psychiatry 2nd le

PSYCHIATRY 2ND

LONG EXAM

1. Which factor is considered to be the most critical indicator of disability in patients with first episode schizophrenia (FES)?

a. Sub-optimal treatment

b. Delayed remission

c. Relapse *

d. Poor follow up

Trans: Relapse is the most critical driver of disability, risk very high without medication

2. Lieberman’s study on early and effective treatment of FES suggested minimizing this complication:

a. Suicide or attempted suicide

b. Neurological deterioration *

c. Relapse/hospitalization

d. Co-morbid illness progression

Trans: Lieberman’s study: Neurologic deterioration 3% of cortical mass, relapsing devastating

and costly

3. Whilst Palmer’s study showed that early and effective treatment of FES would lessen this

unwanted sequela

a. Suicide or attempted suicide *

b. Neurologic deterioration

c. Relapse/hospitalization

d. Co-morbid illness progression

Trans: Palmer: Suicide/suicide attempt

4. A patient with an initial FES and who later relapses two times would usually take how many weeks to remit?

a. 7

b. 14

c. 20

d. 24 *

Trans: 24 weeks (3 relapses)

5. On the contrary, a well-treated patient with FES would take only how many days, on average, to achieve remission?

a. 7 days

b. 14 days

c. 21 days

d. 28 days *

6. A patient with FES who succumbs to a first relapse would take this length of time in

days, on average to gain remission

a. 28 days *

b. 36 days

c. 50 days

d. 70 days

7. How many percent of patient with FES undergo remission within the mean time of 10

weeks?

a. 60%

b. 70%

c. 80% *

d. 90%

8. As shown in Kapur’s study, this remission rate is directly linked to the patient’s a. Early treatment

b. Effective treatment

c. Both a and b

d. Drug resistance *

Trans: Remission is linked to drug resistance

9. The so-called therapeutic “window of opportunity” for early and effective treatment of FES ‘closes’ within how many months after the onset of illness?

a. 1-3 months

b. 2-5 months

c. 3-6 months

d. 4-7 months *

Trans: It says in the trans 365 months. So I guess the answer would be the highest in the choices

assuming it was a typo pertaining to a year.

10. The duration of untreated psychosis (DUP) is very crucial because it is the

a. Most important predictor of clinical outcome *

b. Basis for the therapeutic ‘window of opportunity’

c. Indicator for how early remission would occur

d. Hallmark of families with high emotional expressivity (high EE)

11. High EE families can provoke relapse in a stable schizophrenic members because of the

frequent display of these two hallmark traits

a. Overindulgence and loose discipline

b. Overcritical and overprotective *

c. Moodiness and neglect

d. Irritability and impatience

12. How many percent of patients with FES achieve both positive and negative symptoms

remission?

a. 20%

b. 30% *

c. 40%

d. 50%

Trans: Schizophrenia 1

30% of patients with FES achieve both positive and negative symptoms

13. This remission percentage, from the Early Psychosis Prevention Center (EPSS) involved

more than 650 patients followed up for

a. 12 weeks

b. 24 months

c. 3 years

d. 7 years *


(EPPIC) study (Henry, et al. 2010): 29% of 651 FES patients, followed up for 7 years had both

positive and negative symptom remission. (Henry, et al. 2010)

14. How many percent of patients with FES achieved functional and symptomatic recovery?

a. 10%

b. 15% *

c. 22%

d. 26%


22/15 percent of patients with FES achieve functional and both functional and symptomatic

recovery

15. Marilou, 21, single, overweight, the youngest of four children of middle class parents

with high EE, breaks down with a FES. She was well until 6 weeks PTC when she broke

off with her 35-year-old boyfriend when she found out he was married, with 3 children.

Her parents are livid. In your MSE, you note the auditory hallucination, anhedonia,

avolition and effective incongruity to be quite prominent. She complains early morning

awakening, loss of interest, and loss of appetite. No suicidal ideas elicited. Her sensorium

is intact. You observe also that she is verbally abusive to her parents, but not to you. She

even calms down upon your suggestion. First thing first: what would you do?

a. Ask the patient if she wants to take to you without her parents *

b. Request parents to leave and wait outside to be called later

c. Best to keep it as it is to observe more family dynamics

d. Ask the parents if they want to talk to you first

16. The patient eventually agreed to be confined. PE, lab tests, including chest x-ray, drug

assay and pregnancy test were all negative. Your branded drug of choice would be:

a. Seroquel *

b. Zyprexa

c. Serenace

d. Thorazine


Quetiapine, aripiprazole, and risperidone are good choices (Crespo-Facoro 2011)

17. This drug that you correctly chose has a common side effect like

a. Galactorrhea

b. Weight gain *

c. Sedation

d. EPS


High risk for weight gain and metabolic side effects: Olanzapine, Quetiapine (Patel, et al. 2009)

18. You start Marilou with this medication with this dose

a. Seroquel 50mg HS

b. Zyprexa 2.5mg HS *

c. Serenace 1.0mg HS

d. Thorazine 50mg HS

Reference: Quetiapine (Seroquel): In schizophrenia a target of 400 mg a day is desired and in

mania and bipolar depression 800 mg and 300 mg respectively are desired. It has become evident

that the target dose can be achieved rapidly and that some patients benefit from doses of as much

as 1,200 to 1,600 mg a day. Quetiapine in doses of 25 to 300 mg at night has been used for

insomnia.

Olanzapine (Zyprexa): A starting daily dose of 5 to 10 mg is recommended. After 1 week, the

dosage can be raised to 10 mg a day. Given the long half-life, 1 week must be allowed to achieve

each new steady-state blood level. Dosages in clinical use ranges vary, with 5 to 20 mg a day

being most commonly used, but 30 to 40 mg a day being needed in treatment-resistant patients.

Remember! First episode patient needs the lowest end of dosing; rapid increase of dose not

advised. (Buchanan, et al. 2010)

19. The initial dose goes up gradually and in about a week, your daily dose should be around

a. Seroquel 300mg

b. Zyprexa 10mg *

c. Serenace 5mg

d. Thorazine 100mg

20. At this time and at this dose, Marilou is now stabilized. You have dealt with, quite

effectively, too, the parental high EE, the married lover, who in Marilou’s view is now

history. So, you have done very well indeed. That’s the easy part. Now comes the hard

phase of treatment: how to prevent Marilou from having another episode. This is best

achieved by

a. maintained control to parental high EE

b. drug adherence for a least 6 months *

c. making sure no more married lovers

d. A and C only

21. An interesting question comes from the father, who fancied himself to be brillant:

‘Doctor, what are the chances that Marilou won’t have another episode, even without

maintenance drug? You would say

a. 5-10%

b. 10-15%

c. 15-20% *

d. 20-25%

Trans: Without meds, only 15-20% don’t relapse (Alvarez-Jimenez, et al. 2011) or never

experience a second episode (poor functional recovery)

22. After 3 months, Marilou comes back to you with a second episode, this time, the features

of schizophrenia are, fortunately, less pronounced. The most likely cause of this relapse,

even without taking the history is (are)

a. drug adherence

b. resurgence of parental high EE

c. return to her lover

d. all of the above

23. She tells you she stopped the drug after 6 weeks because of feeling somewhat sleepy after

waking up which soon subsides. She also confides that the real reason why she stopped

the drug was the constant harangues by her parents not to take the medicine anymore

because she was now ‘normal’ what would you do?

a. lower the dose of the medicine to make it less sedating

b. change the medicine to a less sedating type

c. resume the same medicine, same dose *

d. give the medicine to the parents

24. The medicine that you correctly gave Marilou does not usually cause EPS. But one of

these branded drugs can cause EPS at a certain total daily dose.

a. Ability at 2.5mg

b. Riseperidal at 6mg

c. Lexapro 10mg – (escitalopram)

d. Zoloft 50mg – (sertraline)

25. There is one drug listed down that can also cause high prolactin levels, causing some

embarrassing side effects like gynaecomastia in men. This generic drug is

a. Quetiapine

b. Aripiprazole

c. Riseperidone *

d. Olanzapiine

Trans: Risperidone and Haloperidol: hyperprolactinemia (Malik, et al. 2001)

26. It's a good thing you didn't choose the branded drug that can easily cause weight gain.

Remember that Marilou is somewhat overweight. Avoid giving this medicine to patient

like Marilou

a. Seroquel – (Quetiapine)

b. Zyprexa – (Olanzapine) *

c. Abilify – (Apripazole)

d. Risperdal – (Risperidone)

Trans: Olanzapine (not much for quetiapine) not generally recommended because of weight

gain and risk of metabolic syndrome (Buchanan, et al. 2010). Note: Pero all of these can

cause weight gain.

27. Because of the unfortunate relapse of Marilou, it is more crucial for her and particularly

her parents to make sure she continues with the same drug, at the same dose. Everybody

agrees to this proposal of yours. You have to tell them again, especially the parents, that

is Marilou’s medication is again discontinued, the likelihood of relapse within one year is

a. 50%

b. 60%

c. 70% *

d. 80%

Trans: If medication is stopped, 70% relapse within 1 year; 90% relapse after 2 years.

(Wunderink, et al. 2007)

28. And if by some chance they’re not impressed with the figure that you cited, many ne

they’d be impressed when you say relapse rate within 2 years is

a. just under 85%

b. just under 90%

c. 90% *

d. 95%

Trans: If medication is stopped, 70% relapse within 1 year; 90% relapse after 2 years.

(Wunderink, et al. 2007)

29. Based on the sequential imaging studies, how many percent of grey matter is lost in

patients with FES who are not treated early and effectively?

a. 3% *

b. 4%

c. 5%

d. 6%

Trans - Schizophrenia 1

Neurological deterioration(Liebermann 2001) -by as muchas 3% of cortical mass

30. Marilou is again stabilized, albeit longer than the first episode. You’re rightfully

concerned that a second episode might be followed by a third episode. And if that

happens, you may be looking at the possibility of a treatment-resistant type of

schizophrenia (TRS). Just may be, you decide to do a more extensive assessment of

Marilou’s profile and try to discern the presence of ‘harbingers’ of TRS. You check your

notes during the first episode and you notice some items that strongly reinforce your

concern, these include:

a. Negative and depressive symptoms *

b. Cognitive impairment

c. Substance abuse

d. Soft neurologic signs

Trans:Schizophrenia 2

WARNING: HARBINGERS OF TRS!!

Deficit syndrome

Cognitive impairment

Depression

Substance abuse

Physical illness

poor pre-morbid functioning

early onset

maleness

soft neurologic

31. You request for an MRI, some features if present may indicate possible TRS. You’re

hoping not to find any of the following:

a. fronto-temporal decrement in the grey matter

b. Enlarged ventricles

c. lacunar infarcts

d. A and B only *


Sequential imaging studies of progressive brain changes (enlarged ventricles, fronto-temporal

decrements in the grey matter) suggest possible TRS

32. Your worst fears are confirmed. The findings ran counter with her normal physical

findings and other negative test previously done. What would you do?

a. Wait for a third episode; she is stable, on medication, hopefully adherent

b. No time to waste; stop her current medicine, bring clozapine *

c. Repeated engagements with parents, to bring EE to low levels

d. A and C only


After failure from an atypical, switching to clozapine is better than a move to another atypical

33. In one of these engagements with Marilou’s parents, the father again, in a brilliant spark,

asks, “Doctor, I read about something about clozapine. Do you think it's a good drug for

Marilou to take?” Never to be caught flat-footed, you respond with aplomb,

a. Not at the moment, may be later, and make sure the EE stays los

b. Im actually thinking about Marilous, sooner than later

c. You mean now? Why not?

d. It's a very trickery drug to use, a double-edged sword * (Answer found on number 36)

34. Of course you know the depressing figures of TRS. In Kane’s study of 305 TRS patients,

only this much percent responded to high dose haloperidol

a. less than 1

b. less than 2 *

c. more than 2

d. only 3


Only 5 of 305 (1.6%) TRS patients responded to high dose (60 mg) haloperidol after 6 weeks

35. These are multitudes of other depressing statistics on TRS. Numerous studies show the

following:

a. ½ show benefit from drugs

b. 60% remain poor after 6 months

c. 30% on clozapine improve *

d. A and B only


Results: Clz – 30% & Cpz4- 4% improved

36. Marilou’s mother takes it from the father and asks you in a manner that makes you feel

defensive, “so what’s tricky and double edged about clozapine, doctor? Or are they just

big words you love to utter?” you keep your composure and with exquisite grace you

pronounce, clozapine...

a. Is the only antipsychotic with proven efficacy for TRS an possibly for FES too

b. Can produce agranulocytosis at little less than 0.8%

c. Can also provoke fits at about 1%

d. All of the above *


The ONLY antipsychotic with proven efficacy for TRS

Results: clozapine with lowest potential for EPS and highest rating for efficacy BUT

clozapine causes agranulocytosis

Seizures- 1% on less than 300 mg/day (Janicak, et al 2001); a gradual, low start helps prevent

fits

37. And you’re nor finished, yet. Not after they got you started. You also proclaim in a

didactic way that clozapine…

a. Based on PET scans, the mean and ceiling of D2 occupancy rate are 40/70%

b. Has a golden plasma level 250-300ng/ml

c. At a dose of 300mg gives a plasma level of 350ng/ml *

d. All of the above


REMEMBER: About 300 mg/day gives a plasma level of 350 ng/ml

38. Clozapine, on a golden plasma level at 300mg/day

a. Discriminates between responders and non-responders

b. Has 72% sensitivity

c. Has 70% specificity



REMEMBER: About 300 mg/day gives a plasma level of 350 ng/ml Discriminates between

responders and non-responders with 72% sensitivity, 70% specificity

39. Marilou, an interested spectator all the while, winks at you and gives you thumbs up. And

you wink back. this exchange of wink didn't go unnoticed by her parents. The father

remarks, so if clozapine is that good what are you waiting for? Are you waiting for

Godot? What woud be your retort?

a. Marilou is not a case of TRS

b. Her relapse was not due to drug failure per se, but due to parental misjudgement

c. Another relapse whilst on her medicine can be the optimal time for clozapine


40. Finally, you have convinced the inconvincible. Marilou is willing to continue her current

antipsychotic, at an effective and safe maintenance dose. You’ve convinced her parents

the importance of long-term drug adherence, the need to give the medication time to

show its worth, not to mention their need to win over their own barrel of high EE. But it’s

still likely for another recurrence, for such is schizophrenia. If and when it happens again,

the most common culprit is

a. Discontinuation of medication *

b. Parental high EE

c. Another personal relationship loss

d. All of the above

Trans: If medications is stopped, there are 70/90% patients with relapse within 1 year

41. In the use of medications, this aspect of the drug must be very well studied by the

physician

a. Caloric value

b. Cost of medicine

c. Patient’s preference

d. Side effect profile *

Kaplan

Patients will frequently experience side effects of an antipsychotic before they experience

clinical improvement. Whereas a clinical response may be delayed for days or weeks after

drugs are started, side effects may begin almost immediately.

42. Drug switching depends on

a. Patient’s preference

b. Degree of benefit with initial treatment *

c. Prior treatment history

d. All of the above

Trans: If there is failure in the treatment with atypical

43. The pharmacologic treatment of bipolar disorder is divided into these phases

a. Acute and maintenance *

b. Depression and mania

c. Prodromal, subclinical and clinical

d. Current, recurrent remission

Trans: Pharmacologic treatment is divided into 2 phases: acute and maintenance.

44. Which of these goals in the treatment of mood disorder is the most urgent?

a. Provide food and shelter

b. Complete diagnostic evaluation

c. Patient safety *

d. Treatment plan

45. The outcome in depressed patients, if comparing between psychodynamic therapy VS

cognitive therapy

a. Better for psychodynamic therapy

b. Better for cognitive therapy

c. It's the same *

d. Neither of the two is effective

Trans: The outcome in depressed patients is the same for cognitive and psychodynamic

therapy

46. The treatment of choice in treating mood disorders

a. Pharmacotherapy alone

b. Psychotherapy alone

c. Combination of pharmacotherapy and psychotherapy *

d. Neither

Trans: The most effective treatment for MDD is psychotherapy and pharmacotherapy

47. Depressive symptoms may be due to dysfunctional relationships. The best psychosocial

approach would be

a. Cognitive therapy

b. Interpersonal therapy *

c. Family therapy

d. Behavior therapy

Trans: There are 2 assumptions Interpersonal therapy: to have roots in early dysfunctional

relationship and to be involved in precipitating or perpetuating current disorder

48. Vagal nerve stimulation is an approach that is useful for

a. Mania

b. Anxiety

c. Psychosis

d. Depression *

49. Phototherapy is useful for the following conditions EXCEPT

a. Sleep Disorder

b. Mania *

c. Seasonal affective disorder

d. Jet lag

Trans: Mood 2

- Treatment for SAD (mood disorders of SEASONAL pattern, seasonal affective disorder)

- Indicated for SLEEP DISORDERS

- Implicated in switching some depressed patients to HYPOMANIA or MANIA

50. The most common clinical mistake in the use of antidepressants would be

a. Low dosage, long time

b. Low dosage, short time *

c. Maximum dosage, long time

d. Mazimum dosage, short time

Trans: Mood 2

General Clinical Guidelines for Antidepressant use:

o Most COMMON clinical MISTAKE: LOW dosage, SHORT time

o Consider UNSUCCESSFUL: MAXIMUM dosage level x 4-5 Weeks

o Remain at even LOW dosage: if patient is IMPROVING clinically

o RAISE if clinical improvement STOPS or if MAXIMAL benefit not observed

51. In the management of Bipolar disorders, the easiest phase to treat is

a. Acute mania *

b. Acute bipolar depression

c. Maintenance treatment

d. Prodromal phase

Trans: Mood 2

ACUTE MANIA:

EASIEST phase to treat

– to bring patient down from a high

BEST treated in HOSPITAL – aggressive dosing and see ADEQUATE response

within DAYS or WEEKS T and COMPLIANCE

52. In giving prophylatic treatment to depressed patients, the duration should be

a. At least 6 months *

b. Same as the length of the previous duration

c. Which is longer between A and B

d. 6 to 10 years

Trans: Mood 2

PROPHYLACTIC treatment:

DURATION: At least SIX months or length of PREVIOUS duration, whichever is

GREATER o Effective in reducing the NUMBER and SEVERITY of Recurrences.

o Suggest: If study is less than 2 ½ years -> 5 years indicated. (DURATION of episode)

o SUICIDAL ideations on Impairment of PSYCHOSCOCIAL FUNCTION (SERIOUSNESS)

53. Maintenance phase of treatment for depression is

a. For acute depression

b. For reactive depression

c. For the prevention of new mood episodes *

d. Only for suicidal and anhedonic patients

Trans: Mood 2

Aim of MAINTENANCE phase treatment: PREVENTION of NEW episodes; only to

RECURRENT or CHRONIC depression

54. SSRI include the following EXCEPT

a. Sertraline

b. Imipramine *

c. Fluoxetine

d. Paroxetine

Trans: Mood 2

As a general rule, SSRIs (Sertraline, Fluoxetine, Paroxetine) do not cause Ach effects.

Drugs that do are imipramine and trimipramine, both of which are TCAs.

55. This part of management is important in improving the awareness and compliance of the

patient and their family

a. Vagal nerve stimulation

b. Psychoeducation *

c. Psychoanalysis

d. Phototherapy

Trans: Mood 2

Short term psychotherapies (STP)

o 3 types:

l

themes

56. The 3 types of short-term psychotherapy include the following EXCEPT

a. Cognitive therapy

b. Interpersonal therapy

c. Behavioral therapy

d. Family therapy *

57. The goals of cognitive therapy include the ff EXCEPT

a. Alleviate depressive episodes and prevent their recurrence by helping patients identify

and test negative cognition

b. Develop alternative, flexible and positive ways of thinking

c. Rehearse new cognitive and behavioral responses

d. Learn to function in the world in such a way that would receive positive reinforcement *

Trans: Mood 2

Primary Goal: to identify and alter distorted thoughts that contribute to persistent

negative beliefs, allowing depression to persist.

58. The goal of Psychoanalytically-oriented psychotherapy is

a. To focus on cognitive distortions which include selective attention to the negative aspects

of circumstances

b. To effect a change in the personally structure or character *

c. To alleviate symptoms and prevent recurrence

d. To identify the orle of the family in perpetuating patient’s symptoms

Trans: Mood 2

Basis: PSYCHOANALYTIC theories about depression and mania

to alleviate symptoms

- Improvement of:

o interpersonal TRUST

o capacity for INTIMACY

o COPING mechanisms

o capacity to GRIEVE

o ability to expressive and WIDE RANGE of emotions

59. Some studies have shown that if the treatment of choice for depression is psychotherapy

ALONE, this is the most effective

a. Behavioral therapy

b. Family therapy

c. Psychoanalytically-oriented psychotherapy

d. Interpersonal therapy *

Trans: Management of Mood Disorder II – p.2

Some studies: if the treatment of choice is psychotherapy ALONE, Interpersonal Therapy is the

MOST effective method

60. The most effective strategy to achieve a more sustained response to sleep deprivation is

a. Sleep deprivation combined with pharmacotherapy

b. Serial total sleep deprivation with a day or two of normal sleep in between

c. Phase delay in the time patients fo to sleep at night or partial sleep deprivation *

d. Partial and total deprivation used alternately


DELAY in the time patient sleeps or PARTIAL deprivation: MOST effective

61. The most urgent indication for hospitalization is

a. Need for diagnostic procedure

b. Risk for suicide and homicide *

c. Get a baseline blood test and make a treatment plan

d. To remove the patient from stressful condition at home and family

Trans: Mood 2

Indications for hospitalization:

o Suicide risk o Homicide risk

o Reduced ability to get food and shelter

o Diagnostic procedures – to rule out organic causes

o Rapid deterioration/ progressing symptoms

62. Family therapy is indicated

a. When all short-term psychotherapies fail

b. If patient’s marriage of family are supportive of patient’s condition

c. If the mood disorder is promoted or maintained by the family situation *

d. If there is another patient in the family that needs treatment


INDICATION

o if disorder disturbs patient’s marriage and family functioning

o if mood disorder is PROMOTED and MAINTAINED by family situation

63. These are addressed in interpersonal therapy

a. Lack of assertiveness and impaired social skills

b. Defense mechanisms and internal conflicts *

c. Perceptual disturbance and though content disorder

d. Character trait problems


Focus of the therapy: interpersonal events (such as interpersonal disputes / conflicts,

interpersonal role transitions, complicated grief that goes beyond the normal bereavement

period) that seem to be most important in the onset and / or maintenance of the depression

64. Total or Partial sleep deprivation

a. Improve menstrual dysphoria

b. Accelerate response to antidepressants

c. Temporarily relieves depression



Total or Partial SD

o Followed by immediate LITHIUM or ANTIDEPRESSANT- SUSTAINS the antidepressant

effects of SD

o SD ACCELERATES response to antidepressants

o SD IMPROVES menstrual dysphoria

65. This portion of the population achieve remission with the use of antidepressants

a. 0-35%

b. 35-50% *

c. 50-85%

d. 85-100%

Trans: Management of Mood Disorder – p.3

Initial Medication Selection: 35% - 50% - achieve remission

66. The prototype of “mood stablizer” is

a. Lamotrigine

b. Lithium carbonate *

c. Olanzapine

d. Carbamazepine


Lithium carbonate: proto-typical “MOOD STABILIZER”

67. The therapeutic lithium level

a. 0.5-1.0 mEq/L

b. 0.6-1.2 mEq/L *

c. 1.0-1.5 mEq/L

d. 1.2-2.0 mEq/L


Therapeutic Lithium levels – 0.6 – 1.2 meq/L

68. A high potency Benzodiazepine used is acute mania

a. Diazepam

b. Alprazolam

c. Aripiprazole

d. Clonazepam *


Clonazepam (Klonopin) and Lorazepam (Ativan)

o HIGH POTENCY benzodiazepine anticonvulsants

69. The atypical antipsychotic used for management in acute mania and have less EPS

a. Olanzapine and quetiapine

b. Lorazepam and clonazepam

c. Haloperidol and chlorpromazine

d. Lithium carbonate and lamotrigine

70. Used as adjunctive management for agitation, insomnia, aggression and panic in acute

mania

a. Olanzapine and quetiapine

b. Lorazepam and clonazepam

c. Haloperidol and chlorpromazine

d. Lithium carbonate and lamotrigine

71. Use of lithium in acute mania is due to

a. Its high cost *

b. Its EPS effects

c. Frequent lab test

d. Unreliable efficacy

Trans: Acute use of Lithium is LIMITED due to:

UNPREDICTABLE efficacy

PROBLEMATIC Side effect

FREQUENT lab test

72. The usefulness of antidepressant in bipolar depression is controversial because

a. It can induce hypomania and mania

b. It can mask the real course of the disorder

c. There is actually no place for antidepressants in this condition

d. The antidepressant can cause agitation, impaired judgment and akathesia

73. The patient did not improve with lithium or other mood stabilizers but still suicidal.

Which choice is indicated?

a. Hospitalization

b. Brain surgery

c. ECT

d. Antipsychotic

74. ECT is effective for the following condition EXCEPT

a. Depression

b. Adjustment disorder

c. Acute mania

d. Refractory mania

75. In the course of bipolar disorder, hypothyroidism occurs. This consequence is due to:

a. Carbamazepine

b. Lorazepam

c. Quetiapine

d. Lithium *

Trans: THYROID supplementation- necessary during LONG term treatment, Lithium develop

HYPOTHYROIDISM

76. A bipolar patient was given mood stab. The appearance of rash is side effect of

a. Valproate

b. Flurazepam

c. Oalnzapine

d. Lamotrigine *

Trans: Give slowly to avoid RARE side effect of LETHAL RASH (Stevens- Johnson

syndrome- Toxic Epidermal Necrolysis)

77. A pt comes in the ER. He is euphoric, talkative, with impaired insight showed poor

impulse control. What is his diagnosis?

a. Depressive disorder

b. Bipolar disorder *

c. Anxiety disorder

d. Psychotic disorder

Trans: Predominantly manic : talkative, poor impulse control, euphoria

78. Another pt comes to the ER: he is sad and tearful, talks with a very soft voice, claims to

end his life:

a. Depressive d/o *

b. Bipolar d/o

c. Anxiety d/o

d. Psychotic d/o

Trans: MDD, at least one of the following: depression, loss of interest.. 5 or more of the

following:

Lack of appetite, hypersomnia or insomnia, agitation, lack of energy, worthlessness, death

79. 40 y/o F was brought to the hops with the ff sx: elevated mood, insomnia, agitation, flight

of ideas, and sexual indiscretion. She was observed in the past 4 days and hx revealed

feeling of worthlessness, fatigue, excess guilt in the past. Dx is:

a. Bipolar d/o I most recent episode

b. Bipolar I single manic episode

c. Bipolar II *

d. Major depressive d/o

Trans: Bipolar II – presence of one or more MDD episodes (Insomnia), presence of hypomania

(elevated mood, agitation, flight of ideas, sexual indiscretion in 4 days)

80. The goal and greatest challenge in maintenance tx in bipolar d/o:

a. Prevent recurrence *

b. Sustain euthymia

c. Make sure there are no untoward effect

d. Ensure good sleep and calmness

Trans: Mood disorders Part2

Greatest challenge/goal for maintenance treatment is preventing recurrence

81. 25-year old male presented with irritability, grandiosity and recklessness. This is the first

time for the patient to experience these. No depression noted. What is the diagnosis?

a. Bipolar 1, single manic episode *

b. Bipolar 1, most recent hypomania

c. Bipolar 1, most recent episode

d. Bipolar 2

82. Luisa, 30 years old, was diagnosed with bipolar mood disorder. She has had recurring

episodes in the last 2-3 years. Among these drugs, the best choice is:

a. Fluoxetine

b. Haloperidol

c. Carbamazepine *

d. Lorazepam

83. Patient comes in obviously depressed. She has had a long standing problem with her

sister in law which is the reason for her separation with her husband. What is the best

psychotherapy?

a. Psychoanalytically oriented psychotherapy

b. Behavioral

c. Group

d. Interpersonal *

84. Patient complains of severe depression and suspiciousness of others. Patient also thinks

of not doing anything right at work and she might as well resign. The best therapy:

a. Behavioral

b. Family

c. Cognitive *

d. Group

85. Patient presented with psychomotor symptoms and agitation. Upon admission, noted to

have deep disturbance. Start with:

a. Lithium and paroxetine *

b. Risperidone and haloperidol

c.

d. Lamotrigine and sertraline

Trans: Mood Disorders 2

- Psychomotor agitation or retardation nearly every day: one of the symptoms of MDE

- SSRI (Paroxetine, Sertraline): used for MDE

- Lithium – mood stabilizer used for bipolar disorders

- Lamotigrine- superior ACUTE + PROPHYLACTIC AD properties vs. ANTIMANIC

properties

Treatment of the Depression of Bipolar Mood Disorder:

As a general rule, we DO NOT want to give ADs for bipolar mood disorder’s depressive side.

Kaplan suggests that lithium may be a first-line antidepressant in treating the depression of

bipolar disorder. A MAOI may be added, but the patient should be monitored for the emergence

of manic symptoms

-

induce CYCLING, MANIA or HYPOMANIA

- AD use enhanced by MOOD STABILIZER– in FIRST LINE treatment for a FIRST or

ISOLATED episode of Bipolar Depression. Ex. Olanzapine and Flouxetine effective

Many patients with Bipolar in DEPRESSED phase DO NOT RESPOND to AD (ex.

Lamotrigine or Low Dose Atypical Antipsychotic may be OK.)

86. Patient is experiencing suicidal thoughts, hopelessness, insomnia, decreased appetite and

anhedonia of 4 weeks duration. Hospitalization, psychotherapy and Escitalopram

initiated. Afterwards, behavior presented was elevated mood, recklessness and decreased

inhibitions. What could explain this behavior

a. This episode is transient.

b. Antidepressant induced manic episode *

c. Treatment too late

d. Psychotherapy induced

Trans: Mood Disorders 2

Disadvantages of SSRI’s

o Lower remission rates than dual-acting agents

o Increase weight gain and sexual side effects

o Questionable efficacy on painful physical symptoms

o May cause insomnia, agitation, sedation, GI distress, and sexual dysfunction (Kaplan)

87. Dx: Acute bipolar depression

- Olanazapine and fluoxetine

88. A 38 year old male was diagnosed with mood disorder, major depressive. After 3 weeks,

delusions of persecution and auditory hallucinations were noted. What is the appropriate

combination therapy?

a. Fluoxetine and imipramine

b. Fluoxetine and risperidone *

c. Fluoxetine and diazepam

d. Fluoxetine and lithium

Trans: Mood Disorders 2 and Schizophrenia 2

- Fluoxetine – Selective SEROTONIN reuptake inhibitor –> NEWER; clinician and patient

FRIENDLY for MDE

Risperidone – Atypical Antipsychotic First choice for schizophrenia (with positive

symptoms: hallucinations, delusions, disorganized thinking and behavior)

89. Patient diagnosed two years ago with major depression, observed to have insomnia, low

self esteem, wanting to isolate herself and was dysfuntional at work. Patient started on

Sertraline and clonazepam. Follow up showed patient to be less depressed with better

function. However, she is drowsy all day best choice :

a. Start lithium

b. Decrease dose and later continue with benzodiazepine

c. Discontinue all meds and do psychotherapy

d. Start patient on antidepressant to maximize improvement *

Trans: Psychopharmacology 2 and Mood Disorders 2

Benzodiazepine: Rapid anxiolytic sedative effect (rapid onset); they are most commonly used for

immediate treatment of insomnia, acute anxiety; Hypnotic/ sedative – primary function (old

term: sleeping pills; used as soporific, to induce sleep)

An ALTERNATIVE for managing the other symptoms of depression:

o AD + SLEEPING PILLS (midazolam, diazepam, zolpidem, clonazepam)

o AD + ANXIOLYTIC (alprazolam, bromazepam)

Sleeping pills and anxiolytics =ADJUNCTIVE MEDICATIONS – provide IMMEDIATE

SYMPTOM relief

Side Effect Profile of SSRI’s (Fluoxetine, Sertraline, Paroxetine)

- Early and transient: anxiety, headaches, GI upset

- Sexual dysfunction

- Insomnia

- Agitation

- Sedation (yes, the same drug that may cause insomnia may also cause sedation)

Reasons for Acute Treatment Failure:

o SIDE EFFECTS

o IDIOSYNCRATIC adverse effects

o INADEQUATE clinical response

o WRONG diagnosis

ACUTE phase medication trial – 4-6 weeks to determine symptom REDUCTION. If

none, CHANGE AD

Some PROLONG to 8–12 weeks

Selecting Second Treatment Options:

When initial treatment fails, either:

o SWITCH – depends on:

- PRIOR treatment history

- Degree of BENEFIT with INITIAL treatment

- Patient PREFERENCE - preferred after an INITIAL medication FAILURE (VS

augmenting)

o AUGMENT - helpful with patients who have gained some BENEFIT from initial treatment but

have NOT achieved REMISSION

- Ex. SSRI and BUPROPION

- NO combination strategy is more EFFECTIVE than another

BZD’s are commonly used as sleeping pills.

- o Initial insomnia – difficulty initiating sleep; an anxiety feature; will benefit from a rapid onset of drug

- o Middle insomnia – no problem initiating sleep, wakes up at 2 am, then fragmented sleep afterwards or cannot go back to sleep; could be normal; will benefit from

intermediate acting

- o Terminal insomnia – sleep 10-14 hours but wakes up feeling tired; the depressive

insomnia; give anti-depressants; will benefit from a long-acting drug

90. Patient comes to you and is a known bipolar. She was on lithium but didn’t follow up.

What lab tests do you order?

a. CBC, ECG, EEG

b. Serum electrolytes, ECG *

c. Kidney function tests, lithium assay, thyroid function tests

d. Liver function test and bone scans

Trans: Management of Mood Disorders2

Lab tests for patients taking Lithium: Serum Electrolytes (Na, Ca), Phosphorous, ECG,

Creatinine, Urinalysis, CBC, Thyroid battery (with TSH)

91. Dina, a 31-year old manager, climbs 14 flights of stairs everyday to reach her office

because she is terrified of the thought of riding the elevator. She has never had any bad

event occur inside an elevator but she has been afraid since childhood. What is the most

likely diagnosis?

a. Social phobia

b. Specific phobia

c. Generalized anxiety disorder

d. Agoraphobia *

Trans: Management of Anxiety Disorders1

Agoraphobia: Emotion – Situational anxiety; Cognition – Thoughts of collapsing and being left

helpless in public; Behavior - avoidance of panic-provoking situations; Somatic Symptoms –

Physical sensations of panic; Associations – strong association with panic disorder

92. What is the treatment for Dina?

a. Imipramine

b. Clonazepam *

c. Propanolol

d. Exposure therapy


Imipramine (Tricyclic Antidepressant) – for panic disorders; Clonazepam (Benzodiazepine) -

drug of choice for Generalized Anxiety Disorder; Propranolol (Beta blockers) – for PTSD;

Exposure therapy – for specific phobic disorder

93. Yon-yon is a middle aged chronic worker who constantly worries about work, etc. What

is the likely diagnosis?

a. Social phobia

b. Specific phobia

c. Generalized anxiety disorder *

d. Agoraphobia


GAD: Emotion – Anxiety; Cognition - Excessive, disproportionate, uncontrollable worry;

Behavior - Easily startled, on edge; Somatic symptoms – multiple chronic aches, tension,

sweating, headache; Associations – Depression

94. A new serotonin and dopamine antagonist approved for treatment of anxiety is:

a. Risperidone *

b. Olanzapine atypical antipsychotic

c. Quetiapine atypical antipyschotic along with an SSRI properties

d. Perphenazine typical antipyscotic for schizophrenia and mania of bipolar disorders

Risperidone belongs to the class of atypical antipsychotics.[1] It isa dopamine antagonist

possessing antiserotonergic, antiadrenergic and antihistaminergic properties. (wikipedia)

95. Major reservations in the use of benzodiazepines in anxiety disorders are the following

factors except:

a. Dependence

b. Abuse

c. High cost *

d. Cognitive impairment

Trans: management of anxiety disorders 1

Major reservations in the use of BZ: potential for dependence, cognitive impairment, and abuse

after long term use

96. The use of clonidine and propranolol is supported by the involvement of this theory in the

etiology of anxiety disorders:

a. Noradrenergic *

b. Dopaminergic

c. Serotonergic

d. GABAminergic

Trans management of anxiety disorders 1

Use of anti-adrenergic agents like clonidine and propanolol supports noradrenergic

hyperactivity

97. The efficacy of SSRI is due to the following characteristics except:

a. Efficacy

b. Low cost *

c. Safety ratings

d. Tolerability

Trans management of anxiety disorders 2

Advantages of SSRI: effective, safe, no physical abuse and effective on depression.

Disadvantages: possible increase in anxiety, reactivation syndrome, sexual side effects. I checked

the price of Paroxetine at MIMS it costs 1790 pesos.

98. Exposure to the phobic stimulus until the patient reaches a point at which s/he can no

longer face it is called:

a. Catharsis

b. Flooding

c. Abreaction

d. Aversion therapy *

99. Of all the tricyclic and tetracyclic drugs, this is the one best used for OCD:

a. Imipramine

b. Trimipramine

c. Clomipramine *

d. Buspirone

psychiatry 2nd le

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