Rosh + UWorld Psych Quizlet

A 23-year-old woman gives birth to a child with spina bifida after being on an unknown medication during the first trimester of pregnancy. The medication was prescribed to treat a psychiatric condition marked by hypomanic and major depressive episodes. Which of the following medications is most likely to cause spina bifida in the fetus when used during pregnancy?

Carbamazepine

**Carbamazepine is associated with neural tube defects (spina bifida) and similar major malformations to those found with valproate use. However, the risk of neural tube defects is higher with exposure to valproate than carbamazepine.

A 27-year-old man presents to the emergency department in a coma after being found on the side of a street in a parked car. Vital signs are significant for a respiratory rate of 10 breaths per minute. You examine him and notice pinpoint pupils. A standard urine drug test is performed. Which of the following drugs is most likely to return a positive result for the drug class that is suspected to have caused this patient's presentation?

Morphine

**Decreased respiratory drive manifests as a decreased respiratory rate and decreased tidal volume, which can each contribute to hypoxemia and hypercarbia. Opioid overdose also causes miotic pupils and constipation.

A 24-year-old woman presents to her therapist to discuss her dietary habits. She reports that she intermittently consumes large amounts of food, such as two large pizzas or two dozen cookies, and subsequently feels guilty. Which of the following additional features is most suggestive of binge eating disorder?

Absence of compensatory behaviors

**Excessive exercise is an example of a compensatory behavior. This lack of compensatory behavior is what differentiates Binge eating disorder from Bulimia nervosa.

When giving Varenicline for smoking cessation, what population of patients should be cautioned when using this drug?

Patients with depressed mood or suicidal ideations

**Depressed mood is one of the potential side effects of varenicline. Some individuals who take varenicline have reported experiencing symptoms of depression or worsening of pre-existing depressive symptoms while using the medication

A 23-year-old woman presents to the emergency department for evaluation of new-onset psychosis. She is accompanied by a close friend who has been worried about her. Her friend reports that, for several months, there has been a change in the patient's behavior. The patient has been paranoid that someone has been following her and that someone can see her through her cell phone. The friend found the patient's phone in the garbage disposal. The friend was contacted by the patient's job after she had not shown up to work in several days. Today, the patient walked into oncoming traffic in the middle of a busy intersection. The patient said, "They told me to," and reports hearing commanding, unfamiliar voices. The patient reports no drug use or a family history of schizophrenia, but she does report a family history of major depression. She constantly looks over her shoulder during the exam but otherwise has a flat affect and demonstrates apathy. Which part of her history is a poor prognostic feature of the suspected condition?

Negative symptoms (flat affect, apathy)

**Negative symptoms tend to be resistant to treatment, which is why they are associated with a poorer prognosis.

A 25-year-old woman presents to the clinic with her husband due to concerns of difficulty sleeping and irritability. Her husband reports his main concern is that she has been calling out of work and has not been wanting to spend time with family because she is always tired. She reports that she recently stopped marijuana use due to being admitted into a master's program and reports occasional alcohol use. Which of the following is the appropriate treatment for this patient?

Dronabinol

**She is going through cannabis withdrawal. If she had mild symptoms that wasn't affecting her daily life then treatment wouldn't be necessary. However, since it is causing her to call out of work, causing difficulty sleeping and making her irritable, it is more preferred to treat with Dronabinol or Gabapentin. Zolpidem may also be used for her insomnia symptoms.

Indicated treatment for patients undergoing Cannabis withdrawal symptoms that are mild and not affecting their daily life

Relaxation techniques

**Meditation, physical exercise, and improved sleep hygiene are appropriate for patients who have mild cannabis withdrawal symptoms, meaning those whose symptoms do not affect their day-to-day function.

A 45-year-old woman presents to the clinic for her annual physical exam. You have seen the patient over the years and have met her husband multiple times. During the appointment, she discusses the sexual relationship she is having with Brad Pitt and tells you he recently proposed and they are engaged. On the patient's intake form, she wrote down her relationship status as married. When asked about her husband, she states "he is doing well and has no idea about Brad and me." Her physical exam and laboratory results are unremarkable, and the following week her husband comments he is concerned about his wife's claims to be engaged to Brad Pitt. What is the minimum length of time symptoms have to be present for the suspected diagnosis?

1 month

**This is delusional disorder erotomanic type

A 32-year-old man presents to the clinic with recurrent, episodic intense fear with symptoms of choking and dyspnea. He cannot identify a trigger to these episodes but states they resolve spontaneously after 10 to 15 minutes. Which of the following comorbidities is the most likely to be found in this patient?

Major depressive disorder

**Approximately 37% of patients with panic disorder also have a lifetime prevalence of major depressive disorder.

A 23-year-old man presents to the clinic with concerns that he is unable to form relationships with others. He notes that he wants to make friends with his co-workers, but he is always scared to attend social gatherings and happy hours after work. When you ask why the patient is hesitant to attend these events, he reports feeling like he may not be liked by others. Which of the following is the most appropriate intervention for this patient?

Cognitive behavioral therapy (CBT)

**The patient in the above vignette has avoidant personality disorder. These individuals want to develop a relationship with others but avoid them due to feeling inadequate, inferior, or having fear of rejection or humiliation.

A 23-year-old woman reports to the clinic with pain, swelling, and instability in her right knee. She states her symptoms arose while playing soccer 2 days ago when she felt a "pop" while cutting and had subsequent swelling. She reports severe anxiety when discussing first-line diagnostic testing. Which of the following is most appropriate?

Oral diazepam

**This is a MRI claustrophobia (specific phobia) for possible ACL tear -- Magnetic resonance imaging (MRI) claustrophobia is one of the most common procedural related specific phobias and is associated with the fear of suffocating during an MRI scan. Primary intervention for MRI claustrophobia involves adjusting the patient’s position within the scanner. If this is not feasible or does not resolve anxiety, a benzodiazepine (e.g., diazepam, lorazepam, alprazolam) is the first-line medication used for MRI claustrophobia.

A 25-year-old woman presents to a therapist due to persistent conflict in close relationships. She reports that one day it feels like her boyfriend is the love of her life, and the next day she wants to end their relationship. She also reports that she has had trouble maintaining a job because she will abruptly become upset with her boss and leave. She has attempted suicide twice in the past 6 months. Which of the following is the first-line treatment for the suspected personality disorder?

Dialectical behavior therapy

**Evidence-based psychotherapies are the primary treatment of borderline personality disorder. Dialectical behavior therapy and mentalization-based therapy are two therapies with evidence to support their use. Dialectical behavior therapy focuses on changing ineffective behaviors and improving coping skills, emotional regulation, and self-management.

A 32-year-old woman presents to the emergency department with mental status changes, including agitation and confusion. Her vital signs reveal tachycardia and hyperthermia. On a physical exam, the patient is flushed and dilated pupils are noted. She has hyperreflexia and an inducible clonus. Her medical history includes gastroparesis and generalized anxiety disorder for which she takes metoclopramide and sertraline. Which of the following is the most likely diagnosis?

Serotonin syndrome

**Symptoms include a wide spectrum of mental status changes, neuromuscular hyperactivity, and autonomic dysfunction. Mental status changes can include agitation, anxiety, and confusion. Neuromuscular hyperactivity includes hyperreflexia, tremor, muscle rigidity, myoclonus, and a bilateral positive Babinski sign. Autonomic dysfunction can manifest as diaphoresis, tachycardia, or hyperthermia. Physical examination may include increased heart rate, large fluctuations in pulse and blood pressure, dilated pupils, flushed skin, and muscle clonus.

A 45-year-old woman presents to the clinic due to insomnia. She has no trouble falling asleep but awakens in the middle of the night and cannot stay asleep. She has been practicing good sleep hygiene according to a prescribed cognitive behavioral approach for the past 6 months but continues to struggle maintaining sleep. Which of the following medications is most appropriate for this patient?

Doxepin

**The patient in the vignette has no difficulty falling asleep but has problems maintaining sleep. Medications that help maintain sleep include long-acting nonbenzodiazepine benzodiazepine receptor agonists, dual orexin receptor antagonists, and histamine receptor antagonists (low-dose doxepin). These medications can also be used for sleep initiation and mixed insomnia.

A 5-year-old boy presents to the clinic with his father who reports persistent behavioral issues since age 4 that have been recently worsening. The patient's father is concerned about daily temper tantrums and disobedient behavior at home, including arguing with his parents and deliberately annoying his siblings. He also reports teacher concerns about irritable mood and disregard for classroom rules on an almost daily basis. Which of the following interventions is most appropriate for this patient given the most likely diagnosis?

Assess psychosocial situation and parent training

**This is Oppositional Defiant Disorder (ODD). Treatment consists of parent training combined with outpatient psychological therapy. It is important to evaluate the child’s psychosocial environment and also provide proper support to parents, as they may experience adverse mental health effects due to the difficult behavior and social disruption. Parent training is the most important aspect of treatment as it teaches parents to be more positive and less harsh in their discipline style.

A 53-year-old man with a history of schizophrenia was recently transitioned to a new antipsychotic drug after becoming refractory to several other antipsychotics. At his follow-up visit, he has gained 10 pounds. Which antipsychotic most commonly causes weight gain?

Olanzapine

**While second-generation antipsychotics have fewer EPS, they may lead to weight gain, causing metabolic syndrome, cardiac side effects (including QTc prolongation), hyperprolactinemia, or drowsiness. Weight gain can be a common side effect seen with the use of olanzapine. When a patient is on olanzapine, food intake, hyperglycemia, and hyperlipidemia should be monitored by obtaining fasting blood glucose and lipids every 3–6 months and obtaining a weight at each visit.

A 30-year-old woman who is obese and has chronic hepatitis C presents to the clinic with episodes of deep depression followed by weeks of expansive mood, flight of ideas, risk-seeking behavior, and insomnia. Which of the following would need to be monitored frequently if the patient is started on the most appropriate therapy?

Thyroid function tests

**She is on Lithium therefore you need to continue to check TSH levels. Lithium has a narrow therapeutic index, and serum lithium levels should be monitored regularly along with thyroid function, electrolytes, kidney function, and electrocardiography.

A 26-year-old man is sexually aroused by exposing his genitals to nearby drivers while in traffic. Which of the following paraphilic disorders is the most likely diagnosis?

Exhibitionistic disorder

**Exhibitionistic disorder is a paraphilic disorder characterized by an individual becoming aroused from exposing their genitals to an unsuspecting person. Individuals with exhibitionistic disorder frequently masturbate during or after the exposure.

A 22-year-old man presents with "hearing voices." He has had progressively worsening symptoms over the last 7 months. He has heard voices saying negative statements that seem to come from inside of his head. He has also had a belief that his neighbors are trying to poison him and have planted cameras and listening devices inside his house. When speaking about these symptoms, he becomes distracted easily and gets off topic quickly. He is also speaking quickly and is very talkative. He notes he has not slept in 2 days but does not feel tired. He reports no substance use or use of other medications. What is the most likely diagnosis?

Schizoaffective disorder

**Schizoaffective disorder is distinguished from schizophrenia by the presence of manic episodes or a significant depressive episode in addition to the symptoms normally considered for Schizophrenia.

--> "He is also speaking quickly and is very talkative." and "He notes he has not slept in 2 days but does not feel tired." are the examples of manic episodes from the vignette.

A 45-year-old man with a history of chronic alcohol use presents to the emergency department with confusion. You are concerned for a condition caused by thiamine deficiency. Which of the following is the classic triad associated with this condition?

Encephalopathy, oculomotor dysfunction, and gait ataxia

**Wernicke Encephalopathy

A 52-year-old woman with a known diagnosis of chronic glaucoma and schizophrenia presents with a resting tremor, cogwheel rigidity, and bradykinesia. Which of the following therapeutics would be most effective in treating these symptoms?

Amantadine

**Parkisonian syndrome is characterized by cogwheel rigidity, mask-like facies, shuffling gait, resting tremor, and bradykinesia. Amantadine is a nonanticholinergic antiparkinsonian medication that may be used to treat parkinsonian extrapyramidal side effects caused by antipsychotic medications. Anticholinergic medications, such as benztropine, are also used but present an increased risk in patients with glaucoma or cognitive impairment.

A 52-year-old man presents to the clinic for a wellness exam. Which of the following is the most appropriate frequency for screening this patient for unhealthy alcohol use?

12 months

**The United States Preventive Services Task Force recommends all adults in primary care who have services available for follow-up should be screened annually to identify unhealthy alcohol use.

An 18-year-old woman with no prior psychiatric history presents to the emergency department by ambulance after having a witnessed seizure at home. The patient's height is 5 foot 8 inches and weight is 105 pounds (BMI 16 kg/m2). Physical exam reveals lanugo on bilateral upper extremities, brittle nails, and cyanosis of the hands and feet. Laboratory workup reveals hyponatremia with hypokalemic alkalosis. In addition to seizures, which of the following complications is consistent with the suspected diagnosis?

Osteoporosis

**Patients with anorexia nervosa can experience profound bone loss due to malnutrition causing increased resorption and decreased formation of bone and are therefore at increased risk of developing osteoporosis

A 45-year-old man presents to therapy for unusual sexual behavior. He reports being sexually aroused by using binoculars to watch women who live in the complex across the street from him undress. He has been doing this for 12 months. Which of the following paraphilic disorders does this patient most likely have?

Voyeuristic disorder

**Voyeuristic disorder is a paraphilic disorder characterized by sexual arousal from observing an unsuspecting nude or undressing person. Paraphilic disorders require engagement in unusual sexual activities or preoccupation with unusual sexual urges for at least 6 months

Which of the following patients would be most likely to present with generalized anxiety disorder?

A. 16 year-old boy

B. 21 year-old woman

C. 35 year-old man

D. 45 year-old woman

21 year-old woman

**Generalized anxiety disorder is more common in women than men but is most likely to present in younger women.

A 24-year-old man presents to the clinic with depressed mood, feelings of worthlessness, extreme guilt, difficulty concentrating, decreased sleep, decreased appetite, and lack of interest in any activity. These symptoms have been present for more than 1 month and are worsening in severity. The patient states that recently he has felt that life is not worth living. Which of the following is an indication for hospitalization?

Inability to discuss safety planning

A 37-year-old man presents to the office with concerns of increasing stress and "difficulty controlling urges." He notes for the past few years he has found himself sexually aroused by young children. This has manifested through sexual fantasies. He reports he has not acted on these fantasies (he has not watched child pornography or sexually abused a prepubescent child), but he is finding his fantasies are becoming more intense and more difficult to control, and they are causing him significant distress. He recently contacted a young boy over the internet. The patient requests pharmacologic therapy that can reduce the frequency of his fantasies and his sex drive. What should be recommended at this time?

Leuprolide acetate

**Hormonal therapy, such as leuprolide acetate, has been effective in the treatment of pedophilic disorder. Pedophilic disorder is a type of paraphilia, referring to a sexual behavior that deviates from culturally normal sexual interests and behaviors

A 21-year-old man presents to the clinic with his father for a routine follow-up. His father notes he has improved significantly over the past few months. He states the patient is no longer worried that the FBI has hacked his computer and cell phone. The patient reports he is no longer hearing voices, and he has been making efforts to attend social gatherings on the weekend. The patient has been stable and treated with clozapine. Which of the following lab panels should be monitored for this patient?

Complete blood count (CBC)

**Treatment with clozapine has an increased risk for agranulocytosis, in which case a complete blood count must be checked on a weekly basis.

A 25-year-old woman who is 5 weeks postpartum and breastfeeding presents to the clinic with decreased interest in activities that are usually pleasurable for the past 3 weeks. She also reports excessive feelings of guilt, decreased concentration, dysphoria, and fatigue. You offer to refer the patient for psychotherapy, and she declines. She has no prior history of psychiatric conditions. Which of the following is the most appropriate pharmacologic treatment for the suspected diagnosis?

Sertraline

**The preferred first-line pharmacologic treatment is selective serotonin reuptake inhibitors, specifically sertraline or paroxetine. Studies show these two agents are typically undetectable in the serum of breastfed infants whose mothers are taking them. Escitalopram, fluoxetine, and fluvoxamine are less studied in lactating women, thus sertraline and paroxetine are preferred.

A 19-year-old girl presents to the clinic for an annual physical. She states she runs at least 45 miles per week to maintain her figure. The patient has no significant medical history and has been amenorrheic for 6 months. Physical examination reveals a thin patient with peripheral edema and fine, downy hair on her face and arms. Vital signs include body mass index of 16.52 kg/m2, HR of 52 bpm, RR of 17 breaths per minute, BP of 98/52 mm Hg, T of 97.2°F, and SpO2 of 97% on room air. Which of the following is the best diagnosis?

Moderate anorexia nervosa

**The severity of anorexia nervosa is classified by body mass index, with a value ≥ 17 kg/m2 indicating mild disease, values between 16 and 16.99 kg/m2 representing moderate disease, and a body mass index of 15–15.99 kg/m2 defined as severe disease. Extreme anorexia nervosa is diagnosed in patients with a body mass index < 15 kg/m2

BMI:

>17 = Mild

16-16.99 = Moderate

15-15.99 = Severe

< 15 = Extreme

A 23-year-old woman with schizophrenia presents to the clinic for follow-up after beginning risperidone 5 months ago. The patient reports decreased symptoms after starting risperidone, but she has not menstruated for 3 months and has noticed an increased frequency of headaches. Which of the following medications is most appropriate for continued treatment?

Aripiprazole

**Risperidone, a frequently administered second-generation antipsychotic, may also cause hyperprolactinemia leading to hypogonadism (e.g., oligomenorrhea, amenorrhea, galactorrhea, decreased bone mineral density). Patients with these manifestations should be switched to alternative antipsychotic medications with a lower probability of prolactin elevation, such as aripiprazole.

A 35-year-old woman presents due to depressed mood. She states she has felt depressed for 3 years, feels the need to sleep all the time, has poor concentration at work, and feels hopeless her symptoms will ever get better. She has tried cognitive behavioral therapy and several antidepressants at times without significant relief. Which of the following is the most likely diagnosis?

Persistent depressive disorder (Dysthymia)

A 23-year-old woman with an unknown medical history presents to the emergency department via ambulance with altered mental status. The patient's partner reports finding her unconscious at home with an empty bottle of alprazolam nearby. Exam reveals a somnolent patient with slurred speech. Current vital signs are temperature 98.2°F, BP 98/65 mm Hg, HR 52 beats per minute, RR 10 breaths per minute, and oxygen saturation 92% on room air. You and your team suspect benzodiazepine overdose and are considering administering a medication to reverse the effects of the benzodiazepine. Which of the following most accurately describes the method of action of this medication?

Antagonist of the GABA receptor

**Flumazenil is a nonspecific competitive antagonist of the benzodiazepine receptor on the GABA/benzodiazepine receptor complex that can be used to treat benzodiazepine-induced sedation following anesthesia or overdose

A 35-year-old man with a history of previously diagnosed schizophrenia presents to the office with worsening symptoms of his mental illness. He tells you last year he was sent to an inpatient drug treatment facility and has been sober since then. Which of the following antipsychotic medications should be avoided due to the potential for misuse and side effects of sedation?

A. Clozapine

B. Olanzapine

C. Quetiapine

D. Risperidone

Quetiapine

**Quetiapine has been found to have higher rates of misuse than the other second-generation antipsychotics and is known to cause sedation (drowsiness). Use of quetiapine should be avoided in patients with schizophrenia who have a history of substance use.

A 25-year-old man presents to his therapist to discuss his difficulty maintaining romantic relationships. He reports that he is sexually aroused by his partners' toes, which has ended several of his past relationships. Which of the following is another common focus of sexual arousal in the suspected condition?

A. Bracelets

B. Ears

C. Eyes

D. Hair

Hair

**The nonliving object or nongenital body part that leads to the sexual arousal is called the fetish. Common fetishes include women’s underpants, bras, shoes, feet, toes, and hair. Fetishistic disorder can manifest with fantasies, urges, or behaviors about the fetish. It is more common in men.

A 35-year-old woman presents with hearing loss and tinnitus that she says are secondary to working in a loud environment without the proper hearing protection. She is currently involved in a lawsuit against her former employer. An audiogram is performed and shows inconsistent results. An otoacoustic emissions test and an electronystagmography are performed and are within reference range. What is the most likely diagnosis?

Malingering

A 25-year-old man presents, stating his boss told him to be evaluated because he is obsessed with perfectionism. Which of the following historical elements would be present in a patient with obsessive-compulsive personality disorder versus obsessive-compulsive disorder?

Conflicts with his family about excessive perfectionism

**Patients who have obsessive-compulsive personality disorder fulfill the diagnostic criteria as stated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and are obsessed with perfectionism, control, and ritualistic behaviors that interfere with the ability to perform everyday tasks or form friendships. Unlike patients with obsessive-compulsive disorder, patients with the personality disorder are not distressed over their behaviors

A 24-year-old man is found unconscious on a sidewalk and presents to the emergency department via ambulance. Vital signs include an HR of 55 bpm, BP of 100/68 mm Hg, RR of 8 breaths/minute, T of 98.6°F, and oxygen saturation of 90% on room air. Physical examination reveals a comatose man with miotic pupils and no signs of external trauma. His point-of-care glucose is 75 mg/dL. After supplemental oxygen administration, which of the following is the recommended treatment?

Naloxone (Narcan)

**Opioid intoxication is marked by decreased mental status and respiratory drive following exposure to opioids. It is important to determine the drug and dose of exposure (when possible), the presence of co-exposures, and the individual’s history of opioid use.

A 20-year-old woman presents to the clinic due to feeling cold and having irregular menses, stating that her last menstrual cycle was over 6 months ago. Her body mass index is 17 kg/m2, and her urine pregnancy test is negative. She states she exercises every day for at least 2 hours because she is overweight and is terrified of gaining weight. Which of the following physical exam findings is most consistent with the diagnosis?

A. Bradycardia

B. Eroded teeth enamel

C. Hypertension

D. Oily skin

Bradycardia

**Eroded teeth enamel (B) is more likely to be present in bulimia nervosa than anorexia nervosa. Hypotension, not hypertension (C), would normally be seen in anorexia nervosa. Oily skin (D) is not seen in anorexia nervosa, rather dry skin or xerosis is seen due to dehydration.

According to the National Institute on Alcohol Abuse and Alcoholism, which of the following would classify a male patient under the age of 65 years to have an increased health risk due to his alcohol consumption?

Drinking more than 14 standard drinks per week

**They note that men under the age of 65 years old are at increased health risks if they consume more than 14 standard drinks in a given week or more than 4 standard drinks in a single day. Women under the age of 65 years old are noted to be at increased risk if they consume more than 7 standard drinks per week or more than 3 standard drinks in a single day.

A 45-year-old man presents due to feeling depressed for the last several weeks. He reports he feels very depressed and fatigued, has lost interest in his hobbies, never feels like he gets enough sleep, and has not been able to concentrate at work over the last 3 weeks. You note in the patient's history that he has a history of erectile dysfunction and takes sildenafil as needed. Which of the following medications is the most appropriate treatment for this patient?

Bupropion

**Bupropion is used when patients want to avoid sexual dysfunction or have concomitant tobacco use. Trazodone may be used for patients who also have insomnia, as it has somnolence as a side effect. Mirtazapine is avoided in patients who are concerned about weight gain. All medications should be started at a low dose and then titrated to the therapeutic range to minimize side effects and increase adherence.

A 22-year-old man presents to the clinic complaining of sweating, tremors, and nausea. He states he feels this way if he goes 1 day without drinking alcohol. He has been drinking about six beers per day and more on the weekends for the past 2 years. Which of the following signs and symptoms is consistent with a diagnosis of mild alcohol withdrawal?

A. Delirium tremens

B. Hallucinations

C. Insomnia

D. Sinus bradycardia

Insomnia

**Mild symptoms include tachycardia, diaphoresis, tremors, nausea, vomiting, anxiety, mild agitation, insomnia, alcohol craving, and headache. Moderate to severe symptoms include hallucinations, delirium tremens, and seizures, which may be fatal. Delirium tremens manifests as severe agitation, hypertension, tachycardia, fever, drenching sweats, and hallucinations. Delirium tremens occurs 72 to 96 hours after a patient’s last drink and is more common with increasing age, comorbid disease, and misuse of other central nervous system depressants.

A 64-year-old man presents to the clinic with severe depression that is refractory to treatment. Which of the following is considered a contraindication to the most efficacious treatment of severe unipolar depression?

Brain tumor with elevated ICP

**Electroconvulsive therapy consists of inducing seizures in patients to treat refractory psychiatric conditions. One example of an absolute contraindication is a patient with a brain tumor with associated increased intracranial pressure. This condition is a contraindication because electroconvulsive therapy causes increased cerebral blood flow, which can result in neurologic deterioration. Patients with a brain tumor who do not have increased intracranial pressure can undergo electroconvulsive therapy.

A 28-year-old woman presents with a pervasive behavior pattern that includes cognitive-perceptual problems and interpersonal dysfunction. Among her symptoms is the belief she can see auras around others and she can read minds. Which of the following additional symptoms is most likely associated with the diagnosis?

A. Auditory hallucinations

B. Ideas of reference

C. Impulsivity

D. Tangential speech

Ideas of reference

**Schizotypal disorder is characterized by a long-standing and pervasive behavior pattern that includes cognitive-perceptual problems and interpersonal dysfunction associated with significant disability. It is a rare psychiatric disturbance that often co-occurs with borderline personality disorder, bipolar disorder, or panic disorder with agoraphobia. Clinical manifestations include three subgroups: cognitive-perceptual, oddness or disorganized, and interpersonal. The cognitive-perceptual symptoms are chronic distortions that include odd beliefs, unusual perceptual experiences, ideas of reference, and paranoia. Odd beliefs or magical thinking may include mind reading or thought transfer

A 28-year-old woman presents to the clinic reporting ongoing intermittent abdominal pain, fatigue, and back pain for the past 7 months. The patient notes she has been evaluated in the emergency department multiple times and has seen other health care clinicians, none of whom have found a cause of her pain. She is constantly worried about her symptoms. On physical exam, the patient appears anxious. Otherwise, there are no significant findings. Labs and imaging results that she had completed recently are all within normal range. Which of the following is the most appropriate initial treatment for this patient?

Regularly scheduled visits in the office

**The patient in the above vignette has somatic symptom disorder, which is when an individual has one or more somatic symptoms that are not explained by a physical or medical condition. These symptoms cause significant distress or dysfunction on a day-to-day basis. It is important to suspect this disorder when a patient presents with vague symptoms and an inconsistent history.

A 10-year-old boy presents to the clinic for evaluation after his teacher voiced concerns about his behavior in school. She reports the patient has difficulty remaining seated during class, talks excessively, interrupts others, and blurts out answers too quickly. His parents state that, since he was 4 years old, the patient gets angry when waiting for his turn and enjoys boisterous play. His family voices concerns about the first-line medication and would like to try an alternative agent. Which of the following side effects is most likely with this alternative medication?

Nausea

**The alternative treatment for ADHD in kids outside of stimulants like Methylphenidate is Atomoxetine. Stimulants are first-line agents used to treat this condition in children, and common agents include methylphenidate, dexmethylphenidate, dextroamphetamine, and amphetamine-dextroamphetamine. Atomoxetine is the primary alternative nonstimulant medication if a patient or their family prefers this course of pharmaceutical intervention. Side effects for this agent include nausea, vomiting, weight loss, sleep problems, hepatotoxicity, xerostomia, insomnia, drowsiness, hyperhidrosis, erectile dysfunction, priapism, and psychosis with aggressive behavior. Additionally, cardiovascular effects include QT prolongation, hypertension, tachycardia, and cardiovascular collapse.

A 6-year-old boy presents to the clinic for evaluation of a conduct disorder. His mother states he has been irritable and angry several days a week for the past year. When he is irritable, he defies her and his teachers, argues with everyone, and deliberately annoys his siblings. His grades are poor, and his friendships are few due to his anger and defiance. At least once per month, he acts vindictively toward his mother but has never harmed a person or animal. Which of the following environmental elements is more common in patients with this boy's most likely disorder?

A. Maternal aggression

B. Overprotective parenting

C. Paternal absence

D. Rigid structure in the home

Maternal aggression

**These environmental factors include insecure attachment, unresponsive parents, maternal aggression, abuse, community violence, harsh punishment, parental psychopathology, inconsistent discipline, poverty, and peer rejection. Treatment of oppositional defiant disorder includes teaching the child problem-solving skills, behavioral parenting interventions for parents and caregivers, and group cognitive behavioral therapy.

A 30-year-old man with no comorbidities and who takes no medications presents to the clinic with tachycardia that occurs while speaking to large crowds. This has not been a problem in the past, but he has recently been promoted and must address many coworkers on a weekly basis. When he gives his presentations, he sweats profusely, trembles, and feels as if his heart is beating out of his chest. Which of the following is the most appropriate therapy for this man's clinical disorder?

Propranolol

**Social anxiety disorder is characterized by feelings of anxiety in social settings and often leads to avoidance of social gatherings. These patients may only require treatment on an as-needed basis. Such treatment can include benzodiazepines, such as clonazepam or lorazepam, or beta-blockers, such as propranolol.

A 24-year-old man presents to the psychiatry clinic with his wife for follow-up. He was brought to the emergency department 3 months ago after the police found him blocking traffic on the highway and telling drivers that the apocalypse was coming. At that time, he says he could hear voices telling him to save the world. His wife reports that these behaviors began abruptly 3 months ago after his father died, and he was subsequently treated in a psychiatric hospital, where his symptoms improved. However, he has been withdrawn with a flat affect since then and has not been able to function well enough to find a job. The patient had a negative medical workup near the onset of symptoms, and it included a negative drug test result. He reports no depressed mood. Which of the following is the most likely diagnosis?

Schizophreniform disorder

During a sleep study, electroencephalography indicates low voltage, sawtooth waves while electromyography indicates atonia. Electro-oculography indicates conjugate, irregular, sharply peaked eye movements. Which of the following is most accurate of this stage of sleep?

Associated with vivid dreaming

**Sleep can be divided into nonrapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. Sleep in the REM stage is characterized by low voltage, mixed EEG patterns with sawtooth waves; rapid eye movements, including conjugate, irregular, and sharply-peaked movements; and atonia as demonstrated on EMG.

A 43-year-old man presents with anhedonia, insomnia, weight loss, intense fatigue, and feelings of worthlessness for the past 3 weeks. In addition to psychotherapy, you decide to prescribe the most suitable atypical antidepressant based on his symptoms. Which of the following side effects for this medication should you educate the patient about?

A. Diarrhea

B. Drowsiness

C. Orthostatic hypotension

D. Psychomotor agitation

Drowsiness

**The Atypical antidepressants are Mirtazapine, Bupropion, Agomelatine. Bupropion may cause insomnia or psychomotor agitation, while mirtazapine is most likely to result in drowsiness and weight gain.

A 23-year-old woman presents to the clinic due to anxiety attacks. During these attacks, her heart races, she sweats and feels like she is going to die, and she gets tightness in her chest, nausea, and dizziness. Several visits to the emergency department in the past have determined no physical cause for these symptoms. The attacks started 1 year ago and have occurred only three or four times since then, but to avoid another attack, the patient now stays at home nearly all day, every day and is unable to work. Which of the following is the most effective nonpharmacologic clinical intervention for this patient?

CBT

A 22-year-old man presents to the emergency department due to headache, myalgia, and chest pain. He is agitated, appears angry, and is difficult to restrain. Vital signs indicate blood pressure 180/100 mm Hg, pulse 130 beats per minute, and temperature 100.1°F. Physical exam reveals mydriasis, diaphoresis, and diffuse muscular tenderness to palpation. Which of the following is most likely found on this patient's urine toxicology screening?

A. Cocaine

B. Lysergic acid diethylamide

C. Marijuana

D. Opiates

Cocaine

**Signs and symptoms of acute cocaine intoxication include hypertension, tachycardia, agitation, headache, hyperthermia, rhabdomyolysis, intracerebral hemorrhage, gastric ulcers, splenic or renal infarct, mydriasis, and diaphoresis. Treatment of acute cocaine intoxication begins with stabilization of the airway and circulation. Lowering blood pressure can be accomplished with nitroprusside, nitroglycerin, or phentolamine. Beta-blocking agents should be avoided in acute cocaine intoxication to prevent unmitigated alpha-adrenergic stimulation. Diazepam is given in acute cocaine intoxication for treatment of psychomotor agitation. Immersion in ice may be necessary for severe hyperthermia.

A 5-year-old boy presents to the pediatric clinic with his parents who are concerned about episodes that occur during his sleep. They describe the episodes as the patient waking up with a loud scream, facial flushing, and sweating. The episodes usually occur during the first 3 hours of nocturnal sleep. The patient is difficult to console during these episodes and does not remember them the next day. Which of the following is the most likely diagnosis?

Sleep terrors

**Sleep terrors (night terrors) are a parasomnia seen during childhood. They occur most often between 4 and 12 years of age. During a sleep terror episode, children typically awake abruptly from sleep with a loud scream and have associated facial flushing, sweating, and tachycardia. It is often difficult for parents to console children during these episodes. Sleep terrors occur most often during the first one-third of nocturnal sleep, and children typically do not remember them in the morning.

A 31-year-old woman presents to the emergency department after ingesting a full bottle of sertraline 100 mg tablets. Her pulse is 120 beats per minute, blood pressure is 160/100 mm Hg, and temperature is 104.1°F. On exam, she has ocular clonus, hyperreflexia, agitation, dilated pupils, and diaphoresis. Which of the following represents the best first-line therapy for this patient?

Lorazepam 2 mg IV every 4 hours

**Initial treatment of serotonin syndrome is with intravenous benzodiazepines, such as lorazepam 2 mg. This treatment will decrease muscle spasms, neurologic hyperstimulation, and hyperpyrexia. Patients should also be treated with supplemental oxygen and should discontinue all serotonergic agents.

A 26-year-old man presents to the clinic with excessive worrying for the past 6 months. He reports that he worries about career advancement, finding a spouse, and gaining weight. These concerns lead to him having poor sleep, fatigue, and muscle tension in his neck. You decide to start him on a first-line antidepressant for the suspected condition, but you also want to start him on an agent that prevents agitation during initial treatment with an antidepressant. The patient has no history of substance misuse. Which of the following medication combinations is most appropriate?

A. Amitriptyline and clonazepam

B. Duloxetine and lorazepam

C. Duloxetine and pregabalin

D. Sertraline and hydroxyzine

Duloxetine and lorazepam

**The recommended pharmacotherapy is either a selective serotonin reuptake inhibitor, such as sertraline and fluoxetine, or a serotonin and norepinephrine reuptake inhibitor, such as duloxetine or venlafaxine. The most common role for a benzodiazepine, such as lorazepam, in the treatment of generalized anxiety disorder is as a short-term agent either before antidepressants have begun to have efficacy or to treat agitation that may occur during the initial weeks of treatment with a selective serotonin reuptake inhibitor.

A 25-year-old woman with a history of substance use disorder presents to the office for follow-up evaluation. She was started on sertraline and titrated to a dose of 200 mg daily after struggling with symptoms of excessive worry, fatigue, and insomnia. She has tolerated the medication at this dosage for the past 8 weeks but has only noted partial improvement in her anxiety symptoms. What would be an appropriate intervention at this time?

A) Continue sertraline for 6 months and then reassess

B) Start adjunctive treatment with buspirone

C) Supplement sertraline with lorazepam up to 3 times daily if needed

D) Taper off sertraline and change to fluoxetine

Start adjunctive treatment with buspirone

**Buspirone can be used as adjunctive therapy in patients with generalized anxiety disorder who have a partial response to serotonin reuptake inhibitors. Patients who have a partial response to a first-line medication can receive adjunctive therapy with either buspirone, as was observed in this patient, or pregabalin. Taper off sertraline and change to fluoxetine (D) is incorrect. Since the patient had a partial response to sertraline, it is recommended to adjust the response with the addition of a second-line drug, such as buspirone or pregabalin. If the patient did not have any response to sertraline, then tapering off the medication and transitioning to an alternative serotonin reuptake inhibitor would be an appropriate option.

A 36-year-old woman presents to the clinic for an annual physical and reports new-onset intermittent headaches that have been ongoing for the past month. Despite normal laboratory studies, CT, MRI, and EEG, the patient is insistent that part of her brain is rotting and frustrated that no one believes her. She reports no constitutional symptoms, hallucinations, or changes in cognition or memory. Her physical exam results are unremarkable compared to her previous visits. Which of the following medications would be most beneficial for this patient?

A) Aripiprazole

B) Duloxetine

C) Diazepam

D) Fluoxetine

Aripiprazole

**Delusional disorders first-line medication are Antipsychotics. Those with fewer side effects (e.g., aripiprazole, ziprasidone) should be considered with a low initial dose and gradual dosage increases over several days or weeks.

A 66-year-old man with a history of hyperlipidemia, type 2 diabetes, and diabetic neuropathy presents for mood disturbance for the last 3 weeks. He reports feeling his life is worthless and has lost interest in activities that used to bring him joy. He has no interest in seeing friends or family and has recurrent thoughts of death, although he has no specific suicidal plan. He reports a 5 lb unintentional weight loss but states he has lost his appetite. He mentions he has not been controlling his glucose over the last 6 months and thinks his neuropathy has worsened. Which of the following medications would be best for this patient?

A) Duloxetine

B) Gabapentin

C) Pregabalin

D) Sertraline

Duloxetine

**Duloxetine is a first-line treatment for neuropathic pain. Sertraline (D) is used as a first-line treatment for major depressive disorder but is not used in treating diabetic neuropathy. This is why Sertraline is not the right answer, as SSRIs and SNRIs are first-line for MDD. However, considering the profile of the patient, Duloxetine would most benefit the patient in treating both the MDD and Diabetic neuropathy.

A 22-year-old woman with a history of congenital prolonged QT interval presents to the clinic with dysphoria for the past 2 months. She reports she has felt fatigued, been sleeping more than usual, and had decreased appetite. She has not been interested in doing activities she previously viewed as hobbies. Which of the following medications to treat her suspected condition would require an electrocardiogram prior to initiation?

A) Amitriptyline

B) Duloxetine

C) Escitalopram

D) Venlafaxine

Amitriptyline

**Risk of abnormal heart rhythms, such as heart block and ventricular dysrhythmias, is one of the safety concerns associated with tricyclic antidepressants because these medications can prolong the QT interval on electrocardiogram. Therefore, patients should undergo a cardiac evaluation prior to the prescription of a tricyclic antidepressant.

A 35-year-old man presents to the emergency department at his attorneys' request 3 days after a motor vehicle collision. He reports low back pain that radiates down his lower extremities, and he is unwilling to move his lower extremities or walk during your evaluation. However, you later see him ambulating to the restroom without difficulty. Which of the following is the most appropriate treatment for the suspected diagnosis?

A) Antidepressants

B) Opioid pain medications

C) Psychotherapy

D) Subtle confrontation

Subtle confrontation

**Malingering is the intentional faking or exaggerating of symptoms for secondary gain. However, subtle confrontation that indicates you know they are malingering can sometimes make them stop intentionally producing the symptoms. It is important to avoid ordering unnecessary diagnostic or therapeutic tests.

A 22-year-old man is admitted to the psychiatric hospital for a condition marked by recurrent psychosis. You examine him and note that he has a flat affect and is apathetic. In addition, he will maintain unnatural postures that he is put into. He was initially admitted after he attempted to break into the White House because he thought he was the president. Which of the following accurately describes the epidemiology of this condition?

Individuals born in March are at an increased risk

**Schizophrenia risk factors include birth during the late winter or spring, living further from the equator, living in an urban area, immigration, advanced paternal age at conception, perinatal obstetric complications, childhood trauma or central nervous system infections, and cannabis use during adolescence. Birth during the late winter or spring is thought to be a risk factor because of an increased risk of maternal exposure to viruses during pregnancy.

A 32-year-old woman presents to her obstetrician at her 6-week postpartum visit. She reports having a depressed mood for the past 2 weeks with anhedonia and increased guilt. Which of the following is the most widely used screening test for the suspected diagnosis?

Edinburgh Postnatal Depression Scale

A 27-year-old woman presents to the emergency department reporting dysphoria, muscle aches, yawning, diaphoresis, restlessness, rhinorrhea, lacrimation, nausea, vomiting, and diarrhea. Her symptoms began about 12 hours ago. On physical exam, she is tachycardic and hypotensive, with decreased skin turgor, increased bowel sounds, and several scabs and scars noted over both antecubital fossae. Which of the following signs and symptoms is consistent with the patient's most likely diagnosis?

A) Altered mental status

B) Hyperpyrexia

C) Miosis

D) Piloerection

Piloerection

**Classic opioid withdrawal signs and symptoms include piloerection, diaphoresis, yawning, restlessness, dysphoria, myalgia, arthralgia, rhinorrhea, lacrimation, nausea, vomiting, diarrhea, palpitations, mydriasis, insomnia, tremor, and irritability. Tachycardia and hypotension can result if the patient becomes dehydrated due to vomiting and diarrhea.

A 54-year-old woman presents to the office for follow-up for her major depressive disorder. She was started on low-dose imipramine a couple of months ago, and the dose was slowly titrated at her last visit after a partial response in mood symptoms was noted. Today, she reports her mood and anhedonia are improved, but she is concerned about the development of possible side effects related to the increased dosage of her medication. What side effect would she most likely report?

A) Diarrhea

B) Dry mouth

C) Urinary urgency

D) Weight loss

Dry mouth

**Dry mouth is an anticholinergic side effect commonly associated with tricyclic antidepressants (TCAs), which are used to treat major depressive disorder, panic disorder, generalized anxiety disorder, bulimia nervosa, and post-traumatic stress disorder. TCAs are categorized into tertiary amines and secondary amines. Tertiary amines include amitriptyline, doxepin, and imipramine.

A 28-year-old man presents to the emergency department with fatigue and chest pain. Electrocardiogram reveals nonspecific ST changes. Serum erythrocyte sedimentation rate and cardiac troponin are elevated. Physical exam reveals pitting lower extremity edema. The patient states he was recently started on a medication to control hallucinations, self-injurious behavior, and delusions of persecution. Which of the following medications is most likely causing his current symptoms?

A) Amitriptyline

B) Clozapine

C) Olanzapine

D) Risperidone

Clozapine

**Clozapine is a potent antipsychotic medication that is indicated in the treatment of schizophrenia in individuals who are refractory to other first-line agents and in the treatment of schizophrenia in individuals with persistent self-injurious or suicidal behavior. Serious side effects that are specific to clozapine include myocarditis, cardiomyopathy, pulmonary embolism, and agranulocytosis.

A 54-year-old man presents to the emergency department after being found unconscious in the street. He has a history of intravenous heroin use and was given naloxone en route to the emergency department. The patient is alert, irritable, and restless on presentation. Vital signs include a temperature of 98.6°F, heart rate of 115 bpm, and blood pressure of 165/94 mm Hg. You notice pupil dilation, yawning, and piloerection during physical examination. Which of the following is the recommended treatment?

Clonidine

**The patient in the vignette is presenting with symptoms and signs of opioid withdrawal after being treated with naloxone (opioid antagonist) for presumed opioid intoxication. It is difficult to treat patients who withdraw after the administration of naloxone with opioid agonists because the receptors are blocked by naloxone. Furthermore, there is risk of rebound intoxication. Therefore, the best treatment for this patient is symptomatic treatment, such as with clonidine. Alpha-2 adrenergic agonists, such as clonidine, are a common class of medications used in the symptomatic treatment of opioid withdrawal. It is important to consider the patient’s blood pressure prior to using clonidine because it is contraindicated in hypotensive patients as it will further lower blood pressure.

A 22-year-old man presents to the emergency department with acute confusion and paranoia. Vital signs are notable for a temperature of 99.5°F, HR of 132 bpm, and blood pressure of 198/110 mm Hg. You notice that the patient is diaphoretic with dilated pupils on exam. Urine drug screen detects the metabolite benzoylecgonine. Which of the following describes the mechanism of action of the most likely intoxicant?

Increases the uptake of biogenic amines

**Cocaine is a stimulant that is often used recreationally. Cocaine is commonly used by intravenous injection, inhalation, or via intranasal snorting. It achieves its effects through three mechanisms: blocking the reuptake of biogenic amines, sodium channel blockade, and excitatory amino acid stimulation. Urine drug testing for cocaine tests for the metabolite benzoylecgonine, which is usually detectable for 2–4 days but may be detectable for up to 2 weeks with chronic use.

What drug is tested for in urine drug testing for suspected cocaine intoxication?

the metabolite of Cocaine known as Benzoylecgonine

A 34-year-old man presents to the psychiatry clinic for a 3-month follow-up visit. You suspect, based on his flat affect and apparent reacting to internal stimuli, that he has been noncompliant with his prescribed medication regimen. When asked about his medications, he verbalizes words repeatedly and does not answer the question. Which of the following most accurately describes this speech pattern?

Verbigeration

**Speech may become even more disorganized, consisting of repetitive words called verbigeration, or word salad, where words are strung together that do not make logical sense.

An 18-year-old woman with a history of several episodes of major depression presents to the psychiatric clinic accompanied by her parents, who report she has only slept about 10 hours during the past week. Her parents are also concerned about her irresponsible spending spree the past 2 days and uncharacteristic promiscuous behavior on online dating sites. The patient is of Asian descent and reports skipping school to meet up with men she met online. During your assessment, the patient quickly jumps from one topic to another and has rapid speech. Her urine drug screen and urine pregnancy test are negative. Which of the following medications sometimes used to treat the suspected condition requires screening for the HLA-B*1502 allele prior to beginning treatment?

A) Carbamazepine

B) Lithium

C) Olanzapine

D) Valproate

Carbamazepine

**Stevens-Johnson syndrome and toxic epidermal necrolysis are life-threatening rashes that are associated with carbamazepine. The rashes most commonly occur during the first 8 weeks of treatment. Furthermore, these reactions are far more common in patients with the HLA-B*1502 allele, which occurs nearly exclusively in patients of Asian ancestry.

A 26-year-old woman presents to a plastic surgery clinic concerned about the appearance of her nose. She reports that her nose is long and causes her to have an ugly face. She frequently asks her close friends if her nose looks too long and spends several hours each day looking at her nose in the mirror, which temporarily makes her feel better. Physical exam reveals a relatively normal-appearing nose. You review her chart and notice she has previously had two plastic surgeries on her nose. Which of the following is an acceptable first-line treatment for the suspected diagnosis?

Fluoxetine

**SSRIs such as Fluoxetine and Escitalopram are first-line in treatment for patients with Body dysmorphic disorder.

A 45-year-old man with a history of heroin dependence presents to the clinic requesting medical treatment for his addiction. He has tried both cold turkey and 12-step programs without success. He is specifically interested in trying methadone. Which of the following is a potentially life-threatening adverse effect of methadone?

QT prolongation

**Methadone use has been associated with QT prolongation, which can lead to cardiac dysrhythmias. There are a number of risk factors that increase the likelihood of developing QT prolongation while taking methadone, including age > 65 years, female sex, liver and kidney disease, hemodialysis, anorexia nervosa, and cardiovascular disease. Prior to starting a methadone program, patients should be advised of the risk of dysrhythmia; screened for a history of structural heart disease, dysrhythmia, or syncope; and assessed for other risk factors associated with QT prolongation

A 35-year-old man presents to the clinic for an annual wellness exam. You ask him about tobacco use, and he reports that he smokes cigarettes daily. According to the five As approach to helping patients with tobacco cessation, which of the following is the third step?

Assess readiness to quit

**5 A's:

- Ask (1)

- Advise (2)

- Assess (3)

- Assist (4)

- Arrange (5)

A 25-year-old man presents to the emergency department in police custody for aggressive behavior. The police report he has a history of violent acts, including killing his neighbor's dog, and does not have remorse for his actions. You suspect a personality disorder. Which of the following is the recommended daily pharmacologic treatment for individuals with aggressive behavior due to this condition?

Risperidone

**Pharmacologic therapy is not recommended for all patients with antisocial personality disorder. However, individuals with severe aggression who are willing to take medication should be treated with a second-generation antipsychotic, such as risperidone or quetiapine.

An 18-year-old woman presents with concerns for anxiety. She reports that symptoms mostly occur in social situations and fears that her peers will notice her anxiety resulting in embarrassment. Which of the following is a clinical manifestation of the most likely diagnosis?

A) Delusions

B) Inattention

C) Palpitations

D) Poor social skills

Palpitations

**Clinical manifestations may include anxiety or panic, sweating, trembling, and palpitations during the social event. Typically, selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, are used as first-line therapy for social anxiety disorder.

Which of the following is the most commonly abused substance by schizophrenic patients?

A) Cannabis

B) Alcohol

C) Cocaine

D) Tobacco

Tobacco

**Substance abuse can present with a variety of manifestations, depending on the substance being abused. The most commonly used substances include caffeine, alcohol, and tobacco or nicotine products. In an epidemiologic study, researchers found 90% of schizophrenic patients use nicotine.

A 42-year-old woman with a history of schizophrenia presents to the emergency department, brought by EMS, after being found downtown. She is very agitated. The patient is unable to be verbally calmed and is becoming a safety concern to herself and staff. You order haloperidol 5 mg IM to be administered to calm the patient. After administration, the patient begins having involuntary contractions of her neck, causing torticollis. What medication can be used to treat the patient's suspected diagnosis?

Diphenhydramine

**First-generation (typical) antipsychotics, haloperidol specifically, are used to treat acute agitation, but they can cause extrapyramidal symptoms and dystonic reactions, which present as involuntary, repetitive contractions of the face, back, neck, or limb muscles. The acute phase of a dystonic reaction may be treated with diphenhydramine, an anticholinergic medication that can help to balance cholinergic and dopaminergic activity to correct the reaction. Diphenhydramine 50 mg IV or IM should be administered, and correction of the reaction should be seen within 30 minutes to 1 hour.

A 22-year-old man presents to the emergency department in a catatonic state. He was found at home with a few white tablets in his hand. Vital signs show tachypnea, tachycardia, hyperpyrexia, and hypertension. Physical exam shows vertical nystagmus and hyperreflexia. Laboratory results show elevated creatine kinase. Which of the following substances did this patient most likely ingest?

3-Methoxyphencyclidine

**Phencyclidine is a dissociative anesthetic that has been used as a recreational drug since the 1970s. In recent years, synthetic derivatives of phencyclidine have been produced, such as 3-Methoxyphencyclidine (3-MeO-phencyclidine) and 4-Methoxyphencyclidine (4-MeO-phencyclidine), that offer more potent dissociative effects. Signs and symptoms of intoxication with phencyclidine and its synthetic derivatives can include hallucinations, psychosis, catatonia, coma, agitation, hyperreflexia, hyperpyrexia, tachycardia, elevated blood pressure, disorientation, seizures, and nystagmus (horizontal, vertical, or rotatory). Common laboratory abnormalities associated with phencyclidine intoxication include elevated creatine kinase (indicative of rhabdomyolysis), hypoglycemia, elevated liver transaminases, and hyperuricemia.

A patient under your care with a history of symptoms, including hypervigilance, insomnia, nightmares, flashbacks, and an exaggerated startle response, after being involved in a car collision 3 months ago presents requesting help managing their symptoms. Which of the following is the best initial treatment approach?

CBT

**Cognitive behavioral therapy with fluoxetine (B) or lone treatment with fluoxetine (D) are approaches used to treat patients who are refractory to psychotherapy alone or who express a desire for pharmacotherapeutic treatment. While these approaches can be efficacious, psychotherapy alone is the recommended first-line treatment.

A 24-year-old man with a previous history of alcohol use disorder presents to the clinic reporting symptoms of difficulty concentrating, forgetfulness, restlessness, carelessness, and fidgeting during class. He reports having similar symptoms when he was a child. He recently reenrolled in school and is concerned that he may not be able to pass his classes. Which of the following is the most appropriate treatment for this patient?

Atomoxetine

**The patient in the above vignette has attention-deficit/hyperactivity disorder. For patients with a previous history of substance use disorder, such as the patient in the vignette, the first-line treatment for attention-deficit/hyperactivity disorder is atomoxetine because it has little to no overuse potential

A 24-year-old man presents to the emergency department with intractable vomiting. He reports he has had similar episodes previously, and his symptoms seem to be relieved by hot showers. How long is the substance suspected to be causing this patient's symptoms typically detected in the urine?

30 days

**Cannabis hyperemesis syndrome is a rare complication of cannabis use in which individuals experience abdominal pain, nausea, and vomiting that is typically relieved by hot showers. It is most common in chronic cannabis users. Due to its pharmacokinetics, cannabis can be detected in urine testing for as long as 30 days, particularly in chronic users (who it can be found in for many months)

An 8-year-old boy presents to the office for a follow-up evaluation. At prior visits, his teacher expressed concern over him being disruptive in class. The patient had difficulty remaining seated and talking excessively (blurting out answers without raising his hand, interrupting his classmates, and difficulty remaining quiet during silent reading time). This behavior had started to affect his relationships with his peers and his grades in class. The patient's parents noted he had trouble sitting still for long periods of time, such as in church, and he was restless at home, often waking up his baby sister when she was napping. He was started on a medication at his last visit for his suspected diagnosis. What must be monitored throughout treatment in patients taking the first-line agent for this condition?

Weight

**Weight and height are important to monitor in pediatric patients taking stimulant medications for attention-deficit/hyperactivity disorder (ADHD), such as methylphenidate and dextroamphetamine, because of the side effects of decreased appetite and poor growth.

A 32-year-old man presents to the clinic at the request of his family. He reports that it is difficult for him to maintain a job or friendships because he cannot trust anyone. He is also recently separated from his wife who he continuously thought was unfaithful. What are the core characteristics of the cluster that the suspected personality disorder is in?

Odd and eccentric

**Paranoid personality disorder is a cluster A personality disorder. The core features that describe cluster A personality disorders are odd and eccentric. Paranoid personality disorder is characterized by a pervasive pattern of distrust and suspiciousness of others.

A 24-year-old woman with a past medical history of untreated hepatitis C virus presents to the emergency department with suicidal ideation. She reports that, for the past 7 days, she has been on a spending spree and bought three cars, which she cannot afford. She also notes during this time she has felt well-rested with minimal sleep. During your assessment, she is easily distracted and talks rapidly. She has a negative urine drug screen. Which of the following is a concerning possible adverse effect of the recommended mood-stabilizing medication for this patient?

Decline in kidney function

**Lithium is classically known to cause a decline in kidney function over time. The risk factors for this decline include prolonged use, higher serum concentrations, older age, medical comorbidities, and a lower baseline glomerular filtration rate. Lithium is preferred over valproate in this patient because she is of childbearing age and has a history of hepatitis C virus. Valproate can cause hepatotoxicity and is avoided in women of childbearing age due to teratogenicity.

A 28-year-old woman presents to the clinic with 6 or 7 nights of feeling a decreased need to sleep, racing thoughts, irritability, and an elevated mood lasting all day for the past week. She states her roommates are aware of the change in her behavior, but she is able to go to work each day and perform her duties normally. She reports no auditory or visual hallucinations, thoughts of persecution, or paranoia. Her medical history includes one episode of major depression 12 months ago that lasted 3 months and went unmedicated. Which of the following treatment options should be avoided in a patient who is hospitalized for mania but would be an appropriate choice for this patient?

A) Carbamazepine

B) Lamotrigine

C) Lithium

D) Olanzapine

Lamotrigine

**Lamotrigine is an antiepileptic drug that works by inactivating voltage-gated sodium channels in the brain, thus decreasing neuronal synaptic firing. Lamotrigine works well to stabilize mood fluctuations in patients with bipolar II disorder but is not, however, an antimanic drug and is not useful when treating acute mania.

A 22-year-old man with a new diagnosis of schizophrenia presents to the office for medication management. A decision is made to start quetiapine, and you discuss side effects with the patient, along with a need for regular appointments to monitor metabolic changes. Which of the following laboratory tests should be monitored regularly?

Fasting blood glucose

**The most serious side effects caused by second-generation antipsychotic agents are metabolic changes, such as insulin resistance, hyperglycemia, weight gain, and elevated lipids. Initiation of an antipsychotic requires baseline monitoring, which continues through the first year and beyond. Baseline factors to monitor include a family history of diabetes, hypertension, and cardiovascular disease and the individual’s diet and physical activity level, smoking status, weight, body mass index, blood pressure, fasting blood glucose or hemoglobin A1C, and lipid profile. Fasting blood glucose should be checked at the 6-week, 3-month, and 12-month marks after starting a second-generation antipsychotic and then annually.

A 6-year-old boy presents to the clinic for assessment after his teacher noticed that he has difficulty remaining seated during class, difficulty playing quietly, and frequently interrupts others. His mother has noticed a similar pattern at home. You discuss the suspected diagnosis with his mother and decide to start him on the first-line pharmacologic treatment. Which of the following is a common adverse effect of this medication?

Decreased appetite

A 48-year-old man presents to the clinic for a rash. He states he has had poor personal hygiene for as long as he can remember. He likes to wear his shirts until they fall apart then keep a piece of them in his pocket when he picks out a new shirt. He believes his Magic 8-ball gives him good advice every morning. He has been a factory worker for the past 10 years and is often faulted for his disorganization and lack of attention to detail. He reports no auditory or visual hallucinations. He states he has always been too nervous, distrustful, and shy to get married. Which of the following pharmacologic interventions may be beneficial for this patient's personality disorder?

A) Fluoxetine

B) Haloperidol

C) Mirtazapine

D) Quetiapine

Quetiapine

**The patient in the vignette demonstrates several qualities of schizotypal personality disorder. Core characteristics of schizotypal personality disorder include cognitive and perceptual disturbances, interpersonal difficulties, and oddities of behavior or appearance along with disorganized thought or speech. Common perceptual disturbances include magical thinking, paranoia, suspiciousness, and ideas of reference. Quetiapine can help patients with schizotypal personality disorder gain cognitive organization while also decreasing anxiety.

A 35-year-old man presents to the emergency department after getting in a bar fight with another patron. He has been in the emergency department multiple times due to injuries relating to the destruction of private property. He reports alcohol use and occasional marijuana use and has a difficult time retaining employment. On multiple occasions on this visit, he has tried to hit the nursing staff as they attempted to place an IV. Which of the following diagnoses did this patient most likely have during childhood and adolescence?

Conduct disorder

**Antisocial personality disorder is a cluster B personality disorder and is characterized by behaviors that completely disregard and violate the rights of others. Often, antisocial personality disorder begins in childhood or adolescence and is diagnosed as conduct disorder.

For patients with severe antisocial personality disorder that leads to severe aggression, what medications are indicated?

Risperidone or Quetiapine

**For mild cases of antisocial personality disorder, CBT is the recommended therapy.

A 25-year-old man presents to the emergency department, brought by emergency medical services, after getting into an altercation at a nightclub. He is agitated and yelling at the staff in the emergency department. His vital signs are notable for a HR of 135 bpm and blood pressure of 208/115 mm Hg. On exam, you notice that he is diaphoretic and has dilated pupils. You are able to obtain further information from his roommate who reports he is likely intoxicated with a substance made from pseudoephedrine in a home laboratory. Which of the following medications is considered first-line treatment for his elevated blood pressure?

A) Esmolol

B) Haloperidol

C) Lorazepam

D) Nitroprusside

Lorazepam

**Amphetamine intoxication causes increased levels of central nervous system norepinephrine, dopamine, and serotonin. It has a similar mechanism and presentation to cocaine intoxication. Patients classically present with sympathomimetic findings, including tachycardia, hypertension, diaphoresis, and mydriasis. Amphetamine intoxication may also cause paranoia, anxiety, agitation, confusion, and hallucinations. Hypertension related to amphetamines is usually controlled with benzodiazepines, such as lorazepam. However, nitroprusside or phentolamine can be used as second-line agents in patients whose blood pressure is refractory to benzodiazepines. It is important to consider dehydration in patients with amphetamine intoxication and administer intravenous fluids to rehydrate.

A 24-year-old woman presents to the clinic complaining of palpitations and depressed mood. On physical exam, she is visibly cachectic with a body mass index of 13 kg/m2. A systolic murmur and systolic click are appreciated at the cardiac apex, and her skin is cool and dry with an abundance of fine, dark hair over her entire body. The patient reports eating only one small salad per day because she has an intense fear of becoming fat. The patient is admitted for evaluation and treatment. Which of the following medications should be avoided?

Bupropion

**Patients with anorexia nervosa who suffer concomitant generalized anxiety, obsessive-compulsive disorder, or major depression should not be given the atypical antidepressant bupropion, as an increased incidence of seizure activity is found when bupropion is administered to patients with an eating disorder.

A 35-year-old man presents with a persistent pattern of odd behavior since early adulthood. He often believes that people talking on the radio have special messages for him. In addition, he has few close friends, pervasive suspicion of others, and social anxiety. Which of the following personality disorders does this individual most likely have?

Schizotypal

**Schizotypal personality disorder is a cluster A personality disorder marked by cognitive-perceptual abnormalities, oddness or disorganized behavior, and interpersonal difficulties. The cognitive-perceptual abnormalities include odd beliefs, unusual perceptual experiences, ideas of reference, and paranoia.

A 32-year-old man with a history of heavy alcohol use presents to the emergency department with anxiety, tremulousness, diaphoresis, vomiting, and headache. He reports that he has heavily used alcohol for 6 years but abruptly stopped yesterday afternoon. Which of the following can be used to assess this patient's symptom severity and determine the most appropriate site for treatment?

Clinical Institute Withdrawal Assessment for Alcohol

**The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) is a scale that helps measure the severity of alcohol withdrawal symptoms and determine the appropriate setting for alcohol withdrawal management.

A 32-year-old woman presents to the clinic complaining of irritability, difficulty concentrating, and fatigue for the past 8 months. She reports that she feels stressed at home and work and easily becomes anxious in response to trivial stressors. She reports no anhedonia or a depressed mood. You decide to start her on venlafaxine to treat the suspected diagnosis. How long should treatment be continued before increasing the dose or switching to another medication if she is not experiencing improvement on a therapeutic dose?

6 weeks

**It takes on average 4 weeks for patients to experience clinically meaningful action from a serotonin reuptake inhibitor. Therefore, it is recommended that the initial therapeutic dose be given for 4–6 weeks before an adjustment is made in the dose or medication. Patients who are not experiencing a robust response at this point should have the dose increased or be switched to a new medication. Buspirone is frequently used as an augment to selective serotonin reuptake inhibitors or serotonin and norepinephrine reuptake inhibitors. Benzodiazepines, such as lorazepam, can be used long-term in patients who are refractory to antidepressants and do not have a history of substance misuse.

A 20-month-old boy presents to the pediatrician with his mother, who is concerned that he does not seem interested in interacting with her. She has also noticed that he does not like to make eye contact and has intense interests in visual stimuli, such as flashing lights. He seems easily irritated by small changes in the daily routine. At which of the following months does the American Academy of Pediatricians recommend screening for the suspected diagnosis?

18 and 24 months

**The American Academy of Pediatrics recommends screening for autism spectrum disorder at 18 and 24 months of age in all children using the Modified Checklist for Autism in Toddlers, Revised with Follow-up. The purpose of this test is to identify children who are at-risk for autism spectrum disorder, but it does not confirm the diagnosis.

A 48-year-old man presents to the clinic complaining of fatigue. He reports drinking 6 to 10 beers per day for the past 15 years. He currently takes lisinopril for hypertension. Physical exam reveals rhinophyma, facial erythema, hepatomegaly, an abdominal fluid wave, and external hemorrhoids. Which of the following laboratory abnormalities would be most likely in this patient?

Mean corpuscular volume 105 fl

**Health problems attributable to alcohol use disorder include hypertension, anxiety, depression, gastrointestinal reflux, sleep disturbance, liver disease, bone marrow suppression, macrocytosis (mean corpuscular volume over 96 fL), cardiomyopathy, neuropathy, and trauma due to falls.

A 7-year-old girl presents to the pediatrician multiple times for hematuria until it is discovered that her mother is contaminating the urine samples with her own blood. Which of the following is the suspected diagnosis?

Medical child abuse

**It's not factitious disorder because the parent is imposing the symptoms on the child. This makes it child abuse.

A 27-year-old woman with bipolar I disorder is evaluated in the office upon urgent request. She was recently started on a new medication after having difficulty tolerating lithium. The patient reports a concerning skin rash that developed over the past 36 hours. She is concerned it may be an allergic reaction related to her new medication and indicates she did not slowly titrate the dose as indicated. On her physical exam, poorly defined erythematous macules and plaques with purpuric necrotic centers are noted on the trunk and the left cheek. With what medication is this reaction most commonly associated?

Lamotrigine

**Stevens-Johnson syndrome is a serious skin rash associated with the use of lamotrigine, a drug used in the maintenance therapy of bipolar disorder.