1. A 24-year-old man with chronic schizophrenia is brought to the emergency room after his parents found him in his bed and were unable to communicate with him. On examination, the man is confused and disoriented. He has severe muscle rigidity and a temperature of 39.4 °C (103 °F).
His blood pressure is elevated, and he has a leucocytosis. Which of the following is the best first step in the pharmacologic treatment of this man?
a. Haloperidol
b. Lorazepam
c. Bromocriptine
d. Benztropine
e. Lithium

The answer is c. (Kaplan, pp 1046-1047.) The patient has neuroleptic malignant syndrome (NMS), a life-threatening complication of antipsychotic treatment. The symptoms include muscular rigidity and dystonia, akinesia, mutism, obtundation, and agitation. The autonomic symptoms include high fever, sweating, and increased blood pressure and heart rate. Mortality rates are reported to be 10% to 20%. In addition to supportive medical treatment, the most commonly used medications for the condition are dantrolene (Dantrium) followed by bromocriptine (Parlodel), although amantadine is sometimes used. Bromocriptine and amantadine possess direct dopamine receptor agonist effects and may serve to overcome the antipsychotic-induced dopamine receptor blockade. Dantrolene is a direct muscle relaxant.

2. A 54-year-old man with a chronic mental illness seems to be constantly chewing. He does not wear dentures. His tongue darts in and out of his mouth, and he occasionally smacks his lips. He also grimaces, frowns,and blinks excessively. Which of the following disorders is most likely in this patient?
a. Tourette syndrome
b. Akathisia
c. Tardive dyskinesia
d. Parkinson disease
e. Huntington disease

3. A 58-year-old woman with a chronic mental disorder comes to the physician with irregular choreoathetoid movements of her hands and trunk.
She states that the movements get worse under stressful conditions. Which of the following medications is most likely to have caused this disorder?
a. Fluoxetine
b. Clozapine
c. Perphenazine
d. Diazepam
e. Phenobarbitol

The answers are 2-c, 3-c. (Kaplan, p 490.) Tardive dyskinesia (TD) is characterized by involuntary choreoathetoid movements of the face, trunk, and extremities. Tardive dyskinesia is associated with prolonged use of medications that block dopamine receptors, most commonly antipsychotic medications. Typical antipsychotic medications (such as perphenazine) and, in particular, high-potency drugs carry the
highest risk of TD. Atypical antipsychotics are thought to be less likely to cause this disorder.

Questions4-7
4. A 19-year-old woman is brought to the emergency room by her roommate after the patient told her that “the voices are telling me to kill the teacher.” The roommate states the patient has always been isolative and “odd” but for the past 2 weeks she has been hoarding food,  talking  to herself, and appearing very paranoid. Which of the following tests are likely to be abnormal in this patient?
a. PET scan of dopamine receptors.
b. EEG (will show a decreased alpha activity).
c. Test of eye movements (patient will be unable to follow a moving visual target
accurately).
d. CT (lateral and third ventricle enlargement will be seen).
e. All of these tests may be abnormal.

 The answer is e. (Kaplan, p 473.) All of these abnormal findings may be present in a schizophrenic patient. EEG studies may also show increased theta and delta activity, in addition to decreased alpha activity.
On PET scan, there is found an increase in D2 receptors in the caudate nucleus of drug-free schizophrenics. Eye movement dysfunction may be a trait marker for schizophrenia. CT scans have consistently shown enlarged lateral and third ventricles, as well as reductions in cortical volume.

5. In the patient in the above vignette, which of the following features
would be indicative of a good prognosis with this disease?
a. Young onset
b. Withdrawn behavior
c. Poor support system
d. Family history of mood disorders
e. Neurologic signs and symptoms present

The answer is d. (Kaplan, p 476.) Factors weighting toward a good prognosis in schizophrenia include: late onset of the disease, obvious precipitating factors/stressors, an acute onset, good premorbid functioning, the presence of mood disorder symptoms, the patient being married, a family history of mood disorders, good support systems, and the presence of positive symptoms (as opposed to negative symptoms).

6. The patient in question 4 becomes very agitated in the emergency room, screaming that the nurses were there to kill her and that she had to escape. She tried to strike one of the nurses before being restrained. Which of the following treatment options is recommended first?
a. Haloperidol and lorazepam IM
b. Clozapine PO
c. Fluphenazine decanoate IM
d. Mellaril IM
e. Lorazepam PO

The answer is a. (Kaplan, p 489.) The use of a benzodiazepine and a high-potency antipsychotic has several advantages. While the antipsychotic treats the psychosis without a lot of anticholinergic side effects, the benzodiazepine reduces the amount of antipsychotic needed and protects the patient against dystonic reactions. Clozapine or  fluphenazine decanoate would never be given in an acute setting.

7. The patient in the above vignette was admitted and started on a daily dose of fluphenazine. After discharge from the hospital, she was kept on a low dose of the medication for 6 weeks. She showed only a minimal response to the drug, even after it was raised to a moderate dosage level.
Which of the following is the next therapeutic step?
a. Give a high dose of fluphenazine
b. Give a low dose of clozaril
c. Give a low dose of haloperidol
d. Give fluphenazine decanoate IM
e. Give a low dose of olanzapine

The answer is e. (Kaplan, p 490.) If a patient has not responded well to a conventional dopamine receptor antagonist (first-generation antipsychotic), it is unlikely the patient will respond well to another. It is better to switch to a low dose of serotonin dopamine antagonists (second-generation antipsychotic). It is too early in the treatment of this patient (ie,only one antipsychotic tried) to give up on them all together and go to clozapine, which has significant monitoring and the possibility of life-threatening reactions involved.

8. A 24-year-old woman comes to the emergency room with the chief complaint that “my stomach is rotting out from the inside.” She states that for the last 6 months she has been crying on a daily basis and that she has decreased concentration, energy, and interest in her usual hobbies. She has lost 25 lb during that time. She cannot get to sleep, and when she does, she wakes up early in the morning. For the past 3 weeks, she has become convinced that she is dying of cancer and is rotting on the inside of her body.Also, in the past 2 weeks she has been hearing a voice calling her name
when no one is around. Which of the following is the most likely diagnosis?
a. Delusional disorder
b. Schizoaffective disorder
c. Schizophreniform disorder
d. Schizophrenia
e. Major depression with psychotic features

The answer is e. (Kaplan, pp 537-538.) This patient is presenting with a major depression with psychotic features. For over 2 weeks (the minimum for the diagnosis), the patient has been complaining of anhedonia, crying, anergia, decreased concentration, 25-lb weight loss, and insomnia with early morning awakening. She also has somatic delusions that are mood congruent and an auditory hallucination. The presence of psychotic phenomena that follow a clear mood disorder picture makes the diagnosis of major depression with psychotic features the most likely.

9. A 19-year-old man is brought to the physician by his parents after he called them from college, terrified that the Mafia was after him. He reports that he has eaten nothing for the past 6 weeks other than canned beans because “they are into everything––I can’t be too careful.” He is convinced that the Mafia has put cameras in his dormitory room and that they are watching his every move. He occasionally hears the voices of two men talking about him when no one is around. His roommate states that for the past 2 months the patient has been increasingly withdrawn and suspicious.Which of the following is the most likely diagnosis?
a. Delusional disorder
b. Schizoaffective disorder
c. Schizophreniform disorder
d. Schizophrenia
e. Phencyclidine (PCP) intoxication

The answer is c. (Jacobson, pp 53-55) Schizophreniform disorder and chronic schizophrenia differ only in the duration of the symptoms and the fact that the impaired social or occupational functioning associated with chronic schizophrenia is not required to diagnose schizophreniform disorder. As with schizophrenia, schizophreniform disorder is characterized by the presence of delusions, hallucinations, disorganized thoughts and speech, and negative symptoms. The total duration of the illness,including prodromal and residual phases, is at least 1 month and less than 6 months. Approximately one-third of patients diagnosed with schizo-
phreniform disorder experience a full recovery, while the rest progress to
schizophrenia and schizoaffective disorder.
Depending on the predominance of particular symptoms, four subtypes of schizophrenia are recognized: paranoid, disorganized, catatonic,and residual. The man in the question presents with the classic symptoms of paranoid schizophrenia. This subtype of schizophrenia is characterized by prominent hallucinations and delusional ideations with a relative preservation of affect and cognitive functions. Delusions are usually grandiose or persecutory or both, organized around a central coherent theme. Hallucinations, usually auditory, are frequent and related to the
delusional theme. Anxiety, anger, argumentativeness, and aloofness are often present. Paranoid schizophrenia tends to develop later in life and is associated with a better prognosis.

10. A 36-year-old woman is brought to the psychiatrist by her husband because for the past 8 months she has refused to go out of the house, believing that the neighbors are trying to harm her. She is afraid that if they see her they will hurt her, and she finds many small bits of evidence to support this.
This evidence includes the neighbors’ leaving their garbage cans out on the street to try to trip her, parking their cars in their driveways so they can hide behind them and spy on her, and walking by her house to try to get a look into where she is hiding. She states that her mood is fine and would be “better if they would leave me alone.” She denies hearing the neighbors or anyone else talk to her, but is sure that they are out to “cause her death and mayhem.” Which of the following is the most likely diagnosis?
a. Delusional disorder
b. Schizophreniform disorder
c. Schizoaffective disorder
d. Schizophrenia
e. Major depression with psychotic features

The answer is a. (Jacobson, pp 55-56.) The main feature of delusional disorder is the presence of one or more nonbizarre delusions without deterioration of psychosocial functioning and in the absence of bizarre or odd behavior. Auditory and visual hallucinations, if present, are not prominent and are related to the delusional theme. Tactile and olfactory hallucinations may also be present if they are incorporated in the delusional system (such as feeling insects crawling over the skin in delusions of
infestation). Subtypes of delusional disorder include erotomanic,grandiose, jealous, persecutory, and somatic (delusions of being infested with parasites, of emitting a bad odor, of having AIDS). Delusional disorder usually manifests in middle or late adult life and has a fluctuating course with periods of remissions and relapses. The patient in the vignette clearly demonstrates persecutory delusions, but no hallucinations or other bizarre or odd behavior, which makes her diagnosis delusional disorder.

11. A 35-year-old woman has lived in a state psychiatric hospital for the past 10 years. She spends most of her day rocking, muttering softly to her-
self, or looking at her reflection in a small mirror. She needs help with
dressing and showering, and she often giggles and laughs for no apparent
reason. Which of the following is the most likely diagnosis?
a. Schizophrenia
b. Delusional disorder
c. Bipolar disorder, manic phase
d. Schizoaffective disorder
e. Schizophreniform disorder

12. A 20-year-old woman is brought to the emergency room by her family because they have been unable to get her to eat or drink anything for the
past 2 days. The patient, although awake, is completely unresponsive both
vocally and nonverbally. She actively resists any attempt to be moved. Her
family reports that during the previous 7 months she became increasingly
withdrawn, socially isolated, and bizarre; often speaking to people no one
else could see. Which of the following is the most likely diagnosis?
a. Schizoaffective disorder
b. Delusional disorder
c. Schizophreniform disorder
d. Catatonia
e. PCP intoxication

13. A 21-year-old man is brought to the emergency room by his parents
because he has not slept, bathed, or eaten in the past 3 days. The parents
report that for the past 6 months their son has been acting strangely and
“not himself.” They state that he has been locking himself in his room, talk-
ing to himself, and writing on the walls. Six weeks prior to the emergency
room visit, their son became convinced that a fellow student was stealing
his thoughts and making him unable to learn his school material. In the
past 2 weeks, they have noticed that their son has become depressed and
has stopped taking care of himself, including bathing, eating, and getting
dressed. On examination, the patient is dirty, disheveled, and crying. He
complains of not being able to concentrate, a low energy level, and feeling
suicidal. Which of the following is the most likely diagnosis for this
patient?
a. Schizoaffective disorder
b. Schizophrenia
c. Bipolar I disorder
d. Schizoid personality disorder
e. Delusional disorder

14. A 47-year-old woman is brought to the emergency room after she jumped off an overpass in a suicide attempt. In the emergency room she states that she wanted to kill herself because the devil had been tormenting her for many years. After stabilization of her fractures, she is admitted to the psychiatric unit, where she is treated with risperidone and sertraline.
After 2 weeks she is no longer suicidal and her mood is euthymic. However, she still believes that the devil is recruiting people to try to persecute her. In the past 10 years, the patient has had three similar episodes prior to this one. Throughout this time, she has never stopped believing that the devil is persecuting her. Which of the following is the most appropriate diagnosis for this patient?
a. Delusional disorder
b. Schizoaffective disorder
c. Schizophrenia, paranoid type
d. Schizophreniform disorder
e. Major depression with psychotic features

15. A 40-year-old woman is arrested by the police after she is found
crawling through the window of a movie star’s home. She states that the
movie star invited her into his home because the two are secretly married
and “it just wouldn’t be good for his career if everyone knew.” The movie
star denies the two have ever met, but notes that the woman has sent him
hundreds of letters over the past 2 years. The woman has never been in
trouble before and lives an otherwise isolated and unremarkable life.
Which of the following is the most likely diagnosis?
a. Delusional disorder
b. Schizoaffective disorder
c. Bipolar I disorder
d. Cyclothymia
e. Schizophreniform disorder
Questions 16 to 22
Match each type of delusional disorder with the vignette which best
describes it. Each lettered option may be used once, more than once, or not
at all.
a. Erotomanic
b. Grandiose
c. Jealous
d. Persecutory
e. Somatic
f. Mixed
g. Unspecified

16. A 48-year-old woman becomes convinced that her next door neighbor hates her and wants her to move. She states she has evidence, and when asked to explain, tells the psychiatrist that the neighbor gives her “looks,” puts excessive junk in her mailbox, and leaves yard clippings on her side of the yard to harass her.
221. A 62-year-old man is arrested for disturbing people on their way to
work by insisting they take his prepared reading materials with them. The
topic of the materials was the man’s special communications with God and
his instructions for following him on a special path to heaven.

17. A 49-year-old man was arrested for beating up on his wife. He stated
he had to punish her for having an affair––which she vehemently denied.
The man’s wife states to the police that the man has accused her of being
interested in many other men over the course of their marriage. He now
seems fixated on the topic.

18. A 39-year-old woman is arrested for breaking into the compound of a famous television star. She said she knew the star loved her and was giving her special messages to contact him from his weekly show.
224. A 19-year-old college student came to his primary care doctor for help with a foul odor he believed he was unintentionally emitting. The student stated that the odor left him socially isolated and that he was miserable about it. The primary care doctor could detect no odor.

19. A 22-year-old college student told his parents that on his plane ride home from college to see them over the holidays, all the seatmates on the plane had been replaced by aliens that were identical doubles to the humans that they had replaced.

20. A 58-year-old man called the police on his neighbors because he feltthey were against him. When asked why, the man explained that the neighbors knew that he was a genius inventor, and they were unhappy about this because his impending fame would disrupt the neighborhood.

21. A 30-year-old man is brought to the emergency room after he was found wandering on the streets with no shoes on in the middle of winter.
He is admitted to the inpatient psychiatric unit and stabilized on antipsychotic medication. Looking at past records, his psychiatrist notes that he is repeatedly noncompliant with his medication postdischarge, and each time he relapses within 6 months. Which of the following medications is the best one for this patient to be maintained on?
a. Clozapine
b. Haloperidol decanoate
c. Chlorpromazine
d. Thioridazine
e. Quetiapine

22. A 26-year-old woman is brought to the emergency room by her husband after she begins screaming that her children are calling to her and becomes hysterical. The husband states that 2 weeks previously, the couple’s two children were killed in a car accident, and since that time the patient has been agitated, disorganized, and incoherent. He states that she will not eat because she believes he has been poisoning her food, and she has not slept for the past 2 days. The patient believes that the nurses in the emergency room are going to cause her harm as well. The patient is sedated and later sent home. One week later, all her symptoms remit sponta-
neously. Which of the following is the most likely diagnosis for this patient?
a. Delirium
b. Schizophreniform disorder
c. Major depression with psychotic features
d. Brief psychotic disorder
e. Posttraumatic stress disorder

23. A 28-year-old woman is brought to see a psychiatrist by her mother.The patient insists that nothing is wrong with her, but the mother notes that the patient has been slowly but progressively isolating herself from everyone. She now rarely leaves the house. The mother says she can hear the patient talking to “people who aren’t there” while she’s in her room. On examination, the patient is noted to have auditory hallucinations and the delusional belief that her mother is going to kick her out of the house so that it can be turned into a theme park. Which of the following is the life-
time prevalence for this disorder?
a. 1%
b. 3%
c. 5%
d. 10%
e. 15%

24. A 25-year-old woman is diagnosed with schizophrenia when, after
the sudden death of her mother, she begins complaining about hearing the
voice of the devil and is suddenly afraid that other people are out to hurt
her. Her history indicates that she has also experienced a 3-year period of
slowly worsening social withdrawal, apathy, and bizarre behavior. Her fam-
ily history includes major depression in her father. Which of the following details
of her history leads the physician to suspect that her outcome may be poor?
a. She is female.
b. She was age 25 at diagnosis.
c. She had an acute precipitating factor before she began hearing voices.
d. She had an insidious onset of her illness.
e. There is a history of affective disorder in her family.

25. A 22-year-old man is brought to the emergency room after he became exceedingly anxious in his college dormitory room, stating that he was sure the college administration was sending a “hit squad” to kill him.
He also notes that he can see “visions” of men dressed in black who are carrying guns and stalking him. His thought process is relatively intact, with out thought blocking or loose associations. His urine toxicology screen is positive for one of the following drugs. Which drug is the most likely cause of these symptoms?
a. Barbiturates
b. Heroin
c. Benzodiazepines
d. Amphetamines
e. MDMA (Ecstasy)

26. A 72-year-old woman is brought to the emergency room by her daughter after she found her mother rummaging in the garbage cans outside her home. The daughter states that the patient has never had any behavior like this previously. On interview, the patient states she sees “martians hiding around her home, and on occasion, hears them too.” She also demonstrates a constructional apraxia, with difficulty drawing a clock and intersecting pentagons. All of these symptoms point to a medical cause for this patient’s behavior except one. Which symptom is common in patients with a psychiatric cause for their behavior (ie, not a medical cause)?
a. Patient’s age
b. No previous history of this behavior
c. Visual hallucinations
d. Auditory hallucinations
e. Constructional apraxia

27. Families of patients with schizophrenia, who are overtly hostile and
overly controlling, affect the patient in which one of the following ways?
a. Increased relapse rate
b. Decreased rate of compliance
c. High likelihood that this behavior led to the patient’s first break of the disease
d. Increased likelihood that the patient’s schizophrenia will be of the paranoid
type
e. Decreased risk of suicidal behavior

28. A 62-year-old man with chronic schizophrenia is brought to the emergency room after he is found wandering around his halfway house, confused and disoriented. His serum sodium concentration is 123 meq/L and urine sodium concentration is 5 meq/L. The patient has been treated with risperidone 4 mg/day for the past 3 years with good symptom control.
His roommate reports that the patient often complains of feeling thirsty.
Which of the following is the most likely cause of this patient’s symptoms?
a. Renal failure
b. Inappropriate antidiuretic hormone (ADH) secretion
c. Addison disease
d. Psychogenic polydipsia
e. Nephrotic syndrome

29. A 23-year-old woman was diagnosed with schizophrenia after a single episode of psychosis (hallucinations and delusions) that lasted 7 months. She was started on a small dose of olanzapine at the time of diagnosis, which resulted in the disappearance of all her psychotic symptoms.
She has now been symptom free for the past 3 years. Which of the following treatment changes should be made first?
a. Her olanzapine should be decreased and then stopped if she remains symptom
free.
b. Her olanzapine should be decreased, but not stopped.
c. Her olanzapine should be maintained at a constant level, but she can stretch out
the time between her appointments with the psychiatrist.
d. Her diagnosis should be reexamined as she is likely not schizophrenic at all.
e. Her olanzapine should be switched to a long-acting depot antipsychotic med-
ication such as haloperidol decanoate.

30. A 75-year-old man is being cared for in a hospice setting. He has
widely spread prostatic carcinoma and is considered terminal. Which of
the following psychiatric symptoms are seen in 90% of all terminal
patients?
a. Delusions
b. Hallucinations
c. Flight of ideas
d. Anxiety
e. Depression

31. A 52-year-old man is seen by a psychiatrist in the emergency room because he is complaining about hearing and seeing miniature people who tell him to kill everyone in sight. He states that these symptoms developed suddenly during the past 48 hours, but that he has had them “on and off” for years. He states that he has never previously sought treatment for the symptoms, but that this episode is particularly bad. He denies the use of any illicit substances. The patient is alert and oriented to person, place, and time. His mental status examination is normal except for his auditory and visual hallucinations. His thought process is normal. His drug toxicology screen is positive for marijuana. He is quite insistent that he needs to be
“put away” in the hospital for the symptoms he is experiencing. Which of
the following is the most likely diagnosis?
a. Substance-induced psychosis
b. Schizophrenia
c. Schizoaffective disorder
d. Schizophreniform disorder
e. Malingering

32. A 25-year-old man is brought to the physician after complaining about a visual hallucination of a transparent phantom of his own body.
Which of the following specific syndromes is this patient most likely to be
displaying?
a. Capgras syndrome
b. Lycanthropy
c. Cotard syndrome
d. Autoscopic psychosis
e. Folie á deux