Board Review Questions in Psychiatry
Raymond Pary, MD
1. A55-year-old man with no history of mental illness presents with recent onset of disorientation, fluctuating mental status, abnormal autonomic signs, poor coordination, tremor, and seeing "little men" in his bedroom. He has no known history of substance abuse. What is the most likely diagnosis?
A. Schizophrenia
C. Delirium
E. Delusional disorder
2. Which of these statements describes the current understanding regarding the development of post-traumatic stress disorder (PTSD)?
A. The traumatic event must be outside the range of human experience
C. The number of previous traumatic events does not influence the development of PTSD
E. All of the above
3. Which of the following drugs would be the least favorable treatment for a patient with bulimia nervosa without comorbidities?
A. Fluoxetine HCl (Prozac, Sarafem)
C. Carbamazepine (Carbatrol, Tegretol)
E. Cognitive-behavioral therapy
4. Which of the following atypical antipsychotic agents is associated with the most weight gain?
A. Ziprasidone (Geodon)
C. Olanzapine (Zyprexa)
E. Risperidone (Risperdal)
5. Medications of choice for the initial treatment of long-standing anxiety disorder include all the following, except:
A. Venlafaxine (Effexor)
C. Sertraline (Zoloft)
E. Citalopram HBr (Celexa)
6. Which of the following statements about venlafaxine is true?
A. It is a potent inhibitor of dopamine reuptake
C. It can be tapered during 1 to 2 weeks
E. It is approved for the treatment of generalized anxiety disorder
7. Which of these medications would NOT be recommended to control the behavior of an acutely agitated and combative patient in the emergency department?
A. Lorazepam (Ativan)
C. Droperidol (Inapsine)
E. Propofol (Diprivan)
8. All the following factors signal potential risk for suicide, except:
A. A plan to shoot oneself
C. Being married with 3 children
E. History of schizophrenia
9. Which of these criteria is NOT a risk factor for violent behavior?
A. History of violent behavior
C. Agitated and threatening behavior
E. Major depressive disorder
10. A 60-year-old computer programmer is taken to the emergency department with cognitive slowing, slurred speech, dizziness, and poor muscle coordination. He said he had taken some of his girlfriend's "nerve pills" because he was uptight and tense about a presentation he had to make to his supervisor. He cannot remember how many pills he took or their names. Which of the following agents is most likely to have caused his symptoms?
A. Sertraline (Zoloft)
C. Alprazolam (Xanax)
E. Trazodone HCl (Desyrel) ANSWERS 1 - C. The onset of new psychiatric symptoms in a patient older than 40 years with no history of psychiatric illness is most likely the result of an organic disorder. Psychiatric symptoms of delirium include disturbances of consciousness, cognition, mood, perception, and behavior. Neurologic symptoms include tremor, asterixis, nystagmus, poor coordination, and urinary incontinence. Reference Kaplan BJ, Kaplan VA. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:323-324.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
2 - B. The does not require that trauma be outside the range of human experience to qualify for a diagnosis of PTSD. Diagnostic criteria do stipulate that the trauma must involve the threat of death or physical injury. The number of previous traumatic events increases an individual's vulnerability to PTSD, and the trauma may be witnessed rather than experienced directly.
Reference
Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry
Kaplan BJ, Kaplan VA. . 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:623-632.
3 - C. Tricyclic antidepressants carry a risk for lethal overdose but have been used to treat bulimia nervosa. Fluoxetine, topiramate, and cognitive-behavioral therapy have all demonstrated some efficacy for this condition. Carbamazepine has not produced impressive results in patients with bulimia nervosa without comorbidities. It has been used in those with comorbid bipolar disorder, however. Reference Kaplan BJ, Kaplan VA. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:750.
4 - C. Olanzapine has been associated with the most weight gain. A lesser amount of weight is gained with quetiapine and risperidone, and ziprasidone and aripiprazole are associated with the least weight gain.
Reference
Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry
Kaplan BJ, Kaplan VA. . 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:498.
5 - D. Antidepressant drugs are often the best choice for patients with chronic anxiety disorders. They can be given long-term, without risking dependence. Diazepam is excellent for relieving anxiety for the short-term, but it carries too high a risk of dependence when used for an extended time. For most acute anxiety conditions, therapy with one of the benzodiazepines lasts up to 6 weeks, with tapering and discontinuance during the next 2 weeks. Reference Kaplan BJ, Kaplan VA. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:632-636.
6 - E. Venlafaxine is a potent inhibitor of serotonin and norepinephrine reuptake and a weak inhibitor of dopamine reuptake. It has a better percentage response and completeness of response than fluoxetine in patients with severe depression. Venlafaxine must be tapered over 2 to 4 weeks. Clinical trials have shown that blood pressure increases with the 375-mg/day dose but not with 75 to 225 mg/day. Venlafaxine has been successful in reducing the insomnia, irritability, and excessive tension related to generalized anxiety disorder.
Reference
Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry
Kaplan BJ, Kaplan VA. . 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:1136.
7 - E. Propofol is primarily used in a surgical context when patients are intubated. Antipsychotics are the typical drug of choice for agitated, combative patients in emergency settings. High-potency agents are preferred. Benzodiazepines are also used to control agitation and violence, often in combination with an antipsychotic, but they can have a disinhibiting effect and could cause some clouding of consciousness. These medications are usually administered intramuscularly. References Kaplan BJ, Kaplan VA. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:906. Shaner R. Psychiatry. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000:350.
8 - C. Suicide risk is lower in persons who are married and have children and stable support systems. Sudden symptom relief in a patient who recently felt hopeless and/or helpless can indicate a decision to commit suicide. Having a specific plan, lethal means, history of suicide attempts, absence of an emotional support system, and a history of severe mental illness are all risk factors for suicide. The risk of suicide is high among patients with schizophrenia.
Reference
Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry
Kaplan BJ, Kaplan VA. . 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:913-917.
9 - E. All the other options suggest the possibility of imminent violence. Although it is difficult to predict future violence, a history of violent behavior is the single best predictor. Major depressive disorder is not a specific indicator of potential subsequent violence. Reference Kaplan BJ, Kaplan VA. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:904.
10 - C. These symptoms are indicative of benzodiazepine intoxication, and alprazolam is a benzodiazepine. Confusion, cognitive impairment, ataxia, drowsiness, slurred speech, sedation, somnolence, or impaired judgment are all signs of benzodiazepine intoxication.
Reference
Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry
Kaplan BJ, Kaplan VA. . 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:464, 908.
