CAM PSYCH NEW STUFF

CAM III Psychiatry — New Lectures

50-Question Cumulative Practice Exam

Somatic/Eating Disorders  ·  Substance Use Disorders  ·  Personality Disorders  ·  Trauma/Stressor-Related & Sleep Disorders

PAS 5462  ·  South College Atlanta ATL-2026  ·  PANCE-Style Clinical Vignettes

PART I — QUESTIONS (Q1–50)

Q1  |  SOMATIC SYMPTOM & RELATED DISORDERS

A 42-year-old female presents to her PCP for the 14th time this year with multiple vague complaints including pain, fatigue, and nausea. Extensive workup — including MRI, labs, and GI studies — has been negative. She expresses persistent fear that something serious is being missed and spends several hours daily researching her symptoms online. She has missed 3 months of work. She has a history of childhood abuse and prior anxiety disorder. What is the diagnosis, and what is the most important principle of management?

A. Illness anxiety disorder; patient has minimal somatic symptoms but overwhelming fear of disease; SSRI is first-line treatment

B. Somatic symptom disorder; diagnosis of exclusion after ruling out medical causes; ≥1 somatic symptom + excessive thoughts/feelings/behaviors (disproportionate concern, high health anxiety, excessive time devoted) for >6 months; BEST MANAGED by ONE provider at REGULARLY SCHEDULED visits — provide reassurance after ruling out organic cause; psychotherapy if patient accepts; suffering is AUTHENTIC

C. Factitious disorder; patient is intentionally producing symptoms to assume the sick role; confrontation is first-line

D. Malingering; patient seeks disability payments; no psychiatric diagnosis applies

Q2  |  SOMATIC SYMPTOM & RELATED DISORDERS

A 28-year-old male ER nurse presents with persistent tingling and numbness of his entire right arm and leg, with episodes of apparent blindness lasting minutes. Neurological exam is normal and inconsistent — his deficits shift with distraction. MRI brain and spine are normal. EMG is normal. He recently witnessed a traumatic patient death at work. He is not faking. There is no external financial gain. What is the diagnosis, the classic clinical sign that suggests it, and the gender/population most commonly affected?

A. Conversion disorder (Functional Neurological Symptom Disorder); neurologic symptoms incompatible with neurological disease; Hoover sign (hip extension weakness resolves when contralateral hip is flexed against resistance); more common in WOMEN (up to 10:1); NOT intentionally produced

B. Malingering; symptoms inconsistent on exam = patient is faking for secondary gain

C. Somatic symptom disorder; multiple vague somatic symptoms; psychotherapy and scheduled visits

D. Illness anxiety disorder; fear of having a serious neurologic disease; SSRI first-line

Q3  |  SOMATIC SYMPTOM & RELATED DISORDERS

A 55-year-old male presents to his PCP with a chief complaint of "I know I have cancer, but no one will find it." He has had 6 normal physical exams, 3 normal CTs, and 2 negative colonoscopies in the past year. He has NO significant somatic symptoms beyond mild fatigue. He reads medical journals daily and avoids certain foods out of fear they cause cancer. He is otherwise functioning normally at work. What distinguishes this presentation from somatic symptom disorder?

A. Nothing — this is somatic symptom disorder with cancer as the predominant concern

B. ILLNESS ANXIETY DISORDER (formerly hypochondriasis): the PRIMARY feature is FEAR OF HAVING a serious disease with MINIMAL OR NO actual somatic symptoms; preoccupation is with the DISEASE ITSELF, not the symptoms; somatic symptom disorder = significant somatic symptoms + excessive health behaviors

C. Factitious disorder; patient is producing symptoms deliberately

D. This is normal health anxiety; no diagnosis is warranted

Q4  |  SOMATIC SYMPTOM & RELATED DISORDERS

A 9-year-old boy is admitted to the hospital for the 7th time in 18 months with varied symptoms — including seizures, unexplained fever, and hypoglycemia — none of which can be reproduced in the absence of his mother. The nursing staff notices the mother adjusts the IV line before symptoms appear. When child is transferred to a different ward without the mother, all symptoms resolve. What is the diagnosis and the IMMEDIATE required action?

A. Munchausen syndrome (factitious disorder on self) in the child; psychiatry consult

B. FACTITIOUS DISORDER IMPOSED ON ANOTHER (Munchausen syndrome by proxy); caregiver INTENTIONALLY induces or fabricates illness in the child to assume the caregiver/sick role; NO external gain (distinguishes from malingering); IMMEDIATE MANDATORY REPORT TO CPS; SEPARATE child from caregiver; multidisciplinary team (social work, pediatrics, psychiatry, law enforcement)

C. Malingering by proxy; mother seeks insurance payments; no mental disorder diagnosis

D. Somatic symptom disorder by proxy; mother is anxious about the child's health

Q5  |  SOMATIC SYMPTOM & RELATED DISORDERS

A 32-year-old male is seen in urgent care claiming severe back pain and requesting oxycodone. He says he cannot work and needs the medication to cope with a workers' compensation case. On exam, Waddell signs are present and symptoms are inconsistent. He admits he is not in significant pain but states "I need this to get through the lawsuit." Which diagnosis applies and what is the correct management?

A. Somatic symptom disorder; psychotherapy and scheduled visits with one provider

B. Factitious disorder; patient is producing symptoms intentionally but for sick role — no external gain

C. MALINGERING (NOT a psychiatric disorder — it is a V-code/Z-code in DSM-5); INTENTIONAL production/feigning of symptoms for EXTERNAL INCENTIVES (financial gain, avoiding legal consequences, obtaining controlled substances, avoiding military service); DO NOT prescribe requested medications; address secondary gain; consider social work and legal consultation

D. Conversion disorder; symptoms are not intentional; psychological gain is primary

Q6  |  SOMATIC SYMPTOM & RELATED DISORDERS

A 38-year-old female has been seeing 6 different specialists for various complaints over the past 3 years. Her chart includes 47 office visits. She has a "long, complicated medical history surrounding one or more vague complaints," multiple normal labs, and is convinced she has an undiagnosed illness. She has a comorbid diagnosis of anxiety. She agrees to try therapy but refuses psychiatric medications. She asks if she will ever get better. What is the prognosis of somatic symptom disorder?

A. Excellent — most patients remit completely within 2 years with psychotherapy

B. CHRONIC, undulating, and relapsing course; rare to remit completely; almost NEVER symptom-free for greater than 1 year; high level of medical care utilization does NOT alleviate concern; patients often seek multiple providers for same symptoms; if coexisting disorder (anxiety, depression) is present — treat it, as this may improve SSD symptoms

C. Prognosis is uniformly poor with no effective treatment available

D. Most patients improve spontaneously within 6 months without treatment

Q7  |  SOMATIC SYMPTOM & RELATED DISORDERS

A 24-year-old female presents after a motor vehicle accident where she was the driver. She now has complete inability to move her left arm. Neurological exam reveals no objective weakness on formal testing and the deficit is inconsistent — when distracted during conversation she occasionally moves the arm normally. MRI and NCS/EMG are normal. She is not faking, and there is no external financial incentive. She is very distressed. Which clinical feature on physical exam best supports the diagnosis?

A. Babinski sign — indicates upper motor neuron lesion explaining her deficits

B. HOOVER SIGN: ask patient to extend the "paralyzed" hip while simultaneously flexing the contralateral hip against resistance — in functional weakness, the "paralyzed" leg will extend normally (involuntary motor activation) = POSITIVE HOOVER; most clinically useful sign for lower extremity functional weakness; for upper extremity: ask patient to abduct "weak" arm while simultaneously abducting the other arm against resistance

C. Absent deep tendon reflexes — indicates lower motor neuron lesion

D. Pronator drift — confirms organic corticospinal tract lesion

Q8  |  SOMATIC SYMPTOM & RELATED DISORDERS

A PA student is studying the distinction between factitious disorder and malingering. A patient is presented who has been faking seizures to avoid incarceration for a pending DUI trial. He has no genuine neurological disorder. This is done intentionally. Which diagnosis applies and why?

A. Factitious disorder — intentional production of symptoms regardless of motivation

B. MALINGERING — intentional production of symptoms for EXTERNAL GAIN (avoiding legal consequences = external incentive); factitious disorder = intentional but motivated by SICK ROLE with NO external gain; both are intentional (unlike conversion disorder which is NOT intentional)

C. Conversion disorder — the stress of the legal case triggered functional neurological symptoms unconsciously

D. Somatic symptom disorder — excessive focus on health due to legal stress

Q9  |  SOMATIC SYMPTOM & RELATED DISORDERS

A 40-year-old male with somatic symptom disorder has been seeing Dr. Smith for 2 years. He calls between appointments when symptoms flare, often requesting urgent add-on visits and extensive testing. At each urgent visit his symptoms resolve with reassurance. Which management strategy is most appropriate?

A. Order all requested tests to rule out occult disease at each visit

B. SCHEDULE REGULAR BRIEF VISITS at set intervals (e.g., monthly) regardless of symptom status — do NOT schedule solely in response to symptom flares (this reinforces symptom-driven care-seeking behavior); limit but do not eliminate medical testing; use visits for reassurance and support; refer to therapy; treat comorbid anxiety/depression; maintain ONE primary provider relationship

C. Refer immediately to psychiatry and terminate the provider-patient relationship

D. Prescribe benzodiazepines to reduce health anxiety between visits

Q10  |  SOMATIC SYMPTOM & RELATED DISORDERS

Which of the following correctly describes the key differential feature between illness anxiety disorder and somatic symptom disorder?

A. Illness anxiety disorder involves intentional symptom production; somatic symptom disorder does not

B. IAD = FEAR OF HAVING a serious disease with MINIMAL or NO somatic symptoms; SSD = SIGNIFICANT somatic symptoms (pain, fatigue, GI complaints) + excessive thoughts/feelings/behaviors about the symptoms; both are NOT intentional and both cause significant distress

C. Somatic symptom disorder only occurs in women; illness anxiety disorder occurs equally in men and women

D. Illness anxiety disorder is diagnosed when all medical workup is negative; somatic symptom disorder requires at least one positive finding

Q11  |  EATING DISORDERS & OCD-SPECTRUM

A 16-year-old female competitive gymnast is brought in by her parents. BMI is 15.1. She refuses to eat "fattening" foods, exercises 4 hours daily despite team restrictions, and still considers herself "too big." She has had no menses in 9 months. Her resting HR is 46. EKG shows a prolonged QTc of 510 ms. She denies purging. What is the leading cause of death in this condition and what syndrome must be avoided during treatment?

A. Hepatic failure from malnutrition; avoid high-protein refeeding

B. ANOREXIA NERVOSA; LEADING CAUSE OF DEATH = CARDIAC ARRHYTHMIA from electrolyte imbalances and prolonged QT interval — highest mortality of ANY psychiatric disorder; REFEEDING SYNDROME must be prevented: rapid caloric introduction → intracellular shift of phosphate → severe hypophosphatemia → cardiac failure, respiratory failure, seizures; FEED SLOWLY with close electrolyte monitoring

C. Suicide is the leading cause of death; antidepressants are first-line

D. Aspiration pneumonia from NGT feeding is the primary concern

Q12  |  EATING DISORDERS & OCD-SPECTRUM

A 19-year-old female college student presents for a wellness visit. She appears at a normal weight (BMI 21). She discloses she has been binge eating and self-inducing vomiting 5 times per week for the past year. Her dentist recently noted erosion of the lingual surfaces of her teeth. Labs show K+ of 2.8 mEq/L and bicarbonate of 34 mEq/L. She has calluses on the dorsal surface of her right hand. What is the diagnosis, the electrolyte mechanism, and the FDA-approved pharmacotherapy?

A. Anorexia nervosa binge-purge subtype; low BMI required; olanzapine

B. BULIMIA NERVOSA; purging (vomiting) → loss of gastric HCl → HYPOKALEMIA + METABOLIC ALKALOSIS (elevated bicarb); dental erosion on LINGUAL surfaces (acid); RUSSELL SIGN (calluses on dorsal hand from self-induced vomiting); FDA-APPROVED PHARMACOTHERAPY = FLUOXETINE 60 mg/day (highest dose; higher than MDD dose); FIRST-LINE TREATMENT = CBT

C. Binge eating disorder; no compensatory behaviors; lisdexamfetamine (Vyvanse)

D. Somatic symptom disorder; physical complaints without organic cause

Q13  |  EATING DISORDERS & OCD-SPECTRUM

A 22-year-old male college student presents 3 weeks after a rapid weight restoration program for anorexia nervosa. He developed severe weakness, cardiac arrhythmia, and respiratory distress on day 4 of aggressive nutritional supplementation at 3,000 kcal/day. His phosphate is 0.8 mg/dL. What is this complication, what is the mechanism, and how is it prevented?

A. Wernicke encephalopathy; thiamine deficiency; give thiamine before glucose

B. REFEEDING SYNDROME; rapid caloric reintroduction → glucose stimulates insulin release → insulin drives phosphate, potassium, and magnesium INTO cells → severe HYPOPHOSPHATEMIA (primary driver) → ATP depletion → cardiac arrhythmia, respiratory muscle failure, hemolytic anemia, seizures; PREVENTION = start feeds SLOWLY (begin at low kcal and increase gradually over 1–2 weeks), monitor and supplement electrolytes closely before and during refeeding

C. Acute liver failure from protein overload; reduce protein intake

D. Superior mesenteric artery syndrome; mesenteric fat loss compresses the duodenum; surgical bypass

Q14  |  EATING DISORDERS & OCD-SPECTRUM

A 28-year-old female is preoccupied with a perceived defect in her nose — a slight asymmetry that others cannot perceive. She spends 3–4 hours daily checking mirrors, has had 2 rhinoplasties that she found unsatisfying, avoids social situations, and is in significant distress. She does not have distorted body weight perception. What is the diagnosis and first-line treatment?

A. Anorexia nervosa; distorted body perception; nutritional rehabilitation

B. BODY DYSMORPHIC DISORDER (BDD); preoccupation with a perceived or slight defect in physical appearance that others do not observe or consider minor; causes significant distress or impairment; repetitive behaviors (mirror checking, skin picking, reassurance-seeking, camouflaging); FIRST-LINE = CBT (ERP — exposure and response prevention) + SSRI (highest doses, as in OCD)

C. Illness anxiety disorder; fear of having a serious disease

D. Narcissistic personality disorder; preoccupation with appearance

Q15  |  EATING DISORDERS & OCD-SPECTRUM

A 30-year-old male is referred by his girlfriend after she discovers he has not thrown away a single piece of mail, newspaper, or clothing in 8 years. His apartment has paths through floor-to-ceiling clutter. He becomes extremely distressed when she tries to discard items. He endorses that he "might need" everything. There are no obsessions or compulsions beyond the hoarding itself. How is this classified and what is the treatment?

A. OCD; obsessive thought about keeping items drives the compulsive behavior; SSRI + ERP

B. HOARDING DISORDER (distinct DSM-5 diagnosis); persistent difficulty discarding possessions regardless of actual value, due to perceived need to save them and distress associated with discarding; accumulation clutters living areas and compromises their use; treatment = CBT (specialized hoarding-focused); SSRIs have limited evidence; motivational interviewing to increase readiness for change

C. Obsessive-compulsive personality disorder (OCPD); perfectionism and control

D. Schizotypal personality disorder; magical thinking drives the hoarding

Q16  |  EATING DISORDERS & OCD-SPECTRUM

A 14-year-old female presents with patches of hair loss on her scalp and eyebrows. On exam there is short, broken hair at the borders of the patches. Her mother reports she has witnessed the girl pulling her hair out while reading and watching TV. The patient experiences tension before pulling and relief afterward. She is embarrassed and tries to stop but cannot. What is the diagnosis and treatment?

A. Alopecia areata; autoimmune; intralesional corticosteroid injection

B. TRICHOTILLOMANIA (hair-pulling disorder); recurrent compulsive HAIR PULLING resulting in hair loss; tension/urge before pulling + relief/gratification after; ego-dystonic; FIRST-LINE = CBT (HABIT REVERSAL TRAINING — awareness training + competing response); N-acetylcysteine (NAC) has evidence; clomipramine if refractory

C. Body dysmorphic disorder; preoccupation with perceived hair defect

D. Hoarding disorder; collecting hair for perceived future need

Q17  |  EATING DISORDERS & OCD-SPECTRUM

A 26-year-old male has recurrent obsessions about contamination — he fears touching doorknobs will give him a fatal disease. He washes his hands 50–80 times daily, taking 3–4 hours. He knows this is irrational but cannot stop. His hands are raw and cracked. He is in significant distress and has stopped going out. What are the first-line treatments and what is a key distinguishing feature from OCD-related personality disorder?

A. Benzodiazepines for anxiety; exposure and response prevention is contraindicated in OCD

B. OCD; first-line = CBT (ERP — EXPOSURE AND RESPONSE PREVENTION) + SSRI (highest FDA-approved doses: fluoxetine up to 80 mg, sertraline up to 200 mg, fluvoxamine up to 300 mg); clomipramine (TCA) for refractory; KEY DISTINCTION from OCPD: OCD is EGO-DYSTONIC (patient finds obsessions/compulsions distressing and unwanted); OCPD is EGO-SYNTONIC (traits are comfortable to the patient; perfectionism/rigidity without true obsessions or compulsions)

C. Schizotypal personality disorder; contamination fear is a magical belief; antipsychotics

D. Illness anxiety disorder; patient fears contracting a disease; reassurance and SSRIs

Q18  |  EATING DISORDERS & OCD-SPECTRUM

A 34-year-old female presents with uncontrollable urges to pick at her skin — she picks scabs, pimples, and normal skin on her arms and face, often for hours at a time. She has multiple open wounds and scars. She tries to stop but cannot. Which class of disorder does this fall into and what is the treatment?

A. Impulse control disorder; naltrexone

B. EXCORIATION DISORDER (skin-picking/dermatillomania); falls under OCD-SPECTRUM DISORDERS in DSM-5; recurrent compulsive skin picking → skin lesions; tension/urge before picking + relief after; ego-dystonic; treatment = CBT (HABIT REVERSAL TRAINING), N-acetylcysteine (NAC); SSRI evidence limited but used

C. Factitious disorder; patient is deliberately injuring herself for sick role

D. Borderline personality disorder; non-suicidal self-injury for emotional regulation

Q19  |  EATING DISORDERS & OCD-SPECTRUM

A 20-year-old male is preoccupied with performing rituals before leaving his house: touching each doorknob 4 times, checking the stove 12 times, and re-reading each paragraph 3 times before moving on. These rituals take 2–3 hours each morning. He is failing college. He recognizes the behaviors are "stupid" but cannot stop. His psychiatrist is considering pharmacotherapy. Which medication is FDA-approved for OCD and what should the prescriber know about dosing?

A. Diazepam (benzodiazepine); reduces anxiety; standard anxiolytic dosing

B. SSRIs (fluoxetine, sertraline, fluvoxamine, paroxetine) and CLOMIPRAMINE (TCA) are FDA-approved for OCD; SSRIs must be used at HIGHER DOSES than depression (e.g., sertraline 200 mg, fluoxetine 80 mg) and require 8–12 WEEKS before assessing response; clomipramine = most efficacious but anticholinergic/cardiac side effects; combined with CBT/ERP for best outcomes

C. Haloperidol (antipsychotic); blocks dopamine in OCD circuit

D. Lithium; mood stabilizer with anti-OCD properties

Q20  |  EATING DISORDERS & OCD-SPECTRUM

A 17-year-old female presents with increasing difficulty in social situations. She reports intense fear of embarrassment and negative evaluation when speaking in class or eating in the cafeteria. She avoids all social situations. She has a longstanding pattern. She describes wanting friends but being unable to approach peers. Which eating disorder diagnosis must be EXCLUDED and what is the treatment for the correct diagnosis?

A. Bulimia nervosa; excessive anxiety in social situations triggered by body image concerns

B. SOCIAL ANXIETY DISORDER (Social Phobia) — diagnosis of exclusion requires ruling out that the avoidance is NOT better explained by body image concerns (anorexia) or other conditions; she WANTS social relationships (distinguishes from Schizoid PD); extreme fear of SCRUTINY/EMBARRASSMENT in social situations; TREATMENT = CBT (gold standard) + SSRI; this is NOT an eating disorder but eating anxiety in social situations can be a feature

C. Avoidant personality disorder; trait-level pattern; no effective treatment

D. Agoraphobia; fear of specific places; exposure therapy

Q21  |  SUBSTANCE USE DISORDERS

A 48-year-old male with a 20-year history of heavy daily alcohol use is brought to the ED 18 hours after his last drink. He is tremulous, diaphoretic, tachycardic at 118, BP 168/106, and anxious. His last hospitalization 2 years ago included a generalized tonic-clonic seizure during withdrawal. What is the FIRST-LINE pharmacologic treatment, and why should antipsychotics ALONE be avoided?

A. Haloperidol; best agent for agitation and psychosis in alcohol withdrawal

B. BENZODIAZEPINES (diazepam or lorazepam) guided by CIWA-Ar scale; GABA-A agonists CROSS-TOLERANT with alcohol → prevent and treat seizures AND delirium tremens; ANTIPSYCHOTICS ALONE = CONTRAINDICATED as monotherapy because they LOWER THE SEIZURE THRESHOLD and do NOT address the underlying GABA dysregulation; give THIAMINE BEFORE ANY GLUCOSE (prevent Wernicke encephalopathy)

C. Naltrexone; first-line for acute alcohol withdrawal management

D. Disulfiram; aversion therapy to prevent further drinking during acute withdrawal

Q22  |  SUBSTANCE USE DISORDERS

A 36-year-old male with opioid use disorder was started on buprenorphine/naloxone (Suboxone) for maintenance treatment. He asks his PA why naloxone is added to the buprenorphine. His friend told him "the naloxone is what gets you high." Correct him and explain the pharmacologic rationale for the combination.

A. Naloxone provides additional pain relief when combined with buprenorphine — synergistic analgesia

B. ABUSE-DETERRENT FORMULATION: sublingual buprenorphine/naloxone → buprenorphine IS absorbed sublingually (partial mu-agonist → therapeutic suppression of cravings/withdrawal); naloxone has POOR SUBLINGUAL BIOAVAILABILITY → essentially inactive as prescribed. If INJECTED IV (attempted misuse) → naloxone IS absorbed systemically → PRECIPITATES ACUTE WITHDRAWAL in opioid-dependent individuals → deters IV injection abuse

C. Naloxone enhances buprenorphine's analgesic properties for pain management

D. Naloxone prevents respiratory depression at all doses of buprenorphine

Q23  |  SUBSTANCE USE DISORDERS

A 29-year-old female with opioid use disorder has been stable on methadone 80 mg daily for 8 months. She is considering switching to naltrexone (Vivitrol). Her PA explains the key difference between the two medications. Which statement is MOST accurate?

A. Both methadone and naltrexone are partial opioid agonists; the difference is only the route of administration

B. METHADONE = full mu-opioid AGONIST (reduces withdrawal and craving); dispensed ONLY at licensed opioid treatment programs (OTPs); risk of QTc prolongation; highest abuse potential among MAT options. NALTREXONE = opioid receptor ANTAGONIST (NO agonist activity; no opioid effect); monthly IM injection (Vivitrol) improves adherence; patient MUST BE FULLY DETOXIFIED (≥7–10 days opioid-free) before starting — otherwise precipitates acute withdrawal; preferred in motivated patients who have completed detox

C. Naltrexone is a partial agonist and can be started immediately after the last opioid dose

D. Methadone can be prescribed by any licensed provider in an office setting

Q24  |  SUBSTANCE USE DISORDERS

A 52-year-old male with alcohol use disorder has completed medical detoxification and wants to maintain sobriety. He has no liver disease and no current opioid use. His psychiatrist is discussing options for relapse prevention. He is highly motivated. Which medication blocks the REWARDING effects of alcohol by blocking opioid receptors?

A. Disulfiram (Antabuse); inhibits aldehyde dehydrogenase; causes flushing/nausea/vomiting with alcohol — aversion therapy

B. NALTREXONE; opioid receptor ANTAGONIST — alcohol triggers release of endogenous opioids that mediate the rewarding/euphoric effects; naltrexone blocks these mu-opioid receptors → reduces craving and pleasurable effects of alcohol; oral (ReVia daily) or monthly IM injection (Vivitrol — better adherence); CI: current opioid use, acute hepatitis/liver failure

C. Acamprosate; modulates glutamate/GABA; best used during active drinking to reduce withdrawal

D. Methadone; full opioid agonist; cross-tolerant with alcohol

Q25  |  SUBSTANCE USE DISORDERS

A 22-year-old female college student is found unresponsive at a party. Witnesses report she drank alcohol and took "something blue." She has respiratory rate of 5, slurred speech, and pupils are mid-sized and reactive. She smells of alcohol. Naloxone is given with no response. What is the most likely additional substance, what does the pupil finding tell you, and what is the management?

A. Cocaine; mydriasis; supportive care and benzodiazepines for agitation

B. BENZODIAZEPINE (or GHB/barbiturate) COMBINED WITH ALCOHOL; pupils = MID-SIZED AND REACTIVE (benzos/alcohol — contrast with opioids = MIOSIS/pinpoint); naloxone ineffective confirms non-opioid CNS depressant; FLUMAZENIL can reverse benzodiazepines (use CAUTIOUSLY — precipitates SEIZURES in chronic BZD users); management = AIRWAY first, supportive care, respiratory support, monitoring

C. Methamphetamine; mydriasis and tachycardia; benzodiazepines

D. PCP; dissociative effects; nystagmus; quiet environment and benzodiazepines

Q26  |  SUBSTANCE USE DISORDERS

A family presents to a PA seeking advice about their 19-year-old son who is addicted to heroin. His mother admits she still gives him money "so he doesn't steal" and makes excuses to his employer when he misses work. His father refuses to acknowledge the severity of the situation. Which terms describe the family's behavior patterns and what is the neuropharmacological basis of addiction?

A. Enabling = giving money; denial = father's minimization; codependency = pathological relationship dynamic; addiction is a brain disease — all addictive drugs trigger DOPAMINE SURGE in the BASAL GANGLIA (reward center) → reinforces reward pathways → receptor desensitization → tolerance; withdrawal activates the AMYGDALA (fear center); impaired PREFRONTAL CORTEX (decision-making) → impulsivity

B. The family behaviors are normal supportive parenting; addiction is a moral failing, not a brain disease

C. Codependency = giving money; enabling = refusing to acknowledge the problem; denial = father's behavior

D. Addiction neurochemistry involves primarily GABA pathways; dopamine plays no role

Q27  |  SUBSTANCE USE DISORDERS

A 35-year-old male with a history of chronic benzodiazepine use (alprazolam 4 mg daily × 4 years) wants to stop. He stops abruptly and 2 days later presents to the ED with 2 generalized seizures, severe agitation, and confusion. Why is benzodiazepine withdrawal potentially life-threatening and what is the correct management?

A. Benzodiazepine withdrawal is only psychologically uncomfortable; seizures are extremely rare

B. BENZODIAZEPINE WITHDRAWAL IS LIFE-THREATENING: mechanism = CHRONIC BZD USE → GABA-A receptor downregulation/desensitization → abrupt discontinuation → CNS HYPEREXCITABILITY → SEIZURES, DELIRIUM, autonomic instability (similar to alcohol withdrawal because both are GABA-A-ergic); MANAGEMENT = GRADUAL TAPER: convert to equivalent long-acting benzodiazepine (diazepam) and reduce by ~10% per week or slower; NEVER abrupt discontinuation in physically dependent patients

C. Alprazolam withdrawal is only dangerous in elderly patients; standard dose tapering is not needed

D. Flumazenil should be administered to reverse the benzodiazepine dependence and restart the taper

Q28  |  SUBSTANCE USE DISORDERS

A 45-year-old male with alcohol use disorder has maintained 3 months of sobriety after inpatient detox. He is highly motivated but forgets to take daily oral medications. His hepatologist says his liver enzymes are mildly elevated. Which maintenance medication and formulation is BEST suited for him and why?

A. Disulfiram (Antabuse daily) — best for motivated patients; liver enzymes are not a concern

B. NALTREXONE MONTHLY IM INJECTION (Vivitrol) — monthly dosing eliminates daily adherence problem; mild elevated LFTs from AUD are common and do NOT contraindicate naltrexone at standard doses (only acute hepatitis or liver failure is a CI); acamprosate is renally excreted (liver-safe) but less effective for craving; disulfiram requires strict daily motivation and is avoided with elevated LFTs

C. Acamprosate — best for patients who are actively drinking to reduce intake

D. Methadone — full opioid agonist used for maintenance in alcohol use disorder

Q29  |  SUBSTANCE USE DISORDERS

A 17-year-old male is being evaluated for substance use at a well visit. He admits to drinking on weekends and occasionally using marijuana. His PA uses the CRAFFT screening tool. He scores a 3. What does CRAFFT stand for, what score is positive, and what is the appropriate clinical response?

A. CRAFFT = Cravings, Risk, Alcohol, Friends, Family, Trouble; score ≥2 = positive; refer immediately to inpatient detox

B. CRAFFT = Car (ridden in car driven by someone high?), Relax (use to relax?), Alone (use alone?), Forget (forgot things while using?), Friends/Family (told you to cut down?), Trouble (gotten into trouble?); SCORE ≥2 = POSITIVE screen for problematic substance use → warrants further assessment; score 3 = moderate risk; appropriate response = BRIEF MOTIVATIONAL INTERVIEWING, further assessment, possible outpatient referral — NOT immediate inpatient

C. CRAFFT screens only for alcohol; score ≥3 is positive; breathalyzer testing required

D. CRAFFT ≥1 requires mandatory reporting to parents regardless of age

Q30  |  SUBSTANCE USE DISORDERS

A medical toxicology consult is called for a 21-year-old male who is agitated, diaphoretic, has a heart rate of 132, BP 160/98, temperature 38.4°C, and dilated pupils. He admits to "a lot of studying supplements." Which toxidrome is this, what is the most likely drug class, and how is it distinguished from anticholinergic toxidrome?

A. Anticholinergic toxidrome; dry skin, urinary retention, hot, red; physostigmine

B. SYMPATHOMIMETIC TOXIDROME; stimulant use (cocaine, amphetamines, MDMA, caffeine excess); tachycardia + hypertension + hyperthermia + DIAPHORESIS + MYDRIASIS + agitation; DISTINGUISHES FROM ANTICHOLINERGIC: sympathomimetic = DIAPHORETIC (sweaty); anticholinergic = DRY (dry as a bone, hot as a hare, red as a beet, blind as a bat, mad as a hatter + urinary retention); both have tachycardia and mydriasis; TREATMENT: benzodiazepines for agitation/seizures, supportive care, cooling

C. Opioid toxidrome; miosis, respiratory depression; naloxone

D. Cholinergic toxidrome; SLUDGE; atropine

Q31  |  PERSONALITY DISORDERS

A 24-year-old female is admitted after a suicide attempt — her 4th in 3 years. She states her therapist "completely abandoned" her after he went on vacation for one week, after previously calling him "the only person who truly understands me." She has unstable relationships, impulsive spending and sexual behavior, chronic emptiness, and identity disturbance. She cuts her wrists when feeling abandoned. What is the diagnosis, the characteristic defense mechanism, and the gold-standard treatment?

A. Major depressive disorder with suicidal ideation; antidepressants and hospitalization

B. BORDERLINE PERSONALITY DISORDER (BPD); SPLITTING = defense mechanism — alternating idealization and devaluation of others (all good or all bad); pervasive instability in relationships, self-image, affect, and marked impulsivity (≥5 of 9 DSM-5 criteria); suicidal gestures/NSSI; chronic emptiness; identity disturbance; fear of abandonment; GOLD STANDARD TREATMENT = DIALECTICAL BEHAVIOR THERAPY (DBT) — combines CBT with mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness skills

C. Histrionic personality disorder; excessive emotionality and attention-seeking; psychotherapy

D. Bipolar II disorder; hypomanic episodes; mood stabilizer

Q32  |  PERSONALITY DISORDERS

A 38-year-old male CEO is referred by HR after multiple harassment complaints. He interrupts meetings to discuss his own achievements, believes rules do not apply to him, exploits subordinates, lacks empathy for colleagues, becomes rageful when criticized, and expects constant admiration. He is surprised that anyone complains. Which diagnosis and what is the key distinction from borderline personality disorder?

A. Borderline personality disorder; unstable self-image and splitting; DBT

B. NARCISSISTIC PERSONALITY DISORDER (NPD); GRANDIOSITY (sense of self-importance) + need for EXCESSIVE ADMIRATION + LACK OF EMPATHY; entitlement; exploitation; arrogance; envious; fantasies of unlimited success; EGO-SYNTONIC (patient does not experience traits as problematic); KEY DISTINCTION FROM BPD: NPD = STABLE GRANDIOSITY + entitlement with NO significant identity disturbance or self-harm; BPD = UNSTABLE self-image + splitting + suicidal gestures + abandonment fears + identity disturbance

C. Antisocial personality disorder; violates rights of others; conduct disorder before 15 required

D. Histrionic personality disorder; excessive emotionality and attention-seeking behavior

Q33  |  PERSONALITY DISORDERS

A 32-year-old male has no close friends, prefers solitary activities (chess, model trains), appears indifferent to praise or criticism, has a flat affect, and reports no desire for close relationships, including romantic or sexual ones. He states he is "perfectly happy" alone. He is functioning adequately at work in a solo technical job. Which diagnosis applies and what is the key distinction from avoidant personality disorder?

A. Avoidant personality disorder; wants relationships but fears rejection; social skills training and CBT

B. SCHIZOID PERSONALITY DISORDER (Cluster A — odd/eccentric); pervasive pattern of detachment from social relationships + restricted range of emotional expression; DOES NOT WANT relationships (ego-syntonic aloneness) — this is the KEY DISTINCTION from avoidant PD (which WANTS relationships but fears rejection); indifferent to praise or criticism; no psychotic features; often has ONE consuming interest

C. Schizotypal personality disorder; magical thinking and odd perceptions

D. Antisocial personality disorder; exploitative behavior and disregard for others

Q34  |  PERSONALITY DISORDERS

A 27-year-old male has had 11 jobs in 4 years due to aggression and theft. He was expelled from school at 12 for violence. At 17, he was arrested multiple times for assault and fraud. He shows no remorse: "They deserved it." He is charming in interviews. He meets DSM criteria with history apparent since childhood. Which diagnosis requires what specific age-related criterion?

A. Narcissistic personality disorder; grandiosity and entitlement; no age criterion related to childhood behavior

B. ANTISOCIAL PERSONALITY DISORDER (ASPD); REQUIRES: (1) patient must be age ≥18 at time of diagnosis, AND (2) evidence of CONDUCT DISORDER BEFORE AGE 15 (aggression, cruelty, destruction of property, deceitfulness, theft, serious rule violations); pervasive disregard for and violation of rights of others; lack of remorse; ego-syntonic; deceitfulness, impulsivity, aggressiveness, irresponsibility

C. Conduct disorder; no age minimum for conduct disorder itself; antisocial PD cannot be diagnosed under 18

D. Borderline personality disorder; impulsivity and unstable relationships; no childhood criterion required

Q35  |  PERSONALITY DISORDERS

A 44-year-old female presents with dramatic flair. She interrupts the interview to discuss how her last physician "was absolutely enchanted" by her. She dresses provocatively, speaks in vague generalities with theatrical gestures, is easily influenced by others, and is convinced her neighbor is "deeply in love" with her after a brief conversation. What is the diagnosis and cluster?

A. Cluster A — Schizotypal; magical thinking and odd perceptions

B. Cluster B (dramatic/impulsive/erratic) — HISTRIONIC PERSONALITY DISORDER; excessive emotionality + attention-seeking; uncomfortable when not center of attention; sexually provocative/inappropriate behavior; theatrical, vague speech; SUGGESTIBLE (easily influenced by others); considers relationships MORE INTIMATE than they actually are; ego-syntonic

C. Cluster C — Dependent personality disorder; excessive need to be cared for

D. Cluster B — Narcissistic personality disorder; grandiosity and need for admiration

Q36  |  PERSONALITY DISORDERS

A 50-year-old male at work is pervasively suspicious of his colleagues. He believes they are conspiring against him to steal credit for his work, reads criticism into neutral emails, refuses to confide in anyone, and has reported his manager to HR 7 times this year without corroborating evidence. He has no hallucinations or delusions meeting psychotic criteria. His beliefs are overvalued but not clearly delusional in intensity. Which diagnosis and what distinguishes it from delusional disorder?

A. Delusional disorder, persecutory type; fixed false belief not amenable to reality testing

B. PARANOID PERSONALITY DISORDER (Cluster A — odd/eccentric); PERVASIVE DISTRUST and SUSPICIOUSNESS with motives interpreted as malevolent; NOT PSYCHOTIC — beliefs do not reach the threshold for DELUSIONS (overvalued ideas vs. fixed false beliefs); distinguishes from DELUSIONAL DISORDER (which involves fixed false beliefs impervious to contradiction) and SCHIZOPHRENIA (which involves additional positive/negative symptoms)

C. Schizotypal personality disorder; magical thinking and ideas of reference

D. Narcissistic personality disorder; entitlement leading to conflict at work

Q37  |  PERSONALITY DISORDERS

A 29-year-old female has pervasive feelings of inadequacy, is hypersensitive to criticism, and avoids all new work projects out of fear of humiliation. She has no close friends and eats lunch alone — not because she prefers it, but because she is terrified of rejection. She deeply wants connection but cannot risk it. How does this differ from schizoid personality disorder?

A. No difference — both schizoid and avoidant personality disorders present with social isolation and no close friends

B. AVOIDANT PERSONALITY DISORDER (Cluster C — anxious/fearful); patient WANTS relationships and connection but FEARS REJECTION and CRITICISM — social inhibition is driven by ANXIETY about negative evaluation; KEY DISTINCTION from SCHIZOID PD: schizoid = does NOT want relationships (ego-syntonic isolation); avoidant = WANTS relationships, FEARS rejection (ego-dystonic isolation); TREATMENT = CBT (social skills training, exposure to social situations) + SSRI/SNRI for anxiety component

C. Schizoid personality disorder; patient is comfortable with isolation; no treatment needed

D. Dependent personality disorder; patient clings to others and fears abandonment

Q38  |  PERSONALITY DISORDERS

A 33-year-old male works meticulously as an accountant. He takes 4 hours to complete tasks others finish in 1 hour because everything must be "perfect." He cannot delegate ("others will do it wrong"), works 70-hour weeks voluntarily, has no vacations in 5 years, and considers his rigidity and high standards to be virtues. He is frustrated that colleagues are "lazy." He experiences NO obsessions or compulsions as defined by DSM-5. How does this differ from OCD?

A. This IS OCD; the perfectionism and inability to complete tasks are compulsions; SSRIs and ERP are first-line

B. OBSESSIVE-COMPULSIVE PERSONALITY DISORDER (OCPD) — Cluster C; EGO-SYNTONIC (patient values and is comfortable with traits: perfectionism, rigidity, orderliness, control, workaholism, excessive devotion to work — not experienced as intrusive or unwanted); KEY DISTINCTION from OCD: OCD = EGO-DYSTONIC (obsessions are intrusive/unwanted; compulsions are performed to reduce anxiety; patient is distressed); NO TRUE OBSESSIONS (intrusive, unwanted thoughts) or COMPULSIONS (ritualistic anxiety-reducing behaviors) in OCPD

C. Narcissistic personality disorder; believes he is superior to colleagues

D. Major depressive disorder with anhedonia; exhaustion from overworking

Q39  |  PERSONALITY DISORDERS

A PA student is asked to identify which cluster of personality disorders is most closely biologically related to schizophrenia and what the key distinguishing feature of schizotypal personality disorder is.

A. Cluster B (BPD) — most closely related to schizophrenia; BPD has brief psychotic episodes

B. CLUSTER A (odd/eccentric): Paranoid, Schizoid, Schizotypal — most biologically related to schizophrenia spectrum. SCHIZOTYPAL PD specifically: ODD BELIEFS and MAGICAL THINKING (e.g., believes in telepathy, clairvoyance, 6th sense), ODD PERCEPTIONS (illusions, depersonalization), IDEAS OF REFERENCE (not delusional intensity), ODD SPEECH (circumstantial, metaphorical), suspiciousness, inappropriate affect, eccentric appearance; may want social contact but is uncomfortable; NO frank psychosis; distinguishes from schizophrenia (no sustained psychosis)

C. Cluster C (anxious/fearful) — avoidant PD is related to schizophrenia

D. All three clusters have equal biological relationship to schizophrenia

Q40  |  PERSONALITY DISORDERS

A psychiatric PA is treating a patient with borderline personality disorder and is deciding between pharmacotherapy options. The patient has mood swings, impulsivity, and transient paranoid ideation. Which statement about pharmacotherapy in BPD is MOST accurate?

A. Mood stabilizers (lithium) are curative for BPD and should be started immediately

B. MEDICATIONS ARE NOT CURATIVE FOR ANY PERSONALITY DISORDER; pharmacotherapy in BPD is SYMPTOM-TARGETED and ADJUNCTIVE to DBT: low-dose ANTIPSYCHOTICS for cognitive-perceptual symptoms (paranoia, dissociation) and impulsivity; MOOD STABILIZERS (valproate, lamotrigine) for affective instability and impulsivity; SSRIs for depressive symptoms and impulsivity; NO single medication treats all BPD dimensions; DBT = GOLD STANDARD primary treatment

C. SSRIs alone are the gold standard pharmacological treatment for BPD

D. Benzodiazepines are preferred for BPD due to chronic anxiety; long-term use is well tolerated

Q41  |  TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS

A 34-year-old veteran presents 10 months after returning from combat. He has recurrent nightmares replicating combat scenes, intrusive flashbacks when hearing car backfires, avoids driving past bridges (where an IED detonated), reports emotional numbing and feeling detached from his family, hypervigilance, and exaggerated startle response. Symptoms began within 1 month of returning but have persisted. He has significant impairment at work. What are the 4 DSM-5 symptom clusters and what distinguishes this from acute stress disorder?

A. Two clusters: intrusion and avoidance; duration distinguishes from ASD (>1 month vs <1 month)

B. PTSD — 4 DSM-5 SYMPTOM CLUSTERS: (1) INTRUSION (flashbacks, nightmares, intrusive memories, physiologic reactivity to cues), (2) AVOIDANCE (of trauma-related thoughts or external reminders), (3) NEGATIVE ALTERATIONS IN COGNITION AND MOOD (negative beliefs, distorted blame, emotional numbing, anhedonia, detachment, inability to experience positive emotions), (4) HYPERAROUSAL/REACTIVITY (hypervigilance, exaggerated startle, irritability, reckless behavior, sleep disturbance, concentration problems); DURATION >1 MONTH distinguishes from ASD (3 days to 1 month)

C. PTSD has only intrusion, avoidance, and hyperarousal — negative cognition/mood is not a separate cluster

D. ASD and PTSD have identical duration criteria; the distinction is based on symptom severity only

Q42  |  TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS

A 26-year-old female ER nurse witnessed a traumatic patient death during a code. Over the following 10 days she has flashbacks, emotional numbing, avoidance of the ICU, sleep disturbance, and hypervigilance. It is day 12. She meets full symptom criteria for all PTSD symptom clusters. What is her diagnosis RIGHT NOW and what is the most effective early intervention to prevent progression to PTSD?

A. PTSD; start sertraline immediately

B. ACUTE STRESS DISORDER (ASD); duration 3 DAYS to 1 MONTH after trauma; same symptom clusters as PTSD + DISSOCIATIVE SYMPTOMS; most effective early intervention = TRAUMA-FOCUSED CBT (PROLONGED EXPOSURE or CPT initiated early) — reduces conversion to PTSD; SSRIs are NOT first-line for ASD; approximately 50% of ASD cases progress to PTSD

C. Adjustment disorder; disproportionate response to stressor; resolves within 6 months

D. Normal grief response; no treatment warranted at 12 days

Q43  |  TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS

A 19-year-old male broke up with his girlfriend 6 weeks ago. He is tearful, has difficulty sleeping, and has missed several classes but is still functioning. He is distressed but has no suicidal ideation, and symptoms are limited to his romantic/academic life. What is the diagnosis and course?

A. PTSD; the breakup was traumatic; sertraline and trauma-focused CBT

B. ADJUSTMENT DISORDER; maladaptive response to an IDENTIFIABLE STRESSOR occurring within 3 MONTHS of stressor onset; symptoms do not meet criteria for another Axis I disorder; causes clinically significant distress or functional impairment; expected to RESOLVE WITHIN 6 MONTHS after the stressor (or its consequences) ends; treatment = supportive psychotherapy, brief CBT; typically does NOT require pharmacotherapy

C. Major depressive disorder; depressive episode lasting >2 weeks; antidepressants required

D. Normal grief reaction; no diagnosis warranted; no treatment indicated

Q44  |  TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS

A 62-year-old male presents with 3 months of persistent severe grief 4 months after his wife of 38 years died. He has intense yearning for her, difficulty accepting her death, bitterness, avoidance of reminders of her, inability to trust others since her death, and feels life is meaningless without her. He is unable to function socially or professionally. Which term applies and how does it differ from normal grief?

A. Major depressive disorder; ≥5 depressive symptoms for ≥2 weeks; antidepressants

B. PROLONGED GRIEF DISORDER (PGD); formerly complicated grief; CLINICALLY SIGNIFICANT grief that persists >12 MONTHS after the death of a close person (≥6 months in children); intense yearning, difficulty accepting the death, bitterness, avoidance of reminders, difficulty trusting others, feeling life is meaningless, feeling part of oneself has died; DISTINGUISHES FROM NORMAL GRIEF: normal grief = waves of sadness that gradually diminish; PGD = persistent, intense, does not abate; TREATMENT = grief-focused psychotherapy (Complicated Grief Treatment — CGT)

C. Adjustment disorder; develops within 3 months of stressor; resolves within 6 months

D. PTSD; death was traumatic; flashbacks and hypervigilance are required

Q45  |  TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS

A 52-year-old male is referred after his wife reports he "acts out his dreams" — kicking, yelling, and falling out of bed several nights per week. He says he was dreaming of being attacked by animals. He has no memory of these events. He sustains injuries from the episodes. His neurologist notes this condition is associated with a specific neurodegenerative disease. Which diagnosis and association?

A. NREM parasomnias (sleepwalking/night terrors); occur in NREM slow-wave sleep; more common in children

B. REM SLEEP BEHAVIOR DISORDER (RBD); ACTING OUT DREAMS during REM sleep (normally atonic — motor inhibition should prevent movement); PSG shows REM SLEEP WITHOUT ATONIA; STRONGLY ASSOCIATED WITH ALPHA-SYNUCLEINOPATHIES: Parkinson's disease, Lewy body dementia, multiple system atrophy (MSA) — RBD may precede neurodegeneration by YEARS to DECADES; treatment = clonazepam or melatonin; safety modifications (bed rails, floor padding)

C. Obstructive sleep apnea; nocturnal events triggered by hypoxia; CPAP therapy

D. PTSD nightmares; trauma-congruent; prazosin

Q46  |  TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS

A 45-year-old obese male is referred for excessive daytime sleepiness. His wife reports loud snoring and witnessed apneas several nights per week. He wakes with morning headaches and nocturia twice nightly. His Epworth Sleepiness Scale is 17/24. What is the gold standard diagnostic test, and what AHI thresholds define mild, moderate, and severe disease?

A. Multiple sleep latency test (MSLT); AHI not relevant to OSA diagnosis; treatment is CPAP regardless of AHI

B. OVERNIGHT POLYSOMNOGRAPHY (PSG) = GOLD STANDARD; AHI (apnea-hypopnea index): MILD = 5–15 events/hour; MODERATE = 15–30 events/hour; SEVERE = >30 events/hour; DIAGNOSTIC THRESHOLD: AHI ≥5/hour with symptoms OR AHI ≥15/hour regardless of symptoms; FIRST-LINE TREATMENT = CPAP (continuous positive airway pressure)

C. Home sleep apnea test (HSAT) only; overnight PSG is not required for diagnosis

D. Overnight oximetry alone; AHI ≥10 is diagnostic; CPAP if AHI ≥10 with symptoms

Q47  |  TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS

A 38-year-old female nurse has worked night shifts for 10 years. She cannot fall asleep before 4 AM on her days off, even when she tries to sleep at 10 PM. She sleeps soundly until noon if undisturbed and wakes feeling refreshed. When forced to work early day shifts, she is impaired and fatigued. Her sleep quality is normal on her natural schedule. What is the diagnosis and treatment?

A. Insomnia disorder; CBT-I with stimulus control and sleep restriction therapy

B. DELAYED SLEEP PHASE SYNDROME (DSPS) — circadian rhythm sleep-wake disorder; internal clock is PHASE DELAYED (shifted LATER) relative to conventional/desired schedule; patient CAN sleep well on their delayed schedule; impairment occurs only when forced to conform to conventional hours; TREATMENT: morning BRIGHT LIGHT THERAPY (suppresses melatonin at delayed wake time → advances clock), low-dose MELATONIN in the EVENING (3–6 hours before desired target sleep time), CHRONOTHERAPY (gradual phase advancement)

C. Narcolepsy; daytime sleepiness despite normal nighttime sleep; MSLT confirmation

D. Shift work sleep disorder; she is not shifted on her natural schedule; melatonin at bedtime regardless of timing

Q48  |  TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS

A 60-year-old female with chronic insomnia has been taking zolpidem 10 mg nightly for 4 years. She wants to discontinue and asks about alternatives. What is the GOLD STANDARD treatment for chronic insomnia disorder and what are its components?

A. Switch to eszopiclone (longer-acting Z-drug) for a more gradual taper; CBT-I has insufficient evidence

B. CBT-I (COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA) = GOLD STANDARD — SUPERIOR TO PHARMACOTHERAPY both short-term and long-term with NO side effects or dependence risk; COMPONENTS: (1) STIMULUS CONTROL (bed only for sleep and sex; get up if not asleep in 20 min), (2) SLEEP RESTRICTION (reduce time in bed to actual sleep time, then gradually extend as efficiency improves), (3) RELAXATION TECHNIQUES (progressive muscle relaxation, diaphragmatic breathing), (4) COGNITIVE RESTRUCTURING (challenge unhelpful beliefs about sleep), (5) SLEEP HYGIENE education

C. Long-term benzodiazepines are the gold standard for insomnia as they are the most efficacious long-term

D. Ramelteon (melatonin receptor agonist) is the gold standard for all types of insomnia

Q49  |  TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS

A 22-year-old male college student presents with excessive daytime sleepiness despite adequate nighttime sleep (7–8 hours). He reports episodes where his knees buckle when he laughs hard or hears an exciting sports result. He also experiences seeing shadowy figures when falling asleep, and has had 2 episodes of being unable to move when waking up. His sleep latency on MSLT is 4 minutes with 3 SOREMPs. What is the diagnosis and the specific finding that confirms it?

A. Sleep apnea; AHI on PSG confirms; CPAP therapy

B. NARCOLEPSY TYPE 1; MSLT confirmation = mean sleep latency ≤8 minutes AND ≥2 SOREMPs (sleep-onset REM periods); CATAPLEXY (sudden bilateral loss of muscle tone triggered by strong POSITIVE emotion — laughing, excitement) = PATHOGNOMONIC for Type 1; HYPNAGOGIC HALLUCINATIONS (hallucinations when falling asleep); SLEEP PARALYSIS (inability to move when waking/falling asleep); HYPOCRETIN-1 (orexin) DEFICIENCY (CSF level); treatment = SODIUM OXYBATE (cataplexy + EDS), MODAFINIL (EDS), stimulants

C. Depression with hypersomnia; antidepressants; MSLT not required

D. Idiopathic hypersomnia; PSG shows long sleep time; stimulants

Q50  |  TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS

A PA student reviews the four new psych lectures on an exam. Which of the following correctly matches a clinical scenario with its CORRECT diagnosis, key distinguishing feature, and first-line treatment?

A. A patient who fakes paralysis to collect disability insurance → Conversion disorder → ERP + physical therapy

B. A 17-year-old female with recurrent purging and metabolic alkalosis + dental erosion on lingual surfaces → BULIMIA NERVOSA → Fluoxetine 60 mg (FDA-approved) + CBT (first-line therapy)

C. A 55-year-old male with delayed sleep phase syndrome who cannot sleep before 3 AM → Insomnia disorder → Zolpidem at 3 AM

D. A 40-year-old male who meets full PTSD criteria but symptoms began 20 days after the trauma and it has only been 3 weeks → PTSD → Sertraline + prolonged exposure CBT

PART II — ANSWER KEY WITH CLINICAL RATIONALES

Q1  Answer: B  [SOMATIC SYMPTOM & RELATED DISORDERS]

Somatic symptom disorder (SSD): ≥1 somatic symptom causing distress + AT LEAST ONE of: (1) disproportionate/persistent thoughts about seriousness, (2) persistently high anxiety about health, (3) excessive time/energy devoted to symptoms. Present >6 months. DIAGNOSIS OF EXCLUSION. The patient's suffering is AUTHENTIC — pain and symptoms are real even if no organic cause is found. KEY MANAGEMENT PEARL: best treated when patient sees ONLY ONE PROVIDER at REGULARLY SCHEDULED appointments (not as-needed). Reassurance and education once organic cause is ruled out. Psychotherapy if patient is willing. NO pharmacological indication unless comorbid disorder is present. 80% have comorbid mental disorder (anxiety and depression most common). Risk factors: childhood trauma, low SES, sexual/physical abuse.

Q2  Answer: A  [SOMATIC SYMPTOM & RELATED DISORDERS]

Functional Neurological Symptom Disorder (FNSD/Conversion Disorder): one or more voluntary motor or sensory symptoms that CANNOT be explained by neurological disease — and there is EVIDENCE OF INCOMPATIBILITY with neurological disease (e.g., symptoms shift with distraction, inconsistency). HOOVER SIGN: patient is asked to extend the "weak" hip; weakness resolves when simultaneously asked to flex the contralateral hip against resistance — positive Hoover = functional weakness. Not intentionally produced (distinguishes from malingering and factitious). Psychological gain is PRIMARY (internal — not social, monetary, or legal). EPIDEMIOLOGY: women up to 10:1 over men; rural populations; low SES; history of abuse; anxiety/depression comorbidity. Up to 5% of neurology referrals. Treatment: PT/OT, psychotherapy.

Q3  Answer: B  [SOMATIC SYMPTOM & RELATED DISORDERS]

ILLNESS ANXIETY DISORDER (IAD) vs SOMATIC SYMPTOM DISORDER (SSD): IAD = preoccupation with HAVING or ACQUIRING a serious illness; MINIMAL or NO somatic symptoms; distress is about the DISEASE CONCEPT, not about symptoms; excessive health behaviors (checking, avoidance, reassurance-seeking). SSD = significant somatic SYMPTOMS (pain, fatigue, nausea, etc.) that cause distress + excessive thoughts/feelings/behaviors about the symptoms. BOTH are NOT intentional. IAD: 2 types — care-seeking (multiple appointments) and care-avoidant (avoids medical care out of fear of diagnosis). Treatment: CBT; SSRIs have some evidence; avoid unnecessary testing (reinforces anxiety). Distinguishing feature tested: IAD = minimal/no symptoms but preoccupied with disease; SSD = real symptoms + excessive behaviors.

Q4  Answer: B  [SOMATIC SYMPTOM & RELATED DISORDERS]

Factitious Disorder Imposed on Another (FDIA / Munchausen syndrome by proxy): a caregiver deliberately INDUCES, FABRICATES, or EXAGGERATES illness in a VICTIM (usually a child) to assume the caregiver/sick role. Caregiver appears highly attentive and concerned. Child's symptoms resolve when separated from the caregiver. No external gain (this distinguishes FDIA from malingering by proxy). FDIA is CHILD ABUSE. IMMEDIATE ACTION: (1) MANDATORY REPORT TO CPS, (2) SEPARATE child from caregiver immediately, (3) multidisciplinary team. Factitious disorder ON SELF: person produces symptoms in themselves; no external gain; sick role motivation. Malingering: external gain (money, drugs, legal avoidance). KEY DISTINCTION TRIAD: Intentional? External gain? Applied to self or other?

Q5  Answer: C  [SOMATIC SYMPTOM & RELATED DISORDERS]

MALINGERING: intentional symptom production for EXTERNAL GAIN. NOT a mental disorder in DSM-5 — it is classified as a "condition for clinical attention" (V-code/Z-code). External incentives include: financial gain (workers' compensation, lawsuits), obtaining controlled substances, avoiding military service or legal consequences. KEY CLINICAL TIPS: Waddell signs suggest non-organic LBP; symptom inconsistency; patient himself states he is not in real pain. Management: DO NOT prescribe requested medications; do not reinforce the behavior; consider social work, legal consultation, behavioral health referral. COMPARISON: Factitious = intentional, NO external gain (sick role); Malingering = intentional, YES external gain; SSD/Conversion = NOT intentional.

Q6  Answer: B  [SOMATIC SYMPTOM & RELATED DISORDERS]

SSD PROGNOSIS: CHRONIC, undulating, relapsing course. Rarely remits completely. Almost NEVER symptom-free for >1 year. Patients often seek care from multiple providers (doctor shopping). High medical care utilization does NOT alleviate concerns — in fact, extensive workup can reinforce health anxiety. KEY MANAGEMENT STRATEGY: limit unnecessary testing (reinforces disease belief), schedule regular brief visits with ONE provider, offer reassurance once organic cause ruled out, refer to psychotherapy if accepted. Treat any comorbid anxiety or depression (80% have comorbid mental illness) — this can improve overall functioning. Pharmacotherapy has no direct indication for SSD itself.

Q7  Answer: B  [SOMATIC SYMPTOM & RELATED DISORDERS]

FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER (FNSD/Conversion Disorder) EXAM SIGNS: HOOVER SIGN (most classic): in a patient with "paralyzed" hip extension, ask them to flex the CONTRALATERAL hip against resistance; if the "paralyzed" leg extends involuntarily = POSITIVE = functional weakness (normal motor pathways are intact but patient is not consciously activating them). For upper extremity: Arm Drop test — arm held over face; in functional weakness arm drops to side; in true paralysis arm drops onto face. Tremor entrainment: functional tremor changes frequency when patient performs a voluntary rhythmic task with the contralateral hand. These tests demonstrate INCOMPATIBILITY with organic neurological disease — the key diagnostic criterion. Treatment: PT, OT, psychotherapy (CBT most studied); prognosis variable.

Q8  Answer: B  [SOMATIC SYMPTOM & RELATED DISORDERS]

THE INTENTIONALITY/GAIN MATRIX (highest-yield psych distinction): SOMATIC SYMPTOM DISORDER: NOT intentional, NO external gain. ILLNESS ANXIETY DISORDER: NOT intentional, NO external gain. CONVERSION DISORDER: NOT intentional, NO external gain. FACTITIOUS DISORDER: INTENTIONAL, NO external gain (motivated by sick role). MALINGERING: INTENTIONAL, YES external gain (financial, legal, drug-seeking, military avoidance). This patient: intentionally faking seizures to avoid criminal consequences = EXTERNAL GAIN = MALINGERING. Management of malingering: do not validate the claim, do not provide secondary gain, social work and legal consultation, psychiatric referral if underlying mental disorder suspected.

Q9  Answer: B  [SOMATIC SYMPTOM & RELATED DISORDERS]

SSD MANAGEMENT PRINCIPLES from lecture: SINGLE PROVIDER relationship is essential. REGULARLY SCHEDULED VISITS (not symptom-triggered visits) — scheduling visits in response to symptoms reinforces the behavior (operant conditioning; similar to school refusal). Do NOT avoid the patient — this increases anxiety. Use visits for: reassurance after excluding organic cause, psychoeducation, therapeutic relationship building. Limit (but don't eliminate) medical testing. Refer to psychotherapy if patient is receptive (CBT most studied). Treat comorbid anxiety or depression pharmacologically if present. Do NOT prescribe benzodiazepines for health anxiety in SSD — this reinforces avoidance and adds dependence risk. Avoid polypharmacy.

Q10  Answer: B  [SOMATIC SYMPTOM & RELATED DISORDERS]

IAD vs SSD DEFINITIVE DISTINCTION: IAD (formerly hypochondriasis): FEAR of HAVING a serious disease; MINIMAL or NO actual somatic symptoms; preoccupation is with the DISEASE CONCEPT itself (e.g., "I have cancer"); health-related behaviors = excessive checking, reassurance-seeking, avoidance of medical care. SSD: SIGNIFICANT somatic symptoms that are distressing + excessive THOUGHTS/FEELINGS/BEHAVIORS about those symptoms; the focus is on the SYMPTOM (e.g., pain, fatigue) not the disease concept per se. BOTH: NOT intentional; authentic distress; diagnosis of exclusion; psychotherapy is mainstay. Clinical memory trick: IAD = "I'm terrified I HAVE cancer" (no symptoms); SSD = "This pain is ruining my life" (significant symptoms + excessive behaviors around them).

Q11  Answer: B  [EATING DISORDERS & OCD-SPECTRUM]

ANOREXIA NERVOSA: restriction of food intake → significantly low body weight + intense fear of gaining weight + distorted body image. Physical findings: BRADYCARDIA (most common cardiac finding), LANUGO (fine body hair — thermoregulation), AMENORRHEA (hypothalamic suppression), orthostatic hypotension, cold intolerance, dry skin, muscle wasting, bone loss. LEADING CAUSE OF DEATH: CARDIAC ARRHYTHMIA (electrolyte disturbances — hypokalemia, hypomagnesemia, hypophosphatemia → prolonged QT → torsades de pointes). Highest mortality of any psychiatric disorder (~5–10% lifetime). REFEEDING SYNDROME: rapid nutritional rehabilitation → phosphate shifts intracellularly → hypophosphatemia → cardiac/respiratory failure. Prevention: gradual caloric increase (start low, go slow), phosphate monitoring + supplementation, thiamine supplementation. Treatment: medical stabilization, nutritional rehab, CBT, FBT (family-based therapy for adolescents), ± olanzapine.

Q12  Answer: B  [EATING DISORDERS & OCD-SPECTRUM]

BULIMIA NERVOSA: recurrent binge eating + compensatory behaviors (purging, laxatives, fasting, excessive exercise). Normal or slightly below-normal weight (BMI NOT markedly low — distinguishes from anorexia). PURGING ELECTROLYTES: vomiting → loss of HCl → HYPOKALEMIA + METABOLIC ALKALOSIS (↑ bicarb). Classic signs: DENTAL EROSION on LINGUAL surfaces (repeated acid exposure), PAROTID GLAND ENLARGEMENT (salivary gland hypertrophy from repeated purging), RUSSELL SIGN (dorsal hand calluses from induced vomiting — finger touches teeth). PHARMACOTHERAPY: FLUOXETINE 60 mg = ONLY FDA-approved drug for bulimia nervosa (higher than usual 20 mg MDD dose). FIRST-LINE OVERALL: CBT (most effective). Lisdexamfetamine (Vyvanse) = FDA-approved for BINGE EATING DISORDER (not bulimia). Distinguish: Binge eating disorder = recurrent binges WITHOUT compensatory behaviors.

Q13  Answer: B  [EATING DISORDERS & OCD-SPECTRUM]

REFEEDING SYNDROME: life-threatening complication of rapid nutritional rehabilitation in severely malnourished patients. MECHANISM: starvation → intracellular depletion of phosphate (body uses phosphate to maintain ATP). Upon refeeding → carbohydrate intake → ↑ insulin → drives phosphate (and K+, Mg2+) from extracellular INTO cells → SEVERE HYPOPHOSPHATEMIA → ATP depletion → CARDIAC ARRHYTHMIA, RESPIRATORY FAILURE, HEMOLYTIC ANEMIA, RHABDOMYOLYSIS, SEIZURES. PRIMARY DRIVER = HYPOPHOSPHATEMIA. PREVENTION: (1) Slow caloric initiation (start 10–20 kcal/kg/day), (2) MONITOR phosphate, potassium, magnesium BEFORE and DURING refeeding, (3) Supplement electrolytes proactively, (4) THIAMINE supplementation (also at risk in malnourished). High-risk patients: anorexia nervosa, chronic alcoholism, prolonged fasting, cancer cachexia.

Q14  Answer: B  [EATING DISORDERS & OCD-SPECTRUM]

BODY DYSMORPHIC DISORDER (BDD): preoccupation with one or more perceived DEFECTS in physical appearance that are NOT observable or appear slight to others. The preoccupation causes clinically significant distress or impairment. Repetitive behaviors: mirror checking/avoidance, excessive grooming, skin picking, seeking cosmetic procedures (which rarely satisfy), reassurance seeking, camouflaging. FIRST-LINE TREATMENT: CBT (ERP) + SSRI (high doses, similar to OCD). Cosmetic procedures are generally NOT helpful and often worsen the disorder. BDD is ego-DYSTONIC (patient is distressed). Distinguish from anorexia: BDD = specific perceived physical defect (not body weight/shape). Distinguish from IAD: IAD = fear of having a disease; BDD = preoccupation with a perceived physical flaw. Distinct from narcissistic PD (which is ego-syntonic and involves grandiosity, not distress about flaws).

Q15  Answer: B  [EATING DISORDERS & OCD-SPECTRUM]

HOARDING DISORDER: a SEPARATE DSM-5 diagnosis from OCD. Core features: (1) PERSISTENT DIFFICULTY DISCARDING possessions regardless of actual value, (2) difficulty driven by PERCEIVED NEED TO SAVE items and DISTRESS associated with discarding, (3) accumulation results in CLUTTER that compromises the use of living areas, (4) causes significant distress or impairment. DISTINGUISH FROM OCD: OCD hoarding = driven by obsessions (contamination, harm) with compulsive acquisition; hoarding disorder = intrinsic positive/negative reinforcement from saving items without classic obsessions. TREATMENT: CBT (hoarding-specific) including motivational interviewing (many patients are ego-syntonic), exposure (discarding practice), cognitive restructuring. SSRIs: modest benefit. Home visits often necessary. High relapse rate. OCPD: perfectionism + control + rigidity — not the same as hoarding.

Q16  Answer: B  [EATING DISORDERS & OCD-SPECTRUM]

TRICHOTILLOMANIA (Hair-Pulling Disorder): recurrent compulsive pulling of hair (scalp, eyebrows, eyelashes most common) → hair loss. Classic tension/urge BEFORE pulling and relief/gratification/reduced tension AFTER. Ego-dystonic — patient is distressed by the behavior. Multiple failed attempts to stop. TREATMENT: CBT — specifically HABIT REVERSAL TRAINING (HRT): (1) awareness training (recognize urges), (2) competing response (squeeze fist when urge occurs). N-ACETYLCYSTEINE (NAC): reduces glutamate and compulsive urges — has RCT evidence. CLOMIPRAMINE: TCA with anti-OCD properties; used if CBT/NAC insufficient. SSRIs: mixed evidence for trichotillomania specifically. DISTINGUISH FROM ALOPECIA AREATA: AA = smooth, round patches, no broken hairs at margins, autoimmune, nail pitting possible; Trichotillomania = irregular patches, broken hairs at borders, behavioral history.

Q17  Answer: B  [EATING DISORDERS & OCD-SPECTRUM]

OCD TREATMENT: FIRST-LINE = CBT (ERP — Exposure and Response Prevention) AND SSRI (used at HIGHER DOSES than for depression/anxiety: sertraline up to 200 mg, fluoxetine up to 80 mg, fluvoxamine up to 300 mg, paroxetine up to 60 mg). Combined treatment (CBT+SSRI) superior to either alone. CLOMIPRAMINE (TCA): used when SSRIs fail; most efficacious anti-obsessional agent but more side effects (anticholinergic, cardiac). OCD vs OCPD DISTINCTION: OCD = EGO-DYSTONIC (patient recognizes thoughts as irrational, is distressed, DOES NOT want them) + true obsessions (intrusive, unwanted thoughts) + compulsions (rituals to reduce anxiety). OCPD = EGO-SYNTONIC (traits are comfortable, "correct," consistent with self) + perfectionism, rigidity, orderliness WITHOUT true obsessions or compulsions. Illness anxiety disorder: fear of having a disease (not the process of contamination leading to disease).

Q18  Answer: B  [EATING DISORDERS & OCD-SPECTRUM]

EXCORIATION DISORDER (Skin-Picking / Dermatillomania): DSM-5 classifies it under OBSESSIVE-COMPULSIVE AND RELATED DISORDERS. Recurrent compulsive skin picking → skin lesions. Tension/urge before picking, relief/pleasure/reduced tension after. Multiple failed attempts to stop. Ego-dystonic. Distinguishes from: NSSI in BPD (function is emotional regulation, not compulsive urge-relief cycle); Factitious disorder (intentional production of symptoms for sick role, not compulsive behavior). TREATMENT: CBT (HABIT REVERSAL TRAINING — same approach as trichotillomania), N-ACETYLCYSTEINE (NAC — modulates glutamate signaling in compulsive behaviors; evidence from RCTs in trichotillomania and skin picking). SSRIs may have benefit. Compare with trichotillomania: same treatment approach, same disorder class, same mechanism.

Q19  Answer: B  [EATING DISORDERS & OCD-SPECTRUM]

OCD PHARMACOTHERAPY: FDA-APPROVED MEDICATIONS: (1) SSRI class: fluoxetine (20–80 mg), sertraline (50–200 mg), fluvoxamine (100–300 mg), paroxetine (20–60 mg). (2) CLOMIPRAMINE (TCA, 75–250 mg): most efficacious but limited by side effects (anticholinergic, weight gain, cardiac — QTc prolongation; monitor in cardiac patients). DOSING PEARLS: Higher doses required than for depression. SLOWER response: need 8–12 weeks minimum trial before concluding failure (vs 4–6 weeks for depression). AUGMENTATION if partial response: add antipsychotic (risperidone, aripiprazole), add CBT, or switch to clomipramine. COMBINED CBT+SSRI: superior to either alone. OCD circuit: hyperactivity of orbitofrontal cortex → caudate → thalamus → OFC loop (cortico-striato-thalamo-cortical circuit). Benzodiazepines: not effective for OCD (do not address the underlying circuit; may worsen avoidance).

Q20  Answer: B  [EATING DISORDERS & OCD-SPECTRUM]

SOCIAL ANXIETY DISORDER: intense, persistent fear of social situations in which the person is exposed to possible scrutiny by others, accompanied by fear of embarrassment/humiliation. Avoidance of social situations or endured with intense distress. Causes significant functional impairment. TREATMENT: CBT (gold standard — especially exposure-based), SSRI/SNRI (first-line pharmacotherapy). Beta-blockers (propranolol) for performance anxiety (situational). Must distinguish from: AVOIDANT PD (similar features but more pervasive, trait-level — may overlap); SCHIZOID PD (does NOT want relationships — this patient WANTS friends = NOT schizoid); AGORAPHOBIA (fear of specific situations — public transport, crowds — not primarily about social scrutiny). Eating-related social anxiety is a feature of eating disorders but this patient's core fear is social scrutiny, not food/weight.

Q21  Answer: B  [SUBSTANCE USE DISORDERS]

ALCOHOL WITHDRAWAL MANAGEMENT: BENZODIAZEPINES = FIRST-LINE. Cross-tolerant with alcohol (both act at GABA-A receptors). Diazepam (long-acting, preferred in most patients) or lorazepam (preferred in liver disease — no active metabolites). CIWA-Ar score guides dosing (symptom-triggered protocol). TIMELINE: 6–24h = tremors, anxiety, tachycardia, diaphoresis; 24–48h = SEIZURES (generalized tonic-clonic); 48–96h = DELIRIUM TREMENS peak (tremor + autonomic instability + confusion + visual hallucinations). ANTIPSYCHOTICS ALONE: CONTRAINDICATED as monotherapy — they lower the seizure threshold and do NOT treat GABA dysregulation. Can be used as ADJUNCTS to benzos for refractory agitation/psychosis. THIAMINE BEFORE GLUCOSE: IV glucose without thiamine → Wernicke encephalopathy (confusion + ataxia + ophthalmoplegia → Korsakoff with confabulation if untreated). Never naltrexone or disulfiram during acute withdrawal.

Q22  Answer: B  [SUBSTANCE USE DISORDERS]

SUBOXONE (BUPRENORPHINE/NALOXONE) PHARMACOLOGY: BUPRENORPHINE = partial mu-opioid AGONIST with high receptor affinity (displaces full agonists). CEILING EFFECT on respiratory depression → safer than full agonists in overdose. Reduces cravings and withdrawal. NALOXONE = opioid receptor ANTAGONIST. WHEN TAKEN SUBLINGUALLY (as prescribed): naloxone is POORLY ABSORBED sublingually → negligible systemic effect → buprenorphine acts alone therapeutically. WHEN INJECTED IV (misuse): naloxone IS absorbed systemically → blocks opioid receptors → PRECIPITATES ACUTE WITHDRAWAL in opioid-dependent person → severe discomfort → deters IV injection. Buprenorphine monotherapy (Subutex): used in PREGNANCY (naloxone potentially concerns about fetal effects; though evidence limited). Prescribing: DATA 2000 waiver allows office-based prescription (unlike methadone which requires licensed OTP).

Q23  Answer: B  [SUBSTANCE USE DISORDERS]

MAT COMPARISON (high-yield): METHADONE: full mu-opioid AGONIST; eliminates withdrawal and craving; dispensed ONLY at federally licensed OTPs (cannot prescribe from office); long half-life (24–36h) → drug accumulation risk; QTc prolongation concern (monitor EKG); highest misuse/diversion potential. BUPRENORPHINE/NALOXONE: partial agonist; ceiling on respiratory depression; prescribable in office setting (DATA 2000); lower misuse potential. NALTREXONE (oral ReVia or monthly IM Vivitrol): opioid ANTAGONIST — NO agonist activity; blocks opioid receptors; reduces rewarding effects if patient relapses; also used for alcohol use disorder; MUST COMPLETE FULL DETOX FIRST (≥7–10 days off short-acting opioids, ≥14 days off long-acting) before starting — otherwise precipitates severe acute withdrawal. Best for highly motivated patients who have completed detox. Monthly injection (Vivitrol) significantly improves adherence.

Q24  Answer: B  [SUBSTANCE USE DISORDERS]

PHARMACOTHERAPY FOR ALCOHOL USE DISORDER: NALTREXONE: mechanism = OPIOID RECEPTOR ANTAGONIST; alcohol → endogenous opioid release in nucleus accumbens (reward) → naltrexone blocks → ↓ rewarding effects → ↓ craving and drinking. FDA-approved for AUD. Oral (daily adherence issue) or monthly IM Vivitrol (better adherence). CI: current opioid use (precipitates withdrawal); acute hepatitis/liver failure (hepatotoxic at high doses). DISULFIRAM: aldehyde dehydrogenase inhibitor → acetaldehyde accumulates → flushing, nausea, vomiting (disulfiram-ethanol reaction); aversion therapy; requires high motivation; avoid in cardiovascular disease; patient must be sober before starting. ACAMPROSATE: glutamate/GABA modulator; reduces protracted withdrawal discomfort/craving; best for patients ALREADY ABSTINENT; renal excretion → safe in liver disease. Methadone = opioid agonist — not used for alcohol use disorder.

Q25  Answer: B  [SUBSTANCE USE DISORDERS]

POLYSUBSTANCE TOXICOLOGY — PUPIL GUIDE: OPIOIDS = MIOSIS (pinpoint); ANTICHOLINERGICS = MYDRIASIS (dilated, dry, hot, red); STIMULANTS/sympathomimetics = MYDRIASIS; BENZODIAZEPINES/ALCOHOL/GHB = MID-SIZED and REACTIVE (no dramatic pupil change). Naloxone reverses ONLY opioids — no response here confirms non-opioid CNS depressant. FLUMAZENIL: competitive benzodiazepine ANTAGONIST at GABA-A receptor; reverses sedation; use CAUTIOUSLY in chronic BZD users (PRECIPITATES ACUTE WITHDRAWAL + SEIZURES — GABA-A receptor downregulated). SHORT duration (30–60 min) — re-sedation possible. GHB: no reversal agent; short-acting; supportive care. MANAGEMENT priority: AIRWAY (jaw thrust, positioning, OPA/NPA), O₂, consider intubation if GCS <8, monitoring, supportive care. Never induce emesis in obtunded patient.

Q26  Answer: A  [SUBSTANCE USE DISORDERS]

FAMILY BEHAVIOR PATTERNS IN SUD: ENABLING = when a family member tries to "help" but inadvertently REINFORCES harmful behavior (e.g., giving money so the person doesn't steal → enables continued drug use). DENIAL = refusal/unwillingness to acknowledge the loved one's addiction or that it causes problems. CODEPENDENCY = pathological relationship where one person enables a loved one's irresponsible/destructive behavior; involves denial, enabling, pathological interdependencies. NEUROBIOLOGY OF ADDICTION: "brain disease" model. ALL addictive drugs → surge of DOPAMINE in BASAL GANGLIA (nucleus accumbens = reward center) → pleasure/euphoria. Repeated use → receptor DESENSITIZATION → TOLERANCE. WITHDRAWAL → activates AMYGDALA (fear/emotion center) → fear of being without substance. Chronic use → PREFRONTAL CORTEX dysfunction → impaired decision-making, loss of control. Initiating factors ≠ maintaining factors; genetics contribute significantly (twin/adoption studies).

Q27  Answer: B  [SUBSTANCE USE DISORDERS]

BENZODIAZEPINE WITHDRAWAL — LIFE-THREATENING: mechanism parallels alcohol withdrawal (both at GABA-A). Chronic BZD → GABA-A DOWNREGULATION → abrupt stop → GABA-A hypoactivity → CNS hyperexcitability → SEIZURES, DELIRIUM, autonomic instability. Risk is higher with: shorter-acting agents (alprazolam, lorazepam — faster drop in levels), higher doses, longer duration. MANAGEMENT: GRADUAL TAPER — convert to LONG-ACTING equivalent (diazepam) for smooth taper (no peaks/troughs); reduce by ~10% per week. May take weeks to months. NEVER abrupt discontinuation in physically dependent patients. Flumazenil: CONTRAINDICATED in BZD dependence (precipitates acute withdrawal + seizures). Compare with OPIOID withdrawal: miserable (GI distress, piloerection, myalgias, lacrimation, yawning, restlessness) but RARELY life-threatening. GABA-ergic withdrawals (alcohol + BZD + barbiturates) = potentially lethal.

Q28  Answer: B  [SUBSTANCE USE DISORDERS]

ADHERENCE STRATEGY IN AUD: MONTHLY NALTREXONE IM (Vivitrol): excellent choice for adherence issues; once-monthly injection eliminates daily pill burden; opioid antagonist reduces rewarding effects of alcohol. LIVER CONSIDERATIONS: Naltrexone has a BLACK BOX WARNING for hepatotoxicity at HIGH DOSES (e.g., 300 mg used for obesity trials) — NOT typically clinically significant at standard AUD doses (50 mg oral or 380 mg IM monthly). MILD elevated LFTs from AUD itself are common and do NOT contraindicate naltrexone. CI: ACUTE HEPATITIS or LIVER FAILURE. ACAMPROSATE: best for patients who are ALREADY ABSTINENT; reduces protracted withdrawal discomfort; renally excreted → safe in liver disease but requires TID dosing. DISULFIRAM: aversion therapy; CI with elevated LFTs (can worsen hepatotoxicity); requires daily dosing and strict motivation. METHADONE: opioid agonist — NOT for alcohol use disorder.

Q29  Answer: B  [SUBSTANCE USE DISORDERS]

CRAFFT SCREENING TOOL (for adolescent substance use): C = Car: Have you ever ridden in a car driven by someone (including yourself) who was high? R = Relax: Do you ever use to relax, feel better, or fit in? A = Alone: Do you ever use alone? F = Forget: Do you ever forget things you did while using? F = Friends/Family: Have friends/family ever told you to cut down? T = Trouble: Have you ever gotten into trouble while using? SCORE ≥2 = POSITIVE → warrants further assessment and brief intervention. Score 3 = moderate risk level. RESPONSE: brief motivational interviewing in the office, further SUD assessment, consider outpatient counseling referral. NOT automatic inpatient or mandatory parental notification at every positive screen — balance confidentiality with safety (mandatory reporting if serious safety risk). Most common adolescent substances: alcohol, marijuana, then prescription medications.

Q30  Answer: B  [SUBSTANCE USE DISORDERS]

TOXIDROME DISTINCTIONS (high-yield): SYMPATHOMIMETIC (cocaine, amphetamines, MDMA): tachycardia, hypertension, hyperthermia, DIAPHORESIS (key!), MYDRIASIS, agitation, seizures. ANTICHOLINERGIC (diphenhydramine, TCAs, atropine): tachycardia, hypertension, hyperthermia, DRY SKIN (key!), MYDRIASIS, urinary retention, decreased bowel sounds, flushing, delirium. KEY DIFFERENTIATOR: DIAPHORESIS (wet) = sympathomimetic; DRY SKIN = anticholinergic. OPIOID: bradypnea, MIOSIS (pinpoint), decreased consciousness. CHOLINERGIC (SLUDGE = Salivation, Lacrimation, Urination, Defecation, GI cramping, Emesis + bradycardia, miosis, bronchospasm). SEROTONIN SYNDROME: hyperthermia + CLONUS/MYOCLONUS + diaphoresis + agitation + hyperreflexia (confusion: sympathomimetic but clonus is pathognomonic for serotonin syndrome). Treatment of sympathomimetic: benzodiazepines for agitation/seizures, external cooling, avoid beta-blockers alone (unopposed alpha vasospasm).

Q31  Answer: B  [PERSONALITY DISORDERS]

BPD HALLMARKS: (1) Frantic efforts to avoid abandonment, (2) Unstable intense relationships alternating between idealization and devaluation, (3) Identity disturbance, (4) Impulsivity in ≥2 self-damaging areas, (5) Recurrent suicidal/NSSI behavior, (6) Affective instability, (7) Chronic emptiness, (8) Inappropriate intense anger, (9) Transient paranoia/dissociation under stress. SPLITTING: defense mechanism = sees people as entirely good or entirely bad (no middle ground); switches rapidly. GOLD STANDARD: DIALECTICAL BEHAVIOR THERAPY (DBT) — developed specifically for BPD by Marsha Linehan; combines CBT + mindfulness (distress tolerance, emotion regulation, interpersonal effectiveness). Pharmacotherapy: adjunctive (low-dose antipsychotics for brief psychotic episodes, mood stabilizers for impulsivity, SSRIs for depression). Suicide risk: 10% completed lifetime suicide rate in BPD — requires thorough assessment every episode.

Q32  Answer: B  [PERSONALITY DISORDERS]

NPD CORE FEATURES (≥5 of 9 required): grandiose sense of self-importance, preoccupied with fantasies of unlimited success/power/beauty, believes special and unique, requires excessive admiration, sense of entitlement, interpersonally exploitative, lacks empathy, envious of others or believes others are envious of them, arrogant/haughty. EGO-SYNTONIC — traits are acceptable and consistent with patient's self-concept (unlike BPD where identity is unstable and the patient is often distressed). NPD vs BPD: NPD = STABLE (even if inflated) self-image; BPD = UNSTABLE self-image. NPD = no significant self-harm or suicidal behavior; BPD = suicidal gestures/NSSI. NPD = grandiosity; BPD = splitting. NPD vs ASPD: ASPD = BEHAVIORAL violations of others' rights (criminal acts, aggression, fraud) + conduct disorder before 15; NPD = grandiosity/entitlement without required CD history. Both lack empathy.

Q33  Answer: B  [PERSONALITY DISORDERS]

SCHIZOID PD vs AVOIDANT PD — CRITICAL DISTINCTION: SCHIZOID: DOES NOT WANT relationships; aloneness is EGO-SYNTONIC (comfortable); does not experience loneliness; flat, detached affect; indifferent to praise or criticism; no magical thinking (distinguishes from schizotypal). AVOIDANT: WANTS relationships but FEARS REJECTION/CRITICISM; aloneness is EGO-DYSTONIC (distressing); hypersensitive to criticism; low self-esteem; will engage socially if guaranteed of uncritical acceptance. SCHIZOTYPAL (also Cluster A): ODD BELIEFS (magical thinking, ideas of reference, telepathy), ODD PERCEPTIONS (illusions), ODD SPEECH, eccentric appearance; social isolation BUT may want relationships; most closely related to schizophrenia spectrum. Memory: Cluster A = Weird (Paranoid/Schizoid/Schizotypal); B = Wild (Antisocial/Borderline/Histrionic/Narcissistic); C = Worried (Avoidant/Dependent/OCPD).

Q34  Answer: B  [PERSONALITY DISORDERS]

ASPD DIAGNOSTIC REQUIREMENTS: (1) Current age ≥18; (2) Evidence of CONDUCT DISORDER BEFORE AGE 15. Conduct disorder (CD) = same behavioral domains as ASPD: aggression toward people/animals, destruction of property, deceitfulness/theft, serious rule violations (truancy, running away). ASPD FEATURES: pervasive disregard for and violation of rights of others; deceitfulness (chronic lying, manipulation); impulsivity; aggressiveness (fights, assaults); irresponsibility (fails to sustain work/financial obligations); lack of remorse. EGO-SYNTONIC — patient blames others ("they deserved it"). "Psychopathy" and "sociopathy" are colloquial terms related to ASPD. TREATMENT: very difficult; DBT shows some evidence for impulsivity; treat comorbid SUD (46% of ASPD patients have SUD). Conduct disorder in children/adolescents: same domains but age <18. ODD → CD → ASPD is a potential developmental trajectory.

Q35  Answer: B  [PERSONALITY DISORDERS]

HISTRIONIC PD (Cluster B): ≥5 of 8 criteria: (1) uncomfortable when not center of attention, (2) interactions characterized by sexually provocative/inappropriate behavior, (3) shallow and rapidly shifting emotions, (4) uses physical appearance to draw attention, (5) speech excessively impressionistic and lacking in detail (vague, theatrical), (6) SUGGESTIBLE (easily influenced by others or circumstances), (7) considers relationships more intimate than they actually are, (8) self-dramatization and theatricality. EGO-SYNTONIC. More commonly diagnosed in women (though may reflect diagnostic bias). DISTINGUISH FROM NPD: histrionic seeks ATTENTION and emotional response from others; NPD seeks ADMIRATION and specialness. BPD: identity disturbance + splitting + suicidal behavior. Histrionic: no identity instability or self-harm as features. Treatment: psychotherapy (insight-oriented, CBT); patients may initially present seeking attention from the therapist.

Q36  Answer: B  [PERSONALITY DISORDERS]

PARANOID PD vs DELUSIONAL DISORDER vs SCHIZOPHRENIA: PARANOID PD: overvalued SUSPICIONS (not fixed false beliefs); can acknowledge some doubt when pressed; no hallucinations; no formal thought disorder; pervasive across situations since early adulthood. DELUSIONAL DISORDER (persecutory type): FIXED FALSE BELIEFS impervious to evidence/logic; functioning otherwise relatively intact; no hallucinations (or only brief/not prominent); the belief is circumscribed. SCHIZOPHRENIA: positive symptoms (hallucinations, delusions, disorganized speech/behavior) + negative symptoms; significant functional decline. PARANOID PD CRITERIA: suspects exploitation/harm without basis, preoccupied with loyalty of friends, won't confide, reads hidden threatening meanings, bears grudges, perceives attacks on character, unjustified suspicion of partner's fidelity. Epidemiology: 0.5–2.5%; more common in men; higher in relatives of schizophrenia patients. Rarely seeks treatment.

Q37  Answer: B  [PERSONALITY DISORDERS]

AVOIDANT PD (Cluster C) CRITERIA: (1) avoids occupational activities involving significant interpersonal contact due to FEAR OF CRITICISM/DISAPPROVAL/REJECTION, (2) unwilling to get involved unless certain of being liked, (3) shows restraint in intimate relationships due to fear of shame/ridicule, (4) preoccupied with being criticized or rejected in social situations, (5) inhibited in new interpersonal situations due to feelings of inadequacy, (6) views self as socially inept, unappealing, or inferior, (7) reluctant to take personal risks for fear of embarrassment. EGO-DYSTONIC — wants connection but is too afraid. SCHIZOID = does NOT want relationships (ego-syntonic); would not feel distress about eating alone. AVOIDANT vs SOCIAL ANXIETY DISORDER: significant overlap; DSM-5 acknowledges may be same spectrum; AvPD more pervasive trait-level pattern. TREATMENT: CBT (social skills training + graduated exposure), SSRIs/SNRIs for underlying anxiety.

Q38  Answer: B  [PERSONALITY DISORDERS]

OCPD vs OCD — CRITICAL EXAM DISTINCTION: OCPD (Cluster C): preoccupation with orderliness, perfectionism, and mental and interpersonal control. Features: perfectionism that interferes with task completion, excessive devotion to work/productivity, inflexibility about morality/ethics, hoarding of worthless objects, inability to delegate, miserliness, rigidity and stubbornness. EGO-SYNTONIC — patient does NOT experience traits as unwanted or distressing (considers them virtues). NO true obsessions (unwanted intrusive thoughts) and NO true compulsions (rituals performed to reduce anxiety). OCD: EGO-DYSTONIC — obsessions are intrusive, unwanted, anxiety-provoking; compulsions are performed to reduce anxiety from obsessions; patient is DISTRESSED by the symptoms. Treatment: OCPD = psychotherapy (CBT, insight-oriented); OCD = ERP + SSRIs. Comorbidity possible: some patients have both.

Q39  Answer: B  [PERSONALITY DISORDERS]

CLUSTER A AND SCHIZOPHRENIA SPECTRUM: BIOLOGICAL RELATIONSHIP — cluster A PDs occur at HIGHER RATES in family members of schizophrenia patients, particularly schizotypal PD. Schizotypal PD is considered part of the schizophrenia spectrum (DSM-5 places it in both PD chapter and schizophrenia spectrum chapter). SCHIZOTYPAL KEY FEATURES: ODD BELIEFS/MAGICAL THINKING (not just culture-bound; patient endorses paranormal phenomena); IDEAS OF REFERENCE (events seem to have special meaning for the patient — NOT delusional intensity; patient can question this); ODD PERCEPTIONS; ODD SPEECH (loose associations, metaphorical, circumstantial); SUSPICIOUSNESS; inappropriate affect; eccentric appearance. SOCIAL ISOLATION but may desire relationships (distinguishes from schizoid). NO sustained psychotic episode (distinguishes from schizophrenia). Brief psychotic episodes possible under stress. Prevalence: ~3% general population. More common in relatives of schizophrenia patients.

Q40  Answer: B  [PERSONALITY DISORDERS]

BPD PHARMACOTHERAPY PRINCIPLES: FROM LECTURE: "Medications are in NO WAY CURATIVE for any personality disorder." In BPD, pharmacotherapy is ADJUNCTIVE and symptom-targeted: COGNITIVE-PERCEPTUAL SYMPTOMS (paranoia, ideas of reference, dissociation, brief psychotic episodes): LOW-DOSE ANTIPSYCHOTICS (olanzapine, quetiapine, aripiprazole). AFFECTIVE INSTABILITY and IMPULSIVITY: MOOD STABILIZERS (valproate, lamotrigine) — some evidence for reducing impulsivity and affective instability. DEPRESSIVE SYMPTOMS, EMPTINESS, REJECTION SENSITIVITY: SSRIs (limited evidence for core BPD symptoms specifically). BENZODIAZEPINES: AVOID in BPD — risk of dependence (very high SUD comorbidity in BPD, up to 78%), behavioral disinhibition, and use for parasuicidal behavior. GOLD STANDARD: DBT (Dialectical Behavior Therapy) — primary treatment. Pharmacotherapy targets specific symptom dimensions, never the disorder as a whole.

Q41  Answer: B  [TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS]

PTSD DSM-5 CRITERIA: Exposure to actual/threatened death, serious injury, or sexual violence (directly, witnessed, learned of close family/friend, or repeated exposure to traumatic details). Then 4 symptom clusters: (1) INTRUSION: ≥1 of: recurrent involuntary memories, recurrent distressing dreams, dissociative reactions (flashbacks), intense psychological/physiologic distress at trauma cues. (2) AVOIDANCE: ≥1 of: avoidance of trauma-related thoughts/feelings OR external reminders. (3) NEGATIVE COGNITION/MOOD: ≥2 of: inability to remember key aspect, persistent negative beliefs, distorted blame, persistent negative emotional state, anhedonia, detachment, inability to feel positive emotions. (4) HYPERAROUSAL: ≥2 of: irritability/anger, reckless/self-destructive behavior, hypervigilance, exaggerated startle, concentration problems, sleep disturbance. All clusters >1 MONTH, cause significant distress/impairment. ASD = 3 days to 1 month; same symptom domains + dissociation required in ASD.

Q42  Answer: B  [TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS]

ASD vs PTSD TIMELINE: ASD: onset within 4 weeks of trauma; duration 3 DAYS to 1 MONTH. If symptoms persist >1 month = reclassify as PTSD. ASD DIAGNOSIS: same 4 symptom clusters as PTSD + ASD also requires DISSOCIATIVE SYMPTOMS (depersonalization, derealization, or dissociative amnesia). EARLY INTERVENTION: TRAUMA-FOCUSED CBT (Prolonged Exposure, Cognitive Processing Therapy) initiated within days to weeks after trauma significantly REDUCES conversion from ASD to PTSD — most effective early intervention. SSRIs: NOT first-line for ASD. CRITICAL BEER score can help stratify risk. NOTE: ~50% of ASD → PTSD. Approximately 10% lifetime prevalence of PTSD overall. Highest rates: military combat, rape survivors, genocide survivors (up to 50% of those exposed). Risk factors: childhood trauma, female gender, younger age, inadequate social support, prior mental illness.

Q43  Answer: B  [TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS]

ADJUSTMENT DISORDER: maladaptive emotional/behavioral response to an identifiable psychosocial stressor. KEY CRITERIA: (1) emotional/behavioral symptoms develop within 3 MONTHS of stressor onset, (2) symptoms are disproportionate to the stressor or cause significant distress/functional impairment, (3) DOES NOT MEET criteria for another specific mental disorder (e.g., MDD, PTSD), (4) RESOLVES WITHIN 6 MONTHS after the stressor (or its consequences) ends. SUBTYPES: with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance. DISTINGUISHES FROM MDD: MDD requires ≥5 symptoms ≥2 weeks including depressed mood or anhedonia — regardless of a precipitating stressor. MDD is diagnosed even if there is a stressor. From PTSD: no trauma criterion met. TREATMENT: supportive psychotherapy, brief CBT; typically short-term. Pharmacotherapy if severe or if meeting MDD/anxiety disorder criteria.

Q44  Answer: B  [TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS]

PROLONGED GRIEF DISORDER (PGD — new DSM-5-TR diagnosis): persistent, intense grief lasting >12 MONTHS (>6 months in children) after bereavement that causes significant distress/impairment. Core features: intense YEARNING for the deceased, DIFFICULTY ACCEPTING the death, BITTERNESS or ANGER about the loss, difficulty trusting others since the loss, feeling PART OF SELF DIED, difficulty engaging in activities, feeling LIFE IS MEANINGLESS without the deceased, emotional NUMBNESS. DISTINGUISHES FROM NORMAL GRIEF: normal grief = waves of sadness that gradually diminish with time; can experience positive memories and emotions; functional recovery occurs. DISTINGUISHES FROM MDD: PGD focuses on grief-specific symptoms (yearning, difficulty accepting) rather than pervasive depressed mood and anhedonia. TREATMENT: grief-focused therapy (Complicated Grief Treatment — CGT); antidepressants have some evidence but grief-specific therapy superior. From PTSD: death must involve traumatic exposure for PTSD; PTSD requires all 4 symptom clusters.

Q45  Answer: B  [TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS]

REM SLEEP BEHAVIOR DISORDER (RBD): loss of normal REM atonia → motor behaviors during REM sleep (acting out dreams — kicking, punching, yelling). DIAGNOSIS: polysomnography (PSG) shows REM SLEEP WITHOUT ATONIA (normally during REM, muscles are paralyzed; in RBD this atonia is absent). Patient typically has vivid, actionable dream content (being attacked, chased). CRITICAL ASSOCIATION: RBD is STRONGLY ASSOCIATED WITH ALPHA-SYNUCLEINOPATHY neurodegenerative diseases — Parkinson's disease, Lewy body dementia, multiple system atrophy — and may PRECEDE neurodegeneration by years to decades (RBD is a prodromal biomarker). Prevalence increases with age; M > F. TREATMENT: CLONAZEPAM (0.5–1 mg at bedtime) — most studied; MELATONIN (alternative, fewer side effects in elderly). Safety modifications essential (bed rails, floor padding, remove sharp objects). DISTINGUISH FROM NREM parasomnias: sleepwalking and night terrors occur during NREM slow-wave sleep; patient is NOT acting out a coherent dream; more common in children.

Q46  Answer: B  [TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS]

OBSTRUCTIVE SLEEP APNEA DIAGNOSIS: GOLD STANDARD = Overnight POLYSOMNOGRAPHY (PSG) in a sleep lab. Measures AHI (apnea-hypopnea index = # of apneas + hypopneas per hour of sleep). OSA SEVERITY: MILD = AHI 5–15/h; MODERATE = AHI 15–30/h; SEVERE = AHI >30/h. DIAGNOSTIC THRESHOLD: AHI ≥5/h + symptoms (sleepiness, snoring, witnessed apneas, etc.) OR AHI ≥15/h regardless of symptoms. HOME SLEEP APNEA TEST (HSAT): acceptable for high pre-test probability uncomplicated OSA; but PSG is gold standard and required for complex cases. FIRST-LINE: CPAP — most effective treatment for all severity levels. ALTERNATIVES: weight loss, positional therapy (supine-predominant), oral appliance (mandibular advancement), surgical (UPPP, hypoglossal nerve stimulator). CONSEQUENCES of untreated OSA: HTN (most common cardiovascular comorbidity), atrial fibrillation, heart failure, stroke, T2DM, MVA risk, cognitive impairment. MSLT = narcolepsy diagnosis (measures sleep latency and SOREMPs).

Q47  Answer: B  [TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS]

DELAYED SLEEP PHASE SYNDROME (DSPS): circadian rhythm disorder where the internal clock is PHASE DELAYED (shifted later). KEY FEATURE: patient CAN sleep well IF allowed to follow their delayed schedule (e.g., 3–4 AM to 11 AM–noon). Impairment occurs ONLY when forced to maintain conventional hours. No problem with sleep quality or duration on natural schedule — distinguishes from insomnia disorder. Most common in adolescents and young adults. TREATMENT APPROACH: MORNING BRIGHT LIGHT THERAPY: light exposure at desired wake time → suppresses melatonin → advances circadian clock forward. EVENING LOW-DOSE MELATONIN (0.5–3 mg): given 3–6 hours BEFORE desired target SLEEP time → phase-advances the clock. CHRONOTHERAPY: gradually shifting sleep time earlier in 1–3 hour increments over several days. Avoid bright light in the evening (delays clock further). DISTINGUISH FROM INSOMNIA: insomnia = difficulty sleeping regardless of timing; DSPS = sleeps fine on delayed schedule. SHIFT WORK DISORDER: sleep-wake schedule disruption from rotating or night shifts — different treatment (scheduled naps, strategic light exposure).

Q48  Answer: B  [TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS]

INSOMNIA DISORDER CBT-I: GOLD STANDARD for chronic insomnia; proven SUPERIOR to pharmacotherapy both short-term and long-term; no dependence, no side effects, durable remission. COMPONENTS: (1) STIMULUS CONTROL: bed = only sleep and sex; consistent wake time 7 days/week; get out of bed if not asleep in 20 minutes (breaks the bed-wakefulness association). (2) SLEEP RESTRICTION: reduce time in bed to match estimated total sleep time (creates mild sleep deprivation → increases sleep drive); gradually extend as sleep efficiency improves. (3) RELAXATION: progressive muscle relaxation, diaphragmatic breathing, mindfulness. (4) COGNITIVE RESTRUCTURING: identify and challenge unhelpful beliefs (catastrophizing about consequences of poor sleep). (5) SLEEP HYGIENE: limit caffeine, regular schedule, dark/cool/quiet room, avoid screens before bed. PHARMACOTHERAPY (short-term only): Z-drugs (zolpidem, eszopiclone), ramelteon (MT1/MT2 agonist), suvorexant/lemborexant (orexin antagonists), low-dose doxepin. Benzodiazepines: AVOID long-term (dependence risk). Insomnia criteria: difficulty ≥3 nights/week for ≥3 months + daytime impairment.

Q49  Answer: B  [TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS]

NARCOLEPSY TYPE 1: tetrad of CHESS (Cataplexy, Hypnagogic hallucinations, Excessive daytime sleepiness, Sleep paralysis). CATAPLEXY: sudden bilateral LOSS OF MUSCLE TONE triggered by STRONG POSITIVE EMOTION (laughter, excitement, surprise) — preserves consciousness; PATHOGNOMONIC for Type 1 narcolepsy. Type 2: no cataplexy. MSLT (Multiple Sleep Latency Test): diagnostic gold standard. CRITERIA: mean sleep latency ≤8 minutes AND ≥2 SOREMPs (sleep-onset REM periods — reaching REM within 20 minutes of sleep onset on ≥2 nap opportunities). HYPOCRETIN-1 (orexin) deficiency: CSF level ≤110 pg/mL is diagnostic (loss of hypothalamic hypocretin neurons — possibly autoimmune). TREATMENT: SODIUM OXYBATE (Xyrem/Lumryz): gold standard for cataplexy AND EDS; Schedule III controlled substance; taken at night. MODAFINIL (wakefulness-promoting agent): first-line for EDS. STIMULANTS (amphetamines) for severe EDS. SSRIs/SNRIs: suppress REM → reduce cataplexy. Distinguish from DSPS (delayed sleep phase) and OSA (obstructive events on PSG, no cataplexy).

Q50  Answer: B  [TRAUMA/STRESSOR-RELATED & SLEEP DISORDERS]

ANSWER B IS CORRECT: Bulimia nervosa = recurrent binge eating + compensatory behaviors (purging) → purging causes loss of HCl → hypokalemia + METABOLIC ALKALOSIS; dental erosion on LINGUAL surfaces; FLUOXETINE 60 mg = only FDA-approved drug for bulimia; CBT = first-line therapy. WHY OTHERS ARE WRONG: A — Patient faking for disability insurance = MALINGERING (external gain), NOT conversion disorder (which is NOT intentional and has NO external gain); ERP + PT = conversion disorder treatment — incorrect match. C — Delayed sleep phase syndrome: patient CANNOT sleep before 3 AM (true of DSPS) — correct feature; but the diagnosis is DSPS (circadian rhythm disorder), NOT insomnia disorder; treatment = morning bright light + evening melatonin + chronotherapy (NOT zolpidem at 3 AM which would cause oversleeping). D — Full PTSD criteria met but only 3 weeks after trauma = ACUTE STRESS DISORDER (ASD requires <1 month duration; PTSD requires >1 month); first-line for ASD = trauma-focused CBT (NOT SSRIs which are first-line for established PTSD).

CAM III Psychiatry  ·  South College Atlanta ATL-2026  ·  For educational use only