1.

A55-year-old man with no history of mental illness presents with recent onset
of disorientation, fluctuating mental status, abnormal autonomic signs, poor
coordination, tremor, and seeing "little men" in his bedroom. He has no known
history of substance abuse. What is the most likely diagnosis?

A. Schizophrenia
B. Dementia associated with Parkinson's disease
C. Delirium
D. Depression with psychotic features
E. Delusional disorder

2. Which of these statements describes the current understanding regarding the

development of post-traumatic stress disorder (PTSD)?

A. The traumatic event must be outside the range of human experience

B. The traumatic event must involve the threat of death or physical injury
C. The number of previous traumatic events does not influence the development
of PTSD
D. Merely witnessing an assault on another person would not qualify as sufficient
trauma
E. All of the above

3. Which of the following drugs would be the least favorable treatment for a
patient with bulimia nervosa without comorbidities?

A. Fluoxetine HCl (Prozac, Sarafem)

B. Topiramate (Topamax)
C. Carbamazepine (Carbatrol, Tegretol)
D. Atricyclic antidepressant
E. Cognitive-behavioral therapy

4. Which of the following atypical antipsychotic agents is associated with the

most weight gain?

A. Ziprasidone (Geodon)
B. Aripiprazole (Abilify)
C. Olanzapine (Zyprexa)
D. Quetiapine (Seroquel)
E. Risperidone (Risperdal)

5. Medications of choice for the initial treatment of long-standing anxiety disorder

include all the following, except:

A. Venlafaxine (Effexor)
B. Fluoxetine (Prozac, Sarafem)
C. Sertraline (Zoloft)
D. Diazepam (Valium)
E. Citalopram HBr (Celexa)

6. Which of the following statements about venlafaxine is true?

A. It is a potent inhibitor of dopamine reuptake

B. It has been demonstrated to have the same percentage of response and
completeness of response as fluoxetine in severely depressed individuals
C. It can be tapered during 1 to 2 weeks
D. It has been shown in clinical trials to significantly increase blood pressure with
daily doses between 75 and 225 mg
E. It is approved for the treatment of generalized anxiety disorder

7. Which of these medications would NOT be recommended to control the

behavior of an acutely agitated and combative patient in the emergency
department?

A. Lorazepam (Ativan)
B. Ziprasidone (Valium)
C. Droperidol (Inapsine)
D. Haloperidol (Haldol)
E. Propofol (Diprivan)

8. All the following factors signal potential risk for suicide, except:

A. A plan to shoot oneself

B. Previous suicide attempts
C. Being married with 3 children
D. Sudden improvement in depressive symptoms in a patient who recently felt
hopeless and/or helpless
E. History of schizophrenia

9. Which of these criteria is NOT a risk factor for violent behavior?

A. History of violent behavior

B. Use of drugs and/or alcohol
C. Agitated and threatening behavior
D. History of childhood abuse
E. Major depressive disorder

10. A 60-year-old computer programmer is taken to the emergency department

with cognitive slowing, slurred speech, dizziness, and poor muscle coordination.
He said he had taken some of his girlfriend's "nerve pills" because he was uptight
and tense about a presentation he had to make to his supervisor. He cannot
remember how many pills he took or their names. Which of the following agents
is most likely to have caused his symptoms?
A. Sertraline (Zoloft)
B. Haloperidol (Haldol)
C. Alprazolam (Xanax)
D. St. John's Wort
E. Trazodone HCl (Desyrel)

ANSWERS

1 - C. The onset of new psychiatric symptoms in a patient older than 40 years

with no history of psychiatric illness is most likely the result of an organic
disorder. Psychiatric symptoms of delirium include disturbances of
consciousness, cognition, mood, perception, and behavior. Neurologic symptoms
include tremor, asterixis, nystagmus, poor coordination, and urinary incontinence.

2 - B. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,

Text Revision does not require that trauma be outside the range of human
experience to qualify for a diagnosis of PTSD. Diagnostic criteria do stipulate that
the trauma must involve the threat of death or physical injury. The number of
previous traumatic events increases an individual's vulnerability to PTSD, and the
trauma may be witnessed rather than experienced directly.

3 - C. Tricyclic antidepressants carry a risk for lethal overdose but have been
used to treat bulimia nervosa. Fluoxetine, topiramate, and cognitive-behavioral
therapy have all demonstrated some efficacy for this condition. Carbamazepine
has not produced impressive results in patients with bulimia nervosa without
comorbidities. It has been used in those with comorbid bipolar disorder, however.

4 - C. Olanzapine has been associated with the most weight gain. A lesser
amount of weight is gained with quetiapine and risperidone, and ziprasidone and
aripiprazole are associated with the least weight gain.

5 - D. Antidepressant drugs are often the best choice for patients with chronic
anxiety disorders. They can be given long-term, without risking dependence.
Diazepam is excellent for relieving anxiety for the short-term, but it carries too
high a risk of dependence when used for an extended time. For most acute
anxiety conditions, therapy with one of the benzodiazepines lasts up to 6 weeks,
with tapering and discontinuance during the next 2 weeks.

6 - E. Venlafaxine is a potent inhibitor of serotonin and norepinephrine reuptake

and a weak inhibitor of dopamine reuptake. It has a better percentage response
and completeness of response than fluoxetine in patients with severe
depression. Venlafaxine must be tapered over 2 to 4 weeks. Clinical trials have
shown that blood pressure increases with the 375-mg/day dose but not with 75 to
225 mg/day. Venlafaxine has been successful in reducing the insomnia,
irritability, and excessive tension related to generalized anxiety disorder.
7 - E. Propofol is primarily used in a surgical context when patients are intubated.
Antipsychotics are the typical drug of choice for agitated, combative patients in
emergency settings. High-potency agents are preferred. Benzodiazepines are
also used to control agitation and violence, often in combination with an
antipsychotic, but they can have a disinhibiting effect and could cause some
clouding of consciousness. These medications are usually administered
intramuscularly.

8 - C. Suicide risk is lower in persons who are married and have children and
stable support systems. Sudden symptom relief in a patient who recently felt
hopeless and/or helpless can indicate a decision to commit suicide. Having a
specific plan, lethal means, history of suicide attempts, absence of an emotional
support system, and a history of severe mental illness are all risk factors for
suicide. The risk of suicide is high among patients with schizophrenia.

9 - E. All the other options suggest the possibility of imminent violence. Although
it is difficult to predict future violence, a history of violent behavior is the single
best predictor. Major depressive disorder is not a specific indicator of potential
subsequent violence.

10 - C. These symptoms are indicative of benzodiazepine intoxication, and

alprazolam is a benzodiazepine. Confusion, cognitive impairment, ataxia,
drowsiness, slurred speech, sedation, somnolence, or impaired judgment are all
signs of benzodiazepine intoxication.