C. Divorce tends to run in families and rates are highest in couples who marry as teenagers or are from different socioeconomic backgrounds. Problems regarding sex, money, or unrealistic expectations can be other causes of marital distress. However, the parenting experience places the greatest strain on a marriage. Couples without children report gaining more pleasure from their partner than those with children. Illness in a child creates the greatest strain of all in a marriage. More than 50% of marriages in which a child has died through accident or illness end in divorce.

B. Receptors for neurotransmitters can either be ion-channel linked, G-protein linked, membrane-kinase linked (insulin, growth factors) or may mediate their effects through gene transcription (steroids). G-protein receptors, also called metabotropic receptors, are coupled to an intracellular second messenger system via a G-protein. They are responsible for slow neurotransmission. When the transmitter binds to the receptor, alpha-guanyl triphosphate is released, which then either activates or inhibits the adenylate cyclase/cAMP pathway or the phosholipase C/inositol triphosphate (IP₃)/diacylglycerol (DAG) pathway.

D. The executive is using the mature defense mechanism of suppression. She is consciously postponing attention to her internal discomfort. Her discomfort is acknowledged, but temporarily minimized (not completely avoided). On the contrary, repression is a neurotic defense which involves the unconscious expulsion of unwanted ideas or feelings from conscious awareness. Another neurotic defense mechanism is dissociation, which involves the temporary, drastic modification of one’s sense of personal identity (as in a fugue state or Dissociative Identity Disorder [DID]). Sublimation is a mature defense mechanism which refers to gratifying one’s impulses and instincts by acknowledging them, modifying them, and directing them toward socially acceptable channels. Finally, regression is an immature defense mechanism in which one reverts to an earlier stage of development in order to avoid the tension or conflict of the present stage.

A. The PPV refers to the proportion of positive test results that is true positives. PPV indicates the probability that an individual with a positive result has the disease. PPV is dependant on the prevalence of the disease in the population being tested. Because it is dependant on the disease prevalence, screening for diseases in low prevalence populations yields only a few true positive test results regardless of the sensitivity and specificity of the test. In this case, the possible results of the diagnostic test can be represented in the following 2 × 2 table.

PPV would be the number of true positives (patients who have the disease and are tested positive) divided by the total number of patients who are tested positive. In this case, that would be 999/1000; 99.9%.

B. Although the inability to recognize familiar faces is an uncommon disorder, defective discrimination of unfamiliar faces is a common finding in patients with right-hemisphere lesions. The Facial Recognition Test is a test requiring identifying a photograph of a face originally presented in a front view when it is included in various displays (i.e., side view, front view with shadows) and produces a high frequency of failure in patients with posterior right-hemisphere lesions. An abnormal response to the Wisconsin Card Sorting Test appears in people with damage to the frontal lobes or to the caudate and in some people with schizophrenia. Patients with left-hemisphere lesions tend to perform within
normal range in visuospatial tests, but may have defects in the use of language, which can be tested via an aphasia exam. The Rorschach and Thematic Apperception Tests are types of Projective Personality Assessments.

C. Although lamotrigine was approved by the FDA in 2003 for the maintenance treatment of bipolar I disorder, it has been found to have better efficacy for prevention of depression relapse than for the treatment of mania and data supporting its utility appear mixed. The most serious side effect of lamotrigine is rash which may occur in up to 40% of patients and may culminate in Stevens-Johnson syndrome. It is important to determine if lamotrigine associated rash is benign or malignant. A benign rash begins within 5 days of initiating lamotrigine therapy; it is spotty, nontender, nonconfluent, not associated with laboratory abnormalities, and usually resolves in 10 to 14 days. Given that the immune system requires several days to mount a true hypersensitivity reaction, most rashes occurring within a few days of lamotrigine therapy are likely to be benign. The management of lamotrigine induced benign rash includes halting dose escalation temporarily or discontinuing medication while the rash is monitored. The patient is instructed to call should the rash worsen or should new symptoms emerge. Antihistamine or topical steroids may also be prescribed to manage itching. Upon resolution of the rash, lamotrigine therapy may be reinitiated at a much lower dose than recommended: 5 mg to 12.5 mg. A rash occurring more than 5 days following the initiation of lamotrigine therapy is more likely to be drug related. Such rashes are tender, confluent, itchy, widespread, and are usually prominent in the upper trunk and neck areas. It is recommended that lamotrigine be discontinued immediately and permanently if a serious rash occurs. The likelihood of developing lamotrigine induced rash increases with rapid dose escalation or blood level elevations. The latter makes lamotrigine drug-drug interactions pertinent. Gradual titration of lamotrigine is recommended to reduce the potential for rash: beginning at 25 mg daily during week 2, 50 mg per day at weeks 3 and 4, 100 mg per day at week 5, and 200 mg per day at week 6.

C. The prevalence of Schizophrenia in children who have one parent with Schizophrenia is approximately 12%. Schizophrenia affects approximately 1% of the general population. The likelihood of any given person being diagnosed with Schizophrenia is correlated with the closeness of their genetic relationship to an affected patient. The following prevalence rates have been shown: non-twin siblings (8%), dizygotic twins (12%), children with 2 schizophrenic parents (40%), and monozygotic twins (47%).

D. Although the patient’s chest pain, palpitations, and sense that he is going to die are consistent with a simple panic attack, the associated elevated blood pressure in particular suggests that he may have a pheochromocytoma. One would initially do a 24-hour urine collection of vanillylmandelic acid, metanephrines, and unconjugated catecholamines to diagnose a pheochromocytoma; though, if the results were equivocal, one might then consider a plasma collection. Performing an EKG and obtaining routine labs and thyroid function tests are often part of an evaluation for panic disorder; however, elevated blood pressure is not a typical feature of a simple panic attack.

C. Pyromania is the purposeful setting of a fire, which happens more than once, is preceded by tension, and followed by fascination, relief, or pleasure. Fire setting is not performed for another motive or as a result of impaired judgment; nor is it better accounted for by mania, Conduct Disorder, or Antisocial Personality Disorder. This patient has no clear history of trauma or mood disturbance. She has never been in trouble and is not maliciously setting fires for secondary gain, as in conduct disorder or antisocial personality. Pyromaniacs often have a history of absent fathers, depressed mothers, or distant relationships.

B. Systematic desensitization is based on the behavioral principle of counter-conditioning, whereby a patient overcomes maladaptive anxiety by approaching a feared stimulus gradually, in a psychophysiological state that inhibits anxiety. In systematic desensitization, patients attain a state of relaxation (through relaxation training) and are then exposed to an anxiety-provoking stimulus. The negative reaction of anxiety is inhibited by the relaxed state, a process known as reciprocal inhibition. Rather than use actual situations or objects that elicit fear, a graded list or hierarchy of anxiety-provoking scenes is constructed. The learned relaxation and anxiety-provoking scenes are systematically paired in treatment. This results in gradual desensitization of the stimulus and extinguishing of the fear response. Implosion, or flooding, differs from systematic desensitization in that it involves exposing the patient to a feared object in vivo and does not make use of a hierarchy.

D. Transdermal selegiline has been marketed as the EMSAM patch. Randomized controlled trials in patients with major depressive disorder have shown it to have efficacy, as compared to placebo. Selegiline is a selective MAO-B inhibitor, but at doses showing maximal MAO-B inhibition in the brain, it also produces a dose and time dependent inhibition of MAO-A in the brain. At doses producing maximal MAO-A inhibition in the brain, it produces 30% to 40% inhibition of gastrointestinal MAO-A. It is owing to this preferential inhibition of brain MAO-A over gastrointestinal MAO-A, which the patch is devoid of side effects with tyramine-rich foods. In the placebo-controlled trials, there were no adverse reactions such as hypertensive crisis even in the absence of dietary restrictions. Application site reactions appear to be commonly seen with the use of the patch.

C. Benzodiazepines are commonly used for the treatment of anxiety disorders. It is important to know the half life of these medications to prevent oversedation and excessive drug accumulation. Oxazepam has a half life of 5 to 15 hours, alprazolam has a half-life of 8 to 15 hours, lorazepam has a half-life of 10 to 20 hours, Diazepam has a half-life of 20 to 70 hours and chlordiazepoxide has a half-life of 10 to 20 hours. However, some benzodiazepines with long half lives may have a shorter duration of action than other benzodiazepines due to extensive distribution.

E. Anticholinergic agents, such as atropine and glycopyrrolate, are administered to reduce secretions and to decrease the bradycardia, which develops after the electrical stimulus. General anesthetics, used to induce consciousness, include etomidate, thiopental, methohexital, propofol, and ketamine. Succinylcholine is a depolarizing muscle relaxant. If its use is contraindicated by pseudocholinesterase deficiency, a nondepolarizing agent such as mivacurium can be used. Beta-blockers are not contraindicated and are routinely used to address tachycardia or severe hypertension.

E. Motivational interviewing is being widely used in the treatment of substance use disorders. Some of the core principles in this technique include establishing personal goals, developing discrepancy, rolling with resistance, and supporting self-efficacy. The interviewer or clinician tends to avoid confrontation and works on expressing empathy.

D. Levels of 5-HIAA are decreased in the CSF of suicide attempters. Some studies have also shown that low 5-HIAA levels predict suicidal behavior. A relationship between suicide attempt and levels of HVA has not been substantiated.

C. Cerebral hemispheric injury leads to contralateral hemiparesis, where there is weakness and spasticity of the muscles of the lower part of the face, trunk, arm, and leg on the opposite side of the lesion.
These patients also have hyperactive deep tendon reflexes on the contralateral side along with upgoing plantar reflex (Babinski sign). These symptoms result from an injury to the corticospinal tract and are known as upper motor neuron (UMN) lesion. Hypoactive deep tendon reflexes are seen in injury to peripheral nerve or anterior horn cell.

A. Neuropathy is the most common PNS manifestation of AIDS. Guillain-Barré syndrome and mononeuritis multiplex can occur as a result of AIDS but are uncommon. Of note, antiretroviral medications [i.e., ddI (dideoxyinosine/Videx) and ddC (dideoxycytidine/Hivid)] are known to also cause peripheral neuropathy. Myelopathy refers to the spinal cord, and thus is not part of the PNS.

B. TS is an autosomal dominant disorder that exhibits a wide spectrum of manifestations, ranging from no symptoms to profound neurologic disability. Neurological manifestations may include mental retardation, seizure disorders ranging from simple partial seizures to infantile spasms, and autism associated with the growth of cortical tubers during embryogenesis. Almost all individuals with TS (approximately 90%) have an associated skin finding. Hypopigmented macules (“ash leaf spots”) are best viewed with a Wood’s lamp and are generally present by early childhood, while shagreen patches are more prominent after age 5. Facial angiofibromas (adenoma sebaceum), erythematous lesions that typically appear on the face during late childhood and adolescence, may resemble severe acne. Ungual fibromas may also develop. TS can also be associated with cardiac rhabdomyomas, renal angiomyolipomas and cysts, pulmonary lymphangiomyomatosis, and subependymal giant cell tumors of the brain. This disorder results from mutations in one of the two genes, TSC1 (hamartin) or TSC2 (tuberin).

D. When analyzed during an attack of MS, CSF typically has a normal or slightly elevated protein concentration, with an elevated gamma globulin portion (nonspecific finding). Findings typically noted in the CSF of a patient suffering an attack of MS include the presence of myelin basic protein (a myelin breakdown product), oligoclonal bands (an IgG antibody), and an increased rate of synthesis of CSF IgG. It should be noted that these findings are not specific for MS; they may also be found in other chronic inflammatory conditions such as sarcoidosis, Lyme disease, and neurosyphilis. Xanthochromic supernatant is typical of CSF withdrawn from a patient with subarachnoid hemorrhage.

D. The most characteristic finding of hepatic encephalopathy is the triphasic delta wave, also known as the liver wave. They are delta waves (2 to 3 Hz) with a high amplitude positive wave in between two lower amplitude negative waves.

D. Conversion of tyrosine to L-dopa by tyrosine hydroxylase is the rate limiting step in the synthesis of tyrosine to dopamine. Phenylalanine is converted to tyrosine by phenylalanine hydroxylase. Tyrosine is then converted to L-dopa by tyrosine hydroxylase. This is the rate limiting step. Finally, L-dopa is converted to dopamine by dopa decarboxylase.

A. Skin lesions and peripheral neuropathy are the hallmarks of arsenic ingestion. Chronic arsenic poisoning occurs from drinking groundwater contaminated with arsenic over a long period of time. This has become a problem in many third world countries, including Bangladesh. Sensorimotor polyneuropathy can occur insidiously. Skin lesions are characterized by hyperpigmentation and hyperkeratosis. Mees lines (transverse white lines) on the nails are occasionally noted. Patients may also have multisystemic involvement including anemia, leukopenia, skin changes, or elevated liver function tests. Anemia often accompanies skin lesions in patients chronically poisoned by arsenic. Lung cancer and skin cancer are serious long-term concerns. Toluene is a solvent. Repeated high-dose exposures can result in progressive memory loss, fatigue, poor concentration, irritability, persistent headaches, and signs and symptoms of cerebellar dysfunction. Muscular weakness has been noted in patients who develop renal-tubular acidosis. Thallium may result in a scaly rash, hair loss, and sensorimotor
polyneuropathy. Sensory symptoms are often the first sign of polyneuropathy. They are followed by symmetric motor impairment, which is greater distally than proximally and occurs in the legs rather than the arms. Lead toxicity in adults manifests with peripheral neuropathies, which are mainly motor and greater in the arms than in the legs. They typically affect the radial nerves, causing wrist drop, or the peroneal nerves, causing foot drop. Systemic manifestations include anemia, constipation, colicky abdominal pain, gum discoloration, and nephropathy. Lead toxicity is common in persons involved in the manufacture or repair of storage batteries, the ship breaking industry, the smelting of lead or lead containing ores, or from the consumption of home-made alcohol made in lead containing pipes. Radon exposure causes no acute or subacute health effects. The only established human health effect associated with residential radon exposure is lung cancer.

A. The corticospinal tract contains motor axons only. The rest of the choices carry sensory information. The lateral spinothalamic tracts transmit pain and temperature sensations to the thalamus. The anterior spinothalamic tracts carry light touch to the thalamus. The spinocerebellar tracts convey joint position sense to the cerebellum. The posterior columns of the spinal cord transmit position and vibratory sensations to the thalamus.

E. All the signs listed are found in Horner’s syndrome and are found on the same side of the lesion (ipsilateral).

B. The patient has cluster headaches, which are severe unilateral headaches, that often present with significant frequency during a single period and then remitting for months or even years. Patients often describe them as sharp pains boring into one eye. The pain is so excruciating that patients can feel suicidal. Although the patient reports having been suicidal in the past, it is not clear that he is suicidal during this visit and, before one would want to admit him to the psychiatric ER, one would want to assess whether he is currently suicidal and try to treat his symptoms, which would be the likely cause of suicidal ideation. Oxygen inhalation treatment is considered an effective form of abortive treatment for cluster headaches. Lithium is indeed used to treat cluster headaches, although prophylactically. Amitriptyline is a treatment for trigeminal neuralgia.

D. Speech therapy is an important part of the cognitive rehabilitation of patients with aphasia. One of the main goals of the therapist is to identify different areas of receptive and expressive weaknesses and strengths, which can then be used for compensatory purposes. The therapy has to be tailored for each patient, taking into consideration the severity of the patient’s symptoms, other areas of weakness besides speech, and premorbid functioning.

B. Erik Erikson developed eight psychosocial stages, which are points along development that trigger internal crises. They are trust versus mistrust (birth-), autonomy versus shame and doubt (18 months-), initiative versus guilt (3 years-), industry versus inferiority (5 years-), identity versus role confusion (13 years-), intimacy versus isolation (20s-), generativity versus stagnation (40s-), and integrity versus despair (60s-). The major conflict of middle adulthood is between generativity and stagnation. Generativity is the process by which persons guide the oncoming generation or society. This stage includes having and raising children, but having children does not guarantee generativity. To be stagnant means a person stops developing. For Erikson, stagnation also referred to adults without any impulses to guide the new generation or to those who produce children without caring for them.

D. Nicotinic receptors are ion channel-linked receptors. Most serotonin receptors are G-protein receptors except 5 HT3 receptors which are directly coupled to ion channels.

D. Object relations, along with ego psychology and self psychology, is one of the three
major theoretical frameworks used by psychoanalytic clinicians today. Object relations theory originated in the work of Melanie Klein, DW Winnicott, and WRD Fairbairn. It involves the unconscious transformation of interpersonal relationships into internalized structures. In this psychoanalytic theory, object relations always involve an interface between a self and an object with an affect. Unlike ego psychology, which views drives as primary and object relations as secondary, object relations theory views all drives as emerging from the context of the mother-infant relationship. In object relations theory, conflict is seen as a struggle between different “self-object-affect units,” each of which wants primary psychic attention. It is ego psychology which regards conflict as a struggle between wishes/desires or between intrapsychic agencies (i.e., the id and the superego). In object relations theory, character is viewed as heavily influenced by the presence of self-representations and object-representations deriving from introjections and identifications. Introjection is a process where one internalizes an object that functions as it does externally (e.g., a soothing mother or critical father). Identification occurs when one adapts oneself to take on attributes of an internalized object which functions as a role model.

A. The NPV refers to the probability that an individual with a negative test result does not have the disease. NPV is dependant on the prevalence of the disease in the population being tested. In this case, the possible results of the diagnostic test can be represented in the following 2 × 2 table.

The NPV of the test would be the number of true negatives (patients who don’t have the disease and are tested negative) divided by the total number of patients tested negative by the diagnostic test. In this case, that would be 999/1,000; 99.9%.

E. The Bender Visual Motor Gestalt Test is a test of visuomotor coordination that is useful for both children and adults, and in the latter, is used more frequently as a screening device for signs of organic dysfunction. The Wisconsin Card Sorting Test assesses a person’s abstract reasoning ability and flexibility in problem solving, which can reveal damage to the frontal lobes or caudate. The Wechsler Memory Scale screens for verbal and visual memory and can reveal amnestic conditions such as Korsakoff’s syndrome. Language tests, like the Boston Diagnostic Aphasia Exam, can reveal left-hemisphere lesions, if it is the dominant hemisphere. The Benton Visual Retention Test is sensitive to short-term memory loss.

E. The most serious side effect of lamotrigine is rash which may occur in up to 40% of patients and may culminate in Stevens-Johnson syndrome. It is important to determine if lamotrigine associated rash is benign or malignant. A benign rash begins within 5 days of initiating lamotrigine therapy; it is spotty, nontender, nonconfluent, not associated with laboratory abnormalities, and usually resolves in 10 to 14 days. The management of lamotrigine induced benign rash includes halting dose escalation temporarily or discontinuing medication while the rash is monitored. The patient is instructed to call should the rash worsen or should new symptoms emerge. Antihistamine or topical steroids may also be prescribed to manage itching. Upon resolution of the rash, lamotrigine therapy may be re-initiated at a much lower dose than recommended: 5 mg to 12.5 mg. A rash occurring more than 5 days following the initiation of lamotrigine therapy is more likely to be drug related. Such rashes are tender, confluent, itchy, and widespread and are usually prominent in the upper trunk and neck areas. A poor prognostic sign is involvement of eye, lips, and mouth. There may be accompanying systemic signs and symptoms: fever, malaise, anorexia, sore throat, lymph node enlargement, and laboratory abnormalities (complete blood count, liver function and basic metabolic panel). It is recommended that lamotrigine be discontinued immediately and permanently if a serious rash occurs.

B. Affective flattening is considered a negative symptom of schizophrenia, and is not included in the clinical features of catatonia. The Catatonic type of Schizophrenia is diagnosed when a patient’s clinical picture is dominated by at least two of: (i) motoric immobility as evidenced by catalepsy or stupor; (ii) excessive motor activity; (iii) extreme negativism or mutism; (iv) peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, or prominent grimacing; or (v) echolalia or echopraxia.

D. Delusions are positive characteristic symptoms of Schizophrenia and affective flattening, alogia, and avolition are the negative characteristic symptoms. The others are hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. Although anhedonia is a symptom which can occur as part of Schizophrenia, it is not included in the definition.

E. In the DSM-IV-TR, Pathological Gambling falls under the category of impulse control disorders NOS. Many of the criteria resemble those of substance abuse/dependence. The main exclusionary criteria is that behavior is not better accounted for by a manic episode. Otherwise, comorbidity is the nature of the illness, as reflected in the answers.

D. Typical quit rates for smoking cessation strategies include the following: self-quit (5%), self-help books (10%), physician advice (10%), over-the-counter patch or gum (15%), medication plus advice (20%), behavior therapy alone (20%), and medication plus behavior therapy (30%). Behavior therapy is the most widely accepted and well-proven psychological therapy utilized in smoking cessation. In behavior therapy, skills training and relapse prevention identify high-risk situations in addition to planning and practicing coping skills for these situations. Stimulus control involves eliminating cues for smoking in the environment. Several studies have shown that combining nicotine replacement and behavior therapy increases quit rates over either therapy alone.

B. Buprenorphine, a partial opioid agonist, is an alternative choice to methadone for long-term opioid replacement therapy. Although it has some advantages in that it can be prescribed in a traditional office based practice instead of a methadone clinic, no studies have shown any advantage over methadone in maintaining sobriety. It is usually combined with naltrexone to reduce the chance of abuse (the combination reduces the effectiveness of grinding and taking nasally or intravenously), and can be given 16 mg daily or 32 mg 3 times a week. It is metabolized by the 3A4 cytochrome, and drugs that inhibit this enzyme (ketoconazole and fluvoxamine) can raise the serum level and cause increased sedation. When used in combination with other sedatives, it can lead to respiratory depression. It should be used with severe caution in patients with impaired respiration, increased intracranial pressure, symptomatic hypothyroidism, prostatic hypertrophy, CHF, and liver disease.

B. Approximately 70% to 87% of patients with PTSD report sleep disruption. Sleep problems in PTSD have a high impact in the quality of life and symptom-severity in PTSD. Nightmares are frequently reported and are also particularly resistant to pharmacotherapy. SSRIs have been reported to have a positive, but small, effect on sleep problems in PTSD, especially for insomnia. However, occasionally these medications can produce insomnia as a side effect. In the Expert Consensus Guidelines for PTSD, trazodone was considered to be a first-line hypnotic and was rated as the most effective and best-tolerated hypnotic for the treatment of sleep disturbances in this patient population. There are a few studies showing that it might even have a positive effect in the treatment of nightmares. Benzodiazepines are helpful in inducing sleep, but they have not been shown to improve the rate of sleep disruption or frequency of nightmares. These medications should be used with caution, because they can cause dependence, serious withdrawal symptoms, and cognitive impairment after prolonged use. A few case reports
have reported that the antihistamine cyproheptadine might be helpful in the treatment of nightmares and other disturbances in PTSD, but there is limited data to support this notion.

D. Brief pulse stimulation has replaced sine wave forms. The following help minimize cognitive side effects: (i) placing electrodes unilaterally on the right; (ii) administering one seizure per session; (iii) reducing the dosage of lithium, antipsychotics and sedatives; and (iv) reducing the total number of sessions and frequency of sessions.

B. The transtheoretical model of behavior change is commonly used for the treatment of substance abuse disorders. It consists of five different stages, starting with a precontemplation stage, where patients are still not aware of the negative consequences of their behavior. This stage is followed by the contemplation and preparation stages, where making a change is contemplated, as well as the action and maintenance stages, where the change is made and sustained. Meditation is not a formal stage in this psychosocial intervention.

D. The rate of suicide (per 100,000 population) from 1994 to 2004 decreased from 13.8 to 10.4 for those aged 15 to 24 years, and from 21.9 to 16.6 for those aged 80+ years. The rate among men is four times that of women and the rate among whites is twice that of non-whites. Firearm suicides account for 54%, suffocation 21%, poisoning 17%, cutting 2%, and drowning 1% (not all methods are included). In 2004, the last year in which the CDC updated its data, 82-year-olds had the distinction of having the highest suicide rate per 100,000 with 20.2.

D. Muscle flaccidity, atrophy, hypoactive deep tendon reflexes, and absence of plantar reflex (Babinski’s sign) indicates LMN lesion. Common causes of LMN lesion are peripheral nerve lesions, injury to the anterior horn cell of the spinal cord, and motor neuron disease.

B. The lipophilic nature of solvents is what allows them to easily permeate the CNS. Solvents affect both the PNS and CNS via demyelination. CNS changes include cerebral demyelination, optic nerve damage, pyramidal, and cerebellar injury resulting in cognitive impairment, personality changes, inattention, ataxia, depression, fatigue, and headaches. Chronic exposure to solvents such as toluene can result in dementia that is proportional to cerebral myelin injury.

A. The hallmark characteristic of mitochondrial inheritance is transmission through female parents only, with male and female offspring affected. There can be a wide range of expression of the disease. The manifestations of mitochondrial diseases can involve a single organ system, as in Leber’s hereditary optic neuropathy, or involve multiple organ systems. The genes in the mitochondria encode for many of the components of the respiratory transport chain and are responsible for the cell’s energy metabolism, so myopathies, cardiomyopathy, and neurologic problems are typical sequelae of these mutations. Some disorders found to be associated with mitochondrial inheritance patterns are Leber’s hereditary optic neuropathy (midlife sudden central vision loss with cardiac conduction defects and cerebellar dysfunction), myoclonic epilepsy with RRF (ataxia, myoclonic seizures, sensioneural hearing loss, diabetes, short stature, and lactic acidosis), and Kearns-Sayres syndrome (ophthalmoplegia and retinal degeneration, usually before 20 years, ataxia, deafness, diabetes, short stature, and lactic acidosis).

E. NPH is commonly considered a “reversible” form of dementia. The classic triad of symptoms includes cognitive impairment, urinary incontinence, and gait apraxia (usually the first and most prominent symptom of NPH). Common diagnostic tests include withdrawal of 30 mL of CSF by lumbar
puncture or a series of three lumbar punctures, which, theoretically, would reduce hydrocephalus temporarily. CSF pressure, glucose, and protein are all normal. Improvement in the patient’s gait following CSF removal is indicative of the diagnosis of NPH and predicts benefit from shunt installment to permanently drain the CSF. Improvement in cognitive impairment following CSF removal is not necessarily seen. In theory, shunting of CSF from the ventricles to the abdominal cavity can relieve NPH. Unfortunately, shunting produces a clinically beneficial response in only 50% of patients whose NPH has an established cause (such as a subarachnoid hemorrhage) and in only 15% of patients with idiopathic NPH. EEG is not helpful in the diagnosis of NPH.

B. Continuous high voltage delta wave activity is an EEG finding usually seen in patients with subcortical white matter, but it can also be seen in metabolic encephalopathies. It is associated with a poorer outcome than the intermittent rhythmic delta wave activity or the triphasic delta wave activity seen in earlier stages of coma.

C. L-dopa is converted to dopamine by DOPA decarboxylase. Carbidopa inhibits DOPA decarboxylase peripherally allowing more L-Dopa to penetrate the CNS. This allows a greater conversion of L-dopa to dopamine in the CNS at a lower overall L-dopa dose thereby also reducing side effects.

A. Lead can produce both CNS and PNS dysfunction. Children often develop lead poisoning by craving unnatural foods (pica) or eating lead-pigment paint chips from decaying tenement walls. In children, mental retardation and poor school performance may develop. Acute encephalopathy can be the major neurological feature. In contrast, because lead has a different effect on a mature nervous system, adults most often develop mononeuropathies, such as foot drop (peroneal nerve) or wrist drop (radial nerve). There may be loss of or depression of deep tendon reflexes. Adults can develop lead poisoning through the manufacture or repair of storage batteries, the ship breaking industry, the smelting of lead or lead containing ores, or the consumption of home-made alcohol. Other manifestations of lead poisoning include anemia, constipation, colicky abdominal pain, gum discoloration, and nephropathy. Mees lines are horizontal lines of discoloration which occur on the nails of fingers and toes after an episode of poisoning with arsenic, thallium, or other heavy metals.

B. This patient is presenting with Brown-Sequard syndrome, which is due to hemisection of the spinal cord. Patients present with ipsilateral paralysis due to transection of the corticospinal tract, ipsilateral loss of proprioception and vibratory sense due to transection of the posterior columns, and contralateral loss of pain and temperature due to transection of the spinothalamic tract.

D. Vitamin B₁₂ deficiency can cause neuropathy and affect all of the listed parts of the spinal cord. Damage to the dorsal column can lead to loss of tactile discrimination, vibration sense, and position. Damage to the lateral corticospinal tract can result in spastic paresis and spinocerebellar tract damage can result in abnormalities of arm and leg movements.

D. Cluster headaches are severe unilateral headaches often presenting with significant frequency during a single period and then remitting for months or even years. They occur most commonly in men and are not associated with auras. One hundred percent oxygen or sumatriptan injections are treatments for cluster headaches. They often occur with regularity during REM sleep. Chronic paroxysmal hemicrania is a type of cluster headache which can be aborted with indomethacin.

D. Nearly all hemiplegic patients are able to walk to some extent within 3 to 6 months after their stroke. There is research suggesting that more intensive physical therapies are more helpful in helping patients to walk again. Some authors suggest that adding specific focal physical therapy to the affected leg, after the traditional physical therapy for walking, is especially helpful for this goal.

C. Women do not reach their sexual prime until their mid-30s. They have a greater capacity for orgasm in middle adulthood than in young adulthood. However, as they lose their youthful appearance, they may feel less sexually desirable. As a consequence, declines in sexual functioning in middle-aged women are usually related to psychological rather than physical causes.

E. Ionotropic receptors are directly coupled to an ion channel. These receptors are protein structures containing about 20 transmembrane segments. The ion channel opening occurs in milliseconds, leading to rapid excitatory or inhibitory effects, depending on the ion the channel is permeable to.

E. Reinforcement schedules define how a behavior is influenced by the thought of a reward. In a fixed-ratio schedule, there is a rapid rate of response to obtain the greatest number of rewards. In a variable-ratio schedule, because the probability of reinforcement remains relatively stable, there is a fairly constant rate of response. Because the reinforcement occurs at regular intervals in a fixed-interval schedule, the rate of responding drops to near zero after reinforcement and then increases rapidly as the expected time of reward is anticipated. In a variable-rate schedule, there is a fairly constant response, because reinforcement occurs at random intervals, which is similar to variable-ratio schedule. Partial reinforcement, where reinforcement only occurs occasionally to a particular behavior, maintains that behavior at full strength and they are particularly resistant to extinction.

C. The responses in this study, as represented in a 2 × 2 table, showed that 76% of patients on placebo continued to have anxiety compared to 35% in the citalopram group. Given this information, the RR of continued anxiety in the citalopram group as compared to the placebo group can be reported: anxiety in the citalopram group/anxiety in the placebo group: 35%/76% = 0.46.

More effective treatments provide greater reduction in the risk of negative outcome. The RR for effective treatments vary between 0 and 1 with smaller values indicating a more effective treatment.

E. The WAIS is the best standardized and most widely used intelligence test (Answer B) and comprises 11 subtests made up of verbal and performance subtests which yield a verbal IQ, a performance IQ, and a combined or full-scale IQ. A disparity between the verbal test and the performance test may indicate psychopathology, such as ADHD, and has nothing to do with identifying personality disorders (Answer A). Although the reliability of the WAIS is very high, the IQ is a measure of present functioning ability, not of future potential (Answer C), and the average or normal range of IQ is 90 to 110 (Answer D), where an IQ of 100 corresponds to the 50th percentile in intellectual ability for the general population (based on the assumption that intellectual abilities are normally distributed throughout the population). Under ordinary circumstances, the IQ is stable throughout life, but there is no certainty about its predictive properties. According to DSM-IV, mental retardation is defined as an IQ of 70 or below, which is found in the lowest 2.2% of the population and the validity of the WAIS is high in identifying MR and in predicting future school performance.

A. The most serious side effect of lamotrigine is rash which may occur in up to 40% of patients and may culminate in Stevens-Johnson syndrome. It is important to determine if lamotrigine associated rash is benign or malignant. A benign rash begins within 5 days of initiating lamotrigine therapy. The rash is spotty, nontender, nonconfluent, not associated with laboratory abnormalities, and usually resolves in 10 to 14 days. Given that the immune system requires several days to mount a true hypersensitivity reaction, most rashes occurring within a few days of lamotrigine therapy are
likely to be benign. A rash occurring more than 5 days following the initiation of lamotrigine therapy is more likely to be drug related. Such rashes are tender, confluent, itchy, and widespread and are usually prominent in the upper trunk and neck areas. A poor prognostic sign is involvement of eye, lips, and mouth. There may be accompanying systemic signs and symptoms: fever, malaise, anorexia, sore throat and lymph node enlargement, and laboratory abnormalities (complete blood count, liver function, and basic metabolic panel). It is recommended that lamotrigine be discontinued immediately and permanently if a serious rash occurs.

C. DID is a chronic disorder in which two or more distinct personalities exist within the same individual, with at least two of the personalities alternately controlling the individual’s behavior. The median number of personalities is between five and ten. Most often, one personality cannot recall what occurred when another personality was dominant. The personalities may differ significantly in terms of behavior, mannerisms, speech, etc. Switches between personalities can be quite sudden, but are often so rare that they are difficult to pick up on without prolonged treatment. The mean age at diagnosis is 30 years, although the disorder likely begins earlier, in childhood or adolescence. Although female:male ratios of 5 to 9:1 have been reported, men may be under diagnosed. Almost all individuals with DID have a history of trauma, most often childhood sexual abuse. Common symptoms include losing time, being recognized by strangers, finding oneself suddenly in an unexpected place or with objects for which one cannot account, and voices coming from within. Treatment may focus on integrating the various personalities, to help the individual gain better control over their behavior.

D. To receive a diagnosis of Schizophrenia, patients must have at least two of the “characteristic” symptoms (delusions, hallucinations, disorganized speech, disorganized behavior, or negative symptoms) for at least a month and attenuated signs of the disease for at least 6 months. One of the exceptions to the requirement that the patient have at least two of the characteristic symptoms occurs when the auditory hallucinations consist of two or more voices conversing (as well as a voice containing running commentary or bizarre delusions). A diagnosis of Schizophreniform Disorder requires the presence of characteristic symptoms for at least 1 month but less than 6 months, and a Brief Psychotic Disorder requires the presence of characteristic symptoms for at least 1 day but less than 1 month.

B. Trichotillomania is recurrent hair pulling with noticeable hair loss. Pulling is preceded by tension and followed by relief or gratification. Pulling is not better accounted for by another mental or medical disorder, and causes significant distress or impairment. It may be more common in females than males, and is most common in pre-adolescents. Diurnal variation and premenstrual exacerbations frequently occur. Stress often triggers or worsens symptoms. Comorbidity is common, especially with OCD, Mental Retardation (MR), Schizophrenia, Depression, and Borderline Personality Disorders. Trichophagia is common and may result in a bezoar. Alopecia areata or tinea capitis would have been diagnosed by the referring dermatologist.

E. The receptors present in the respiratory tract are beta-subtype-2 receptors, whereas those present in the heart are beta-subtype-1 receptors. The cardioselective (or beta-1-receptor selective) agents are most suitable for patients with chronic obstructive pulmonary disease (COPD) and bronchial asthma. Of all the drugs listed only bisoprolol is beta-1 selective.

D. When a patient is acutely agitated, the most important factor is to maintain the patient’s safety and to prevent anyone around him from getting hurt. The patient’s behavior must be controlled by physical restraints when other alternatives fail.
Patients that are very agitated can get hurt even while restrained, either through self-inflicted behaviors or through aspiration or limb ischemia. Studies have shown that intramuscular haloperidol has a sigmoidal dose-effect curve between 2.5 mg and 15 mg given within the first 4 hours of treatment. Doses greater than 15 mg have not shown to be more efficacious, and can even provide lesser degrees of improvement and higher risks of side effects. Benzodiazepines, and in particular lorazepam, have proven to be efficacious and fast acting for the treatment of acute agitation, alone, or in combination with antipsychotics. Benztropine is helpful to treat extrapyramidal symptoms, but it does not seem to have a therapeutic effect in the treatment of agitation.

B. Pregabalin has demonstrated efficacy in the treatment of general anxiety disorder with efficacy rates similar to those of benzodiazepines, and it is generally well tolerated. Although its mechanism of action is still unclear, pregabalin binds selectively and with high affinity to voltage-gated calcium channels in CNS tissues and acts as a presynaptic modulator of the excessive release of excitatory neurotransmitters. Despite being structurally similar to GABA, pregabalin does not interact with GABA-A, GABA-B orbenzodiazepine receptors, or to presynaptic or postsynaptic serotonin receptors. The onset of action of pregabalin has been shown to be similar to that of alprazolam, with improvements seen 1 week after starting treatment. In contrast to benzodiazepines, pregabalin has not been associated with rebound anxiety or severe withdrawal symptoms.

A. The mechanism of action of ECT remains unknown, but animal studies have suggested that neurogenesis and other changes occur in the hippocampus.

D. Over 50% of patients who received initial treatment for substance use disorder relapsed within 3 months. During this period, called early recovery period, craving is at its peak and remains significantly strong for months. Although this number is not very encouraging, 10% to 20% of treated patients never relapse after their first treatment, and approximately 2% to 3% achieve sobriety after each additional year of attempted abstinence.