1.
Questions 2–4
A 22-year-old male college student is taken to the emergency department by police because he tried to enter a state office building to "have a conference with the governor" about conducting a fund drive to "finance my cure for cancer." When police prevent him from entering the building, he becomes irritable and hostile and resists attempts to restrain him.
The most effective long-term treatment for this patient is
Correct Answer
B. Lithium
Explanation
The answer is B.
2.
Questions 2–4
A 22-year-old male college student is taken to the emergency department by police because he tried to enter a state office building to "have a conference with the governor" about conducting a fund drive to "finance my cure for cancer." When police prevent him from entering the building, he becomes irritable and hostile and resists attempts to restrain him.
This college student has two brothers. The first is his monozygotic twin; the second is two years younger. The risks that his first and second brothers will develop bipolar disorder are respectively about
Correct Answer
B. 75% and 20%
Explanation
The answer is B. This patient is most likely to have bipolar I disorder. While this disorder involves episodes of both mania and depression, a single episode of mania defines the illness. The beliefs that one is important enough to demand a conference with the governor and cure cancer are grandiose delusions. Schizophrenic delusions are commonly paranoid in nature. Irritability and hostility are also common in a manic episode. Of the listed treatments, the one most effective for bipolar disorder is lithium. Heterocyclic antidepressants, electroconvulsive therapy, monoamine oxidase inhibitors, and psychotherapy are used primarily to treat depression. Antidepressants and psychotherapy are used to treat dysthymia. The chances of the monozygotic twin and first-degree relative (e.g., brother) of this bipolar patient developing the disorder are about 75% and 20%, respectively.
3.
A 65-year-old woman, who was diagnosed with advanced lung cancer 3 months ago, has lost 18 pounds, wakes frequently during the night, and has very little energy. Over the past month she has been preoccupied with feelings of guilt about "people I have hurt in my life" and expresses concern that she will die in pain. The sign or symptom most likely to indicate that this patient is experiencing a major depressive episode rather than a normal reaction to life-limiting illness is
Correct Answer
D. Preoccupation with feelings of guilt
Explanation
The answer is D. The sign or symptom most likely to indicate that this patient is experiencing a major depressive episode rather than a normal reaction to serious illness is her preoccupation with feelings of guilt. Such feelings are more characteristic of depression than sadness about being very ill. The other symptoms that the patient shows (e.g., weight loss, decreased energy, and sleep problems) are characteristic of patients with advanced cancer. Fear of dying in pain is realistic and commonly seen in patients with life-limiting illnesses.
4.
Questions 2–4
A 22-year-old male college student is taken to the emergency department by police because he tried to enter a state office building to "have a conference with the governor" about conducting a fund drive to "finance my cure for cancer." When police prevent him from entering the building, he becomes irritable and hostile and resists attempts to restrain him.
The most appropriate diagnosis for this patient is
Correct Answer
C. Bipolar disorder
Explanation
The answer is C.
5.
Questions 5 and 6
For the past few months, a 28-year-old woman has seemed full of energy and optimism for no obvious reason. Although she gets only about 6 hours of sleep a night, she has been very productive at work. She is talkative and gregarious and relates that she belongs to four clubs and two different sports teams. A few years previously, friends say she was often pessimistic and seemed tired and "washed out." During that period, she continued to work but did not seek out social activities and had little interest in sex. There is no evidence of a thought disorder and the patient denies suicidality or hopelessness. Physical examination including body weight is normal.
This patient shows evidence of
Correct Answer
E. Cyclothymic disorder
Explanation
The answer is E.
6.
Questions 5 and 6
For the past few months, a 28-year-old woman has seemed full of energy and optimism for no obvious reason. Although she gets only about 6 hours of sleep a night, she has been very productive at work. She is talkative and gregarious and relates that she belongs to four clubs and two different sports teams. A few years previously, friends say she was often pessimistic and seemed tired and "washed out." During that period, she continued to work but did not seek out social activities and had little interest in sex. There is no evidence of a thought disorder and the patient denies suicidality or hopelessness. Physical examination including body weight is normal.
The most effective long-term treatment for this patient is
This patient shows evidence of
Correct Answer
B. Lithium
Explanation
The answer is B. This patient shows evidence of cyclothymic disorder. This disorder involves periods of both hypomania (energy and optimism) and dysthymia (pessimism and feeling "washed out") occurring over a 2-year period with no discrete episodes of illness. Of the listed treatments, the one most effective for cyclothymic disorder, as for bipolar disorder, is lithium. Heterocyclic antidepressants, electroconvulsive therapy, monoamine oxidase inhibitors, and psychotherapy are primarily used to treat depression. Antidepressants and psychotherapy are used to treat dysthymia.
7.
Questions 7 and 8
A 62-year-old woman whose husband died 6 months ago tells her physician that she believes killing herself would end her suffering. Physical examination is unremarkable.
Of the following signs and symptoms, which is most likely to be seen in this patient?
Correct Answer
E. Poor grooming
Explanation
The answer is E.
8.
Questions 7 and 8
A 62-year-old woman whose husband died 6 months ago tells her physician that she believes killing herself would end her suffering. Physical examination is unremarkable.
Analysis of neurotransmitter availability in the brain of this patient is most likely to reveal
Correct Answer
E. Decreased serotonin
Explanation
The answer is E. This woman is showing evidence of major depression (note: suicidality is not characteristic of a normal grief reaction). Depressed people typically show poor grooming. She is also more likely to show weight loss, and to feel better in the evening than in the morning. Auditory hallucinations are common in schizophrenia but uncommon in depression. Flight of ideas is characteristic of mania. Analysis of neurotransmitter availability in this patient is most likely to reveal decreased serotonin, commonly reflected in decreased plasma levels of its major metabolite 5-HIAA. Increased dopamine is seen in schizophrenia, and decreased acetylcholine is seen in Alzheimer disease.
9.
A 25-year-old male patient who is slow moving and has a flat affect is put on fluoxetine (Prozac). Within 2 weeks, the patient is showing greatly increased activity level, flight of ideas, and pressured speech. In this patient, the medication has
Correct Answer
A. Precipitated a manic episode
Explanation
The answer is A. In this depressed patient, the antidepressant fluoxetine has precipitated a manic episode (i.e., greatly increased activity level, flight of ideas, and pressured speech). This indicates that the patient has bipolar disorder rather than major depressive disorder. There is no evidence of increased depression, increased anxiety, or a delayed or toxic effect in this patient.
10.
A 35-year-old physician tells his internist that he has lost interest in playing in the hospital string quartet, an activity he formerly enjoyed. He reports that over the past 3 months he commonly wakes up a few hours before his alarm goes off and cannot fall back to sleep, and has lost 12 pounds without dieting. He states "maybe my family would be better off without me." He says that although he has lots of aches and pains and often feels tired, he feels somewhat better as the day progresses. Physical examination and laboratory studies are unremarkable. The most appropriate diagnosis for this patient is
Correct Answer
B. Major depressive disorder
Explanation
The answer is B. This patient is most likely to have major depressive disorder. Evidence for this is that he has lost interest in his usual activities, wakes up too early in the morning, has vague physical symptoms, shows diurnal variation in symptoms (worse in the morning), has lost a significant amount of weight, and is showing suicidal ideation (e.g., "maybe my family would be better off without me"). Also, his symptoms have been present for a discrete, identified amount of time. Dysthymic disorder involves mild or moderate depression most of the time, occurring over a 2-year period with no discrete episodes of illness. Bipolar disorder involves episodes of both mania and depression. Cyclothymic disorder involves episodes of hypomania and dysthymia occurring over a 2-year period with no discrete episodes of illness. In hypochondriasis, patients believe that normal body functions or minor illnesses are serious or life threatening. People who are malingering fabricate symptoms for obvious gain (e.g., to win a lawsuit).
11.
A 28-year-old man comes in complaining of headaches and a variety of other aches and pains that have been present for the past 6 months. He denies that he is sad or hopeless. After a 4-week trial of antidepressant medication, the patient's physical complaints have disappeared. The most appropriate diagnosis for this patient is
Correct Answer
C. Masked depression
Explanation
The answer is C. This patient's physical complaints (i.e., headaches and other aches and pains) were relieved by antidepressant medication. This indicates that these symptoms were manifestations of masked (hidden) depression rather than hypochondriasis. There is no evidence in this patient of bipolar disorder, dysthymic disorder, cyclothymic disorder, or malingering (see answer 10).
#10. The answer is (?). This patient is most likely to have major depressive disorder. Evidence for this is that he has lost interest in his usual activities, wakes up too early in the morning, has vague physical symptoms, shows diurnal variation in symptoms (worse in the morning), has lost a significant amount of weight, and is showing suicidal ideation (e.g., "maybe my family would be better off without me"). Also, his symptoms have been present for a discrete, identified amount of time. Dysthymic disorder involves mild or moderate depression most of the time, occurring over a 2-year period with no discrete episodes of illness. Bipolar disorder involves episodes of both mania and depression. Cyclothymic disorder involves episodes of hypomania and dysthymia occurring over a 2-year period with no discrete episodes of illness. In hypochondriasis, patients believe that normal body functions or minor illnesses are serious or life threatening. People who are malingering fabricate symptoms for obvious gain (e.g., to win a lawsuit).
12.
A 65-year-old Catholic male patient has been abusing alcohol for the past 15 years. His history reveals that his wife recently asked him for a separation.
Which of the following characteristics is this patient's greatest risk factor for suicide?
Correct Answer
E. Age
Explanation
The answer is E.
Although male sex, alcohol abuse, and marital separation all are risk factors for suicide, the highest risk factor of those mentioned is age. Catholic religion is associated with a reduced risk of suicide. Nonprofessionals are at a lower suicide risk than professionals. Among professionals, those at the highest risk for suicide are police officers, physicians, lawyers, and dentists. The method of suicide most likely to fail is slashing the wrists ortaking pills. Shooting, crashing a car, jumping from a high place, and hanging are more lethal methods of committing suicide.
13.
A 65-year-old Catholic male patient has been abusing alcohol for the past 15 years. His history reveals that his wife recently asked him for a separation.
This man is at the lowest risk for suicide if he works as a
Correct Answer
A. Messenger
Explanation
The answer is A.
Although male sex, alcohol abuse, and marital separation all are risk factors for suicide, the highest risk factor of those mentioned is age. Catholic religion is associated with a reduced risk of suicide. Nonprofessionals are at a lower suicide risk than professionals. Among professionals, those at the highest risk for suicide are police officers, physicians, lawyers, and dentists. The method of suicide most likely to fail is slashing the wrists ortaking pills. Shooting, crashing a car, jumping from a high place, and hanging are more lethal methods of committing suicide.
14.
A 65-year-old Catholic male patient has been abusing alcohol for the past 15 years. His history reveals that his wife recently asked him for a separation.
If this patient tries to commit suicide, the method most likely to fail is
Correct Answer
C. Slashing his wrists
Explanation
The answer is C. Although male sex, alcohol abuse, and marital separation all are risk factors for suicide, the highest risk factor of those mentioned is age. Catholic religion is associated with a reduced risk of suicide. Nonprofessionals are at a lower suicide risk than professionals. Among professionals, those at the highest risk for suicide are police officers, physicians, lawyers, and dentists. The method of suicide most likely to fail is slashing the wrists ortaking pills. Shooting, crashing a car, jumping from a high place, and hanging are more lethal methods of committing suicide.
15.
The percentage of depressed patients who seek treatment for their symptoms is about
Correct Answer
C. 25%
Explanation
The answer is C. Only about 25% of depressed patients seek treatment, although treatment (antidepressants, psychotherapy, electroconvulsive therapy) is effective in most depressed patients.
16.
A 15-year-old girl is brought to the emergency room after ingesting 20 acetominophen tablets. She tells the physician that she tried to commit suicide because she was not admitted to an honors English class. The girl is the president of her grade in school and always tries to be perfect. The most important factor in whether this girl tries to kill herself again is
Correct Answer
D. That she tried to commit suicide once
Explanation
The answer is D. This girl shows a number of risk factors for depression and attempted suicide, including female sex and her excessive need to be perfect. However, the most important factor in whether she tries to kill herself again is that she tried to commit suicide once. Taking pills such as aspirin or acetominophen is less lethal than other methods, but young people such as this teenager may not know this. Thus, this girl has made a serious suicide attempt. (See also answers to questions 12– 14.)
#14. The answer is (?). Although male sex, alcohol abuse, and marital separation all are risk factors for suicide, the highest risk factor of those mentioned is age. Catholic religion is associated with a reduced risk of suicide. Nonprofessionals are at a lower suicide risk than professionals. Among professionals, those at the highest risk for suicide are police officers, physicians, lawyers, and dentists. The method of suicide most likely to fail is slashing the wrists ortaking pills. Shooting, crashing a car, jumping from a high place, and hanging are more lethal methods of committing suicide.
17.
A 43-year-old woman says that when she is under stress, she often feels as if she is "outside of herself" and is watching her life as though it were a play. She knows that this perception is only a feeling and that she is really living her life. This woman is showing evidence of
Correct Answer
D. Depersonalization disorder
Explanation
The answer is D. This woman, who feels as if she is "outside of herself," watching her life as though it were a play, is showing evidence of depersonalization disorder, a persistent feeling of detachment from one's own body or the social situation. In contrast to some of the other dissociative disorders and psychotic disorders such as schizophrenia, this woman knows that this perception is only a feeling and that she is really living her life.
18.
A 38-year-old man asks his doctor to refer him to a physician who attended a top-rated medical school. He says that he knows the doctor will not be offended because she will understand that he is "better" than her other patients. Which of the following disorders best fits this picture?
Correct Answer
K. Narcissistic personality disorder
Explanation
This 38-year-old man, who asks to be referred to a physician who attended a top-rated medical school because he is "better" than other patients, is demonstrating narcissistic personality disorder
19.
A 20-year-old female college student tells the doctor that because she was afraid to be alone, she tried to commit suicide after a man with whom she had had two dates did not call her again. After the interview, she tells him that all of the other doctors she has seen were terrible and that he is the only doctor who has ever understood her problems. Which of the following disorders best fits this picture?
Correct Answer
A. Borderline personality disorder
Explanation
The answer is A. This 20-year-old college student, who made a suicide attempt after a relatively trivial relationship broke up and who uses splitting as a defense mechanism (e.g., all of the other doctors she has seen were terrible and he is the best), is demonstrating borderline personality disorder.
20.
Whenever a 28-year-old woman comes to the doctor's office, she brings gifts for the receptionist and the nurses. When she hears that one of the nurses has taken another job, she begins to sob loudly. When the doctor sees her, she reports that she is so hot that she must have "a fever of at least 106°." Which of the following disorders best fits this picture?
Correct Answer
B. Histrionic personality disorder
Explanation
The answer is B. This 28-year-old woman who brings gifts for the receptionist and the nurses because she needs to have everyone pay attention to her is demonstrating histrionic personality disorder. Patients with this personality disorder tend to exaggerate their physical symptoms for dramatic effect (e.g., "a fever of at least 106°").
21.
Two weeks after a 50-year-old, overweight, hypertensive woman agreed to start an exercise program, she gained 4 pounds. She reports that she has not exercised yet because "the gym was so crowded that I couldn't get in."
Which of the following disorders best fits this picture?
Correct Answer
J. Passive-aggressive personality disorder
Explanation
The answer is J. This 50-year-old woman, who agreed to start an exercise program and then makes weak excuses for her failure to follow the program, is demonstrating passive-aggressive personality disorder. She really never intended to follow the doctor's exercise program (was inwardly defiant) but agreed to do it (was outwardly compliant).
22.
The parents of a 26-year-old woman say that they are concerned about her because she has no friends and spends most of her time hiking in the woods and working on her computer. The doctor examines her and finds that she is content with her solitary life and has no evidence of a formal thought disorder. Which of the following disorders best fits this picture?
Correct Answer
M. Schizoid personality disorder
Explanation
The answer is M. This 26-year-old woman, who shows no evidence of a thought disorder, has no friends, and spends most of her time at solitary pursuits, is demonstrating schizoid personality disorder. In contrast to those with avoidant personality disorder, schizoid patients are content with their solitary lifestyle.
23.
A 22-year-old medical student is unable to stop studying until she has memorized the entire set of notes for each of her courses. Making comprehensive lists of all the subjects she must study also takes up her study time. Because of this, she is constantly behind in her work and in danger of failing her courses.
The personality disorder that best fits this clinical picture is?
Correct Answer
C. Obsessive-compulsive personality disorder
Explanation
The answer is C. This medical student, who must constantly make lists and review and memorize her notes, is showing evidence of obsessive-compulsive personality disorder. This behavior is ultimately inefficient and has resulted in her academic problems.
24.
A 40-year-old patient with bruises on his arms, neck, and back tells the doctor that his lover often berates him and physically abuses him. He begs the doctor not to interfere because he is afraid that the man will desert him and that he will be alone. The personality disorder which best fits this clinical picture is
Correct Answer
F. Dependent personality disorder
Explanation
The answer is F. This abused man shows evidence of dependent personality disorder. He tolerates his partner's abuse because of his overriding fear of being deserted by his lover, being alone, and having to make his own decisions