B. Men and women display differences in cognitive skills. Men appear to have a slight advantage in mathematical calculations, fund of general information, and select visual-perceptual and spatial tasks, whereas women may show a minor advantage on rote verbal memory tasks, select executive skills, and speeded eye-hand coordination. These may become more pronounced with advancing age.

A. Humans are born with an ultradian sleepwake pattern, which develops into a circadian rhythm during the first few years of life. Slow-wave sleep declines precipitously during adolescence, likely related to pruning phenomena. Sleep efficiency gradually declines through adulthood. In addition to lighter sleep, it becomes more fragmented with age, with a greater percentage of daytime naps. The incidence of insomnia and many sleep-wake disorders increases with age.

E. Isolation of affect, reaction formation, and undoing are common defense mechanisms utilized by patient with diagnosis of OCD. Isolation of affect is the unconscious process in which there is dissociation of affect from an impulse. If isolation of affect fails to control anxiety associated with a given impulse, patients with OCD resort to compulsive acts, which are unconscious attempts to neutralize anxiety. In reaction formation, patients exhibit attitudes that are diametrically opposite to underlying impulse. Denial is a narcissistic defense in which some painful aspects of reality are avoided, while regression is an attempt to return to an earlier libidinal stage of functioning to avoid conflict, it is an immature defense. These latter defenses are not commonly utilized in OCD. Denial is common in patients with substance-related disorders, and regression is frequently utilized by the severely mentally ill. Projection is an immature defense mechanism used by patients with Borderline Personality Disorder or psychotic illness.

B. Third-party payers and their agents may request data from psychiatric evaluations to make determinations about whether a hospital admission or a specific treatment will be covered by a particular insurance plan. When such information is requested the psychiatrist must obtain the patient’s consent for such communications. It is necessary to inform the patient about the specific information that has been requested and obtain specific consent for the release of that information. The psychiatrist may also withhold information about the patient not directly relevant to the utilization review or preauthorization decisions.

C. The mental status examination is the part of the clinical assessment that describes the sum total of the examiner’s observations and impressions of the psychiatric patient at the time of the interview. Hallucinations (visual, auditory, olfactory, or tactile) are described as perceptual abnormalities, as are feelings of depersonalization and derealization (extreme feeling of detachment from the self or the environment). Agitation is characterized as behavior in the general description of the patient. Other aspects that are included in this category include mannerisms, tics, gestures, stereotyped behavior, and psychomotor retardation.

B. Cataplexy is described in the DSM-IV-TR as brief episodes of sudden bilateral loss of muscle tone, most often in association with intense emotion. Cataplexy is present in approximately 50% of cases of Narcolepsy, a primary sleep disorder that consists of irresistible sleep attacks and one or both
of cataplexy and abnormal manifestations of REM sleep. Sleep paralysis is an uncommon symptom that occurs most often upon awakening in the morning. During sleep paralysis, patients are apparently awake and conscious, but unable to move a muscle. In contrast, Catatonia can be seen in various psychiatric (and medical) disorders and is usually manifested by a combination of motoric immobility, excessive motor activity (which is apparently purposeless and not influenced by external stimuli), extreme negativism or mutism, peculiarities of voluntary movement, and echolalia/echopraxia. Catalepsy is a general term for an immobile position that is constantly maintained.

D. The goal of treatment for Unipolar Depression is the complete remission of symptoms. Partially remitted symptoms are powerful predictors of relapse. These findings have led to the hypothesis that residual symptoms upon recovery may progress to become prodromal symptoms of relapse.

B. Glutamate is the main excitatory neurotransmitter in the CNS. Its physiologic and excitotoxic activities are mediated through stimulation of the NMDA receptor and result from the influx of calcium ions. Excitotoxicity is believed to play a role in the pathogenesis of several diseases, including Parkinson’s disease and AD. Several NMDA receptor antagonists have been described. PCP and MK-801 cause psychotomimetic side effects, due to their activities on the NMDA receptors. Memantine, approved by the FDA for the treatment of moderate to severe AD, is a noncompetitive NMDA receptor antagonist with moderate affinity that protects against excessive stimulation of the receptor while allowing normal physiologic activities unhindered.

B. Cigarette use is the single most preventable cause of death in our society, causing 1 of every 5 deaths. By the 2004 estimate, about 22.5% of adults (46 million Americans) were cigarette smokers, with the highest prevalence among Native Americans and Alaska natives (40.8%); followed by whites (23.6%). Available data indicates that the use of pharmacotherapy by smokers in conjunction with behavioral modification can produce long-term abstinence at up to double the rate achieved by smokers without pharmacotherapy. Pharmacotherapies that have approved by the FDA for treatment of Nicotine Dependence include nicotine replacement therapies (e.g., gum, lozenges, nasal spray, inhaler, and transdermal), antidepressants (e.g., bupropion), and anxiolytic drugs (e.g., clonidine, nortriptyline, and mecamylamine), although anxiolytics have been used as second-line agents. Varenicline was approved by the FDA on May 11, 2006 for the treatment of Nicotine Dependence.

C. The evidence is not strong enough to support superior efficacy of clomipramine over SSRIs. SSRIs have a better side effect profile compared to clomipramine resulting in improved acceptability and tolerability. In a comparator study, the drop-out rate from adverse effects on clomipramine (approx. 17%) was consistently higher than for paroxetine (9%). Clomipramine is associated with significantly more early withdrawals associated with side-effects than fluvoxamine. The risk of dangerous side effects such as convulsions (occurring in up to 2% on clomipramine, compared to 0.1% to 0.5% on high-dose SSRIs), cardiotoxicity, and cognitive impairment is substantially lower with SSRIs. Clomipramine is associated with dry mouth, constipation, and blurred vision, and is lethal in overdose. All SSRIs are associated with impaired sexual performance, but clomipramine (80% cases) appears more problematic than SSRIs (up to 30% cases). SSRIs are responsible for more asthenia, insomnia, and nausea. Weight gain is more with clomipramine as compared to SSRIs. SSRIs are equally effective at relieving obsessional thoughts and compulsive rituals. Their improved safety and tolerability offer considerable benefits for the long-term treatment of OCD. SSRIs should usually be considered the treatments of choice, with clomipramine reserved for those who
cannot tolerate or who have failed to respond to them.

B. A recent meta-analysis supports the effectiveness of behavioral interventions for the treatment of insomnia in older patients. This meta-analysis of randomized controlled trials (n=23), found cognitive-behavioral treatment, relaxation, and behavioral therapy to have similar effects. Both middle-aged and persons older than 55 years of age showed similar robust improvements in sleep quality, sleep latency, and wakening after sleep onset.

A. Bupropion, a dopamine and norepinephrine reuptake inhibitor, has been found to significantly improve abstinence from smoking. Nicotine gum, inhaler, nasal spray, and transdermal patch appear to be equally effective and approximately double the abstinence rates as compared to placebo. Both bupropion and nicotine replacement therapy has been approved by the FDA for Nicotine Dependence. Nortriptyline and clonidine are second-line medications for treatment of Nicotine Dependence and are not approved by the FDA. Several behavioral therapies including practical counseling (problem solving training, coping skills, and relapse prevention), intratreatment support (encourage patients to quit, and communicate care and concern), extratreatment support (encourage patient to solicit social support, and arrange outside support), and aversive smoking procedures (rapid smoking, rapid puffing) have been found to be effective in increasing abstinence from smoking compared to no-contact controls.

A. Fluoxetine has a half-life of about 4 to 6 days, therefore, has the lowest risk of discontinuation symptoms with abrupt discontinuation. The half-lives of other SSRIs (fluvoxamine: 15 hours, paroxetine: 21 hours, sertraline: 26 hours, and citalopram: 35 hours) are shorter. Therefore, sudden discontinuation of shorter-acting agents can result in anxiety, irritability, crying spells, dizziness, nausea and vomiting, lethargy, sleep disturbances, and flu-like symptoms.

A. Most frequent adverse effects associated with valproate are gastrointestinal effects (nausea, vomiting, and diarrhea) and neurological effects (tremors, sedation, and ataxia). It is also commonly associated with weight gain. Hair loss is usually transient, but total alopecia has been rarely associated with valproate therapy. Reversible thrombocytopenia may occur in the initial phase of valproate treatment. It often produces modest elevations of hepatic enzymes. On rare occasions, valproate may be associated with agranulocytosis, severe hepatotoxicity, and hemorrhagic pancreatitis. Unlike carbamazepine, it does not potentiate hepatic metabolism of concomitant drugs. It can cause neural tube defect with use in pregnancy. Hematologic and hepatic parameters should be regularly monitored in patients receiving valproate.

C. Benedict-Augustin Morel (1809–1873) was a French psychiatrist who proposed an early version of biological psychiatry which held that mental illness is congenitally inherited and can be activated by the environment. Bleuler coined the term Schizophrenia, and introduced autism and ambivalence to the psychosis literature. Boyle suggested in 1826 that the general paresis (of syphilis) was an organic disease, which was not conclusively demonstrated until 1912. Esquirol expanded the theory of moral therapy, wrote an influential textbook, coined the concept of hallucination, and wrote a law detailing provisions for patient care. Cerletti and Lucio Bini developed electroshock therapy in 1938.

B. This patient has sub-acute combined degeneration of spinal cord. It is a neurologic manifestation of vitamin B₁₂ deficiency and is characterized by a myelopathy that involves the posterior and lateral columns of the spinal cord in the
cervical and upper thoracic regions. The involvement of anterior columns of the spinal cord is rare. Pathological changes include spongiform changes and foci of myelin and axon destruction in the spinal cord white matter. There is also loss of myelin followed by axonal degeneration and gliosis. Clinical features include spastic paraparesis, extensor plantar response, and impaired perception of position and vibration. Symptoms usually start in the feet and are symmetric. Other neuropsychiatric manifestations include decreased memory, personality change, psychosis, and delirium. Majority of patients who develop vitamin B₁₂ deficiency have pernicious anemia. It is also more common in the elderly and can be seen after gastric surgery, as well as with acid reduction therapy with H₂-blockers. It may also be caused by malabsorption syndromes due to ileal disease or resection, bacterial overgrowth, and tropical sprue. Vitamin B₁₂ deficiency is also seen in HIV-infected patients. Vitamin B₁₂ deficiency can also occur in strict vegetarians. This phenomenon is usually rare and the consequences of this deficiency are often mild and subclinical. Clinical manifest disease occurs only when poor intake begins in childhood.

E. The technique of PRC has a wide range of applications in diagnostic, experimental, and forensic settings. In genetic fingerprinting, for example, an accused may either be virtually placed on a crime scene or excluded as a suspect by comparing DNA from a crime scene with his or her sample. Given that the crime scene sample may contain a tiny amount of DNA, the task is accomplished by first fragmenting the sample from the crime scene and then amplifying these fragments by several magnitudes. By utilizing several genetic fingerprints, the relationship between parent and child may be established in a paternity case. Using the methods of gene amplification and sequencing, disease causing mutations can be detected in a given genome. Gene cloning is another potential use of PCR. This utilizes gene engineering and amplification.

C. Drug-induced movement disorders are mainly caused by DRB that are used as antipsychotics (neuroleptics) and antiemetics. Acute dystonic reactions usually occur within the first 4 days of treatment with these drugs. Usually, cranial, pharyngeal, and cervical muscles are affected. Young men are at a particularly high risk of developing this disorder. The use of anticholinergics produces a prompt relief in symptoms. Neuroleptic malignant syndrome is a rare, but life-threatening, adverse reaction to DRB, which may occur at any time during treatment with DRB. It is characterized by hyperthermia, rigidity, reduced consciousness, and autonomic failure. Therapeutically immediate DRB withdrawal is crucial. Additional dantrolene or bromocriptine application together with symptomatic treatment may be necessary. Akathisia is also a common side effect of DRB, and is characterized by exceedingly bothersome feeling of restlessness and the inability to remain still. It usually occurs within a few days after the initiation of treatment with DRB and subsides when the DRB is discontinued.

B. The new paradigm in gerontology views aging not as an inevitable deterioration, but one that includes the potential for development and growth. Recent studies examining both objective and subjective indicators of successful aging found that only 10% of the sample could be classified as “successfully aged” when based on objective criteria that included quantitative assessments of physical, cognitive, and social functioning and measures of well being. However, when successful aging was defined as a subjective sense of having adapted well to the demands of life, many more individuals could be classified as having aged successfully. Recent research studies determining predictors of successful aging indicate that high education, absence of alcohol abuse and cigarette smoking, absence of depression, maintenance of appropriate weight, regular exercise, and social support are all predictors of successful aging. Social class, however, does not appear to be an important predictor for successful aging.

C. Melatonin is a hormone chemical produced and secreted by the pineal gland, and in smaller amounts by the retina. Melatonin levels in the CSF may be up to twenty times greater than serum levels. Its levels increase in the evenings, and decrease during the day. Melatonin is not required for sleep in humans, and without it (e.g., removal of the pineal gland) there may be little change in the sleep-wake cycle. Regardless, it is an important hormone in synchronizing the onset of sleep
and environmental light signals. Although melatonin production generally declines with age, how such a decline occurs is debated. Some say it occurs gradually, and others say there is a large decline in adolescence, and again with the CNS degeneration of advancing age. Release of melatonin is via a complex multisynaptic system regulated by the suprachiasmatic nucleus, and culminates in noradrenergic projections from the superior cervical ganglion to pinealocytes.

D. The transitional object is a blanket, pacifier, song, or other object that a child uses to comfort herself when separated from her parents, such as a “security blanket.” The concept was put forth by Winnicott, a pediatrician and psychoanalyst of the British object relations school, who theorized that the transitional object was a representation of the object of the original relationship (mother or breast), and provides a transition from the physical relationship with the original object, to a physical relationship with the transitional object, to a symbolic representation of the original object. The transitional object is used as a defense against anxiety, frequently when the child is going to sleep.

B. A history of prior malpractice claims is not needed to prove malpractice. The elements of a malpractice claim are called the four Ds: duty, deviation, damage, and direct causation.

D. Delusions are described as thought content and not as process of thought. Flight of ideas, loosening of association, circumstantiality, along with thought blocking, word salad, clang associations, punning, and neologism are all used to describe abnormalities in thought process.

A. Various researchers have attempted to divide Alcohol Dependence into subtypes based primarily on phenomenological characteristics. One relatively recent classification denotes Type A Alcohol Dependence as characterized by a late onset, few childhood risk factors, relatively mild dependence, few alcohol-related problems, and little psychopathology. In contrast, Type B Alcohol Dependence is characterized by many childhood risk factors, severe dependence, an early onset of alcohol-related problems, much psychopathology, a strong family history of alcohol abuse, frequent polysubstance abuse, a long history of alcohol treatment, and a high number of severe life stresses. Some research has suggested that patients with Type A Alcohol Dependence may respond better to interactional psychotherapies, whereas patients with Type B Alcohol Dependence may respond better to coping skills training.

B. Over a million Americans sustain TBIs every year, making it a leading cause of morbidity and mortality. TBI exhibits a bimodal age frequency. It is more prevalent in people between the ages of 15 to 25 years and those 75 years and older. While motor vehicle accidents account for a large proportion of TBI in younger people, a majority of elderly patients sustain TBI by way of falls.

D. DSM-IV-TR criteria for GAD include excessive anxiety and worry about a number of events or activities occurring more days than not for at least 6 months. The person finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months): restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance. The focus of the anxiety and worry is not confined to features of an axis I disorder. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism) and does not occur exclusively
during a mood disorder, a psychotic disorder, or a pervasive developmental disorder.

E. Patients with Histrionic Personality Disorder have pervasive and excessive emotionality and attention-seeking behavior. The following are the DSM-IV-TR criteria for the diagnosis of this personality disorder: (a) these individuals are uncomfortable in situations in which they are not the center of attention, (b) they often exhibit inappropriate sexually seductive or provocative behaviors, (c) they display rapidly shifting and shallow expressions of emotions and consistently use physical appearance to draw attention to self, (d) they have a style of speech that is excessively impressionistic and lacking in detail, (e) they show self-dramatization and exaggerated expression of emotion, and (f) others easily influence them, and they consider relationships to be more intimate than they actually are. Furthermore, patients with Narcissistic Personality Disorder require excessive admiration from others.

E. The available evidence indicates that psychological and drug treatments appear to be equally effective for children, adolescents, and adults. CBT is recommended as the first-line treatment for children and adolescents, because of the assumption that it has fewer risks than SSRIs. For adults, CBT or pharmacotherapy can be offered as first-line treatments. There is still uncertainty as to whether pharmacotherapy combined with CBT is superior to either treatment modality provided alone.

E. Management of Opioid Intoxication involves general supportive measures, as well as institution of the specific antidote, naloxone. An adequate airway is established, and respiratory and cardiac functions are assessed and maintained. IV access is essential for fluids and nutrition. Naloxone hydrochloride, a pure opioid antagonist, is used to reverse the CNS effects of opioid intoxication. An initial IV dose of 0.4 to 0.8 mg is administered to counteract neurologic and cardiorespiratory depression. The onset of action of intravenously administered naloxone is approximately 2 minutes. The subcutaneous route has been found to be equally effective since the slower rate of absorption via this route is offset by the delay in establishing IV access. Overdose with opioids that are more potent, such a fentanyl or longer acting agents like methadone, require higher doses of naloxone administered over prolonged periods.

B. TCAs derive their name from their three-ring structure. The tertiary amine tricyclic compounds, such as amitriptyline and imipramine, have two methyl groups at the end of the side chain. These compounds are demethylated to secondary amines, such as desipramine and nortriptyline. The tertiary amines are more potent as inhibitors of serotonin reuptake, and the secondary amines are more potent than norepinephrine inhibitors. The TCAs also possess cholinergic and histaminergic receptor blocking property. Desipramine is the most biochemically selective compound that blocks norepinephrine reuptake, and is unlikely to affect serotonin reuptake. Additionally, desipramine has little affinity for muscarinic-cholinergic, histaminergic, and α1-adrenergic receptors. The tetracyclic compounds, maprotiline and amoxapine, have a four-ring structure.

C. Reboxetine is an SNRI that has been shown to be effective for the treatment of major depression. It is rapidly absorbed after oral administration, and is metabolized by P450 isoenzyme 3A4. It is generally well tolerated, and has fewer side effects (dry mouth, constipation, and other anticholinergic side effects) as compared to the TCAs. Reboxetine does not adversely affect the cardiac conduction, and is safer in overdose. Atomoxetine is another SNRI that has shown efficacy in the treatment of ADHD. Among TCAs, desipramine is the most biochemically selective compound that blocks norepinephrine reuptake. Bupropion is a norepinephrine-dopamine reuptake inhibitor, imipramine is a tricyclic agent, and sertraline is an SSRI.

B. Controlled studies have not confirmed the efficacy of gabapentin or topiramate as
effective mood stabilizers. Lamotrigine has been found to be effective in treating both mania and depression. It acts at voltage-sensitive sodium channels, and inhibits the presynaptic release of glutamate and aspartate. Most common side effects of lamotrigine include ataxia, dizziness, headache, diplopia, blurred vision, nausea, vomiting, and rash. Lamotrigine does not cause weight gain. It is rarely associated with Stevens-Johnson syndrome and toxic epidermal necrolysis. Valproate inhibits the metabolism of lamotrigine, and carbamazepine and phenobarbitone enhance its metabolism.

A. PMDD is characterized by lethargy and easy fatigability. Other symptoms of PMDD include depressed mood, increased anxiety, difficulty concentrating, and persistent anger or irritability.

C. This patient has sub-acute, combined degeneration of spinal cord, a neurologic manifestation of vitamin B₁₂ deficiency, which is characterized by a myelopathy that involves the posterior and lateral columns of the spinal cord in the cervical and upper thoracic regions. The involvement of anterior columns of the spinal cord is rare. Pathological changes include spongiform changes and foci of myelin and axon destruction in the spinal cord white matter. There is also loss of myelin followed by axonal degeneration and gliosis. Majority of patients who develop vitamin B₁₂ deficiency have pernicious anemia. It is also more common in the elderly, after gastric surgery, with H₂-blockers therapy, malabsorption syndromes, bacterial overgrowth, and tropical sprue. Clinical features include spastic paraparesis, extensor plantar response, and impaired perception of position and vibration. Symptoms usually start in the feet and are symmetric. Serum vitamin B₁₂ level determination is the mainstay for evaluating vitamin B₁₂ status. Serum vitamin B₁₂ measurement has technical and interpretive problems, and it lacks sensitivity and specificity for the diagnosis of vitamin B₁₂ deficiency. Low levels may often be seen in pregnancy, with oral contraceptive or anticonvulsant use, with transcobalamine deficiency, with folate deficiency, in association with HIV infection, and in multiple myeloma. Falsely elevated vitamin B₁₂ levels may be seen with renal failure, liver disease, and myeloproliferative disorders. Levels of serum MMA and plasma total homocysteine are useful ancillary diagnostic tests for vitamin B₁₂ deficiency. MMA is a byproduct of methylmalonyl-CoA and it accumulates in vitamin B₁₂ deficiency. Its specificity is superior to that of plasma homocysteine in vitamin B₁₂ deficiency.

B. Hepatitis C virus infection has been associated with depression independent of therapeutic complications. Personality Disorders, Anxiety and Somatization Disorders are no more prevalent in hepatitis patients than in the general population. Interferon-α is a cytokine host defense protein and immune modulator. Produced by lymphocytes, it is indicated for the treatment of hepatitis C, melanoma, and renal cell carcinoma. Interferon-α therapy is associated with a variety of psychiatric symptoms. For example, some studies indicate depression rates as high as 40%. Other less well documented neuropsychiatric symptoms include poor concentration, memory deficits, anxiety, and rarely psychosis. Treatment emergent depression is a frequent reason for premature termination of INF therapy. There is evidence suggesting well defined risk factors for the development of depression in these patients. Dose and duration of INF therapy and pretreatment depressive symptoms, particularly mild depression, have been shown to be risk factors for INF-induced depression. Age, gender, and history of substance use have not been shown to impact this risk. Depression occurring in INF-treated patients typically becomes evident and peaks at week 4 and week 24, respectively. Although there are studies suggesting that prophylactic antidepressant therapy may lead to significant reduction in depression rates among patients undergoing INF therapy, this mode of intervention is currently not approved by the FDA nor is it routine standard of care.

C. Akathisia is the Greek word for the inability to sit down. It is one of the most common movement disorders induced by DRB. Patients often suffer from a feeling of restlessness and the inability to remain still. Objectively, they present
with increased motor activity, consisting of complex, semi-purposeful, stereotypic, and repetitive movements. They have the urge to move. Acute akathisia develops in 20% to 40% of patients receiving DRB. In 75% of patients acute akathisia develops within three days after therapy initiation. There are direct correlation between the potency of the neuroleptics, the neuroleptic dose and the rate of dosage increase, and the risk and severity of akathisia. There is no age or gender predisposition to developing akathisia. Acute akathisia usually tends to continue for as long as the neuroleptic medication is maintained and subsides shortly after cessation of treatment. It is very bothersome to the patients and often limits the patient’s compliance. Anticholinergics, amantadines, and benztropines may be helpful as may be clonazepam and clonidine. Acute akathisia may also be caused by serotonergic agents, SSRIs, or cocaine.

C. Currently, implantation of cardiac pacemakers, defibrillators, and brain and spinal cord stimulators are all considered absolute contraindications to undergoing an MRI, because the strong magnets may induce unwanted currents in these devices. Ventilation may be performed by hand or by non-ferromagnetic machines. Newer, weakly ferromagnetic heart valves, access ports, and aneurysm clips are typically not a problem with MRI. Joint prostheses, even metal ones (as long as they are not significantly ferromagnetic), are typically okay for MRI. Some animal studies have reported the development of cataracts in fetuses exposed to MRI in utero. Human studies have not borne this out, and when the situation warrants, MRI may be performed on a pregnant patient.

E. Marchiafava-Bignami disease is a demyelinating condition of the corpus callosum. It presents with rapidly progressive neurologic symptoms and ends fatally within a few months. It is specifically associated with alcoholism. Psychiatric manifestations include depression, mania, paranoia, and dementia predominate. Seizures are common, and hemiparesis, aphasia, dyskinesia, and ataxia are variably present.

E. Neurologic manifestations may be the earliest and often the only manifestation of vitamin B₁₂ deficiency. The neurologic manifestations of this deficiency include a myelopathy with or without an associated neuropathy, cognitive dysfunction, optic neuropathy, and paresthesias without abnormal signs. Studies have also demonstrated that the severity of the hematologic and neurologic manifestations may be inversely related in a particular patient. Relapses in the illness are usually associated with the same neurologic phenotype.

D. Complex regional pain syndrome is an emerging diagnostic entity comprising reflex sympathetically mediated pain, regional sympathetic dystrophy (RSD) and causalgia. Autonomic dysfunction, disproportionate pain and soft tissue alteration are the common factors underlying these entities. Precipitating injuries are largely minor but may include fractures, peripheral vascular disease, and gun shot wounds. Of these entities, RSD is the commonest. It is not associated with direct nerve damage and treatment consists of blockade of regional sympathetic nerve ganglion, physical therapy, and adjunctive medications. An interesting phenomenon in RSD is pain extending far beyond the precipitating injury, as in this case. The most commonly used agents to treat this condition include anticonvulsants, antidepressants, steroids, biphosphates, and opiates, but they have not been adequately studied in the treatment of complex regional pain syndrome. All these agents should be used in conjunction with a comprehensive interdisciplinary approach aimed at functional restoration and improved quality of life of the patient.

C. Her child is at increased risk of developing MS as there is a genetic susceptibility for developing MS. Monozygotic twins have a greater than 30% concordance rate for developing MS while dizygotic twins have 4% to 5% concordance rates. Environmental factors also play a significant role in development of MS. Spending your childhood in cool temperate latitudes of the Northern Hemisphere increases the risk of developing MS. Pregnancy can precipitate an MS episode especially in the first 3 postpartum months. MS is not known to increase
the risk of obstetric complications, fetal malformations, or spontaneous abortions. Exacerbations of MS in pregnancy are not believed to affect outcome of the fetus. Pregnancy also does not affect the long-term outcome or prognosis of MS.

B. Friedreich’s ataxia is an autosomal, recessive disorder of trinucleotide repeats that presents in late childhood. This condition should be distinguished from the spinocerebellar degenerations or types of spinocerebellar ataxias (SCAs), which are transmitted in an autosomal dominant fashion with trinucleotide repeat expansion on various chromosomes. Some consider the pes cavus foot deformity pathognomonic (high arch, elevated first dorsum, and retracted first metatarsal) of Friedreich’s ataxia. Another feature of Friedreich’s ataxia is that it is often associated with cardiomyopathy and posterior column sensory deficits. A “steppage gait” of raising the feet high is common in Friedreich’s and other ataxias associated with damage to posterior column of the spinal cord. His younger siblings are at risk to develop his symptoms later on in their lives.

C. Olivopontocerebellar atrophy may be familial (sometimes autosomal dominant or recessive) or sporadic. They often present in the 40s. The sporadic form is more common, and presents at a younger age. Progressive ataxias, often beginning in the lower limbs, may develop into parkinsonism in half the cases. It may be related to multiple system atrophy in some cases. Pathologically there is extensive degeneration in middle cerebellar peduncles, cerebellar white matter, and specific nuclei (pontine, olivary, and arcuate). This may be secondary to myelin degeneration. Other associated features may include retinal degeneration, spastic paraplegia, areflexia, dementia, ophthalmoplegia, neuropathies, and dystonias. Lesions to olivary nuclei are characteristic of olivopontocerebellar atrophy. Friedreich’s ataxia is a more common hereditary form of ataxia, and it presents earlier and with different associated findings. Lack of cardiac and spinal problems makes the diagnosis of Friedreich’s ataxia less likely. Stroke could present similarly, but the patient is healthy and without evidence of vascular disease. It would also be unusual to have a lesion specific to the olivary nuclei presenting with progressive ataxia. Parkinson’s disease does not typically present with prominent ataxia. No tumors are seen on MRI, and paraneoplastic ataxias are more common in women with ovarian and breast cancers.

B. Topiramate is a new anticonvulsant drug that has been used for both partial and generalized seizures. It can precipitate renal stones in patients taking the medication. It has also been associated with hyperchloremic metabolic acidosis and angle-closure glaucoma. It can produce rashes, especially when used with valproic acid. This medication has not been commonly associated with priapism, hepatic adenomas, or coma.

C. Given equivalent stressors, those individuals with strong social supports appear to have better outcomes than those who are isolated or those who perceive that support is unavailable or unhelpful from those in their social network. The elderly have reduced social networks and the frequency of their social contacts as compared to younger adults. This is true for the oldest-old, whose social networks have been shown to be one half the size of the young-old. For many older adults, this reduction in social contact is not voluntary and may be more related to disability and reduced mobility than preference. Although overall social contacts decrease in late life, it is only contact with acquaintances and other peripheral individuals that decreases significantly. Social contacts with very close friends and family remain stable, and older adults’ satisfaction with these close relationships remains high. Older adults with nuclear family members tended to have social networks that were both larger, as well as more emotionally close, than older adults without nuclear family. However, those without nuclear family report greater feelings of closeness to friends than those with nuclear family, suggesting that older adults can adapt to the absence of family by creating satisfying relationships with others. Recent studies of the social structure of the oldest-old indicate that most individuals over the age of 85 have at least one surviving relative, but approximately one fourth had little or no contact with that relative. For the oldest-old the family, especially adult children, appears to play a crucial role in providing social support.

D. Many hormones have a diurnal pattern. Prolactin levels usually increase during the sleep period, as do luteinizing hormones (especially in adolescents). Growth hormone has a similar pattern. TSH has a different pattern, with increased levels in the evening hours, which decrease after sleep onset. Cortisol production usually decreases at night, and increases toward morning. This pattern may be disrupted by depression.

B. Also called “doing and undoing,” undoing is a defense mechanism employed to essentially attempt to reverse unconscious hostile wishes by recreating and “re-writing” a situation, to remove the aggressive thoughts before they are enacted. In this case, obsessive thoughts about the driver of the car being killed in an accident lead the man to perform an elaborate ritual to maintain the driver’s safety. From a psychoanalytic perspective, the auto mechanic’s behavior could be interpreted as a defense against unconscious impulses to cause harm to the driver by performing an action (loosening the lug nuts) that must then be “undone.” Splitting is a primitive defense mechanism that results in division of good and bad aspects of an object into two separate objects, allowing the patient to avoid the ambivalent conflict of maintaining contradictory aspects of an object together. Reaction formation refers to a defense mechanism in which the person acts in a way diametrically opposed to their inner wishes, such as being excessively friendly to a person he dislikes. In sublimation, unconscious urges are partially expressed in a socially acceptable way, such as the channeling of aggressive impulses to competitive sports. Projective identification is a complicated form of primitive defense, in which the patient projects intolerable feelings to the therapist, which can then be identified by the therapist and processed, reducing anxiety. Sudden feelings experienced by the therapist during a session that seem foreign can be reflections of the inner world of the patient, projected onto the therapist.

C. The core of the insanity defense is the presence of a mental disorder. Mental disorders that meet criteria for the insanity defense do not include symptoms manifested solely as criminal behavior or antisocial acts. Presence of a defect of reason, lack of knowledge of wrongfulness, and incapacity to refrain from the criminal act are basic components of the insanity defense. However, the importance of these elements may vary depending on jurisdiction.

A. All of the choices are disorders of thought process. Circumstantiality is a disorder in which the patient is unable to be goal directed and incorporates exhausting details that are unnecessary, and has difficulty in arriving at an end point. Tangentiality describes a thought process in which the patient digresses from the subject and introduces thoughts that seem unrelated, skewed, and irrelevant. Blocking is a sudden cessation in the middle of a sentence, at which point a patient cannot recover what was said and is unable to complete their thoughts. Loose associations refer to switching from one topic to another with no apparent connection between the topics. Perseveration refers to repeating the same response to any questions with an inability to change the response or topic.

B. A history of drug abuse has no connection with Factitious Disorder by Proxy. This disorder is also known as Münchhausen syndrome by proxy, and involves the intentional feigning or production of physical or psychological symptoms in another person who is under a perpetrator’s care, where the perpetrator’s motive is to assume the sick role by proxy. The perpetrator may give a false medical history and provide symptoms that do not make sense, as well as alter records or contaminate laboratory samples while the victim remains passive to the perpetrator’s deeds, and there is often a family history of similar sibling illness.

C. Although post-TBI recovery is a gradual process, most patients show significant recovery within 3 years, while most of the recovery occurring within 6 months as the brain regenerates. Recovery following the more severe TBI is individualized and depends on nature, location, and severity of the injury. Most spouses of patients with moderate to severe TBI are appropriately concerned and
perhaps apprehensive, thus this behavior falls within the norm.

C. The feature of acute stress disorder is the development of characteristic anxiety, dissociative, and other symptoms that occurs within 1 month after exposure to a traumatic stressor. Either while experiencing the traumatic event or after the event, the individual has at least three of the following dissociative symptoms: (i) a subjective sense of numbing, detachment, or absence of emotional responsiveness, (ii) a reduction in awareness of his or her surroundings, (iii) derealization, (iv) depersonalization, or (v) dissociative amnesia. Following the trauma, the traumatic event is persistently reexperienced, and the individual displays marked avoidance of stimuli that may arouse recollections of the trauma and has marked symptoms of anxiety or increased arousal. The symptoms must cause clinically significant distress, significantly interfere with normal functioning, or impair the individual’s ability to pursue necessary tasks. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks after the traumatic event. If symptoms persist beyond 4 weeks, the diagnosis of PTSD may be applied. The symptoms are not due to the direct physiological effects of a substance or a general medical condition, are not better accounted for by brief psychotic disorder, and are not merely an exacerbation of a preexisting mental disorder.

D. Subjects with Dependent Personality Disorder have an excessive need to be taken care of, and show submissive behavior and fear of separation. They think that they would be unable to function without the help of others and actively seek this help. They have unrealistic fears of being left to take care of themselves and they urgently seek other relationships as a source of support. They also have a hard time making decisions and need constant advice and support. Patients with avoidant personality disorder show restraint within intimate relationships because of the fear of being shamed or ridiculed.

D. A recent Cochrane review included twenty-two studies with 1,060 participants with GAD. Based on thirteen studies, psychological therapies, all using a CBT approach, were more effective than TAU/WL in achieving clinical response at posttreatment (relative risk [RR]: 0.63; 95% confidence interval [CI]: 0.55 to 0.73), and also in reducing anxiety, worry, and depression symptoms. No studies conducted longer-term assessments of CBT against TAU/WL. Six studies compared CBT against supportive therapy (non-directive therapy and attention-placebo conditions). No significant difference in clinical response was indicated between CBT and supportive therapy at post-treatment (RR: 0.86; 95% CI: 0.70 to 1.06). Based on their findings, the authors concluded that psychological therapy based on CBT principles is effective in reducing anxiety symptoms for short-term treatment of GAD. The body of evidence comparing CBT with other psychological therapies is small and heterogeneous, which precludes drawing conclusions about which psychological therapy is more effective.

E. Pharmacologic agents used for assisting patients through a safer and more comfortable opioid withdrawal include use of an opioid agonist (methadone), α2-adrenergic agonist (clonidine), and a mixed opioid agonist/antagonist (buprenorphine). In addition, opioid antagonists, such as naltrexone and naloxone, are use in combination with clonidine or general anesthesia for rapid withdrawal from opiates.

A. TCAs are absorbed rapidly and completely in the small intestine. They are extensively bound to plasma proteins. They are mainly metabolized in the liver by demethylation of the side chain and hydroxylation of the ring structure. Elimination half-lives for most tricyclics is about 24 hours, therefore, they can be administered in once a day dosing schedule. The tricyclic and tetracyclic compound are lipophilic amines, therefore, have a high volume of distribution. They are concentrated in a variety of tissues in the body, and their concentration in cardiac tissues exceeds those in plasma.

B. Venlafaxine is an SNRI, which is well absorbed in the gastrointestinal tract, and metabolized by P450 isoenzymes 2D6 and 3A4. Other SNRIs include milnacipran and duloxetine. Venlafaxine and milnacipran have been shown to be safe and effective antidepressants. In addition, research studies have suggested a role of venlafaxine in GAD, OCD, Panic Disorder, Social Phobia, Agoraphobia, and ADHD. Most common adverse effects observed with venlafaxine include asthenia, sweating, nausea, constipation, anorexia, vomiting, somnolence, dizziness, anxiety, tremor, blurred vision, impaired orgasm or ejaculation, and impotence in men. Venlafaxine is associated with sustained hypertension in patients treated with more than 300 mg/day. Duloxetine has been shown to be effective in treating depression and pain syndromes.

A. Although statistics vary, approximately 3% to 5% of women meet criteria for PMDD. Most women of childbearing age experience some symptoms of MDD during the course of some of their menstrual cycles. PMDD is best determined by prospective daily symptom rating scales completed over a 2-month interval.

A. Temporal lobes are unaffected in Wernicke’s encephalopathy. Symmetric lesions are usually seen in the periventricular regions of the thalamus and hypothalamus, the nuclei at the level of the third and fourth ventricle, superior cerebellar vermis, and the mammillary bodies. The changes seen include necrosis, neuronal loss, edema, prominent capillaries with endothelial proliferation, and hemorrhage. In the late stages of the illness, cell loss with astrocytic and microglial proliferation may also be seen.

D. Hepatitis C virus infection has been associated with depression independent of therapeutic complications. Personality Disorders, anxiety, and Somatization Disorders are no more prevalent in hepatitis patients than in the general population. Interferon-α is a cytokine host defense protein and immune modulator. Produced by lymphocytes, it is indicated for the treatment of hepatitis C, melanoma, and renal cell carcinoma. Interferon-α therapy is associated with a variety of psychiatric symptoms. For example, some studies indicate depression rates as high as 40%. Other less well documented neuropsychiatric symptoms include poor concentration, memory deficits, anxiety, and rarely psychosis. Treatment emergent depression is a frequent reason for premature termination of INF therapy. Well defined risk factors for depression in these patients have been documented. Dose and duration of INF therapy, pretreatment depressive symptoms particularly mild depression have been shown to be risk factors for INF-induced depression. Age, gender, and substance use history have not been shown to impact this risk. Depression occurring in INF-treated patients typically becomes evident and peaks at week 4 and week 24, respectively. Although there are studies suggesting that prophylactic antidepressant therapy may lead to significant reduction in depression rates among patients undergoing INF therapy, this mode of intervention is currently not approved by the FDA, nor is it routine standard of care.

D. In between seizures, a single EEG recording will show a normal pattern in 30% of patients with absence seizures and 50% of those with grand mal epilepsy. Another 30% to 40% of epileptics, though abnormal between seizures, are nonspecific. Therefore, the diagnosis of epilepsy can be made only by the correct interpretation of clinical data in relation to the EEG abnormality.

C. Cerebral angiography (using dye and x-rays) is most useful in diagnosing cerebrovascular disorders. This does not necessarily include stroke or certain types of hemorrhages, for which CT and MRI are extremely useful. Conventional angiography
is particularly useful in diagnosing aneurysms, vascular malformations, arterial and venous occlusion, angiitis, and dissection. CTA and a CTA (CTangiography) and MRA (MRangiography) may eventually replace traditional angiography, but for now it is still used, particularly in interventional procedures. It is a potentially dangerous and invasive technique. Tumors are best visualized on MRI (sometimes CT, e.g., men and genome is), fractures on CT. Certain infections can be seen on CT or MRI (e.g., cysticercosis, toxoplasmosis, and the effects of meningitis), but LP remains vital.

B. Alcoholic myopathy ranges in severity from asymptomatic elevation of serum creatine kinase, to a progressive polymyositis-like presentation, to acute rhabdomyolysis. Muscle weakness is common, but fever is not typically present.

C. This patient has developed Wernicke’s encephalopathy due to the deficiency of thiamine. The clinical features of Wernicke’s encephalopathy include a subacute onset of ocular palsies, nystagmus, gait ataxia, and confusion. Thiamine functions as a coenzyme in the metabolism of carbohydrates and branched-chain amino acids. Thiamine deficiency results in reduced synthesis of high-energy phosphates and causes an accumulation of lactate. The recommended daily requirement for adults is 1.2 mg/day for men and 1.1 mg/day for women, and its highest concentrations are found in yeast and in the pericarp of grain. Most cereals and breads available in the United States are fortified with thiamine. Organ meats are good sources of thiamine, while dairy products, seafood, and fruits are poor sources. Prolonged cooking of food, baking of bread, and pasteurization of milk remain potential causes of thiamine loss. The areas most vulnerable to thiamine deficiency in the brain are those with the highest turnover rates like the caudal part of the brain and the cerebellum. As its turnover rate is rapid (half-life of 10 to 14 days) and there is lack of storage, a continuous dietary supply of thiamine is necessary to balance the body’s requirement. In some cases thiamine deficiency may manifest in just 2 to 3 weeks on a deficient diet. Thiamine deficiency in alcoholism occurs because of inadequate dietary intake, reduced gastrointestinal absorption, and reduced liver thiamine stores. Additionally, alcohol also inhibits the transport of thiamine in the gastrointestinal system and blocks phosphorylation of thiamine to thiamine diphosphate, the active form of thiamine.

D. Four case series have documented mental status changes associated with cases of Addison’s disease. Mood symptoms and decreased motivation are common in less severe cases, and an “acute organic brain syndrome” is associated with severe cases. These series indicates that mild disturbances in mood, motivation, and behavior are core clinical features of Addison’s disease. Psychosis and extensive cognitive changes (including delirium) do occur, but are associated with severe disease and may be the presenting feature of Addisonian crisis. Rare presentations of Addison’s disease have included catatonia and self-mutilation. In 80% of the case reports, symptoms occurred before diagnosis and treatment, indicating that the mental status changes are a feature of Addison’s disease and not caused by treatment with cortisone. In the majority of cases, both physical and mental symptoms were resolved with cortisone treatment in 1 week. A diagnosis of Addison’s disease is based on the measurement of low plasma cortisol, elevated ACTH, and the results of a corticotropin stimulation test. In a short corticotropin stimulation test, 250g of cosyntropin (a synthetic form of ACTH) is given before 10 AM, and plasma cortisol is measured before the test and 60 minutes after the injection. In patients with Addison’s disease, the adrenal cortex is unable to increase cortisol secretion in response to cosyntropin. When patients present with an Addisonian crisis, glucocorticoid treatment must not be delayed. Blood for serum cortisol, ACTH, and serum chemistry should be drawn, and therapy with IV saline and dexamethasone should be initiated immediately. A short corticotropin stimulation test can then be performed as dexamethasone does not interfere with cortisol radioimmunoassay. Following testing, therapy with dexamethasone can be replaced with hydrocortisone. Low aldosterone and high renin are consistent with the diagnosis of Addison’s disease. If the cause of primary adrenal insufficiency is unknown, adrenal autoantibody tests and imaging of the adrenal glands can be performed.

D. In MS, total “lesion load” assessed via imaging is the most predictive of cognitive deficits. Total physical disability also correlates with cognitive deficits. Location of lesions often corresponds well with specific deficits (commonly enlarged ventricles, corpus callosum atrophy, and periventricular white matter demyelination). However, many lesions are clinically asymptomatic. Initially the patient usually appears cognitively normal, despite MS symptoms that interfere with full assessment. Subtle deficits may be found early on more sophisticated testing. Impairments are often first noted in memory and concentration, but may eventually deteriorate to dementia. Age of onset and length of time since onset are less well correlated with cognitive impairment. The spinal form of MS is less likely to be associated with “subcortical” cognitive deficits or dementia, which may occur in advanced MS.