A. Children with a history of in utero alcohol exposure are given a diagnosis of FAS if they have the characteristic physical appearance or neurological dysfunction, which may include all of the following:

In the general population, FAS occurs in about 1 per 3,000 live births. In alcoholic mothers the prevalence is much higher at about 2.5% to 10%. Even in the children who do not meet the full criteria for FAS, infants born to alcoholic mothers show an increased incidence of intellectual impairment, congenital anomalies, and decreased birth weight.

D. The long thoracic nerve is a motor nerve that arises from the C5–7 roots. It can be damaged due to pressure on the shoulder (sudden trauma or carrying heavy objects on the shoulder such as a backpack). Patients present with a winged scapula that is only apparent when the patient is asked to push the arm forward against resistance or hold the arms up in front of the body. Patients complain of shoulder weakness and get easily tired when they raise their arm above their head. When the suprascapular nerve is damaged or entrapped, patients may present with shoulder pain. Supraspinatus weakness causes weakness of arm abduction, whereas infraspinatus weakness causes impaired external rotation of the shoulder. Patients with dorsal scapular nerve injury are unable to press the elbow back against resistance. The thoracodorsal nerve arises from C6–8 and it produces latissimus dorsi paresis.

A. Jean Piaget, a Swiss psychologist, emphasized the ways that children think and acquire knowledge, and described four major stages leading to the capacity for adult thought: (i) sensorimotor stage (up to 2 years of age), during which individuals acquire control of their motor functions and notion of object permanence, (ii) stage of preoperational thought (2 to 7 years), where symbols and language are used, notions of imminent justice and magical thinking exist, and children are egocentric, (iii) stage of concrete operations (7 to 11 years), where egocentric thought is replaced by operational thought, syllogistic reasoning occurs, conservation and reversibility are understood, and (iv) stage of formal operations (11 years through end of adolescence), which involves acquiring deductive reasoning skills and abstract thinking with use of complex language. Psychologists like Harry Stack Sullivan and Heinz Kohut emphasized the importance of interpersonal relationships. Freud’s theories related to an individual’s psychosexual development. Erik Erickson is best known for his theories of psychosocial development. Carl Jung defined archetypes as symbolic images that recur in dreams and are part of the collective unconscious.

D. The doctrine of parens patriae (father of his country) originally referred to a monarch’s (King Edward I’s) duty to protect the people. In United States common law, the doctrine has been transformed into a paternalism in which the state acts for people who are mentally ill and for minors and allows the state to intervene. Actus rea and mens rea are components in criminal law to determine if a crime has been committed: (i) actus reus, which means voluntary conduct, and (ii) mens rea, which refers to evil intent. There cannot be mens rea when an offender’s mental status is so deficient, depriving him or her of
the capacity of rational intent, which is the basis for the insanity defense. A writ of habeas corpus occurs when involuntary hospitalized patients who believe they have been illegally deprived of liberty ask for a legal proceeding in which a court decides if he or she has been hospitalized without due process of law. Respondeat superior is a Latin phrase that means let the master answer for the deeds of the servant, which refers to a person occupying a higher position in a hierarchy of responsibility being liable for the actions of people under his or her supervision (e.g., an attending psychiatrist being responsible for the clinical work of the resident that he or she is supervising).

B. Therapeutic blood levels for lithium in the treatment of acute mania is about 0.8 to 1.5 mEq/L. Patients who have serum lithium levels in the upper range should be alert for possible early signs of lithium toxicity. Stable, steady-state lithium levels are generally obtained about 4 to 5 days after either initiating lithium or adjusting the dose. Blood samples for lithium levels are generally drawn about 12 hours after the last dose of lithium. After resolution of an acute manic episode, maintenance therapy with lithium is at levels of 0.6 to 0.9 mEq/L. During maintenance therapy, lithium levels should be drawn every 1 to 3 months but more often if clinically indicated. The lithium level can alter dramatically in patients who are pregnant or immediately postpartum in patients who are taking thiazide diuretics or are dehydrated, and in patients with deteriorating renal function. In these situations, lithium levels should be drawn more frequently.

B. The typical delirious patient will have an EEG pattern of diffuse theta or delta waves (i.e., diffuse slowing), poor organization of the background rhythm, and loss of reactivity to eye opening and closing. One exception to this pattern is the patient with delirium tremens, who will generally have a pattern of low-voltage fast activity. The pattern of 3-per-second spike and wave is typical of absence seizures, not delirium. Though the EEG is the only technological method to assist in the diagnosis of delirium, it is not necessary to make a clinical diagnosis in most cases. EEG is most useful when seizures are suspected or when the differential diagnosis is difficult. The EEG pattern in children with delirium is similar to that of adults. The degree of EEG slowing correlates with the severity of delirium.

A. The past month prevalence for inhalant use in the United States peaks at about 1.2% in 14- and 15-year-olds and declines thereafter, although prevalence of lifetime use increases with age.

E. Undetected thyroid dysfunction is found in 5% to 10% of depressed patients manifested by elevated basal TSH levels or increased TSH release in response to TRH. A larger number of patients, 20% to 30%, have a blunted TSH response when challenged by TRH. This type of response would suggest hyperthyroidism, but this is rare in depressed patients. Blunted TSH in a euthyroid person may result from downregulation at the pituitary level.

D. Many patients with multiple sclerosis suffer cognitive impairments, and difficulty with memory is the most common such impairment. Of the patients with multiple sclerosis, 40% to 60% complain of memory problems, which are thought to be associated with plaque formation in the temporal lobe and diencephalic areas. Moreover, approximately 25% of patients develop a type of euphoria that is not quite hypomanic and is often distinct from their mood before the onset of the disease; 25% to 50% develop depression associated with a higher rate of suicide; and 20% to 40% develop personality changes, which frequently include irritability and apathy. Psychosis can occur, but is considered rare.

B. Symptoms of overdose with dopamine receptor antagonists include extrapyramidal symptoms, mydriasis, tachycardia, hypotension, and diminished deep tendon reflexes. In severe cases, delirium, respiratory depression, seizures, and coma may occur. Overdose with dopamine receptor antagonists, especially haloperidol, generally has a favorable prognosis, unless complicated by ingestion of CNS depressants such as alcohol or benzodiazepines. Thioridazine and mesoridazine have the
worst prognosis owing to their cardiotoxicity in overdose.

D. Hyperprolactinemia associated with prolactinomata can result in loss of sexual desire, erectile failure, and reduced spermatogenesis in men. In women it can lead to altered ovarian cyclic function, amenorrhea, reduced sexual desire, and hirsutism. Conventional antipsychotic drugs can increase prolactin levels to a range associated with sexual dysfunction in nonpsychiatric patients, so hyperprolactinemia is a probable explanation of some of the sexual dysfunction seen during treatment with antipsychotics. Drug induced priapism results from alpha-adrenergic blockade and anticholinergic activity.

E. Tricyclics are effective antidepressants, but have a number of side effects that have caused them to fall out of favor as first-line agents. Anticholinergic side effects are common, including dry mouth, constipation, visual changes, urinary hesitancy, delirium, and an ocular crisis in patients with narrow-angle glaucoma. Tricyclic agents do not affect patients with chronic open-angle glaucoma. The central anticholinergic effects of the tricyclics can produce dose dependent delirium and seizures. A fine rapid tremor is fairly common and is also dose dependent. Tachycardia occurs with all the tricyclics, not just the more anticholinergic agents. Orthostatic hypotension is the most common reason for discontinuation, and often occurs at blood levels that are relatively low. Sexual dysfunction is a potential problem, and appears to be more frequent with clomipramine. It is often most bothersome to the patient in the second or third month of treatment, after the depression has improved.

A. SSRIs are the treatment of choice for PMDD. The diagnosis of this disorder is done by prospectively charting mood and physical symptoms over the course of the menstrual cycle. According to the DSM-IV-TR, symptoms need to be present 5 days or less prior to menstruation and resolve by day 4 of menstruation. During this time patients need to endorse five out of eleven symptoms, one of which needs to be related to mood (i.e., depressed mood, increased irritability, mood lability, anxiety, etc.). Somatic complaints only count as one of the five criteria for diagnosis, even if the person had multiple physical complaints. Other symptoms include changes in neurovegetative symptoms (i.e., changes in sleep, appetite, energy, and concentration). These symptoms should not be better accounted for by another axis I disorder.

E. The patient is unable to tolerate an unpleasant internal object (i.e., viewing herself as incompetent) and projects this object onto the psychiatrist. This projection becomes projective identification because the psychiatrist begins to feel or react in a manner consistent with the patient’s projection (i.e., the psychiatrist has identified with the internal object of the patient). There is no clear evidence that the patient is in denial of not getting the promotion or of being angry with herself. The patient may also have acting out behavior and a transference toward the psychiatrist, but these are not the most specific or key aspects of this example.

E. None of the statements are true. About 10% of pregnant women experience depressive episodes (major or minor). This rate is similar to that of nonpregnant women. Depressive episodes during pregnancy are usually associated with poor prenatal care, inadequate nutrition, a risk of postpartum depression, suicide, greater incidence of preterm deliveries, and small-for-gestational-age babies. Mild to moderate depressive episode can be treated by nonpharmacological treatment modalities such as psychotherapy and stress-reduction counseling. If patient’s with severe symptoms fail to respond to nonpharmacological treatments, it mandates a trial of pharmacotherapy. Ideally, antidepressant medications should be withheld when possible during the first trimester, when major organogenesis occurs. Whenever possible, the dosage of drugs should be kept at the minimum necessary for symptom control. The most extensive data on the prenatal use of antidepressants is for fluoxetine. Prospective studies have not found an association
between the use of fluoxetine during pregnancy and major congenital anomalies in the neonate. Studies have also evaluated the use of citalopram, sertraline, paroxetine, fluvoxamine, and venlafaxine during pregnancy and have found no link with congenital malformations. TCAs are not associated with congenital anomalies, although transient perinatal toxicity or withdrawal symptoms may be seen when they are used near the time of birth. If the decision is made to treat with a TCA, tertiary amines like nortriptyline or desipramine are preferable, given that they are less likely to cause anticholinergic and hypotensive side effects. Antidepressant dosages will need to be adjusted over the course of pregnancy as blood levels may fall, particularly after the patient begins the third trimester. There are no trial data for the use of bupropion, trazodone, venlafaxine, mirtazapine, or nefazodone in pregnancy. The MAOIs are contraindicated in pregnant women because of the risk of hypertensive crisis and interaction with tocolytic agents like terbutaline. There is no data as yet that children prenatally exposed to fluoxetine or TCAs have any difference in IQ, temperament, mood, behavior, or attention in children up to age 7 years compared to nonexposed children.

E. Atropine is a sympathomimetic causing pupils to dilate. Heroin causes the pupils to constrict. Phencyclidine, alcohol, and ecstasy do not alter the size of the pupils.

E. The basic unit of integrated reflex activity is the reflex arc. It consists of a sense organ, an afferent neuron, one or more synapses that are generally in a central integrating station, an efferent neuron, and an effector. In humans, the connection between afferent and efferent somatic neurons occurs in the brain or the spinal cord. The afferent neurons enter via the dorsal roots or cranial nerves and have their cell bodies in the dorsal root ganglia or in the homologous ganglia on the cranial nerves. The efferent fibers leave via the ventral roots or corresponding motor cranial nerves. This principle in which the dorsal rods of the spinal cord are sensory and the ventral roots are motor is known as the Bell–Magendie law. When a stimulus arises in the sensory receptor, it generates an all-or-none action potential in the afferent nerve with the number of action potentials being proportional to the size of the generator potential. All-or-none responses are also generated in the efferent nerve. When these reach the effector, they set up a graded response. The connection between the afferent and efferent neurons is usually in the CNS. The activity in the reflex arc is modified by the multiple inputs converging on the efferent neurons.

B. RLS is a common and often disabling sensorimotor disorder with a prevalence rate of about 7% to 10% of the general population in the United States and Northern Europe. The prevalence and disease severity of this disorder increases with age. The incidence in women is twice that of men and higher-than-normal prevalence (from 25% to 30%) of RLS is found in patients with iron deficiency, pregnancy, and end-stage renal disease. Neurologic conditions linked with RLS include spinal cerebellar atrophy, Charcot-Marie-Tooth disease type 2, spinal stenosis, lumbar sacral radiculopathy, and Parkinson’s disease. A strong family history of RLS is more closely correlated with an early age of onset (<45 years). RLS developing at an older age is more often associated with neuropathy and faster disease progression.

B. Developmental reflexes present at birth include the following: the rooting reflex (puckering of lips in response to perioral stimulation), palmar grasp reflex, Babinski (extensor plantar response) reflex, startle (Moro) reflex, and the tonic neck reflex. In normal children, these reflexes disappear with development. The rooting reflex usually disappears by 3 months. The palmar grasp, Moro, and tonic neck reflexes usually disappear by 4 to 6 months. The Babinski reflex usually disappears by the twelfth month.

A. TIAs are temporary interruptions in cerebral circulation. They give rise to constellations of deficits. They may occur in either the distribution of the carotid artery or of the basilar artery and typically last from 30 to 60 minutes but never more than 24 hours. TIAs can result from platelet emboli arising from extracranial arteries. They usually indicate underlying atherosclerotic cerebrovascular disease and signal an increased risk of sustaining a
stroke; after a TIA, 4% of individuals develop a stroke within a month and 12% within a year. Strokes cause permanent physical and neuropsychiatric deficits. They can result from arterial thrombosis, embolus, or hemorrhage in the cerebral blood flow. Age, hypertension, and smoking are the greatest risk factors. Other risk factors are migraine headaches, diabetes mellitus, drug abuse, cardiac disease, vasculitis, and sickle-cell disease. In terms of distribution, anterior cerebral artery strokes are characterized by contralateral lower extremity paresis, mutism, apathy, and pseudobulbar palsy (with bilateral infarctions). Middle cerebral artery strokes are associated with contralateral hemiparesis, hemisensory loss, aphasia with dominant hemisphere lesions, and hemi-inattention with nondominant hemisphere lesions. These infarctions are the most common. Posterior cerebral artery strokes are connected with contralateral homonymous hemianopsia and alexia without agraphia. Wallenberg’s syndrome results from lateral medullary infarction. It is caused by proximal vertebral artery occlusion. Clinical manifestations consist of vertigo, nausea, vomiting, dysphagia, hoarseness, nystagmus, ipsilateral Horner’s syndrome, limb ataxia, impairment of all sensory modalities over the face, and loss of light touch and position sense in the limbs. There is also impairment of pinprick and temperature sensation in the contralateral extremities from involvement of the spinothalamic tract. Horner’s syndrome results from involvement of the descending sympathetic tract. Hemiataxia stems from inclusion of the inferior cerebellar peduncle. Vertigo results from participation of the vestibular nuclei.

A. This patient has acute intermittent porphyria, which is a disease inherited as an autosomal dominant trait. The metabolic defect is in the liver, and there is increased production and urinary excretion of porphobilinogen and its precursor d-aminolevulinic acid. The urine turns dark upon standing due to formation of porphobilin, which is an oxidation product of porphobilinogen. The initial and most prominent symptom is moderate to severe colicky abdominal pain. Pain may be generalized or localized. Constipation is frequent. Radiographs show intestinal distention or ileus. Attacks last for days to weeks, and repeated vomiting may occur. Neurological symptoms are those of an acute polyneuropathy involving the motor nerves more severely than the sensory ones. Often, the weakness predominates in the proximal muscles of the limbs and limb girdle. There may also be acute confusion, delirium, psychosis, depression, and/or convulsions. These attacks are usually recurrent. They are often precipitated by drugs, which induce the enzyme d-aminolevulinic acid synthetase such as sulfonamides, griseofulvin, estrogens, barbiturates, phenytoin, and the succinimide anticonvulsants (ethosuximide and methsuximide). Other precipitants include infection, fasting, pregnancy, or occasionally menses. The first attack rarely occurs before puberty or after late adulthood. The course of the disease is variable. Severe cases can lead to fatal respiratory or cardiac paralysis. Treatment is with intravenous glucose, which suppresses the heme biosynthetic pathway and intravenous hematin.

B. The development of dementia is a poor prognostic sign with most patients dying within 6 months. The dementia may be cortical or subcortical in origin. The differential diagnoses include CNS infections, neoplasms, abnormalities caused by systemic disorders and endocrinopathies, and adverse reactions to pharmacotherapy.

B. The EEG shows nonspecific slowing in the early stages with later localization of periodic spike and slow wave activity in one or both temporal lobes. CT scan of the brain may be normal initially. Later, the characteristic low density areas in one or both temporal lobes appear. MRI is more sensitive in the early stages when therapy is likely to be useful. Increased antibody titers are rarely present prior to 10 days into the illness; they are useful retrospectively but not usually useful in establishing the diagnosis early in the course of the illness. Brain biopsy provides the best means to diagnose and establish alternative causes of encephalitis.

C. Neurosyphilis may be meningeal, meningovascular, and parenchymatous. Parenchymatous type includes both general paresis and tabes dorsalis.
The interval from infection to symptoms range from a few months to 20 years for meningeal syphilis (usually in the first year) and meningovascular syphilis (average of 7 years), 20 years for general paresis and 20 to 25 years for tabes dorsalis. Meningeal syphilis may involve the brain or spinal cord; patients present with headache, nausea, vomiting, cranial nerve palsies, and changes in mental status. Meningovascular syphilis is associated with inflammation of the pia and arachnoid mater with focal or widespread involvement of small, medium, and large arteries. The commonest presentation is a stroke syndrome in a young person involving the middle cerebral artery. General paresis presents with symptoms relating to personality, affect, reflexes, eye, speech, intellect, and sensorium. Tabes dorsalis presents symptoms and signs of demyelination of the posterior columns, dorsal roots, and dorsal root ganglia. Symptoms include wide-based gait, paraesthesias, incontinence, areflexia, loss of position, vibration, deep pain, and temperature sensations. Atypical and attenuated presentations are common these days due to the partial suppression of the infection in earlier stages by antibiotics given for other purposes. Grandiose delusions are seen in 10% to 20% of affected persons with general paresis. The pupils are abnormal in two thirds of the patients. Argyll-Robertson pupils are small, irregular pupils, which are reactive to accommodation but not to light. Optic atrophy may develop in the absence of complaints about visual impairment. The classical Argyll-Robertson pupils are seen more commonly in the combined taboparetic type than with general paresis alone.

D. There are neuropathologic similarities between Down syndrome and AD. Neuropathologically, Alzheimer-type abnormalities are seen in demented and nondemented patients with Down syndrome and more than half of the patients with Down syndrome above the age of 50 years develop AD. The ApoE epsilon4 allele, oestrogen deficiency, high levels of Aβ1–42 peptide, elevated expression of BACE2, and valine polymorphism of PrP are associated with earlier onset of dementia in patients with Down syndrome. Up to 84% of demented individuals with Down syndrome develop seizures. Late-onset epilepsy in Down syndrome is associated with AD, while early-onset epilepsy is not. In patients with Down syndrome, slowing of the dominant occipital rhythm is related to AD and the frequency of the dominant occipital activity decreases at the onset of dementia.

C. Dopamine agonists are those drugs that directly stimulate the dopamine receptors. The FDA approved dopamine agonists include bromocriptine (Parlodel), pergolide (Permax), pramipexole (Mirapex), and ropinirole (Requip). These drugs alone or combined with levodopa have been shown in studies to be effective in treating symptoms of early Parkinson’s disease. Controlled studies comparing ropinirole or pramipexole to levodopa showed that levodopa was more effective in reducing the motor symptoms of Parkinson’s disease, but the dopamine agonists had a lower incidence of motor complications. Selegiline (Eldepryl) is a MAO-B inhibitor that gives some mild symptomatic benefit to patients with early Parkinson’s disease. Data indicates that in patients with Parkinson’s disease, MAO-B inhibitors reduce disability, the incidence of motor fluctuations, and the need for levodopa without more adverse effects or increased mortality.

C. Goodness of fit and poorness of fit are terms used to describe the way in which children and parents adjust to one another. Even the most expert of parents may find it difficult to deal with some children. Difficult temperamental characteristics, unusual sensitivities, and developmental characteristics of activity and reactivity can make caregiving difficult. On the other hand, even some well behaved children may be disappointing to the caregivers because of their unconscious meaning. These problems of mutual adjustment interfere with parent-child relationship and may lead to various forms of deprivation and traumatic separation. Early recognition and intervention helps prevent such problems in reciprocity and mutual adjustment.

E. The pudendal nerve arises from the first through fourth sacral segments. It may be damaged by buttock injections, pelvic fractures, surgery, and prolonged biking. It innervates areas of the anal sphincter, penis, clitoris, and scrotum. When damaged, patients present with sensory disturbances in
the innervated areas, as well as erectile impotence and difficulty with bladder and bowel control. The sciatic nerve proper is the largest of the body and it innervates areas starting around the gluteus and then divides into two different branches at the area of the apex of the popliteal fossa. When the superior gluteal nerve is damaged, patients tilt the pelvis toward the side of the unaffected raised leg. Patients with a lesion of the inferior gluteal nerve present with weakness when asked to extend the thigh against resistance. The tibial nerve is involved in innervating muscles in the feet.

B. Jean Piaget, a Swiss psychologist, emphasized the ways that children think and acquire knowledge, and described four major stages to accomplish that lead to the capacity for adult thought, including: (i) sensorimotor, (ii) preoperational thought, (iii) concrete operations, and (iv) formal operations. The other psychologists listed were all important contributors to work on attachment theory. John Bowlby formulated the theory that normal attachment in infancy is crucial to healthy development. Harry Harlow demonstrated the emotional and behavioral effects of isolating monkeys from birth and preventing formation of attachments. Mary Ainsworth expanded on Bowlby’s work and is known for describing the “strange situation,” the research protocol for assessing the quality and security of an infant’s attachment. She observed that about 65% of infants are securely attached by the age of 24 months. Rene Spitz first described anaclitic depression after he studied the effects of emotional deprivation on normal attached infants when suddenly separated from their mothers and placed in institutions or hospitals.

B. In a malpractice lawsuit, the plaintiff must show four elements of malpractice are present by a preponderance of evidence. There are the so-called four “Ds” of malpractice: (i) a doctor-patient relationship existed that created a duty of care; (ii) a deviation from standard of practice occurred; (iii) this deviation bore a direct causal relationship to the untoward outcome; and (iv) damage occurred as a result. Proof by a preponderance of the evidence as required in a malpractice suit simply means more likely than not, or just enough evidence to tip the scale one way or the other.

B. At this time, the only indication that CMS will reimburse the cost of a PET scan of the brain in routine clinical care is the differentiation of frontotemporal dementia from Alzheimer’s dementia.

C. The patient’s symptoms and exam findings are most consistent with dementia due to vitamin B₁₂ deficiency. This is often considered a “reversible” form of dementia, as exogenous B₁₂ replacement may result in improvement in neuropsychiatric symptoms if the condition is diagnosed early enough. The presence of subacute combined degeneration of the spinal cord (involvement of both posterior columns and pyramidal tracts) is indicated by weakness, hyperreflexia, and loss of position and vibration sense in the lower extremities. Though often associated with a macrocytic anemia, vitamin B₁₂ deficiency can produce cognitive impairment in the absence of megaloblastic bone marrow changes. The pathophysiology of vitamin B₁₂ deficiency may involve increased plasma homocysteine levels; elevated homocysteine may be associated with response to treatment of B₁₂ deficiency in patients with dementia.

C. The ion gated receptors alpha 7 and alpha 4/beta 2 are thought to be involved in nicotine dependence. They quickly desensitize and increase with nicotine use. The alpha 2 receptor is involved in norepinephrine regulation and is the site of action of clonidine and guanfacine (antihypertensives), also used in psychiatric treatment.

A. Bipolar disorder is more heritable than MDD. All the other options are correct.

A. Patients displaying depressive symptoms after a stroke range from 30% to 50%. Though some strokes are associated with a lesion in the left frontal lobe, it is not necessarily the case that patients who display such symptoms must have lesions in the left frontal lobe. Such associations have been made with several other areas of the brain as well. Post-stroke depression is associated with increased age. ECT is considered safe for patients with such depression, though such patients may be more confused after receiving the treatment. Antihypertensive medications (e.g., reserpine) can induce depression as well.

C. In 2005, the FDA warned of an increased risk in cardiac defects following in utero exposure to paroxetine and thus changed paroxetine’s fetal risk classification from class C to class D. Two large unpublished studies showed a one and a half to two times increased risk of cardiac defects in newborns exposed to paroxetine in the first trimester. The most common cardiac defects included ventricular and atrial septal defects. Venlafaxine and mirtazapine have been examined in only one small study but to date has not been associated with any major malformations. The other SSRIs are classified as class C drugs in pregnancy.

C. While the risk of seizures is about 1% for the other serotonin dopamine antagonists, the risk is higher for patients treated with clozapine. This effect is dose dependent with risk approaching 4% at or above 600 mg/day dosing. The clozapine should be stopped temporarily, but can be resumed at half the previous dose after commencing anticonvulsant treatment. Carbamazepine and phenytoin should not be used in these patients due to their risk of causing agranulocytosis. People with preexisting seizure disorders and with history of head injury are at greater risk of seizures during clozapine treatment.

D. The combination of ECT and lithium can result in confusional states and prolonged seizures. These adverse effects appear to be dose related. In an acute course of ECT, lithium should be discontinued. In continuation and maintenance ECT, lithium should be held for 24 hours prior to treatment. Maintenance antihypertensive medications should be administered prior to ECT. Anticoagulant medications also should be continued. Antipsychotic medications are safe to use in combination with ECT.

B. This patient has symptoms characteristic of an atypical depression, not a melancholic type of depression. For patients with atypical depression, MAOIs are thought to have the better efficacy than TCAs. SSRIs do not have proven efficacy for this condition.

B. The psychiatrist is using confrontation, an intervention in which the subject that the patient does not want to accept or wants to avoid is presented to them. Unlike interpretation, confrontation does not necessarily pull something from the unconscious into consciousness. Confrontation introduces unspoken information or the psychiatrist’s insight into the session, unlike clarification, which involves organizing and reflecting back information that the patient has already presented. Empathic validation and affirmation are more supportive interventions than confrontation.

C. The diagnoses related to the highest frequencies of violent behaviors are schizophrenia (14.8%), depression (28.5%), and bipolar disorder (22%). An important finding in these patients is that the strongest predictor of violent behavior was having a history of such behavior. Violent acts, including murder, are about eight times more common among the patients discharged from forensic hospitals than among those discharged from general
psychiatric hospitals. Mental disorders are significantly more common among homicidal individuals than among other criminals (35% versus 21%) with mental disorder being diagnosed prior to the murder. In summary, the association between severe mental disorders and violent or homicidal behavior has been demonstrated in all types of studies. As yet, no apparent association has been found between antisocial personality disorder (which generates behavior that is more violent than that generated by psychoses) and violent behavior. Some studies indicate that psychotic individuals are more likely to murder family members or close acquaintances, whereas the murder of strangers are more frequently perpetrated by abusers of alcohol or drugs.

A. Although there are no absolute medication contraindications with ECT, concurrent use of lithium and ECT adds significant risk of post-ECT delirium. Risks associated with antiepileptic medications (i.e., valproate, carbamazepine, lamotrigine, gabapentin, and topiramate) are that they may inhibit seizure activity but do not cause post-ECT delirium. Carbamazepine may prolong the action of succinylcholine. The combination of antipsychotics and ECT as well as the combination of ECT with most antidepressants is well tolerated. Caution should be taken when combining ECT with MAOIs, especially the irreversible MAOIs, due to risk of catecholamine surge.

B. Of the following pairings, the only incorrect one is that of B fiber and postganglionic function. The B fiber is preganglionic autonomic in function. C fibers supply both postganglionic sympathetics and dorsal roots of spinal cord. In the dorsal root, they carry pain, temperature, some mechanoreception, and reflex responses. Erlanger and Gasser divided mammalian nerve fibers into A, B, and C groups, further subdividing the A group into α, β, γ, δ and fibers. The greater the diameter of a given nerve fiber, the greater its speed of conduction. The large axons are concerned primarily with proprioceptive sensation, somatic motor function, conscious touch, and pressure, while the smaller axons subserve pain and temperature sensations and autonomic function.

B. Among these disorders, Lesch Nyhan syndrome is the only one that has an X-linked recessive mode of inheritance. Acute intermittent porphyria, Huntington’s disease, and spinocerebellar ataxias all have an autosomal mode of inheritance.

B. Ataxia is incoordination or clumsiness of movements. It is not the result of muscular weakness, but can be caused by vestibular, cerebellar, or sensory disorders. The clinical manifestations of cerebellar ataxia include irregularities in the rate, rhythm, amplitude, and force of voluntary movements. Alcoholic cerebellar degeneration is a syndrome which develops in chronic alcoholics. Affected patients often have a drinking history of 10 or more years which includes complications of alcoholism such as liver disease, delirium tremens, Wernicke’s encephalopathy, and/or polyneuropathy. Alcoholic cerebellar degeneration is more common in men and has its onset between ages 40 and 60 years. The pathological finding is largely restricted to the superior vermis of the cerebellum. The disease is usually insidious in onset and is gradually progressive. Gait ataxia is a common feature. The gait is wide-based often with a staggering quality similar to drunkenness. Other commonly associated findings are distal sensory deficits in the feet and absent ankle reflexes, from polyneuropathy, and signs of malnutrition such as loss of subcutaneous tissue, generalized muscle atrophy, or glossitis. Less frequently ataxia of the arms, nystagmus, dysarthria, hypotonia, and truncal instability occurs. There is no specific treatment for this condition. Patients should receive thiamine because the syndrome is closely related to Wernicke’s encephalopathy. Abstinence along with adequate nutrition leads to stabilization in most cases. The corticospinal tracts contain motor axons that originate in the cerebral cortex that pass through the internal capsule, the brainstem, and then cross over at the level of the medulla (lateral corticospinal tracts) and terminate by synapsing with the anterior horn cells of the spinal cord. The corticobulbar tract is an upper motor neuron (UMN) tract that innervates the brainstem motor nuclei and their nerves supplying the head and neck muscles. It is the cranial counterpart to the corticospinal tract. Bilateral cerebral hemisphere damage to the corticobulbar tract produces several disturbances including pseudobulbar palsy. This condition is characterized by emotional lability, dementia, and aphasia. Injury of the nondominant parietal lobe typically results in hemi-inattention. This is a constellation of disorders in which patients
neglect left-sided visual and tactile stimuli. The subthalamic nucleus is part of the basal ganglia which also includes the globus pallidus, the putamen, and the substantia nigra. The basal ganglia controls muscle tone, regulates motor activity, and generates the postural reflexes. The main feature of basal ganglia injury is often an involuntary movement disorder. Hemiballismus results from small infarctions of the contralateral subthalamic nucleus. It is associated with intermittent flinging of the arm and leg on one side of the body.

C. Aphasia is a loss or impairment of the ability to produce or comprehend language due to an acquired lesion of the brain. It can be divided into two classes: fluent and nonfluent. There are three types of nonfluent aphasias: Broca’s aphasia, transcortical motor aphasia, and global aphasia. Fluent aphasias include Wernicke’s aphasia, conduction aphasia, and transcortical sensory aphasia. In terms of the nonfluent aphasias, Broca’s aphasia is characterized by effortful but agrammatical speech. Comprehension is preserved, though repetition of language is impaired. Broca’s is often associated with right arm and face weakness. It is localized to the frontal lobe. Global aphasia is another nonfluent aphasia where speech output is scant, comprehension is very impaired, and there is no repetition and there is often associated hemiplegia. This syndrome is due to destruction of the language zone, including both Broca’s and Wernicke’s areas and much of the territory between them. Lastly, transcortical motor aphasia is characterized by nonfluent speech, good comprehension, and intact repetition. The lesions are localized to either the anterior or superior to Broca’s area. In terms of the fluent aphasias, in Wernicke’s aphasia, speech is voluble and well articulated but lacking in meaning. Comprehension is greatly impaired and there is no repetition of words. It may be associated with hemi- or quadrantanopia, and there are usually no signs of paresis. The lesion is localized to the posterior temporal lobe. Conduction aphasia is another fluent aphasia where the patients are able to comprehend language, but unable to repeat phrases. There are no other associated signs. Localization is to the arcuate fasciculus. Finally, with transcortical sensory aphasia, patients have impaired comprehension similar to Wernicke’s aphasia. Unlike Wernicke’s aphasia, they are able to repeat phrases. The lesion is localized to the region surrounding Wernicke’s area in the brain.

D. This patient has chronic paroxysmal hemicrania, a unilateral form of headache which resembles cluster headaches but with some distinctive features. These headaches are of short duration; they last from 2 to 45 minutes, usually affect the temporo-orbital region of the head, and are accompanied by tearing, conjunctival injection, rhinorrhea, and occasionally a partial Horner’s syndrome. Unlike cluster headaches, attacks occur several times each day and recur daily over long periods of time. These headaches are more common in women than men by a ratio of 3:1; whereas cluster headaches occur predominantly in young men by a ratio of 5:1. Chronic paroxysmal hemicrania has a dramatic treatment response to indomethacin. Tension headaches are characterized by pressure, tightness, and aching. Their distribution is bilateral with occipitonuchal, temporal, or frontal predominance or diffuse extension over the top of the cranium. They occur mainly in adults and are more common in women. They occur with variable intensity and are provoked by fatigue or nervous strain. Tension headaches are associated with depression and anxiety, and can be treated with antianxiety and antidepressant drugs. Migraine without aura is also known as common migraine. These migraines are characterized by pulsatile, throbbing pain which is often worse behind one eye or ear. The headaches then become dull and generalized. Scalp sensitivity occurs, along with occasional nausea and vomiting. Common migraines occur in a frontotemporal, either unilateral or bilateral, distribution and are more common in women. They are seen in adolescents and young to middle-aged adults and last from 4 to 24 hours and occur either upon awakening or later in the day. Common migraines decrease in frequency during pregnancy and in middle age. Provoking factors include bright light, noise, tension, and alcohol. Headaches are relieved by darkness and sleep. Treatment includes ergotamine, sumatriptan, and/or NSAIDs. Propranolol and amitriptyline have been used for prevention. Tolosa-Hunt syndrome involves unilateral, mainly retro-orbital facial pain. The pain is intense, sharp, or aching. Ptosis and miosis are also observed. The syndrome is associated with granulomatous lesion of the cavernous sinus or
superior orbital fissure. It is treated with corticosteroids.

D. This patient appears manic. There are important confidentiality issues to consider when treating this patient so it is prudent to discuss his case with hospital attoneys. From the informant account, this patient may be putting others at risk of becoming infected and due to his lack of insight, has to be admitted involuntarily to prevent danger to others. He may be delirious and a full medical workup would be helpful in determining the onset of a new CNS related process. In the absence of any identifiable cause for his presentation, it is likely that he has progressed into the late stages of the disease. Manic symptoms most commonly arise in later stages of the disease complicated by neurocognitive impairment. As he is manic, the antidepressant would need to be discontinued. When antipsychotic medications are to be prescribed, they should be done so at lower doses as these patients are at higher risk of extrapyramidal side effects from these medications.

A. The commonest organisms implicated (in over 50% of cases) of cerebral abscess, are streptococci. Staphylococci are implicated in traumatic brain injury and neurosurgery. Brain abscesses occur in association with contiguous foci of infection (e.g., otitis or hematogenous) spread from distant sites (e.g., lung infections or from trauma). Hematogenous brain abscesses are likely to be multiple and are associated with higher mortality. Brain abscess occurs in the following regions of the brain in decreasing order of frequency: frontal > frontoparietal > parietal > cerebellar > occipital. Brainstem, basal ganglia, and thalamic abscesses are rare. MRI is more sensitive than CT scans in detecting early satellite lesions and extraparenchymal extension of an abscess, and is not hindered by bony artifacts whilst permitting mutiplanar imaging. Mortality rate is about 10%. Long term neurological sequelae occur in 30% to 50% of cases with up to 70% of survivors developing late seizures.

B. Nonsmall-cell lung cancer is the most common primary lesion leading to a brain metastasis. Melanoma and small-cell lung cancer also have a great propensity to metastasize to the brain. Other primary cancers that commonly metastasize to the brain include breast, renal, and gastrointestinal (GI) cancers. Cancers of the prostate, pancreas, and uterus rarely metastasize to the brain. About 50% of all patients with brain metastases have a single lesions with an additional 20% having only two lesions.

E. All of the statements are true. Patients with Down syndrome start developing AD earlier than the general population. The incidence of AD in patients with Down syndrome is 75% by the age of 60 years compared with less than 5% in the general population. By the age of 40 years, 100% of these patients show AD pathology in their brains. Visual memory loss and impaired learning capacity are the first symptoms of cognitive dysfunction in these patients. MRI findings in these patients include cerebellar atrophy, basal ganglia calcification, and hippocampal atrophy.

D. Entacapone (Comtan) and tolcapone (Tasmar) are COMT inhibitors that decrease the degradation of levodopa and extend its half-life. By doing so, they reduce the end-of-dose wearing-off effect and thereby reducing the “off” time. Compared to placebo, adjuvant COMT inhibitors treatment reduces the “off” time with levodopa dose and modestly improves the motor symptoms and disability in patients with advanced Parkinson’s disease and motor complications. Tolcapone use requires close monitoring of liver function tests as they can rarely cause potentially fatal hepatotoxicity. A combination of carbidopa/levodopa/entacapone (Stalevo) is currently available in the market.

D. Lead poisoning is the most common preventable pediatric health problem in the United States today. Lead is either eaten or breathed, in the form of dust. It accumulates in soft tissues and bones, where it can be stored for many years. It is currently estimated that more than 3 million children 6 years of age and younger have lead poisoning. Lead poisoning has no obvious signs, and most children do
not report any abnormal symptoms. However, they may present with stomach aches, decreased appetite, hyperactivity, sleep problems, or irritability. Symptoms may mimic flu or common cold. In children elevated lead levels can cause learning disabilities, mental retardation, behavioral problems, lowered IQ, stunted growth, and hearing impairment. In serious cases, seizures, followed by coma and death can occur. Diagnosis of lead poisoning can be made by checking the blood level of lead. A level of 10 mcg/dL or greater is considered unsafe and all children between the ages of 6 months to 6 years of age who are entering day care, preschool, or kindergarten must be assessed for lead poisoning. Chelating drugs like ethylenediaminetetraacetic acid (EDTA) are used to treat children with very high blood lead levels. In cases of severe poisoning, repeated treatment with these drugs may be needed. Lead poisoning can be prevented by taking simple precautions around the house to remove or avoid lead contamination.

A. Lateral medullary syndrome (Wallenberg syndrome) is usually secondary to intracranial vertebral artery or posterior inferior cerebellar artery occlusion. Signs and symptoms arise from damage to an area of the lateral medulla and inferior cerebellum. The clinical picture varies widely and can include many different signs and symptoms, but the characteristic picture includes the following: (i) diminished ipsilateral facial pain and temperature perception, (ii) diminished contralateral trunk and extremity pain and temperature perception, ipsilateral palatal, pharyngeal, and vocal cord paralysis, and (iii) ipsilateral Horner syndrome, vertigo, and nausea and ipsilateral cerebellar signs and symptoms. Motor function, vibration and proprioception are spared. Medial medullary syndrome presents with ipsilateral paresis atrophy and fibrillation of the tongue, contralateral hemiplegia, and loss of position and vibratory sensation. Submedullary syndrome consists of signs and symptoms of Wallenberg syndrome in addition to ipsilateral hemiplegia. Lateral pontomedullary syndrome presents with ipsilateral facial weakness, tinnitus, and sometimes hearing disturbances. Millard-Gubler syndrome is caused by a unilateral lesion of the ventrocaudal pons and it presents with contralateral hemiplegia and ipsilateral lateral cranial nerves VI (CN VI) and VII (CN VII) paresis.

B. Donald Winnicott, a British psychologist, was one of the central figures in the school of object relations theory instead of emphasizing instincts, and discussed the role of a transitional object. This is an object that a young child becomes attached to, provides a bridge between the child’s inner and other worlds, and serves as a substitute for the mother during the infants’ efforts to separate and become independent. Winnicott viewed the transitional object as an influence on the development of play, creativity, religion, and cultural life in general. Carl Jung was behind the term archetype, which he defined as symbolic images that recur in dreams and are part of the collective unconscious.

C. Bias is a systematic error in a study that leads to distortion of the results. Selection bias can occur when the selection process affects the type of patient that enrolls. In this study, the selection bias would be represented by patients with stressful events and depression being less likely to volunteer. Misclassification (or information) bias can occur when there is random or systematic inaccuracy in measurement. This bias comes in two types: differential (misclassification of one variable is dependent on the other variable) or nondifferential (misclassification is independent). This question is an example of differential misclassification bias, in which subjects are more likely to answer affirmatively about risk in an effort to explain their serious disease. Confounding is the mixing of the effect of an extraneous variable with the effects of the exposure and disease of interest such as if patients with a family history of depression being more likely to experience both stressful life events and depression. Confounding occurs when the effects of multiple factors on an event cannot be separated. Random error represents the
variability seen during sampling a particular population.

A. The Wisconsin Card Sort is a neuropsychological test commonly used to evaluate executive function. Others include the Stroop Test, Flanker Test, and the Tower Test. The MMSE does not thoroughly assess executive function, so additional ones are often performed in conjunction such as the Executive interview (EXIT) and Clock Drawing Test. Executive functions include planning, organizing, sequencing, problem solving, set-shifting, abstract thinking, judgement, and grasping similarities. Executive function is generally based in the frontal lobes of the cerebral cortex (although injury to other brain regions can produce similar impairments due to functional connections). The Rorschach is a projective test. The Vineland scale is used to evaluate functional ability of impaired (i.e., mentally retarded) individuals.

A. The patient’s symptoms are most consistent with cyclothymia. The lifetime prevalence of cyclothymic disorder is estimated to be about 1%. Patients with cyclothymic disorder may constitute 3% to 5% of all psychiatric outpatients, with a female to male ratio of 3:2. The DSM-IV-TR criteria for cyclothymia include at least 2 years of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet the criteria for MDEs. This is an important distinguishing factor between cyclothymia and bipolar disorder type II, which includes hypomanic episodes alternating with MDEs. For the diagnosis of cyclothymia to be made, there can be no episodes of mania or major depression in the 2-year period of mood disturbance. The patient’s absence of psychiatric hospitalization and psychosis is important, as these symptoms, if occurring during a period of euphoric or irritable mood, would be more consistent with mania versus hypomania. Like dysthymic disorder, cyclothymic disorder frequently coexists with borderline personality disorder. Treatment of cyclothymia includes mood stabilizers and antimanic drugs as well as psychotherapy aimed at education to raise symptom awareness and increase coping skills.

E. Insomnia not hypersomnolence is common in opioid withdrawal. Piloerection, nausea, vomiting, lacrimation, muscle aches, and yawning are also common in withdrawal from opioid drugs.

E. Bipolar disorder is a recurrent disorder. An earlier onset increases the risk of recurrence. The time between episodes tends to decrease as the individual ages.

B. The patient has pellagra, a disorder caused by niacin deficiency. It is associated with vegetarian diets, alcoholism, and extreme malnutrition, and the main results are commonly dermatitis, diarrhea, dementia, delirium, and death (the “five Ds”). The rashes are typically in a bilateral distribution in exposed areas, and patients often have peripheral neuropathies. Thiamine deficiency, vitamin B₁₂ deficiency, mercury poisoning, and manganese poisoning can all cause neuropsychiatric symptoms of different constellations, some of which overlap with niacin deficiency. However, the rashes, the vegetarian diet, and diarrhea point to niacin deficiency. Mercury poisoning (associated with working in the lead industry and eating certain fish and grain) is classically associated with the Mad Hatter syndrome (depression, irritability, and psychosis) as well as, among other medical problems, visual field defects. A vitamin B₁₂ deficiency arises from deficiency in intrinsic factor, which transports B₁₂, and, is therefore, necessary for absorption. This condition is classically associated with peripheral neuropathies, as well as dementia and other neuropsychiatric symptoms. Patients develop megaloblastic anemia, which can be seen on peripheral smear. Thiamine deficiency is associated with alcoholism and is classically associated with Wernicke-Korsakoff syndrome, as well as beriberi. Manganese poisoning in its early stages leads to “manganese madness,” which includes joint pains, headaches, somnolence, and irritability.
It eventually leads to neuropsychiatric symptoms, among which the most prominent is the distinctive symptom of pathological laughter.

E. A registry study of 119,547 births showed higher rates of respiratory distress and birth weight below the 10th percentile in SSRI exposed fetuses compared to nonexposed fetuses. In a case-control study, SSRI exposure during the second trimester was associated with persistent pulmonary hypertension (6 to 12 in 1,000 births) compared to nonexposure (1 to 2 per 1,000 births). Lastly, in a study of 120 term infants, 30% of the 60 infants with prolonged exposure to SSRIs (versus 0% of nonexposed infants) developed neonatal abstinence syndrome.

D. Pimozide has a half-life ranging between 29 to 150 hours. This may be of clinical importance in the treatment of patients who are irregularly compliant with their treatment.

B. Among the listed drugs, temazepam is the only one that is not metabolized by the hepatic microsomal enzyme system (3A4 isoenzyme family). The other benzodiazepines that are not metabolized by his system include lorazepam and oxazepam.