D. Impotence, retarded and premature ejaculation, and hypoactive sexual desire are all sexual disorders. Needing more time and more direct stimulation to achieve an erection is common in an aging man.

C. The prefrontal cortex of patients with Schizophrenia is thinner when compared to normal subjects. This thinning is thought to be mainly due to loss of neuropil; the area between neuronal and glial cell bodies. The absence of gliosis in brains of subjects with Schizophrenia most likely points to the absence of an inflammatory process in the pathogenesis of this illness. The hippocampus is smaller in size and functionally abnormal in patients with Schizophrenia. Studies of the thalamus have revealed controversial data. Some authors have found a reduced number of neurons in the medial dorsal nucleus of the thalamus, whereas others have found no differences.

E. Ethologist Konrad Lorenz is well known for his study of aggression. He wrote about the practical function of aggression and showed that although aggression among members of the same species is common, it seldom leads to killing or serious injury under normal conditions. Rather, a certain balance appears between tendencies to fight and flight, with the tendency to fight being strongest in the center of the territory and the tendency to flight strongest at a distance from the center. The learned helplessness model of depression was developed by Martin Seligman, where he observed that dogs exposed to electric shocks from which they could not escape eventually gave up and made no more attempts to escape, and this behavior generalized to other situations. Ethologist Nikolaas Tinbergen described displacement activities as those that occur when a conflict arises and the need for fight and for flight are of roughly equal strength, so the animal engages in behavior that appears to be irrelevant to the situation.

A. Incidence of Social Phobia is estimated at 4:1 ratio for female:male. Most other anxiety disorders (with the exception of OCD) have a female:male ratio close to that of Major Depression, which is 2:1. Schizophrenia and Bipolar Disorders have roughly equal female:male ratios overall for lifetime. For most substance abuse disorders (the main exception being cocaine and stimulant abuse), including alcoholism, the male:female ratio approaches 2:1. Although not listed, gender differences are greatest for eating disorders, with female:male ratios ≥10:1.

D. PET scans show that OCD is associated with increased glucose metabolism in the orbitofrontal cortex (a.k.a., anterior cingulate cortex), caudate, thalamus, and putamen. This overactivity trends back toward normal with response to treatment. The brainstem (midbrain) is not thought to be significantly involved in OCD.

C. In Malingering, the motivation for symptom production is an external incentive, whereas in Factitious Disorder there are no external incentives. In Factitious Disorder, there is evidence of an intrapsychic conflict and the need to maintain the sick role. In Conversion Disorder, there is no intentional production of symptoms and no obvious external incentives associated with it. In Malingering, in contrast to Conversion Disorder, there is usually no symptom relief from suggestion or hypnosis.

E. This patient does not show any signs of a pathologic bereavement, and a diagnosis of MDD is generally not given unless symptom criteria for depression are still present after 2 months. In acute bereavement, up to 50% of grieving spouses have reported hearing a recently deceased loved one’s voice or feeling the presence of the deceased. The patient does not show evidence of a primary psychosis requiring treatment with an antipsychotic, and her current condition does not warrant hospitalization or head imaging at this time as she does not show any suicidality, homicidality, or psychotic symptoms. The patient scored within normal range for her age on MMSE, does not give evidence of a dementing illness with complaints of memory loss, and does not need medication for dementia at this time.

B. Postpsychotic Depressive Disorder of schizophrenia requires depressive symptoms, including depressed mood, that occur only during the residual phase of Schizophrenia. It is estimated that approximately 25% of patients with Schizophrenia develop the disorder. Although the depressive symptoms can be hard to distinguish from negative symptoms, the symptoms are not identical and refer to two distinct diagnostic entities. Antidepressants have been used as treatment and several studies have found a positive effect. There is a significant correlation between Postpsychotic Depressive Disorder and extrapyramidal symptoms secondary to antipsychotic medications.

C. Residual Schizophrenia is diagnosed via DSM-IV-TR criteria in patients who once met full criteria for Schizophrenia and no longer have prominent psychotic symptoms, but still have some evidence of ongoing illness, often in an attenuated form. They may have ongoing negative symptoms, as in this case, or also attenuated positive symptoms. The Paranoid subtype presents with prominent delusions or hallucinations, often with preserved cognition. The Disorganized subtype presents with prominent disorganization of speech or behavior, inappropriate affect, with severe social impairment, and poor long-term functioning, and was once termed hebephrenia. Catatonic Schizophrenia presents with at least two catatonic symptoms, a prominent psychomotor disturbance, with early onset, and poor prognosis. The Undifferentiated subtype is the most commonly diagnosed subtype of schizophrenia, where criteria are met for the active phase but do not fully meet criteria for any of the other subtypes of the illness.

D. Wilfred Bion worked to elucidate group dynamics at the Tavistock Institute in London, and described two main subgroups: the work group and the basic assumption group. The work group is involved in performing the actual task assigned to the group. The basic assumption group is divided into three categories: dependency, fight or flight, and pairing. These basic assumptions pertain to the unconscious fantasies of the group members and they interfere with the accomplishment of the work group’s task. The group members’ behavior reveals which basic assumption predominates. In this vignette, the group members are focusing on one pair whose love is hoped will rescue/save the group; behavior that is a defense against negative emotions (hate and hostility) within the group. Bion came from the school of Kleinian object relations, and he also developed the concept of the psychiatrist as the container for the patient in therapy.

E. Several factors have been shown to negatively affect successful nonspecialized short-term alcohol rehabilitation. These include unstable living environment (homelessness), additional substance related disorders, serial treatment failures, and the presence of concomitant serious mental illnesses. The presence of any of these factors is a red flag for possible poor outcome and an
indication for referral to specialized long-term treatment program.

C. Unlike the straightforward presentation of uncomplicated characterological dependency, individuals with Passive-Aggressive subtype of Dependent Personality Disorder resent being tied to another, yet cannot separate psychologically. Their dependency has a hostile edge and manifests itself via a tendency to punish others indirectly. Normal aggression is expressed obliquely in an effort to vent negative affect without threatening attachment. Dependent Passive-Aggressive individuals define themselves by reference to others, but with a negative valence (e.g., “I am the husband of that bitch”). Like paranoid patients, they attack to preempt expected attack by others, but they do so indirectly. Like masochistic patients, they expect mistreatment, but they fight back, albeit insidiously. They have core narcissistic concerns, but are more interpersonally engaged than characterologically narcissistic people. Because they locate themselves in opposition to others’ agendas, it is hard for them to conceive of and to pursue their own goals. The Passive-Aggressive subtype of Dependent Personality disorder’s pathogenic belief about self is that “The only route to dignity is to sabotage the achievements of others.” In contrast, sadistic personality disorder’s pathogenic belief about self is that “I am entitled to hurt and humiliate others.”

B. Evaluation of behavioral and relaxation interventions for chronic pain in adults found the following: (i) relaxation, (ii) hypnosis, (iii) CBT, (iv) BF, and (v) multimodal treatment were all helpful in pain reduction. The evidence is strong for the effectiveness of the relaxation class of techniques in reducing chronic pain in a variety of medical conditions. The evidence supporting the effectiveness of hypnosis in alleviating chronic pain associated with cancer seems strong. In addition, data suggests that it is effective in other chronic pain conditions, which include irritable bowel syndrome, oral mucositis, temporomandibular disorders, and tension headaches. The evidence is moderate for the usefulness of CBT in chronic pain. CBT has been found to be superior to placebo and to routine care for alleviating low back pain and both rheumatoid arthritis and osteoarthritis-associated pain, but inferior to hypnosis for oral mucositis and to electromyography (EMG) BF for tension headache. The evidence is moderate for the effectiveness of BF in relieving many types of chronic pain. Data shows that EMG BF to be more effective than psychological placebo for tension headache but equivalent in results to relaxation. For migraine headache, BF is better than relaxation therapy and better than no treatment, but superiority to psychological placebo is less clear. Several meta-analyses have examined the effectiveness of multimodal treatments in clinical settings. Although relatively good evidence exists for the efficacy of several behavioral and relaxation interventions in the treatment of chronic pain, the data are insufficient to conclude that one technique is usually more effective than another for a given condition. For any given individual patient, however, one approach may be more appropriate than another.

B. Venlafaxine is an SNRI. It works by blocking the serotonin (5-hydroxytryptamine) and norepinephrine (noradrenaline) reuptake. Venlafaxine is well absorbed with at least 92% of an oral dose being absorbed into systemic circulation. It is extensively metabolized in the liver via the CYP2D6 isoenzyme to O-desmethylvenlafaxine, which is just as potent an SNRI as the parent compound. This means that the differences in metabolism between extensive and poor metabolizers are not clinically important. Steady-state concentrations of venlafaxine and its metabolite are attained in the blood within 3 days and therapeutic effects are usually achieved within 3 to 4 weeks. The half-life of venlafaxine is about 5 hours for venlafaxine and 10 hours for its active metabolite O-desmethylvenlafaxine. It can produce withdrawal symptoms even with missing a single dose.

Venlafaxine is not recommended in patients hypersensitive to venlafaxine. It should never be used in conjunction with an MAOI, due to the potential to develop serotonin syndrome. Caution should also be used in those with a seizure disorder as it has a seizure risk of about 0.3%. The clearance of venlafaxine is reduced in patients with hepatic and renal disease, and hence the dosage should be reduced by 50% in these patients. Venlafaxine should only
be used during pregnancy if clearly needed. It is contraindicated in breast-feeding.

D. Bipolar disorders are prevalent, disabling illnesses with elevated lethality largely due to completed suicide. Suicide rates average approximately 1% annually, sixty times higher than the international population rate of 0.015% annually. Suicidal acts typically occur early in the illness and usually associated with severe depressive or mixed states. The high lethality of suicidal acts in Bipolar Disorders is suggested by a much lower ratio of attempts:suicide (approximately 3:1) than in the general population (approximately 30:1).

D. Taste sensation is provided by two different cranial nerves. The facial nerve (CN VII) provides sensation in the two anterior thirds of the tongue, whereas the glossopharyngeal nerve (CN IX) is responsible for taste sensation in the posterior third of the tongue. Cranial nerves IV, V, and VI are not involved in taste sensation.

E. The patient’s symptoms cannot be explained by a single lesion, and a blatant psychogenic gait impairment occurs when patients drag a “weak” leg. In contrast, patients with a true hemiparetic gait end up swinging their leg outward with a circular motion. If she had a left cerebral lesion causing a right hemiparesis, then the patient’s visual deficit should be a right homonymous hemianopia, and there should be the usual accompanying symptom of aphasia. There are no physical exam findings to indicate any cranial nerve deficits that would make one suspect a lesion in the brainstem, and a cerebellar lesion would be associated with ipsilateral limb ataxia. The patient’s symptoms cannot be confirmed by objective signs, and her gait is suggestive of an absence of a true neurologic disease.

E. The Lambert-Eaton syndrome is an autoimmune disorder where antibodies directed against voltage-gated calcium channels develop in the peripheral nerve terminals. It usually occurs in adults, and is seen in about 60% of patients with small cell carcinoma of the lung. In these patients, the neurologic symptoms mostly precede those of the tumor by almost 5 years in some cases. About 33% of cases of Lambert-Eaton syndrome are not associated with any tumors. These patients tend to have the HLA-B8, DR-3 haplotype. The diagnosis is made based on the clinical manifestations and is confirmed by the characteristic incremental response to repetitive nerve stimulation which is the opposite of the pattern in myasthenia gravis.

C. This patient is most likely experiencing carpopedal spasm and EEG slowing from hyperventilation. Having the patient hyperventilate will most certainly recreate her symptoms, a useful bedside diagnostic test. Prolonged hyperventilation could result in altered consciousness which is quickly aborted by breathing into a bag. All the other techniques mentioned are not useful in recreating a popedal spasm.

A. Tyrosine hydroxylase converts the amino acid tyrosine into DOPA, and is the rate-limiting step in the production of both dopamine and norepinephrine. DOPA is converted into dopamine by the action of DOPA decarboxylase (a.k.a., L-aromatic amino acid decarboxylase). DβH converts dopamine to norepinephrine, but is not the rate-limiting step. COMT degrades intrasynaptic norepinephrine after it is formed. NET removes norepinephrine to intracellular monoamine oxidases (MOAs) for degradation, not formation, and is the primary means of norepinephrine removal. Neither COMT nor NET is active in production or synthesis of norepinephrine.

A. The patient described has an essential tremor, which is one of the most common movement disorders. This postural tremor may have its onset anywhere between the second and sixth decades of life, and its prevalence increases with age. The positive family history and improvement with alcohol are typical features of essential tremor. Parkinson’s disease typically has a characteristic resting tremor that appears like a “pill-rolling” motion and begins asymmetrically. The patient is young and does not present with other common signs of Parkinson’s
disease: rigidity, bradykinesia, and postural instability. The patient’s history is not consistent with MS, which is a demyelinating illness. Huntington’s disease is characterized by a choreiform movement disorder and a myriad of psychiatric manifestations, which this patient does not present with at this time. He is not presenting with symptoms of Wilson’s disease (hepatolenticular degeneration), which is characterized by a Parkinson-like tremor and ataxia, or a characteristic wing-beating tremor where patients move their arms as if they were attempting to fly. It is an autosomal recessive genetic illness that is characterized by the development of dementia with involuntary movements from copper deposits in the brain and other organs, and symptoms tend to manifest by adolescence.

B. Atrophy of arms is present in both conditions, thus would not be a clinical feature useful in making a diagnosis between CSM and ALS. However, tongue fasciculations, atrophy of legs, and denervation are all present in ALS, but are absent in CSM. Likewise, sensory loss is present with CSM, but is absent in ALS.

C. The American Academy of Neurology (AAN) practice parameter on immunotherapy for GBS states that plasma exchange or IVIG hastens the recovery from GBS. The beneficial effects of plasma exchange and IVIG are equivalent and that combining the two treatments has not been found to be beneficial. They also state that treatment with steroids alone is not beneficial in these patients. The AAN recommends plasma exchange for nonambulatory adult patients with GBS who start treatment within 4 weeks of the onset of neurologic symptoms. Plasma exchange is also recommended for ambulatory patients who start treatment within 2 weeks of the onset of neurologic symptoms. IVIG is recommended for non-ambulatory adult patients with GBS who start treatment within 2 or possibly 4 weeks of the onset of neurologic symptoms.

C. The essential features of CJD are neuronal degeneration, astrocytic proliferation, and status spongiosus of the cortical grey matter. The cortex is almost always involved with relative sparing of the parietal and occipital lobes. The corticospinal and extrapyramidal pathways are often severely affected. Whilst being characteristic of CJD, status spongiosus is not entirely pathognomonic of this disorder, as it is sometimes seen in other degenerative conditions such as Alzheimer’s disease and Wilson’s disease. There are no neurofibrillary tangles as seen in Alzheimer’s disease or massive circumscribed atrophy as in frontotemporal dementias such as Pick’s disease. There is no evidence of an inflammatory reaction.

E. Akathisia is an extremely unpleasant subjective sensation of “inner” restlessness that manifests itself as an inability to sit still or remain motionless. It ranges from mild to a total inability to sit still with overwhelming anxiety and severe dysphoria. In severe cases, the dysphoria can be so severe that patients may attempt suicide. It may often be misdiagnosed as an anxiety disorder. It can be measured by using the Barnes Akathisia Scale. Akathisia is most often seen as a side effect of antipsychotic drug therapy, either as acute akathisia or tardive akathisia. It may also be seen in encephalopathies, in some dementias, and in Parkinson’s disease. Paroxetine, tricyclics antidepressants, trazodone, promethazine, diphenhydramine, metoclopramide, and prochlorperazine may also cause akathisia. Drugs of abuse like gammahydroxybutyrate (GHB) and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) may cause akathisia in overdoses. Treatment includes the reduction or discontinuation of the offending agent. Propranolol is often considered as the drug of choice for the treatment of akathisia. Cyproheptadine or benztropine may be second-line agents for the treatment of this condition.

A. Blindness occurs in about 50% of the patients with temporal arteritis, if left untreated. In patients with visual symptoms, treatment should be initiated with intravenous formulations such as methylprednisolone (Medrol). Treatment should not
be delayed while awaiting temporal artery biopsy. Corticosteroid therapy has no effect on biopsy results for up to 4 weeks after initiation of treatment. Hence, prompt treatment should be initiated on suspicion of this condition. Patients may also develop thrombosis of any peridural artery or an aortic aneurysm with rupture if left untreated. The ESR is often elevated in these patients, but a normal ESR does not 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. Treatment with methotrexate is not routinely recommended, as studies using methotrexate in temporal arteritis are still inconclusive.

E. Suicide risk increases with age for both sexes, but the rates in older men are generally higher than in those for women. In the United States, men commit suicide four times more often than women, but women attempt suicide three 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 compared to cutting or overdoses). In the United States, women in middle ages are at highest risk of suicide than at any other time in their lives. Suicide attempts are also more common in women with borderline personality disorder, those with a history of domestic violence, and a history of physical and/or sexual abuse. 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 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.

A. Tau-protein normally binds to microtubules and stabilizes the neuronal skeleton, axonal flow, and cell circuitry. In Alzheimer’s disease, tau-proteins become hyperphosphorylated and this weakens its affinity for the microtubules. Neurofibrillary tangles are filaments found in axonal processes throughout the neuropil in brains of patients with Alzheimer’s disease.

Amyloid plaques are universally immunoreactive to anti-Aβ antibodies because the Aβ peptide is the most common protein in these lesions. Neuritic plaques are associated with a glial response, which is thought to produce a chronic state of proinflammatory activation. Hirano bodies are eosinophilic inclusions found most commonly in the hippocampus. They are thought to represent degeneration of the neuronal cytoskeleton.

C. Delusions are disturbances in content of thought that are fixed, false beliefs out of keeping with the patients’ cultural background. In this well related patient, belief in spirits is a part of the patient’s cultural background and is supported by her family. The patient does not show any other signs concerning for psychiatric illness and is functioning optimally in academic and social settings. She does not require in-patient hospitalization, nor does her cultural belief require an antipsychotic prescription that would be helpful in patients with frank delusions. There is no indication that the patient is being neglected or abused by her parents; situations that would warrant separation and referral to foster care. It would be inappropriate to recommend family counseling for a cultural belief that is not a delusional disorder and would not be sensitive to cross-cultural beliefs.

E. As our knowledge of the effects of most psychotropic medications on the developing fetuses is limited, nonpharmacologic treatments (e.g., psychotherapy, support groups, lifestyle modification, etc.) should be the preferred choice whenever possible. Higher potency antipsychotics are believed to confer lower risk of congenital malformation than low potency antipsychotics. Also, extrapyramidal symptoms and anticholinergic agents are associated with increased risk of congenital anomalies. First trimester lithium use has been
associated with increased risk of congenital malformations, notably cardiac anomalies (Ebstein’s anomaly). Valproic acid and carbamazepine are associated with increased incidence of fetal neural tube defects due to their anti-folate effect. Of note, bipolar women not treated with mood stabilizers during pregnancy are at increased risk for postpartum decompensation. Antidepressants should also be approached with the risk:benefit ratio in mind. Fluoxetine and TCA have been studied and were found to have increased risk for transient perinatal symptoms in newborns. Studies suggest that antidepressants are not associated with an increased risk of major malformations, but most studies are limited or small, and none are definitive. Many antidepressants have not been adequately studied during pregnancy, and MAOIs increase the risk of hypertensive crisis. Although some consider the judicious use of benzodiazepines during pregnancy safe, it is controversial, and some studies show an association with cleft palate (especially for alprazolam and diazepam). Newborns may also be at risk for intoxication or withdrawal.

D. Aluminum is the offending agent in dialysis dementia, being a contaminant of dialysis fluid or a component of phosphate-binding compounds.

C. The DSM-IV-TR specifies diagnostic criteria for caffeine intoxication, including the recent consumption of an amount of caffeine usually in excess of 250 mg. Clinical signs and symptoms associated with caffeine intoxication include restlessness, nervousness, excitement, insomnia, flushing, diuresis, gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, tachycardia, periods of inexhaustibility, and psychomotor agitation. Consumption of more than 1 g of caffeine is likely to additionally cause confusion, cardiac arrhythmias, tinnitus, and visual hallucinations. Consumption of more than 10 g of caffeine can cause generalized tonic-clonic seizures, respiratory failure, and death. On the positive side, ingestion of 50 to 100 mg of caffeine can produce increased alertness, a mild sense of well-being, and a sense of improved verbal and motor performance.

B. While cocaine use occurs in all socioeconomic demographics, the highest prevalence is in males between the ages of 20 to 30 years, who are unemployed, live in urban areas, and have no more than a high school education.

B. The DSM-IV-TR classifies all of the above disorders as learning disorders except Stuttering which is classified as a Communication Disorder.

D. Being unmarried, along with social isolation, longer duration of psychotic episode, and a history of childhood behavioral problems and prior psychiatric treatment are the five most powerful indicators of poor outcome in Schizophrenia, according to the World Health Organization International Pilot Study on Schizophrenia. Other poor prognostic factors in Schizophrenia include younger age at onset, male gender, low socioeconomic status, positive family history of Schizophrenia, a history of peri-natal complications, poor premorbid functioning, insidious onset, chronic course, clear sensorium, negative symptoms, lack of mood disturbance, neurological soft signs, and structural brain abnormalities. Being married is a relatively protective factor in predicting long-term outcome in Schizophrenia. Even with modern treatment, less than one third to one half of patients will have a recovery of any kind.

B. Naltrexone is an opiate receptor antagonist that reduces craving in alcohol dependent patients. Given at a dose of 50 mg/day orally, it is contraindicated in patients receiving concurrent opioid analgesic (it inhibits and renders opioid analgesics ineffective) and liver impairments. Naltrexone is indicated in patients who crave alcohol but are motivated to quit drinking. Naltrexone leads to reduced craving or drinking in positive responders in 7 to 10 days, failure to respond in 10 days is suggestive of failed therapy and an indication for discontinuation.

C. Buprenorphine is a partial agonist of the mu-opioid receptor. It is different from a full opioid agonist, like methadone and heroin, in that the receptor activation increases as the dose increases until it reaches a plateau. For full opioid agonists, higher doses continues to create greater receptor activation. Because of this partial activation, chronic opioid users are less likely to abuse buprenorphine. It has high affinity for and a slow dissociation from mu-opioid receptors and can block other opioids temporarily. Due to its high affinity, buprenorphine displaces opioids from the mu receptor, causing withdrawal in patients who have used opioids recently. It is absorbed through gastrointestinal and mucosal membranes, but the oral formulation has poor bioavailability due to its extensive metabolism in the gastrointestinal tract. Sublingual buprenorphine has a bioavailability ranging from 30% to 50% of the intravenous dose. Maximal plasma concentration that is reached within 1 hour of oral dosing and it is metabolized primarily in the liver via the cytochrome P450. The majority of buprenorphine and its metabolites are excreted in the feces; less than 30% are eliminated in the urine. Its mean plasma elimination half-life is 37 hours.

D. Individuals with Schizoid Personality structure believe that the social world is dangerously engulfing. They are highly sensitive and reactive to interpersonal stimulation, which they tend to respond to with defensive withdrawal. They easily feel in danger of being engulfed, enmeshed, controlled, intruded upon, and traumatized; dangers that they associate with becoming involved with other people. In contrast, individuals with depressive personality structure believe that people who really get to know them will reject them because they believe that there is something essentially bad or incomplete about them. When mistreated, rejected, or abandoned, they tend to believe that they are somehow at fault. This belief may be a residue of the familiar tendency of children in difficult family situations to deny that their caregivers are negligent, abusive, or fragile—ideas that are too frightening. Instead, they attribute their suffering to their own badness—something they can try to change.

D. Available evidence indicates that behavioral treatments produce improvements in sleep architecture, which are most pronounced for sleep latency and time awake after sleep onset. Relaxation and BF were both found to be effective in alleviating insomnia. Cognitive forms of relaxation, such as meditation, were slightly better than somatic forms of relaxation such as PMR. Sleep restriction, stimulus control, and multimodal treatment were the three most effective treatments in reducing insomnia. Improvements seen at treatment completion were maintained at follow-ups averaging 6 months in duration. Although these effects are statistically significant, it is questionable whether the magnitude of the improvements in sleep onset and total sleep time are clinically meaningful. Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia can be synergestic.

E. Bupropion is a dopamine and norepinephrine reuptake inhibitor. It is about twice as potent inhibitor of dopamine uptake than norepinephrine uptake. Bupropion is metabolized in the liver. It has at least three active metabolites: hydroxybupropion, threohydrobupropion and erythrohydrobupropion. These active metabolites are further metabolized to inactive metabolites and eliminated through excretion into the urine. The half-life of bupropion and hydroxybupropion is 20 hours. Threohydrobupropion’s half-life is 37 hours and erythrohydrobupropion’s is 33 hours. The therapeutic benefit of bupropion can be attributed to its active metabolites. It is contraindicated in epilepsy and other conditions that lower the seizure threshold (alcohol withdrawal, active brain tumors, etc.). It should not be use concomitantly with MAOIs. When switching medications, it is important that there be a short period of about 2 weeks between the medications in order to reduce risk of complications that might lead to things such as a decrease in
seizure threshold. It should be used with caution in patients with AN and bulimia as they have decreased seizure thresholds. Bupropion is primarily metabolized to hydroxybupropion by the CYP2B6 isoenzyme. Combination of bupropion with nicotine replacement therapies can elevate blood pressure, so it is recommended that the patient’s blood pressure is monitored. It is a category B in pregnancy.

E. Psychiatrists are not able to accurately predict future behavior of patients, but are able to assess the risk of future violent behavior. Each of the other answers represents risk factors for an increased probability of future violence. Not listed, a prior history of violent behavior is perhaps the strongest risk factor for future violent behavior. Male gender is another strong risk factor for future violent behavior.

E. Bulbar palsy is caused by cranial nerve injury within the brainstem or along the course of the nerves. Patients usually have a thick, nasal intonation while talking, dysphagia due to impaired palatal and pharyngeal movement, loss of the gag reflex, and, in some cases, a depressed jaw jerk reflex. If the bulbar damage is extensive, the medullary respiratory center might be affected and patients may present with respiratory depression. Taste sensation in the two thirds of the tongue is provided by the facial nerve (CNVII).

A. Given that this patient’s depressive presentation is recent and sudden, it is likely due to a medical disorder rather than a primary psychiatric disorder. Lesions of the frontal lobe may present with a clinical syndrome indistinguishable from a depressive illness. The frontal lobes play a major role in personality, especially in acquired social behavior, and lesions here often result in a change in personality as an apathetic dementia results. Occipital lobe tumors are associated with hemianopia and unformed visual disturbances. Parietal lesions present with language and speech difficulties if in the dominant hemisphere, or with visuospatial integration problems and neglect syndromes. Temporal lobe lesions are also associated with language disturbance from the dominant hemisphere, olfactory and partial-complex seizures, and visual field deficits.

B. Linkage analysis is one of a number of techniques that molecular geneticists use to map the location of genes that contribute to psychiatric disorders. It depends on the law of independent assortment. Genes are typically inherited independently (because of recombination and segregation), unless they are located close together on a chromosome. When genes are relatively close together, the likelihood of recombination is proportional to the distance between the genes. It is an essentially hypothesis-free approach (i.e., it is not essential to have a candidate gene in mind before beginning). Classical linkage analysis is most useful in mapping traits caused by single genes, and has to be modified for use in polygenic disorders, which include most psychiatric disorders. Identification of a chromosomal abnormality is not necessary; this is important for cytogenetic studies.

D. The severity of TBI is perhaps the most important determinant of outcome. Severity is estimated by one of the following three parameters: length of LOC, duration of PTA, and the Glasgow Coma Scale. The longer the length of LOC, the worse the prognosis of a given TBI, as this represents a more severe TBI. PTA is defined as the time interval between the attainment of full consciousness following TBI and the time at which new memories are formed. Longer periods of PTA portends worse prognosis. The Glasgow Coma Scale is a 15-item scale with scores ranging from 3 to 15. The lower the score the more severe the injury.

A. Glutamate (an amino acid) is the major excitatory neurotransmitter in the CNS. Glucose and glutamine are converted to, via the enzyme glucan mayonnaise, and to glutamate. It is widely
distributed in the CNS, and receptors include N-methyl-D-aspartic acid (NMDA), AMPA, and kainate receptors (each inotropic), and some metabotropic receptors. Excess glutamatergic stimulation may result in seizures or neuronal damage (kindling). Decarboxylase of glutamate via glutamic acid decarboxylase (GAD) forms GABA, a major inhibitory neurotransmitter in the brain. Glycine is a major inhibitory neurotransmitter in the spinal cord. Norepinephrine and dopamine function vary depending on involved tracts.

B. Huntington’s disease is a genetic disorder that is inherited as an autosomal dominant trait, thus each child of a parent who is carrying a defective gene has a 50% risk of inheriting the disease gene. There are several genes that are known to cause PD but they account for a very small minority of cases. Parkinson’s mutations are the most common genetic cause of PD (causes young-onset PD) but still account for less than 1% of all cases, and is thought to be inherited in an autosomal recessive pattern. Sydenham’s chorea is a neurologic movement disorder that frequently occurs in children or adolescents following acute rheumatic fever, and appears to result from an autoimmune or antibody-mediated inflammatory response involving certain regions of the basal ganglia and is not genetically transmitted. Wilson’s disease is a genetic disorder that is inherited as an autosomal recessive trait and causes neurological and psychiatric symptoms and liver disease. Lesch-Nyhan syndrome is inherited as an x-linked recessive trait and involves an enzyme deficiency that results in hyperuricemia, with associated mental retardation, choreoathetosis, and self-destructive biting of the lips and fingers.

B. This patient presents with signs consistent with Brown-Sequard syndrome, which refers to hemisection of the spinal cord. The following signs are found in this syndrome: ipsilateral paresis, ipsilateral corticospinal signs (hyperactive DTRs and Babinski), contralateral loss of pain and temperature sensation (from injury of the spinothalamic tract), and ipsilateral impairment of vibration and joint-position sense (from posterior column injury). The loss of pain sensation contralateral to the paresis is the readily identifiable hallmark of this syndrome. Complete transection of the cord results in permanent bilateral motor, sensory, and autonomic paralysis below the level of the lesion. The central-cord syndrome is characterized by weakness that is more marked in the arms than the legs, with urinary retention and sensory loss below the level of the lesion. The arms or hands may be paralyzed or moderately weak. In the legs there may be severe paresis or only minimal weakness, overactive tendon reflexes, and Babinski signs. Micturition may be normal. While complete-cord transection may be diagnosed at first because there seems to be no cord function below the level of the lesion, careful testing may reveal sacral sparing, showing an incomplete lesion. In the anterior-cord syndrome, immediate complete paralysis is associated with mild-to-moderate impairment of pinprick response and light touch below the injury, with preservation of position and vibration sense (from dorsal columns). This syndrome may be caused by an acutely ruptured disc, fracture, or dislocation in the cervical region impinging on the anterior spinal artery and compromising blood flow to the anterior cervical spine. The posterior-cord syndrome is characterized by pain and paresthesia in the neck, upper arms, and trunk, which is usually symmetric and has a burning quality. The sensory manifestations may be combined with mild paresis of the arms and hands, but the long tracts are only slightly affected.

A. Diabetic polyneuropathy is the most common type of neuropathy in the Western world affecting up to half of all diabetic patients. Longer the duration of diabetes, greater is the chance of the patient developing neuropathy. Diabetic neuropathy can be classified into various distinct clinical syndromes which are characterized by a characteristic set of signs and symptoms. The common types of diabetic neuropathies are distal symmetric polyneuropathy, autonomic neuropathy, mononeuropathy mainly affecting the oculomotor and median nerves, thoracic and lumbar polyradiculopathies, and mononeuritis multiplex.

D. Huntington’s disease is a rare autosomal dominate neurodegenerative disease. There are no available disease-modifying treatments, only
treatments to manage symptoms associated with the disease. Huntington’s chorea is characterized by involuntary muscle movements usually of the limbs that can be somewhat reduced by the D2 blockade action of haloperidol. Pramipexole, ropinirole, and L-dopa all act to increase dopamine transmission and would likely worsen Huntington’s chorea. Benztropine would likely have no effect on Huntington’s chorea.

C. DBS of the STN is an effective therapeutic modality for well selected patients with medically intractable symptoms of PD. GPi DBS, although a safe treatment, is yet to be studied on its strength of effect to treat patients with PD. DBS is nondestructive and may be a bilateral procedure of low neurologic morbidity. It can be modified over time to deal with changing or progressing patient symptoms, but it is not helpful for axial symptoms (i.e., such as postural instability or speech problems) and it does not slow the progression of the underlying neurodegenerative disease. It is also expensive and can introduce infection into the brain. It may also have mechanical breakdowns and need reprogramming.

E. Many drugs prescribed by neurologists and psychiatrists have significant drug–drug interactions of which clinicians must be aware. Common inducers of hepatic drug metabolism include phenytoin, phenobarbital, carbamazepine, primidone, and rifampin. Of the list above, only divalproex sodium (Depakote) is an inhibitor of drug metabolism. Other inhibitors of drug metabolism that psychiatrists in particular should be aware of include SSRIs (except citalopram and escitalopram), TCA, bupropion, methylphenidate, and disulfiram.

C. Erik Erikson described generativity as a process by which adults contribute to the next generation through guidance, care, productivity, creativity, and raising children.

E. Neurofibrillary tangles are fibrillary intracellular deposits found in dendrites of neurons, especially pyramidal neurons. These pathological lesions are not unique to Alzheimer’s disease, and have also been found in normal aging, some frontotemporal dementia subtypes, dementia pugilistica, and subacute sclerosing panencephalitis. Neurofibrillary tangles are not commonly associated with Huntington’s disease.

A. A psychiatrist cannot avoid some manner of self-disclosure, even if it is just their office decoration and style of dress. Most agree that some form of self-disclosure is not only unavoidable, but also often useful, but there are no generally accepted technical guidelines. Generally, if the therapist’s feelings are obvious to the patient, such as if the therapist has become angry, it is disingenuous not to disclose. One should still disclose with caution, and it is generally a good idea to discuss process. While some have argued for select disclosure of countertransference love, most argue for extreme caution, as such feelings can be deeply disturbing to the patient, even without actualization in action.

C. Although published clinical practice guidelines may be considered in malpractice cases, they are not comprehensive or without fault, and should never supersede professional judgment. It is not required that the physician deviated from guidelines for malpractice. Any carefully crafted guideline will have an opening disclaimer that it does not represent the standard of care. The four requirements for malpractice are summed up in the remaining answers. They may also be described in the four D’s of malpractice: duty, deviation, damages, and direct causation.

A. This patient has Huntington’s disease. It is inherited as an autosomal dominant allele on chromosome 4. Patients develop dementia and chorea, with deficient GABA activity. Huntington’s disease is also an excessive trinucleotide repeat disorder. Radiological findings in these patients include the atrophy of caudate nuclei and the presence of bat wing lateral ventricles. Other excessive trinucleotide repeat disorders include myotonic dystrophy, Fragile-X syndrome, Friedrich’s ataxia, and the spinocerebellar degenerations.

D. Nicotine dependence amongst patients with schizophrenia is extremely common and has been found to range from 75% to 90%. Nicotine is by far the most common substance of dependence for patients with Schizophrenia. Comorbidity of Schizophrenia and other substance use disorders is also common. Thirty to fifty percent of patients with Schizophrenia have been found to meet the diagnostic criteria for Alcohol Abuse/Dependence. Other commonly used substances are cannabis (approximately 15% to 25%) and cocaine (approximately 5% to 10%).

D. Unlike opiates and sedatives, cocaine withdrawal includes mainly psychological symptoms and is not usually medically serious. Depressed mood, problems concentrating, increased dreaming (due to increased rapid eye movement [REM] sleep), anhedonia, fatigue, and cocaine craving are often experienced. Occasionally, an initial period of severe symptoms occurs, during which the patient may become severely depressed and suicidal. However, typically symptoms are milder, and resolve within 2 weeks.

D. The treatment of choice for Reading Disorder is first an accurate assessment of the child’s specific deficits and weakness and matching them appropriately to an educational approach. A specific method developed by Samuel Orton suggests therapeutic attention to the mastery of simple phonetic units, followed by the blending of these units to words and sentences. An approach that systematically engages several senses is recommended. Children should be placed in a grade as close as possible to their social functional level and should receive special remedial work in reading. Coexisting emotional and behavioral problems should be treated by appropriate psychotherapeutic means. Parent counseling may also be helpful.

A. Although the sex ratio for rates of Schizophrenia is still debated, it does seem that men generally develop Schizophrenia at an earlier age than women. Despite some pockets of high and low rates of Schizophrenia, with clearly defined criteria the incidence and prevalence is relatively consistent worldwide. The association with lower socioeconomic class is thought to be explained by the downward drift hypothesis. Even with improved treatments, persons with Schizophrenia do suffer higher mortality rates, largely due to suicide and accidents, but also from poorer general medical health. Rates of attempted and completed suicide remain high in Schizophrenia.

E. Prochaska and DiClemente have provided a model for change in addictive behaviors. According to this paradigm, patients move through several distinct stages beginning with problematic drinking and ending with stable sobriety. Movement through these stages may be progressive but not necessarily chronologic. It is important for clinicians to recognize the specific stage a given patient has attained to be able to deploy the most effective motivational change strategy. In the precontemplation stage, patients are in denial of their drinking difficulties and have no desire to engage in meaningful lifestyle changes to address their drinking problem. Patients in contemplation stage are no longer in denial but evidence profound ambivalence towards the habit: they acknowledge all the ill effects of excessive alcohol consumption but are unable to take specific remedial actions. Patients who have made a decision to quit drinking and indeed able to make gestures (initiate small changes) are said to be in the preparation stage, whereas patients who go beyond making symbolic gestures and actually initiate specific
changes, including accepting pharmacologic or psychological interventions are in the action stage. In the maintenance stage, new behavior pattern is applied consistently and consolidated. Because maintenance of sobriety is fraught with several remissions and relapses, the authors recognize that positive changes that have necessitated sobriety may be abandoned (i.e., the relapse stage).

B. Studies comparing buprenorphine to methadone maintenance therapy for opioid dependence have shown that buprenorphine (less than 40 mg) is as effective as low-dose methadone (less than 40 mg). However, high-dose methadone (greater than 60 mg) may be more effective than buprenorphine. Hence, patients requiring higher methadone doses may not be good candidates for buprenorphine. A Cochrane meta-analysis reviewed the use of buprenorphine as maintenance treatment. This review demonstrated the superior efficacy of buprenorphine maintenance treatment when compared with placebo, as well as treatment retention and heroin suppression efficacy comparable with that of low-dose methadone maintenance. However, high-dose methadone demonstrated superior heroin suppression efficacy compared with buprenorphine. Advantages of buprenorphine over methadone include higher doses having lower risk of toxicity, potential effectiveness at less than recommended daily dosage, less severe withdrawal symptoms after discontinuation, less abuse potential, and more accessible for office-based treatment programs. Advantages of methadone maintenance over buprenorphine maintenance therapy include lower cost of treatment, more effective in patients with higher tolerances, and higher treatment retention rates.

A. Masochistic patients tend to reenact with a therapist the drama of the child who needs care but can only get it if they are demonstrably suffering and helpless. The therapist may be seen as a parent who must be persuaded to save and comfort the patient, who is too weak, threatened, and unprotected. The patient’s subjective task is thus to persuade the therapist that they both need and deserve to be rescued. Coexisting with these aims is the fear that the therapist is an uncaring, critical, selfish, and abusive authority. They fear that the therapist will expose their worthlessness, blame the victim for being victimized, and abandon the relationship. To combat such fears, they try to make obvious both their helplessness and their efforts to be good. On the other hand, manic patients tend to be winsome, insightful, and fascinating. They also tend to be confusing and exhausting. Depressive patients attach quickly to the therapist, ascribe benevolence to their aims, work hard to be “good” in the patient role, and appreciate bits of insight as if they were morsels of life-sustaining food. They tend to idealize the clinician as morally good, in contrast to their subjective badness. Depressive patients try hard not to be burdensome. At the same time, they project onto the therapist their internal critics or harsh superego. Depressive patients are subject to the chronic belief that the therapist’s concern and respect would vanish if they really knew the patient.

A. Varenicline acts as a partial agonist selective for the alfa₄ beta₂ nicotinic acetylcholine receptor subtype. Maximal plasma concentrations are reached within 3 to 4 hours and it reaches a steady-state concentration within 4 days. It has a half-life of 24 hours and its oral bioavailability is not affected by food or time of administration. It has linear pharmacokinetics and low plasma protein binding (≤20%) regardless of a patient’s age and renal function. Pharmacokinetic studies in the elderly have demonstrated activity similar to that observed in young adults. Dosage adjustments are not required in patients with hepatic insufficiency. It has no clinically significant drug–drug interactions. In vitro studies do not demonstrate a cytochrome P450 enzyme effect. The safety of coadministration of nicotine replacement products with varenicline has not been established. No significant differences in dosing have been established with regards to age, race, gender, tobacco use, or concurrent use of other drugs. Clinical trials indicate that varenicline was superior to sustained-release bupropion and placebo in two trials with regards to the incidence of abstinence,
adverse event rate, and tolerability. Varenicline has also been shown to increase long-term abstinence from cigarette smoking compared with placebo. Nausea was the most common adverse event associated with varenicline use. A dose reduction should be considered in patients with intolerable nausea. Varenicline has been designated as a pregnancy category C drug. Since there are no studies that have been conducted to investigate whether varenicline is excreted in human milk, it should be avoided in lactating women. Teratogenicity with varenicline is unknown.

E. During intoxication, patients will typically have dilated pupils and, at high doses, are at increased risk of developing autonomic instability and hyperthermia, strokes, and seizures. Patients experiencing cocaine toxicity, especially chronic users, may experience paranoia as this patient has done. If patients continue to exhibit paranoia after 12 hours, one should consider hospitalization and, if not, ensure that the patient is discharged to the care of someone reliable.

D. Psychiatric diagnoses fall into the category of static risk factors. According to ECA data, the base rate of violent behavior amongst those without a psychiatric diagnosis is 2%. Amongst those with a DSM-III psychiatric diagnosis of OCD, Panic Disorder, Major Depression, Bipolar Disorder, or Schizophrenia, the base rate is about 12%. The base rate of violence jumps dramatically for any substance related disorder (with cannabis-related disorders at 19%, alcohol-related disorders at 25%, and other drug-related disorders at 35%). Do not be fooled that marijuana is calming and reduces rates of violence. Substance-related disorders react synergistically with other diagnoses to increase violence rates even further. Substance abuse of any kind is the most significant axis I risk factor for violent behavior. Chronic abuse and intoxication are the most important. Half to two thirds of violent offenders were drinking just before committing the violent act, and an additional 20% to 25% similarly used other drugs.