C. This child is approximately 24 months old. At his age, he should be able to run without falling and go up and down the stairs. His separation anxiety is starting to diminish, and he should be able to build a tower with six or seven cubes. An 18-month-old child can walk without falling frequently, but is unable to run freely and can only build a tower of three or four cubes. A 36 month old can ride a tricycle, build a tower of nine or ten cubes, and is able to copy a circle or cross. A 15 month old can usually walk without support.

D. Cells transmit electrical signals either via an electrical synapse or chemical synapse. With cells that communicate via electrical synapses, there is minimal delay at the synapse because they communicate via the direct flow of current. These cells are typically joined by less than 3 nm gap junctions and are bidirectional. On the other hand, with cells that communicate via chemical synapses, the presynaptic cell releases a transmitter at the terminal bouton, which alters the postsynaptic membrane potential, the release of the transmitter contributing significantly to a synaptic delay.

B. J. B. Skinner’ s theory of learning is called operant or instrumental conditioning. In this form of learning, a behavior is followed by a response. Thus, the learning occurs as a consequence of action. In this form of learning, the participant is active and behaves in a way to get a positive response. Pavlov’ s classical conditioning depends on the repeated pairing of a neutral conditioned stimulus with a stimulus that evokes a response (unconditioned stimulus). This pairing of a conditioned and unconditioned stimulus results in the neutral stimulus evoking a response called the conditioned response. In classical conditioning, the participant is passive and the behavioral reinforcement is not under its control.

E. Karl Ludwig Kahlbaum’ s monograph, “Die Katatonie oder das Spannungsirresein,” characterized catatonia as a specific disturbance in motor functioning that represents a phase in a progressive illness that includes stages of mania, depression, and psychosis and that typically ends in dementia. Carl Jung described, collective unconscious, archetypes, complexes, introverts, extroverts, persona, animus, anima, and individuation. Alfred Adler, the founder of individual psychology, coined the term inferiority complex. Erik Erickson described the epigenetic principles, which describe the development of an individual in sequential and clearly defined stages. Sigmund Freud is the originator of psychoanalysis and has described various theories and models of the mind including topographical and structural models.

A. According to the DSM-IV-TR, NMS (333.92) should be coded on axis I of the multiaxial classification system. In the multiaxial classification system, axis I should include clinical conditions or other conditions that may be a focus of clinical attention. Conditions that fall under the category of other “conditions that may be a focus of clinical attention” include: NMS, psychological factors affecting medical conditions, medication-induced movement disorders, other medication induced movement disorders, and additional conditions that may be a focus of clinical attention, such as noncompliance with treatment. Axis II includes personality disorders/mental retardation. Axis III includes general medical conditions. Axis IV includes psychosocial and environmental problems, and axis V includes global assessment of functioning.

A. Rapid cycling (four or more affective episodes a year) occurs more commonly in women with bipolar disorder. The use of an antidepressant, especially tricyclics, has been associated with the development of rapid cycling. Other consistent risk factors are hypothyroidism and the number of affective episodes during the course of illness. Patients with rapid cycling tend to have a weaker response to lithium in comparison to other patients with bipolar disorder.

D. Substance abuse cannot be diagnosed if the patient has ever met the criteria for substance dependence in that class of substance. The first 1 to 12 months of remission is designated “early.” Following 12 months of remission, the designation of “sustained” is given. “Full” remission indicates that no criteria for substance abuse or dependence have been met in that time period. The “partial” specifier is used if one or more of the criteria for abuse or dependence have been met, but the full criteria for dependence have not been met.

D. According to the DSM-IV-TR, patients with undifferentiated somatoform disorder present with one or more physical complaints lasting at least 6 months that are below the threshold for the diagnosis of somatization disorder. Two symptom patterns in undifferentiated somatoform disorder have been proposed: those involving the autonomic nervous system and those involving the experience of fatigue/weakness. The latter has also been described as “neurasthenia” and may overlap with chronic fatigue syndrome.

A. The DES, which was developed by Eve Bernstein Carlson and Frank Putnam in the mid-1980s, has 28 items and the overall score can range from 0 to 100. The PDEQ, which was developed by Charles R. Marmar et al., assesses dissociative experiences at the time of the traumatic event, and the most widely used version is the PDEQ ten-item self-report version (PDEQ-10-SRV). The CDC is a parent–caretaker–teacher 20-item report measure using a three-point scale, used for children from 5 to 12 years of age, with scores ranging from 0 to 40. The A-DES is an adolescent-oriented version of the DES with 30 items on a 0 to 10 answer format, which also includes questions regarding depersonalization and derealization in its questionnaire.

D. The SSRI with the longest half-life (t 1/2) is fluoxetine; it has a t 1/2 of approximately 2 to 5 days. Its metabolite norfluoxetine has a t 1/2 of 7 to 10 days. Citalopram has a t 1/2 of 35 hours, and escitalopram has a t /12 of 30 hours. Sertraline has a t 1/2 of 24 hours and its metabolite, desmethylsertraline, has a t 1/2 of 2 to 4 days. Paroxetine and fluvoxamine have the shortest t 1/2 among the SSRIs; their t 1/2 is approximately 15 to 20 hours (THINK WITHDRAWAL!).

C. Approximately 30% to 45% of patients diagnosed with depression do not have an adequate response to a first trial of an antidepressant. Patient-related and treatment-related risk factors that have been identified and increase the chances of nonresponse to antidepressant treatment include: disease severity, coexisting medical or psychiatric disorders, such as alcohol abuse or anxiety, and a possible familial predisposition to a poor response to antidepressants in which serotonin transporter gene polymorphisms may play a role.

D. Benzodiazepines are contraindicated in inhalant intoxication because they potentiate the effects of inhalants. They can be used in all the other conditions.

D. The patient is experiencing an opisthotonic reaction to haloperidol (Haldol), which is an acute dystonic reaction. Of these, benztropine (Cogentin) is the most appropriate treatment for acute dystonia. (Another good choice is diphenhydramine.) Although a treatment for akathisia, propanolol would not be a good choice for an acute dystonic reaction. Although a change in medications after an acute dystonic medication is not necessarily warranted as long as the dystonic reaction is treated and the patient remains on the antiparkinsonian medication, the experience is often disturbing enough for patients to request a medication change. Depending on the clinical circumstances, quetiapine, olanzapine, or risperidone may ultimately be an appropriate alternative medication for this patient; however, the first thing to do would be to relieve the acute dystonic reaction by giving, for example, benztropine.

C. A β-adrenergic blocker, such as propranolol, can help reduce tremors in patients taking lithium. It can be taken a half hour prior to an activity where tremors can interfere with functioning or taken daily to constantly suppress tremors. Before treating tremors, it is important to complete a neurological exam to rule out other possible etiologies for tremors as well as to check the lithium level, because tremors can be a sign of lithium toxicity. Antidepressants and diuretics can increase lithium levels, which would likely worsen the tremors. Alprazolam and benztropine would not help decrease tremors and alprazolam is likely to impair coordination.

B. Highest rates of completed suicides are seen in white men over the age of 75 years. Although they only constitute 10% of the total population, they account for 25% of suicides. The rates in those older than 75 years is >3 times the rate among younger people. Presence of multiple medical problems, loneliness, hopelessness, psychiatric disorders, substance abuse, and a prior history of suicide attempts are all major risk factors for suicide.

E. Adult neurogenesis is an ongoing process in the subventricular zone, resulting in granule cells in the olfactory bulb, and in the subgranular zone, resulting in granule cells in the adult hippocampus. Stress results in suppression of neurogenesis, possibly through sustained elevations of cortisol in brains with dysfunctional regulation of the Hypothalamo-pituitary-adrenal axis (HPA) axis. Antidepressant treatments increase neurogenesis. Antidepressants increase expression of BDNF, which itself, increases neurogenesis.

B. Sturge-Weber syndrome is typically characterized by calcification of vessels in one cerebral hemisphere. Vascular malformations of the face, not thin skin, cause a port-wine stain. Cluster headaches are not a usual feature of Sturge-Weber syndrome. Although patients with this disease can have learning disabilities and mental retardation, these are not caused by facial vascular malformations. Sclerotic lesions in the brain can lead to neurologic problems, such as hemiparesis.

D. All of the previously described diseases are excessive trinucleotide repeat (ETR) disorders. Unlike the others types of diseases in this group, Friedreich’ s ataxia is inherited via autosomal recessive transmission. The early onset form (teen years) is caused by a mutation on chromosome 9q13–2. The later onset type (20 to 30 years) is also caused by a mutation on chromosome 9. In the vast majority of cases, mutation is an example of a GAA trinucleotide repeat within an intron. The mutation affects the protein frataxin by decreasing its level and function.

B. The patient has had an injury to the left cerebral hemisphere. When there is damage to one frontal gaze center or its descending fiber tract, the eyes drift toward the involved cerebral hemisphere due to unopposed action of the remaining frontal gaze center (i.e., the eyes appear to look at a destructive hemispheric lesion and look away from the resulting hemiplegia). In pontine lesions where there is damage to the paramedian pontine reticular formation (PPRF) and to the descending pyramidal tract fibers that cross the midline in the medulla, eyes look away from the side of the destructive pontine lesion, but look toward the hemiplegia. Damage to the medulla involves the nuclei and the initial portion of the cranial nerves IX through XII, the descending corticospinal, and the ascending sensory and sympathetic nervous system. Lesions to the medulla result in bulbar palsy, lateral medullary infarction of Wallenberg, and locked-in syndrome.

B. This patient has an ataxic gait, scanning speech, and an intention tremor, which are characteristic of cerebellar lesions. Scanning speech is also seen in bulbar and pseudobulbar palsy. Formal testing for an intention tremor includes finger-to-nose and heel-to-shin tests. Another cerebellar sign is dysdiadochokinesia, which is difficulty in performing rapid alternating movements.

D. The patient is presenting with symptoms consistent with bilateral hemianopsia, which is likely a chromophobe pituitary adenoma compressing the optic chiasm. (Prolactinomas are usually microscopic in size when diagnosed.) This is not a side effect of olanzapine. Although olanzapine can cause sedation and orthostatic hypotension, the patient denies fatigue and does not have orthostatic hypotension. At this point, there is no indication to check liver function or obtain a complete blood count. One may confirm the cause of the findings by requesting an MRI of the brain for ruling out a pituitary tumor. However, the first stage in management of this patient’ s complaints is to confirm the findings by a thorough neurological examination.

B. The classical triad of tuberous sclerosis is skin lesions, seizures, and mental retardation. Depigmented macules are usually present at birth and persist through life. Three or more macules measuring 1 cm or more in length are diagnostic. Facial adenoma sebaceum are usually never present at birth, but are clinically evident by the age of 4. Yellowish-brown elevated plaques called Shagreen patches are usually found in the lumbosacral region after the age of 10 years. Café au lait spots and small fibromas may be seen after puberty. Seizures and mental retardation indicate a diffuse encephalopathy. The younger the patient is when the seizures begin, the greater the risk of mental retardation. However, focal neurological examination is usually normal. Hamartomas of the retina or optic nerve are also observed in approximately half the number of patients.

C. This patient is presenting with the classic Cushing’ s triad, which consists of rising blood pressure, bradycardia, and respiratory irregularity. It is usually seen in patients who sustain an epidural hemorrhage and are experiencing a dangerously high intracranial pressure. Epidural hemorrhages are most commonly encountered after a temporal or parietal fracture and present with headaches, vomiting, aphasia, and seizures that can progress to coma. Death is imminent unless there is a rapid surgical intervention. A chronic subdural hematoma does not have such a drastic progression and is frequently seen in elderly patients. A concussion is a mild impairment in mental status with or without loss of consciousness that does not involve intracranial bleeding. An acute subarachnoid hemorrhage presents with sudden onset of extremely severe headache, neck stiffness and fever, and is usually caused by a ruptured aneurysm. The most common sports-related head trauma is a concussion, which causes a short change in mental status with or without loss of consciousness. An acute carotid-cavernous fistula involves the laceration of the internal carotid artery and causes a pulsating exophthalmos and a painful orbit; the eye may become immobile.

A. Patients with cerebellar ataxia need to keep their legs far apart from each other to keep their balance. They tend to fall when their feet are together whether their eyes are open or closed. They usually feel more comfortable walking with support and tend to fall when walking in tandem. Patients with Parkinson’s disease usually have a shuffling gait with small steps and loss of the normal arm swing. Patients with sensory ataxia, which results from a loss of sensory perception, are unable to know where their limbs are positioned. They are able to remain stable with their feet together and their eyes open, but they tend to lose balance when their eyes are closed (positive Romberg sign). Patients with chorea have sudden and abrupt movements of the trunk and extremities that are unpredictable and tend to worsen while walking. The gait in muscular dystrophy is characterized by weakness of the trunk and the proximal part of the legs. Patients have lumbar lordosis, a positive Gower’ s sign, and a need to walk with their legs wide apart.

E. Acetylcholine receptor antibodies are detected in 70% of the ocular form of the illness and in 80% to 90% of patients with generalized myasthenia gravis. Antibodies directed against the MuSK are seen in approximately one third of patients without acetylcholine receptor antibodies. Antititin (antistriatal muscle antibodies) are present in approximately 30% of the adult patients with myasthenia gravis and in 80% of patients who have thymomas. Approximately, 70% of patients with myasthenia gravis have thymic hyperplasia and 10% of those patients have thymoma. Thymomas are more common in patients older than 50 years of age and are usually malignant.

E. Analgesics like acetaminophen are useful in the treatment of other types of headaches, but not trigeminal neuralgia. Anticonvulsant medications like phenytoin, carbamazepine, lamotrigine, sodium valproate, and gabapentin are the mainstay of the treatment for this condition. Other drugs useful in the treatment include muscle relaxants like baclofen and benzodiazepines like clonazepam. Most patients can be treated effectively with medications and there may be spontaneous remission of symptoms especially early in the illness.

D. The ability to live independently is a major task of Erickson’ s stage of identity versus role diffusion, which usually occurs earlier than the stage of generativity versus stagnation. The age range for generativity is generally between 40 to 60 years. There is an increase in the risk of depression and alcohol use at this stage than in younger adults.

B. Myelin, which is formed by Schwann cells and oligodendrocytes, increases conduction velocity down an axon. Myelination is not continuous down the axon. An action potential jumps between breaks in the myelination (nodes of Ranvier), which have a significant amount of voltage-gated sodium channels and enable the action potential to regenerate and spread to the next node. (This kind of “jumping” conduction is called salutatory conduction.) Thus, the myelin sheathing is not continuous. Assuming no difference in myelination, conduction is faster in axons of greater diameter than axons of smaller diameters, because there is less resistance to current flow than in axons with a smaller diameter.

B. Albert Ellis is the founder of REBT, which is a form of cognitive behavioral therapy. Paul Meehl, Starke Hathaway, and J. Charnley McKinley invented the Minnesota and Multiphasic Personality Inventory (MMPI). Sigmund Freud is the founder of psychoanalysis.

A. The most common reason for a malpractice claim is incorrect treatment (33%), followed by attempted or completed suicide (20%), and incorrect diagnosis (11%). Claims for improper supervision and medication errors are less common at 7% of the cases. Other less common causes are improper commitment (5%), breach of confidentiality (4%), unnecessary hospitalization (4%), and abandonment, electroconvulsive therapy, or third-party injury (4%).

C. According to DSM-IV-TR, malingering “is the intentional production of false or exaggerated physical or psychological symptoms, motivated by external incentives.” This patient’s mental status examination does not correlate with his presenting complaints and history. The incentive associated with hospital admission is avoidance of the rival gang members who wish to harm him. DSM advises to consider a diagnosis of malingering when there are medicolegal issues involved in the patient’s case (a lawsuit), when there is a discrepancy between subjective disability and the objective findings, when there is a lack of cooperation with assessment and treatment, or in the presence of antisocial personality disorder. This individual has a history suggestive of antisocial personality disorder: previous incarcerations, ongoing illegal behavior, secondary personal gain associated with his symptoms, and admission to the hospital. With factitious disorder, external incentives are absent. Somatization disorder would require multiple systemic complaints. A person with conversion disorder might be indifferent to their symptoms (la belle indifference), their symptoms would not be intentionally produced, and their symptoms would be more responsive to suggestion or hypnosis. An individual with Lewy body dementia would be expected to be older and would have a history of motor and cognitive disturbance in addition to possible visual hallucinations.

A. Patients with OCD are most commonly worried about being contaminated and need to compulsively wash themselves or clean their environment. The second most common pattern of obsessions is doubt (forgetting to lock the car, leaving the door open) with checking patterns, followed by intrusive thoughts that are not followed by compulsions, and a need for a specific symmetry.

C. The double bind hypothesis of schizophrenia was proposed by Gregory Bateson and Donald Jackson. It suggested that children who receive conflicting parenting messages withdraw into a psychotic state to escape the confusion of the double bind, ultimately resulting in schizophrenia. The clinical example given in this question illustrates the concept of the double bind, which is not currently accepted as a causal explanation for schizophrenia. The schizophrenogenic mother (derived from early psychoanalytic formulations of schizophrenia), expressed emotion within families (high levels of which have been shown to increase relapse rates in schizophrenic patients), and the decathexis theory (originally proposed by Freud) have all been offered as causal explanations for the development of schizophrenia.

C. Sigmund Freud introduced the term conversion, which was based on his work with Anna O. Freud hypothesized that the symptoms of conversion disorder reflect unconscious conflicts. Paul Briquet and Jean-Martin Charcot noted the influence of heredity on conversion symptoms and highlighted their common association with a traumatic event. The syndrome, now called somatization disorder, was previously referred to as Briquet’ s syndrome. Thomas Sydenham observed that psychological factors were involved in the pathogenesis of somatization disorder. Emil Kraeplin (of “dementia precox” fame) coined the term dysmorphophobia, which is a term that is now replaced in the DSM-IV-TR by body dysmorphic disorder.

A. Ataque de nervios is an example of a trance state disorder form of dissociative disorder NOS. Somatic symptoms, including seizurelike convulsive movements, may be seen. Crying, cursing, self-harm, or harm to others, may be seen. These episodes are usually followed by partial or complete amnesia. Interpersonal conflicts or loss are common stressors seen in this condition. From a demographic standpoint, females who are 45 years of age or older; who are widowed, divorced, or separated; who are of low-income socioeconomic status; and who have less than a high school education are more likely to have attacks of ataque de nervios. The estimated lifetime prevalence rate in Puerto Rico is approximately 14%. In depersonalization disorder, there are recurrent feelings of being detached from one’ s body, which causes significant distress or impairment. In dissociative convulsions, features of convulsions, such as tongue biting and urinary/fecal incontinence may be seen. In dissociative amnesia, the unavailable memories are usually related to routine information that is a part of day-to-day conscious awareness. Adjustment disorder does not involve amnesia or dissociative symptoms.

B. This patient is presenting with lithium toxicity. It is most possibly due to the recent addition of an ACE-inhibitor, which has been reported to decrease lithium clearance and cause toxicity. Although most non-steroidal anti-inflammatory drugs (NSAIDs) have been reported to have dangerous interactions with lithium, aspirin has not been reported to produce toxicity. The major risk of using lamotrigine is the development of severe dermatological reactions, especially when used in combination with valproic acid, started at higher doses, or titrated rapidly. Valproic acid inhibits the metabolism of lamotrigine and increases its level in the blood.

E. Unlike many tricyclic antidepressants, SSRIs do not have a linear-response curve and thus higher dosages do not necessarily result in increased effectiveness. At least 90% of the clinical response to SSRIs occurs at the starting dose. Higher doses tend to mainly increase adverse effects. Sertraline is the most likely to be raised above its starting dose, 50 mg/day to 150 to 200 mg/day, whereas paroxetine is the most likely to be continued at its starting dose of 20 mg/day.

B. In patients 70 years or older with major depression, monthly interpersonal psychotherapy does not help prevent recurrence of major depression. Paroxetine and clinical management is the best treatment option.

A. Of these choices, labeling and emotional reasoning are the only two that are cognitive distortions. In this scenario, the patient is using a fixed, global label (“idiot”) to describe herself, which is a generalization that is highly unlikely to be true. Emotional reasoning involves incorrectly inferring that something is true based on the way that one feels (e.g., believing that feeling that one cannot perform a task implies that one actually cannot perform the task). Projection, reaction formation, and intellectualization are all defense mechanisms.

C. Approximately 5% of patients receiving long-term lithium therapy will develop hypothyroidism compared to 0.3% to 1.3% of the general population who will develop noniatrogenic hypothyroidism. A patient with antithyroid antibodies prior to starting lithium therapy will have a greater chance of developing hypothyroidism.

B. Lung cancers are the primary cancers most likely to metastasize to the brain, with breast cancers being the second most common, with melanoma third, colon cancers fourth, rectal cancers fifth, and renal cancers sixth in order of occurrence.

D. A lesion in the middle cerebral artery territory will result in contralateral hemiparesis and contralateral hemisensory loss of the face, arm, and hand. If a lesion develops in the dominant hemisphere, which is typically the left side, aphasia also can be seen. A contralateral homonymous hemianopsia also can occur as well as limb ataxia, astereognosis, and agraphesthesia. A lesion in the posterior cerebral artery territory would not result in arm and hand weakness. A lesion involving the internal carotid artery territory could resemble a middle cerebral artery lesion; however, the lesion here is on the left. A posterior inferior cerebellar artery lesion would not present with the previously mentioned symptoms and would include ipsilateral facial sensory loss, contralateral pain and temperature loss, and ipsilateral Horner’ s syndrome (ptosis, miosis, and anhidrosis).

A. Axonal plaques are areas of the nervous system where the axons have become demyelinated in MS. Neurofibrillary tangles, Hirano bodies and granulovacuolar degeneration are all seen in Alzheimer’s disease and not in MS.

E. Cardiomyopathy is seen in more than 50% of Friedreich’ s ataxia cases. Many of these patients die of a cardiac arrhythmia or congestive heart failure. A minority of patients may abruptly become ataxic after febrile illness, and infrequently one leg may become clumsy before the other. Hand incoordination is a later finding with dysarthria occurring even further in the course of the illness.

A. Triphasic waves are generalized bisynchronous waves that occur in brief runs. Half the patients with triphasic waves have hepatic encephalopathy with the other half having other toxic-metabolic encephalopathies like uremic encephalopathy. PLEDs are seen in acute destructive cerebral lesions. They are characterized by recurrent focal epileptiform discharges (1 to 2 cycles per second [cps]) in the setting of focally slow/attenuated background activity. PLEDs are seen in acute cerebral infarction, cerebral abscess, and anoxia. Periodic complexes are seen in subacute sclerosis panencephalitis and Creutzfeld-Jakob disease where patients present with myoclonic jerks. Beta waves (13 to 25 cps) are usually seen in frontal and central regions. They become prominent when the people become anxious, concentrate, or use sedative-hypnotic medications. Delta waves (1 to 3 cps) are seen in children or when people enter deep sleep and are usually absent in awake, alert, and healthy adults. The presence of diffuse delta waves on an EEG recording suggests a metabolic abnormality or degenerative illness.

B. This patient is demonstrating “alien hand syndrome,” an extreme form of hemi-inattention in which the patient believes that he or she does not possess his or her hand (usually the left) and that it is moving either independently or under someone else’ s power. The limb maintains some basic sensory and motor functions and may perform simple tasks, but the patient does not feel aware or in control of these. Hemi-inattention refers to the neglect of sensory stimuli, including visual and tactile, which originate from the patient’ s left side. It is generally the result of injury to the nondominant parietal lobe cortex and the underlying thalamus and reticular activating system.

B. Primary cerebral lymphomas occur in patients who are immuonsuppressed, including patients with AIDS. They are typically aggressive and patients often present with focal findings, evidence of intracranial pressure, or confusion. All of the tumors listed are primary brain tumors. Oligodendrogliomas are rare tumors, which typically grow slowly; cerebellar astrocytomas tend to occur in children. Astrocytoma and medulloblastomas typically occur in the cerebellum. One would not typically expect a pituitary adenoma to cause a right-sided hemiparesis; these patients usually present with bilateral hemianopsia.

C. The most common sports-related head trauma is a concussion, which causes a short change in mental status with or without loss of consciousness. A contusion is less common and involves minor intracranial bleeding. An epidural hematoma is most commonly seen after a temporal bone fracture, subdural hematomas are frequently seen in elderly people, and subarachnoid hemorrhages are usually the result of a ruptured aneurysm.

B. The Glasgow Coma Scale is used in the ER and other acute care settings to predict the patient’ s risk of mortality. It consists of three different sections, which include motor, eye, and verbal components. In patients with Glasgow Coma Scale scores of less than 8, the mortality rates can be as high as 71%. Although this scale is useful in grading the severity of a case, and thereby predicts the risk of complications, its most useful function is to assess the outcome or risk of mortality.

C. Lesions in the afferent fibers of peripheral nerves, dorsal roots, or dorsal columns of the spinal cord present with sensory ataxia. Patients are unaware of their leg positioning and, therefore, loose balance when they close their eyes (positive Romberg sign). Patients with cerebellar ataxia have balance problems when their feet are held together, regardless of whether their eyes are open or closed. The frontal and temporal cortices are not involved in gait.

E. Involvement of the central nervous system (CNS) occurs in 5% of the patients with sarcoidosis. The parts most frequently involved are the cranial nerves, meninges, hypothalamus, and pituitary. Granulomatous meningitis affects mainly the basal brain regions. Involvement of the hypothalamus and third ventricular region leads to somnolence, obesity, hyperthermia, memory difficulties, or a change of personality. Pituitary involvement may present as menstrual disturbances, diabetes insipidus, and other endocrine disturbances. Neurosarcoidosis is often accompanied by mental disturbance. Hydrocephalus may arise as a consequence of basal meningitis or CSF obstruction due to granulomatous masses. Metabolic disturbances, such as hypercalcemia and renal failure, may contribute to psychiatric symptoms as does steroid therapy. Although liver involvement occurs in 90% of the cases, liver dysfunction is not usually clinically important. Only 20% to 30% of the patients have hepatomegaly or biochemical evidence of liver dysfunction.

B. Monoamine oxidase A inhibitors should not be taken with levodopa because doing so could precipitate a hypertensive crisis. For this reason, phenelzine is contraindicated when a patient is taking levodopa.

C. As the brain ages, there is a decrease in the weight of the brain with widening of sulci and an enlargement of the ventricles. There is also slight reduction in the blood flow to the brain. Lewy bodies are inclusion bodies that are found in neurons of the cerebral cortex and are associated with Lewy body dementia. They are also found in the basal ganglia of patients with Parkinson’s disease.

D. The PS-1 on chromosome 14 has been recognized as a major locus for Alzheimer’ s disease in early onset familial Alzheimer’s disease, contributing to as many as 70% of the cases. A coding DNA sequence showing high homology to the PS-1 gene on chromosome 14 was found to map within the chromosome 1 region of interest for Alzheimer’ s disease, which was subsequently named presenilin-2 (PS-2). Missense mutations have been found in PS-2 in several families with early onset Alzheimer’s disease. Individuals with Down syndrome (trisomy 21) develop an early onset dementia that is clinically and histopathologically indistinguishable from Alzheimer’s disease. For this reason, chromosome 21 was considered to be an excellent candidate region for initial genetic studies of Alzheimer’s disease. A number of missense mutations identified near or within the β-amyloid sequence of the Amyloid precursor protein (APP) on chromosome 21 are present in families with early onset Alzheimer’s disease. A linkage study using markers in late-onset Alzheimer’s disease families found a susceptibility gene on the long arm of chromosome 19. A candidate gene known to map to this is the apolipoprotein E (apoE) lipoprotein gene.

E. MMPI is an example of objective personality testing, whereas Rorschach, TAT, Draw-A-Person, and APT are all examples of projective personality tests.

A. Although it is important for patients to be aware of the fee schedule for their visits, it is not part of the accepted standard of information disclosure for any given psychiatric treatment. The five main elements in the accepted standard for information disclosure are diagnosis, available treatments, consequences of these treatments, alternative treatments, and their risks and prognosis.

B. In DSM-IV-TR, malingering is described as an “additional condition that may be the focus of clinical attention,” and is recorded as a “V code” on axis 1. Most “V codes” are documented on axis I with the exception of borderline intellectual functioning, which is recorded on axis II. Malingering and other “V codes” are not considered mental disorders. Other examples include: noncompliance with treatment, bereavement, religious, or spiritual problem. Personality traits, personality disorders, defense mechanisms, mental retardation, and borderline intellectual function are all coded on axis II.

E. This patient is presenting with a culture bound syndrome called “Brain fag.” It is usually seen in male students from Nigeria and Saharan Africa and it is thought to be caused by stress at school. These patients usually complain of unpleasant feelings in the head, visual problems, poor memory, fatigue, and sleepiness. It is thought to be a form of anxiety, depression, or somatoform disorder, which responds well to relaxation therapy, antidepressants, and anxiolytics. Koro is a CBS seen in Malaysia and South East Asia, which is characterized by symptoms of anxiety with the fear that the genitalia will be retracted completely into the abdomen and then the person would die. Latah is a CBS seen in Malaysia and is characterized by hypersensitivity to sudden fright, echopraxia, echolalia, command obedience, and a trancelike state and is commonly seen in women of lower socioeconomic status. Amok is another CBS seen in Malaysia and is characterized by brooding, homicidal frenzy, exhaustion, and amnesia. Pibloktoq, also called “Arctic Hysteria,” is seen in Eskimos in the Arctic and sub-Arctic regions and is more common in women. It is characterized by severe agitation/excitement and is followed by seizures and a transient coma after which the victim sleeps for many hours and then resumes normal function.

A. Late onset, obvious precipitating factors, acute onset, good premorbid functioning, mood symptoms, being married, family history of mood disorders, good support systems, and predominant positive symptoms are all considered good prognostic factors in schizophrenia. Poor prognostic factors include young age at onset, lack of precipitating factors, insidious onset, poor premorbid functioning, family history of schizophrenia, poor support systems, and predominant negative symptoms.

B. The DSM-IV-TR criteria for somatization disorder include a history of many physical complaints beginning before the age of 30 years, impairment in functioning, and the occurrence of four pain symptoms, two gastrointestinal symptoms, one sexual (or reproductive) symptom, and one pseudoneurological symptom. The symptoms cannot be intentionally produced or feigned.

E. Tricyclic antidepressants and SSRIs have been shown to be beneficial in cataplexy. Amphetamines and modafinil improve wakefulness, and hence target symptoms of narcolepsy, not cataplexy. Benzodiazepines and phenobarbitone are obviously contraindicated in narcolepsy-cataplexy.

B. Buspirone is a partial agonist at the postsynaptic 5-hydroxytryptamine1A (5-HT_1A) receptor. As an augmentation agent, it works to enhance the activity of SSRIs through the 5-HT_1A receptors. Bupropion produces its antidepressant effects by blocking the reuptake of dopamine and norepinephrine. Unlike buspirone, it is an antidepressant monotherapy agent. The evidence for efficacy of either medication for augmentation of SSRIs, up till this point, has been derived from case reports, case series, and small, inconclusive placebo-controlled trials. In the STAR*D trial, sustained-release bupropion produced a greater reduction in the number of and severity of symptoms and had fewer side effects and adverse reactions than buspirone. Although, rates of remission on the Hamilton Rating Scaled for Depression (HSRD-17) were 29.7% for sustained release bupropion and 30.1% for buspirone.

C. Tremor is seen in 5% to 10% percent of patients taking SSRIs, a frequency two to four times that of placebo. SSRIs may cause akathisia, dystonia, tremor, cogwheel rigidity, torticollis, opisthotonos, gait disorders, and bradykinesia. Also cases of tardive dyskinesia have been reported. Patients with Parkinson’s disease or spasticity may experience some worsening of their motor symptoms when taking an SSRI. Extrapyramidal effects are most closely associated with fluoxetine, particularly at doses >40 mg/day. The pathogenesis of such adverse reactions is unknown, but it has been hypothesized that they may be caused by serotonergically mediated inhibition of dopaminergic transmission.

C. Dopamine receptor antagonists have been shown to lower seizure threshold and this effect is greater with low-potency antipsychotic medications. Clinically, those with a history of seizure disorders are at greater risk of this adverse effect thus it is preferable to use a high-potency antipsychotic medication in patients with seizure disorders.

D. Generally, it makes sense to wait on starting an antidepressant for a patient who presents to the ER in this manner until clinicians have managed to do a more thorough evaluation. It does make sense, however, to order a CBC with differential, chemistry panel (including LFTs), thyroid functions tests, rapid plasma reagin (RPR), EKG, and urine toxicology so that this information will be available before the patient is started on an antidepressant. All of the other choices are essential parts of the interview process. Of note, one wants to particularly ascertain whether the patient is experiencing command auditory hallucinations, the content of the hallucinations, and how long the patient has been hearing them. Also of note, untreated pain, once treated, can result in an alleviation of suicidal ideation.

D. Schizophrenia is associated with spontaneous TD rate in otherwise healthy young adults of about 0.5% per year when compared to the normal population. After the age of 60 years, spontaneous TD occurs at about 0.5% per year in the general population. The risk of TD is highest in the first 5 years of treatment with typical antipsychotics, and the incidence of decreases after this period. Approximately 20% of patients develop TD in the first 3 years of treatment with typical antipsychotics. In the elderly, the risk of TD in patients with schizophrenia who are treated with typical antipsychotics is as high as 29%, and rises to approximately 63% after 3 years. The risk of an elderly patient developing TD in the first year is approximately five times higher than a younger patient who is treated with a typical antipsychotic.

A. The best known principles in medical ethics are those described by philosophers Tom Beauchamp, James Childress and Raanon Gillon. The four ethical principles described by them include: autonomy, beneficence, nonmaleficence, and justice. They described these four principles as being pertinent in any medical ethical problem (i.e., prima facie). In each case, the relevant ethical principles should be considered, weighed appropriately, and a conclusion should be reached only after appropriately balancing these principles. Autonomy versus shame and doubt and basic trust versus basic mistrust are Erikson’s epigenetic stages and not ethical dilemmas.

D. In transcortical motor aphasia, repetition and comprehension are intact but speech is nonfluent. In Wernicke’s aphasia, repetition and comprehension are impaired and speech is fluent. In Broca’s aphasia, speech is nonfluent and repetition is impaired, whereas comprehension is intact. In conduction aphasia, repetition is impaired, comprehension is spared, and speech is fluent. In transcortical sensory aphasia, speech is fluent, comprehension is impaired, and repetition is intact.