiac conduction defects
D) Renal insufficiency
E) Prior deep venous thrombosis
View Answer
Answer and Discussion
The answer is A. An extract of the dried leaves of the Ginkgo biloba tree is used in Europe to alleviate symptoms that are associated with a range of cognitive problems and has been approved in Germany for the treatment of dementia. Ginkgo is thought to have antioxidant properties, although its exact mechanism of action is unclear. Le Bars and colleagues conducted a randomized, double-blind, placebo-controlled trial to test the efficacy of ginkgo in the management of patients with Alzheimer's disease and multi-infarct dementia. Adverse events were not significantly different between the treatment and placebo groups and were considered to be mild to moderate in intensity. The authors conclude that treatment with extract of Ginkgo biloba is safe for up to 1 year in patients with dementia and can improve cognitive performance and functioning. The improvement was significant enough to be identified by the patient's caregiver. The most common adverse affect is headache. Caution should be exercised when using ginkgo combined with anticoagulant treatment including aspirin when there is risk of bleeding as in peptic ulcer disease and subdural hematoma. Safety in pregnancy and in lactation has not been determined.
Le Bars PL, Katz MM, Berman N, et al. A placebo-controlled, double-blind, randomized trial of an extract of ginkgo biloba for dementia. JAMA. 1997;278:1327–1332.
99. Yohimbine has been associated with which of the following?
A) Colon polyps
B) Priapism
C) Cataract formation
D) Skin pigmentation
E) Hypertensive complications
View Answer
Answer and Discussion
The answer is E. Yohimbine is an indole alkaloid that is obtained from the bark of a West African tree (Pausinystalia yohimba). The product is an α-adrenergic receptor antagonist that is marketed for the treatment of impotence. Results of studies have shown consistent ability of the drug to enhance erectile functioning. Yohimbine increases sympathetically mediated plasma norepinephrine, which in turn produces a pressor response. Therefore, yohimbine should be administered with caution to patients with high blood pressure or those who are undergoing concomitant treatment with tricyclic antidepressants or other drugs that interfere with neuronal uptake or metabolism of norepinephrine. The drug may induce panic attacks in patients with anxiety disorders.
Saddock BJ, Saddock VA. Kaplan and Saddock's Comprehensive Textbook of Psychiatry, 7th ed. Philadelphia: Lippincott Williams & Wilkins. 2000:2014.
100. Cognitive therapy is defined as:
A) repeated exposure to one's fears to overcome associated anxiety
B) a treatment that helps patients reverse false self-beliefs that lead to certain moods and behaviors
C) a confrontation with the patient that exposes certain inadequacies in social interaction
D) an exhaustive review of past events that outlines previous failures
E) an introspective review of past behaviors that highlights poor judgment
View Answer
Answer and Discussion
The answer is B. Cognitive therapy is defined as a treatment process that helps patients reverse false self-beliefs that lead to certain moods and behaviors. The basic principle behind cognitive therapy is that a thought comes before a mood, and that both are associated with a person's environment, physical reaction, and subsequent behavior. As a result, changing a thought that arises in a given situation changes mood, behavior, and physical reaction. Motivated patients who have an internal locus of control and the capacity for introspection likely would benefit most. During cognitive therapy, the therapist assists the patient with several steps. First, the patient accepts that some of his or her perceptions and interpretations of reality may be false (because of past experience or hereditary or biological reasons) and that these interpretations lead to negative thoughts. Next, the patient learns to recognize the negative (surface or “automatic”) thoughts and discovers alternative thoughts that reflect reality more closely. The patient then decides internally whether the evidence supports the negative thought or the alternative thought. Ideally, the patient will recognize distorted thinking and “reframe” the situation. As cognitive therapy progresses, it focuses more on reframing deeply held or “core” beliefs about self and the world. In cognitive behavior therapy (CBT) for depression, behavioral principles are used to overcome a patient's reluctance at the beginning of therapy and to reinforce positive activities. An important part of CBT for depression is having the patient participate in pleasurable activities, especially with others, that usually give positive reinforcement. Other CBT techniques include assigning projects and tasks and acting out difficult behavioral situations.
Rupke SJ, Blecke D, Renfrow M. Cognitive therapy for depression. Am Fam Physician. 2006;73:83–86, 93.
101. Which of the following medications is preferred in the treatment of alcohol withdrawal syndrome?
A) Haloperidol
B) Lorazepam
C) Phenytoin
D) Phenobarbitol
E) Carbamazepine
View Answer
Answer and Discussion
The answer is B. Pharmacologic treatment of alcohol withdrawal syndrome involves the use of medications that are cross-tolerant with alcohol. Benzodiazepines have been shown to be safe and effective, particularly for preventing or treating seizures and delirium, and are the preferred agents for treating the symptoms of alcohol withdrawal syndrome.
Bayard M, McIntyre J, Hill KR, et al. Alcohol withdrawal syndrome. Am Fam Physician. 2004;69:1443–1450.
102. Which of the following medications is least likely to cause problems with libido?
A) Risperidone (Risperdal)
B) Cimetidine (Tagamet)
C) Bupropion (Wellbutrin)
D) Fluoxetine (Prozac)
E) Citalopram (Celexa)
View Answer
Answer and Discussion
The answer is C. The loss of libido is a common problem that is addressed by family physicians. Many individuals have coexisting depression that is being treated. Patients whose depression improves with treatment but who continue to experience a lowered libido should be asked about their use of other medications. Several antipsychotic agents, including haloperidol, thioridazine, and risperidone, can decrease libido. Cimetidine, in contrast to ranitidine, has been found to lower libido and cause erectile dysfunction. Perimenopausal women who take oral contraceptives and postmenopausal women who are given estrogen replacement therapy may experience an improvement of depressive symptoms but a lowering of libido as a result of estrogen-induced deficiency of free testosterone. Testosterone testing and supplementation should be considered in women who experience a decline in libido after starting estrogen therapy. Testosterone testing should also be considered in men who have a gradual loss of libido and no improvement despite adequate treatment for depression. Psychologic and interpersonal factors commonly affect depression and sexual desire. These factors include stressful life events (loss of job or family trauma), life milestones (children leaving home), and ongoing relationship problems. Alcohol and narcotics are known to decrease libido, arousal, and orgasm. Consistent evidence shows that, with the exception of bupropion (Wellbutrin), mirtazipine (Remeron), and trazodone (Desyrel), antidepressant medications may cause a decline in libido or sexual functioning despite improvement of depression. Up to one-half of patients surveyed before and after starting therapy with the SSRIs fluoxetine, paroxetine, fluvoxamine, citalopram, and sertraline reported a decline in libido with medication use.
Phillips RL, Slaughter JR. Depression and sexual desire. Am Fam Physician. 2000;62:782–786.
103. Adenosylmethionine (SAMe) is thought to affect levels of the neurotransmitter
A) acetylcholine
B) gamma-aminobutyric acid (GABA)
C) serotonin
D) norepinephrine
View Answer
Answer and Discussion
The answer is C. SAMe is an alternative medication that is used for the treatment of depression. The rationale for the use of SAMe in depression stems from its role in the metabolism of serotonin, dopamine, and melatonin. Oral and intravenous SAMe supplementation has been shown to increase SAMe levels significantly in cerebrospinal fluid, indicating SAMe's crossover through the blood-brain barrier. This has been associated with increased levels of serotonin metabolites in cerebrospinal fluid. Depressed patients may have low serotonin levels associated with low levels of SAMe. Because no studies have yet validated the long-term safety or efficacy of SAMe, further large long-term studies should be conducted before it receives widespread recommendation.
Morelli V, Zoorob RJ. Alternative therapies (Pt I). Depression, diabetes, obesity. Am Fam Physician. 2000;62:1051–1060.
104. Puerperal psychosis typically develops
A) during the first month after delivery
B) 3 to 4 months after delivery
C) 6 to 12 months after delivery
D) after the child has reached the age of 1 year
View Answer
Answer and Discussion
The answer is A. When trying to determine if the presence of a symptom is a sign of depression or a normal postpartum reaction, the physician should consider the circumstances. Loss of energy and diminished concentration are frequently the result of sleep deprivation. However, for a postpartum woman to have no energy or to have such difficulty in concentrating that she frequently loses her train of thought or has considerable difficulty in making decisions is not normal. Determining how much time has elapsed since delivery helps the physician to distinguish PMD from subclinical mood fluctuations, which occur with such frequency during the first 2 weeks after delivery that they are considered part of the normal postpartum experience. Many women experience the “baby blues,” which are characterized by mild depressive symptoms, tearfulness (often for no discernible reason), anxiety, irritability, mood lability, increased sensitivity, and fatigue. The blues peak 4 to 5 days after delivery, may last hours to days, and resolve by the tenth postnatal day. Women who experience them have an increased risk for PMD later in the postpartum period, especially if the blues symptoms were severe. Subclinical mood swings in either direction (high vs. low) after delivery are an indication for more intensive follow-up later in the postpartum period.
Finally, PMD must be distinguished from puerperal psychosis. Most puerperal psychoses have their onset within the first month of delivery and are related to mania. An inability to sleep for several nights, agitation, expansive or irritable mood, and avoidance of the infant are early warning signs that herald the onset of puerperal psychosis. Because the woman is at risk of harming herself or her baby (or both), postpartum psychosis is a medical emergency. Most patients with puerperal psychosis are treated in a hospital with neuroleptic agents and mood stabilizers. Before a definitive diagnosis of PMD is made, depression caused by a medical condition such as thyroid dysfunction or anemia must be ruled out.
Epperson CN. Postpartum major depression: detection and treatment. Am Fam Physician. 1999;59:2247–2254, 2259–2260.
Many women experience the “baby blues,” characterized by mild depressive symptoms, tearfulness (often for no discernible reason), anxiety, irritability, mood lability, increased sensitivity, and fatigue.
105. Alcohol affects which of the following neurotransmitters?
A) Gamma-aminobutyric acid (GABA)
B) Dopamine
C) Norepinephrine
D) Acetylcholine
E) None of the above
View Answer
Answer and Discussion
The answer is A. Alcohol enhances the effect of GABA on GABA-A neuroreceptors, resulting in decreased overall brain excitability. Chronic exposure to alcohol results in a compensatory decrease of GABA-A neuroreceptor response to GABA, evidenced by increasing tolerance of the effects of alcohol.
Bayard M, McIntyre J, Hill KR, et al. Alcohol withdrawal syndrome. Am Fam Physician. 2004;69:1443–1450.
106. A 56-year-old business executive with a history of alcoholism and associated liver disease presents to your office and would like to stop drinking. In order to prevent alcohol withdrawal, you select which of the following medications?
A) Lorazepam
B) Clonazepam
C) Diazepam
D) Flurazepam
E) Buspirone
View Answer
Answer and Discussion
The answer is A. An evidence-based guideline from the American Society of Addiction Medicine recommends benzodiazepines as a first-line agent for the treatment of alcohol withdrawal. The guideline notes that although agents with a longer duration of action may provide fewer breakthrough symptoms, those with a shorter duration of action, such as lorazepam (Ativan), may be preferred when there is concern about prolonged sedation (e.g., in patients with significant comorbidities or liver disease).
Ntais C, Pakos E, Kyzas P. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. 2005;(3):CD005063.
107. Which of the following statements regarding mass psychogenic illness is true?
A) Outbreaks are usually slow to develop.
B) Causes are usually readily identifiable.
C) Children and adolescents are rarely affected.
D) Incidents precede an environmental trigger.
E) Media coverage can escalate the outbreak.
View Answer
Answer and Discussion
The answer is E. Mass psychogenic illness has been defined as a constellation of symptoms that are suggestive of organic illness with no identifiable cause and little clinical or laboratory evidence of disease that occurs among persons who share beliefs regarding their symptoms. Outbreaks often involve acute onset and rapid spread of symptoms with minimal physical or abnormal laboratory findings (except those that are associated with hyperventilation). Person-to-person spread within minutes has been called pathognomonic of this illness, although it is not always present. Symptoms include headache, dizziness, light-headedness, abdominal cramps, nausea, cough, irritated eyes, dyspnea, chest tightness or pain, inability to concentrate, vomiting, and nervousness. Symptoms may suggest an environmental cause, but no such cause can be identified, and other putatively exposed persons do not become ill. Rash has been described in several outbreaks of psychogenic illness. Outbreaks affect women disproportionately more often than men, and frequently involve adolescents or children. Incidents often follow an environmental trigger such as an odor, and many outbreaks are preceded by illness in an index case that generates a substantial emergency response. Illness can spread through exposure to audiovisual cues and by “line-of-sight” transmission. The latter term refers to the apparent spread of symptoms among persons who see others become ill. Symptoms can recur in the setting of the initial outbreak. Media coverage frequently escalates such outbreaks.
Jones TJ. Mass psychogenic illness: role of the individual physician. Am Fam Physician. 2000;62:2649–2653, 2655–2656.
108. Which of the following is not associated with anorexia nervosa in adolescent females?
A) Bradycardia
B) Low blood pressure
C) Low bone density
D) Low estradiol levels
E) Precocious puberty
View Answer
Answer and Discussion
The answer is E. Adolescent girls with anorexia nervosa have an increased risk for hematologic, metabolic (low estradiol levels), hemodynamic, and skeletal abnormalities (low bone density), including bradycardia, low blood pressure, and pubertal delay, compared with healthy girls.
Misra M, Aggarwal A, Miller KK. Effects of anorexia nervosa on clinical, hematologic, biochemical, and bone density parameters in community-dwelling adolescent girls. Pediatrics. 2004;114:1574–1583.
109. When distinguishing delirium from preexisting psychiatric disorders, which of the following is characteristic of delirium?
A) Slow onset with a variable course
B) Slowing on EEG recordings
C) Auditory hallucinations
D) Memory impairment
E) Feelings of hopelessness
View Answer
Answer and Discussion
The answer is B. Specific signs and symptoms can assist physicians in distinguishing between delirium and a preexisting psychiatric disorder. Visual hallucinations are an indicator of an underlying metabolic disturbance or adverse effect of medication or substance abuse. Although visual hallucinations can occur in patients with primary psychiatric illnesses such as schizophrenia, they are much less common than auditory hallucinations. In primary psychiatric disorders, visual hallucinations are associated with other, more characteristic signs and symptoms of the disorders. Visual hallucinations that occur in patients with delirium can be formed (e.g., people, animals) or unformed (e.g., spots, flashes of light). Electroencephalography (EEG) can be useful in differentiating delirium from other conditions. In patients with delirium, the EEG displays a diffuse slowing of the background rhythm. An exception is patients with delirium tremens, where the EEG shows fast activity. EEGs are also useful in detecting ictal and postictal seizure activity, as well as nonconvulsive status epilepticus, all of which can present as delirium. Abnormal EEG readings would not be expected in patients with psychotic disorders or depression. However, slowing may occur in patients with dementia. Additionally, the acute onset and fluctuating nature of delirium are hallmark features in distinguishing it from primary psychiatric disorders. Patients are often unable to provide an adequate history. It is important to interview family members and caregivers to determine the time of onset of symptoms and other pertinent medical and psychiatric information, including a review of medications and a history of substance abuse. It is also important to know how patients are currently different from their normal cognitive state. Psychiatric symptoms that arise in persons 50 years and older without a prior psychiatric history or the development of new symptoms in patients with preexisting psychiatric illness should undergo a thorough medical work-up.
Gleason OC. Delirium. Am Fam Physician. 2003;67:1027–1034.
Although visual hallucinations can occur in patients with primary psychiatric illnesses such as schizophrenia, they are much less common than auditory hallucinations.