Abnormalities of Mood and Personality

8/10/2019 Abnormalities of Mood and Personality

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A college student is brought to the student health center at the urging of hisroommate. He has been missing class because he needs tocheck the room lock many times before he can leave. Once he starts to ride hisbicycle to class, he frequently returns several times to lock thedoor. He repeats this ritual every morning and often when he leaves the house.He misses his appointments and his academic performancesuffers. His hands are chafed.Question 1 of 4

Which of the following is the most likely diagnosis?/ A. enerali!ed an"iety disorder/ #. Obsessive compulsive disorder/ $. %anic disorder

/ &. %aranoid personality disorder/ '. %osttraumatic stress disorder

Explanation - Q: 1.1

Close

The correct answer is B. %atients with obsessive compulsive disorder(O$&) suffer from obsessive thoughts and compulsive behaviors that impaireveryday function. Obsessions are defined as recurrent and persistentthoughts, impulses, or images that are intrusive, inappropriate, and causean"iety and distress. %atients reali!e that these thoughts and images are aproduct of their own mind and they will attempt to suppress them. *n additionto obsessions, patients e"perience compulsions. $ompulsions are repetitivebehaviors or mental acts that a person performs in accordance with anobsession. +he behaviors are aimed at reducing distress or preventing somedreaded event or situation. ocking doors is a common compulsion, and thusthis patient meets the diagnostic criteria for obsessive compulsive disorder.

enerali!ed an"iety disorder (choice A)is characteri!ed by e"cessivean"iety and apprehensive e"pectation for a period greater than - months.%atients e"perience an"iety, cognitive vigilance, autonomic hyperactivity,motor tension, irritability, and poor concentration. $ompulsions are not a partof this disorder.

%anic disorder (choice C)is characteri!ed by episodes of panic. %atientshave a discrete period of intense fear with tachycardia, palpitations, sweating,trembling, shortness of breath, chest pain and tightening, abdominaldiscomfort, fear of dying, and paresthesias.

%aranoid personality disorder (choice D)is characteri!ed by enduringpatterns of personality characteri!ed by mistrust and suspiciousness ofpeople.

%osttraumatic stress disorder (choice E)is an an"iety disorder that develops
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around a traumatic event. ymptoms revolve around the event and includeree"periencing of the trauma, psychic numbing, and increased autonomicarousal.

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A college student is brought to the student health center at the urging of hisroommate. He has been missing class because he needs tocheck the room lock many times before he can leave. Once he starts to ride hisbicycle to class, he frequently returns several times to lock thedoor. He repeats this ritual every morning and often when he leaves the house.He misses his appointments and his academic performancesuffers. His hands are chafed.Question of 4

+he patient/s incessant door locking is an e"ample of which of the following?/ A. $ompulsion/ #. &elusion

/ $. 0agical thinking/ &. Obsession/ '. %aranoid ideation

Explanation - Q: 1. Close

The correct answer is A. $ompulsions are repetitive behaviors or mentalacts that patients perform in accordance with an obsession (choice D). *t isimportant to reali!e that obsessions are the mental processes and thatcompulsions are the actions or behaviors.

&elusions (choice B)are fi"ed false beliefs that are not culturally accepted.(%eople that believe in anta $laus are not deluded.)

0agical thinking (choice C)is a mental process, not a behavior, like doorlocking. %atients with magical thinking believe they have special, 1magical1capacities that others do not have. +hus door locking does not e"emplifymagical thinking.

&oor locking does not e"emplify paranoid ideation (choice E). However,paranoid ideation, or the patient/s belief that others are out to harm him2her,may provide the source of an"iety to drive the compulsion.

A college student is brought to the student health center at the urging of hisroommate. He has been missing class because he needs tocheck the room lock many times before he can leave. Once he starts to ride hisbicycle to class, he frequently returns several times to lock thedoor. He repeats this ritual every morning and often when he leaves the house.He misses his appointments and his academic performancesuffers. His hands are chafed.Question ! of 4


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Which of the following is the most appropriate pharmacotherapy for this patient?/ A. $*o!apine/ #. &esipramine/ $. 3*uo"etine/ &. Haloperidol

/ '. ora!epam*** Klepting eeryt!ing" ***

Explanation - Q: 1.! Close

The correct answer is C. +he effectiveness of selective serotonin reuptakeinhibitors (4*s) in treating O$& has contributed significant indirectevidence to the role of the serotonergic system in the pathophysiology ofO$&. *t is hypothesi!ed that dysregulation of this neurotransmitter couldcontribute to the repetitive obsessions and ritualistic behaviors. +hishypothesis is also supported by the relative ineffectiveness of noradrenergicantidepressants, such as desipramine.

$lo!apine (choice A)is an atypical antipsychotic, and would not play a role inthe treatment of O$& unless psychotic features were noted.

&esipramine (choice B)is a noradrenergic antidepressant, and as notedabove, has no effect on O$& symptoms.

Haloperidol (choice D)is an antipsychotic drug that has no effect on O$&symptoms unless psychotic features were noted.

ora!epam (choice E)is a ben!odia!epine that is used to treat acuteagitation. *t would not be used to treat O$&.

*** #ut message bo$ contents to email ***

A college student is brought to the student health center at the urging of hisroommate. He has been missing class because he needs tocheck the room lock many times before he can leave. Once he starts to ride hisbicycle to class, he frequently returns several times to lock thdoor. He repeats this ritual every morning and often when he leaves the house.He misses his appointments and his academic performancesuffers. His hands are chafed.Question 4 of 4

According to psychoanalytic theory, this patient/s disorder develops whendefense mechanisms fail to contain the patient/s an"iety. Onedefense mechanism employed in this patient/s constellation of symptoms isreaction formation. Which of the following is an e"ample ofreaction formation?/ A. A man ignores the fact that his spouse is cheating on him and they invest ina house together/ #. A man in the intensive care unit becomes infantile and unruly


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/ $. A man in the intensive care unit tells his nurse, 15ou that are the best nurse lhave ever seen6unlike those horrible nurses yesterday whomade me wait for pain medicine. +hose nurses were horrible and l never want tosee them again.1/ &. A man who is e"tremely angry with his spouse treats her gently and kindly

/ '. A promiscuous man accuses his spouse of being unfaithful to him

Explanation - Q: 1.4 Close

The correct answer is D. Obsessional patients often show the defensemechanism of reaction formation. 4eaction formation is when affects aretransformed into their opposites and ambivalence is resolved in the oppositemanner from which it arises. +his man resolves his anger with his wife bycreating the opposite affect.

Choice Ae"emplifies the defense mechanism known as denial. &enial is the

invalidation of an unpleasant or unwanted piece of information. He deniesthat his marriage is compromised, and continues investing in it.

Choice Be"emplifies regression. When regression is employed, patientsreturn to an earlier level of functioning. +his patient/s infantile behaviorrepresents regression. 4egression is often seen in medically ill patients.

Choice Ce"emplifies splitting. *n splitting, aspects of mental content are keptseparate. +he man has overideali!ed those who met his needs, and devaluedthose who frustrate him. +his defense is often seen in patients with borderlinepersonality disorder.

Choice Ee"emplifies pro7ection. *n pro7ection, a person rids him2herself ofunacceptable thoughts by attributing them to others. While this rids theaffected individual of the unwanted affect, he2she then lives in a world ofothers who harbor the unacceptable material. +his is often seen in paranoidpatients.

A 896year6old married lawyer presents to the emergency department with acomplaint of 1having a heart attack.1 He e"plains he was 1doingnothing particular1 at home about :; minutes ago when he began having chest

pain with shortness of breath and nausea. His symptomspeaked within ten minutes, and he 1knew this was the big one.1 His wife noted hewas 1shaking and sweaty.1 His wife immediately broughthim to the hospita*. He has no significant past medical history, takes nomedications, and denies substance use. His family medical history issignificant for a paternal grandfather that 1died of a massive heart attack1 at age;-. %hysical e"amination reveals an an"ious diaphoretic


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man taking short, shallow breaths.


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0yocardial infarction, hypothyroidism, and carcinoid syndrome should beruled out.

%anic attacks may begin while driving, or awaken patients from sleep(choices A an# B).

%anic attacks may occur anywhere, including work and home (choice C).%anic attacks O=5 occurring with the trigger of being in open spaces arediagnostic of agoraphobia (a phobia).

*n panic disorder, panic attacks are unprecipitated (1out of the blue1> choiceD). %anic attacks triggered by a feared event or ob7ect are seen in phobias.

A 896year6old married lawyer presents to the emergency department with acomplaint of 1having a heart attack.1 He e"plains he was 1doingnothing particular1 at home about :; minutes ago when he began having chestpain with shortness of breath and nausea. His symptoms

peaked within ten minutes, and he 1knew this was the big one.1 His wife noted hewas 1shaking and sweaty.1 His wife immediately broughthim to the hospita*. He has no significant past medical history, takes nomedications, and denies substance use. His family medical history issignificant for a paternal grandfather that 1died of a massive heart attack1 at age;-. %hysical e"amination reveals an an"ious diaphoreticman taking short, shallow breaths.


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accumulation of acetaldehyde.

ithium (choice D)is a first line treatment for bipolar disorder, and can beused to augment antidepressant medicines.

4isperidone (choice D)is an atypical antipsychotic medication withprominent &9 blockade. *t is used to treat psychotic conditions, such asschi!ophrenia

A 896year6old married lawyer presents to the emergency department with acomplaint of 1having a heart attack.1 He e"plains he was 1doingnothing particular1 at home about :; minutes ago when he began having chestpain with shortness of breath and nausea. His symptomspeaked within ten minutes, and he 1knew this was the big one.1 His wife noted hewas 1shaking and sweaty.1 His wife immediately broughthim to the hospita*. He has no significant past medical history, takes no

medications, and denies substance use. His family medical history issignificant for a paternal grandfather that 1died of a massive heart attack1 at age;-. %hysical e"amination reveals an an"ious diaphoreticman taking short, shallow breaths.


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can be changed by challenging errors in thinking (cognitive distortions).1Homework1 is used to ascertain the underlying (negative) assumptions.

3amily psychotherapy (choice C)is based on the theory that a family is a

system striving to maintain homeostasis, which leads to behaviors.

roup psychotherapy (choice D)is based on many theories, and techniquesinclude identificationand universalization.

%sychoanalytic psychotherapy (choice E)is an intensive type of therapy,usually :6; times per week> the goal is for the patient to develop insightintounconscious conflicts, and become more aware of the underlying causes ofbehavior.

Also, it is not uncommon for a patient to develop more than one an"iety

disorder (panic disorder and a phobia).*** #ut message bo$ contents to email ***A 896year6old married lawyer presents to the emergency department with acomplaint of 1having a heart attack.1 He e"plains he was 1doingnothing particular1 at home about :; minutes ago when he began having chestpain with shortness of breath and nausea. His symptomspeaked within ten minutes, and he 1knew this was the big one.1 His wife noted hewas 1shaking and sweaty.1 His wife immediately broughthim to the hospita*. He has no significant past medical history, takes nomedications, and denies substance use. His family medical history issignificant for a paternal grandfather that 1died of a massive heart attack1 at age

;-. %hysical e"amination reveals an an"ious diaphoreticman taking short, shallow breaths.


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symptoms.

$oronary vasospasm (choice A)occurs with cocaine use and usuallypresents with the signs and symptoms of a myocardial infarction (with apositive urine to"icology screen for cocaine).

'bstein/s anomaly (choice B)is a rare, albeit notorious, congenital defectassociated with prenatal e"posure to lithium.

0yocarditis (choice D)has occurred with clo!apine, which received a 1blackbo"1 warning in the %&4 in 9@@9.

+c prolongation (choice E)can occur with antipsychotic medicines andtricyclic antidepressants. +orsades may develop.

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A 896year6old married lawyer presents to the emergency department with a

complaint of 1having a heart attack.1 He e"plains he was 1doingnothing particular1 at home about :; minutes ago when he began having chestpain with shortness of breath and nausea. His symptomspeaked within ten minutes, and he 1knew this was the big one.1 His wife noted hewas 1shaking and sweaty.1 His wife immediately broughthim to the hospita*. He has no significant past medical history, takes nomedications, and denies substance use. His family medical history issignificant for a paternal grandfather that 1died of a massive heart attack1 at age;-. %hysical e"amination reveals an an"ious diaphoreticman taking short, shallow breaths.


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scleral in7ection, and a dry cough are all associated with cannabis use.

Alpra!olam (choice A)may cause sedation, slurred speech, disinhibition andata"ia. %atients seem 1drunken.1

$affeine use (choice B)may initially present with panic attacks, but whencarefully questioned, the patient will report caffeine intake (coffee, tea,chocolate, cocoa, over6the6counter cold medications) and usually developsheadaches (during withdrawal) from caffeine. $affeine into"icated patientscould develop paranoia and tachycardia, but cannabis use e"plains all thelisted symptoms.

0ethamphetamine (choice D)and pseudoephedrine (choice E)arestimulants. %atients may initially present with panic attacks, and can developparanoia and tachycardia, but the additional history of inappropriate laughterand scleral in7ection indicates cannabis use. Amphetamine abuse mimics

symptoms of schi!ophrenia.

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A 8@6year6old man is brought to the emergency department by police, whoarrested him because he was in the parking lot of a local mal*,yelling 1* am a golden god1 as he stepped in front of moving cars. Whenquestioned about his identity, he talks incessantly in a rapid fashionand threatens to 1unleash od/s wrath on those who do not submit.1 He reportsthat he has not slept in a week, and does not need sleep. Hehas spent the last week preparing for a secret government mission that only thepresident knows about. When asked if he ever hears odtalking to him, he says, 1Of course not, * am odC1 %olice report that he has hadseveral prior arrests for reckless driving and lewd acts. One"amination, he is disheveled and malodorous. *t is nearly impossible to get anyfurther history, as he rapidly paces about and mutters, 1*must go, * must go1 over and over again.Question 1 of %

Which of the following is the most likely preliminary diagnosis?/ A. Antisocial personality disorder/ #. #ipolar disorder/ $. #orderline personality disorder

/ &. %ost traumatic stress disorder/ '. chi!ophrenia

Explanation - Q: !.1

Close

The correct answer is B. +his patient is displaying many of the diagnosticcriteria for bipolar disorder. He has had a distinct period of abnormally andpersistently elevated mood lasting at least one week. *n addition, his thoughtsare grandiose (1* am a golden god1), he has a decreased need for sleep, and


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he has pressured and e"cessive speech. His arrest history indicates possibleprevious se"ual indiscretions, which are a hallmark of bipolar disorder(e"cessive involvement in pleasurable activities that have a high potential forpainful consequences). His pacing indicates psychomotor agitation, also ahallmark of bipolar disorder. +his patient probably has a history of severe

depressive episodes, but the occurrence of a single manic episode allows thediagnosis of bipolar disorder to be made.

Antisocial personality disorder (choice A)refers to a long6standing pattern ofsocially irresponsible behavior that reflects a disregard for the rights of others.+hese individuals were formerly called psychopaths, and generally lack aconscience. 0any people with this disorder engage in unlawful acts. +hemost pervasive characteristic is a lack of remorse for the harm they causeothers.

#orderline personality disorder (choice C)refers to a lifelong pattern of

unstable affect and self6image with erratic behavior. #orderlines haveinterpersonal relationships that are intense, but very unstable (1love6hate1relationships). +hey are prone to self6mutilation and the defense mechanismof splitting. #ut they have a life of chaos, not a sense of grandeur and power,so the diagnosis does not fit this case.

%osttraumatic stress disorder (choice D)is an an"iety disorder that developssurrounding a traumatic event. ymptoms revolve around the event andinclude ree"periencing of the trauma, avoidance of associated stimuli,psychic numbing, and increased autonomic arousal.

While the psychotic symptoms of mania and schi!ophrenia (choice E)may,at times, be difficult to distinguish, the grandiose content of this man/ssymptoms suggest that he is having a manic episode. =ote that hiscomments that od does not talk to him can be taken as a denial of auditoryhallucinations.

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A 8@6year6old man is brought to the emergency department by police, whoarrested him because he was in the parking lot of a local mal*,yelling 1* am a golden god1 as he stepped in front of moving cars. Whenquestioned about his identity, he talks incessantly in a rapid fashionand threatens to 1unleash od/s wrath on those who do not submit.1 He reports

that he has not slept in a week, and does not need sleep. Hehas spent the last week preparing for a secret government mission that only thepresident knows about. When asked if he ever hears odtalking to him, he says, 1Of course not, * am odC1 %olice report that he has hadseveral prior arrests for reckless driving and lewd acts. One"amination, he is disheveled and malodorous. *t is nearly impossible to get anyfurther history, as he rapidly paces about and mutters, 1*must go, * must go1 over and over again.


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Question of %

#efore a definitive diagnosis can be made, which of the following should beperformed?/ A. $ranial nerve e"am/ #. $+ scan of the head/

$. '*ectroencephalogram/ &. 0agnetic resonance imaging of the head/ '. +o"icological screen

Explanation - Q: !. Close

The correct answer is E. *nto"ication with a number of agents such asamphetamines, cocaine, or other sympathomimetics can mimic mania seen inbipolar disorder. Other possibilities to consider are antidepressantmedications, thyroid hormone replacements, hyperthyroidism, and otherneurologic conditions. *t is often difficult to distinguish the mania of bipolar

disorder from the mania of substance abuse. Often the two are comorbidconditions as patients 1treat1 their condition. *f a manic episode is substance6induced, it cannot contribute to a diagnosis of bipolar disorder.

$ranial nerve e"am (choice A)cannot be performed on an uncooperativepatient and would likely not contribute to reaching a diagnosis in this patient.

$+ scan of the head (choice B)would not likely aid in the diagnosis of thispatient unless something in the patient/s medical history suggests an organiccause (e.g., frontal neoplasm).

An electroencephalogram (choice C)would not contribute to the diagnosis ofthis patient as there is no evidence of sei!ures.

04* (choice D)would not contribute to the diagnosis for the same reasons a$+ scan would not.

*** 0ont 1$ploring ersus font guessing ***

A 8@6year6old man is brought to the emergency department by police, whoarrested him because he was in the parking lot of a local mal*,yelling 1* am a golden god1 as he stepped in front of moving cars. Whenquestioned about his identity, he talks incessantly in a rapid fashionand threatens to 1unleash od/s wrath on those who do not submit.1 He reportsthat he has not slept in a week, and does not need sleep. Hehas spent the last week preparing for a secret government mission that only thepresident knows about. When asked if he ever hears odtalking to him, he says, 1Of course not, * am odC1 %olice report that he has hadseveral prior arrests for reckless driving and lewd acts. One"amination, he is disheveled and malodorous. *t is nearly impossible to get anyfurther history, as he rapidly paces about and mutters, 1*


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must go, * must go1 over and over again.Question ! of %

+his patient is started on lithium to stabili!e his mood. #*ood levels of lithiumneed to be closely monitored as therapeutic levels are close toto"ic levels. +he ratio of to"ic dose to therapeutic dose is known as which of thefollowing?/ A. 3ractional elimination constant/ #. Half life/ $. oading dose/ &. +herapeutic inde"/ '.


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depressive symptoms while taking lithium needs to have his2her thyroidassessed.

Agranulocytosis (choice A)is commonly reported for patients taking theatypical antipsychotic drug clo!apine or carbama!epine, which is sometimes

employed as a second6line treatment for bipolar disorder.

Choice Bis incorrect. =eurological side effects of lithium include tremor,choreoathetosis, ata"ia, motor hyperactivity, dysarthria, and aphasia.

ithium is not known to cause aplastic anemia (choice C). Aplastic anemia isa serious potential adverse effect of the mood stabili!er carbama!epine.$arbama!epine would present an alternative to lithium in this patient, but aperiodic blood count must be performed to assess for aplastic anemia.

ithium is not known to affect fertility in males (choice E)or females.

However, lithium has strong teratogenic effects ('bstein/s anomaly of thetricuspid valve) and should =O+ be given to any woman who is pregnant oreven thinking about becoming pregnant.

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A 8@6year6old man is brought to the emergency department by police, whoarrested him because he was in the parking lot of a local mal*,yelling 1* am a golden god1 as he stepped in front of moving cars. Whenquestioned about his identity, he talks incessantly in a rapid fashionand threatens to 1unleash od/s wrath on those who do not submit.1 He reportsthat he has not slept in a week, and does not need sleep. Hehas spent the last week preparing for a secret government mission that only the

president knows about. When asked if he ever hears odtalking to him, he says, 1Of course not, * am odC1 %olice report that he has hadseveral prior arrests for reckless driving and lewd acts. One"amination, he is disheveled and malodorous. *t is nearly impossible to get anyfurther history, as he rapidly paces about and mutters, 1*must go, * must go1 over and over again.Question 4 of %

Which of the following is a known adverse effect of lithium?/ A. Agranulocytosis/ #. A*tered 7udgement/ $. Aplastic anemia/ &. Hypothyroidism/ '. 0ale infertility

Explanation - Q: !.$

Close

The correct answer is B. #en!odia!epines are frequently used to treat acuteagitation and can help manage acute mania until lithium can e"ert its effects.#en!odia!epines potentiate the inhibitory effect on the $= neurons by


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binding to A#A receptors and increasing the frequency of the opening ofchloride channels in response to A#A stimulation. +he net effect is $=depression and reduction in the patient/s agitation.

#arbiturates bind the A#A receptor and prolong the duration of opening of

chloride channels in response to A#A (choice A). +his acts to suppress the$=.

ora!epam has no effect on dopamine receptors. 0any antipsychoticmedications act by inhibiting dopamine receptors (choice C).

ora!epam does not effect the release of epinephrine from the adrenalmedulla (choice D).

As noted above, lora!epam has no effect on dopamine receptors (choice E).

- - -A 8@6year6old man is brought to the emergency department by police, whoarrested him because he was in the parking lot of a local mal*,yelling 1* am a golden god1 as he stepped in front of moving cars. Whenquestioned about his identity, he talks incessantly in a rapid fashionand threatens to 1unleash od/s wrath on those who do not submit.1 He reportsthat he has not slept in a week, and does not need sleep. Hehas spent the last week preparing for a secret government mission that only thepresident knows about. When asked if he ever hears odtalking to him, he says, 1Of course not, * am odC1 %olice report that he has hadseveral prior arrests for reckless driving and lewd acts. On

e"amination, he is disheveled and malodorous. *t is nearly impossible to get anyfurther history, as he rapidly paces about and mutters, 1*must go, * must go1 over and over again.Question " of %

+he patient later reaches a steady state level of lithium that produces to"ic sideeffects. *f he decides to discontinue his medication, how longwould it take for his lithium blood levels to reach 9; of his original steady statelevels assuming a half life of 99 hours for lithium?/ A. EE hours/ #. 99 hours

/ $. 88 hours

/ &. :: hours/ '. ;; hours/ 3. -- hours

/ . GG hours/ H. FF hours*** )!at3s in t!e status line? )rite to us ***

Explanation - Q: !."

Close


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The correct answer is D. ithium, like most drugs follows first6order kinetics,which means a constant percent of the drug is eliminated per unit time. Hisdrug levels will decrease by ;@ every half6life. +herefore, they will be ;@

of original levels after one half6life, 9; after two half6lives, E9.; after threehalf6lives, etc. +wo half6lives is 99 " 9 :: hours.

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A 8@6year6old man is brought to the emergency department by police, whoarrested him because he was in the parking lot of a local mal*,yelling 1* am a golden god1 as he stepped in front of moving cars. Whenquestioned about his identity, he talks incessantly in a rapid fashionand threatens to 1unleash od/s wrath on those who do not submit.1 He reportsthat he has not slept in a week, and does not need sleep. Hehas spent the last week preparing for a secret government mission that only thepresident knows about. When asked if he ever hears odtalking to him, he says, 1Of course not, * am odC1 %olice report that he has hadseveral prior arrests for reckless driving and lewd acts. One"amination, he is disheveled and malodorous. *t is nearly impossible to get anyfurther history, as he rapidly paces about and mutters, 1*must go, * must go1 over and over again.Question % of %

A screening test is developed for assessing vulnerability to developing thiscondition. A sample of E@,@@@ people between the ages of EF to9: is recruited from the general population and given the screening test. Of thissample, 9@@ individuals are identified as likely to develop the

condition. +he sample is tracked over the ne"t twenty years. 3orty of the originalsample, although none of those selected by the test, are lostto follow6up. A total of E@@ people from the sample eventually were diagnosedwith this condition, of which I@ were correctly identified by thescreening test. #ased on this study, the positive predictive value of the screeningtest is best estimated as which of the following?/ A. :;/ #. -@

/ $. G;/ &. I@/ '. E@@

Explanation - Q: !.% Close

The correct answer is A. %ositive predictive value assesses the proportionof those identified as having the condition that actually end up developing thecondition. *n this case, I@ of the original 9@@ identified by the test developedthe disorder. (I@29@@ :;). =ote the test has a sensitivity (ability to detect


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disease) of I@. (I@ of the E@@ people who actually developed the conditionwere correctly identified by the screening test)

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A 9;6year6old man presents to the emergency department with multiplelacerations to both wrists. He says he has a history of 1everydiagnosis in the book, &oc.1 +he patient reports several recent stressors,including being fired from his 7ob after 1*osing it1 with a 1rottencustomer,1 financial problems, and a fight with his girlfriend three hours ago.When asked about suicidal ideation, the patient responds with1would you want this life?1 With permission, the doctor speaks with the man/spsychiatrist. His psychiatrist describes a long6standing patternof unstable relationships, career changes, and e"treme mood swings with erraticsleep patterns. +he patient has taken multiple overdoses inthe past, usually when his psychiatrist is out of town. After the doctor listensseveral minutes to the patient empathetically, the man respondswith multiple compliments, proclaiming the doctor is 1the best doctor ever.1 Anhour later the doctor is summoned by the nurses to again seethe patient. +he man is sullen and angry 15ou don/t even care what happens tome. 5ou never did> none of you do, and you 7ust let me sit hereforever. What kind of lousy doctor are you? 5ou/re an embarrassment to yourprofession.1Question 1 of "

Which of the following is the most likely diagnosis?/ A. Antisocial personality disorder/ #. #orderline personality disorder/ $. Histrionic personality disorder/ &. =arcissistic personality disorder

/ '. %aranoid personality disorder

Explanation - Q: 4.1

Close

The correct answer is B. #orderline personality disorder is characteri!ed bya pattern of instability in E) relationships (fights with girlfriend and customers),9) self image (career changes may be one), 8) affect (mood swings), A=&marked impulsivity (multiple overdoses). Another clue is the frantic efforts toavoid abandonment (overdoses precede separation from doctor, wrist

slashing after break up with girlfriend). %ersons with borderline personalityare prone to rages and complain of chronic feelings of emptiness.

Antisocial personality disorder (choice A)is characteri!ed by a pervasivepattern of disregard for the rights of others.

Histrionic personality disorder (choice C)is characteri!ed by a pervasivepattern of e"cessive emotionality and attention6seeking. +hese individuals are


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usually the 1life of the party,1 and may be associated with 1creating a scene.1+hey are not self6destructive, like persons with borderline personalitydisorder.

=arcissistic personality disorder (choice D)is characteri!ed by a pervasivepattern of grandiosity, need for admiration, and lack of empathy. +hey e"hibita stable self6image and are not self6destructive like persons with borderlinepersonality disorder.

%aranoid personality disorder (choice E)is characteri!ed by a pervasivepattern of distrust and suspiciousness.

A 9;6year6old man presents to the emergency department with multiplelacerations to both wrists. He says he has a history of 1everydiagnosis in the book, &oc.1 +he patient reports several recent stressors,including being fired from his 7ob after 1*osing it1 with a 1rotten

customer,1 financial problems, and a fight with his girlfriend three hours ago.When asked about suicidal ideation, the patient responds with1would you want this life?1 With permission, the doctor speaks with the man/spsychiatrist. His psychiatrist describes a long6standing patternof unstable relationships, career changes, and e"treme mood swings with erraticsleep patterns. +he patient has taken multiple overdoses inthe past, usually when his psychiatrist is out of town. After the doctor listensseveral minutes to the patient empathetically, the man respondswith multiple compliments, proclaiming the doctor is 1the best doctor ever.1 Anhour later the doctor is summoned by the nurses to again seethe patient. +he man is sullen and angry 15ou don/t even care what happens to

me. 5ou never did> none of you do, and you 7ust let me sit hereforever. What kind of lousy doctor are you? 5ou/re an embarrassment to yourprofession.1uestion of "

+he doctor repeatedly reassures the patient that he deserves the best care andhis doctors are working on it. +he patient refuses to acceptthe reassurance, and begins yelling loudly. +he doctor screams at the patient tobe quiet. ater, he says 1 * *et him have it, because what he4'A5 needed was some tough love for once.1 +he doctor is using which of thefollowing defense mechanisms?/ A. &enial/ #. *solation/ $. 4ationali!ation/ &. ublimation/ '. uppression*** Sure some your friends are waiting for Kleptomania ***

Explanation - Q: 4. Close

The correct answer is C. 4ationali!ation, which is providing a logical reason


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(what the patient needs) for a behavior, is usually employed to avoid beingblamed (e.g., for unprofessional behavior).

&enial (choice A)is usually used to avoid awareness of a painful reality, andis often seen in patients given the news of a fatal illness, or in patients

confronted about substance abuse.

*solation (choice B)splits the thought from the feeling, and can be seenwhen doctors discuss 1interesting cases1 or 1severe pathology1 in completelyintellectual terms.

ublimation (choice D)is replacing an unacceptable wish with a moreacceptable one. *n this e"ample, the doctor might have 1taken out hisaggression1 in the e"ercise room.

uppression (choice E)is consciously deciding to remove an idea or feeling

from awareness. 1*/m not going to think about that.1A 9;6year6old man presents to the emergency department with multiplelacerations to both wrists. He says he has a history of 1everydiagnosis in the book, &oc.1 +he patient reports several recent stressors,including being fired from his 7ob after 1*osing it1 with a 1rottencustomer,1 financial problems, and a fight with his girlfriend three hours ago.When asked about suicidal ideation, the patient responds with1would you want this life?1 With permission, the doctor speaks with the man/spsychiatrist. His psychiatrist describes a long6standing patternof unstable relationships, career changes, and e"treme mood swings with erraticsleep patterns. +he patient has taken multiple overdoses in

the past, usually when his psychiatrist is out of town. After the doctor listensseveral minutes to the patient empathetically, the man respondswith multiple compliments, proclaiming the doctor is 1the best doctor ever.1 Anhour later the doctor is summoned by the nurses to again seethe patient. +he man is sullen and angry 15ou don/t even care what happens tome. 5ou never did> none of you do, and you 7ust let me sit hereforever. What kind of lousy doctor are you? 5ou/re an embarrassment to yourprofession.1Question ! of "

Which coping mechanism is illustrated by the statement, 15ou are the best doctorever, the rest of the staff is cold and heartless.1?/ A. &enial/ #. %ro7ection

/ $. 4epression/ &. plitting/ '. uppression*** icrosoft beyond t!e screen+ Kleptomania aboe t!e screen ***

Explanation - Q: 4.!

Close


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The correct answer is D. plitting is a primitive defense that oversimplifiesall relationships into 1good1 and 1bad.1 +he self, others, and situations arecompletely polari!ed into one category or the other. %ersons with borderlinepersonality disorder have difficulty tolerating ambivalence (concurrent positiveand negative feelings).

&enial (choice A)is the outright re7ection of information. 1* do not havecancer.1

%ro7ection (choice B)is attributing one/s traits2feelings to another person.15ou/re mad at me.1 When, in fact, * am mad at you.

4epression (choice C)is unconscious e"clusion of thoughts2feelings, 1Whatanger? * was never angry.1

uppression (choice E)is active e"clusion of thoughts2feelings from

consciousness, 1*/m not going to think about that right now.1A 9;6year6old man presents to the emergency department with multiplelacerations to both wrists. He says he has a history of 1everydiagnosis in the book, &oc.1 +he patient reports several recent stressors,including being fired from his 7ob after 1*osing it1 with a 1rottencustomer,1 financial problems, and a fight with his girlfriend three hours ago.When asked about suicidal ideation, the patient responds with1would you want this life?1 With permission, the doctor speaks with the man/spsychiatrist. His psychiatrist describes a long6standing patternof unstable relationships, career changes, and e"treme mood swings with erraticsleep patterns. +he patient has taken multiple overdoses in

the past, usually when his psychiatrist is out of town. After the doctor listensseveral minutes to the patient empathetically, the man respondswith multiple compliments, proclaiming the doctor is 1the best doctor ever.1 Anhour later the doctor is summoned by the nurses to again seethe patient. +he man is sullen and angry 15ou don/t even care what happens tome. 5ou never did> none of you do, and you 7ust let me sit hereforever. What kind of lousy doctor are you? 5ou/re an embarrassment to yourprofession.1Question 4 of "

+his patient is started on tra!odone to help with sleep. $ommon side effects oftra!odone include which of the following?/ A. &rowsiness, di!!iness, fatigue, and fatal liver failure/ #. &rowsiness, di!!iness, hypertension, and nervousness

/ $. &rowsiness, di!!iness, hypotension, and priapism/ &. &rowsiness, di!!iness, nervousness, and sei!ures/ '. &rowsiness, nervousness, * distress and se"ual dysfunction*** 5our time wort! 678.89 for in4nite /lepting at!ttp-www.structurise.com/leptomania

Explanation - Q: 4.4 Close


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The correct answer is C. +his question illustrates the fact that manyantidepressant drugs have similar side effects, but often have a certainparticular side effect worth knowing. +he clue to choice C(tra!odone) ispriapism, a painful sustained erection. *t is a medical emergencyC

+he clue to choice A(nefa!odone) is fatal liver failure> this drug now has a1black bo"1 warning in the %&4.

+he clue to choice B(venlafa"ine) is hypertension, specifically diastolichypertension.

+he clue to choice D(bupropion) is sei!ures. &O =O+ give this medicine topatients at risk for sei!ures (e.g., metabolic derangement, head in7ury).

+he clues to choice E(any and all 4*s) are * distress and se"ualdysfunction, which are very troublesome side effects. *nquire about se"ual

dysfunction in all patients taking 4*s.

*** :elp your best friend to /now Kleptomania+ send trial ***

A 9;6year6old man presents to the emergency department with multiplelacerations to both wrists. He says he has a history of 1everydiagnosis in the book, &oc.1 +he patient reports several recent stressors,including being fired from his 7ob after 1*osing it1 with a 1rottencustomer,1 financial problems, and a fight with his girlfriend three hours ago.When asked about suicidal ideation, the patient responds with1would you want this life?1 With permission, the doctor speaks with the man/spsychiatrist. His psychiatrist describes a long6standing pattern

of unstable relationships, career changes, and e"treme mood swings with erraticsleep patterns. +he patient has taken multiple overdoses inthe past, usually when his psychiatrist is out of town. After the doctor listensseveral minutes to the patient empathetically, the man respondswith multiple compliments, proclaiming the doctor is 1the best doctor ever.1 Anhour later the doctor is summoned by the nurses to again seethe patient. +he man is sullen and angry 15ou don/t even care what happens tome. 5ou never did> none of you do, and you 7ust let me sit hereforever. What kind of lousy doctor are you? 5ou/re an embarrassment to yourprofession.1Question $ of "

+he doctor calls the insurance company to authori!e admission for 1moodstabili!ation.1 When asked, the patient says he does not want toharm himself at this point. +he insurance company denies authori!ation for aninpatient admission. +he doctor determines the patient/spresentation is too despondent and hopeless to be safe. +he most appropriateintervention is for the doctor to call the insurance companyback and do which of the following?


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/ A. ay 1+he patient is a danger to himself in my opinion, get your supervisor onthe phone now.1/ #. ay 1+he patient is a danger to himself in my opinion, *et me e"plain myreasoning.1/ $. ay 1+he patient says he is actively suicidal now.1, even though he did not

/ &. +ell the patient to say he is suicida*, then say 1+he patient says he isactively suicidal now.1/ '. 1+his is unacceptable. et your supervisor on the phone now, or you will bee"posing yourself to legal liability.1

Explanation - Q: 4.$ Close

The correct answer is B. +he 3*4+ intervention is for the doctor to calmlye"plain the reasoning involved in the assessment.

Choice Ais an unnecessary beginning to the conversation> calmly asking for

the supervisor later (if needed) would be the appropriate response.

Choice Cis lying. *t/s illegal, for one. $ontacting the attending, the board, theadministrator, etc., may help the doctor get the patient/s needs met throughhonest means.

Choice Dis illegal and unethical, and the doctor will ultimately suffer formodeling to the patient 1we can make deals.1

Choice Eis a threat and implies coercion, at the very least it could damagethe doctor/s professional reputation.

A 9;6year6old man presents to the emergency department with multiplelacerations to both wrists. He says he has a history of 1everydiagnosis in the book, &oc.1 +he patient reports several recent stressors,including being fired from his 7ob after 1*osing it1 with a 1rottencustomer,1 financial problems, and a fight with his girlfriend three hours ago.When asked about suicidal ideation, the patient responds with1would you want this life?1 With permission, the doctor speaks with the man/spsychiatrist. His psychiatrist describes a long6standing patternof unstable relationships, career changes, and e"treme mood swings with erraticsleep patterns. +he patient has taken multiple overdoses inthe past, usually when his psychiatrist is out of town. After the doctor listens

several minutes to the patient empathetically, the man respondswith multiple compliments, proclaiming the doctor is 1the best doctor ever.1 Anhour later the doctor is summoned by the nurses to again seethe patient. +he man is sullen and angry 15ou don/t even care what happens tome. 5ou never did> none of you do, and you 7ust let me sit hereforever. What kind of lousy doctor are you? 5ou/re an embarrassment to yourprofession.1Question " of "


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+he nurse calls to tell the doctor that the patient has taken an overdose in theemergency department. When the doctor arrives, the patienthas slurred speech and is sedated. Within five minutes the patient is sleeping, hisrespiratory rate is E@2min and he responds minimally topainful stimuli. +he family tells the doctor that the man takes clona!epam at

home for nocturnal myoclonus. +he most appropriatepharmacologic intervention is to administer which of the following?/ A. &e"trose/ #. 3*uma!enil/ $. =alo"one/ &. =altre"one

/ '. +hiamine*** ,uy your time at !ttp-www.structurise.com/leptomania ***

Explanation - Q: 4."

Close

The correct answer is B. +he history is consistent with respiratorydepression secondary to ben!odia!epine overdose. 3luma!enil is aben!odia!epine receptor antagonist.

&e"trose (choice A)treats hypoglycemia.

=alo"one (choice C), an opioid antagonist, reverses opioid overdose.+hiamine, nalo"one, and de"trose are often given to patients who are 1founddown1 and present to the emergency department in a coma without anyhistory.

=altre"one (choice D)blocks the effects of opiates via opioid antagonism(people cannot 1get high1). *t is used to prevent relapse in a previously opioiddependent individual.

+hiamine (choice E)prevents Wernicke6Jorsakoff syndrome.

A -I6year6old white man visits a physician in the outpatient clinic for the first time.Over the past ; months, he reports increasing lethargy,weight loss, and crying 1for no reason.1 +he patient had always been anoptimistic person, but today he feels 1detached from everything.1 Hedescribes his mood 1as if there was a pane of glass between me and the rest ofthe world and l don/t think */m going to make it. 0y family andfriends are like cardboard cutouts.1 His speech is slow and methodica*,punctuated by frequent sighs. +he patient has also lost interest inwatching movies, which had been his favorite pastime. He also admits that hisdrinking has become a problem over the past few weeks, andhe currently consumes a bottle of white wine every evening. He recently lost his

7ob and is currently filing for divorce, which would end a


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seventeen6year marriage. His son has attention6deficit disorder, for which he isprescribed amphetamine. +he patient was hospitali!ed forma7or depression three years ago. +he patient/s previous doctor had started himon a medication, but he is unable to recall the name oranything about it e"cept that he is not supposed to eat cheese, aged meats, or

chocolate while taking it. On physical e"amination, the patientappears emaciated. His abdomen is very distended, with hepatomegaly 8 cmbelow the right costal margin. He also has a slight tremor. Hisgait is norma*. His latest calcium level is [email protected] mg2d.Question 1 of $

Which of the following is the most likely diagnosis at this time?/ A. Acute stress disorder/ #. Ad7ustment disorder/ $. A*cohol abuse/ &. #ipolar disorder/ '. Hypercalcemia/

3. Bnipolar disorder*** 'ne of a /ind to grab te$t anyw!ere+ you /now ***

Explanation - Q: $.1

Close

The correct answer is &. +he patient/s symptoms of weight loss, lethargy,tearfulness, hopelessness (1*/m not going to make it1), and depersonali!ation(1world through a pane of glass> family and friends are like cardboardcutouts1) for at least one month meet the criteria for unipolar disorder (ma7ordepression). 'ven more specific are his loss of interest in favorite activities,as well as the feelings of sadness. +he symptoms have been going on for atleast two weeks and represent a change from previous functioning, which

defines depression. +hree stressors in his life are 7ob loss, the upcomingdivorce. and his son/s attention6deficit disorder. +he lifetime rate of ma7ordepression in men in the B is about E@.

Acute stress disorder (choice A)is the consequence of the e"perience of atraumatic event outside the realm of normal human e"perience. =eitherdivorce nor 7ob loss fits this criterion. ymptoms of acute stress disorder(A&) must also include ree"periencing the event as dreams, recollections offlashback, and avoidance of associated stimuli, along with diffuse othersymptoms such as irritability, sleep disruption, and difficulty concentrating.

Ad7ustment disorder (choice B)is a dysfunctional change in behavior withinthree months of an identifiable stressor. +he dysfunction can only last -months after the stressor has ended. An ad7ustment disorder cannot be agrief response A=& the diagnosis only applies if no other A"is * diagnosis canbe used. iven the patient/s current symptoms and previous treatmenthistory, the criteria for this diagnosis are not met.

Alcohol abuse (choice C)is probably occurring as a coping mechanism for


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the depression, and is unlikely to be a specific cause of the depressivesymptoms. Ascites, hepatomegaly, tremor, macrocytosis (raised meancorpuscular volume, and increased liver en!ymes are suggestive of chronicalcohol use.

#ipolar disorder (choice D)can have a similar presentation to unipolardisorder when in the depressive phase. +he differential is based on beingable to identify one or more manic episodes in the patient/s past. #ecausenone are presented here, there is no evidence for this diagnosis.

Hypercalcemia (choice E)may present with symptoms of confusion, polyuria,polydipsia, and abdominal pain. +his patient has none of these symptomsand, in addition, his calcium levels are actually normal.

*** 'rder at !ttp-www.structurise.com/leptomania and return us our tips***


7ob and is currently filing for divorce, which would end aseventeen6year marriage. His son has attention6deficit disorder, for which he isprescribed amphetamine. +he patient was hospitali!ed forma7or depression three years ago. +he patient/s previous doctor had started himon a medication, but he is unable to recall the name oranything about it e"cept that he is not supposed to eat cheese, aged meats, orchocolate while taking it. On physical e"amination, the patientappears emaciated. His abdomen is very distended, with hepatomegaly 8 cmbelow the right costal margin. He also has a slight tremor. Hisgait is norma*. His latest calcium level is [email protected] mg2d.Question of $

Which of the following medications is the patient most likely currently taking?/ A. Amitriptyline/ #. $hlorproma!ine/ $. 3*uo"etine/ &. ora!epam/ '. %henel!ine

Explanation - Q: $. Close


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The correct answer is E. 0onoamine o"idase inhibitors (0AO*s) includephenel!ine and tranylcypromine. 0AO*s have the potential for severe sideeffects when taken with sympathomimetic medications or tyramine6containingfoods (e.g., cheeses, red wines, beers, meats, fruits, beans, liver, yeast

e"tracts) because they can cause a hypertensive crisis. 0AO*s can alsocause orthostatic hypotension, nausea, insomnia, and se"ual dysfunction.

+ricyclic antidepressants include amitriptyline (choice A)and nortriptyline.+hey take anywhere from 9 to - weeks to take effect. +hey haveanticholinergic side6effects including dry mouth, blurred vision, constipation,ileus, urinary retention, and even delirium.

=euroleptics such as chlorproma!ine (choice B)reduce psychotic symptomsthat result from a number of illnesses, including schi!ophrenia, bipolardisorder, ma7or depressive disorder with psychotic features, psychosis

secondary to stimulant drugs, and organic psychoses from Al!heimer diseaseor Huntington disease.

elective serotonin reuptake inhibitors (4*s) include fluo"etine (choice C).+hey have a reduced side6effect profile and are effective in depressiontreatment. +he risk of overdose is low. +heir main pharmacologic effect is toblock the presynaptic serotonin uptake site. *ncreasing the availability ofserotonin in the synaptic cleft is thought to improve depressive symptoms.

A ben!odia!epine such as lora!epam (choice D)is primarily used for an"ietyrather than depression. Adverse reactions include sedation, di!!iness,

weakness, unsteady gait, headache, and sleep disturbance.

*** )e appreciate your suggestions at [email protected] ***


7ob and is currently filing for divorce, which would end aseventeen6year marriage. His son has attention6deficit disorder, for which he isprescribed amphetamine. +he patient was hospitali!ed forma7or depression three years ago. +he patient/s previous doctor had started himon a medication, but he is unable to recall the name or


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anything about it e"cept that he is not supposed to eat cheese, aged meats, orchocolate while taking it. On physical e"amination, the patientappears emaciated. His abdomen is very distended, with hepatomegaly 8 cmbelow the right costal margin. He also has a slight tremor. Hisgait is norma*. His latest calcium level is [email protected] mg2d.Question ! of $

+o gather more details about the patient/s current state of mind, which of thefollowing questions would be most appropriate for the physicianto ask at this time?/ A. 1 Are you taking your antidepressant medications as your previous doctorinstructed?1/ #. 1 Have you ever made plans to kill yourself?1/ $. 1 *s there any history of depression in your family?1/ &. 1 On a depression scale of one to ten, how depressed do think you feel right

now?1/ '. 1 On average, how much alcohol do you drink in one day?1

Explanation - Q: $.!

Close

The correct answer is B. At this stage, it is crucial to ask a direct questionabout suicidal ideation, particularly because this is the first time the physicianis meeting the patient. *n addition, the patient is a white male over the age of;@ who has already been hospitali!ed once for ma7or unipolar depression,which places him at a greater risk for suicide. +he suicide rate among peoplewho have been hospitali!ed at least once for unipolar depression has beenestimated to be E;. A physician is the last person patients have seen beforetaking their own life in E@ of suicides. Asking this question as part of the

mental status e"amination also gives information on how severe thedepression is. *f the patient has a plan about how they will take their own life,then this suggests that they are more likely to follow through with their plan.

$ompliance with medication (choice A)is an important cause of depressionrelapse. *t has been estimated that fewer than E@ of people suffering fromunipolar ma7or depression are likely to be receiving a full therapeutic dose ofmedication. 0ore than 9@ of patients fail to fill the first prescription theyreceive for ma7or depression, and the ma7ority of patients who do begintreatment discontinue the medication within E: weeks, usually due to sideeffects.

&epression in the family (choice C)is a risk factor for recurrentdepression.%ursuing this line of questioning is useful for the long6term management ofdepression but does not address any ma7or life6threatening issues. Other riskfactors for recurrent depression include a history of multiple episodes(patients with 8 or more prior episodes have at least a I@ recurrence rate),depression associated with dysthymia, onset after age -@, long duration ofindividual episodes, poor symptom control during therapy, comorbid an"iety


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disorder, or substance abuse.

Ob7ective analysis of depression such as a depression score of E to E@(choice D)is also useful in the long term care of patients with depression. *n

doing so, the physician is able to ob7ectively document the effectiveness ofthe patient/s antidepressant therapy. Another useful method is counting thenumber of improvements in the quality of the patient/s life, e.g., more familyinteraction, being able to go to church, returning back to work. 3or this to beuseful, it is important to get an idea of where the patient is at in the initial visit.*t does not, however, take precedence over asking about suicidal ideation.

Alcoholic intake (choice E)is an important question to ask since the patientappears to have signs of alcoholism (hepatomegaly, increasing abdominalgirth as an indication of ascites, weight loss, and tremor). However, it doesnot necessarily have to be addressed on the initial visit. uicidal risk is a

more ominous life6threatening event in this instance. Accurate answers canbe derived when asking the patient to describe their drinking habits during thecourse of the day rather than asking about alcohol intake as a singlenumerical quantity.

A -I6year6old white man visits a physician in the outpatient clinic for the first time.Over the past ; months, he reports increasing lethargy,weight loss, and crying 1for no reason.1 +he patient had always been anoptimistic person, but today he feels 1detached from everything.1 Hedescribes his mood 1as if there was a pane of glass between me and the rest ofthe world and l don/t think */m going to make it. 0y family and

friends are like cardboard cutouts.1 His speech is slow and methodica*,punctuated by frequent sighs. +he patient has also lost interest inwatching movies, which had been his favorite pastime. He also admits that hisdrinking has become a problem over the past few weeks, andhe currently consumes a bottle of white wine every evening. He recently lost his

7ob and is currently filing for divorce, which would end aseventeen6year marriage. His son has attention6deficit disorder, for which he isprescribed amphetamine. +he patient was hospitali!ed forma7or depression three years ago. +he patient/s previous doctor had started himon a medication, but he is unable to recall the name oranything about it e"cept that he is not supposed to eat cheese, aged meats, or

chocolate while taking it. On physical e"amination, the patientappears emaciated. His abdomen is very distended, with hepatomegaly 8 cmbelow the right costal margin. He also has a slight tremor. Hisgait is norma*. His latest calcium level is [email protected] mg2d.Question 4 of $

+he physician decides to discontinue his current medication and prescribessertraline instead. ertraline directly affects which of thefollowing neurotransmitters?


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/ A. Acetylcholine/ #. &opamine/ $. 'pinephrine/ &. =orepinephrine

/ '. erotonin

*** Kleptomania- clic/;clic/ to write e;mail to any e;address on t!e screen"***

Explanation - Q: $.4

Close

The correct answer is E. ertraline specifically blocks the reuptake ofserotonin into the presynaptic a"on terminal. +his enhances serotoninactivation and brings about a cascade of events ultimately resulting in areduced sensitivity of presynaptic autoreceptors for serotonin and reducedserotonin synthesis. +he most common adverse reactions to the 4*s aregastrointestinal (especially nausea), neuropsychiatric (particularly headacheand tremor), and changes in se"ual functioning. 4*s also treat an"ious

depression, dysthymia, and atypical depression.

Acetylcholine (choice A)has been cited as the main neurotransmitterinvolved in Al!heimer dementia. &rugs that utili!e this concept are tacrine anddonepe!il, which work in the brain as cholinesterase inhibitors at the neuronalsynapse. #y inhibiting the cholinesterase en!yme, they increase the level ofacetylcholine and aid in maintaining mental function, although they do notstop the degeneration of cholinergic cells. ertraline has no effect on thelevels of acetylcholine.

&opamine (choice B)is found in both small and large neuronal pathways in

the $=. +he latter include the nigrostriatal pathway involved, in the etiologyof %arkinson disease and mesolimbic2mesocortical pathways, implicated inpsychosis. 6dopa, which is converted to dopamine, is the primaryreplacement therapy in %arkinson disease. &opamine antagonists are used inthe treatment of psychosis. &opaminergic input to the chemoreceptor trigger!one is the basis of the use of the agonist apomorphine as an emetic to treatpoisoning, and the use of antagonists as antiemetics. Hypothalamicdopaminergic neurons inhibit prolactin secretion and lead to the use ofagonists in inhibiting lactation. +here are a number of drugs that interactpresynaptically with dopamine terminals including reserpine, amphetamine,0AO inhibitors, and cocaine.

'pinephrine (choice C)is a neurotransmitter, and a hormone. *t stimulatesalphaE6, alpha96, betaE6, and beta96adrenergic receptors in a dose6relatedfashion. *t is the initial drug of choice for treating bronchoconstriction andhypotension resulting from anaphyla"is as well as all forms of cardiac arrest.*t is useful in managing reactive airway disease, but beta6adrenergic agentsare often used initially because of their convenience and oral inhalation route.'pinephrine is not a neurotransmitter specifically affected by any


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antidepressants currently available.

=orepinephrine (choice D), like serotonin, is a neurotransmitter that mayinduce depression if depleted. +here are several antidepressants that

increase norepinephrine levelsK

A -I6year6old white man visits a physician in the outpatient clinic for the first time.Over the past ; months, he reports increasing lethargy,weight loss, and crying 1for no reason.1 +he patient had always been an

optimistic person, but today he feels 1detached from everything.1 Hedescribes his mood 1as if there was a pane of glass between me and the rest ofthe world and l don/t think */m going to make it. 0y family andfriends are like cardboard cutouts.1 His speech is slow and methodica*,punctuated by frequent sighs. +he patient has also lost interest inwatching movies, which had been his favorite pastime. He also admits that hisdrinking has become a problem over the past few weeks, andhe currently consumes a bottle of white wine every evening. He recently lost his

7ob and is currently filing for divorce, which would end aseventeen6year marriage. His son has attention6deficit disorder, for which he isprescribed amphetamine. +he patient was hospitali!ed for

ma7or depression three years ago. +he patient/s previous doctor had started himon a medication, but he is unable to recall the name oranything about it e"cept that he is not supposed to eat cheese, aged meats, orchocolate while taking it. On physical e"amination, the patientappears emaciated. His abdomen is very distended, with hepatomegaly 8 cmbelow the right costal margin. He also has a slight tremor. Hisgait is norma*. His latest calcium level is [email protected] mg2d.Question $ of $


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hould this particular patient commit suicide, the likeliest method of suicide iswhich of the following?/ A. A drug overdose/ #. #y running his car in a closed garage for an e"tended period of time

/ $. $utting his wrists

/ &. Hanging himself/ '. With a firearm*** !ttp-www.structurise.com/leptomania ; your source of /leptingtec!nologies ***

Explanation - Q: $.$

Close

The correct answer is E. 3irearms were the commonest method of suicideused by persons aged -; years or older representing GE of suicides. *nEIIF, firearms were the most common method of suicide by both males andfemales, accounting for GF of male and 8; of female suicides in this agegroup.

Overdose with liquids, pills or gas (choice A), EG, and suffocation (choiceD),EE, represents the other two most common methods of suicide used bypersons aged -; years or older. 'lderly patients make fewer attempts percompleted suicide, have a higher6male6to6female ratio than other groups,have often visited a health6care provider before their suicide, and have morephysical illnesses. *t is estimated that 9@ of elderly (over -; years) personswho commit suicide visited a physician within 9: hours of their act, :Evisited within a week of their suicide and G; have been seen by a physicianwithin one month of their suicide. +he suicide rate of white males risesdramatically after age -; and accounts for the ma7ority of all suicides in the

elderly.

*n 9@@@, the death rate by car e"haust fumes (choice B)was less than E perE@@ @@@ per year.

#etween the age group of -; to G@ years, the mortality rate from suicide by acut or stab (choice C)was @.89 deaths per E@@ @@@ per year.

Abnormalities of Mood and Personality

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Transcript of Abnormalities of Mood and Personality