A. As people age, they are at increased risk of loss of loved ones, including their spouse, friends, and family. This results in diminished access to familiar forms of social support. Often, older adults respond to this with an increase in reminiscence of the past. Reminiscence serves as a source of comfort as well as a means of coping with adversity. As adults grow older, the physical demand of their daily routine lessens and there is an increased enjoyment of solitude, which should not be mistaken for purposeful social isolation. It is important to distinguish between being alone and being lonely. Several studies of the elderly have reported no greater feelings of loneliness than in early life (exceptions may include widowed men and women who had lived with a spouse for several years contrasted to those who lived alone).

E. RCTs are usually prospective studies, often for evaluation of treatment modalities or other interventions. Especially with ethical concerns, RCTs are currently of limited use in determining heritability in humans. Observational and naturalistic studies have so far provided the strongest evidence in humans. Twin studies (comparing rates of disorders in monozygotic and dizygotic twins) and adoption studies (comparing twins separated from birth) help to separate genetic from shared environmental influences. Family risk studies definitely help determine heritability, but cannot as clearly separate how much a given disorder may be due to shared environment, and how much may be due to genetic transmission. Molecular studies use various techniques (linkage studies, genetic association studies, and other genome studies) to help determine heritability, and isolate involved genes. Some of the strongest evidence for heritability of psychiatric conditions has been found in Bipolar Disorder and Schizophrenia. Other disorders such as Major Depression, Alcoholism, Somatization/sociopathy, Personality Traits, and possibly Anxiety and Eating Disorders have shown some results suggestive of being heritable.

B. Ataque de nervios is a Latin culture-bound syndrome characterized by behavioral dyscontrol, emotional expression, and disrupted consciousness often seen as a result of a stressful event relating to the family. Amok is a dissociative episode characterized by a period of brooding followed by a violent outburst. Brain fag, or brain fatigue, is a West African term used to describe difficulty with concentration and memory. Falling out is a culture-bound syndrome seen in the southern United States and the Caribbean characterized by a sudden collapse and an inability to see despite open eyes. Koro is a syndrome reported in South and East Asia in which there is a sudden, intense anxiety that the penis or vulva and nipples will recede into the body.

C. The study described is a cohort study, which is prospective in nature. Case-control studies are similar, but retrospective. Cross-sectional studies simply gather data from a population at a particular point in time. An RCT follows at least two different populations prospectively over time, but the intervention (exposure) is manipulated in a randomized fashion. Single blind studies are a form of RCT where only the subjects are unaware of their intervention (exposure) status. In double-blind RCTs, the subjects and investigators are blinded. In triple-blind RCTs, the subjects, investigators and statisticians are blinded to the interventions.

D. Carbamazepine (Tegretol) may produce anemia, aplastic anemia, leukopenia, and thrombocytopenia so pretreatment evaluation typically includes a CBC. Many clinicians monitor the CBC every 2 weeks for the first 2 months of administration. Then, if the counts have been within normal limits, the CBC is monitored every quarter. Carbamazepine should be discontinued if the WBC count is less than 3,000 per mm³, the erythrocyte count is less than 4.0 × 10⁶ per mm³, hemoglobin is less than 11 mg/dL, the neutrophil count is less than 1,500 per mm³, and the platelet count is less than 100,000 per mm³. Because carbamazepine may cause hepatitis, baseline LFTs also are indicated. Carbamazepine has a molecular structure similar to TCAs and has the same propensity as TCAs to effect cardiac conduction (QTc and QRS prolongation). Many clinicians obtain pretreatment EKGs before starting carbamazepine. Patients with a QTc of longer than 0.440 second are at an increased risk for serious cardiac arrhythmias with carbamazepine treatment. Carbamazepine may produce hyponatremia and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and hence serum electrolytes should be monitored. Carbamazepine may produce a variety of congenital abnormalities, including spina bifida and anomalies of the fingers. A pretreatment urine pregnancy test is usually obtained in women of childbearing years. Women should be cautioned to use adequate contraception when taking carbamazepine. TSH is monitored with lithium therapy, not carbamazepine.

E. Anxiety is common in patients with respiratory illness, and is often multi-factorial in nature. Hypoxia itself causes anxiety, and many treatments to improve hypoxia (e.g., albuterol, theophylline) will worsen anxiety. Difficulty adjusting to an illness is a common exacerbating factor, and patients always must deal with difficult stressors such as bereavement, often reacting with anxiety.

B. Memory impairment is the most prominent feature of Alzheimer’s disease. Vascular dementia is characterized by poor attention, decreased speed of processing, decline in executive functioning, and “non-cognitive” changes, such as depression and anxiety.

A. This patient likely has psychophysiological insomnia. The question highlights a typical scenario. Patients with psychophysiological insomnia have a conditioned state of heightened arousal associated with the act of going to bed or the environment in which sleep typically occurs, which often develops after some emotionally traumatic event. Long after the event has been forgotten, the patient associates going to bed with an uncomfortable condition generating anxiety and heightened arousal, which are incompatible with sleep. This heightened arousal is often specific to their bedroom. The PSG usually indicates objectively disturbed sleep with a relatively long sleep latency, shortened total sleep time, or frequent awakenings during the night. These patients are usually fairly accurate on the amount and quality of sleep they get.

A. If all of the criteria are met for schizophrenia, but symptoms are present for less than 6 months, the most appropriate diagnosis is Schizophreniform disorder. Patients with Delusional Disorder report non bizarre delusions, but have relatively intact functioning. Brief Psychotic Disorder typically presents with psychotic symptoms for less than 1 month, and clearly following a stressful event. Both Schizoaffective Disorder and Residual Type Schizophrenia require the presence of psychotic symptoms for greater than 6 months.

A. Several studies have found that younger couples respond more favorably to BCT. In addition, less-educated couples had better response to BCT than those with higher education. Being unemployed or being employed in a position of unskilled labor also predicts poorer treatment outcome. Couples who are married longer also showed the greater treatment gains. Couples having the greatest difficulties in their relationship are less likely to benefit from treatment. Lack of commitment and behavioral steps taken toward divorce have been associated with poor treatment outcome to BCT. Poor outcome was also predicted by negative communication behavior, lower relationship quality, greater negative relationship affect and disengagement, and greater desired change in the relationship. Inequality prior to the therapy predicted positive treatment outcome at posttest and at six-month follow-up. Wife-dominant couples improved the most in response to couple therapy in terms of increased satisfaction and improved communication. Greater interpersonal sensitivity and emotional expressiveness—as determined by measures of “femininity”—have been found to predict better outcome at termination. Couples in which partners exhibit a higher degree of traditionality (i.e., higher affiliation needs in the wife and higher independence needs in the husband) have been shown to have poorer response to BCT. Partners’ higher levels of depressed affect have been linked to poorer outcome.

A. The most consistently identified risk factors for developing NMS are prominent psychomotor agitation, higher doses of neuroleptics (mean and maximum dose), greater neuroleptic dose increments over a short time period (increased dose within 5 days), the magnitude of increase from initial dose, and parenteral administration of the drugs (for example, intramuscular injections). Combination of two or more neuroleptics may also precipitate NMS. Other psychotropic drugs like lithium, when administered concomitantly with neuroleptics, are also reported to be associated with NMS. Psychiatric illness, including affective disorders, altered sensorium, psychomotor agitation, acute disorganization, and catatonia are also potential risk factors for the development of NMS. Infectious encephalitis, AIDS, organic brain disorders, and tumors also increases the susceptibility for NMS. Young age and male gender and the development of dehydration are also considered risk factors for the development of NMS. Other factors, such as trauma, infection, malnutrition, alcoholism leading to malnutrition, premenstrual phase in females, and sympathoadrenal hyperactivity (e.g., thyrotoxicosis) also have been implicated independently in cases of NMS.

C. The most prominent area of alcohol absorption is the proximal small intestine. It is also absorbed through the mucosal lining in the mouth, esophagus, and the stomach. The rate of absorption can be delayed by the presence of food in the small intestine.

A. Disulfiram inhibits acetaldehyde dehydrogenase and, therefore, prevents metabolism of acetaldehyde to acetate. Although it has been used to treat alcohol dependence for more than 40 years, the evidence for its effectiveness is weak. It is usually used in the dosage range of 250 to 500 mg per day. Disulfiram is administered only after the patient has been abstinent from alcohol for at least 12 hours, and it is recommended to avoid alcohol for at least 2 weeks from the last usage of disulfiram. It is not generally recommended to be used in the primary care setting. It is FDA approved, and is category C in pregnancy.

C. Most barbiturates are derived from barbituric acid with various side chains from the parent molecule. Barbiturates presumably work by enhancing pre- and postsynaptic GABA receptors to reduce postsynaptic excitatory potentials. Barbiturates are typically very lipophilic (not hydrophilic), and the higher their lipid solubility, the greater the potency, and the quicker and briefer the action. The ionized forms of barbiturates enter the brain faster, and lower blood pH (more acidic) increases the entry of barbiturates into the brain. Barbiturates are mostly metabolized in the liver, and metabolites are then excreted by the kidneys.

C. The Tarasoff issue is based on an initial 1974 ruling by the California supreme court that clinicians have a duty to warn potential victims of violence, which was subsequently reconsidered with a new 1976 ruling that clinicians have a duty to protect potential victims. Interpretation of the Tarasoff ruling varies from state to state, and you should be familiar with the laws in your state. The ruling is based on what obligation a clinician has to a third party based on knowledge gained in a “special relationship.” Duty to protect may be interpreted more vaguely than duty to warn. Protection may arise from hospitalization, medication adjustments, changing frequency of meetings, involving family, increasing social support, notification of police, involving the potential victim, or various other means, but should be individualized for the patient in question. The MacArthur studies examined risk factors for violent behavior. The McNaughten ruling involves the potential for absolution of guilt by reason of insanity. The Miranda rulings relate to being informed of your rights.

A. Dopamine is a biogenic amine neurotransmitter. There are four major dopamine pathways in the brain: the nigrostriatal tract, the mesolimbic tract, the mesocortical tract, and the tuberoinfundibular tract. The nigrostriatal tract projects from the substantia nigra to the corpus striatum. When D₂ receptors at the end of the pathway are antagonized, Parkinsonian side effects can emerge. Moreover, in Parkinson’s disease, this tract degenerates causing the motor symptoms of the disease. The mesolimbic tract links the ventral tegmentum in the midbrain to the nucleus accumbens in the limbic system. Excess dopamine in this area has been linked to psychosis and the positive symptoms of schizophrenia. The mesocortical pathway connects the ventral tegmentum to the cortex and especially to the frontal lobes. The tract is essential to normal cognitive function and may be involved in motivation and emotional responses. Through this relationship, it may be associated with the negative symptoms of Schizophrenia. The tuberoinfundibular pathway innervates the median eminence and the posterior and intermediate lobes of the pituitary. Dopamine released at this site regulates the section of PRL from the anterior pituitary gland. Drugs that block dopamine in this tract can cause an increase in PRL levels. The corticospinal tract contains motor axons and is not one of the four major dopamine pathways.

B. The circadian rhythm is set by both internal and external forces called zeitgebers or time clues. The main influences on the cycle stem from the suprachiasmatic nuclei (SCN) of the hypothalamus and the pontine reticular formation. The typical period of human circadian rhythms is 24.5 hours. The sleep-wake cycle is linked to changes in levels of several circulating hormones, particularly melatonin, and to light. Melatonin is secreted at night and terminates upon retinal stimulation by sunlight. Other hormones whose concentrations are affected by sleep include cortisol, TSH, GH, PRL, and LH. Specifically, serum cortisol levels are lowest at sleep onset and the highest in the morning. TSH secretion is suppressed by sleep onset. GH levels surge during deep sleep. PRL and LH also reach their highest levels during sleep. Other hormones such as testosterone vary throughout the day. The circadian rhythm begins in the first few months of life and starts to fragment in old age. In terms of psychiatric disorders, depression has most often been associated with disruptions of biological rhythms. Early morning awakening, decreased latency of rapid eye movement (REM) sleep, and neuroendocrine perturbations all account for this change.

E. Cognitive dysfunction in HD usually spares long-term memory, but impairs executive functions, such as organizing, planning, checking, or adapting alternatives. It also delays the acquisition of new motor skills. These features worsen over time with speech deteriorating faster than comprehension.

E. Aphasias (fluent, nonfluent, conduction, isolation) are generally signs of dominant hemisphere lesions, because language function is usually associated with the dominant hemisphere. The remaining answers (hemi-inattention, hemineglect, anosognosia, and constructional apraxia) are generally characteristic of nondominant hemisphere lesions.

B. This patient most likely has a right-sided medullary infarct (brainstem). Remember: cranial nerve palsies with “alternating hypalgesia” is usually a medullary lesion (lower brainstem). Wallenberg syndrome results from a posterior inferior cerebellar artery occlusion, which results in a medullary infarct with the following complex symptom cluster: paralysis of ipsilateral palate (nucleus ambiguous of CN IX and XI damage), ipsilateral face hypalgias (trigeminal nucleus/cranial nerve V damage) with contralateral body anesthesia (due to ascending spinothalamic tract damage), ipsilateral ataxia (cerebellar damage), and sympathetic fiber damage, which may also cause a Horner’s syndrome (ptosis and miosis). The ipsilateral face hypalgesia combined with contralateral body anesthesia has been termed “alternating hypalgesia.” Infarct to neither cortex could cause this complex symptom pattern. Basal ganglia lesions are usually associated with motor disturbances more than weakness and sensory changes. Spinal cord lesions would not result in cranial nerve signs.

E. NPH is a clinical syndrome which is characterized by dementia, urinary incontinence, and gait apraxia. Gait apraxia is usually the first and most prominent symptom and is generally the first symptom to improve with treatment. Urinary incontinence and gait abnormality present at the onset of dementia generally distinguish NPH from Alzheimer’s disease. Classically, the acute presentation of Wernicke’s encephalopathy is characterized by confusion, ataxia, and ocular motility abnormalities which include conjugate gaze paresis, abducens nerve paresis, and nystagmus. The dementia of Lewy body disease is often accompanied by a combination of Parkinsonian-like features (including resting tremor and bradykinesia), sensitivity to neuroleptics, and visual hallucinations. The noncognitive symptoms of frontotemporal dementia include aggression or apathy, disinhibition, hyperorality, and other aspects of Klüver-Bucy syndrome. In most cases, Creutzfeldt-Jacob disease causes a triad of dementia, myoclonus, and distinctive periodic EEG complexes.

E. This patient has Lesch-Nyhan syndrome, which is a sex-linked autosomal recessive inborn error of purine nucleotide metabolism. The gene involved is on the X chromosome and so the disorder occurs almost entirely in males. Occurrence in females is very rare. The onset of self-injury occurs as early as 1 year or rarely as the late teens. The enzyme HGPRT is present in all cells, but is highest in the brain, especially the basal ganglia. Its absence prevents the normal metabolism of hypoxanthine, resulting in hyperuricemia and manifestations of gout without specific treatment. HGPRT levels are related to the extent of motor symptoms, presence or absence of self-injury, and possibly cognitive function. Hypoxanthine accumulates in the brain; uric acid does not accumulate in the brain, because it is not produced in the brain and does not cross the blood–brain barrier.

D. Mucopolysaccharidoses are inherited disorders leading to the incomplete breakdown and storage of mucopolysaccharides or glycosaminoglycans. The storage product is heparan sulphate, keratin sulphate, dermatan sulphate, or chondroitin 4/6 sulphates. Although mental retardation is seen with all mucopolysaccharidoses, growth retardation is not seen in the Sanfilippo and Scheie syndromes where linear growth is unaffected. Carrier detection and prenatal diagnoses are available for each of the mucopolysaccharidoses.

D. Fabry’s disease is transmitted via an X-linked recessive mode of inheritance.

C. Multiple system atrophy is a progressive neurodegenerative disorder causing pyramidal, cerebellar, and autonomic dysfunction. It includes three disorders previously thought to be distinct: olivopontocerebellar atrophy, striatonigral degeneration, and Shy-Drager syndrome. Parkinsonian symptoms (predominant in striatonigral degeneration) include rigidity, bradykinesia, postural instability, and jerky postural tremor. High-pitched, quavering dysarthria is common. In contrast to Parkinson’s disease, resting tremor and dyskinesia are uncommon, and symptoms respond poorly and transiently to levodopa. Symptoms of cerebellar dysfunction (predominant in olivopontocerebellar atrophy) include ataxia, dysmetria, dysdiadochokinesia, poor coordination, and abnormal eye movements. Typical symptoms of autonomic failure are orthostatic hypotension often with syncope urinary retention or incontinence, constipation, and erectile dysfunction. Sleep apnea and respiratory stridor are common. Diagnosis is suspected clinically based on the combination of autonomic failure and Parkinsonism or cerebellar symptoms. Similar symptoms may result from Parkinson’s disease, Lewy body dementia, pure autonomic failure, autonomic neuropathies, progressive supranuclear palsy, multiple cerebral infarcts, or drug-induced parkinsonism. No diagnostic test is definitive, but MRI abnormalities in the striatum, pons, and cerebellum are highly suggestive. Multiple system atrophy can be diagnosed based on these findings plus symptoms of generalized autonomic failure and lack of response to levodopa.

D. Severity of TBI severity is defined by the LOC, altered mental status (e.g., confusion) or PTA. However, the severity of functional impairments after TBI often is not related to the severity of the injury. Mild TBI is defined as a blow to the head followed by an LOC of less than 30 minutes, an altered mental status with PTA of less than 24 hours or Glasgow Coma Scale score of 13 to 15. Patients are classified as having a moderate-to-severe TBI if they have an LOC over 30 minutes or altered mental status greater than 24 hours or Glasgow Coma Score below 12. For majority of those with a mild TBI, they attain full recovery within 3 to 6 months; however, approximately 15% of patients will continue to experience long-term cognitive, physical, and behavioral difficulties that interfere with their ability to function. This condition is known as persistent postconcussion syndrome. Because these consequences are not well understood, many family members and professionals assume that these individuals are exaggerating or “faking” their symptoms and emotional or behavioral problems are seen as psychogenic. However, these symptoms are most likely secondary to neurological events and not due to an underlying psychiatric disorder.

D. Harry Harlow studied social learning and the effects of social isolation in monkeys. In a series of experiments, monkeys were raised in various degrees of isolation (e.g., total isolation, mother-only reared, peer-only reared, partial isolation, and separation from caretaker after a bond had developed). The effects seen in those monkeys raised in total isolation (not allowed to develop caretaker or peer bonds) included self-orality, self-clasping, fearfulness of peers, and inability to copulate. If impregnated, females were unable to nurture their own young. If the duration of total isolation lasted beyond 6 months, no recovery was found to be possible.

E. Several neuropsychological deficits have been found in relatives of Schizophrenics, including (but not limited to) the Wisconsin Card-Sort Test, Minnesota Multiphasic Personality Inventory, and tests of sustained attention (e.g., Continuous Performance Test). Various psychotic spectrum personality traits (Cluster A) have also been found in relatives of schizophrenics. More objective physiological findings, such as smooth pursuit eye movement dysfunction or impaired p50 suppression on auditory evoked potentials, have even been found in nonaffected relatives of schizophrenics.

B. While smaller clinical trials have reported on the efficacy of tricyclic antidepressants, gabapentin, capsaicin cream, mexiletine, and opiates for the treatment of painful diabetic polyneuropathy, none of them are formally approved by the FDA for the treatment of this condition. Only duloxetine and pregabalin are the drugs that are approved by the FDA for the treatment of painful diabetic polyneuropathy. Both drugs appear to have equal efficacy in treating this condition.

C. According to the ECA study, Substance Use Disorders had a lifetime prevalence of 16.4%, bolstered largely by Alcohol Abuse and Dependence Disorders with a prevalence of 13.3%. Substance Use Disorders were followed closely by Anxiety Disorders, which had a 14.6% lifetime prevalence (phobias alone had a 12.5% lifetime prevalence). Perhaps pointing to their chronic nature, the 1-month prevalence of anxiety disorders was highest at 7.3%. Lifetime prevalence in the ECA study for the remaining disorders were: Affective Disorders 8.3%, Schizophrenia and Schizophreniform Disorders 1.5%, and Somatization Disorder 0.1%. Conducted in the 1980s, the ECA study included subjects from the community and institutions who were 18 years of age to elderly, but were limited to five study sites.

D. Antipsychotic treatment is associated with metabolic side effects that include weight gain, dyslipidemia, and type 2 diabetes. In addition, patients with chronic psychotic disorders have increased coronary heart disease (CHD) mortality. Obesity is a major risk factor for hypertension, diabetes, cardiovascular disease, cerebrovascular disease, and lipid abnormalities. Weight gain also contributes to medication noncompliance and poor self-image. Weight and waist circumference should be monitored weekly in hospital care and monthly in ambulatory care. Intervention is recommended in the form of nutritional counseling, exercise program, or change in antipsychotic medication when BMI increases by one unit or when waist circumference measures greater than 35 inches for a woman or 40 inches for a man. Hyperlipidemia is associated with cardiovascular and cerebrovascular disease. Total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides should be monitored every 3 MONTHS for the first year of treatment, then ANNUALLY. Although antipsychotics do not cause hypertension directly, it is a major contributing factor in the development of CHD. In clinical trials, antihypertensive therapy has been associated with up to a 25% reduction in myocardial infarction, a 50% reduction in heart failure, and a 40% reduction in stroke incidence. Hence, blood pressure should be monitored every 3 MONTHS in patients on antipsychotics. Antipsychotic agents have been associated with abnormalities in serum glucose levels, including the development of diabetes mellitus. Fasting blood glucose should be monitored depending on risk factors and drugs—monthly in patients with family history of diabetes/obesity and/or with manifested overweight or obesity, and/or with impaired fasting glucose. In patients without risk factors, fasting blood glucose (FBG) should be monitored after 6 and 12 weeks, and then quarterly. The usual diagnostic test for diabetes is the fasting plasma glucose (FPG) (> 7.0 mmol/L, or 126 mg/dL). The 2-hour plasma glucose level taken after a 75-gm glucose drink (> 11.1 mmol/L, or 200 mg/dL), that is, the postload plasma glucose in the OGTT, is also diagnostic, as is the random glucose level (> 11.1 mmol/L, or 200 mg/dL) when there are clear symptoms of diabetes. Any abnormal result should be confirmed by a repeat test on a different day. The OGTT is not used for routine monitoring of patients on antipsychotics, although it is considered the gold standard test and has greater diagnostic sensitivity than FBG. The fasting glucose level is the favored screening test for diabetes because of its diagnostic specificity and its ease of use.

B. This patient has Factitious Disorder with predominantly physical signs and symptoms, also known as Münchhausen syndrome, hospital addiction, polysurgical addiction, and professional patient syndrome. In this disorder, patients intentionally misrepresent medical signs and symptoms with the objective of assuming the role of a patient without any external incentive, and are able to present physical symptoms so well that they can gain admission to and stay in a hospital. Such patients often insist on surgery, and continue to be demanding and difficult in the hospital. As each test is returned with a negative result, they may become generally abusive and even accuse doctors of incompetence. Anecdotal case reports indicate that many patients with Factitious Disorder suffered childhood abuse or deprivation, and that the patient perceived one or both parents as rejecting figures. Other specific predisposing factors include: true physical disorders during childhood leading to extensive medical treatment, or a family history of serious illness or disability, a grudge against the medical profession, employment as a medical paraprofessional, and an important relationship with a physician in the past. Factitious Disorders usually have a poor prognosis. Factitious Disorder is distinguished from Malingering, in which there is an obvious, recognizable environmental incentive, and patients can stop producing their signs and symptoms when they are no longer considered profitable or when the risk becomes too great.

C. Richard Asher, in a 1951 article in the Lancet, coined the term Münchhausen syndrome to refer to a syndrome in which patients chronically embellish their personal history and fabricate symptoms to gain hospital admission and move from hospital to hospital. Wilford Bion expanded the concept of projective identification to include an interpersonal process in which the therapist feels forced by a patient to play a role in their internal world. Sandor Ferenczi developed a procedure known as active therapy, in which the patients developed an awareness of reality through active confrontation by the therapist. Alfred Adler coined the term inferiority complex. Eric Berne developed transactional analysis.

B. The characteristics of Avoidant Personality Disorder include pervasive and excessive hypersensitivity to negative evaluation, social inhibition, and feelings of inadequacy. There is an equal sex ratio between men and women. There is an increased risk for mood and anxiety disorders, but the most frequent comorbidities are Schizotypal, Schizoid, Paranoid, Dependent, and Borderline Personality Disorders (BPD). Impairment is often severe and includes occupational and social difficulties. Prevalence rates of 10% for psychiatric outpatients are reported. Avoidant Personality Disorder is hard to differentiate from Social Phobia, and many experts believe that they represent the same disorder. Disfiguring illness and shyness in childhood predispose children for this personality disorder.

E. Excessive daytime somnolence, cataplexy, sleep paralysis, and hypnogogic hallucinations are commonly referred to as the tetrad of symptoms seen in narcolepsy. Interepisodic symptoms are not seen in these patients.

E. The available evidence on the clinical and cost-effectiveness of psychological therapies for BPD indicates that there is some evidence that DBT is more effective than TAU for the treatment of chronically parasuicidal and drug-dependent borderline women. DBT-orientated therapy is also more effective than CCT for the treatment of BPD. DBT is also as effective as comprehensive validation therapy plus 12-step for the treatment of opioid-dependent borderline women. There was also some evidence that partial hospitalization is more effective than TAU in the treatment of BPD. There is also good evidence that MACT is no more effective than TAU in the treatment of BPD and some evidence that interpersonal group therapy is no more effective than individual mentalization-based partial hospitalization (MBT) for the treatment of BPD. However, these results should be interpreted with caution as not all of these studies were primarily targeted to borderline symptoms and there were considerable differences between the studies. Studies do not support the cost-effectiveness of DBT, although, they suggest it has the potential to be cost-effective. The results for MBT are promising, although again surrounded by a high degree of uncertainty and for MACT the analysis suggests that the intervention is unlikely to be cost-effective.

A. It was Carl Gustav Jung who believed that archetypes such as the animus, the anima, the shadow and others manifested themselves in dreams, as dream symbols or figures. In his book, The Interpretation of Dreams, Sigmund Freud stated that the foundation of all dream content is the fulfillment of wishes, conscious or otherwise. He described the conflict between superego and id that leads to “censorship” of dreams. Freud listed four transformations applied to wishes in the dreams to avoid censorship. These are: condensation — one dream object stands for several thoughts; displacement — a dream object’s psychical importance is assigned to an object that does not raise the censor’s suspicions; representation — a thought is translated to visual images; and symbolism — a symbol replaces an action, person, or idea. These transformations help to disguise the latent content, transforming it into the manifest content, what is actually seen by the dreamer. The basis for all of these systems, he claimed, was “transference,” in which a would-be censored wish of the unconscious is given undeserved “psychical energy” (the quantum of attention from consciousness) by attaching to “innocent” thoughts. Freud indicated that the wishes are not revealed in dream analysis for the sake of conscious fulfillment, but instead for conscious resolution of the inner conflict.

E. Alcohol is metabolized primarily in the liver by the action of ADH, which converts alcohol to acetaldehyde. Aldehyde dehydrogenase, subsequently, catalyzes the conversion of acetaldehyde into acetic acid. Alcohol metabolism follows the zero order kinetics, that is, a constant amount is oxidized per unit of time.

B. Glaucoma is not a relative contraindication for the use of disulfiram. Consumption of alcohol after taking disulfiram results in a reaction that results in palpitation, flushing, nausea, vomiting, hypotension, sweating, dizziness, blurry vision, and headaches. Most reactions are short and self-limited, lasting about thirty minutes. However, a more severe reaction may occur, presenting with congestive heart failure, myocardial infarction, respiratory depression, convulsions, and death. It is, therefore, contraindicated in patients who have taken alcohol or metronidazole, have psychosis or cardiovascular disease, severe pulmonary disease, chronic renal failure, diabetes, or those older than 60 years of age. It is also not recommended in patients with peripheral neuropathy, seizures, or cirrhosis with portal hypertension. Hepatotoxicity is a rare but potentially fatal adverse effect. It is, therefore, recommended to closely monitor liver functions in patients receiving disulfiram.

B. Amphetamines stimulate respiration and suppress appetite. Cardiac effects include tachycardia and hypertension. Subjective effects include anxiety and psychosis, and amphetamines are particularly known to induce paranoia. Amphetamines may produce an initial euphoric effect and can be highly addictive in some patients. Amphetamines have been widely used for a variety of indications (e.g., including obesity, depression, and fatigue), but rebound and withdrawal effects may counteract their intended use. Amphetamines’ therapeutic usefulness is best known in narcolepsy (by promoting wakefulness) and ADHD (by enhancing focus and concentration).

C. Sigmund Freud (1856–1939) is generally believed to have created the field of psychoanalysis. Freud studied under the famous neurologist Charcot (1825–1893), and utilized hypnosis along with Breuer (1841–1925), but is believed to have initiated psychoanalytic theory, beginning with his technique of free association. Freud coined the term psycho-analysis in 1896. Rush (1745–1813) is known as the “father of American psychiatry,” and believed in somatic causation of mental illness, not accepting the moral treatments popular in his day. Meyer (1866–1950) was a prominent American psychiatrist of the early 20th century who espoused psychobiology, a belief that mental illness was neither purely biological nor purely psychological. Meyer’s influence on modern American psychiatry is profound and deep-rooted.

C. Serotonin is synthesized in the axonal terminal. Its precursor amino acid is tryptophan. The availability of tryptophan is the rate-limiting step in its synthesis. The enzyme tryptophan hydroxylase is not rate limiting. Tryptophan hydroxylase converts tryptophan to 5-hydroxytryptophan, which is then converted to serotonin by the enzyme amino acid decarboxylase. Because tryptophan concentrations are rate limiting in the synthesis of serotonin, dietary variations in tryptophan can measurably affect serotonin levels in the brain. Tryptophan depletion causes irritability and hunger, while tryptophan supplementation can relieve anxiety, induce sleep, and promote a sense of well-being. The key enzyme involved in the metabolism of serotonin is MAO, preferentially MAO_A, and the main metabolite is 5-hydroxyindoleacetic acid (5-HIAA). Norepinephrine, epinephrine, and dopamine are all catecholamines. They are synthesized from tyrosine. The rate limiting step in their production is the enzyme tyrosine hydroxylase. In neurons which release norepinephrine and dopamine, β-hydroxylase converts dopamine to norepinephrine. In neurons that release epinephrine, phenylethanolamine-N-methyltransferase (PNMT) further converts norepinephrine into epinephrine. The major routes of deactivation of dopamine, epinephrine, and norepinephrine are through uptake back into the presynaptic neuron and metabolism by MAO_A and catechol-O-methyl transferase (COMT).

B. Bupropion and nicotine replacement therapies (such as nicotine gum or patches) are first-line agents for reducing nicotine use and withdrawal symptoms. Clonidine and nortriptyline are considered second-line agents for treating Nicotine Dependence. The best outcomes combine medication and psychosocial therapies, such as CBT, motivational enhancement therapy, brief interventions, and behavioral therapy. Choice B is false because hypnosis and 12-step programs have not shown significant efficacy in treating nicotine dependence.

C. The gene for HD is located on the short arm of chromosome four. It is associated with an expanded trinucleotide repeat. The normal alleles at this site contain CAG repeats. When these repeats reach 41 or more, the disease becomes fully penetrant. Incomplete penetrance happens with 36 to 40 repeats, and 35 or less are not associated with the disorder. The number of CAG repeats accounts for about 60% of the variation in age of onset, with the remainder represented by modifying genes and environment.

B. Nystagmus is often a sign of brainstem lesion, eye movements are controlled by cranial nerves whose nuclei reside in the brainstem. Incontinence usually denotes a spinal cord injury. Intention tremor usually results from cerebellar dysfunction. Basal ganglia lesions result in Parkinsonism. Any sensory loss may occur with unilateral cerebral hemisphere lesions, or possibly with loss to a “level” secondary to a spinal cord injury. Cortical sensory loss usually consists of deficits in contralateral position sense, two-point discrimination, and stereognosis. Pain sensation remains intact as it is localized to the thalamus at the uppermost portion of the brainstem.

B. This case describes classic Brown-Séquard syndrome. Brown-Séquard syndrome is the result of the hemi-transection of the spinal cord. Transection of cortical spinal tracks causes ipsilateral weakness from that level down. Injury to the spinothalamic tract results in contralateral loss of temperature and pain below the level of the lesion. This is because the fibers of the spinothalamic tract cross over in the spinal cord. If the dorsal columns are affected, ipsilateral impairment of vibration and position sense occurs. Complete transection of the cord would result in all symptoms bilaterally. Injury of the anterior or dorsal horns may cause deficits of either motor or sensory function, but typically not a mixture of both, and are separated anatomically so that such an injury becomes more improbable than Brown-Séquard syndrome.

C. Patients with essential tremor generally present with fine oscillations of their wrists, hands, or fingers. (They may also display a head tremor or tremor in their voice.) Certain actions or postures characteristically elicit the tremor, which is usually in a single plane. Essential tremor is the most common involuntary movement disorder and usually develops in young and middle-aged adults. It follows a pattern of autosomal dominant inheritance with variable penetrance, and about 30% of patients will endorse a positive family history. In 50% of affected individuals, alcohol-containing beverages suppress the tremor. Anxiety generally intensifies it. Essential tremor must be differentiated from those with other etiologies, including the few listed above. In contrast with essential tremor, the pill-rolling tremor of Parkinson’s disease occurs characteristically at rest and is diminished by movement. Wilson’s disease characteristically produces a “wing-beating” tremor, which is course and centered at the shoulders. Patients with Huntington’s disease demonstrate chorea, which consists of random, discrete, brisk movements which jerk the pelvis, trunk, and limbs. Sydenham’s chorea is a major diagnostic criterion of rheumatic fever and almost exclusively affects children between the ages of 5 and 15 years. It generally begins insidiously as grimaces and limb movements and has a duration of approximately several weeks.

E. A quarter to a third of untreated children with PKU develop seizures. In classical untreated PKU, the clinical features include mental retardation, neurological symptoms and varying degrees of systemic symptoms. In classical untreated PKU, the most consistent feature is mental retardation which becomes evident in mid-infancy. Behavioral problems such as hyperactivity, impulsivity, and self-injury have been reported. Autism and schizophrenia-like psychoses have also been documented. The affected child usually has fair, lightly pigmented skin, blonde hair and blue eyes. Photosensitivity and eczematous rash have been reported. A mousy odor may be present. Brain damage from untreated PKU is irreversible; however, dietary treatment with low phenylalanine foods may reduce behavioral disturbance. Guthrie test or heel-prick test is done on the fourth and seventh day to screen for PKU in the newborn.

A. Hunter’s syndrome is transmitted via an X-linked recessive mode of inheritance.

D. Maple syrup urine disease is an autosomal recessive disorder of aminoacid metabolism that causes acidosis (in the first week of life in severe cases) and central nervous system symptoms. The urine of these patients smell like maple syrup due to their inability to metabolize the branched-chain amino acids leucine, isoleucine, and valine due to deficiency of branched chain ketoacid decarboxylase. Symptoms of this disorder appear in the first week of life. It can lead to decerebrate rigidity, seizures, respiratory irregularity, hypoglycemia, recurrent ketoacidosis, and death, if untreated. Death usually occurs in the first few months of life, if untreated. Survivors are usually severely mentally retarded. Dietary treatment of maple syrup urine disease follows principles similar to that for PKU. The diet in this case should be low in leucine, isoleucine, and valine.

C. This patient has the signs and symptoms of MS. It has a prevalence of less than 1 per 100,000 in equatorial areas, and 30 to 80 per 100,000 in northern latitudes with a less well-defined gradient in the Southern Hemisphere. Immigrants from a high-risk to a low-risk zone carry with them at least part of the risk of their country of origin, even though the disease may not become apparent until 20 years after migration. The critical age of immigration appears to be about 15 years. A familial concordance of MS is also seen, with 15% having an affected relative, with the greatest concordance between siblings. About two thirds of the cases of MS have their onset between 20 and 40 years of age. Although many environmental factors have been proposed as causative (e.g., surgical operations, trauma, anesthesia, exposure to household pets [small dogs], mercury in silver amalgam fillings in teeth), these are unsupported by evidence.

A. When a patient presents with Addisonian crisis, treatment with glucocorticoids must not be delayed. Blood for serum cortisol, ACTH and serum chemistry should be drawn, and therapy with IV saline and dexamethasone should be initiated immediately. A short corticotropin stimulation test can then be performed as dexamethasone does not interfere with cortisol radioimmunoassay. Following testing, therapy with dexamethasone can be replaced with hydrocortisone. Low aldosterone and high renin are consistent with the diagnosis of Addison’s disease. If the cause of primary adrenal insufficiency is unknown, adrenal autoantibody tests and imaging of the adrenal glands can be performed, but is not an important test in the acute management of this patient’s condition.

D. According to Piaget, moral judgment can be divided into two stages. Children younger than 10 years of age think about moral dilemmas in one way and older children consider them differently. Younger children regard rules as being fixed and absolute. They believe that rules are handed down by adults or by God and that one cannot change them according to the needs of the situation. The older children view these rules as being more relativistic. They understand that it is permissible to change rules, with everyone’s agreement. Rules are not sacred and absolute, but are devices by which humans use to get along cooperatively. Younger children base their moral judgments more on consequences, whereas older children base their judgments on intentions. Younger children primarily consider the amount of damage and hence the consequence, while the older child is more likely to judge wrongness in terms of the motives underlying the act. Moral issues continue to develop throughout adolescence.

A. Polygenetic multifactorial transmission is now believed to be the most likely mode of inheritance for susceptibility to development of schizophrenia. Possible contributing loci have been found at multiple chromosome sites (1q, 6p, 8p, 22q, etc.). Most monogenetic models have been rejected. Although tri-nucleotide repeat model explanations of some rarer forms of psychosis may be valid, they do not explain Schizophrenia.

D. The ability to learn to recognize differences between similar but different stimuli is an important characteristic of learning. If two stimuli are significantly different, an animal could respond to one and not the other. This is termed discrimination. Studies show that dogs respond differently to similar bell sounds. A related but diametrically opposite phenomenon is stimulus generalization which occurs when a conditioned response is transferred from one stimulus to the other. According to learning theory, generalization explains phobias and PTSD: in both disorders, patients are not able to discriminate between the phobic object or cues of trauma on one hand and the inducing feared object or precipitating trauma on the other hand. Extinction occurs when a conditioned stimulus is constantly repeated without the unconditioned stimulus until the response generated by the stimulus weakens and then disappears. In the “Pavlovian” experiment, ringing the bell (conditioned stimulus) without presenting the piece of meat (unconditioned stimulus) following an initial period of pairing these two stimuli did not result in salivation. The neutral stimulus (bell) is the conditioned stimulus, because it would not on its own induce the response.

B. According to the NCS, Substance Use Disorders had a lifetime prevalence of 26.6% (highest in men), closely followed by Anxiety Disorders (highest in women) at 24.9% lifetime prevalence. Lifetime prevalence for Affective Disorders was 19.3% (higher in women), and for Psychotic Disorders was 0.7% (relatively equally distributed between sexes). Personality Disorders as a class were not broadly studied, though the NCS did study Antisocial Personality Disorders (ASPD). Anxiety disorders did have the highest 12-month prevalence, likely reflecting their chronic nature. The NCS included subjects from all 48 contiguous states, but was limited to ages of 15 to 54 years and only considered non-institutionalized people and people living in the community.

C. The HAM-D is a clinician-rated scale with a focus on somatic symptoms of depression. The version in most common use has 17 items, but it does not include some of the symptoms for depression in DSM-IV, most notably the so-called reverse neurovegetative signs (increased sleep, increased appetite, and psychomotor retardation). HAM-D total score ranges from 0 to 50. Scores of 7 or less may be considered normal; 8 to 13, mild; 14 to 18, moderate; 19 to 22, severe; and 23 and above, very severe depression. Ratings are completed by the examiner based on patient interview and observations. The BDI is a self-report scale with a focus on behavioral and cognitive dimensions of depression. The current version, the Beck-II, has added more coverage of somatic symptoms to be compatible with DSM-IV. The BDI includes 21 self-report items, each of which has four statements describing increasing levels of severity and the total score ranges from 0 to 84. Scores of 0 to 9 are considered minimal; 10 to 16, mild; 17 to 29, moderate; and 30 to 63, severe. Internal consistency has been high but the test–retest reliability is not consistently high, but this may reflect changes in underlying symptoms. Validity is supported by correlation with other depression measures. The instrument’s strength lies in measuring the depth of depression and in its comprehensive coverage of the cognitive dimension of depression.

D. Factitious Disorders are distinguished from Malingering because in Factitious Disorders, patients intentionally misrepresent signs and symptoms with the objective of assuming the role of a patient (primary gain) without any external incentive, whereas in Malingering, there is an obvious, recognizable environmental incentive (secondary gain), and patients can stop producing their signs and symptoms when they are no longer considered profitable or when the risk becomes too great. Ganser’s syndrome may be a variant of Malingering in which patients respond to simple questions with astonishingly incorrect answers. Factitious Disorders usually begin in early adult life, although they may appear during childhood or adolescence. Anecdotal case reports indicate that many patients with Factitious Disorder suffered childhood abuse or deprivation, and that the patient perceived one or both parents as rejecting figures. Factitious Disorders usually have a poor prognosis, and no specific psychiatric therapy has been effective. The type of Factitious Disorder is based on the presence of predominantly psychological versus physical signs and symptoms.

A. According to the DSM-IV-TR diagnostic criteria, choice A is the definition of factitious disorder. The diagnosis of Malingering (choice B) is made when there is evidence of secondary gain. Choice C represents the diagnostic criteria for Somatization Disorder, choice D is Conversion Disorder, and choice E represents Body Dysmorphic Disorder. Choices C, D, and E are classified under Somatoform Disorders. In contrast to Factitious Disorders and Malingering, Somatoform Disorder symptoms are not under voluntary control.

D. Patients with sleep state misperception (also known as subjective insomnia) have a disconnect between objective and subjective measures of sleep. Patients claim to have slept only 1 to 2 hours in a night, but have a normal PSG. This disorder is not related to being a light sleeper, as patients are not easier to awaken by an auditory stimulus than normal sleepers. The misperception does not appear to be intentional or psychological, because there is a limited placebo response. After receiving placebo, subjective insomniacs generally report that they had been awake when asked after being awakened from nonrapid eye movement (NREM) sleep by an auditory tone. After receiving a hypnotic, the same patients respond similarly to normal sleepers, having a good match between subjective and objective measures. Despite the normal PSG, patients with sleep state misperception tend to respond poorly to hearing that there is nothing objectively wrong with their sleep. This often leads to alienating the patient.

D. While establishing a regular exercise routine is thought to contribute to good sleep hygiene, it is likely best to engage in physical exercise in the morning.

C. IPT designed by Klerman and Weissman is a flexible, integrative, time-limited, and structured psychotherapy. IPT is based on interpersonal theories with the main principle abstracted from these theories is that life events occurring after the early childhood years influence psychopathology. This model incorporates psychoeducation, is “medication friendly,” and agrees with a medical model of psychiatric illness. Similar to CBT, it is structured and open, using a collaborative therapeutic relationship without invoking transference issues. Rating scales monitor each patient’s progress. IPT does not involve formal “homework” or rely on extensive paperwork. However, patients are encouraged to develop skills and experiment actively with these between sessions. IPT is particularly accessible to patients who find dynamic approaches mystifying and/or the “homework” demands of CBT difficult. It has been manualized as a treatment for depression, bulimia nervosa, as a group treatment for binge eating disorder, and modified and extended for treatment of anxiety, dysthymia, primary care disorders, chronic fatigue, mood disorders associated with human immunodeficiency virus (HIV), somatization, adolescent disorders and depression of later life, and for use with couples and groups. However, this model has not so far been modified for the management of psychoses.