D. All are stages of the Kübler-Ross model except for D. Depression is the stage that is not listed in the answers. Although mood may improve and even seem euphoric during the acceptance stage, compensatory mania is not listed as a separate stage in this model.

A. The lesion is in the contralateral (left) subthalamic nucleus and the condition is hemiballismus. The patient probably has toxoplasmosis. It is one of the more dramatic disorders caused by lesions to the basal ganglia and, as described previously, is characterized by wild flailing of one arm and leg. The subthalamic nucleus is connected by way of the globus pallidus and the substantia nigra to the ipsilateral motor cortex, which controls the motor function of the other side of the body. Lesions to the caudate nucleus would cause chorea (i.e., nearly continuous movements of the face, tongue, or limbs, as is found in Huntington’s disease). Lesions to the substantia nigra would cause Parkinson’s disease (i.e., resting tremor, bradykinesia, and rigidity). The globus pallidus regulates the output of the basal ganglia.

E. Jean Piaget was a Swiss philosopher, natural scientist, and developmental psychologist, who was well known for his work in studying children and for developing theories of cognitive development. Piaget noticed that even infants have certain skills by which they react to objects in their environment. These rudimentary skills were sensorimotor in nature, but were used by the infant to explore his or her environment and gain more knowledge of the world, and develop more sophisticated exploratory skills. Piaget termed these skills as schemas. Addition of new information to the preexisting schema was termed assimilation. Changing the preexisting schema based on the new information was called accommodation. According to Piaget, assimilation and accommodation are the two sides of adaptation, or learning. Piaget saw adaptation as a broader learning experience than the kind of learning that behaviorists in the United States were describing. He envisaged it as a biological process that directs a balance between the structure of the mind and the environment. When there is congruency between the two, it would indicate that you have a good enough model of the universe and he called this ideal state “equilibrium.” Carl Jung described archetypes as unlearned tendencies to experience things in a certain way. An archetype has no form of its own, but it acts as an “organizing principle” on the things we see or do. It works the same way that instincts work in Freud’s theory.

A. NNH represents the number of patients who would need to be treated with a drug to produce one more adverse event than would have occurred with control treatment. The NNH is simply a reciprocal of the absolute risk increase (ARI). ARI is calculated as the difference between the experimental event rate (EER) and control event rate (CER). In this case, the ARI is 3.5% (EER) – 2.3% (CER) = 1.2% (or 0.012). The NNH then would be 1/0.012 = 84. An NNH of 84 means that 84 patients with dementia would have to be treated with an atypical antipsychotic drug before one more patient would have an adverse event (i.e., death).

A. Insight is defined as the patient’s degree of awareness and understanding about being ill. This person clearly is in denial of her illness and places the blame for her behavior on external factors rather than the illness, showing lack of insight. Thought process refers to the way in which a person puts together ideas and associations and includes examples
like flight of ideas, tangentiality, circumstantiality, and thought blocking. Similarly, thought content refers to what a person is actually thinking about and includes examples like delusions, preoccupations, obsessions, phobias, and suicidal thoughts. Perception refers to experiencing sensory phenomenon as in hallucinations or illusions. Although this patient’s judgment is shown to be poor, it has been markedly influenced by her lack of insight.

D. Antisocial Personality Disorder is more common in first-degree biological relatives of those with the disorder. The risk to biological relatives of women with the disorder tends to be higher than the risk to biological relatives of men with the disorder. Biological relatives of patients with this disorder are also at increased risk for somatization disorder and substance-related disorders. Within a family that has a member with Antisocial Personality Disorder, men often have Antisocial Personality Disorder and Substance-Related Disorders, whereas women more often have Somatization Disorder. But in such families, there is an increase in the prevalence of all of these disorders in both men and women compared to the general population. Both adopted and biological children of parents with Antisocial Personality Disorder have an increased risk of developing this disorder. Adopted-away children resemble their biological parents more than their adoptive parents, but the adoptive family environment influences the risk of developing a personality disorder and related psychopathology.

C. To diagnose a Feeding Disorder of Infancy and Early Childhood according to DSM-IV-TR, the age of onset must be before the age of 6 years. The feeding disturbance is manifested as a failure to eat adequately with significant failure to gain weight or significant loss of weight over at least 1 month. It is not attributable to a gastrointestinal or other medical condition or to lack of food.

A. A variety of basal ganglia abnormalities have been considered in Tourette’s syndrome, including loss of normal right-left symmetry, increased dopamine receptor availability in more severely affected co-twins, changes in neuronal activity, and—more consistently—smaller caudate volumes.

D. Studies have suggested cognitive compromises in patients with schizophrenia begin in early childhood, long before symptoms of psychosis. Cognitive deficits are largely independent of symptom severity in schizophrenia. Little evidence exists to suggest cognition improves with antipsychotic treatment. The level of cognitive impairment remains relatively stable from the time of a first psychotic break through late-middle age. Executive dysfunction is the most commonly impaired cognitive function in these patients.

A. Fatigue and drowsiness are the most common side effects of benzodiazepines. Patients who are started on benzodiazepines should be cautioned to avoid driving or operating heavy machinery until they are certain the drug will not affect their performance. Impaired memory or other cognitive functions are also seen. Transient anterograde amnesia (inability to learn new information) may occur after an acute dose of benzodiazepines is given; this effect is worsened when benzodiazepines are combined with alcohol use. Impaired motor coordination is another, less common side effect of benzodiazepines. Depression is a potential side effect of all benzodiazepines, although a direct causative link has not been established. Patients who develop depressed mood on benzodiazepines may benefit from the addition of an antidepressant or switching to an antidepressant. Behavioral disinhibition (e.g., agitation, rage attacks) may occur as a paradoxical response to benzodiazepines, most notably among patients with personality disorders and a history of behavioral dyscontrol. When this occurs, antipsychotic medications are often effective in reversing the disturbances.

C. AA is a self-help group comprised of individuals who share one thing in common: a desire for
help with an alcohol-related problem. AA is multiracial, apolitical, nonprofessional, and available worldwide. There are no age or education requirements for membership. AA is not a religious organization and does not charge dues or fees. Members of AA often have help available 24 hours a day. AA is not a medical organization and does not provide medications or psychiatric advice. Patients with psychiatric comorbidities are welcome to join AA, but they may need education from physicians on how to cope should group members inappropriately suggest they stop taking medications. Similar organizations are available to family members and loved ones of alcoholics (Al-Anon and Alateen).

A. Pimozide and haloperidol are used in the treatment of Tourette’s syndrome. The dose of pimozide is limited to 20 mg per day due to increased risk of prolonged QT interval (and risk of torsades de pointe and ventricular tachycardia) with higher doses.

A. While higher doses of neuroleptics are a risk factor for neuroleptic malignant syndrome, it is not a dose dependant phenomenon (i.e., the effects change when the dose of the drug changes). All of the other statements are true regarding neuroleptic malignant syndrome.

D. NSAIDS, metronidazole, hydrochlorothiazide, and captopril (any Angiotensin-Converting Enzyme [ACE] inhibitor) increase lithium levels. Acetazolamide decreases the lithium levels.

C. Except “White race,” all of the following are protective factors in preventing suicides. Other protective factors include life satisfaction, reality testing ability, positive coping skills, positive problem solving skills, positive social supports, and positive therapeutic relationships. White race is a risk factor for suicide.

B. The middle cerebral artery supplies blood to the perisylvian arc, which includes Wernicke’s area, the arcuate fasciculus, and Broca’s area.

E. Confabulation is when a patient falsifies memories in a state of clear sensorium. It can occur during chronic alcohol abuse, which may lead to Korsakoff’s syndrome, but also can occur in other causes of organic brain damage, embarrassment, and Schizophrenia.

C. Mutations of mitochondrial deoxyribonucleic acid (DNA) causes a wide variety of clinical neuromuscular syndromes that can affect any part of the nervous systems, muscles, and other organs. Such mutations may arise sporadically where there is no family history of disease, or may be transmitted via maternal inheritance with up to 100% of a mother’s offspring receiving the genetic defect. This is because all mitochondria are inherited from the ovum. Mitochondrial inheritance also arises from a mixture of normal and abnormal mitochondria within a single cell, but also in different tissues. Homoplasmy is the state of having uniformly normal or abnormal mitochondria in a tissue and heteroplasmy is the mixture of normal and abnormal mitochondria in a single tissue. Normally, 90% of the mitochondria need to be abnormal before abnormal symptoms and signs can manifest.

E. The MMPI is one of the most frequently used personality tests. The original MMPI was developed at the University of Minnesota Hospital and was first published in 1942. The current standardized version for adults 18 years or older is the MMPI-2 which was first released in 1989. The MMPI-2
has 567 items, or questions (all true or false format), and takes approximately 60 to 90 minutes to complete. The short form of the test is comprised of the first 370 items on the long-form of the MMPI-2. It has ten clinical scales which are as follows: hypochondriasis, depression, hysteria, psychopathic deviate, masculinity-femininity, paranoia, psychasthenia, schizophrenia, mania, and social introversion. It also has four validity scales (i.e., if the test-taker was truthful, answered cooperatively, and not randomly) and assesses the test-taker’s response style (i.e., cooperative). The four validity scales are the “cannot say” scale, the L (lie) scale, the F (deviant or rare response) scale, and the K (clinically defensive response) scale. Although its standardization sample was limited in racial diversity, this test has acceptable norms. When using the MMPI-2, care needs to be exercised in the interpretation especially when applied to patients with brain damage as many of the symptoms elicited by MMPI-2 questions are common to patients with neurological disorders.

E. While it is possible for patients with Parkinson’s disease to develop a concomitant aphasia, aphasia is not normally part of the presentation of Parkinson’s disease. The other symptoms listed are commonly seen in patients with this movement disorder.

C. This patient is presenting with third nerve palsy, likely secondary to diabetic infarction of the third nerve. Damage to the nerve causes ptosis—drooping of the upper eyelid (because the levator palpebrae is supplied mainly by the third nerve)—and an inability to rotate the eye upward, downward, or inward. When the lid is passively elevated, the eye is found to be deviated outward and slightly downward because of the unopposed actions of the intact lateral rectus and superior oblique muscles. Common causes of this condition are neoplastic diseases, aneurysms and diabetic infarction. The palsy is usually chronic, progressive, and painless. Enlargement of the pupil is a sign of extramedullary third nerve compression because of the peripheral location in the nerve of the pupilloconstrictor fibers.

Infarction of the nerve in diabetics, however, usually spares the pupil. Because the damage is situated in the central portion of the nerve. It usually develops over a few hours and is accompanied by pain, usually severe, in the forehead and around the eye. The prognosis for recovery (as in other nonprogressive lesions of the oculomotor nerves) is usually good because of the potential of the nerve to regenerate. Usually the other eye is spared, but infarction may occur in the other optic nerve at a later date.

C. A brachial plexus injury occurs when the plexus is stretched when the head is turned away from the shoulder. It is most likely to occur in a large infant with a cephalic presentation. Milder injuries involve cervical roots 5 and 6; more serious injuries involved the entire plexus. In milder cases, full recovery is expected. However, in more severe cases, consultation with a neurologist and surgeon is indicated to evaluate the need for intervention. Physical abuse always warrants exploration, but does not explain the finding nor would intracranial hemorrhage explain such a localized finding. Signs of congenital syphilis in a young child include notched teeth, clouded cornea, decreased hearing, bone pain, and bone problems of the lower legs, among others. In utero toxoplasmosis infection may lead to a range of outcomes, from mild to severe. At birth, severely infected newborns often have eye infections and an enlarged liver and spleen. If they recuperate, eventual problems may include mental retardation, seizures, CP, and severely impaired eyesight.

A. This patient has Alpers’ disease which has an underlying metabolic defect. Death usually occurs within the first decade of life by unrelenting seizures, liver failure, or cardiorespiratory failure. Optic atrophy can lead to blindness. Dementia is also a common finding. Alpers’ disease, however, is a rare condition.

C. Neurosyphilis occurs in many different forms and can manifest any time from a year
after the initial infection to 25 years later. Many different forms may overlap and coexist to confuse the making a diagnosis. CSF invasion is common in early stages of untreated syphilis. If CSF abnormalities persist for over 5 years in the untreated patient, it is highly predictive of the development of clinical neurosyphilis. Asymptomatic neurosyphilis can only be diagnosed via the examination of the CSF. Acute syphilitic meningitis is the earliest clinical manifestation of neurosyphilis and occurs within the first year of infection in most patients. It may occur later on in the course of the illness, if untreated. Meningovascular syphilis is more common than meningitis and can cause syphilitic endarteritis and resultant vascular occlusion and infarction. General paresis occurs due to tertiary syphilis, but is a rare condition. It presents with neuropsychiatric manifestations about 15 to 20 years after the initial infection due to the infection of the meninges and cerebral cortex. It results in changes in personality, delusions, mood lability, and dementia. Tabes dorsalis used to be the most common type of neurosyphilis, but is now rare. It affects the posterior columns of the spinal cord and the dorsal roots. It usually occurs 18 to 25 years after initial untreated infection and manifests with paresthesias, abnormal gait, and lightning pains of the extremities or trunk.

D. The human prion diseases may be sporadic, infectious, or genetically inherited. Most of the cases of CJD (80% to 90%) are sporadic. Iatrogenic CJD and familial CJD (autosomal dominant inheritance) each account for about 5% to 10% of CJD cases. Sporadic CJD does not spread like an ordinary infection as the agent has low infectivity. Those with prior head and neck trauma or medical personnel are at higher risk because of increased exposure to the agent. CJD can be transmitted by implanting electrodes or during corneal transplants from infected patients. Iatrogenic disease may also occur due to dura mater grafts and administration of growth hormone extract prepared from pooled human pituitary glands. Mutations in the PrP gene causes the disease that are heritable and transmissible.

C. Surgical treatments of Parkinson’s disease are thalamotomy or pallidotomy. They are helpful when patients become unresponsive to pharmacological treatment or develop intolerable adverse reactions to antiparkinsonian medications. Surgery is also sometimes more effective in young patients with mainly unilateral disease who have failed to respond to medications. Thalamotomy is more helpful for tremor, while pallidotomy is more helpful for hypokinesia. Contraindications include dementia or diffuse vascular disease. The rate of significant complications is less then 5% after unilateral surgery, but is about 20% or greater after bilateral procedures. Regarding the other choices, thymectomy is a treatment option in patients with uncomplicated myasthenia gravis who are between puberty and age 55 years. The remission rate is 35% and another 50% show some improvement. Response is usually evident after several months to 3 years. Individuals with intractable bilateral frontal seizures or infants with atonic seizures occasionally benefit from commissurotomy or corpus callostomy. In this procedure, the anterior two thirds or the entire corpus callosum is split longitudinally. This interrupts the spread of discharges between the cerebral hemispheres. A complication of the surgery may be split-brain syndrome.

B. Psychological causes, rather than organic disorders, are more often the reason for chronic sexual impotence in middle-aged men. Alcohol, certain antidepressants, stress, and hormonal problems can cause impotence. Although sexual functioning may decline with age, chronic impotence is not a feature of normal mid-life aging.

C. The autoregulation is normally inhibitory. The dopamine autoreceptor at both sites is the D2 receptor; similarly, the noradrenaline autoreceptor is the alpha2 receptor. With the serotonin neurons, the 5-HT1a receptor acts as the main somatodendritic autoreceptor, but the 5-HT1b/1D receptor is the terminal autoreceptor.

D. It is seen across cultures that men are more violent than women. This observation is related to
the biology of male/female differences and polygyny (where one male associates with multiple females). In all polygynous species, males are more prone to violence than are females, and the greater the degree of polygyny is, the greater the male/female disparity becomes for proneness to violence. This observation is probably related to adaptive need for males to succeed in competition with other males for a mate. Violence is also influenced by cultural expectations of male and female stereotypes. In most cultures, men are taught that aggression and violence are signs of “manliness,” whereas it is “unfeminine” for women to be violent. It is the interaction between cultural expectation and the biological tendency for violence in men that ultimately results in higher rates of violence in men than in women. Although homicide rates vary substantially among different cultures, with rates being 10 times higher in the United States than in Canada, the difference in rates of homicide between male and female have remained remarkably constant regardless of the society and over time. Homicide rates are higher in poorer and less educated societies.

C. To prevail in a malpractice claim, the plaintiff must establish four elements: (i) physician is derelict in his duties, (ii) the defendant (physician) has a specific duty or obligation to the plaintiff (patient)—the existence of physician-patient relationship, (iii) the dereliction of duty is a direct cause of an injury, and (iv) economic, physical, emotional pain, and other types of damages must be proven. Although breach of confidentiality could result in emotional damages and may be grounds for a malpractice suit, it falls under the rubric of damages and by itself is not one of the four required elements of a malpractice suit.

B. The most widely used test of current cognitive functioning is the MMSE, which is used to detect cognitive impairments, follow the course of an illness, and monitor the patient’s treatment responses. In this case, it would be the first appropriate test to use. The Facial Recognition Test is a test which requires the 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. The WAIS-R is an assessment of intellectual abilities and gives intelligence quotient (IQ) scores. Some of the component tests hold up as aging progresses, while others do not, but this would not be the first test to use for detecting cognitive deficits in dementia. The Thematic Apperception Test and Sentence Completion Test are types of Projective Personality Assessments that are designed to tap into patient’s emotions, motivations, and core personality conflicts, and are not helpful for detecting cognitive deficits in dementia.

D. Major Depressive Episode (MDE) with Atypical Features is defined by predominance of specific symptoms during the most recent 2 weeks of a current MDE in Major Depressive Disorder or Bipolar Disorder and is characterized by mood reactivity and two or more of the following: significant weight gain or increase in appetite, hypersomnia, laden paralysis, and long standing pattern of rejection sensitivity. In addition, criteria are not met for MDE with melancholic or with catatonic features. Loss of pleasure in all or almost all activities is a feature of Melancholic Depression.

B. DSM-IV-TR stipulates that both multiple motor and one or more vocal tics be present at some time during the illness but not necessarily concurrently (criterion A). The symptoms must last more than 1 year, and tic-free periods cannot last more than 3 months (criterion B). Criterion C refers to age of onset before 18 years and criterion D refers to exclusionary conditions.

C. GABHS can trigger a variety of immune mediated diseases in susceptible individuals. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) describes the exacerbation of tics or obsessive-compulsive symptoms triggered by GABHS autoimmune effects. The use of plasmapheresis or intravenous immunoglobulin infusion for PANDAS has
been successful in limited trials but is not considered a standard of care.

B. A diagnosis of Delusional Disorder, Jealous type is the most likely diagnosis. Given this history, she does not have two or more characteristic symptoms needed for a diagnosis of Schizophrenia or Schizophreniform Disorder. Her delusions persist at times when there has been no mood disturbance, making Major Depressive Disorder an unlikely diagnosis. Given her age and the lack of cognitive dysfunction, a dementing illness is also unlikely.

D. Serious drug-drug interactions with benzodiazepines are rare, but may occur. Due to competition for microsomal enzymes, certain drugs (including cimetidine, estrogens, SSRIs, disulfiram, and erythromycin) increase blood levels of benzodiazepines. Carbamazepine, an inducer of liver enzymes, decreases blood levels of benzodiazepines. Antacids, as well as meals, tend to decrease benzodiazepine absorption; hence, patients taking these medications should be instructed to take them on an empty stomach and in the absence of antacids. Other interactions of concern with benzodiazepines include those drugs which may potentiate CNS depression, such as barbiturates, cyclic antidepressants, antihistamines, and alcohol. When taken together in overdose, alcohol and benzodiazepines may result in death.

B. EKG is not used in biofeedback. The EMG gives feedback of striate muscle tension. The EEG gives feedback of brain waves. The EDR involves feedback of sweat gland activity, measured from the fingers. The perineometer gives feedback of anal, sphincter, and pelvic floor muscles. Thermal feedback, which gives feedback of peripheral blood flow as monitored by skin temperature, is also used.

A. Risperidone is most likely to elevate plasma prolactin levels resulting in prolactinemia. Prolactinemia in premenopausal women can result in hypogonadism, manifested by infertility, oligomenorrhea, or amenorrhea and, less often, galactorrhea. Prolactinemia also causes hypogonadotropic hypogonadism in men, which is manifest by decreased libido, impotence, infertility, gynecomastia, or rarely galactorrhea. In both men and women, there is an approximate correlation between serum prolactin levels and the presence of any of these symptoms. Other medications that can result in prolactinemia include metoclopramide, cimetidine, methyldopa, reserpine, and verapamil.

A. Available information indicates that age, sex, and time of year are not significantly correlated with risk of developing NMS. NMS is not specific to any neuropsychiatric diagnosis, but catatonic patients may be at risk of progressing to NMS after receiving antipsychotics. Agitation, dehydration, restraint, preexisting abnormalities of central nervous system dopamine activity or receptor function, and iron deficiency are all risk factors for NMS. Use of high-potency typical antipsychotics are associated with a greater risk compared to low-potency agents or atypical antipsychotics. Parenteral routes, higher titration rates, and total dose of drug administration have been associated with an increased risk of NMS.

E. Given the side effects of lithium, it is recommended that baseline levels of BUN, T₃, T4, T₃ resin uptake, and TSH be obtained prior to starting lithium. Women who could potentially bear children should have a beta-hCG checked. Patients who are over 50 years of age or have cardiac histories should receive an EKG. Although low sodium levels can lead to lithium toxicity, checking sodium levels is not one of the tests recommended as necessary before starting lithium.

C. Although thoughts of death are more common in older than in younger adults, the elderly are less likely to endorse suicidal ideation than their younger counterparts. Suicide attempts are also less
frequent among the elderly than among the younger age group. The ratio of attempted suicides to suicides in adolescents is often as high as 200:1. In the elderly, the ratio is as low as one to four attempts for each suicide. Self-destructive acts that occur in the elderly are more lethal. This lethality is due to greater burden of illness, greater social isolation, and a greater determination to die. Elders give fewer warnings about their suicidal intent, use more violent and potentially deadly methods, and apply those methods with greater planning and resolve. Hence, suicide attempt in an older person confers a higher level risk for future suicides.

E. Echolalia occurs in isolation aphasia and is in fact one of the key features of the syndrome. Echolalia is also seen in patients with autism, Tourette’s syndrome, dementia, and Schizophrenia.

E. Delirium tremens is a serious form of alcohol withdrawal. Visual hallucinations of small animals or tiny men, known as Lilliputian hallucinations, can occur during delirium tremens. These hallucinations are usually characterized by all of the above noted features.

E. An important category of mutations is the trinucleotide repeat expansion mutations, characterized by an elongation of a gene region with repeats of a trinucleotide sequence. When the trinucleotides lie outside of the coding region, the expansions can reach a very large size. Some important disorders caused by the trinucleotide repeat expansion include Huntington’s disease, Myotonic dystrophy, Fragile X syndrome, Friedreich, ataxia, and X-linked spinal and bulbar atrophy.

B. The human brain weighs approximately 350 grams at birth and approximately 1,450 grams by adulthood. This increase is mainly in the neocortex.

C. Axons of mesolimbic and mesocortical pathways arise from the ventral tegmental area. These pathways are an important site of action of antipsychotics (D2 and D4 antagonists). The tuberoinfundibular pathway arises from dopaminergic neuronal cell bodies in the median eminence that project to the pituitary. Release of dopamine inhibits prolactin release via activation of D2 receptors. Drugs that antagonize D2 receptors increase prolactin secretion causing amenorrhoea, lactation, and sexual dysfunction.

D. The cornerstone of psychoanalytic theory is free association, in which patients say whatever comes to mind. It does more than provide content for the analysis; it induces the necessary regression and dependency connected with establishing and working through transference. Freud originally used the cathartic method in conjunction with hypnosis to attempt to remove hysterical symptoms through a process of recovering and verbalizing suppressed feelings with which the symptoms were associated, known as abreaction, but due to the forces of repression and resistance, he abandoned this cathartic method and switched to free association. He was originally convinced that childhood sexual seduction played a major role in causing the neuroses, but later shifted his thinking and placed much greater emphasis on childhood sexual fantasies as the core of neuroses. Freud believed that the interpretation of dreams was the road to understanding the unconscious. Dreamwork is defined as the unconscious mental operations by which latent dream content is transferred into manifest content.

B. Claims of abandonment may be made if harm results from the unilateral termination of a therapeutic relation by the physician without consent or justification. Persistent no shows, violent behaviors, and noncompliance are likely justifications that could mitigate the claim of abandonment. Should termination of a therapeutic relationship
become necessary, claims of abandonment may be ameliorated by making the following available to the patient: access to emergency care, referral to another clinician, medications in the period between termination, and appointment with another provider. A physican may be held liable for abandonment for failure to provide adequate and competent coverage in his/her absence. The very nature of a therapeutic relationship makes such a claim more likely to succeed regardless of whether the physician is physically present or not.

E. The disorder-centered interviewing style follows a descriptive and theoretical model of psychiatric disorders. It sees psychiatric disorders in a similar way to medical disorders, using specific diagnostic criteria. The patient-centered interviewing style is based on an introspective model, and it focuses on the intra-psychic battle of conflicts that each patient presents with. It is sensitive to a patient’s educational, social, and emotional background, and it gives a lot of importance to the individuality of each patient.

D. The specifier “with Melancholic Features” can be applied to depressive episodes occurring in Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder. It is characterized by either the loss of pleasure in all—or almost all—pleasurable activities or the lack of reactivity to usually pleasurable stimuli, in addition to the following: (i) distinct quality of depressed mood, (ii) depression worse in the morning, (iii) early morning awakening, (iv) marked psychomotor retardation or agitation, and (v) anorexia or weight loss and excessive or inappropriate guilt. Characteristics of an MDE with Atypical Features include mood reactivity and two or more of the following: (i) significant weight gain or increase in appetite, (ii) hypersomnia, (iii) laden paralysis, and/or (iv) long standing pattern of rejection sensitivity.

B. Initial symptoms of Tourette’s syndrome generally appear in prepuberty between the ages of 5 and 8 years. Motor tics appear before vocal tics by age 1 or 2 years and are often simple tics initially such as eye blinking or grimacing.

E. Voiding of urine into bed or clothes must occur twice a week for 3 consecutive months for the condition to meet the DSM-IV-TR criteria for Enuresis. However, in the presence of significant impairment or distress, the criteria for frequency and duration are not required. An age of at least 5 years or equivalent developmental level is required. The types to be specified are Nocturnal Only, Diurnal Only, or Nocturnal and Diurnal.

A. Presence of negative symptoms is associated with poor outcome in Schizophrenia. Acute onset, late onset, good premorbid functioning, and a short time between psychotic symptoms and medication initiation are predictors of good outcomes.

E. It has been hypothesized that NA systems are an integral component of fear and anxiety. As such, beta-blockers are competitive antagonists of norepinephrine and epinephrine at beta-adrenergic receptors. They may be clinically useful in the treatment of heightened anxiety states. Beta-blockers have not been convincingly shown to be useful for generalized social anxiety disorder, but may be more useful for anxiety limited to a specific situation (i.e., performance anxiety). When used for performance anxiety, a single dose of 10 to 40 mg of propranolol may be beneficial in reducing the peripheral effects of anxiety (i.e., dry mouth, palpitations, and tremors). Unlike benzodiazepines, which may also be helpful for heightened anxiety states, beta-blockers do not have an effect on memory or learning. They may, in fact, improve performance on tasks involving memory and learning by reducing anxiety levels, as such tasks are very sensitive to anxiety. In addition, beta-blockers do not induce tolerance nor do they have abuse potential like benzodiazepines. Lipophilic beta-blockers, including propranolol and metoprolol, cross the blood-brain barrier and have central, as well as peripheral, effects. Metoprolol and atenolol are considered
selective beta-blockers, with greater activity at B1 then B2 receptors, thereby reducing the risk of bronchospasm with these medications. However, this selectivity is relative, and physicians must still exercise caution when using any beta-blocker in certain patient populations (i.e., those with asthma and those with diabetes, as beta-blockers may also mask the symptoms of hypoglycemia).

E. Zolpidem is a non-benzodiazepine hypnotic of the imidazopyridine class. It is primarily beneficial for sleep-onset-related insomnia but has no muscle relaxant, anxiolytic, or anticonvulsant effects. Zolpidem is rapidly absorbed after oral administration and reaches peak blood levels in about 2.2 hours. It is also highly protein bound. Its elimination half-life is 2 to 3 hours, and its duration of action is 6 to 8 hours. It does not have any active metabolites.

Zolpidem has sleep-enhancing properties, but is less likely to affect sleep architecture. Zolpidem appears to be well tolerated in adults and in the elderly when administered appropriately. The available data indicates that when zolpidem is administered according to instructions the risk of abuse or dependence is low. Zolpidem has minimal rebound effects and less abuse potential than benzodiazepines. Its starting dose in adults is 10 mg orally immediately before bedtime, and its maximal dose is 20 mg. In the elderly, the starting dose is 5 mg immediately before bedtime.

C. Clozapine has affinity for five types of receptors: dopamine, muscarinic, serotonin, alpha-adrenergic, and histamine receptors.

D. Although all of the above choices are treatment considerations in dealing with patients with neuroleptic malignant syndrome, the single most important intervention is discontinuation of the neuroleptic agent.

A. A high potency, short-acting benzodiazepine, such as immediate release alprazolam, has an increased risk of interdose rebound symptoms. Clonazepam and diazepam are low-potency, longer-acting benzodiazepines. Venlafaxine and buspirone do not cause interdose rebound anxiety.

E. Suicide risk increases with age for both sexes, but the rates in older men are generally higher than those for women. In the United States, men commit suicide 4 times more commonly than women, but women attempt suicide 3 times as often as men. However, this female predominance among suicide attempters varies with age and the ratio of women to men approaches 1:1 in the elderly. Men also tend to use more lethal suicide methods than women (e.g., firearms or hanging, as compared to cutting or overdoses). Factors that contribute to these gender differences include the presence of depression and co-morbid alcohol and/or substance abuse. Men are also less likely to seek and accept help or treatment. Women tend to have lower rates of alcohol and substance abuse, are less impulsive, are more socially embedded, and are more willing to seek help. In women, pregnancy is a time of significantly reduced suicide risk. Women with young children in the home are less likely to kill themselves. But those women with a history of depression or suicide attempts are at greater risk during the postpartum period, as compared to women who don’t have such a history. Suicide is most likely to occur in the first month after delivery, but the risk continues throughout the postpartum period. Teenagers, women of lower socioeconomic status, and women hospitalized with postpartum psychiatric disorders are particularly at increased risk in the postpartum period.

D. Gait apraxia is seen in normal pressure hydrocephalus. Apraxia is characterized by the inability to perform learned or familiar movements on command, even though the command is understood and both sensory and motor functions are in tact. There are several different forms of apraxia. Ideomotor apraxia is the inability to carry out a command from the brain to mimic limb or head movements
performed or suggested by others. Conceptual apraxia is much like ideomotor ataxia but infers a more profound malfunctioning, in which the function of tools is no longer understood. Ideational apraxia is the inability to create a plan for a specific movement. Constructional apraxia affects the person’s ability to draw or copy simple diagrams or to construct simple figures. Buccofacial apraxia (sometimes called facial-oral apraxia) is the inability to coordinate and carry out facial and lip movements such as whistling, winking, or coughing on command. This form includes verbal or speech developmental apraxia, perhaps the most common form of the disorder.

E. All of the choices from A to D are possible manifestations of an acute dystonic reaction. Dystonia can be a result of antidopaminergic medications and is manifested by muscular contractions, repetitive or abnormal movements, or abnormal postures. Akathisia is not classified as a dystonic reaction.

D. Temporal arteritis has an annual incidence of about 25 per 100,000 in people older than 50 years. It occurs predominantly in women (65%). The average age of onset is 70 years. Blindness occurs in about 50% of the patients, if untreated. Patients may also develop thrombosis of any predural artery or aortic aneurysm with rupture, if left untreated. The most common initial symptom is headache. It commonly occurs with malaise and myalgia. It may be unilateral or bilateral and is located to the temporal area in only about 50% of the patients. Headache, polymyalgia rheumatica, jaw or tongue claudication, fever, and weight loss can also occur. The pain usually develops slowly and is described as a dull ache with occasional sharp pains. Patients may have allodynia with marked scalp tenderness. Headaches are often worse at night and are worsened by exposure to cold. The ESR is often elevated, but a normal ESR does not exclude temporal arteritis. Serum viscosity and C-reactive protein levels are often elevated and may be helpful in the diagnosis or to follow-up the effect of treatment, in those with normal ESR. Plasma interleukin-6 (IL-6) is thought to be the most sensitive marker of disease activity. After temporal artery biopsy is done, prednisone therapy should be promptly initiated at 80 mg daily for 4 to 6 weeks.

E. The Folstein MMSE is a brief examination consisting of 11 questions that evaluates an adult’s level of cognitive functioning. Introduced in 1975, it is designed to evaluate cognitive functioning in elderly patients who are able to cooperate at an optimum level with an examiner for only a brief period of time. It is used most often to evaluate older adults for delirium or dementia. The MMSE can also be used to detect a decline in cognitive function, to follow the course of the patient’s illness, and to monitor responses to treatment. It was recently approved as a measurement of the patient’s ability to complete an advance directive (living will). The test has also been used in research studies. The MMSE evaluates six areas of cognitive function: orientation, attention, immediate recall, short-term recall, language, and the ability to follow simple verbal and written commands. It also provides a total score allowing the examiner to place the patient on a scale of cognitive function. It correlates well with a standard measure of cognition in adults like the WAIS-R. The results of the MMSE should be interpreted in the context of the patient’s history, a full mental status examination, a physical examination, and laboratory findings. A score on the MMSE must be interpreted according to the patient’s age and educational level. A median score of 29 is normal for a person 18 to 24 years of age, whereas a score of 25 is normal for someone 80 years or older. The median score is 22 for persons with a fourth-grade education or less, 26 for those who completed the eighth grade, and 29 for those who completed high school or college. The MMSE should only be administered and scored by a qualified health care professional.

C. When the index of suspicion is high for subarachnoid hemorrhage, but the CT scan does not reveal any bleeding, a lumbar puncture must be performed to rule out this high mortality condition (Note: 5% of cases can have normal CT scans). The patient’s vascular risk factors (hypertension and tobacco use), as well as late stage pregnancy, increase the likelihood that subarachnoid hemorrhage is present. A CT scan is preferable to MRI when
assessing intracerebral bleeding, and the utility of emergent surgery in subarachnoid bleeds has not been well established in research trials.