B. This child is 9 months old. Nine-month-old children should be very attentive to people and things around them. They are able to point at things and are able to pick things up between their finger and thumb. They can sit unsupported, and some of them start crawling. They usually babble and shout and clearly distinguish people they know from strangers. They are able to pull themselves up, but cannot lower themselves without help. A 6-month-old child is unable to pull himself up. A 12-month-old child can pull himself up and sit down.

C. K complexes are negative sharp waves followed by positive slow waves found on EEG in stage II sleep. High amplitude slow waves, or delta waves, occupying >50% of epoch are found in stage IV sleep. Alpha activity is seen in wakefulness when the patient’s eyes are closed. Slow alpha activity is seen in REM sleep. Theta activity is seen in stage I and REM sleep. High amplitude slow waves, or delta waves, occupying 20% to 50% of epoch are seen in stage III sleep.

C. This patient is exhibiting mixed transcortical aphasia or isolation aphasia. The pattern of speech is equivalent to global aphasia with preserved repetition. These patients do not speak unless spoken to and show classic echolalia. Their ability to name objects, read out loud, and to comprehend reading and writing are severely impaired. Damage to both the anterior and posterior vascular borderzone cortical areas (watershed area) of the left hemisphere is responsible for this pattern of speech impairment. It occurs in its pure form in individuals with acute left internal carotid occlusion, residuals of severe cerebral edema, or prolonged hypoxia due to cardiac or respiratory arrest. Anomia is the inability to name objects and it can be seen in small strokes or dementias. Conduction aphasia is due to a lesion of the arcuate fasciculus, which connects the Wernicke’s and Broca’s areas. Wernicke’s aphasia, also called sensory aphasia or receptive aphasia, is due to a lesion of the posterosuperior portion of the first temporal gyrus of the left temporal lobe. Broca’s aphasia occurs due to a lesion to the suprasylvian area extending from the Broca’s area to the posterior extent of the sylvian fissure.

D. Type II error occurs when there is a true difference between the two groups, regardless of how small the difference. The test does not detect this difference, because this difference does not exceed the threshold for statistical significance. In a diagnostic test, a type II error would be considered to be equivalent to a false negative result. Type II error is also known as a beta error.

E. Although increases in CSF volume, ventricular volume, and high-intensity lesion volume, as well as decreases in cerebral hemisphere volume, have been seen in healthy control subjects, it has been shown that hippocampal volume is diminished in patients with Alzheimer’s disease, and not normal aging.

B. Dissociative fugue is characterized by purposeful travel away from home or the usual place of stay/operations with an inability to recall the past, either partially or completely. There are three types of fugue: fugue with awareness of loss of personal identity, fugue with change in personal identity, and fugue with retrograde amnesia. Fugue usually occurs in the wake of a traumatic episode, such as rape, childhood sexual abuse, natural disasters, wars/combat situations, and social dislocations, which results in the urge to flee.

C. Several studies have tried to find different risk factors associated to PTSD to try to intervene as early as possible in susceptible individuals. Some of the risk factors found to date include higher levels of anxiety in the peri-event period, female gender, being involved in litigation, previous psychiatric history, autonomic hyperarousal, acute stress symptoms, and persistent medical problems. Previous substance abuse has not been associated with a higher risk of developing PTSD.

C. This patient is presenting with symptoms consistent with an adjustment disorder. The most recommended treatment for an acute adjustment disorder (less than 6 months) is supportive psychotherapy. Pharmacological options, such as SSRIs, have been tried empirically in patients with adjustment disorders, but there is little evidence for their use when a patient does not meet criteria for major depressive disorders. Long-term psychodynamic psychotherapy could be considered if the patient’s symptoms did not improve gradually, but it should not be considered as the best initial approach. This patient does not meet criteria for inpatient psychiatric admission at this point.

E. All the statements regarding the prognosis of elderly patients with bipolar disorder are true.

C. Sex therapy as a treatment modality for sexual dysfunction typically requires a supportive and healthy relationship to best allow for collaborative work by both members of the couple.

D. N-acetyl cysteine is an antioxidant. It is used in the treatment of acetaminophen toxicity. It exerts glutamate-modulating properties by its conversion to cystine, which is a substrate for the glutamate/cystine antiporter that is located on glial cells. The uptake of cystine by glia corresponds to increased release of glutamate into the extrasynaptic space, resulting in stimulation of metabotropic receptors that are inhibitory in nature. It is proposed that N-acetyl cysteine improves clearance of synaptic glutamate by glial cells. N-acetyl cysteine is hence a promising drug for use in treatment-resistant OCD, because glutamatergic dysfunction has been suggested to be a significant neurobiological correlate of OCD.

B. In 1938, Cerletti and Bini induced seizures in a human patient with electricity. Prior to that, Meduna had used pentylenetetrazol (Metrazol) and intramuscular camphor to induce therapeutic seizures chemically. Freud developed psychoanalysis, and Jung was his contemporary. Kesey, of course, wrote the book One Flew Over the Cuckoo’s Nest, which was made into a movie that portrayed ECT harshly.

B. IPT focuses on life events that occur after early childhood. The others are the four main problem areas generally cited as areas for focus with IPT.

A. The symptoms of trigeminal neuralgia (tic douloureux) include persistent burning, unprovoked paroxysms of lancinating pain, and dysesthesias. Even innocuous stimuli applied to the affected region may produce severe pain (allodynia) at times. Carbamazepine is the drug of choice for the treatment of trigeminal neuralgia (tic douloureux). It is more effective for this condition than phenytoin, which is also an effective treatment. Clonazepam may have a role in neuropathic pain. Tricyclic antidepressants have shown effectiveness in the treatment of chronic pain, especially neuropathic pain. The use of opioids for neuropathic pain remains controversial, because studies have been small, have yielded equivocal results, and have not established the long-term risk-benefit ratio of this treatment.

E. The main purpose of informed consent is to promote individual autonomy. There are three essential ingredients to informed consent. They are competency, information, and volition. Competency refers to the clinician’s determination whether or not to accept the patient’s treatment decision. The patient must be given adequate information regarding the treatment proposed. The patient must voluntarily either consent to or refuse the proposed therapy. There are four basic exceptions to obtaining informed consent. They are emergencies, incompetence, therapeutic privilege, and waiver. When emergency treatment is necessary to save a life or prevent imminent serious harm and it is impossible to obtain the patient’s consent, the law will presume consent is granted. This exception does not apply if the patient is competent and refusing treatment (e.g., in the case of blood transfusion in a Jehovah’s Witness). Under the condition that someone lacks sufficient capacity to provide consent or has been judged legally incompetent, then consent is obtained from a substitute decision-maker. Therapeutic privilege is the most difficult to apply. Essentially, the exception allows that informed consent may not be required if a psychiatrist determines that a complete disclosure of possible risks and alternatives may have a negative impact on the patient’s health and welfare. Waiver constitutes that a physician need not disclose the risks of treatment when the patient has competently, knowingly, and voluntarily waived his or her right for information. Finally, mental retardation does not create a general exception to obtaining informed consent. There are different degrees of mental retardation, ranging from mild to profound, and patients may or may not be able to provide consent depending upon the extent of the patient’s illness and the specific situation in question.

C. The ventricular system is filled with CSF, which is a colorless liquid containing low concentrations of protein, glucose, and potassium and relatively high concentrations of sodium and chloride. The CSF circulates through the lateral ventricles to the third ventricle and then to the fourth ventricle. It then flows through the medial and lateral apertures to the cisterna magna and pontine cistern to travel over the cerebral hemispheres and is then absorbed by the arachnoid villi to be released into the superior sagittal sinus. Interruption to the flow of CSF causes hydrocephalus. CSF acts to cushion the brain against trauma, to maintain the extracellular environment of the brain, and to transport the endocrine hormones.

A. Monocular quadrantanopsia, hemianopsias, scotomas, and blindness occur due to an injury to the optic nerve.

A. The pattern of development of Parkinson’s disease is consistent with a multifactorial etiology. Although no clear cause has been found, multiple studies have found that cigarette smoking and coffee drinking are protective.

In the 1980s, a group of young opiate abusers developed acute Parkinsonian symptoms after intravenous injection of MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine), a meperidine derivative. MPTP was found to have a direct toxic effect on the cells of the substania nigra with depletion of dopaminergic neurons. In animal studies, the neuronal changes predate the onset of clinical symptoms, so it was theorized that early exposure to viral infection or toxins, such as pesticides, would kill dopaminergic neurons until a certain threshold of loss had been reached, resulting in the disease state in genetically vulnerable individuals. This was thought to implicate an interplay of genetic and environmental causes.

B. Brainstem auditory evoked potentials (BAER) will help us decide on continued care for this unfortunate child. An abnormal brainstem auditory evoked response is indicative of brainstem damage and can be used for prognostic purposes in patients with head trauma. In a BAER, a series of clicks sequentially activates cranial nerve VIII, the cochlear nucleus, the superior olivary nucleus, the lateral lemniscus, and the inferior colliculus. Interpretation of the BAER is based on the time interval between the initial waves and the interpeak latencies. The BAER can also be used to evaluate hearing in patients unable to cooperate with behaviorally based hearing tests (infants).

E. Although much of the use of BOLD fMRI has been in research involving changes in cerebral blood flow during language, motor, and cognitive activation, it has proven very useful in presurgical mapping of these same pathways, aiding in more precision and preservation of as much intact functioning as possible after neurosurgical intervention.

D. This patient’s symptoms are characteristic of cervical spondylosis, in which degenerative changes of the annulus fibrosus can eventually lead to compression of the spinal cord or nerve roots. An MRI is often helpful in visualizing the compression of the spinal cord and narrowing or absence of the CSF space surrounding the spinal cord. Neck and arm pain are not typical features of multiple sclerosis. Calcification and narrowed disc space can occur in both cervical spondylosis and osteoarthritis. Amyotrophic lateral sclerosis is purely a motor disease and usually presents with muscle weakness and atrophy and not sensory symptoms like pain.

B. The most likely diagnosis is the Miller-Fischer syndrome, a variant of Guillain-Barré syndrome. Anti-G1Qb antibodies are found in the serum in over 90% of the cases. The classic triad of Miller Fisher syndrome is ataxia, opthalmoplegia, and areflexia. Ataxia, confusion, and opthalmoplegia is the triad of Wernicke’s encephalopathy. Ataxia, urinary incontinence, and dementia constitute the triad of normal pressure hydrocephalus.

C. Peripheral nerve involvement is common in diabetes mellitus. It may be characterized by polyneuropathy which is mixed (sensory, motor, and autonomic) in 70% of cases or predominantly sensory in the remaining 30%. Polyneuropathy is generally symmetric with greater involvement of the distal lower extremities than the upper limbs. It often manifests as impaired vibratory sense in the legs along with depressed tendon reflexes. Mononeuropathy multiplex occurs in a mixed distribution. Mononeuropathy simplex can involve the peripheral nerves (i.e., ulnar, median, radial, lateral femoral cutaneous, sciatic, peroneal, and others, or the cranial nerves, (CN), CNIII > CNVI > CNVII). Diabetic amyotrophy is due to plexopathy or polyradiculoneuropathy. Pain, weakness, and atrophy of the pelvic girdle and thigh muscles are characteristic. Quadriceps reflexes are absent and there is little sensory loss. The distribution is asymmetric and proximal. Diabetes is not associated with syringomyelia, cavitation of the spinal cord, in which there is usually sensory loss and wasting of the muscles at the level of the lesion.

A. Myotonic dystrophy is a dominantly inherited disorder. It is caused by a CTG repeat. There is weakness and wasting of the facial, sternocleidomastoid, and distal limb muscles. Patients may have cataracts, frontal baldness, testicular atrophy, diabetes mellitus, cardiac abnormalities, and intellectual changes. The disorder usually becomes apparent in the third or fourth decade, although it may occur earlier. Myotonia congentia (Thomsen’s disease) is inherited as a dominant trait. It is caused by a mutation on chromosome 7q35. Symptoms may not develop until early childhood and include muscle hypertrophy and muscle stiffness, which is enhanced by cold and inactivity and relieved by exercise. Inclusion body myositis is more common in men. It has an insidious onset and usually begins after age 50. There is painless proximal weakness of the lower and then the upper extremities. The course is progressive. The etiology suggests T-cell mediated myocytotoxicity and multifactorial genetic susceptibility. Duchenne’s dystrophy is an X-linked recessive disorder. Symptoms begin by age 5. Early signs include impaired toe walking, waddling gait, and inability to run. Weakness is pronounced in the proximal lower extremities. Patients with this disorder may be incapable of rising from a supine position without using their arms to climb up their body, Gower’s sign. Pseudohypertrophy of the calves caused by fatty infiltration of muscle occurs commonly. The genetic defect responsible for Duchenne’s dystrophy is located on the short arm of the X chromosome. It codes for the protein dystrophin, which is absent or reduced in the muscle of patients with this disorder. Paramyotonia congenita is dominantly inherited and involves mutation of the SCN4A gene. Weakness and myotonia (i.e., an abnormality of muscle fiber membranes, which leads to muscle stiffness) are provoked by cold and worsened by exercise. Attacks of hyperkalemic periodic paralysis may also occur.

B. On average, 30% to 50% of patients develop depression following a stroke. The involvement of the frontal lobe was once thought to be a correlate for depression; however, recent studies have challenged this claim. Older age, functional disability, aphasia, cognitive impairment, and a slower recovery than expected, given the deficits, are all associated with post-stroke depression.

B. Functional recovery from traumatic brain injury is usually measured on the Glasgow Outcome Scale, which ranges from “good recovery” to “death.” The Glasgow Coma Scale measures a patient’s level of consciousness based on readily apparent neurological functions including eye opening, best verbal response, and best motor response. The Global Assessment of Functioning is recorded on axis V of a DSM-IV-TR diagnosis and is considered a composite of three major areas: social, occupational, and psychological functioning. The Scales for the Assessment of Negative and Positive Symptoms were developed by Dr. Nancy Andreason to evaluate symptoms of schizophrenia.

B. This child is approximately 24 months old. Children at this age run and are able to start and stop without major problems. They squat and climb on furniture. They can go up and down the stairs holding onto the rail, and can throw a ball forwards. They are not able to use pedals yet. They can build a tower of six blocks and are able to hold a pencil. They usually use around 50 words and can form simple sentences and can carry out simple instructions. They can feed themselves with a spoon and like parallel play. A 15-month-old child is unable to run yet. A child 36 months or older is able to use pedals, can throw and catch a ball, and builds a tower of at least nine cubes.

B. Muscle twitches are characteristic of the phasic (episodic) component of REM sleep. Theta activity and an activated EEG similar to stage I sleep are characteristics of the tonic (persistent) phase of REM sleep. Extraocular muscle atonia is not seen in REM sleep. Diaphragmatic atonia during sleep is not compatible with life.

C. Each of the scenarios depicts examples of operant conditioning. Operant conditioning, elaborated upon by B.F. Skinner, describes a form of learning in which behavior is either increased or decreased via the application of positive and negative consequences. In negative reinforcement (scenario C), behavior (sitting in the back of class) is increased because the behavior removes an aversive consequence (being called upon in class). Scenario A depicts punishment, whereby an aversive consequence (being sent to his room) leads to a reduction in the child’s behavior (hitting the sibling). Scenarios B and E depict positive reinforcement: positive reinforcers (money and praise, respectively) result in an increase in behavior (achieving good grades and cleaning the room, respectively). Finally, scenario D depicts extinction, where the removal of a positive reinforcer (mother’s attention) results in a reduction in behavior (child’s crying).

B. Power is the term given to a study’s ability to detect a true difference when such a difference truly exists. In a diagnostic test, the power is equivalent to a true-positive result. In general, a large number of subjects are usually required for the power of the study to be able to detect a real difference between the groups.

A. The Rorschach test is a projective personality test as opposed to an objective one in the sense that, rather than lending itself to numerical analysis, it forces the test takers to impute their own meanings onto the test object. The Rorschach involves showing patients inkblots and evaluating their responses to, for example, form, color, and shading. The way patients respond to the color of an inkblot, for example, is viewed as reflecting their emotional responses. Only among highly skilled clinicians are its results reliable. It is not a test of organic brain function.

B. This patient is most likely to have an insulinoma, a tumor of the islet cells of the pancreas, which results in a triad of symptoms: hypoglycemia, central nervous system (CNS) dysfunction and a reversal of CNS dysfunction on glucose administration. This insulinoma is possibly causing episodes of hypoglycemia and the feelings of depersonalization. Depersonalization is a symptom that may be observed in a variety of conditions, which may be neurological (such as epilepsy, migraine, etc.), toxic and metabolic (hypoglycemia, hypothyroidism, hypoparathyroidism, carbon monoxide poisoning, etc.), psychiatric (schizophrenia, anxiety disorders, etc.), in normal people (in conditions such as exhaustion or emotional shock), and hemidepersonalization (usually in right parietal lobe lesions). To diagnose a Depersonalization Disorder (according to DSM-IV-TR), these episodes of depersonalization should not be due to a general medical condition. In this case, depersonalization is a symptom and not a disorder given that the patient has an insulinoma that is causing hypoglycemia resulting in depersonalization. It should subside following complete surgical resection of the tumor. According to the DSM-IV-TR, derealization unaccompanied by depersonalization in adults is classified as a “Dissociative Disorder NOS”

C. This patient is experiencing an acute stress disorder, which is characterized by the development of anxiety and specific symptoms within 4 weeks after being exposed to a traumatic event. The prevalence ranges from 14% to 33% in persons exposed to severe trauma. Patients feel numb or detached during the event and may have dissociative amnesia. They usually re-experience the event through thoughts, dreams, or flashbacks and tend to avoid situations that can trigger memories of the event. The disturbance must cause significant distress or impairment in the patient’s functioning, and it must last between 2 days and 4 weeks in order to be considered an acute stress disorder. PTSD stress disorder requires the presence of symptoms for more than a month. In generalized anxiety disorder, patients have usually not been exposed to a traumatic event and tend to worry about situations that should usually not cause such stress. Although a stressor also triggers adjustment disorder, the stressor does not have to be as extreme as the one in acute stress disorder and it can involve a wide array of possible symptoms, which are not as specific as the ones for acute stress disorder.

E. This patient is presenting with symptoms of an adjustment disorder. Adjustment disorders are characterized by an emotional response to a stressful event, such as a break-up, medical, or financial problems. Patients develop unspecific symptoms that do not fit the criteria for any other axis I diagnosis and that cause some impairment in social or emotional functioning. An acute stress disorder is characterized by the presence of a life-threatening or very disturbing events such as a natural disaster or abuse, and it includes very specific symptoms, such as hyperarousal and nightmares. This patient does not meet criteria for major depressive disorder. Dysthimia is a chronic disorder that is characterized by minor depressive symptoms that are present more often than not for at least 2 years. In cyclothymic disorder, the patient presents with fluctuating mood with separate episodes of hypomanic and depressive symptoms for a 2-year period.

A. All the statements are true except that carbamazepine is a second line drug for the treatment of a manic episode in the elderly. Lithium and divalproex sodium are the first-line drugs for the treatment of a manic episode.

E. Buprenorphine is a partial opioid agonist approved for use as replacement therapy in the treatment of opioid dependence. It is a schedule III narcotic, which may only be prescribed by physicians who meet certain qualifying requirements. It is available in sublingual and injectable forms, and its long half life allows for dosing once a day or every other day. Methadone is a long-acting synthetic opioid with agonist effects at mu receptors, which is used for abstinence in opioid-addicted patients. It prevents opioid withdrawal symptoms while having minimal euphoric effects. Unlike buprenorphine, methadone is only prescribed by specialized treatment centers. LAAM is an mu-receptor agonist very similar to methadone, but with a longer half life (it may be dosed 3 times per week). Clonidine is an alpha-2 agonist that is frequently used for the treatment of acute opioid withdrawal. Naltrexone is a semisynthetic opioid antagonist at mu receptors used for the treatment of both alcohol and opioid dependence.

B. The treatment modalities used in the different levels of the STAR*D trial are as follows:

E. All of the statements are indications for ECT, especially mood disorders, disorders refractory to pharmacotherapy, and conditions requiring a rapid response, when there is a strong preference or a history of response to ECT. ECT should not always be considered merely a treatment of last resort.

C. This patient has developed NMS, and a dose change in typical high-potency antipsychotics is usually antecedent, although other antipsychotics may also be causative. Concurrent lithium use increases the risk for NMS and may cause leukocytosis, but is usually not causative for the full presentation of NMS. Serotonin syndrome from citalopram would have a different presentation with prominent hyperthermia, hypertonicity, and myoclonus. Clonazepam or benztropine intoxication may cause delirium, and benzodiazepine withdrawal can be associated with hypertension, but neither is known to cause the symptom pattern mentioned.

E. Antidepressants have shown efficacy in the treatment of a number of medical disorders. With regard to TCAs, amitriptyline has been used in the treatment of migraine and cluster headaches. Amitriptyline and doxepin may be more effective for diabetic neuropathy than serotonin reuptake inhibitors. TCAs also may be useful in facial pain, fibrositis, and arthritis. However, they have not been useful in the treatment of low back pain and cancer pain. Desipramine has also been used in the treatment of cocaine craving. Protriptyline may be helpful in the treatment of sleep apnea. Uncommon uses include the treatment of peptic ulcer disease, because many tricyclics are potent histamine blockers, particularly doxepin and amytriptyline. Finally, their quinidine-like effect makes them plausible anti-arrhythmic agents.

C. Major depression in the medically ill does not typically cause a patient to be unable to render medical decisions. Depression may influence a patient’s ability to tolerate uncomfortable symptoms, maintain hope, and assess a treatment’s risk-benefit ratio. Untreated depression has been linked to poor compliance with medical care, increased pain and disability, and a greater likelihood of considering euthanasia and physician-assisted suicide. However, refusal of life-saving treatment by a depressed patient should not be assumed to constitute suicidality and/or lack of decision-making capacity. Depressed patients should be encouraged to begin treatment for their depression. Decisions overriding refusal of medical treatment should be based on whether or not the patient lacks decision making capacity and not solely on their depressed mood.

D. The thalamus is the largest portion of the diencephalon which is located medial to the basal ganglia and serves as a major synaptic relay station for the information reaching the cerebral cortex. It can be divided on an anatomical basis into six groups of nuclei: anterior, medial, lateral, reticular, intralaminar, and midline nuclei. The myelinated fibers of the internal medullary lamina divide the anterior, medial, and lateral groups of nuclei. The lateral group of nuclei is covered by the myelinated fibers of the external medullary lamina. In between the external medullary lamina and the internal capsule are a group of neurons that form the reticular nucleus of the thalamus. The medial geniculate nuclei receive afferents from inferior colliculus and project to the visual cortex. Lateral geniculate nuclei receive afferents from the optic tract and project to the visual cortex. The ventral posterior medial nuclei of the thalamus receive the afferents from the sensory nuclei of the trigeminal nerve and project to the somatosensory cortex.

C. Injury to the optic tract between the optic chiasm and occipital cortex produces homonymous quadrantanopsia and hemianopsia. It is most commonly associated with middle cerebral artery infarction, where it also produces hemisensory loss and hemiparesis.

D. Friedreich’s ataxia has an autosomal recessive inheritance, with greater than 96% of affected individuals found to have a GAA triplet-repeat expansion in the FXN gene on chromosome 9. Onset of symptoms is generally between ages 10 to 15, although there can be a wide range of onset. The initial presenting symptoms are usually gait ataxia, followed by slurring of speech, and arm ataxia with later lower extremity weakness and loss of position and vibration sense. Two thirds of the affected individuals also have scoliosis and/or hypertrophic cardiomyopathy. Diabetes mellitus, visual deficits, and hearing deficits may also occur. The life span of affected children used to be in the mid-thirties, but with improved treatment and physical mobility, and greater monitoring of cardiac problems, life expectancy has increased.

E. When epilepsy is suspected, an EEG is the most useful diagnostic test to obtain. The presence of characteristic interictal EDs are diagnostic, although their absence does not exclude the diagnosis of epilepsy. In patients with epilepsy, only 30% to 50% have EEGs with EDs on the first study. Of patients with epilepsy, 60% to 90% will have documented EDs by the third EEG; further EEGs after this time have not been shown to increase the yield of the test. To improve the likelihood of interictal discharges being detected on EEG, obtaining the study under sleeping or sleep-deprived conditions, while the patient is hyperventilating, and during exposure to photic stimulation have been successfully employed. Even with these measures, 10% to 40% of individuals with epilepsy will have negative interictal EEGs.

A. The MMPI is an extensively researched and widely used personality assessment test. It is an objective personality test and has the distinctive feature of validity scales, which assess the test taker’s disposition while taking the test. In part, because it takes into account the complexities of such variables as social and educational backgrounds and may incorporate racial and religious variables, it requires significant experience to interpret the results. Although developed in 1937, the test has been updated based on a contemporary sample.

C. This patient has hepatic encephalopathy, a syndrome remarkably diverse in its course and evolution. It usually appears over a period of days to weeks and may terminate fatally. With appropriate treatment, the symptoms may regress completely or fluctuate in severity for several weeks or months. The EEG is a sensitive and reliable indicator of impending coma, becoming abnormal during the earliest phases of the disordered mental state. The concentrations of blood ammonia usually are in excess of 200 mg/dL, and the severity of the neurologic and EEG disorders roughly parallels to the ammonia levels. With treatment, a fall in the ammonia levels precedes clinical improvement. The few effective means of treating this disorder include restriction of dietary protein; reduction of bowel flora by oral administration of neomycin or kanamycin, which suppresses the urease-producing organisms in the bowel; and the use of enemas. Definitive treatment, however, is liver transplantation.

B. The boy is suffering from Wilson’s disease or hepatolenticular degeneration. This is characterized by low serum levels of copper and ceruloplasmin. It is coupled with abnormally elevated levels of hepatic copper and increased 24-hour urinary copper excretion. There are two possible presentations: the hepatic and the neurological. The most common symptom in neurological presentation is difficulty in speech and swallowing, along with drooling. In the hepatic presentation, there may be jaundice, ascites, hematemesis, and melena. This condition has an autosomal recessive mode of inheritance.

E. These symptoms described are consistent with a diagnosis of Guillain-Barré syndrome (GBS). This syndrome typically follows an upper respiratory or gastrointestinal illness and is an acute inflammatory demyelinating polyradiculopathy of the peripheral nervous system. Cases following a week’s episode of watery diarrhea are often due to Campylobacter jejuni infection. GBS occasionally complicates mononucleosis, Lyme disease, hepatitis, cytomegalovirus (CMV), or HIV. Symptoms include progressive weakness of more than one limb, distal areflexia with proximal areflexia or hyporeflexia, relatively symmetric deficits, mild sensory involvement, autonomic dysfunction, increased CSF protein after 1 week, CSF WBC count <10/mm, and nerve conduction slowing or block by several weeks. Symptoms stop progressing by about 4 weeks into the illness. It can become life-threatening if the muscles of respiration or swallowing are affected. In GBS, as in most other peripheral neuropathies other than diabetic neuropathy, bladder, bowel, and sexual function are preserved. Friedreich’s ataxia is caused in many cases by a triplet repeat expansion and has an autosomal recessive inheritance. Ataxic gait, clumsiness of the hands, and other signs of cerebellar dysfunction develop. Peroneal nerve lesions occur secondary to the trauma or pressure around the knee at the head of the fibula. They result in weakness or paralysis of the foot and toe extension. They are accompanied by impaired sensation over the dorsum of the foot and lower anterior leg. The ankle reflex is preserved. Poliomyelitis is a viral infection of the anterior horn (motor neuron) cells of the spinal cord and lower brainstem. It presents with lower motor neuron (LMN) signs such as asymmetric paresis, muscle fasciculations, and absent DTRs. Sensation is not affected. Multiple sclerosis is a chronic illness in which the myelin sheaths, white matter of the nerves in the central nervous system are demyelinated, as opposed to GBS which involves demyelination of peripheral nerves. Symptoms include paresis, sensory disturbances, ataxia, ocular impairments, bladder dysfunction, and psychiatric disturbances.

E. For many years, people took tryptophan pill to treat insomnia and depression. Tryptophan is an amino acid, which is converted in the brain into serotonin. However, in 1989, the Food and Drug Administration (FDA) banned all sales of over-the-counter tryptophan because of an outbreak of Eosinophilia-Myalgia Syndrome among thousands of people taking the pill. Eosinophilia-myalgia syndrome results from tryptophan or tryptophan-containing products. Patients may develop several days of severe myalgias. They may also develop fatigue, rash, neuropathy, cardiopulmonary impairments, and mild depression. On laboratory tests, they may have an elevated number and proportion of eosinophils in the blood. These patients are often in danger of being mislabeled with chronic fatigue syndrome, because of their variable symptoms and lack of objective findings, except for eosinophilia. Chronic Fatigue Syndrome results in a generalized sense of weakness, sometimes preceded by flu-like symptoms with myalgias. Many patients also complain of impaired memory and poor concentration. Symptoms are variable and unaccompanied by objective findings. Fibromyalgia is characterized by pain and stiffness of muscles, ligaments, and tendons. There are local areas of tenderness known as “trigger points.” Pain must be present for 3 months and be widespread. Digital palpation must elicit pain in at least 11 of 18 possible tender-point sites. The illness is more common in women. The etiology is unknown, but is often precipitated by stress. There are no pathognomonic laboratory findings, and it is a diagnosis of exclusion. Fibromyalgia is often present in depressive disorders and Chronic Fatigue Syndrome. The patient’s symptoms of depression appear to be related primarily to a general medical condition, and so diagnoses of depressive disorder NOS or major depressive disorder would not be warranted at this time.

C. Athetosis, chorea, rigidity, and tremors are all involuntary movements that result from varying disorders of the basal ganglia. Spasticity results from damage to the corticospinal (pyramidal) tract.

C. Topiramate should not be used in patients taking oral birth-control (OBC). Topiramate is a cytochrome inducer and will reduce the efficacy of OBC. Other medications listed will not reduce the efficacy of OBC. Other anti-epileptic medications that should be avoided when taking OBC include carbamazepine, phenytoin, and phenobarbital.

E. This child is around 5 years of age. Children at that age can walk on a narrow line, run easily, and skip on alternate feet. They have a strong grip and can bend to touch their toes without flexing their knees. They can follow rules, like to play with playmates, and can engage in all types of ball games. They can draw a recognizable man, copy a square, and by 5 1/2 years of age, they can copy a triangle. Children younger than 5 years of age are still trying to master their skills in ball games and are not able to walk on a narrow line; they are also not able to copy a square and still have problems with elaborate models. They need more help with dressing and are unable to tie their shoelaces. They enjoy playmates, but they are still unable to follow rules.

B. A young healthy adult spends about 50% of the sleep period in stage II. Five percent of the sleep period is spent in stage I. Stages III, IV, and REM each comprise approximately 20% to 25% of the sleep period.

A. The brain has two main forms of memory: implicit and explicit. Implicit memory is an emotional, behavioral, and perceptual form of memory, which is present from birth and remains active throughout the lifespan. Implicit memory is also known as early, procedural, or nondeclarative memory. It cannot be expressed in words and does not require conscious attention. This form of memory lacks the subjective internal experience of recalling something from the past. An example of implicit memory is riding a bicycle; while riding, one is not aware of recalling the memory of how to ride. Neural circuits hypothesized to be involved in implicit memory include those of the basal ganglia, limbic system, and sensory cortices. Explicit memory, also known as late, semantic, or declarative memory, involves a subjective sense of recalling something from the past. Examples of explicit memory are factual and autobiographical information. It may be expressed in words and, as such, may be shared with others. Autobiographical recall requires the maturation of the hippocampus and orbitofrontal cortex, which does not occur until after the first 2 years of life.

A. The term standard deviation was introduced to statistics by Karl Pearson in 1894. It is defined as the square root of the variance. Standard deviation is the most common measure of statistical dispersion, which measures the spread of the values in a data set when compared to its mean. The mean and the standard deviation are usually reported together. The standard deviation is measured in the same units as the value of the data set. Approximately 95% of the values having a normal distribution are within two standard deviations away from the mean. The standard deviation is the root mean square (RMS) deviation of the values from their arithmetic mean. If the data points are all close to the mean, then the standard deviation is close to zero. If the data points are far from the mean, then the standard deviation is far from zero. If all the data values are equal, then the standard deviation is zero. Standard deviation may also serve as a measure of uncertainty and the standard deviation of a group of repeated measurements gives the precision of those measurements. In normally distributed data, about 68% of the values are within one standard deviation of the mean, about 95% of the values are within two standard deviations, and about 99.7% lie within three standard deviations. This is known as the “68–95-99.7 rule.” For a normal distribution, the two points of the curve, which are one standard deviation from the mean are also the inflection points.

C. The Salpetriere Retardation Scale was developed by Daniel Widlocher and his colleagues. It is a scale to measure psychomotor retardation with precision. It includes several symptoms, but lays special stress on all of the following:

C. According to the DSM-IV-TR, derealization unaccompanied by depersonalization in adults is classified as a Dissociative Disorder NOS. The specific dissociative disorders recognized by the DSM-IV-TR are: Dissociative Amnesia, Dissociative Fugue, Depersonalization Disorder, and Dissociative Identity Disorder. The category of “Dissociative Disorders NOS” includes: clinical presentations similar to dissociative identity disorder in which the criteria for dissociative identity disorder are not met, derealization unaccompanied by depersonalization, dissociative states in persons subjected to prolonged and intensive coercive persuasion (e.g., brainwashing), dissociative trance disorder, including culture-bound syndromes, such as Amok (Indonesia) and Possession (India), loss of consciousness/stupor/coma that cannot be attributed to a general medical condition (due to “nonorganic” causes) and Ganser syndrome.

B. Chronic anxiety symptoms such as panic attacks, startle, hyperarousal, and insomnia are secondary to increased noradrenergic function. Some patients with chronic anxiety report improvement in their symptoms with the use of depressant drugs, such as alcohol, benzodiazepines and opiates, which typically decrease locus ceruleus firing. Different studies have shown elevated plasma norepinephrine (NE) levels in subjects with anxiety disorders, such as PTSD. Some theories speculate that different 5-hydroxytryptamine (5HT/serotonin) receptors may be involved in the development of chronic anxiety, but a clear pattern of abnormal functioning of serotonin receptors has not been established yet.

B. The most common psychiatric diagnosis in patients with cancer includes adjustment disorders and a Major Depressive Disorder. In a recent study, the prevalence of psychiatric disorders among terminally ill cancer patients was 14% for depression and 14% for adjustment disorders. Another study showed prevalence rates for adjustment disorder of 16% in a similar population. Lower performance status, concern about being a burden to others, and lower satisfaction with social support were significantly associated with the presence of an adjustment disorder. These finding suggests that patients with cancer should have a routine screening for adjustment and affective disorders to improve their quality of life and general care.

B. Phobias are the most common anxiety disorder in the elderly, affecting 3% to 10% of the elderly. GAD is the next most common (3% to 7%) followed by PTSD (2%), Panic Disorder (0.1% to 1%) and OCD (0.6% to 0.8%).

A. Currently available cholinesterase inhibitors approved for the treatment of Alzheimer’s disease include donepezil, galantamine, and rivastigmine. These medications have been shown to improve cognitive performance and activities of daily living in patients with Alzheimer’s disease compared to placebo, but do not alter the course of the disease. With progression of the disease, these medications may lose efficacy. All of these medications inhibit acetylcholinesterase; galantamine additionally modulates nicotinic acetylcholine receptors, while rivastigmine also inhibits butyrylcholinesterase. No one medication in this class has been proven to be more efficacious than the others. Gastrointestinal side effects such as nausea, vomiting, and diarrhea are not uncommon with this class of medications and are the main reason these medications require titration. Most side effects are mild and time-limited. Rivastigmine, not donepezil, may be less well-tolerated than the others due to significant GI side effects. Tacrine is associated with hepatic toxicity, not renal failure, and hence is not considered a first-line treatment. Memantine is not a cholinesterase inhibitor, but is an NMDA-receptor antagonist, which is indicated for the treatment of moderate to severe Alzheimer’s disease.

E. Unlike nicotine replacement treatment, the patient should wait for 2 to 3 weeks before quitting smoking. Bupropion is one of the most effective smoking cessation treatments and might be more effective in combination with nicotine replacement treatment. The mechanism of action in smoking cessation is unknown. It appears to be effective in both depressed and nondepressed patients, and side effects might be less in nondepressed patients.

D. Although diarrhea may occur, it is not a common side effect of ECT. Temporary confusion, headaches, muscle aches, and both anterograde and retrograde memory loss are common side effects of ECT.

C. Myoclonus is more typical of serotonin syndrome than of NMS. Each of the other symptoms is typical of NMS, although they may overlap with other syndromes.

A. The weight gain associated with lithium ranges from 5 to 15 kg in 20% to 60% of patients who take lithium. Of the three randomized placebo-controlled trials (RCTs) of lithium done as of 2003, in two of these studies, mean weight gain among lithium-treated patients over 1 year was 4 kg and significantly greater than placebo. Two studies reported that most weight gain occurred during the first and second years of treatment and then stabilized. In one RCT that analyzed the use of depakote to treat bipolar disorder, weight gain >5 kg occurred in 21% of the patients receiving depakote and in 7% of patients receiving placebo in one year. In another RCT, mean weight gain was 1 kg per approximately 1 year of follow-up. According to the epilepsy and migraine prophylaxis studies of depakote, 20% to 60% of the patients report weight gain. In two RCTs of carbamazepine in bipolar disorder, mean weight change ranged from 2 kg gain in one study to 3 kg loss in the other one. According to the epilepsy trials, carbamazepine is associated with 2% to 14% average weight gain. Oxcarbazepine and levetiracetam have an improved obesity side effect profile relative to carbamazepine according to epilepsy trials data. In three RCTs that analyzed the use of lamotrigine to treat bipolar disorder, mean weight change ranged from 1 kg gain to 2 kg loss per 0.5 to 1.5 years of follow-up. There are no RCTs of topiramate in bipolar disorder. However, available open-label trials all support mean weight loss of 1 to 6 kg during 1 month to 1 year of follow-up.

B. Approximately 10% of patients with schizophrenia commit suicide. However, a greater number, between 20% and 40%, make at least one attempt over the course of the illness. The risk for suicide remains high over the whole lifespan, but the risk is elevated during postpsychotic periods. Specific risk factors for suicide include male gender, being under 45 years of age, depressive symptoms, feelings of hopelessness, being unemployed, and a recent hospital discharge. Men successfully complete suicide more often than women, but both groups are at increased risk relative to the general population.