C. Although it is often the first cognitive function affected by dementia, short-term memory is generally unaffected in the normal aging individual. The geriatric patient without dementia may exhibit decline in other cognitive areas, such as reduced ability to sustain attention over long periods, decline in motor speed and response times, and difficulty performing visuospatial tasks. A greater amount of time is often required for the elderly to learn new information, and there may be problems accessing data from long-term memory. Cognitive changes with age are not inevitable and may vary from individual to individual.

C. Tryptophan is hydroxylated by tryptophan hydroxylase to form serotonin. Tyrosine is the amino acid precursor of epinephrine and dopamine. Histamine is synthesized from histidine. ACh is synthesized by the transfer of an acetyl group from acetyl coenzyme A.

E. The California Verbal Learning Test II is a test of memory, which documents encoding, recognition, and immediate recall followed by a 30-minute recall. It tests for possible learning strategies and susceptibility to semantic interference. The Boston Naming Test (Revised), Verbal fluency, Token Test, and Boston Diagnostic Aphasia Examination are all tests for language functioning.

A. Most state statutes require that the psychiatrist perform some intervention to prevent harm from occurring when their patient threatens harm to others. This duty is not just limited to warning, but to protect the identifiable victim. According to Tarasoff v Regents of the University of California, a psychiatrist who treats violent or potentially violent patients may be sued for failure to control aggressive behavior. A psychiatrist is most liable for a lawsuit if he was aware of the patient’s violent tendencies and failed to safeguard the public from these tendencies. In Tarasoff v Regents of the University of California, the California Supreme Court had ruled that mental health professionals have a duty to protect identifiable third parties from imminent threats of serious harm made by their outpatients. Some states have adopted the Tarasoff ruling, whereas others have accepted this ruling in a limited or modified manner. However, most states expect the mental health professional to act affirmatively to protect an identified third party from their patient’s violent or dangerous acts. Although not a federal law, a clinician should consider the Tarasoff duty to be a national standard of care. Most statutes require an actual threat to be made against a clearly identifiable victim before a duty to warn or to protect arises. This duty involves warning the intended victim and the local law enforcement authority.

B. The Rey-Österreich Complex Figure Test is a helpful tool to assess visuospatial skills. When patients have a lateralized dysfunction to the right hemisphere, they frequently loose the capacity to capture the global features of a design, and they are only able to reproduce isolated details. On the other hand, when there is lateralized damage to the left hemisphere, patients are able to draw the main framework of a design, but they lose the capacity to reproduce details. The amygdala and putamen are not directly involved in visuospatial functions.

C. There is an 11% to 26% comorbidity in pediatric OCD and tic disorders. Patients with OCD and Tourette’s syndrome in particular are more likely to have the following OCD symptoms: repetitive touching, counting, ordering and arranging, and
a need for symmetry, whereas OCD without comorbid tic disorders is more frequently associated with fears of contamination or of harm befalling self or others.

B. This child meets the criteria for ODD as his behavior, for a period >6 months, has had five of the eight criteria for ODD. From this vignette, these include: arguing with his parents and teachers; actively defying rules and requests from adults; deliberately annoying others (his sister) and often blaming others (his sister) for his mistakes or misbehavior; and finally, being touchy or easily annoyed with others. ODD is often present at home, but may not necessarily manifest at school. The child may not regard himself as having oppositional or defiant behavior. The lack of aggressive behavior to people or animals, destruction of property, deceitfulness, and theft excludes the diagnosis of conduct disorder. Because there are no reports of hyperactivity, inattention and impulsivity, the diagnosis of ADHD is excluded; moreover, onset of some ADHD symptoms must occur before age 7. Disruptive behavior disorder NOS is characterized by conduct or oppositional defiant behaviors that do not meet the criteria for ODD or conduct disorder. Finally, child antisocial behavior is diagnosed when the focus is on antisocial behavior or isolated acts. Also note that the history does not give evidence for a psychotic or mood disorder which also should be excluded from the differential.

A. The following disorders have all been associated with autism: epilepsy, Fragile X syndrome, tuberous sclerosis, cerebral palsy, phenylketonuria, neurofibromatosis, Down syndrome, congenital rubella, and visual and hearing impairments. Huntington’s disease has not been associated with pervasive developmental disorders.

A. Studies have found that the lifetime prevalence of depression in eating disorders is close to 75%. The CNS effects of starvation sometimes confound the diagnosis. Depressed patients with eating disorders present frequently with labile mood and strong neurovegetative symptoms secondary to the starvation. The lifetime prevalence of substance abuse in this population ranges from 17% to 46%. OCD is also common among patients with eating disorders (lifetime prevalence of around 40%). It can sometimes be hard to distinguish OCD from an eating disorder, because a lot of these patients have specific rituals, including exercising and repetitive weighing. General anxiety disorder and panic attacks have similar lifetime prevalence in patients with eating disorders of about 10% each.

D. Buspirone is the single 5HT_1A agonist approved for the treatment of anxiety. It is generally well tolerated and has no significant pharmacokinetic drug interactions. It is considered a serotonin partial agonist which, unlike benzodiazepines, is not associated with a risk of abuse/dependence or withdrawal.

D. The euphoric effect of alcohol is related to its ability to increase both dopamine activity and opioid activity in the brain. Alcohol acts to increase the release of endorphins, the body’s naturally occurring opiates, and these opiates bind to receptors in the brain. This results in the pleasurable effects of alcohol. Naltrexone is an opioid receptor antagonist. In studies, although it does not typically improve abstinence rates, it helps patients keep one drink from turning into a relapse, where relapse is defined as a man having five or more drinks in one day or a woman having four or more drinks in one day. By blocking the “high” associated with alcohol, naltrexone also reduces craving for alcohol and the percentage of days in which drinking occurs. Its major side effect is nausea. It can also cause vomiting, anorexia, constipation, and abdominal pain. CNS side effects include nervousness, headache, insomnia, and agitation. Joint pain and muscle pain occur in 10% of patients. Finally, it can also cause hepatic enzyme elevation.

D. The most prevalent renal effect of lithium is impairment of concentrating ability, estimated to be present in up to 55% of patients on chronic lithium therapy and caused by an unclear
mechanism. This defect may translate into overt polyuria (>3 L per 24 hours) in 20% to 40% of patients on lithium. Polyuria can cause dehydration and significant discomfort. Polyuria usually resolves within 3 weeks of lithium discontinuance, but can also persist beyond a year. Approximately 5% to 20% of patients on lithium will develop NDI. In NDI, the kidney response to vasopressin is impaired. The established treatment for NDI and severe cases of polyuria includes thiazide diuretics. The mechanism by which thiazide diuretics produce the paradoxic antidiuretic effect remains unclear, but it may have to do with upregulation of aquaporin-2, Na-Cl cotransporter. Amiloride works by inhibiting sodium reabsorption in the distal convoluted tubules and collecting ducts in the kidneys. This promotes the loss of sodium and water from the body, but without depleting potassium. Unlike thiazides, amiloride has a weak natriuretic effect and is less likely to increase plasma lithium levels by causing volume contraction. Nonsteroidal anti-inflammatory drugs (NSAIDs) may have a more favorable tolerability and safety profile relative to thiazides and amiloride. Lithium causes excess production of prostaglandins, which decrease the ability of kidneys to reabsorb free water. NSAIDs inhibit prostaglandin synthesis, which is hypothesized to explain their efficacy in treatment of li-induced polyuria. Rehydration must be strictly monitored because of the risk of renal failure connected with NSAIDs. Indomethacin treatment of lithium-induced NDI has preliminary evidence of being efficacious and safe. Intravenous ketoprofen, with its rapid onset of action, may be an effective alternative to indomethacin in the treatment of severe lithium-induced NDI. Furosemide is not used for NDI, because it will exacerbate the renal collecting tubule defect in concentrating capacity and worsen NDI.

C. Emotional lability, hyperexcitability, inappropriate temper outburst, crying spells or unpredicted euphoric mood, distractibility, impairment of recent memory, and poor attention span can be seen in patients with hyperthyroidism. In severe cases, psychosis can also occur. In many cases, a major depressive episode and generalized anxiety disorder can occur. Hyperthyroidism occurs seven times more frequently in females than males and has a clear familial predisposition. It usually occurs in women in their third and fourth decades of life, whereas in men, the majority of cases occur in the later decades of life. When hyperthyroidism occurs in the elderly, it is usually manifested by lethargy, apathy, social withdrawal, and overtly depressed mood. In subclinical hyperthyroidism, where there is a normal T3 level with elevated T4 levels, some patients develop an agitated form of depression, which is manifested by irritability, intensity, and diminished sleep. Although mania may occur in hyperthyroidism, it is much less common than agitated depression. When hyperthyroidism is medically treated with the return of T3, T4, and TSH levels to normal, most psychiatric symptoms will subside.

D. Disulfiram is an irreversible inhibitor of aldehyde dehydrogenase, a hepatic enzyme involved in the intermediary metabolism of ethanol. When alcohol is consumed in the presence of this enzyme inhibition, acetaldehyde levels rise five to 10 times higher than normal, resulting in noxious physical symptoms. Five to 10 minutes after consuming alcohol, the patient taking disulfiram experiences whole-body flushing, severe headache, dizziness, nausea, vomiting, and sweating. The symptoms last from 30 minutes to 2 hours, after which time the patient typically sleeps and fully recovers. Disulfiram is recommended only for alcohol-dependent patients who seek total abstinence and are willing and able to comply with the drug. Hence, it is not recommended for use in patients who are psychotic, suicidal, or impulsive. Medical contraindications include pregnancy, renal failure, moderate to severe hepatic dysfunction, and cardiac disease. Although there is no evidence that agents such as disulfiram have any long-term efficacy, the drug may be useful for patients who have a history of sobriety followed by relapse, or for sober patients facing a time of relapse risk (vacation or holidays). Prior to use, patients must be completely detoxified from alcohol. A dose of disulfiram, typically 250 mg/day, results in sensitivity to alcohol for 6 to 14 days. Patients must be advised to avoid alcohol in all forms, including cough syrups and aftershave.

D. More than 30,000 people die by suicide each year in the United States. The number of attempted suicides is estimated to be 650,000. Suicide rates, in the United States, have averaged 12.5 per 100,000 in the 20th century. Suicide is ranked as the eighth overall cause of death in the United States. Marriage reinforced by children is a protective factor and significantly lessens the risk of suicide. The suicide rate is 11 per 100,000 among married persons. Previously married persons, though, have much higher rates than those who have never been married. Previous medical care appears to be a positively correlated risk factor for suicide. Psychiatric patients have an increased risk for suicide that is three to 12 times greater than nonpatients. Among psychiatric outpatients, the period following discharge from an inpatient setting is a time of significantly increased risk. The psychiatric diagnosis with the greatest risk of suicide in both sexes is a mood disorder. The suicide risk in patients with depressive disorders is 15%. Suicide is more common early in the illness than later. Up to 10% of patients with schizophrenia commit suicide. Suicide is also more common during the first few years of the illness. Up to 15% of all alcohol-dependent persons commit suicide. Despite these risk factors, a past suicide attempt is the best indicator that a patient is at increased risk of suicide. Approximately 40% of depressed patients who attempt suicide have made a previous attempt; 19% to 24% of completed suicides occur after a prior attempt. The risk of a second suicide attempt is highest within 3 months of the first attempt.

A. The stimulation of guanylyl cyclase is not mediated via G-protein coupling, but by the elevation in intracellular calcium and increased nitric oxide production. The cGMP system plays an important role in mediating the responses of photoreceptor cells to light. When it is dark, cGMP levels in these cells are high and when it is light, the cGMP are low. Light mediates its effect by the activation of a phosphodiesterase that hydrolyzes cGMP to guanosine monophosphate (GMP). Drugs such as Viagra block the cGMP phosphodiesterase in the smooth muscles and elevate the cGMP levels, thus exerting their vasodilatory effects.

C. All of the statements regarding the noradrenergic system in the brain are true except that the activity of LC neurons is highest when the subject is most awake.

D. According the Office of Rare Diseases of the National Institute of Health, a rare disease is one that affects <1 per 200,000 people in the United States population. Ophanet, who are a consortium of European partners, currently defines a condition rare when if affects 1 person per 2,000.

D. Patients with cerebellar ataxia present with a wide-based, staggering gait that is similar to that seen in patients intoxicated with alcohol. Patients oscillate the head and trunk while walking. When there is a cerebellar lesion, patients tend to deviate toward the lesion when walking in a straight line. Tandem gait is always abnormal in patients with cerebellar ataxia. On the other hand, patients with sensory ataxia usually lift the legs high off the ground and slap the feet down heavily on the floor while walking. Gait markedly worsens if patients are asked to close their eyes. Patients that have a conversion disorder or may be malingering sometimes present with marked lurching movements, but don’t lose their balance while walking.

E. MRI remains the neuroimaging method of choice for most intracranial and intraspinal abnormalities. It has greater soft tissue contrast and provides better definition of anatomic structures and greater sensitivity to pathologic lesions. Its multiplanar capability displays dimensional information and relationships that are not available on a CT scan. It is also better able to demonstrate physiologic processes such as blood flow and CSF motion. It is also better for visualization of the posterior fossa and intraspinal contents. Its lack of ionizing radiation is also an advantage. Disadvantages of the MRI include the need for cooperation from the patient because most individual MRI sequences require several minutes and a complete study may last anywhere between 20 minutes and 60 minutes. Some patients are also claustrophobic inside the conventional MR unit. MRI is contraindicated in patients with some metallic implants, especially cardiac pacemakers, cochlear
implants, older-generation aneurysm clips, metallic foreign bodies in the eye, and implanted neurostimulators. Some authorities also consider pregnancy (especially in the first trimester) to be a relative contraindication to MRI, but the safety data is incomplete. To date, no harmful effect of MRI has been demonstrated in pregnant women or fetuses.

A. Tuberous sclerosis (epiloia, Bourneville’s disease) arises spontaneously in two thirds of patients. In the remaining, it can arise through autosomal dominant inheritance or through gonadal mosaicism (where a portion of one of the parent’s gonadal cells contains the defective gene without the other cells of the body being involved). Tuberous sclerosis is caused by mutations, on two genes—TSC1 and TSC2. The TSC1 is on chromosome 9 and produces a protein called hamartin. The TSC2 gene is on chromosome 16 and produces the protein tuberin. The classical picture includes the triad of mental subnormality, epilepsy, and adenoma sebaceum (a misnomer as these are facial angiofibromas). Hypomelanotic macules (ash-leaf spots) are hypopigmented spots seen over the buttocks and trunk, are the most frequent cutaneous manifestation of tuberous sclerosis, and are best seen using a Wood’s light. Shagreen patches are areas of thick, leathery, and pebbly skin seen especially over the nape of the neck. Tumors can grow on any organ, but they most commonly occur on the brain, kidneys, heart, lungs, and skin. Malignant tumors are rare, and those that do occur primarily affect the kidneys. Seizures are the most common presenting complaint, which occur in 60% of the individuals with the most commonly described being infantile spasms. However, the full range of seizures may be seen, including complex partial, tonic, and atonic attacks. The earlier the disorder becomes apparent, the more rapid the course. When it declares itself in childhood, the course is usually progressive with death in the second or third decade.

B. The previously mentioned disorder is called Bell’s palsy, which is the most common disease of the facial nerve. There is equal incidence in men and women, and evidence is accumulating that the majority of cases are caused by viral agents. The onset is typically acute with maximum paralysis achieved in 48 hours in 50% of cases, which is often preceded by pain behind the ear. Early on, most patients have some impairment in taste, indicating involvement above the joining of the motor and chorda tympani fibers. There is evidence that cases with more-pronounced enhancement of the facial nerve have a worse prognosis, and electromyography (EMG) can help determine the degree of denervation. Eighty percent of the patients recover at least partially in one month, and the most favorable prognostic sign is some motor recovery in the first week.

B. This patient has symptomatic neurosyphilis and is showing signs of general paresis. The onset is usually 20 years after infection and indicates widespread parenchymal damage. The abnormalities can be remembered with the acronym paresis personality, affect, reflexes (hyperactive), eye (Argyll Robertson Pupils [ARP] accommodate, but don’t react), sensorium (psychosis), intellect (decrease in memory, orientation, calculation, insight, and judgment), and speech.

A positive CSF VDRL provides a definitive diagnosis, but has a high false-negative rate (up to 40%). The diagnosis can also be made from the clinical and CSF (elevated protein >45 and lymphocytosis) profile. Bacterial meningitis would likely have a cloudy CSF with a much higher white count and lower glucose. Bipolar disease would have a normal CSF and a lack of physical findings. Alzheimer’s disease would also have a normal CSF and would not have the physical findings. Wernicke’s encephalopathy does also present with memory impairments, but would also have nystagmus and occulomotor impairment.

A. Neuropsychiatric manifestations are seen in up to 60% of patients with SLE. They show a tendency to appear in the later stages. Any region of the brain can be involved in SLE. CNS events often occur when SLE is active in other organs. Mild cognitive
impairment is the most frequent manifestation. Depression and anxiety are common. Seizures may occur. Less often, psychosis, organic brain syndromes, headache, focal infarcts, extrapyramidal disorders, cerebellar dysfunction, hypothalamic dysfunction, subarachnoid hemorrhage, aseptic meningitis, transverse myelitis, cranial nerve palsies, and peripheral sensorimotorneuropathy occur.

B. Tremors at rest are characteristic of Parkinson’s disease. Intention tremors can indicate cerebellar disorders. Bradykinesia, rigidity, and masked facies are all features of Parkinson’s disease.

D. Comprehensive management of the poststroke patient is multifaceted and often includes physical therapy (to maintain the patient’s muscle tone, prevent contractures, and regain mobility), consistent reorientation and explanation, repositioning (to prevent complications such as decubitus ulcers), and speech therapy. Although cognitive interventions (such as cognitive behavioral therapy) may be useful if the patient develops depression, routine cognitive therapy in stroke patients is without proven value.

B. Erik Erikson created a theory of psychological development that occurs in stages across the life cycle. He proposed that the developmental task of late life (defined as about 60 years of age to the time of death) is to reflect upon and find meaning across one’s lifespan. In doing so, the goal is to maintain one’s integrity rather than despair. The individual at this stage is expected to abandon the wish that important people in his/her life had been different and to accept responsibility for his/her own life. Erikson’s psychosocial stages include: trust versus mistrust (birth to 18 months); autonomy versus shame/doubt (18 months to 3 years); initiative versus guilt (3 to 5 years); industry versus inferiority (5 to 13 years); identity versus role confusion (13 to 20 years); intimacy versus isolation (20 to 40 years); generativity versus stagnation (40 to 60 years); and integrity versus despair (60+).

A. 5-HT_1A has been shown to be involved in the antidepressant action of psychiatric drugs. 5-HT_2A is thought to affect psychotic symptoms and interacts with neuroleptics. 5-HT_1D and 5-HT_1F are involved with migraines. 5-HT_2B regulates stomach contraction.

B. Hemineglect is usually seen in right-hemispheric damage compared to the left hemispheric damage. Aphasia, right–left disorientation, finger agnosia, dysgraphia (aphasic), dyscalculia (number alexia), constructional apraxia (details), and limb apraxia are also seen in left hemispheric damage. Visuospatial deficits, dysgraphia (spatial, neglect), dyscalculia (spatial), constructional apraxia (gestalt), dressing apraxia, and anosognosia are all seen in right hemispheric damage.

C. The National Co-morbidity Survey (NCS) was the first national mental health survey to use a structured diagnostic interview to determine the prevalence and correlates of DSM-III disorders. Overall, substance abuse disorders and anxiety disorders were somewhat more prevalent than mood disorders. Approximately one in four persons surveyed reported a lifetime substance abuse disorder. Data from the NCS revealed alcohol dependence to be one of the most common psychiatric disorders with a lifetime prevalence of 14.1%. The lifetime prevalence of alcohol abuse was reported to be 9.4%. The NCS found the following to be correlated with alcoholism: male gender, younger age, being separated or divorced, low educational level, and low occupational level.

D. The clock-drawing test is an easy and reliable screening test for dementia. The severity of clock drawing failures progresses over time in Alzheimer’s disease, and it correlates with longitudinal changes in cognitive testing. Several neuropsychological functions are tested during this procedure, and they include comprehension, visuospatial
tasks, verbal and semantic memory, as well as executive and constructional functions. Functional neuroimaging has shown that the major area activated during this procedure is the right parietal cortex. Other activated areas include the dorsal premotor areas, left ventral prefrontal cortex, and bilateral cerebellum.

E. This patient does not meet DSM-IV-TR criteria for an eating disorder. She currently has a normal weight for her height, has normal menstrual periods, has not been engaging in purging behavior, and her amount of exercise is not “excessive.” Her pattern of food consumption would not be classified as “binge eating.” The primary care physician may offer reassurance and information about eating disorders and agree to follow the patient for any changes in her behavior, mental status, and/or physical condition.

C. This question attempts to reveal the logic of the diagnostic criterion for ADHD. According to the DSM-IV-TR criterion, a child can meet criteria for ADHD solely with inattentive symptoms if he has six out of nine symptoms of inattention: he would be diagnosed with ADHD, predominantly inattentive type. However, a child cannot meet criteria with impulsive symptoms alone, and because there are only three symptoms of impulsivity, this behavior cannot fulfill the criterion of six or more symptoms of hyperactivity and impulsivity for diagnosis. Hyperactive and impulsive symptoms only would indicate the diagnosis, ADHD, predominantly hyperactive-impulsive type. Criterion B requires that impairment for some of the symptoms must have been present before 7 years of age (“adult-onset ADHD” does not exist, although a significant percentage of children continue to experience ADHD symptoms as adults). Criterion C requires that the symptoms be present in two—not just one—settings, often meaning home and school (or work). Finally, oppositional behavior is not a criterion for the diagnosis; however, children with ADHD can exhibit oppositional behavior.

B. The Threvatan criteria for the diagnosis of Rett’s disorder include eight main criteria and eight supportive criteria for the diagnosis. The following include some of the main criteria included in both the DSM-IV-TR and the Threvatan criteria: normal prenatal and perinatal history, normal psychomotor development for the first 6 months, normal head circumference at birth, postnatal deceleration of head growth in most individuals, loss of purposeful hand skills by the age of 2, hand stereotypes and evolving social withdrawal, communication dysfunction, loss of acquired speech, and cognitive impairment and impairment or deterioration of locomotion. The other problems listed are common in Rett’s disorder, but are not necessary to make the diagnosis.

E. The four criteria to diagnose anorexia nervosa according to the DSM-IV-TR are the following: refusal to maintain body weight above 85% of that expected; intense fear of gaining weight or becoming fat; disturbance in the way in which one’s body and weight are experienced; and the absence of at least three consecutive menstrual cycles. Patients with anorexia nervosa usually feel guilty about being “fat,” although they are underweight. Binge eating can be present in anorexia nervosa, but it is more common in bulimia nervosa, and it is not a diagnostic criterion for anorexia.

E. When a drug is administered orally, it is absorbed in the small bowel and enters the portal circulation to reach the liver. Cytochrome enzymes in the bowel wall and in the liver metabolize a portion of the drug before it reaches the systematic circulation. This metabolism of the drug in the bowel wall and the liver is called first-pass metabolism. This effect can be altered by processes/diseases affecting
the bowels and the liver. Transporters in the bowel wall can either increase or decrease the absorption of the drug. Dietary factors, drugs and diseases of the liver like hepatitis, cirrhosis, or congestive heart failure can alter the first-pass metabolism of the drug. Once first-pass metabolism has occurred, metabolites are excreted into the bile and then the small bowel. Lipid soluble metabolites are reabsorbed into the portal circulation and then reach the systemic circulation. Intramuscular or intravenous administration of drugs avoids the first-pass metabolism and the drugs enter the systemic circulation directly. Medical conditions, such as cirrhosis, can cause portacaval shunting, allowing drugs to avoid the first-pass metabolism and enter the systemic circulation directly and, therefore, enhance their effect.

E. The mechanism of action of acamprosate in the treatment of alcohol dependence is unclear. It is thought, however, that it affects both GABA and glutamate activity. It may help to restore the normal balance between neuronal excitation and inhibition that is altered in chronic alcohol dependence. Although naltrexone generally improves relapse rates and alcohol craving, it has little effect on abstinence rates. Acamprosate, however, produces significant improvements in abstinence rates and increases the time before any drinking occurs. It also reduces alcohol craving. The main side effect is diarrhea, which occurs in approximately 12% of patients. Headache is another common side effect. It has no abuse potential and does not produce any significant drug interactions. The combination of naltrexone and acamprosate may be more effective than either agent alone.

B. In this review, less-educated couples were observed to have better outcomes in therapy. The review also indicted that younger couples have a better outcome and that unemployed couples and couples with more severe difficulties have worse outcomes.

D. In a recent paper, the authors chose to identify, review, and analyze studies comparing atomoxetine with psychostimulants with the intent of determining the role of atomoxetine in the pharmacologic management of ADHD. They found five head-to-head trials had compared psychostimulants and atomoxetine in the treatment of ADHD. No significant difference between atomoxetine and methylphenidate immediate-release were found on the ADHD Rating Scale total score. Osmotic oral release system (OROS) methylphenidate showed significantly greater improvement at weeks 1 and 2, and significantly more patients treated with OROS methylphenidate were classified as being responders. Patients on both atomoxetine and mixed amphetamine salts extended-release (MAS XR) showed significant improvements at endpoint over baseline; however, Swanson, Kotkin, Agler, M-Flynn, and Pelham (SKAMP) scores were significantly better with MAS XR. Tolerability was similar between atomoxetine and stimulant medications. Based on available evidence, the authors concluded that psychostimulants are regarded as the first-line pharmacologic treatment for children and adolescents with ADHD, because the efficacy and safety of these agents have been well established based on clinical trials and extensive naturalistic use. Atomoxetine represents an alternative treatment for ADHD and is unlikely to be associated with abuse. However, more long-term safety data are needed to further establish its place in therapy.

E. Acamprosate should be started after the patient has been detoxified from alcohol and should not be stopped if the patient relapses into drinking. In controlled trials, the medication has shown modest benefit in reducing drinking in alcoholics. Approximately 20% of patients treated with acamprosate maintained abstinence over the course of 1 year compared to 10% of placebo-treated patients. The starting dose is 333 mg three times daily with meals, titrating as tolerated to a dose of 666 mg three times daily. The optimal duration of treatment is not known, but 6 to 12 months of treatment is appropriate when combined with psychosocial treatment. Acamprosate’s mechanism of action is not fully understood, but hypotheses include stimulation of GABAergic neurotransmission and antagonism of excitatory amino acids, such as glutamate. Acamprosate is not a sedative and is not habit-forming. Although mild and time-limited, the most common side effects are GI in nature (nausea, diarrhea, flatulence). The medication is contraindicated in
pregnancy, renal failure, and in patients with significant liver disease.

A. Unfortunately, it is not uncommon for psychiatrists or mental health providers to be assaulted. It has been estimated that more than 50% of psychiatrists and 75% of mental health nurses have experienced an act or threat of violence within the past year. A 15-year analysis of assaults on staff in a Massachusetts mental health care system divided the acts into four types: physical, sexual, nonverbal threats/intimidation, and verbal assault. Risk factors for violence among psychiatric patients include an individual history of violence; active paranoid delusions; hallucinations associated with negative effects; manic states, neurological abnormalities; alcohol or drug intoxication and withdrawal states; and a history of abuse, family violence, or “rootlessness.” A history of past violence is the strongest predictor of future violence in psychiatric patients. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) found an increased risk of violence in patients with positive psychotic symptoms (i.e., in schizophrenic patients with combined low negative and high positive Positive and Negative Syndrome Scale (PANSS) scores). This group of patients was at the highest risk to have caused bodily injury or have harmed someone with a weapon within the past 6 months. On the other hand, there was a decreased risk of violence in patients with predominantly negative symptoms.

B. All of the statements are true except that most, but not all, of the actions of G proteins are mediated by diffusible second messengers and, in many cases, the G proteins themselves link to neurotransmitter receptors to activate ion channels.

E. All of the statements regarding the histaminergic system in the brain are true. Histaminergic fibers project diffusely to the hypothalamus, thalamus, hippocampus, amygdala, rostral forebrain, diagonal band, septum, olfactory bulb, midbrain, and spinal cord. These fibers do not make synaptic connections and act as a local hormone at a distant site, away from their original release site.

E. Answer choices B, C, and D are three diagnostic criteria for RLS. The fourth criteria indicates that symptoms improve (not worsen) with movement. Family history supports the diagnosis with more than 50% of the patients with idiopathic RLS endorsing such. Presence of periodic leg movements in sleep and positive response to dopaminergic therapy also support the diagnosis. Current first-line treatment recommendations include dopaminergic agents and gabapentin.

B. Dystonic movements are abnormal movements that are usually slow and sinuous in nature. They are not present during sleep and are usually exacerbated by emotional stress. These types of movements sometimes only occur during voluntary movements and during specific activities, such as chewing or speaking. Many disorders can present with dystonic movements, including neurological disorders like Parkinson’s disease, Wilson’s disease, and Huntington’s disease, as well as the use of certain medications, such as levodopa, SSRIs, and antipsychotic medications.

E. Because the use of gadolinium adds to the direct costs of the MRI, increases the imaging time, and also increases the discomfort to the patient from the intravenous needle placement, it should only be used for specific clinical situations in which its efficacy has been demonstrated or compared to where its use may detect significant abnormality as a routine noncontrast MRI. Clinical situations where gadolinium enhanced MRI is not useful, because of relatively few contrast-enhancing lesions, include complex partial seizures, headaches, dementia, head trauma, workup of psychosis, low back or neck pain,
and congenital craniospinal anomalies. MRI in these conditions should use special MR pulse sequences directed to detect lesions in the structures of greatest interest.

D. The patient has AIP, an autosomal dominant disease. The attacks can be precipitated by certain drugs, including barbiturates. This disorder often mimics other diseases (e.g., Guillain-Barré syndrome, bowel obstruction, and psychotic disorders) and, for this reason, the diagnosis can be overlooked. The cardinal features which present in different forms include colicky abdominal pain, psychotic symptoms and an ascending paralysis. If the urine is allowed to oxidize, it turns a dark red color secondary to porphobilin, which is an oxidation product of porphobilinogen. Acute intermittent porphyria can be fatal. Depending on the severity, it is treated with intravenous glucose and hematin. (Although one can see syndrome of inappropriate antiduretic hormones (SIADH) and liver damage, LFTs and serum and urine sodium and osmolality would not be the appropriately specific diagnostic tests. CSF protein would be helpful for diagnosing Guillain-Barré syndrome—where one would expect to see a high protein, but low white blood cell count.)

D. Huntington’s chorea is a neurodegenerative disorder manifesting in middle age. It is associated with CAG repeat expansions located on chromosome 4. Progressive cognitive impairment is a cardinal feature. It has autosomal dominant inheritance, and the carriers who are heterozygous for the deleterious gene have a 50% chance of transmitting it to their children. CAG repeats of 40 or larger are associated with disease expression, and those with 26 or less repeats are normal.

D. Porphyrias are a group of disorders relating to heme metabolism. VP is a hepatic porphyria that results from the deficiency of protoporphyrinogen oxidase inherited as an autosomal dominant trait. It frequently occurs in white South Africans with an incidence of 3 in 1,000. Neurovisceral signs and symptoms develop after puberty usually in the third decade. Symptoms are more common in males than in females. VP is clinically indistinguishable from AIP and HCP. The skin lesions are similarly indistinguishable from HCP and PCT by biopsy; these conditions are diagnosed by measurements of porphyrins and porphyrin precursors in blood, urine, and feces. Cutaneous manifestations are present in 80% of the patients usually in light exposed areas. Acute attacks are seen in 50% of the patients and cause neuropsychiatric, GI, and cardiovascular symptoms, which are precipitated by increases in hepatic Aminolevulinic acid synthase (ALA synthase) (e.g., by drugs that increase cytochrome P450, such as sulfonamide antibiotics or by starvation dieting). Other triggers include intercurrent illnesses, alcohol excess, and endocrine influences, such as steroid hormones, menstrual hormonal changes, and estrogens and progesterone. During attacks, symptoms include delirium, colicky abdominal pain, dark urine, axonal neuropathy that can mimic Guillain-Barré syndrome, seizures, coma, tachycardia, and hypertension. Epileptic fits may occur in 20%; status epilepticus may develop. Mental symptoms, such as anxiety, depression, paranoia and hallucinations, delirium, and agitated behaviors, may arise. It may be mistaken for psychiatric illness during attacks, which may be reinforced if a history of unexplained intermittent physical complaints emerges, leading to diagnoses, such as personality disorders and somatoform disorders. In addition to increased fecal protoporphyrin and coproporphyrin and urinary coproporphyrin, the fluorescence emission spectrum of plasma porphyrins is helpful in the diagnosis; the latter especially in differentiating from PCT where there are no CNS signs. The attacks last from a few days to several months. Treatment is with intravenous hematin and avoidance of sun exposure and trigger factors. EPP, the most common of the erythropoietic porphyrias, results from deficiency of ferrochelatase and is transmitted as an autosomal dominant trait. It usually presents in childhood with cutaneous photosensitivity.

E. Procainamide, hydralazine, chlorpromazine, D-penicillamine, isoniazid, methyldopa, quinidine, alpha interferon, valproate can all cause
drug-induced lupus erythematosus, carbamazepine, hydantoins, and ethosuximide. There is genetic predisposition to drug induced lupus, which is partly determined by drug acetylating rates. Most common are systemic complaints and arthralgias. CNS and renal diseases are rare.

C. Dementia secondary to Parkinson’s disease is more common in patients who develop Parkinson’s disease after 65 years of age and is not typically an early symptom of this disorder. Patients with Parkinson’s disease can have a unilateral tremor for years before it progresses bilaterally. Atenolol can decrease essential tremor and not be a cause for it. There is no evidence of symptoms specific to Huntington’s disease, and he has no family history for this disorder. A cerebellar stroke would cause an intention tremor, and hyperthyroidism would likely produce bilateral fine tremors.

D. Since 1968, under generally accepted criteria, the criteria for brain death has been irreversible coma with no discernable CNS criteria. Although it has been argued that the diagnosis of brain death fails to correspond to any coherent biological or philosophical understanding of death, and that it is nearly impossible to demonstrate the irreversible cessation of all functions of the entire brain, including the brainstem, brain death continues to be an accepted diagnosis. According to United States law, brain death equals death. After death is declared, it is medically ethical to donate organs. Although the criteria are controversial, brain death can be diagnosed if cardiac function is maintained, there is no spontaneous respiratory functioning, irreversible coma, no posturing, no cranial reflexes, and no evidence of hypothermia. Brain death can be diagnosed in this case, and organ donation is allowable. Choice E is partially correct, but a patient has to be declared dead before donating organs.

B. Statement A describes stage 1; statement C describes stage 2; statement D describes stage 4; and statement E describes stage 6. Stage 5 is of a contractual and legalistic orientation with a sense of obligation to the law, but with the acceptance that people can have a variety of different values; regardless, their individual right takes precedence over the social contract. Colby et al. (1983) grouped these six stages into three levels: level 1 is the premoral (stages 1 and 2); level 2 is the conventional role of conformity (stages 3 and 4); and level 3 (self-accepted moral principles).

E. Studies in depression have demonstrated that decreased inhibitory tone from serotonin, as well as excitatory effects of norepinephrine, ACh, and corticotrophin-releasing factor, may be responsible for the upregulation of the hypothalamic-pituitary axis, but none have suggested a role for the thyroid releasing factor.

D. Finger tapping, grooved pegboard, and grip strength are all tests of motor speed.

B. Community-based psychiatry means that the large majority of psychiatric patients should have the opportunity to be treated at the community level. Primary health care is one of the major components of the mental health care system. This basic level of care stands between the general population and psychiatric specialty services. Primary care providers are often the first to see emotional distress, although they may not always recognize it. Another important, unavoidable component of community psychiatry is patient and family involvement. Provision of emotional support and appropriate information (regarding not only psychiatric illness, but also patient rights and resources) to patients and families can reduce individual suffering, illness relapse, and family/caregiver burden. Psychosocial rehabilitation
is yet another integral component of community psychiatry. By improving individual competencies and affecting environmental changes, psychosocial rehabilitation allows individuals disabled by mental illness to reach their optimal level of functioning in the community. Community psychiatric services should be local, accessible, and able to address the multiple needs of individuals.

C. Every test should adhere to a number of statistical and psychometrical principles in order to be helpful. Some of these principles include satisfactory reliability and validity. Internal consistency is the degree to which one test item correlates with all other test items. Parallel-form reliability is the degree to which two equivalent versions of a test give the same result. Test-retest reliability is the degree to which a test will give the same result on two different occasions separated in time. Interrater reliability is the probability that two judges will give the same score to a given answer, rate a given behavior in the same way, or add up the score properly. Content validity is the degree to which a test measures all the aspects of the quality that is being assessed.

A. In patients with anorexia nervosa, a younger age at onset has been consistently associated with better outcomes. Chronicity of illness, obsessive-compulsive personality traits, self-induced vomiting, and binge eating behavior have each been identified as negative prognostic factors in the literature, although their association has been inconsistent across studies. These factors may be more predictive of short-term outcome than longer-term outcome. In general, adolescents have better outcomes than adults, and younger adolescents have better outcomes than older adolescents.

E. Children with ADHD often perform better in one-to-one interactions as opposed to group interactions. Consequently, this deficit causes them great difficulty in peer relations in a group context such as camps, sports, extra-curricular activities, and group games, leading to unpopularity with peers and siblings. ADHD is the most commonly diagnosed childhood psychiatric disorder and is estimated to occur in 3% to 5% of school-age children. Epidemiological data document prevalence rates ranging from 2% to 12%. Children with ADHD injure themselves more frequently and have an elevated risk of developing other psychiatric and behavioral difficulties in childhood, adolescence, and adulthood, including antisocial/criminal behavior, substance abuse, mood and anxiety disorders, as well as academic and vocational underachievement. This disorder is tremendously costly for society, costing schools over $3 billion annually. Moreover, poor insurance coverage for ADHD can compound the financial burden for families.

C. There is a strong association between birth weight and the development of autism. Other risk factors include low Apgar score, gestational age at birth <35 weeks, and parental psychiatric history. Although it was suggested that the month of birth could be associated with the development of autism, larger and more recent studies have not confirmed this association. Parental alcohol use, exposure to the tetanus vaccine, and low parental age have not been associated with autism.

A. Patients with anorexia nervosa can present with hypercholesterolemia due to reduced catabolism. Other common laboratory abnormalities include leukopenia with relative leukocytosis, hypercortisolemia, hypercarotenemia, hypoglycemia, abnormal liver function tests, low serum zinc levels, and electrolyte abnormalities. Patients can also have hormonal abnormalities, such as abnormal T4 levels with normal TSH.

B. MAOIs may be the treatment of choice in atypical depressive disorders. Their adverse effect profile includes serotonin syndrome (as described in the clinical vignette). There are numerous contributors to serotonin syndrome, including
prescription medications, over-the counter (OTC) remedies, drugs of abuse, and dietary supplements. Treatment includes discontinuation of the offending agent, supportive care, 5HT2A antagonists, cyproheptadine or second-generation antipsychotics, control of autonomic instability, and hyperthermia. Diphenhydramine (Benadryl) does not cause this condition. A major complication of diphenhydramine use is anticholinergic syndrome, manifested by hypoactive bowel sounds, dry hot skin, normal reflexes, and urinary retention as well as an altered mental status and other typical symptoms. Malignant hyperthermia would be distinguished by hyporeflexia and rigor mortis-like rigidity.

C. Several studies have shown that fluoxetine and TCAs, such as desipramine, produce significant improvement in depression in active alcoholic patients and decrease alcohol intake simultaneously. In the past, many believed that alcoholic patients should be abstinent for at least 4 weeks (and remain depressed) before starting any antidepressants. However, a 1998 study by Greenfield, et al. found that all alcoholic patients admitted to a hospital for detoxification, who also had a recent diagnosis of major depressive disorder, relapsed into drinking after discharge. None of the patients had been prescribed antidepressants. Given this data, the use of antidepressants in treating depressed alcoholic patients is encouraged even if the patients are likely to still be drinking. Bupropion, although an antidepressant, is contraindicated in conditions that lower the seizure-threshold, such as alcohol withdrawal, and thus would not be an optimal choice in this patient.

E. Cardiac arrhythmias have been noted to occur in patients receiving lithium. This side effect, however, almost always occurs in patients with pre-existing cardiac disease. The most common types of arrhythmias that occur in patients taking lithium with preexisting cardiac disease is sinoatrial (SA) node dysfunction (sick sinus syndrome), thus patients with this history should not receive lithium unless a cardiac pacemaker is in place. Before initiating lithium therapy, clinicians should obtain a cardiac history and a baseline electrocardiogram (ECG) in patients over 50 years of age. While a patient is on lithium therapy, cardiac side effects (i.e., palpitations, dizziness, syncope) should be monitored and an ECG should be repeated when clinically indicated. Lamotrigine, valproate, and gabapentin do not have cardiac side effects. QTc prolongation is unlikely to occur with olanzapine and it is safe to use in patients with sick sinus syndrome.

D. In an excellent Cochrane review, the authors assessed the effects of day hospital versus inpatient care for people with acute psychiatric disorders. Combined data suggested that at the most, day hospital treatment was feasible for 23% (CI 21 to 25) of those currently admitted to inpatient care. Individual patient data from three trials showed no difference in the number of days in hospital between day hospital patients and controls (CI 1.32 to 0.55). However, compared to controls, people randomized to day hospital care spent significantly more days in day hospital care (CI 1.97 to 2.70) and significantly fewer days in inpatient care (CI 3.63 to 1.87). There was no significant difference in readmission rates between day hospital patients and controls (RR 0.91, CI 0.72 to 1.15). For patients judged suitable for day hospital care, individual patient data from three trials showed a significant time-treatment interaction, indicating a more rapid improvement in mental state (Chi-squared 9.66, p = 0.002), but not social functioning (Chi-squared 0.006, p = 0.941) amongst patients treated in the day hospital. Four of five trials found that day hospital care was less expensive than inpatient care (with cost reductions ranging from 20.9% to 36.9%). The authors’ concluded that caring for people in an acute day hospital can achieve substantial reductions in the numbers of people needing inpatient care, while also improving patient outcome.

B. Medications most commonly implicated in causing hyperprolactinemia are antipsychotic (neuroleptic) agents. These drugs are dopamine receptor blockers. Their effects are mediated by D2
receptors in the hypothalamic tuberoinfundibular system and on the lactotrophs. The antipsychotic potency of the older phenothiazines, butyrophenones, and dibenzoxazepine was found to parallel their potency in increasing prolactin levels. The level of prolactin found with these drugs is usually <100 μg/L. Among the atypical antipsychotic medications, risperidone is known to cause elevations in prolactin level even higher than those caused by the typical antipsychotics. In contrast, clozapine, olanzapine, quetiapine, ziprasidone, and aripiprazole are much less likely to elevate prolactin levels. It is believed that the lack of effect of these atypical agents is due to their being only transiently and weakly bound to the D2 receptor or to their having agonist activity as well as antagonist activity at the D2 receptor. Hyperprolactinemia causes decreased libido, erectile dysfunction in men, and galactorrhea and amenorrhea in women.