1. Answer D. (MN-153) The patient in this vignette most likely has schizophrenia, which is characterized by prominent hallucinations, disorganized thinking, functional impairment, and typical onset in the second decade of life (Table 20.1.1). Moreover, the patient has been having symptoms for greater than 6 months, thus meets criteria for schizophrenia. Of note, hallucinations are not present in delusional disorder and 7-month duration of illness is too long for schizophreniform disorder. Although marijuana use may exacerbate or precipitate psychosis, his occasional use does not appear to meet criteria for a disorder.

2. Answer B. (MN-153) The clinical history is most consistent with delirium. An underlying infection, such as a urinary tract infection, is among the more common causes in an aging patient, although the differential is broad (see Chapter 11). Acute onset of a primary psychiatric disease such as delusional disorder or schizophrenia at age 84 years is very unlikely, especially in a patient with no prior history of psychiatric illness. None of the patient’s medications is associated with drug-induced psychosis.

3. Answer C. (MN-153) Clozapine is the only antipsychotic approved for treatment-resistant schizophrenia. Clozapine, although effective, is associated with agranulocytosis, and thus, patients taking clozapine must be enrolled in a clozapine registry (Risk Evaluation and Mitigation Strategy, REMS) required by the Food and Drug Administration (FDA) and carefully monitored for decrease in granulocyte count.

4. Answer A. (MN-153) First-generation antipsychotic medications, such as haloperidol and perphenazine, as opposed to second-generation antipsychotic medications, such as quetiapine, have a higher risk of TD and drug-induced parkinsonism due to less D2 receptor antagonism (Table 20.4.1). Long duration and higher doses are most associated with tardive dyskinesias, although they can occur less often in patients prescribed these medications at lower doses and over shorter periods of time. Women and older adults are at higher risk of TD.

5. Answer E. (MN-154) It is fundamental to differentiate between major depressive disorder (MDD) and bipolar disorder (BD). They differ in clinical presentation, prognosis, etiologies, genetic factors, and treatments. Making the differential diagnosis can be challenging due to poor patient recollection and lack of collateral information and when mania symptoms are not explored. In persons with established diagnoses of bipolar disorder, antidepressants should be used with caution and always in the presence of a mood stabilizer. Risks of antidepressant include antidepressant-induced mania (10%), rapid cycling, and mood instability. As per DSM-5, a hypomanic/manic episode induced by antidepressants justifies the diagnosis of bipolar disorder. Treatment of bipolar disorder includes mood-stabilizing agents such as lithium, second-generation antipsychotics (especially if patient has bipolar disorder with psychotic features), and in some cases anticonvulsants such as valproic acid or carbamazepine. Given the patient is a woman of childbearing age and teratogenic effects of valproic acid, options other than valproic acid in such patients should be considered for mood stabilization.

6. Answer C. (MN-154) The diagnosis of bipolar disorder 2 requires at least one episode of hypomania regardless of how long ago it happened. Although college students can have risky and disorganized behavior, in this case the behavior was episodic with clear boundaries in time and meets the criteria for hypomania. Disruptive mood dysregulation disorder refers to a mood disorder characterized by persistent irritability that manifests as frequent outbursts and loss of temper.

7. Answer A. (MN-154) Although lithium can have significant toxicity and has a narrow therapeutic window, it is still the first-line treatment for most cases of bipolar disorder. Many patients tolerate it well, although it can produce significant side effects, including nephrotoxicity (diabetes insipidus, edema, renal insufficiency and, rarely, ESRD), hypothyroidism, skin toxicity (acne, hair loss, worsening psoriasis), brain toxicity (cognitive impairment, tremor, delirium, ataxia), GI disturbances, and death. Lithium may be teratogenic (1% risk of Ebstein abnormality) when exposure occurs during the first trimester (Table 20.7.1).

8. Answer D. (MN-154) Valproic acid is better tolerated and less toxic than lithium but less effective except in rapid cycling bipolar disorder. The main organs and systems that valproic acid can adversely affect are liver (liver failure), blood (thrombocytopenia), brain (cognitive impairment, tremor, delirium), pancreas, skin (hair loss), increased weight, and polycystic ovary syndrome. Valproic acid can also be teratogenic (neural tube defects) (Table 20.7.1). Renal and thyroid function should be monitored for patients being treated with lithium.

9. Answer C. (MN-154) Prefrontal/limbic dysregulation in major depressive episode is characterized by a decrease in activity and/or volume in several dorsal structures: the dorsolateral prefrontal cortex, dorsomedial prefrontal cortex, dorsal anterior cingulate cortex, and rostral anterior cingulate cortex. In contrast, there is increased activity in ventral structures, the amygdala, the subgenual anterior cingulate cortex, the ventral lateral prefrontal cortex, and orbitofrontal and prefrontal cortex.

10. Answer D. (MN-154) A DSM-5 criterion for persistent depressive disorder in adults is 2 years and 1 year for children and adolescents. The time criterion for major depressive disorder is 2 weeks.