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Answers and Explanations
*USMLE is a joint program of the Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners.
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Psychiatry Assessment Exam
1. A 17-year-old African American girl comes to the clinic for a precollege health checkup. She reports no current symptoms and states she has generally been well. As an adolescent she was diagnosed with major depressive disorder after a prolonged period of depressive symptoms and a suicidal gesture. At that time, approximately 4 years ago, she was started on a selective serotonin reuptake inhibitor (SSRI) that helped her immensely. She discontinued her medication approximately 1 year ago and has been well since then. She denies any current neuropsychiatric symptoms. Her examination is unremarkable, appropriate vaccinations and laboratory studies are ordered, and she is given a clean bill of health. Later in the day the patient’s mother calls. She is concerned about her daughter’s risk for recurrent depression and suicide, which she has heard is a growing trend in the college-age population. There is a family history of suicide, and the mother is concerned that this may place her daughter at a high risk. She wonders if she should arrange to have the young woman seen by a psychiatrist while at college. Given this patient’s presentation, which of the following is her greatest risk factor for dying from suicide? (A) (B) (C) (D) (E) Family history Female sex Psychiatric illness Suicidal gesture Young age 2. A 36-year-old man comes to the clinic accompanied by his wife for a scheduled appointment. The man has apparently been suffering from a depressed mood since losing his job 5 months prior. A review of depressive symptoms reveals that the patient has significant sleep disturbances, often waking early in the morning and napping in the afternoon; has lost interest in most activities he previously enjoyed; reports feeling sluggish and without energy; and has a markedly diminished appetite. His wife reports that the patient “no longer seems to be himself ” and is paying little attention to friends and family. The patient often cries for no apparent reason, yet does not wish to discuss what is on his mind. Which of the following is the most appropriate strategy for suicide risk screening in this patient? (A) Admit patient immediately given high risk; further evaluate in the hospital (B) Avoid explicitly discussing suicide to minimize risk for initiating suicidal ideation (C) Openly ask wife and patient about any thoughts, mention, or plans of suicide (D) Send wife away and ask explicitly about suicidal ideation, plan, and intent (E) Stratify suicide risk according to epidemiologic risk factors; admit if high risk
USMLE Step 2 Assessment Exam
A forensic psychiatrist is assessing a patient who has pleaded not guilty to arson by reason of mental illness. The patient is a 37-year-old man who has a past history of insurance fraud and arson for burning buildings and splitting the insurance settlement with the buildings’ owners. During the assessment, the patient does not seem to be in any distress. He states that he does not have any control over his urges to start fires. His urges become uncontrollable when people offer him money to burn things. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Bipolar disorder Intermittent explosive disorder Major depressive disorder Malingering Pyromania
A 31-year-old woman comes to the psychiatrist because she has “lost control of her life.” She has an “uncontrollable urge” to steal items from stores that she does not need. She states, “I feel like going to the store all the time to the point that I get all wound up.” She also explains that her life is very “dull,” except for the moment when she is about to steal something. Afterward, the patient feels relieved but then guilty and believes that she is “an awful person.” Outside of these episodes, the patient is a responsible wife and participates actively in her church and community. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Antisocial personality disorder Borderline personality disorder Factitious disorder Intermittent explosive disorder Kleptomania
A 68-year-old woman is being evaluated for a sleep disorder. Over the past few months her sleep cycle has become progressively more disrupted. She wakes early and often lies in bed for prolonged periods of time. She reports feeling tired and fatigued and not like speaking much. Despite being fatigued, she has trouble falling and staying asleep. During the day she has trouble paying attention and has little interest in her surroundings, which she attributes to fatigue when asked. She reports having no appetite and is not sure how much she has been eating. Her past medical history is remarkable for panic disorder and hypertension, both diagnosed years ago, for which she has taken beta-blockers and alprazolam since diagnosis. Physical examination reveals a tired-appearing, moderately overweight woman. She is easily distracted, slow to respond to questions, and seems distant. Otherwise, physical examination is basically normal. A sleep study is performed that reveals decreased total sleep time, increased sleep latency, decreased rapid eye movement (REM) latency with increased REM density, and decreased stage 4 sleep. Which of the following is the most likely cause of this patient’s sleep study findings? (A) (B) (C) (D) (E) Age-related changes Depression Drug side effects Narcolepsy Obstructive sleep apnea
A 19-year-old college student is brought to the emergency department after being found naked running through the campus. According to paramedics, he was apparently attempting to climb the lampposts and screaming something about the second coming of Christ. Friends state that he does not normally act like this, although over the last week he has been acting a little “stressed out” and has been studying all night for approaching final exams. Apparently, the patient was seen earlier in the evening at a postexam party, where he seemed anxious and distracted. Currently, the patient refuses to answer questions from anyone other than one of the nursing aids because everyone else is “a demon.” He is obviously agitated and extremely paranoid and informs the nursing agent that he can see spirits who are speaking to him. He repeatedly picks at his skin, stating that he is removing “holy scarabs” that are infesting his earthly body. His temperature is 37.0 C (98.6 F), blood pressure is 158/98 mm Hg, pulse is 118/min, and respirations are 25/min. Physical examination reveals an anxious, diaphoretic, wide-eyed man, but is basically unremarkable. Which of the following is the most likely cause of this patient’s symptoms? (A) (B) (C) (D) (E) Acute intoxication Drug withdrawal Personality disorder Schizophrenia Schizophreniform disorder
A previously healthy mother comes to the clinic for a follow-up visit 5 weeks after her young son was killed in an automobile accident in which she was driving. She reports being a wreck and being unable even to consider “moving on with [her] life.” She suffers from diffuse aches and pains and is unable to face her husband, as she is overwhelmed with guilt and a feeling of personal responsibility for her son’s death. Most concerning, she continues to be preoccupied with images of her son in which he seems to be calling to her. Although she knows that he is indeed dead, she cannot help but think about him constantly. Her sleep is poor, and she is constantly awakened by nightmares. She denies having a suicide plan and states that she needs to be strong for the rest of her family, though she does not know where she will get the energy to do this. Given this patient’s presentation, she is most likely suffering from which of the following? (A) (B) (C) (D) (E) Dysthymic disorder Major depression with melancholia Major depression with psychotic features New onset cyclothymic disorder Normal grief reaction
A forensic psychiatrist is evaluating a patient before a criminal trial. The suspect is a 17-year-old girl who is accused of fatally stabbing her stepfather while he was asleep. There is substantial forensic evidence against the suspect, including a murder weapon with her fingerprints. The suspect states that she does not remember stabbing her stepfather. However, she feels no sense of loss that her stepfather is dead because of a long history of being sexually abused by him. During the assessment, the suspect’s facial expression and voice rapidly change. She says that she is now the “adopted older brother” of the suspect and that he stabbed the suspect’s stepfather without her knowledge. For the remainder of the interview, the psychiatrist is unable to speak to the suspect directly. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Depersonalization disorder Dissociative fugue Dissociative identity disorder Major depressive disorder, with psychotic features Schizophrenia, paranoid type
A 26-year-old woman is brought to the psychiatry clinic by her mother because she has been talking to herself and believes that people are trying to find her. She has been living in a group residence for the past 6 years, although her parents are wealthy and have repeatedly attempted to have her live with them. The patient’s reason for not wanting to live with her parents is based on a belief that they had been poisoning her food and are attempting to brainwash her. Her parents have always been caring and generous and have never done anything to harm her. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Bipolar disorder, most recent episode manic Major depressive disorder Post-traumatic stress disorder Schizophrenia, catatonic type Schizophrenia, paranoid type
USMLE Step 2 Assessment Exam
A 28-year-old man comes to the clinic complaining of depressed mood. He has seen advertisements for a variety of medications for depression and feels he is a candidate. Since graduating from college 5 years ago, the patient reports symptoms of low self-esteem, low energy, and mild anhedonia. These symptoms are present almost all of the time. He denies any sleep disturbance, reports mild weight gain over this period, and states his concentration is “okay.” When asked specifically, he denies any suicidal thoughts. Vital signs and physical examination are normal. Given this patient’s presentation, which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Adjustment disorder with depressed mood Cyclothymic disorder Dysthymic disorder Major depression Minor depression
An 11-month-old boy is brought to the physician for a well-child examination. The mother states that her son is eating well and is generally healthy. She also says that he seems to be developing a little bit ahead of the children in his day care. In trying to understand her son’s development, however, the mother begins to ask many questions. She should be told that according to Erik Erikson, which of the following constitutes the critical challenge for infants during the first year of life? (A) Development of a feeling of basic trust that their needs will be satisfied by their caregivers (B) Development of gender identity (C) Gaining a sense of separateness from others (D) Having a mastery over their drives (E) Using simple objects
13. 11. A 33-year-old woman with a history of depressive episodes comes to the clinic for a routine health care checkup. She reports feeling down and having significant fatigue and insomnia but feels her condition is “under control” with her current combination of exercise, psychotherapy, and St. John’s wort. She states that she has been “smoking like a chimney,” however, and would like some assistance quitting. She has enrolled in a smoking cessation group and has purchased over-thecounter nicotine replacement transdermal patches. She is interested in any additional appropriate pharmacologic therapies. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate pharmacotherapy? (A) (B) (C) (D) (E) Bupropion Buspirone Clonidine Fluoxetine Nortriptyline
A 33-year-old woman comes to the clinic after a recent hospitalization for atypical chest pain, for which she was advised to follow up with her primary care provider. Further discussion reveals that the patient has had recurrent episodes of chest pain, often accompanied by palpitations and a sensation of smothering. When this occurs, she often feels as if she is going to die and fears that she is going crazy. She trembles and shakes, occasionally has sweats or chills, and often feels choked. The symptoms peak in approximately 10 minutes and usually resolve within half an hour. There is no clear precipitant to these symptoms. The attacks have increased in frequency over the past 2 years to the point that the patient fears leaving her house. Based on her presentation, she is referred for cognitive behavioral therapy and is prescribed a short-acting benzodiazepine. Which of the following is an additional appropriate pharmacologic agent for this patient? (A) (B) (C) (D) (E) Bupropion Buspirone Fluoxetine Phenelzine Risperidone
A concerned mother brings her 6-year-old child to the clinic for an evaluation. Over the past year the child has developed some concerning habits. Without warning, he has episodes of bizarre shoulder shrugging, facial grimacing, and blinking. Additionally, he often grunts, spits, and repeats the few obscenities he has overheard his parents use. Given the patient’s presentation, he is treated with dopaminergic antagonists, after which his symptoms improve. His mother, understandably, is concerned about his risk for future psychiatric disease. It is appropriate to advise the mother that this condition is most closely associated with which of the following? (A) (B) (C) (D) (E) Asperger syndrome Future suicide risk Major depressive disorder Obsessive-compulsive disorder Schizophrenia
For the past 6 months a 20-year-old man with no past psychiatric or neurologic history has been told by friends that he falls asleep during dinner and in class. There are times on awakening when he is unable to move for up to 2 minutes. He sometimes “sees shadows and figures” when he is about to fall asleep or immediately after waking up. Additionally, when in very stressful situations, he becomes “unable to control” his muscles. He is otherwise healthy, does not take any medications, and does not drink alcohol or use drugs. Several members of his family have similar symptoms and they, too, do not take any medications or use any drugs. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Conversion disorder Insomnia Narcolepsy Psychotic disorder, not otherwise specified (NOS) Somnambulism
A 42-year-old woman is being evaluated for an anxiety disorder. Over the last year she has developed severe fear and anxiety about several events and activities. She rarely leaves her house as she is worried about terrorism, and when she does she tries to avoid taking a car or bus for fear of traffic accidents. Further questioning reveals that she has several other odd concerns and worries, with fear out of proportion to the likelihood or impact of the feared events. Although she is aware that these worries are irrational, she reports that the fear is nonetheless difficult to control. She constantly feels restless, is easily fatigued, and because of her anxiety and poor sleep is unable to concentrate on daily tasks. Her past medical history is significant for drug and alcohol abuse, though the patient has been sober for the last 6 years. In the past she has tried to treat similar episodes of anxiety with drugs and alcohol. She is scared of medications with abuse potential and wants the least addictive treatment for her condition. Which of the following is an appropriate treatment for this patient’s condition? (A) (B) (C) (D) (E) Alprazolam Buspirone Chlordiazepoxide Electroconvulsive therapy Propranolol
A 39-year-old man comes to the clinic for a routine health evaluation. He states that his health has never been better. He does not smoke, rarely drinks alcohol, and runs 4 to 5 miles a day. Although his physical health is great, he tells you that recently he has been suffering a great deal of anxiety. Recently he received a significant promotion at work. He realizes he should be ecstatic. The new position requires him to occasionally speak in front of boardrooms and large groups of potential investors, however. He is petrified of public speaking and often breaks out in a sweat and develops a tremor severe enough to cause him to drop his notes. The patient has been scared of public speaking all his life and has, until now, simply avoided the situation whenever possible. Which of the following is the most appropriate medical treatment for this patient’s anxiety? (A) (B) (C) (D) (E) Buspirone Diazepam Hydroxyzine Imipramine Propranolol
USMLE Step 2 Assessment Exam
Late one night, a worried nurse gives the attending physician a frantic page. A new admission recently transferred from the nursing home has developed a high fever and has had no urine output in the last shift, despite the placement of a Foley catheter. Apparently, the 73-year-old man was transferred earlier in the day, at which time he was afebrile, for evaluation of a progressive decline in mental status and functional capacity. The patient was disoriented and confused at the hospital surroundings, and the nurse, as ordered, has been giving the patient haloperidol and lorazepam as needed. Now, however, the patient seems more agitated despite repeated doses of haloperidol. Arriving at the bedside, the physician finds a confused, somnolent, elderly man. His temperature is 40.0 C (104.0 F), and he is hypertensive and tachycardic. He is extremely stiff, noncommunicative, and sweaty. Additionally, he is tremulous and seems to be writhing in bed. Intravenous fluids and rectal acetaminophen are administered. Which of the following is an additional appropriate therapy for this patient’s current condition? (A) (B) (C) (D) (E) Benztropine Chlorpromazine Dantrolene Flumazenil Risperidone
A 17-year-old girl with no significant past medical history comes to the physician for a pregnancy test because of several missed periods and “weight gain.” She otherwise has no complaints, is at the top of her high school class, is the star of the track team, and helps take care of her younger brother while her mother is at work. The patient is found to be at least 20 pounds below her expected body weight. When questioned about this, she admits to taking laxatives and vomiting because of her self-perception that she is overweight. She does not see this as a problem because many of her friends engage in similar behavior. She also belongs to an Internet organization of other girls her age who engage in similar behavior. Urine pregnancy test is negative. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Adjustment disorder Anorexia nervosa Bulimia nervosa Delusional disorder Major depressive disorder
A married couple comes to the clinic for couple’s therapy. They have been married for 2 years and were dating for 5 years before this. They love each other very much and would “do anything to salvage” their marriage. The problem in the couple’s relationship pertains to the husband being unable to “control his rage.” Seemingly trivial arguments have resulted in the husband breaking furniture, punching walls, and “screaming hateful things.” The husband has repeatedly admitted that he “can’t control the temper.…it has a life all of its own.” The husband has no history of drug abuse or alcoholism. Notably, the couple is experiencing financial difficulty because the husband was fired from his job after an angry outburst at work. Which of the following is the husband’s most likely diagnosis? (A) (B) (C) (D) (E) Adjustment disorder Borderline personality disorder Intermittent explosive disorder Major depressive disorder Schizophrenia, paranoid type
A psychiatrist is called to assess a 45-year-old independent computer consultant who is being discharged from the hospital where he was admitted for the treatment of pneumonia. His medical team is concerned because he wants to be discharged without an escort. He does not harbor any animosity toward his family but does not keep any kind of regular contact with them. He just naturally prefers to be by himself and only derives any true satisfaction in life by working independently on his home computer. He has always been this way and has never had any close friends. He denies any overt paranoia, perceptual disturbances, or mood symptoms. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Adjustment disorder Delusional disorder Major depressive disorder Schizoid personality disorder Schizophrenia, paranoid type
A 28-year-old woman is brought to the emergency department after attempting suicide by cutting her wrists in an effort to keep her boyfriend of 2 weeks from breaking up with her. She has had several previous evaluations with a similar presentation. She is known to many of the staff from several previous emergency department evaluations and psychiatric admissions. As in previous evaluations, the patient relays that she is chronically empty and has very little sense of what her own values and identity are. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Bipolar disorder Borderline personality disorder Delusional disorder Panic disorder Schizoid personality disorder
A consulting psychiatrist is asked to assess a 51-year-old “difficult patient” who has been hospitalized for a cholecystectomy. The patient is described as “intolerably rude” to the staff and makes unreasonable demands for special treatment. On evaluation, the patient makes it a special point to state that he is the chief executive officer of a large corporation. He is quick to note the amenities that other executives have received when hospitalized. He also implies that he should only receive consultations from chairmen of departments. When told that many of his requests will not be feasible, he angrily demands that the physician leaves the room. There are no associated mood or anxiety complaints. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Adjustment disorder Borderline personality disorder Major depressive disorder Narcissistic personality disorder Psychotic disorder, not otherwise specified (NOS)
A 48-year-old man is being evaluated for a depressed mood. Approximately a year ago, he and his spouse separated, and since then he has become progressively more withdrawn. Activities that once interested him are now unappealing, he has lost most of his appetite, and he has difficulty falling and staying asleep. Although he denies any suicidal ideation, he does report that his sense of self-worth is diminished, and he has trouble “just getting by” from day to day. Before this he has been healthy and does not take any prescription or herbal medications. Physical examination reveals a mildly disheveled, tired-appearing man, but is otherwise unremarkable. After much discussion with this patient, it is decided to start him on sertraline, a selective serotonin reuptake inhibitor (SSRI), and to refer him for psychologic counseling and a support group. Approximately 10 days later the patient calls to say that he is concerned that the medicine is not working, as he has noticed no difference in his mood, volition, appetite, or insomnia. At this time, which of the following is the most appropriate response to this patient’s concern? (A) Add bupropion to treat negative symptoms of depression (B) Change sertraline to paroxetine; re-evaluate in 10 days (C) Discontinue sertraline; start monoamine oxidase inhibitor (MAOI) (D) Increase the dose of sertraline; re-evaluate in another 10 days (E) Reassurance; continue sertraline for at least 4 to 6 weeks
A previously healthy 6-year-old girl is kept home from school for 3 days because she has been complaining of severe stomachache when she gets up in the morning. The pain dissipates as the day goes on without any intervention. Physical examination and other review of systems are normal. Privately, the patient is asked how she is doing, and she says that she has been having nightmares about her parents dying since the death of her grandmother 2 months ago. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Attention deficit hyperactivity disorder (ADHD) Conduct disorder Oppositional defiant disorder Separation anxiety disorder Social phobia
Psychiatry Assessment Exam Answers and Explanations
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. C D D E B A C E E C A A C 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. D B C E C C B D B E D D
USMLE Step 2 Assessment Exam
The correct answer is C. By far the strongest predictor of suicide is a history of psychiatric illness. Ninety-five percent of patients who die from suicide have a psychiatric history (commonly, depression, bipolar disorder, or schizophrenia), whereas 90% of suicide attempts occur in patients with psychiatric disease. Among patients with psychiatric disease, other risk factors such as age, family history, sex, and previous suicide attempts and gestures can give an idea of a patient’s risk for successfully committing suicide. Even with all of the available epidemiologic data, however, it is extremely difficult to predict who will attempt suicide. As such, the best strategy for evaluating patients at risk for suicidal behavior is to ask explicitly about thoughts of hurting oneself when taking a psychiatric history. Family history (choice A) is a suicide risk factor, though this is difficult to quantify. In any case, it is not as significant as this patient’s history of psychiatric illness. This patient’s sex (choice B) does not increase her risk for dying from suicide, though it does increase the likelihood of a suicide attempt. Women attempt suicide four times more frequently than men. Male patients are successful three times more often than female patients, however. Previous suicide attempts and gestures (choice D) are a major risk factor for future suicide attempts. This patient’s previous suicidal gesture needs to be evaluated to determine if it really was a suicide attempt, which is more significant than a gesture. Suicide rates are increasing in teenage and college-aged people. Most occurrences occur in older patients, however, and the rate of suicide generally increases with age. As such, age (choice E) is not this patient’s greatest risk factor. The correct answer is D. Depressed patients always need to be asked explicitly about any suicidal thoughts, plans, and intent. It is impossible to predict who will commit suicide. Despite explicit epidemiologic data and risk factors, it is impossible to do a good job of stratifying patients’ risk for suicide (choice E) in any clinically meaningful way without asking. Using epidemiologic risk factors results in a false negative rate of greater than 40% (i.e., patients predicted not to commit suicide who do). Many patients may have feelings of worthlessness or hopelessness; many of these also have intermittent thoughts of suicide. The most concerning patients have intent, a plan, and a timeframe. This latter group needs aggressive care, including, if necessary, involuntary admission. Until these factors are known there is no way to decide if one should admit this patient immediately (choice A).
Many physicians are worried that explicitly discussing suicide will initiate suicidal ideations (choice B). There are no data to support this assertion. In contrast, many patients appreciate a chance to discuss these disturbing thoughts that they have likely not discussed with friends or family. Indeed, given the stigma associated with suicidal thoughts, openly asking the wife and the patient (choice C) about suicide is likely to be less effective than sending the wife away. 3. The correct answer is D. The patient is attempting to feign a diagnosis of pyromania to avoid standard prosecution. Past experiences with starting fires for this patient were started solely for the intention of financial gain. Patients with an actual diagnosis of pyromania are compelled by the act of starting and observing fires. This patient evidences no signs of mania (expansivity, euphoria, neurovegetative signs of mania). Therefore, a diagnosis of bipolar disorder (choice A) is incorrect. Intermittent explosive disorder (choice B) is characterized by episodes of failure to resist aggressive/assaultive impulses. It is not evidenced by this patient’s presentation. The patient does not evidence any complaint of depressed mood or neurovegetative or cognitive symptoms of depression. Therefore, a diagnosis of major depressive disorder (choice C) is incorrect. Pyromania (choice E) is a disorder that involves deliberate fire setting with an anxiety and excitement before the act of setting a fire and a relief or excitement in observing the fire. This occurs outside the presence of secondary gain (such as financial gain). The correct answer is E. The patient described has an uncontrollable urge to steal items, feeling a sense of excitement immediately before and during the act of stealing and a mixed sense of relief and shame after the act. The actual items being taken are of no relevance to these patients. It is the act of stealing that is the goal. Stealing and crimes of dishonesty are common features of antisocial personality disorder (choice A). Patients with antisocial personality disorder, however, evidence a belief system that excludes feelings of guilt or remorse about their actions. Therefore, choice A is incorrect. The patient in question does not evidence the instability of personal identity and relationships that characterize borderline personality disorder (choice B). Factitious disorder involves the conscious feigning of symptoms to assume the sick role. The patient does not manifest this. Therefore, choice C is incorrect. Intermittent explosive disorder (choice D), like kleptomania, is an impulse control disorder. Intermittent
Psychiatry Answers and Explanations
explosive disorder involves the failure to resist aggressive impulses, however, and not stealing. Therefore, choice D is incorrect. 5. The correct answer is B. The diagnosis of depression is not always straightforward, and patients may receive an extensive medical workup. Depression often causes sleep disturbances that may be a major clue to the diagnosis. This patient, who seems to have vegetative signs of anergia, severe distraction, anorexia, and fatigue, has major depression with melancholia. Common sleep disturbances include decreased total sleep time, increased sleep latency, decreased rapid eye movement (REM) latency, increased REM density, and decreased stage 4 sleep. A simpler screening test is to ask about insomnia and early morning wakefulness, which are often present in major depression. Age-related changes (choice A) include an increase in stage 1 sleep and a decrease in stage 3 and 4 sleep with little effect on REM sleep. Further, the impact of these sleep changes does not explain this patient’s sudden decline. Drug side effects (choice C) are important to consider in a patient taking beta-blockers and benzodiazepines. Beta-blockers can cause insomnia, hallucinations, and nightmares; can suppress REM sleep; and can worsen depression, at least theoretically. Given this patient’s acute decline and sleep study results, it is unlikely to be the cause of her condition. Benzodiazepines, which are used as sleep aids, reduce sleep latency, increase total sleep time, and have little or no effect on REM sleep. Narcolepsy (choice D) is characterized by daytime sleepiness and decreased REM latency, sleep attacks, cataplexy, hypnagogic and hypnopompic hallucinations, and sleep paralysis. This patient does not have the characteristic findings associated with narcolepsy. Obstructive sleep apnea (choice E) causes periods of wakefulness that may be associated with increased airway resistance and chest wall impedance, oxygen desaturation, and frequent episodes of wakefulness. It is unlikely to be the cause of this patient’s symptoms. The correct answer is A. Differentiating psychiatric illness from medical causes of psychosis can be difficult, and a toxicology screen will be invaluable in assessing this patient. Paranoia, aggressiveness, and psychotic symptoms can be associated with any of the answer choices. This patient also has numerous signs of sympathetic stimulation: insomnia, tachycardia, mydriasis, hypertension, and sweating, together with classic formications, or “cocaine bugs,” which all point toward
drug intoxication, likely cocaine, another amphetamine, or a hallucinogenic agent. Formication is a tactile hallucination in which patients feel a sensation of insects creeping under the skin; it is strongly associated with substance-induced psychotic conditions, classically from cocaine or PCP. Drug withdrawal (choice B) usually does not cause these hyperadrenergic symptoms and is less likely in this patient. A personality disorder (choice C) does not cause acute dysfunction and would not be expected to start suddenly. Schizophrenia (choice D) often presents in college-aged men. This patient has symptoms pointing more toward drug use: a recent string of all-nighters, a psychotic break at a party, formications, and signs of a hyperadrenergic state. The diagnosis of schizophrenia usually is made for conditions lasting longer than 6 months, whereas patients with a condition lasting less than 6 months are classified as schizophreniform (choice E). 7. The correct answer is C. Patients with dissociative identity disorder manifest multiple distinct personalities that assume control of the patient’s awareness of the environment and behavior. Common comorbidities for patients with dissociative identity disorder include borderline personality disorder, posttraumatic stress disorder, and physical or sexual abuse. Depersonalization disorder (choice A) is defined by the perception that one is detached from his/her mental processes or body. It is not characterized by the assumption of multiple personalities. Dissociative fugue (choice B) is a rare dissociative disorder involving abrupt travel and an amnesia for events that may include the circumstances preceding arrival at one’s destination and one’s identity. The etiology of dissociative fugue is unknown, though a possible correlation between dissociative fugue and recent life stressors may exist. The condition is usually selflimited. This patient does not report symptoms consistent with a major depressive disorder (choice D), such as depressed mood or neurovegetative signs of depression. The patient in question has periods of dissociation involving the assumption of another personality. This is not to be confused with a chronic psychotic state such as found in schizophrenia, paranoid type (choice E). Patients with schizophrenia typically evidence a disorganization of thought process, and reality-testing mechanisms are often inadequate. Patients with dissociative identity disorder have a fragmentation of actual conscious functions with intact reality testing.
USMLE Step 2 Assessment Exam
The correct answer is E. Grief and mourning can be severe and involve multiple sensory hallucinations of the deceased. In general, acute grief reactions last less than 2 months, but during this time frame they can closely mimic major depression. In general, if patients have prolonged symptoms, are unable to identify hallucinations for what they are, or have prolonged feelings of worthlessness or suicidal ideation, major depression is a more appropriate diagnosis. Dysthymic disorder (choice A) is a chronic condition in which patients have a depressed mood on most days for a period of time greater than 2 years. It is not an acute condition. Major depression comes in a variety of flavors. Major depression with melancholia (choice B) describes patients with vegetative symptoms, such as those with catatonia or severe anergia. Major depression with psychotic features (choice C) includes, obviously, psychosis. Patients with this condition have hallucinations but are not able to differentiate reality from internal creations, a problem this patient does not have. Cyclothymic disorder (choice D) does not describe this patient. It is a condition marked by mood swings not severe enough to cause the social dysfunction of bipolar disorder. The correct answer is E. The patient in question has been chronically psychotic, as seen by her paranoid delusions directed toward her parents. Paranoid schizophrenia differs from other forms of schizophrenia in its predictable symptom presentation within a given patient—patients are often preoccupied with consistent paranoid delusions or hallucinations of a consistent type and theme. The patient does not present with episodic, manic symptoms that characterize bipolar disorder (choice A). The patient’s psychotic symptoms are ongoing and not dependent on a manic episode to commence. The patient does not present with depressive symptoms (choice B) and is instead chronically delusional. This patient’s presentation is not consistent with a major depressive disorder. There is no evidence of a traumatic event (choice C) that is being relived or avoided in this patient’s history. The patient in question is best described as being chronically psychotic and presently having an acute exacerbation superimposed on her chronic psychosis. Catatonic schizophrenia (choice D) is characterized by gross, odd psychomotor behavior (such as waxy flexibility), seeming unawareness of environmental cues, and extreme negativism. Left untreated, it can lead to
severe medical consequences such as high fevers, rhabdomyolysis, and renal failure. This patient is clearly not catatonic. 10. The correct answer is C. Patients with dysthymic disorder suffer from chronic depressed mood that does not meet the criteria for major depression. To meet the diagnosis, a patient needs to have a depressed mood and two or more of the following features: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness, with a duration of symptoms greater than 2 years. Major depression (choice D) requires five of the nine symptoms to be present concurrently for at least 2 weeks. The criteria for depression are as follows: Criteria for a Major Depressive Episode Depressed mood Anhedonia Significant weight or Insomnia or hypersomnia appetite change Guilt or sense of worthlessness Significant fatigue Decreased concentration Agitation or retardation Recurrent morbid or suicidal thoughts Adjustment disorder with depressed mood (choice A) requires a clear precipitant, such as a move to a new city, a divorce, or a diagnosis of cancer. It is also a discrete event and resolves within 6 months or with removal of the precipitating cause. Cyclothymic disorder (choice B) does not describe this patient, who lacks symptoms of hypomania. It is a condition marked by mood swings not severe enough to cause the social dysfunction of bipolar disorder. Minor depression (choice E) shares a different time frame from dysthymic disorder and is very common in primary care. The condition requires two to four of the criteria for major depressive disorder, which must be present simultaneously for 2 weeks. Many of these patients develop major depression or suffer severe social dysfunction from their condition. Patients who continue to have symptoms for longer than 2 years meet the criteria for dysthymic disorder. 11. The correct answer is A. Bupropion is a heterocyclic antidepressant believed to aid in smoking cessation by noradrenergic and dopaminergic modulation, in effect increasing volition and decreasing craving. Studies have indicated that, compared with placebo and nicotine replacement, the addition of bupropion can approximately double the success of smoking cessation and can
Psychiatry Answers and Explanations
increase the abstinence rate 1 year post treatment. Additionally, an activating antidepressant would likely be useful in treating this patient’s mood disorder, as pharmacotherapy is usually more effective than adjunct therapies, such as exercise and St. John’s wort (though both have evidence of success in mild, acute depression). Buspirone (choice B) is an anxiolytic that is not approved for smoking cessation, has shown minimal if any short-term benefit, and, unfortunately, has a name that looks similar to bupropion. Clonidine (choice C) is generally not an effective pharmacologic treatment for smoking cessation. Other antidepressants such as fluoxetine (choice D) and nortriptyline (choice E) may be effective in smoking cessation. These agents are not currently approved for this purpose, however, and do not have the strong data available for bupropion. Bupropion is a more appropriate agent for this patient. 12. The correct answer is A. Erikson referred to the first year of life as the stage of developing basic trust versus mistrust. Infants are dependent on their parents (or other caregivers) for all of their needs. Before the development of a sense of separateness and exploration, basic trust that one will not be left alone and vulnerable in an unpredictable environment needs to develop. Gender identity (choice B) occurs much later in childhood than in the first year of life. Therefore, choice B is incorrect. Gaining a sense of separateness from others (choice C) is thought to occur during Erikson’s stage 2, autonomy versus shame and doubt. Mastery over drives (choice D) occurs during Erikson’s stage 2, autonomy versus shame and doubt. This stage is generally thought to occur between the ages of 1 and 3 years, coinciding with toilet training. Use of simple objects (choice E) is beyond the expectation of normal infant development. Up until the first year of life, the infant’s development of basic trust depends on his or her caregivers’ manipulation of the environment and not their own manipulation of it. The correct answer is C. This patient has panic disorder with agoraphobia. The pharmacologic treatment of panic disorder centers around four proven classes of drugs: the selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), benzodiazepines, and monoamine oxidase inhibitors (MAOIs). The advantage of long-acting agents such as SSRIs is that they provide prophylactic rather than reactive treatment and have less abuse potential and tolerance
issues than the benzodiazepines. Cognitive behavioral therapy that focuses on reactions to stressful situations is at least as effective as pharmacologic treatment. Atypical antidepressants such as bupropion (choice A) are not used to treat panic disorder. Buspirone (choice B) is an anxiolytic. Its use is usually reserved for generalized anxiety disorder, however, making it a poor first choice for this patient. Phenelzine (choice D) is an MAOI and is efficacious in the treatment of this disorder. MAOIs are generally not first line agents, however, given the significant drug and food interactions and overdose potential. Risperidone (choice E) is used for psychosis and occasionally for depression. It is not a treatment for panic disorders. 14. The correct answer is D. This patient has a classic presentation of Tourette syndrome, a movement disorder that often presents with complex tics, grunts, and other involuntary vocalizations, and occasionally coprolalia (repetition of obscenities) and bizarre thoughts and ideas. Almost a third of these patients suffer from obsessive-compulsive disorder or obsessive-compulsive behavior as an adult, and almost 60% have attention deficit hyperactivity disorder as children. Asperger syndrome (choice A) is a milder, functional form of autism. Tourette syndrome is not strongly associated with Asperger syndrome. Psychiatric disease in general increases the risk for suicide. Tourette syndrome is not strongly associated with suicide risk (choice B), however, and does not warrant discussion at this time. Diseases that are strongly associated include recurrent depression, schizophrenia, and bipolar disorder. Major depressive disorder (choice C) is not closely associated with Tourette syndrome; neither is schizophrenia (choice E), though it is also a disease believed to be related to dopaminergic dysregulation. The correct answer is B. Buspirone is an anxiolytic agent used to treat generalized anxiety disorder, though it is not effective for the treatment of panic disorder and panic attacks. The medication can be used instead of benzodiazepines and has significantly less abuse potential than these agents. The medication works by selective antagonism of the 5HT1A receptor. Alprazolam (choice A) and chlordiazepoxide (choice C) are benzodiazepines, a class of agents commonly used to treat anxiety disorders. Overall, benzodiazepines are not widely abused by patients. Patients with a history of abuse, particularly if the patient is concerned about
USMLE Step 2 Assessment Exam
relapse, however, are at a greater risk for drug dependency. Electroconvulsive therapy (choice D) is not used to treat anxiety disorders. Its main use is to treat severe depression, catatonia, or mania. In those capacities, electroconvulsive therapy is safe and effective despite a negative public perception. Propranolol (choice E) is a nonselective beta-blocker that can be used to treat mild anxiety that occurs in specific situations, such as public speaking. Although it is extremely useful for a discrete set of phobias, it is not useful in the treatment of generalized anxiety disorder. 16. The correct answer is C. This patient demonstrates the hallmark symptoms of narcolepsy, including sudden “sleep attacks,” sudden losses in muscular tone during times of emotional stress (cataplexy), sleep paralysis, and hypnagogic and hypnopompic hallucinations. Conversion disorder (choice A) is characterized by the sudden appearance of neurologic symptoms without a neurologic lesion that occurs in the presence of an emotional stressor. This patient has a true sleep disorder and accompanying neurologic symptoms. Insomnia (choice B) is characterized by difficulties initiating or maintaining sleep. It is not accompanied by sleep attacks or other symptoms of narcolepsy. Although the patient is experiencing hallucinations, they occur exclusively within the context of sleep. This patient is not psychotic. A diagnosis of psychotic disorder NOS (choice D) is therefore incorrect. Somnambulism (choice E) is what is known in lay terms as “sleepwalking.” This patient does not experience the action of coordinated movements while asleep. The correct answer is E. Propranolol is a nonselective beta-blocker that can be used to treat mild anxiety that occurs in specific situations, such as public speaking. It reduces the autonomic arousal that often serves as a positive feedback loop in specific phobic situations. Buspirone (choice A) is a serotonin antagonist used to treat generalized anxiety disorder. It is not approved for short-term treatment of specific phobias. Diazepam (choice B) is a benzodiazepine with a long half-life, often used for more severe anxiety disorders. This patient should not have a sedating agent before leading a board meeting. Propranolol, which can help control specific symptoms, is more appropriate for this patient’s mild, situation-specific anxiety. Hydroxyzine (choice C) is an antihistamine. It has no anxiolytic properties.
Imipramine (choice D) is a long-acting tricyclic antidepressant (TCA). Although these agents are classified as antidepressants, TCAs can be used to treat generalized anxiety disorder or panic disorder. Given the long half-life of these agents compared with this patient’s intermittent anxiety symptoms, an agent such as propranolol is more appropriate. 18. The correct answer is C. This patient has neuroleptic malignant syndrome, a life-threatening and idiosyncratic extrapyramidal response to antipsychotic medications that induces a central, dopaminergic-receptor blockade. High potency antipsychotics (in particular, haloperidol) are associated with the condition, though lower potency agents such as chlorpromazine (choice B) or, more uncommonly, atypical agents such as risperidone (choice E) can also cause this reaction. The major treatments involve cessation of the antipsychotic, supportive care for fever and the very likely present rhabdomyolysis, cooling measures such as acetaminophen and ice packs, and the administration of dantrolene or bromocriptine. Benztropine (choice A) is an anticholinergic useful for treating acute dystonia, akathisia, or Parkinsonism that is induced by an antipsychotic-related dopamine blockade. Flumazenil (choice D) reverses the effects of benzodiazepines such as lorazepam. This patient’s symptoms are unlikely to be caused by lorazepam, which is more likely to result in sedation, confusion, and a depressed respiratory rate. The correct answer is C. Intermittent explosive disorder is characterized by episodes of inability to resist aggressive expressions of anger or frustration. Of significance, these episodes are not better accounted for by a personality disorder (antisocial or borderline), psychotic state, or substance use. The patient’s episodes of aggression do not seem to be in response to a discrete social stressor as would occur in an adjustment disorder (choice A). In fact, it seems that these episodes have been of a chronic, repetitive nature. Episodes of impulsivity and violence can be features of borderline personality disorder (choice B). The other features of the disorder, however, such as identity insecurity, self-mutilation, and intense fear of abandonment, are prominently absent in this patient. The patient does not exhibit any prominent mood symptoms or neurovegetative signs of depression. Therefore, a diagnosis of major depressive disorder (choice D) is incorrect.
Psychiatry Answers and Explanations
The patient has not evidenced any psychotic symptoms, such as disorganized thought process, hallucinations, or paranoia. Therefore, schizophrenia, paranoid type (choice E) is incorrect. 20. The correct answer is B. The patient demonstrates the classic symptoms of anorexia nervosa that must include below-appropriate body weight, preoccupation or distress at the prospect of gaining weight, and amenorrhea. An important diagnostic consideration is that purging can occur in both anorexia and bulimia. Adjustment disorder (choice A) is defined as the presence of symptoms in response to a social stressor that the clinician believes to be in excess of what is appropriate given the nature of the stressor. A defined social stressor is not present in this patient, and an eating disorder of likely chronicity is a more appropriate diagnosis. Bulimia nervosa (choice C) is a diagnosis that requires recurrent episodes of binge eating and purging and a preoccupation with body weight. Patients with bulimia do not have to be underweight, however, and menstrual cycle irregularities are not a part of the diagnosis. Prognostically, the distinction between bulimia and anorexia is important because of the significantly better course of cohorts of patients with bulimia versus anorexia. The patient’s body weight preoccupation is not a delusion. It is a matter of subjective self-perception. A diagnosis of delusional disorder (choice D) is therefore incorrect. The patient gives no history of depressed mood, poor sleep, or guilt that characterizes a major depressive disorder (choice E). Depressive symptoms should be elicited in patients with eating disorders, however, as it is a common comorbidity. The correct answer is D. Schizoid personality disorder is characterized by a pattern of limited social interaction, emotional distance, a preference for solitary activities, and few close personal relationships. These patients are not psychotic or disorganized and the social withdrawal is not better accounted for by a depression or anxiety disorder. Adjustment disorder (choice A) is defined as the presence of symptoms in response to a social stressor that the clinician believes to be in excess of what is appropriate given the nature of the stressor. This patient’s social limitations are very much his own choice and attributable to his personality style. This patient did not at any point state that the reason for his wanting to be discharged by himself was secondary to suspiciousness, and there is no evidence of a delusional belief system in this patient. A diagnosis of delusional disorder (choice B) is therefore incorrect.
No complaints of depressed mood, anhedonia, or neurovegetative symptoms of depression are evident in this patient. A diagnosis of major depressive disorder (choice C) is therefore incorrect. This patient does not manifest any paranoid delusions, hallucinations, or disorganization that would warrant a schizophrenia-spectrum diagnosis. A diagnosis of paranoid schizophrenia (choice E) is therefore incorrect. 22. The correct answer is B. Patients with borderline personality disorder manifest instability in their personal relationships and their own self-identity and representation. Obvious behavioral features of borderline personality disorder include heated arguments, repeated suicide gestures, and “splitting” of opinions of others into “all good” or “all bad.” Patients with bipolar disorder (choice A) may manifest features in common with patients with borderline personality disorder, such as impulsivity and potential for mood lability. Bipolar disorder, however, is characterized by a more intermittent or episodic course and has additional neurovegetative symptoms, such as pressure of speech and thought process, little need for sleep, and euphoria. This patient’s presentation is more attributable to her baseline personality and pattern of behavior under emotional duress. The patient did not manifest any delusions in the clinical history. There is no reason to believe, based on this clinical vignette, that there is anything historically inaccurate from the patient’s account. Delusional disorder (choice C) is therefore incorrect. The patient in question reports no history of recurrent panic attacks (fulminant episodes of autonomic symptoms and fear of mortality in the circumstance). A diagnosis of panic disorder (choice D) is therefore incorrect. Schizoid personality disorder (choice E) is characterized by a pattern of limited social interaction, emotional distance, a preference for solitary activities, and few close personal relationships. Patients with borderline personality disorder, such as this patient, crave relationships in which they will be taken care of. The correct answer is E. SSRIs can take 4 to 6 weeks of treatment before patients notice a change in mood. In general, approximately half of patients respond in 2 weeks, with 90% of patients responding by 4 weeks. If a patient does not respond in 4 to 6 weeks, the agent should be changed. Because many patients who do not respond to one SSRI respond to a different one, changing sertraline to paroxetine (choice B) would be an appropriate strategy. At times, another class of agents, such as the heterocyclics (bupropion) (choice A) or MAOIs (choice C), is necessary. In general, MAOIs are
USMLE Step 2 Assessment Exam
reserved for patients who do not respond to any other pharmacotherapy. These agents have a significant number of food and drug interactions and have serious overdose potential, limiting their usefulness in depressed patients. Assuming that the patient was prescribed a reasonable and usual starting dosage, increasing the dosage (choice D) is not appropriate if there is absolutely no response at 4 to 6 weeks, though it may be appropriate if a small improvement is seen. It is not appropriate at this juncture, as the patient has not had enough time to determine if the current dose is effective. 24. The correct answer is D. Patients with narcissistic personality disorder demonstrate a need for excessive admiration and often make unreasonable requests for special treatment when hospitalized. They are often envious of others (note the patient pointing out the treatment other executives received when hospitalized). These patients are also likely to make insulting and demeaning comments to medical staff when their requests are not honored and to lack empathy for others. The patient’s haughty, demanding behavior is more demonstrative of a personality style rather than a reaction to a social stressor. A diagnosis of adjustment disorder (choice A) is therefore inappropriate. Patients with borderline personality disorder (choice B) demonstrate a pattern of instability in their own selfidentity and relationships with others. They often engage in self-injurious behaviors and, when under extreme duress, dissociative symptoms. This patient does not demonstrate this sort of symptomatology. The patient does not demonstrate depressed mood or neurovegetative symptoms of depression. A diagnosis of major depressive disorder (choice C) is therefore incorrect. The patient does not manifest any psychotic symptoms, and there is nothing from the history of present illness to indicate that the patient is paranoid. A diagnosis of psychotic disorder NOS (choice E) is therefore incorrect. The correct answer is D. Separation anxiety disorder is commonly seen in children after an acute stress or family event. In this patient’s case, the death of her grandmother likely contributes to the patient fearing for her parents’ lives. There is no history mentioned in the question stem of inattention, academic difficulties, or hyperactivity/ impulsivity that characterize ADHD (choice A). Conduct disorder (choice B) is characterized by juvenile delinquency and a disregard for the rights of others. It is not demonstrated in this narrative.
The patient’s refusal to go to school is much more attributable to her fear of the safety of her parents than it is to the rebelliousness and obstinacy that are a part of oppositional defiant disorder (choice C). The patient’s attempts to avoid going to school are much more attributable to a fear of separation from her parents than a fear of the social environment of school. Therefore, social phobia (choice E) is not the correct choice.
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