BRS Behavioral Science/Drugs

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1. A 30-year-old man who has had many negative life experiences becomes upset when he sees photographs of himself taken during these times. The brain area most likely to be activated by these photographs is the

(A) dorsolateral convexity of the frontal lobe

(B) hypothalamus

(D) reticular system

(E) amygdala

(F) nucleus basalis of Meynert

The answer is E.

The amygdala is an important brain area for the evaluation of sensory stimuli with emotional significance. Thus, the brain area most likely to be activated by these photos is the amygdala.

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2. A 43-year-old man comes to the emergency department of a large hospital. He is very anxious and complains of abdominal cramps and diarrhea. The physician observes intense flushing of the man's skin. In this patient, a 24-hour urine study is most likely to reveal elevated levels of

(A) acetylcholine

(B) 5-hydroxyindoleaceticacid (5-HIAA)

(D) vanillylmandelicacid(VMA)

(E) homovanillicacid(HVA)

The answer is D.

A 24-hour urine study is most likely to reveal elevated levels of VMA, a metabolite of norepinephrine. Anxiety, abdominal cramps and diarrhea, and skin flushing are symptoms of pheochromocytoma, a norepinephrine-secreting adrenal tumor. This picture is not seen with elevated levels of other neurotransmitter metabolites.

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3. In a clinical experiment, a 48-year-old female patient with chronic pain who, in the past, has responded to placebos is given naloxone. Shortly thereafter the patient is given an inert substance that she believes is a painkiller. After the patient receives the inert substance, her pain is most likely to:

(A) increase

(B) decrease

(D) respond to lower doses of opioids than

previously

(E) fail to respond to opioids in the future

The answer is C.

Since the placebo response is based in part on activation of the endogenous opioid system, it will be blocked by naloxone, and this patient's pain will be unchanged. This experiment will not necessarily affect her response to opioids in the future.

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4. A 65-year-old female patient has had a stroke affecting the left hemisphere of her brain. Which of the following functions is most likely to be affected by the stroke?

(A) Perception

(B) Musical ability

(D) Language

(E) Artisticability

The answer is D.

Dominance for language in both right-handed and left-handed people is usually in the left hemisphere of the brain. Perception, musical ability, artistic ability, and spatial relations primarily are functions of the right side of the brain.

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5. Which of the following two structural entities connect the cerebral hemispheres?

(A) Basal ganglia and anterior commissure

(B) Anterior commissure and reticular system

(D) Hippocampal commissure and corpus

callosum

(E) Amygdala and habenular commissure

The answer is D.

The corpus callosum and the hippocampal, habenular, and anterior commissures connect the two hemispheres of the brain. The basal ganglia, reticular system, and amygdala do not have this function.

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6. A 23-year-old patient shows side effects such as sedation, increased appetite, and weight gain while being treated with antipsychotic medication. Of the following, the mechanism most closely associated with these effects is

(A) blockade of serotonin receptors

(B) blockade of dopamine receptors

(D) blockade of histamine receptors

(E) decreased availability of serotonin

The answer is D.

Sedation, increased appetite, and weight gain are side effects of treat- ment with certain antipsychotic agents. The mechanism most closely associated with these side effects is blockade of histamine receptors since these antipsychotics are not specific for dopamine blockade. Blockade of dopamine receptors by these antipsychotic medications is associated with side effects such as Parkinsonism-like symptoms and elevated prolactin levels.

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7. A 3-year-old girl who had been develop- ing typically since birth begins to withdraw socially and then stops speaking altogether. Also, instead of purposeful hand movements, the child has begun to show repeti- tive hand wringing behavior. The chromosome most likely to be involved in this disorder is chromosome

(A) 1

(B) 16

(D) 21

(E) X

The answer is E.

This 3-year-old girl is showing signs of Rett's disorder which is linked to the X chromosome. Rett's disorder is characterized by loss of social skills after a period of typical functioning as well as hand wringing and breathing abnormalities (see also Chapter 15).

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8. The major neurotransmitter implicated in both Alzheimer disease and schizophrenia is

(A) serotonin

(B) norepinephrine

(D) g-aminobutyric acid (GABA)

(E) acetylcholine (Ach)

(F) glutamate

The answer is F.

While acetylcholine (Ach) is the major neurotransmitter implicated in Alzheimer disease, abnormalities in glutamate are seen in both Alzheimer disease and schizophrenia.

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9. The major neurotransmitter involved in the antidepressant action of fluoxetine (Prozac) is

(A) serotonin

(B) norepinephrine

(D) g-aminobutyric acid (GABA)

(E) acetylcholine(Ach)

(F) glutamate

The answer is A.

Blockade of serotonin reuptake by presynaptic neurons is the primary action of the antidepressant fluoxetine.

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10. The neurotransmitter metabolized to 5-HIAA (5-hydroxyindoleacetic acid) is

(A) serotonin

(B) norepinephrine

(D) g-aminobutyric acid (GABA)

(E) acetylcholine(Ach)

(F) glutamate

The answer is A.

Serotonin is metabolized to 5-HIAA.

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11. A 25-year-old male patient sustains a serious head injury in an automobile accident. He had been aggressive and assaultive, but after the accident he is placid and cooperative. He also makes inappropriate suggestive comments to the nurses and masturbates a great deal. The area(s) of the brain most likely to be affected in this patient is (are) the

(A) right parietal lobe

(B) basal ganglia

(D) reticular system

(E) amygdala

(F) left frontal lobe

The answer is E.

The patient is showing evidence of the Klüver-Bucy syndrome, which

includes hypersexuality and docility and is associated with damage to the amygdala.

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12. A 35-year-old female patient reports that she has difficulty sleeping ever since she sustained a concussion in a subway accident. The area(s) of the brain most likely to be affected in this patient is (are) the

(A) right parietal lobe

(B) basal ganglia

(D) reticular system

(E) amygdala

(F) left frontal lobe

The answer is D.

Sleep-arousal mechanisms are affected by damage to the reticular system.

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13. A 55-year-old woman was diagnosed with schizophrenia at the age of 22. If this diagnosis was appropriate, the volume of the hippocampus, the size of the cerebral ventricles, and glucose utilization in the frontal cortex of this patient are now most likely to be, respectively

(A) increased, increased, increased

(B) decreased, decreased, decreased

(D) decreased, increased, decreased

(E) increased,decreased,increased

The answer is D.

Although neuroimaging cannot be used to diagnose psychiatric disor- ders, brains of patients with schizophrenia such as this woman are likely to show decreased volume of limbic structures such as the hippocampus; increased size of cer- ebral ventricles due, in part, to brain shrinkage; and decreased glucose utilization in the frontal cortex.

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14. An 80-year-old female patient has a resting tremor of her left hand, little expression in her face, and problems taking a first step when she has been standing still. The area(s) of the brain most likely to be affected in this patient is (are) the

(A) right parietal lobe

(B) basal ganglia

(D) reticular system

(E) amygdala

(F) left frontal lobe

The answer is B.

This 80-year-old female patient is showing signs of Parkinson disease (e.g., a resting tremor, little facial expression, and problems initiating movement). This disorder is associated with abnormalities of the basal ganglia.

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15. A 69-year-old former bank president cannot tell you the name of the current president and has difficulty identifying the woman sitting next to him (his wife). He began having memory problems 3 years ago. The area(s) of the brain most likely to be affected in this patient is (are) the

(A) right parietal lobe

(B) basal ganglia

(D) reticular system

(E) amygdala

(F) left frontal lobe

The answer is C.

This patient is showing evidence of Alzheimer disease. Of the listed brain areas, the major one implicated in Alzheimer disease is the hippocampus.

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16. A 45-year-old male patient becomes depressed following a head injury. The area(s) of the brain most likely to be affected in this patient is (are) the

(A) right parietal lobe

(B) basal ganglia

(D) reticular system

(E) amygdala

(F) left frontal lobe

The answer is F.

Of the listed brain areas, depression is most likely to be associated with damage to the left frontal lobe.

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17. A 28-year-old male patient is brought to the emergency room after a fight in which he attacked a man who cut into his line at the supermarket checkout. In the emergency room he remains assaultive and combative. The body fluids of this patient are most likely to show

(A) increased 3-methoxy-4-hydroxyphenylglycol (MHPG)

(B) decreased MHPG

(D) decreased 5-HIAA

(E) decreased homovanillic acid (HVA)

The answer is D.

Assaultive, impulsive, aggressive behavior like that seen in this 28-year-old male patient is associated with decreased levels of serotonin in the brain.

Levels of 5-HIAA (5-hydroxyindoleacetic acid), the major metabolite of serotonin, have been shown to be decreased in the body fluids of violent, aggressive, impulsive individuals as well as depressed individuals.

MHPG (3-methoxy-4-hydroxyphenylglycol), a metabolite of norepinephrine, is decreased in severe depression, while homovanillic acid (HVA), a metabolite of dopamine, is decreased in Parkinson disease and depression.

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18. A 30-year-old woman who is withdrawing from heroin shows intense anxiety, increased pulse, elevated blood pressure, and a hand tremor. Her symptoms improve when she is given clonidine, an alpha-2- adrenergic receptor agonist. The area(s) of the brain most likely to be involved in the improvement in this patient's symptoms is (are) the

(A) right parietal lobe

(B) basal ganglia

(D) raphe nuclei

(E) amygdala

(F) substantia nigra

The answer is C.

The effectiveness of clonidine in treating withdrawal symptoms asso- ciated with the use of opiates and sedatives is believed to be due to its action on alpha- 2-adrenergic receptors, for example, reducing the firing rate of noradrenergic neurons, most of which are located in the locus ceruleus.

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19. A very anxious 25-year-old patient is examined in the emergency room. There is no evidence of physical illness. If it could be measured, the g-aminobutyric acid (GABA) activity in the brain of this patient would most likely be

(A) increased

(B) decreased

(D) higher than the activity of serotonin

(E) higher than the activity of norepinephrine

The answer is B.

g-Aminobutyric acid (GABA) is an inhibitory amino acid neurotransmitter in the CNS.

Thus, the activity of GABA in the brain of this anxious patient is likely to be decreased.

Decreased serotonin and increased norepinephrine are also involved in anxiety

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20. A 24-year-old man sustains a head injury in an automobile accident. His father relates that prior to the accident, the patient was respectful, modest, controlled, and hard working. In the hospital, the patient is rude to the nurses and aides, loses his temper with the slightest provocation, and refuses to wear a hospital gown or anything else. These behavioral changes after the accident indicate that the area of the brain most likely to have been injured in this patient is the

(A) dorsolateral convexity of the frontal lobe

(B) hypothalamus

(D) reticular system

(E) amygdala

(F) nucleus basalts of Meynert

The answer is C.

Behavioral changes such as decreased impulse control, poor social behavior, and lack of characteristic modesty indicate that the area of the brain most likely to have been injured in this patient is the orbitofrontal cortex. Lesions of this brain area result in disinhibition, inappropriate behavior, and poor judgment.

In contrast, lesions of the dorsolateral convexity of the frontal lobe result in decreased executive functioning (e.g., motivation, concentration, and attention).

The hypothalamus is associated with homeostatic mechanisms and the reticular system with consciousness and sleep.

Damage to the amygdala results in decreased, not increased, aggression.

The nucleus basalis of Meynert is a site of Ach production; its damage could result in deficits in intellectual functioning.

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21. Analysis of the blood plasma of a 45-year-old male patient shows increased concentration of homovanillic acid (HVA). This elevation is most likely to be associated with which of the following conditions?

(A) Parkinson disease

(B) Depression

(D) Pheochromocytoma

(E) Schizophrenia

The answer is E.

Increased body fluid level of homovanillic acid (HVA), a major metabolite of dopamine, is seen in schizophrenia.

Decreased HVA is seen in Parkinson disease, depression, and in medicated schizophrenic patients. Increased vanillylmandelic acid (VMA), a metabolite of norepinephrine, is seen in pheochromocytoma. Decreased body fluid level of 5-HIAA, a metabolite of serotonin, is seen in depression and in bulimia (Table 4.5).

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22. Remembering that school closes early before Thanksgiving Day every year is an example of which of the following types of memory?

(A) Semantic

(B) Episodic

(D) Working

The answer is A.

Remembering that school closes early before Thanksgiving Day every year is an example of semantic memory. Semantic memory is a type of declarative memory which involves remembering general knowledge about the world. Episodic memory involves remembering personally experienced events, procedural memory involves remembering things one does automatically, and working memory involves remembering recent information.

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23. A 55-year-old patient who is taking tiotropium bromide (Spiriva) for chronic obstructive pulmonary disease has memory problems due to the agent's action on which of the following receptors?

(A) Adrenergic

(B) Cholinergic

(D) Histaminergic

(E) Serotonergic

The answer is B.

Decreased availability of acetylcholine by blockade of muscarinic acetylcholine receptors (i.e., anticholinergic activity) in the CNS is associated with memory problems. Blockade of adrenergic, dopaminergic, histaminergic, and serotonergic receptors are not specifically associated with memory problems.

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24. A 6-year-old child shows seizures, cognitive defects, and autistic behavior. The child also shows raised discolored areas on her forehead (forehead plaques). Which of the following chromosomes is most likely to be involved in the etiology of this child's symptoms?

(A) 1

(B) 16

(D) 21

(E) X

The answer is B.

Chromosome 16 and chromosome 9 are both associated with tuberous sclerosis. Seizures, cognitive defects, autistic behavior, and forehead plaques in this 6-year-old child are signs of this disorder.

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25. A 72-year-old man with Alzheimer disease is being treated with memantine. What is believed to be the basis of the therapeutic action of memantine on neurons in the brain?

(A) To inhibit the action of acetylcholinesterase

(B) To block the influx of calcium

(D) To increase the influx of glutamate

(E) To facilitate the influx of calcium

The answer is B.

The therapeutic action of memantine is believed to be to decrease the influx of glutamate which ultimately blocks the influx of calcium which can lead to nerve cell degeneration and death. In contrast to a group of drugs also used to treat Alzheimer's, that is, the acetylcholinesterase inhibitors, memantine does not directly affect acetylcholine.

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1. A female patient who is hospitalized after making a suicide attempt because her doctor did not respond to her offer to friend him on Facebook states that all female doctors are good but all male doctors are incompetent. The best explanation for this statement by the patient is

(A) prejudice

(B) lack of basic trust

(D) splitting

(E) bias

The answer is D.

Dividing people or situations into categories of good and bad charac- terizes the defense mechanism of splitting. Splitting is commonly used by people with the borderline personality disorder (see Chapter 14).

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2. A physician becomes very angry with a patient when the patient does not take his medication. The patient reminds the doctor of her rebellious son. This physician's intense reaction to the patient's behavior is most likely to be a result of

(A) positive transference

(B) negative transference

(D) dislike of the patient

(E) fear of the patient

The answer is C.

The doctor who becomes very angry at her patient for not taking his medication is showing a countertransference reaction. This excessive show of emotion is a result of re-experiencing feelings about her son's behavior in her relationship with the noncompliant patient. It is important for the doctor to identify this reaction because it can interfere with her medical judgment (see also answer to the TBQ). This doctor's reaction to the patient is less likely to be related to dislike or fear of the patient.

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3. Which of the following structures of the mind work on an unconscious level?

(A) The id only

(B) The id and the ego only

(D) The ego and superego only

(E) Not the id, ego, or superego

The answer is C.

In Freud's structural theory, the mind is divided into the id, ego, and superego. The id operates completely on an unconscious level, while the ego and superego operate partly on an unconscious and partly on preconscious and conscious levels.

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4. Which of the following structures of the mind are at least partly developed in a typical 4-year-old child?

(A) The id only

(B) The id and the ego only

(D) The ego and superego only

(E) Not the id,ego,or superego

The answer is B.

The id is present at birth, the ego begins to develop immediately after birth, and the superego begins to develop at about age 6 years.

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5. A primary care physician notices that many of her patients use statements like "I can't stop smoking because I'll gain weight," or "when I'm sick, I only want to eat junk food." Statements like these

(A) produce conflict in the conscious mind

(B) are conscious mental techniques

(D) are examples of the use of defense mechanisms

(E) decrease a patient's sense of self-esteem

The answer is D.

Statements such as "I can't stop smoking because I'll gain weight," or "when I'm sick, I only want to eat junk food" are examples of the defense mechanisms of rationalization and regression, respectively. In rationalization, a person distorts her perception of an event so that its negative outcome seems reasonable, for example, because she feels unable to stop smoking, this patient claims (and so she reasonably feels) that gaining weight is worse than smoking, a life-threatening habit. In regression, ill patients revert to behavior patterns like those seen in someone of a younger age (e.g., eating junk food, crying). Defense mechanisms such as these are unconscious mental techniques that decrease anxiety and help people to maintain a sense of equilibrium and self-esteem.

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6. Of the following defense mechanisms, which is considered the most mature?

(A) Denial

(B) Sublimation

(D) Regression

(E) Intellectualization

The answer is B.

Sublimation, expressing an unacceptable emotion in a socially accept- able way, is classified as a mature defense mechanism. Denial, dissociation, regression, and intellectualization are all classified as less mature defense mechanisms.

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7. When having a manic episode, a 53-year- old patient with bipolar disorder shows primary process thinking. This type of thinking

(A) is logical

(B) is closely attuned to time

(D) is accessible to the conscious mind

(E) is associated with pleasure seeking

The answer is E.

Primary process thinking is associated with pleasure seeking, disregards logic and reality, has no concept of time, and is not accessible to the conscious mind.

Secondary process thinking is logical and is associated with reality.

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8. About 1 week after her final examination for a biochemistry course, a medical student's knowledge of the details of the Krebs cycle is most likely to reside in her

(A) unconscious mind

(B) preconscious mind

(D) superego

(E) ego

The answer is B.

Memory of the details of the Krebs cycle, while no longer in the fore- front of the medical student's mind, can be recalled relatively easily 1 week after the examination. This memory therefore resides in the preconscious mind. The uncon- scious mind contains repressed thoughts and feelings, which are not available to the conscious mind. The conscious mind contains thoughts that a person is currently aware of. The id contains instinctive sexual and aggressive drives and is not influenced by external reality. The ego also controls the expression of the id, sustains satisfying interpersonal relationships, and, through reality testing, maintains a sense of reality about the body and the external world

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9. A 15-year-old steals from family members and friends. When no one is watching, he also tortures the family cat. Which aspect of the mind is deficient in this teenager?

(A) The unconscious mind

(B) The preconscious mind

(D) The superego

(E) The ego

The answer is D.

The superego is associated with moral values and conscience, and controls impulses of the id. This teenager who steals from family members and friends and tortures the family cat is showing deficiencies in his superego. Children and ado- lescents under age 18 years, who have poor superego development, may be diagnosed with conduct disorder

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A 29-year-old man comes to the emergency department complaining of stomach cramps, agitation, severe muscle aches, and diarrhea. Physical examination reveals that the patient is sweating, has dilated pupils, a fever, and a runny nose, and shows goose bumps on his skin.

1. Of the following, the most likely cause of this picture is

(A) alcohol use

(B) alcohol withdrawal

(D) heroin withdrawal

(E) amphetamine withdrawal

The answer is D.

The most likely cause of this patient's symptoms of sweating, muscle aches, stomach cramps, diarrhea, fever, runny nose, goose bumps, yawning, and dilated pupils is heroin withdrawal.

While alcohol withdrawal may be associated with pupil dilation, alcohol use and withdrawal and amphetamine withdrawal are less likely to cause this constellation of symptoms.

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2. Of the following, the most effective immediate treatment for relief of this patient's symptoms is

(A) naloxone

(B) naltrexone

(D) a stimulant

(E) clonidine

The answer is E.

Of the choices given, the most effective immediate treatment for heroin withdrawal is clonidine to stabilize the autonomic nervous system.

Psychotic symptoms are uncommon in opioid withdrawal and this patient does not need an antipsychotic. Naloxone and naltrexone as well as stimulants will worsen rather than ameliorate the patient's withdrawal symptoms.

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3. Which of the following drugs is (are), by self-report, the most frequently used in the United States?

(A) Hallucinogens

(B) Inhalants

(D) Heroin

(E) Marijuana

The answer is E.

Almost 17 million Americans report that they use marijuana. In co trast, 1.6 million, 1.3 million, 0.6 million, and 0.2 million report that they use cocaine, hallucinogens, inhalants, and heroin, respectively.

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4. A physician is doing an employment physical on a 40-year-old male patient. The physician suspects that the patient has a problem with alcohol. The next step that the physician should take is to

(A) check his liver function

(B) ask him if he has a problem with alcohol

(D) ask him the CAGE questions

(E) check for the stigmata of alcoholism

(e.g., stria, broken blood vessels on the nose)

The answer is D.

The next step in management is for the physician to ask this patient the CAGE questions. Positive answers to any two of these questions or to the last one alone indicate that he has a problem with alcohol. Patients with such problems typically use denial as a defense mechanism and so rarely believe or admit that they have a problem with alcohol. Liver function problems or presence of the stigmata of alcoholism (e.g., stria, broken blood vessels on the nose) do not necessarily indicate the patient currently has a problem with alcohol. It is inappropriate for the doctor to call the previous employer for information.

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5. A 20-year-old female patient tells the doctor that she has little interest in going back to school or in getting a job. She also reports that she often craves snack food and has gained over 10 pounds in the past 4 months. What substance is this patient most likely to be using?

(A) Phencyclidine (PCP)

(B) Lysergic acid diethylamide (LSD)

(D) Cocaine

(E) Heroin

The answer is C.

The amotivational syndrome (e.g., lack of interest in getting a job or going to school) and increased appetite, particularly for snack foods, are characteristically seen in chronic users of marijuana.

Use of cocaine, heroin, phencyclidine (PCP), or lysergic acid diethylamide (LSD) may cause work-related problems, but are less likely to increase appetite.

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6. A 22-year-old student tells the doctor that he has been using "speed" nightly. Which of the following effects of the drug is the student most likely to experience when he is using?

(A) Increased fatigue

(B) Decreased pain threshold

(D) Decreased appetite

(E) Decreased libido

The answer is D.

Like other stimulant drugs, amphetamines like "speed" reduce appetite; use can thus result in decreased body weight.

Amphetamines also decrease fatigue, increase pain threshold, and increase libido.

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7. A patient has been using heroin for the past year. Which of the following is most likely to characterize this patient?

(A) Age 48 years

(B) Female gender

(D) Anxious mood when using the drug

(E) Elevated mood when using the drug

The answer is E.

Heroin users show an elevated, relaxed mood and somnolence. Users are most likely to be young adult males.

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8. A person who uses illegal drugs is most likely to be in which of the following age groups?

(A) 10-15 years

(B) 15-18 years

(D) 25-35 years

(E) 35-45 years

The answer is C.

Illegal drug use is most common in people 18-25 years of age.

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9. A 60-year-old man is brought to the hospital after a fall outside of a neighborhood bar. Radiologic studies indicate that the patient has a fractured hip and surgery is performed immediately. Two days later, the patient begins to show an intense hand tremor and tachycardia. He tells the doctor that he has been "shaky" ever since his admission and that the shakiness is getting worse. The patient states that while he feels frightened, he is comforted by the fact that the nurse is an old friend (he has never met the nurse before). He also reports that he has started to see spiders crawling on the walls and can feel them crawling on his arms. The doctor notes that the patient's speech seems to be drifting from one subject to another. Of the following, what is the most likely cause of this picture?

(A) Alcohol use

(B) Alcohol withdrawal

(D) Heroin withdrawal

(E) Amphetamine withdrawal

The answer is B.

The most likely cause of tremor, tachycardia, illusions (e.g., believing the nurse is an old friend), and visual and tactile hallucinations (e.g., formication—the feeling of insects crawling on the skin) in this patient is alcohol withdrawal, since the use of alcohol during the past few days of hospitalization is unlikely (see also the TBQ). His fractured hip may have been sustained in the fall while he was intoxicated.

Heroin use and heroin and amphetamine withdrawal generally are not associated with psychotic symptoms.

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10. A physician discovers that his 28-year- old female patient is abusing cocaine. Which of the following can the doctor expect to see in this patient?

(A) Severe physical signs of withdrawal

(B) Little psychological craving in withdrawal

(D) Delusions

(E) Sedation with use

The answer is D.

Delusions and other symptoms of psychosis are seen with the use of cocaine. The intense euphoria produced by cocaine lasts only about 1 hour.

Severe psychological craving for the drug peaks 2-4 days after the last dose, although there may be few physiologic signs of withdrawal.

Cocaine intoxication is characterized by agitation and irritability, not sedation.

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11. A 20-year-old man who has been drinking eight cups of coffee a day for the past week comes in for a physical examination. At this time, this man is most likely to show

(A) tachycardia

(B) decreased peristalsis

(D) fatigue

(E) headache

The answer is A.

Tachycardia, increased peristalsis, increased energy, and decreased appetite are physical effects of stimulants like caffeine. Headaches are more likely to result from withdrawal rather than use of stimulant drugs.

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12. A 40-year-old female patient who has been taking a benzodiazepine daily in moderate doses over the past 5 years abruptly stops taking the drug. When a physician sees her 2 days after her last dose, she is most likely to show

(A) hypersomnia

(B) tremor

(D) respiratory depression

(E) sedation

The answer is B.

Withdrawal from benzodiazepines is associated with tremor, insomnia, and anxiety. Respiratory depression and sedation are associated with the use of, not withdrawal from, sedative drugs.

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13. A 24-year-old patient is experiencing intense hunger as well as tiredness and headache. This patient is most likely to be withdrawing from which of the following substances?

(A) Alcohol

(B) Amphetamines

(D) Phencyclidine (PCP)

(E) Heroin

The answer is B.

Tiredness and headache are seen with withdrawal from stimulants. While increased appetite can be seen in withdrawal from all stimulants, the most intense hunger is seen with withdrawal from amphetamines.

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14. In the United States, the group in which smoking currently shows the largest increase is

(A) teenaged males

(B) middle-aged males

(D) middle-aged females

(E) elderly females

The answer is C.

In the United States, the group in which smoking currently shows the largest increase is teenaged females.

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15. What is the major mechanism of action of cocaine on neurotransmitter systems in the brain?

(A) Blocks reuptake of dopamine

(B) Blocks release of dopamine

(D) Blocks release of serotonin

(E) Blocks release of norepinephrine

The answer is A.

The major mechanism of action of cocaine on neural systems is to block the reuptake of dopamine, thereby increasing its availability in the synapse. Increased availability of dopamine is involved in the "reward" system of the brain and the euphoric effects of stimulants.

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16. After 20 years of smoking, a 45-year-old female patient has decided to quit. Of the following, what physical effect is most likely to be seen as a result of this patient's withdrawal from nicotine?

(A) Weight gain

(B) Euphoria

(D) Delirium tremens

(E) Long-term abstinence

The answer is A.

Weight gain commonly occurs following withdrawal from stimulants such as nicotine. Mild depression of mood and lethargy are also seen. Long-term abstinence is uncommon in smokers; most smokers who quit relapse within 2 years.

Delirium tremens occur with withdrawal from sedatives such as alcohol.

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17. A 43-year-old man with a 5-year history of HIV tells his physician that he has been smoking marijuana a few times a day to treat his symptoms of nausea and lack of appe- tite. To obtain the marijuana, the patient notes that he grows it in his backyard. The doctor's best response to this patient's revelation is

(A) "I am sorry but growing or using marijuana is illegal and I must notify the police"

(B) "I have read about other patients grow- ing marijuana"

(D) "There are a number of medications that I can prescribe to help alleviate your nausea and lack of appetite in place of marijuana"

(E) "Do you think that using marijuana has negative long-term effects?"

The answer is D.

The best response to this patient's revelation about growing and using marijuana is to recommend effective but safer substitutes, for example, pre- scription medications to treat his nausea and lack of appetite. It is neither appropriate nor necessary for a physician to report the patient's actions to the police.

Also, this HIV-positive patient is likely to be more concerned about feeling ill in the short-term than long-term consequences of marijuana use such as respiratory problems.

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18. A 35-year-old man is brought to the emergency department confused and anxious. The man reports that someone is trying to kill him but he does not know who the person is. Initial physical examination reveals elevated heart and respiration rates. While in the emergency room the patient has a seizure and then develops life-threatening cardiovascular symptoms. The drug that this patient is most likely to be withdrawing from is

(A) phencyclidine (PCP)

(B) lysergic acid diethylamide (LSD)

(D) secobarbital

(E) marijuana

The answer is D.

This 35-year-old patient is most likely to be withdrawing from secobarbital, a barbiturate.

Barbiturate withdrawal symptoms appear about 12-20 hours after the last dose and include anxiety, elevated heart and respiration rates, psychotic symptoms (e.g., the belief that someone is trying to kill him), confusion, and seizures, and can be associated with life-threatening cardiovascular symptoms.

There are few physical withdrawal symptoms associated with marijuana, phencyclidine (PCP), or lysergic acid diethylamide (LSD), and those associated with heroin are uncomfortable but rarely physically dangerous.

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19. A 32-year-old man is brought to a New York City hospital. He appears sedated, but shows an elevated mood. A blood test reveals the presence of HIV.

(A) Alcohol

(B) Secobarbital

(D) Methylphenidate

(E) Caffeine

(F) Diazepam

(G) Heroin

(H) Marijuana

(I) Nicotine

(J) Phencyclidine (PCP)

(K) Lysergic acid diethylamide (LSD)

The answer is G.

The presence of HIV as well as signs of sedation and euphoria indicate that this patient is an intravenous heroin user.

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20. A 25-year-old man is brought to the hospital after being involved in an automobile accident in which he was driving and the other driver was killed.

(A) Alcohol

(B) Secobarbital

(D) Methylphenidate

(E) Caffeine

(F) Diazepam

(G) Heroin

(H) Marijuana

(I) Nicotine

(J) Phencyclidine (PCP)

(K) Lysergic acid diethylamide (LSD)

The answer is A.

Alcohol use is commonly associated with automobile accidents.

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21. When a physician examines a 17-year- old high school student, she notes that he has erythema of the nose. During the interview, the student seems withdrawn and sad.

(A) Alcohol

(B) Secobarbital

(D) Methylphenidate

(E) Caffeine

(F) Diazepam

(G) Heroin

(H) Marijuana

(I) Nicotine

(J) Phencyclidine (PCP)

(K) Lysergic acid diethylamide (LSD)

The answer is C.

Erythema of the nose is a result of snorting cocaine, and depressed mood is seen in withdrawal from the drug.

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22. A 28-year-old man is hospitalized after trying to jump from the roof of one apart- ment building to another. His friends relate that prior to the jump, the man angrily threatened them because they would not jump with him.

(A) Alcohol

(B) Secobarbital

(D) Methylphenidate

(E) Caffeine

(F) Diazepam

(G) Heroin

(H) Marijuana

(I) Nicotine

(J) Phencyclidine (PCP)

(K) Lysergic acid diethylamide (LSD)

The answer is J.

Aggressiveness and psychotic behavior (jumping from one rooftop to another) indicate that this patient has used PCP.

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23. A 22-year-old woman is brought to the emergency room at 8 AM by her friend, who states that the woman has been acting strangely since the previous evening. While lying on the examining table the patient states that she feels like she is floating in the air and the sun is big and glaring above her.

(A) Alcohol

(B) Secobarbital

(D) Methylphenidate

(E) Caffeine

(F) Diazepam

(G) Heroin

(H) Marijuana

(I) Nicotine

(J) Phencyclidine (PCP)

(K) Lysergic acid diethylamide (LSD)

The answer is K.

This woman, who has been acting strangely over a number of hours and is experiencing out-of-body experiences (e.g., feelings of floating in the air) and illusions (e.g., mistaking the overhead light for the sun), has probably taken LSD.

The patient's lack of aggression or agitation indicates that the hallucinogen she has used is less likely to have been PCP.

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A 26-year-old medical student is brought to the emergency department by her husband. The husband tells the doctor that his wife has shown odd behavior ever since failing an exam 2 weeks ago. In particular, she tells him that people are trying to poison her. The woman has no prior psychiatric history, and physical examination and laboratory results are unremarkable.

1. What is the most appropriate diagnosis for this patient at this time?

(A) Schizophrenia

(B) Schizoaffective disorder

(D) Brief psychotic disorder

(E) Delusional disorder

(F) Shared psychotic disorder

(G) Psychosis due to a general medical

condition

The answer is D.

This patient is showing evidence of brief psychotic disorder. This disorder is characterized by psychotic symptoms lasting >1 day, but <1 month; she has had symptoms for the past 2 weeks.

Also, the stress of failing the exam is likely to be a precipitating psychosocial factor in this patient.

Schizoaffective disorder is characterized by symptoms of both a mood disorder and schizophrenia, as well as psychotic symptoms that occur even in the absence of mood symptoms, and lifelong social and occupational impairment.

In schizophrenia, psychotic and residual symptoms last 6 months, and there is lifelong social and occupational impairment.

Schizophreniform disorder is characterized by psychotic and residual symptoms lasting 1-6 months.

In delusional disorder, which often lasts for years, there is a fixed, non-bizarre delusional system; few, if any, other thought disorders; and relatively normal social and occupa- tional functioning.

In shared psychotic disorder, a person develops the same delusion as a person with delusional disorder with whom they are in a close relationship.

Psychosis due to a general medical condition involves psychotic symptoms occurring as a result of physical illness

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2. The patient's belief that people are trying to poison her is an example of

(A) an illusion

(B) a neologism

(D) a delusion

(E) an idea of reference

The answer is D.

Believing that you are being poisoned is a delusion, that is, a false belief.

A hallucination is a false perception;

an illusion is a misperception of real external stimuli;

an idea of reference is the false belief of being referred to by others;

and a neologism is a new, invented word.

All of these phenomena can be seen in patients exhibiting psychotic symptoms no matter what the cause.

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3. Analysis of neurotransmitter availability in the brain of this patient is most likely to reveal

(A) increased dopamine

(B) decreased dopamine

(D) decreased histamine

(E) decreased serotonin

The answer is A.

Analysis of neurotransmitter availability in the brain of this patient with a positive psychotic symptom (e.g., a delusion) is most likely to reveal increased levels of dopamine or serotonin.

Acetylcholine and histamine are not so closely involved in the pathophysiology of psychotic symptoms.

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4. A 27-year-old patient with schizophrenia shows extreme psychomotor agitation to the point of physical exhaustion. At times, he holds unusual, uncomfortable-looking body positions. This patient is most likely to have which of the following subtypes of schizophrenia?

(A) Catatonic

(B) Disorganized

(D) Residual

(E) Undifferentiated

The answer is A.

This patient who shows extreme psychomotor agitation and unusual uncomfortable-looking body positions is most likely to have catatonic schizophrenia.

Disorganized schizophrenia is characterized by disinhibition, poor grooming, poor personal appearance, and inappropriate emotional responses.

Paranoid schizophrenia is characterized by delusions of persecution;

undifferentiated schizophrenia has the characteristics of more than one subtype.

In residual schizophrenia, there is one previous psychotic episode and residual symptoms, but no current psychotic symptoms.

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A 36-year-old patient with schizophrenia tells the physician that the government has been listening in on all of his phone conversations for the past year.

5. This symptom indicates that the patient is most likely to have which of the following types of schizophrenia?

(A) Catatonic

(B) Disorganized

(D) Residual

(E) Undifferentiated

The answer is C.

This patient is most likely to have paranoid schizophrenia, which is characterized by delusions of persecution (see also answer to Question 4).

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A 36-year-old patient with schizophrenia tells the physician that the government has been listening in on all of his phone conversations for the past year.

6. The patient's false belief about the government is an example of a disorder of

(A) thought processes

(B) thought content

(D) perception

(E) affect

The answer is B.

This paranoid belief is a delusion, an example of a disorder of thought content.

An idea of reference is also an example of a disorder of thought content.

Illusions and hallucinations are disorders of perception, and loose associations and tangentiality are disorders of form of thought.

Problems with affect are more characteristic of the mood disorders but also are seen in schizoaffective disorder.

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7. Which of the following symptoms of schizophrenia is likely to respond best to antipsychotic medication?

(A) Delusions

(B) Flattening of affect

(D) Lack of motivation

(E) Social withdrawal

The answer is A.

When compared to negative symptoms (e.g., flattening of affect, poor speech content, lack of motivation, and social withdrawal), positive symptoms such as delusions respond better to antipsychotic medication.

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8. When compared to traditional antipsy- chotic medication, atypical antipsychotic medication is more likely to be helpful for which of the following symptoms?

(A) Hallucinations

(B) Delusions

(D) Over-talkativeness

(E) Social withdrawal

The answer is E.

Social withdrawal is a negative symptom of schizophrenia. Negative symptoms respond better to atypical antipsychotic medication than to traditional antipsychotics.

Hallucinations, delusions, agitation, and over-talkativeness are positive symptoms of schizophrenia.

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9. A 20-year-old woman tells the physician that sometimes she becomes frightened when her room is dark because her computer looks like a lion lurking in the corner. This is an example of

(A) an illusion

(B) a neologism

(D) a delusion

(E) an idea of reference

The answer is A.

An illusion is a misperception of a real external stimulus (e.g., a computer looking like a lion lurking in the corner in a darkened room).

A hallucination is a false sensory perception, and a delusion is a false belief not shared by others.

An idea of reference is the false belief of being referred to by others, and a neologism is a new word invented by a psychotic person.

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10. A 53-year-old hospitalized patient with schizophrenia tells the physician that a newscaster was talking about her when he said on television, "A woman was found shoplifting today." This patient's statement is an example of

(A) an illusion

(B) a neologism

(D) a delusion

(E) an idea of reference

The answer is E.

An idea of reference is the false belief of being referred to by others (e.g., a newscaster talking about the patient on television)

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11. A 35-year-old man who lives in a group home says that his roommates are spying on him by listening to him through the electrical outlets. For this reason, he has changed roommates a number of times over the last 5 years. He dresses strangely, is dirty with unkempt hair, and seems preoccupied. He reports that he has trouble paying attention to the doctor's questions because "I am listening to my leader giving me instructions in my head." Neuropsychological evaluation of this patient when he is not hearing voices is most likely to reveal

(A) memory impairment

(B) inability to state his name

(D) frontal lobe dysfunction

(E) lack of orientation to place

The answer is D.

This man, who dresses strangely, shows poor grooming, and has para- noid delusions and auditory hallucinations over a prolonged period, is most likely to have schizophrenia.

Neuropsychological evaluation of a patient with schizophrenia is most likely to reveal frontal lobe dysfunction. People with schizophrenia usually show intact memory; orientation to person, place, and time; and normal intelligence.

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12. A 20-year-old man reports that he just found out that his mother (whom he believed had died when he was a child) has been in an institution for the past 15 years with schizophrenia. He asks what the chances are that he will develop schizophrenia over the course of his life. The most correct answer is approximately

(A) 1%

(B) 5%

(D) 50%

(E) 80%

The answer is C.

The chance that the son (or other first-degree relative) of a person with schizophrenia will develop the disorder over the course of his life is approximately 10%.

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13. A patient reports that his 19-year-old identical twin brother has just been diagnosed with schizophrenia and wants to know what the likelihood is that he will develop this disorder. The most correct answer is approximately

(A) 1%

(B) 5%

(D) 50%

(E) 80%

The answer is D. The chance that the identical twin of a person with schizophrenia will develop the disorder over the course of his or her life is approximately 50%.

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14. The percentage of patients with schizophrenia who attempt suicide is approximately

(A) 1%

(B) 5%

(D) 50%

(E) 80%

The answer is D.

Approximately 50% of patients with schizophrenia attempt suicide at some point in their lives.

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15. Which of the following is most closely associated with a good prognosis in schizo- phrenia?

(A) Younger age of onset

(B) Catatonic symptoms

(D) Many relapses

(E) Mood symptoms

The answer is E.

Mood symptoms are associated with a good prognosis in schizophre- nia. A good prognosis is also associated with older age of onset, positive symptoms, and few relapses. Catatonic symptoms are associated with a poor prognosis.

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16. The most common type of hallucination seen in schizophrenia is

(A) visual

(B) gustatory

(D) olfactory

(E) hypnagogic

The answer is C.

Auditory hallucinations are the most common type of hallucinations seen in schizophrenia.

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17. A 45-year-old man with a 20-year history of severe depression and psychotic symp- toms has held different jobs, but none of them for more than 6 months. He is successfully treated for his severe depressive symp- toms, but he remains withdrawn and odd and expresses the belief that he has been "chosen" for a special mission on earth. What is the most appropriate diagnosis for this patient?

(A) Schizophrenia

(B) Schizoaffective disorder

(D) Brief psychotic disorder

(E) Delusional disorder

(F) Shared psychoticdisorder

(G) Psychosis due to a general medical

condition

The answer is B.

This patient is showing evidence of schizoaffective disorder. This disorder is characterized by symptoms of a mood disorder, as well as psychotic symptoms (the delusion that he has been "chosen") as well as and lifelong social and occupational impairment (see also answer to Question 1).

Schizoaffective disorder is distinguished from a mood disorder in that the psychotic symptoms persist in the absence of mood symptoms.

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18. A 68-year-old patient tells the physician that for the last 7 years his neighbor has been trying to get him evicted from his apartment by telling lies about him to the landlord. The patient is married and is working full time in a job, which he has held for over 30 years. What is the most appropriate diagnosis for this patient?

(A) Schizophrenia

(B) Schizoaffective disorder

(D) Brief psychotic disorder

(E) Delusional disorder

(F) Shared psychoticdisorder

(G) Psychosis due to a general medical

condition

The answer is E.

This patient is showing evidence of delusional disorder, persecutory type. In this disorder, there is a fixed, non-bizarre delusional system (paranoid in the persecutory type); few, if any, other thought disorders; and relatively normal social and occupational functioning (e.g., this patient is married and has held a job for over 30 years) (see also answer to Question 1).

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19. A 60-year-old woman whose husband believes (in the absence of any evidence) that their house is filled with radioactive dust worries about her ability to clear the house of the dust when he is hospitalized. What is the most appropriate diagnosis for this woman?

(A) Schizophrenia

(B) Schizoaffective disorder

(D) Brief psychotic disorder

(E) Delusional disorder

(F) Shared psychotic disorder

(G) Psychosis due to a general medical condition

The answer is F.

This patient is showing evidence of shared psychotic disorder. She has developed the same delusion that her husband has (i.e., their house is filled with radioactive dust).

If separated for a period of time from her husband (the inducer), her psychotic symptoms are likely to remit (see also answer to Question 1).

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20. In a 50-year-old patient with schizophrenia, the size of the cerebral ventricles, glucose utilization in the frontal lobes, and size of limbic structures are most likely to be, respectively

(A) increased, decreased, decreased

(B) increased, decreased, increased

(D) decreased, decreased, decreased

(E) decreased,increased,decreased

(F) decreased,increased,increased

The answer is A.

In patients with schizophrenia, the size of cerebral ventricles, glucose utilization in the frontal lobes, and size of limbic structures are most likely to be increased, decreased, and decreased, respectively.

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1. A 65-year-old woman, who was diagnosed with advanced lung cancer 3 months ago, has lost 18 pounds, wakes frequently during the night, and has very little energy. Over the past month she has been preoccupied with feelings of guilt about "people I have hurt in my life" and expresses concern that she will die in pain. The sign or symptom most likely to indicate that this patient is experiencing a major depressive episode rather than a nor- mal reaction to life-limiting illness is

(A) weight loss

(B) decreased energy

(D) preoccupation with feelings of guilt

(E) concern about dying pain

The answer is D.

The sign or symptom most likely to indicate that this patient is experiencing a major depressive episode rather than a normal reaction to serious illness is her preoccupation with feelings of guilt.

Such feelings are more characteristic of depression than sadness about being very ill. The other symptoms that the patient shows (e.g., weight loss, decreased energy, and sleep problems) are characteristic of patients with advanced cancer. Fear of dying in pain is realistic and commonly seen in patients with life-limiting illnesses.

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A 20-year-old male college student is taken to the emergency department by police because he tried to enter a state office building to "have a conference with the governor" about conducting a fund drive to "finance my cure for cancer." When police prevent him from entering the building, he becomes irritable and hostile and resists attempts to restrain him.

2. The most appropriate diagnosis for this patient is

(A) dysthymic disorder

(B) major depressive disorder

(D) hypochondriasis

(E) cyclothymic disorder

The answer is C.

This patient is most likely to have bipolar I disorder. While this disorder involves episodes of both mania and depression, a single episode of mania defines the illness. The beliefs that one is important enough to demand a conference with the governor and cure cancer are grandiose delusions. Schizophrenic delusions are commonly paranoid in nature. Irritability and hostility are also common in a manic episode.

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3. The most effective long-term management for this patient is

(A) a heterocyclic antidepressant

(B) lithium

(D) psychotherapy

(E) a monoamine oxidase inhibitor

The answer is B

Of the listed treatments, the one most effective for bipolar disorder is lithium. Heterocyclic antidepressants, electroconvulsive therapy, monoamine oxidase inhibitors, and psychotherapy are used primarily to manage depression. Antidepressants and psychotherapy are used to manage dysthymia

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4. This college student has two brothers. The first is his monozygotic twin; the second is 2 years younger. The risks that his first and second brothers will develop bipolar disorder are respectively about

(A) 75% and 60%

(B) 75% and 20%

(D) 50% and 10%

(E) 10% and 1%

The answer is B

The chances of the monozygotic twin and first-degree relative (e.g., brother) of this bipolar patient developing the disorder are about 75% and 20%, respectively.

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For the past few months, a 28-year-old woman has seemed full of energy and optimism for no obvious reason. Although she gets only about 6 hours of sleep a night, she has been very productive at work. She is talkative and gregarious and relates that she belongs to four clubs and two different sports teams. A few years previously, friends say she was often pessimistic and seemed tired and "washed out." During that period, she continued to work but did not seek out social activities and had little interest in sex. There is no evidence of a thought disorder and the patient denies suicidality or hopelessness. Physical examination including body weight is normal.

5. This patient shows evidence of

(A) dysthymic disorder

(B) major depressive disorder

(D) hypochondriasis

(E) cyclothymic disorder

The answer is E

This patient shows evidence of cyclothymic disorder. This disorder involves periods of both hypomania (energy and optimism) and dysthymia (pessimism and feeling "washed out") occurring over a 2-year period with no discrete episodes of illness.

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6. The most effective long-term management for this patient is

(A) a heterocyclic antidepressant

(B) lithium

(D) psychotherapy

(E) a monoamine oxidase inhibitor

The answer is B

Of the listed treatments, the one most effective for cyclothymic disor- der, as for bipolar disorder, is lithium. Heterocyclic antidepressants, electroconvulsive therapy, monoamine oxidase inhibitors, and psychotherapy are primarily used to manage depression. Antidepressants and psychotherapy are used to manage dysthymia.

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A 62-year-old woman whose husband died 6 months ago tells her physician that she believes killing herself would end her suffering. Physical examination is unremarkable.

7. Of the following signs and symptoms, which is most likely to be seen in this patient?

(A) Weight gain

(B) Flight of ideas

(D) Feeling better in the morning than in the evening

(E) Poor grooming

The answer is E.

This woman is showing evidence of major depression (note: Suicidality is not characteristic of a normal grief reaction). Depressed people typically show poor grooming. She is also more likely to show weight loss, and to feel better in the evening than in the morning. Auditory hallucinations are common in schizophrenia but uncommon in depression. Flight of ideas is characteristic of mania.

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A 62-year-old woman whose husband died 6 months ago tells her physician that she believes killing herself would end her suffering. Physical examination is unremarkable.

8. Analysis of neurotransmitter availability in the brain of this patient is most likely to reveal

(A) increased dopamine

(B) decreased histamine

(D) decreased acetylcholine

(E) decreased serotonin

The answer is E

Analysis of neurotransmitter availability in this patient is most likely to reveal decreased serotonin, commonly reflected in decreased plasma levels of its major metabolite 5-HIAA. Increased dopamine is seen in schizophrenia, and decreased ace- tylcholine is seen in Alzheimer disease.

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9. A 25-year-old male patient who is slow moving and has a flat affect is put on fluoxetine (Prozac). Within 2 weeks, the patient is showing greatly increased activity level, flight of ideas, and pressured speech. In this patient, the medication has

(A) precipitated a manic episode

(B) had a toxic effect

(D) increased anxiety

(E) increased depression

The answer is A.

In this depressed patient, the antidepressant fluoxetine has precipi- tated a manic episode (i.e., greatly increased activity level, flight of ideas, and pressured speech). This indicates that the patient has bipolar disorder rather than major depressive disorder. There is no evidence of increased depression, increased anxiety, or a delayed or toxic effect in this patient.

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10. A 35-year-old physician tells his internist that he has lost interest in playing in the hospital string quartet, an activity he formerly enjoyed. He reports that over the past 3 months he commonly wakes up a few hours before his alarm goes off and cannot fall back to sleep, and has lost 12 pounds without dieting. He states "maybe my family would be better off without me." He says that although he has lots of aches and pains and often feels tired, he feels somewhat better as the day progresses. Physical examination and laboratory studies are unremarkable. The most appropriate diagnosis for this patient is

(A) dysthymic disorder

(B) major depressive disorder

(D) hypochondriasis

(E) cyclothymicdisorder

(F) malingering

(G) bipolar disorder

The answer is B.

This patient is most likely to have major depressive disorder. Evidence for this is that, while there are no physical findings, he has lost interest in his usual activities, wakes up too early in the morning, has vague physical symptoms, shows diurnal variation in symptoms (worse in the morning), has lost a significant amount of weight, and is showing suicidal ideation (e.g., "maybe my family would be better off without me"). Also, his symptoms have been present for a discrete, identified amount of time.

Dysthymic disorder involves mild or moderate depression most of the time, occurring over a 2-year period with no discrete episodes of illness.

Bipolar disorder involves episodes of both mania and depression.

Cyclothymic disorder involves episodes of hypomania and dysthymia occurring over a 2-year period with no discrete episodes of illness.

In hypochondriasis, patients believe that normal body functions or minor illnesses are serious or life threatening.

People who are malingering fabricate symptoms for obvious gain (e.g., to win a lawsuit) (see Chapter 13).

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11. A 28-year-old man comes in complaining of headaches and a variety of other aches and pains that have been present for the past 6 months. He denies that he is sad or hopeless. After a 4-week trial of antidepressant medication, the patient's physical complaints have disappeared. The most appropriate diagnosis for this patient is

(A) dysthymic disorder

(B) major depressive disorder

(D) hypochondriasis

(E) cyclothymic disorder

(F) malingering

(G) bipolar disorder

The answer is C.

This patient's physical complaints (i.e., headaches and other aches and pains) were relieved by antidepressant medication. This indicates that these symp- toms were manifestations of masked (hidden) depression rather than hypochondriasis. There is no evidence in this patient of bipolar disorder, dysthymic disorder, cyclothymic disorder, or malingering (see also answer to Question 10).

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13. This man is at the lowest risk for suicide if he works as a

(A) messenger

(B) policeman

(D) lawyer

(E) dentist

The answer is A

Nonprofessionals are at a lower suicide risk than professionals. Among professionals, those at the highest risk for suicide are police officers, physicians, lawyers, and dentists

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14. If this patient tries to commit suicide, the method most likely to fail is

(A) shooting himself with a gun

(B) crashing his car

(D) jumping from a high place

(E) hanging himself

The answer is C.

The method of suicide most likely to fail is slashing the wrists or taking pills. Shooting, crashing a car, jumping from a high place, and hanging are more lethal methods of committing suicide.

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15. The percentage of depressed patients who seek treatment for their symptoms is about

(A) 1%

(B) 5%

(D) 50%

(E) 75%

The answer is C.

Only about 25% of depressed patients seek treatment, although man- agement (antidepressants, psychotherapy, electroconvulsive therapy) is effective in most depressed patients.

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16. A 15-year-old girl is brought to the emergency room after ingesting 20 acetaminophen tablets. She tells the physician that she tried to commit suicide because she was not admitted to an honors English class. The girl is the president of her grade in school and always tries to be perfect. The most important factor in whether this girl tries to kill herself again is

(A) that she is female

(B) the method of the suicide attempt

(D) that she tried to commit suicide once

(E) her need to be perfect

The answer is D.

This girl shows a number of risk factors for depression and attempted suicide, including female sex and her excessive need to be perfect. However, the most important factor in whether she tries to kill herself again is that she tried to commit suicide once. Taking pills such as aspirin or acetaminophen is less lethal than other methods, but young people such as this teenager may not know this. Thus, this girl has made a serious suicide attempt.

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17. When compared with a man, the chances that a woman will develop major depressive disorder, dysthymic disorder, or bipolar disorder over the course of her lifetime are, respectively

(A) higher, higher, equal

(B) higher, higher, lower

(D) higher, higher, higher

(E) equal, higher, equal

(F) equal, higher, lower

(G) equal, equal, equal

The answer is A.

When compared with a man, a woman is twice as likely to develop major depressive disorder, and three times as likely to develop dysthymic disorder. Bipolar disorder and cyclothymic disorder occur equally in men and women.

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18. A 30-year-old financial consultant tells her doctor that over the past 5 years she has felt "down" most of the time. She relates that when colleagues ask her to dinner or to a get-together she usually says "yes" but then rarely feels like going when the time comes and does not have a good time when she does go. There are no significant physical findings. While the patient denies suicidality, she notes that she never feels really excited or happy about anything. The best diagnosis for this patient at this time is

(A) major depressive disorder

(B) bipolar I disorder

(D) dysthymic disorder

(E) cyclothymic disorder

(F) substance-induced mood disorder

(G) mood disorder due to a general medical

condition

The answer is D.

This best diagnosis for this patient is dysthymic disorder. The patient has had a low mood for years, but although she is never really happy or excited about what should be pleasant experiences, because she is functional. For example, she is working and is not suicidal, it is less likely that she has major depressive disorder

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19. A 45-year-old man with bipolar disorder tells his doctor that he has remarried and would like to have a child with his new wife. He is concerned because the 19-year-old daughter that he had with his first wife has just been diagnosed with bipolar disorder. Neither of the patient's wives has bipolar disorder. What is the probability that this patient will have another child with bipolar disorder?

(A) 1%

(B) 10%

(D) 50%

(E) 70%

The answer is C.

The likelihood that this man with bipolar disorder will have a child with bipolar disorder is about 20%. The fact that his older child has bipolar disorder is not relevant to the chances that his next child will have the disorder

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A 23-year-old medical student comes to the emergency room with elevated heart rate, sweating, and shortness of breath. The student is convinced that she is having an asthma attack and that she will suffocate. The symptoms started suddenly during a car ride to school. The student has had episodes such as this on at least three previous occasions over the past 2 weeks and now is afraid to leave the house even to go to school. She has no history of asthma and, other than an increased pulse rate, physical findings are unremarkable.

1. Of the following, the most effective immediate treatment for this patient is

(A) an antidepressant

(B) a support group

(D) buspirone

(E) aβ-blocker

The answer is C

This patient is showing evidence of panic disorder with agoraphobia. Panic disorder is characterized by panic attacks, which include increased heart rate, dizziness, sweating, shortness of breath, and fainting, and the conviction that one is about to die. Attacks commonly occur twice weekly, last about 30 minutes, and are most common in young women, such as this patient.

This young woman has also developed a fear of leaving the house (agoraphobia) which occurs in some patients with panic disorder.

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A 23-year-old medical student comes to the emergency room with elevated heart rate, sweating, and shortness of breath. The student is convinced that she is having an asthma attack and that she will suffocate. The symptoms started suddenly during a car ride to school. The student has had episodes such as this on at least three previous occa- sions over the past 2 weeks and now is afraid to leave the house even to go to school. She has no history of asthma and, other than an increased pulse rate, physical findings are unremarkable.

2. Of the following, the most effective long-

term management for this patient is

(A) an antidepressant

(B) a support group

(D) buspirone

(E) aβ-blocker

The answer is A

While the most effective immediate treatment for this patient is a benzodiazepine because it works quickly, the most effective long-term (main- tenance) management is an antidepressant, particularly a selective serotonin reuptake inhibitor (SSRI) such as paroxetine (Paxil).

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A 23-year-old medical student comes to the emergency room with elevated heart rate, sweating, and shortness of breath. The student is convinced that she is having an asthma attack and that she will suffocate. The symptoms started suddenly during a car ride to school. The student has had episodes such as this on at least three previous occa- sions over the past 2 weeks and now is afraid to leave the house even to go to school. She has no history of asthma and, other than an increased pulse rate, physical findings are unremarkable.

3. The neural mechanism most closely involved in the etiology of this patient's symptoms is

(A) nucleus accumbens hyposensitivity

(B) ventral tegmental hypersensitivity

(D) locus ceruleus hypersensitivity

(E) peripheral autonomic hypersensitivity

The answer is D

The neural etiology most closely involved in panic disorder with agoraphobia is hypersensitivity of the locus ceruleus.

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4. A 35-year-old woman who was raped 5 years ago has recurrent vivid memories of the incident accompanied by intense anxiety. These memories frequently intrude during her daily activities, and nightmares about the event often wake her. Her symptoms intensified when a coworker was raped 2 months ago. Of the following, the most effective long-term management for this patient is

(A) an antidepressant

(B) a support group

(D) buspirone

(E) aβ-blocker

The answer is B.

This patient is most likely to have post-traumatic stress disorder (PTSD). This disorder, which is characterized by symptoms of anxiety and intrusive memories and nightmares of a life-threatening event such as rape, can last for many years in chronic form and may have been intensified in this patient by re-experiencing her own rape through the rape of her coworker. The most effective long-term management for this patient is a support group, in this case a rape survivor's group.

Pharmacologic treatment is useful as an adjunct to psychological management in PTSD.

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A 45-year-old woman says that she frequently feels "nervous" and often has an "upset stomach," which includes heartburn, indigestion, and diarrhea. She has had this problem since she was 25 years of age and notes that other family members also are "tense and nervous."

5. Which of the following additional signs or symptoms is this patient most likely to show?

(A) Flight of ideas

(B) Hallucinations

(D) Ideas of reference

(E) Neologisms

The answer is C.

This patient is most likely to have generalized anxiety disorder (GAD). This disorder, which includes chronic anxiety and, often, gastrointestinal symptoms is more common in women and often starts in the 20s. Genetic factors are seen in the observation that other family members have similar problems with anxiety.

Additional signs or symptoms of anxiety that this patient is likely to show include tingling in the extremities and numbness around the mouth, often resulting from hyperventilation.

Flight of ideas, hallucinations, ideas of reference, and neologisms are psychotic symptoms, which are not seen in the anxiety disorders or the somatoform disorders.