Adult Psychopathology

Dr RayRay and Dr KayKay

Question 1
The natural course of an untreated
manic episode lasts approximately
what length of time?
A. 3 days
B. 1 week
C. 1 month
D. 3 months
E. 6 months

Answer is D
3 months
While untreated depressive episodes
typically last 6-12months, manic
episodes left untreated can last 36months.

Question 2

A 40 year old patient has been unable to speak at all after having
a screaming argument with the spouse. The patient writes, I
have been trying to speak, but cannot make a single sound.
Physical examination, including examination of the throat, is the
unremarkable except for occasional loud cough. Which of the
following is the most likely diagnosis for this patient?
A. Selective mutism
B. Conversion disorder
C. Illness anxiety disorder
D. Somatic symptom disorder
E. Aphonia due to vocal cord injury

Answer is B
B. Conversion disorder- (functional neurologic symptom disorder) is
characterized by neurologic symptoms that are inconsistent with a
neurologic disease, but cause distress, and/or impairment. Conversion disorder
can present with seizures, weakness, paralysis, movement disorders, speech
disturbances, sensory complaints, visual symptoms and cognitive symptoms.
The symptoms can be episodic or sustained, and acute or chronic
As opposed to Somatic symptom disorder(ie somatization) -Somatization is a
syndrome of physical symptoms that are distressing and may not be fully
explained by a known medical condition after appropriate investigation. In
addition, the symptoms may be caused or exacerbated by anxiety, depression
and it is common for somatization, depression, and anxiety to all occur
together. These symptoms can be pain symptoms(headaches, joint pain), GI
distress, chest pain/SOB. This would be the answer if there was more context
of chronic symptoms as well as psychiatric symptoms

Question 3
Dissociative amnesia is a disorder that
involves difficulty in retrieving which if
the following types of memory?
A. Procedural
B. Semantic
C. Working
D. Implicit
E. Episodic

Answer is E
Episodic- memory of a specific events and their context
Dissociative amnesia is a potentially reversible memory impairment that
primarily affects autobiographical/episodic memory. In dissociative amnesia,
the patient cannot recall important autobiographical information, usually of a
traumatic or stressful nature, although more extensive memory loss may be
reported
Just a refresher
Procedural memory- memory of how to perform different actions and skills,
such as riding a bike/tying shoes
Semantic memory- Memory of objects, facts, and concepts, including words
and their meaning, such as learning the skill of reading
Working memory-the part of short-term memory that is concerned with
immediate conscious perceptual and linguistic processing
Implicit memory- acquired and used unconsciously. Procedural memory is a
kind of implicit memory. In juxtaposition with explicit memory which is
conscious, intentional recollection of facts

Question 4
A 24 year old office worker presented to the primary care physician
with a one month history of increasing fatigue, difficulty falling
asleep, poor motivation and trouble paying attention in night
school. No family/personal hx of depression. Remeron 15mg Qhs
was prescribed. After two doses, the patient suddenly became
euphoric, hyperactive, talkative and full of creative ideas. The
patient stood on a chair at night school and offered hearty
congratulations to the teacher for contributing to the patients
certain future success. Which of the following diagnoses is best
supported by the available evidence
A. Bipolar I
B. Bipolar II
C. Cyclothymic disorder
D. Substance Induced bipolar disorder
E. Attention Deficit hyperactivity disorder

Answer is D
Substance induced- The mood
disturbance develops during or soon
after using substances (eg,
phencyclidine or cocaine) or
medications (eg, stimulants,
antidepressants or corticosteroids) that
are capable of producing the
symptoms.

Question 5
Which of the following is the first step
in the management of restless leg
syndrome?
A. Prescribe pergolide
B. Prescribe Bromocriptine
C. Evaluate for hyponatremia
D. Evaluate for iron deficiency
E. Prescribe L-dopa and carbidopa

Answer is D
Restless legs syndrome (RLS), also called Willis-Ekbom
disease (WED), is a common sleep-related movement
disorder characterized by an often unpleasant or
uncomfortable urge to move the legs that occurs during
periods of inactivity, particularly in the evenings, and is
transiently relieved by movement.
Reduced CNS iron stores are a robust and consistent finding
in RLS/WED, even in the setting of normal systemic iron
studies
1st make behavioral modifications(eliminating caffeine,
increasing exercise) and correct iron deficiency. If continued
symptoms consider dopamine agonist(pramipexole) or alpha
2-delta calcium channel ligands(like lyrica or gabapentin)

Question 6
Which of the following personality
disorders may be associated with
transient psychotic symptoms?
A. Dependent
B. Antisocial
C. Borderline
D. Histrionic
E. Avoidant

Answer is C
If you hear micropsychotic symptoms
think Borderline personality disorder

Question 7
Patients with intermittent explosive
disorder may have which of the
following changes in CSF?
A. Decreased dopamine levels
B. Decreased serotonin levels
C. Decreased norepinephrine levels
D. Increased acetylcholine levels
E. Increased GABA levels

Answer is B
Patients with intermittent explosive disorder are
periodically unable to restrain impulses that result in verbal
or physical aggression. Impulsive, aggressive behavior has
been conceptualized as an imbalance between excessive,
aggressive drives originating in limbic brain structures such
as the amygdala, and insufficient control of these impulses
by cortical structures such as the orbital frontal cortex and
anterior cingulate cortex. On a molecular level, studies
suggest that serotonergic activity in patients with
intermittent explosive disorder is reduced. Also serum
inflammatory markers are elevated in these patients.
As an aside (for why some of the other things were wrong) if dopamine was reduced they would
likely be more calm(blunted) and if gaba was increased they would also be inhibited

Question 8
A 20 year old female patient reports that her menses
stopped 4 months ago and that she is pregnant. She reports
morning sickness and vomiting, and that her breasts feel
bigger. On examination her abdomen appears distended.
Her pregnancy test was negative. She insists on having an
ultrasound of her uterus, which is also negative. She
remains convinced that she is pregnant. Which of the
following is the appropriate diagnosis?
A. Pica
B. Pseudocyesis
C. Kleine-Levin Syndrome
D. Postpartum Psychosis
E. Hyperemesis gravidarum

Answer is B
Pseudocyesis- In this rare clinical syndrome, a nonpregnant, non-psychotic woman believes she is pregnant
and exhibits signs and symptoms of pregnancy.
Affected women have a belief that they are pregnant and
also have one or more of the following signs or symptoms:
Abdominal enlargement
Menstrual irregularities
Sensation of fetal movement
Gastrointestinal symptoms
Breast changes
Abdominal pain
Urinary frequency

Question 9
A patient believes the television is sending
special messages intended just for the
patient. Which of the following of best
describes this symptoms?
A. Thought broadcasting
B. Delusion of reference
C. Thought withdrawal
D. Delusion of control
E. Thought insertion

Answer is B
Delusion of reference/ideas of
reference-describe the phenomenon of
an individual's experiencing innocuous
events or merecoincidences and
believing they have strong personal
significance.It is "the notion that
everything one perceives in the world
relates to one's own destiny.

Question 10
Interpersonal exploitativeness is a
diagnostic feature of which of the
following personality disorders?
A dependent
B borderline
C histrionic
D narcissistic
E passive-aggressive

Answer is D
Narcissistic PD
In DSM-5:
Grandiosity, either overt or covert
Excessive need for admiration
Superficial and exploitative relationships
Lack of empathy
Not in DSM-5(cluster B traits)
Identity disturbance
Difficulty with attachment and dependency
Chronic feelings of emptiness and boredom
Vulnerability to life transitions

Question 11
Postpartum psychosis is often
associated with which of the following
disorders?
A. Bipolar
B. Delusional
C. Schizophrenia
D. Major Depressive
E. Posttraumatic stress

Answer is A
Women are more likely to experience psychosis
during the period following childbirth than at
any other time in their lives.
Risk factors The risk factors for postpartum
psychosis include
History of postpartum psychosis
History of bipolar disorder
Family history of postpartum psychosis
First pregnancy
Recent discontinuation of mood stabilizer

Question 12
The parents of an 18 yr old adolescent who is overweight notice
that their child is avoiding high caloric foods, such as meat and
pasta. When the parents inquire about this, the teen says I am
afraid of eating. The evaluating psychiatrist asks when the eating
changed and the teen reports having an episode of panic that
occurred while eating and was accompanied by choking feelings. A
fear of choking while eating and a wish to avoid foods that may
cause choking developed. The teen denies other episodes of panic.
Which of the following is the most likely diagnosis?
A. Specific Phobia
B. Acute stress disorder
C. Panic disorder with agoraphobia
D. Adjustment disorder with anxiety
E. Eating disorder NOS

Answer is A
Specific phobia is an anxiety disorder characterized by
clinically significant fear of a particular object or
situation that typically leads to avoidance behavior.
Phobic fears include animals, insects, heights, water,
enclosed places, driving, flying, seeing blood, getting an
injection, and choking or vomiting.
The phobic anxiety may be triggered by anticipation of
the stimulus, actual exposure to the stimulus, and even
hearing the stimulus name spoken aloud (eg, hearing
the word spider for a spider phobic). The focus of fear
may include disgust, danger of harm, and/or the
experience of physical symptoms in the phobic situation

Question 13
A 25 yr old patient is hospitalized for appendicitis. Psychiatry
is consulted after the patient reports to the nurse being
bothered by the surgeons aura. The patient reports living
alone, not having close friends, and enjoying frequenting
websites discussing auras and crystals. The psychiatrist
speaks with the patients mother who affirms that the
patient has always been this way. Which of the following
personality disorders is the most likely diagnosis?
A. Avoidant
B. Borderline
C. Paranoid
D. Schizoid
E. Schizotypal

Answer is E
Schizotypal PD-Social and interpersonal
deficits marked by acute discomfort with,
and reduced capacity for, close relationships
as well as by cognitive or perceptual
distortions and eccentric behavior
Whereas Schizoid PD hallmarks are
detachment from social relationships and a
restricted range of expression of emotions in
interpersonal settings

Question 14
A 35 y/o patient has recurrent episodes of abrupt awakening from sleep.
The patients spouse reports that these episodes typically begin with the
patient sitting up in bed with a panicked scream. The patient appears to
experience intense, inconsolable fear with sweating and racing heartbeat.
The episodes resolve with the patient falling back to sleep. The patient
cannot remember these episodes or any dreams the next morning. The
patient does not experience anxiety during the day, but reports that work
performance is beginning to be affected due to daytime drowsiness. Initial
laboratory evaluation, including serum and urine toxicology, does not
reveal any abnormalities, nor does a routine EEG. These symptoms are
most consistent with which of the following disorders?
A.Panic
B.Nightmare
C.Sleep terror
D.Sleepwalking
E.REM sleep behavior

Answer is C
Sleep Terrors
Sleep terrors (also referred to as night terrors or pavor
nocturnus) are characterized by a sudden arousal from sleep
associated with sitting up in bed, intense fear, a piercing scream,
and intense autonomic activation including tachycardia,
tachypnea, diaphoresis, facial flushing, and mydriasis
Affected individuals appear frightened and confused and are
inconsolable and difficult to arouse. They typically have no
recollection of events the following morning. In contrast to
children, adults typically present with explosive episodes during
which they may bolt out of bed in a violent or agitated manner
and have partial dream recollection after the event. Episodes
typically last several minutes and are followed by the individual
calmly and quietly returning to sleep.

Question 15
Which of the following did Kurt
Schneider consider to be a first-rank
symptom of schizophrenia?
A.Depressed mood
B.Voices arguing
C.Waxy flexibility
D.Blunted affect
E.Paranoia

Answer is B
Kurt Schneider was a German psychiatrist known for his writing on thediagnosisand
understanding ofschizophrenia, He was also concerned with differentiatingschizophreniafrom
other forms ofpsychosis by listing the psychotic symptoms that are particularly characteristic
of schizophrenia. These have become known asSchneiderian First-Rank Symptoms
1) Auditory hallucinations: Hearing voices conversing with one another, voices heard
commenting on one's actions, thought echo (patient hears his/her thoughts spoken aloud)
2) Passivity experiences: The experience of the mind or body being under the influence or
control of some kind of external force or agency
3) Thought withdrawal:The delusional belief that thoughts have been 'taken out' of the
patient's mind
4) Thought insertion:Thoughts are ascribed to other people who are intruding into the
patient's mind
5) Thought broadcasting(aka thought diffusion)
6) Delusional perception: linking a normal sensory perception to a bizarre conclusion, e.g.
seeing an airplane means the patient is the president
The reliability of using first-rank symptoms for the diagnosis of schizophrenia has since been
questioned, although the terms might still be used descriptively by mental health professionals
who do not use them as diagnostic aids.
Mneumonic: ABCD:Auditory hallucinations,Broadcasting of thought,Controlled thought
(delusions of control),Delusional perception.

Question 16
A patient is brought to the emergency department by several family
members. The family members are concerned about the patients
continuing inability to recognize any of them since a head injury one
month ago when the patient was pushed down a flight of stairs by an
abusive romantic partner. The patient was woozy and may have briefly
lost consciousness after the traumatic event. Tenderness and swelling
over the left temporal area resolved after about 1 week. Neurological
examination, including cognitive examination, is intact and the patient
can provide own name. However, the patient is unable to identify family
members and other events related to the family. A CT scan of the head
was read as normal. The most likely diagnosis is:
A.Conversion disorder
B.Adjustment disorder
C.Dissociative amnesia
D.Transient global amnesia
E.Left fusiform gyrus contusion

Answer is C
Dissociative Amnesia
Dissociative amnesia is a potentially
reversible memory impairment that
primarily affects autobiographical
memory. In this condition, the patient
cannot recall important
autobiographical information, usually
of a traumatic or stressful nature,
although more extensive memory loss
may be reported.

Question 17
Which of the following is a feature of
the melancholic subtype of major
depression?
A.Anhedonia
B.Hypersomnia
C.Hopelessness
D.Leaden paralysis
E.Increase in appetite

Answer is A
Per DSM-V, to meet criteria for Melancholic depression (aka MDD with melancholic
features):
One of the following is present during the most severe period of the current episode:
Loss of pleasure in all, or almost all, activities (Anhedonia) -There is a near-complete
absence of the capacity for pleasure, not merely a diminution.
Lack of reactivity to usually pleasurable stimuli (does not feel much better, even
temporarily, when something good happens)
Three (or more) of the following:
A distinct quality of depressed mood characterized by profound despondency, despair,
and/or moroseness or by so-called empty mood
Depression that is regularly worse in the morning
Early-morning awakening (i.e., at least 2 hours before usual awakening)
Marked psychomotor agitation or retardation
Significant anorexia or weight loss.
Excessive or inappropriate guilt.
Note:These episodes are more frequent in inpatients, as opposed to outpatients; are
less likely to occur in milder than in more severe major depressive episodes; and are
more likely to occur in those with psychotic features.

Question 18
A pt presents to the psychiatrist with a chief
complaint of, I cant seem to get along
because theres a strong song that lays along
and beckons a throng of people who dont
belong. This is an example of:
A.Echolalia
B.Cluttering
C.Paraphasia
D.Dysprosody
E.Clang associations

Answer is E
Clang associations refer to a mode of
speech characterized by association of
words based upon sound rather than
concepts. For example, this may
include
compulsiverhymingoralliterationwith
out apparent logical connection
between words. This is associated with
the irregular thinking apparent
inpsychotic illnesses

Question 19
Which of the following is the key
factor distinguishing factitious disorder
from malingering?
A.Likelihood of secondary gain
B.Evidence for intent to deceive
C.Motivation to be identified as ill
D.Lack of concern about symptoms
E.Conscious awareness of symptom
production

Answer is C
In factitious disorder, the primary aim
is to obtain sympathy, nurturance, and
attention accompanying the sick role.
This is in contrast tomalingering, in
which the patient wishes to obtain
external gains such as disability
payments or to avoid an unpleasant
situation, such as military duty.
Factitious disorder and malingering
cannot be diagnosed in the same

Question 20
Avoidant personality disorder differs
from schizoid personality disorder by
the:
A.absence of eccentric beliefs
B.desire for social relationships
C.inability to express aggressive or
hostile feelings
D.indifference to praise or criticism
E.preference for solitary activities

Answer is B
In Avoidant Personality Disorder, individuals avoid occupational activities that
involve significant interpersonal contact because of fears of criticism, disapproval, or
rejection, are unwilling to get involved with people unless certain of being liked,
show restraint within intimate relationships because of fear of being shamed or
ridiculed, are preoccupied with being criticized or rejected in social situations, are
inhibited in new interpersonal situations because of feelings of inadequacy, view
themselves as socially inept, personally unappealing, or inferior to others, and are
unusually reluctant to take personal risks or to engage in any new activities because
they may prove embarrassing.
In Schizoid Personality Disorder, individuals neither desire nor enjoy close
relationships, including being part of a family, almost always choose solitary
activities, have little, if any, interest in having sexual experiences with another
person, take pleasure in few, if any, activities, lack close friends or confidants other
than first-degree relatives, appear indifferent to the praise or criticism of others, and
show emotional coldness, detachment, or flattened affectivity.
The key to this question is that in Avoidant PD, the person wants relationships but
are unable to form connections due to fear of rejection, shame, or embarrassment,
whereas in Schizoid PD, the person has no interest in forming connections with
others.

The End!