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Anxiety Disorders
Bipolar and Related Disorders
Depressive Disorders
Substance Related and Addictive Disorders
Schizophrenia Spectrum and Other Psychotic Disorders
100
Criteria for specific phobia do not include: A. Marked fear or anxiety about a specific object or situation. B. The phobic object or situation almost always provokes immediate fear or anxiety. C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the socio-cultural context. E. The disturbance is better explained by the symptoms like fear, anxiety and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms.
What is Correct Answer: E DSMV criteria for Specific Phobia include: A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). B. The phobic object or situation almost always provokes immediate fear or anxiety. C. The phobic object or situation is actively avoided or endured with intense fear of anxiety. D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E. The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms ( as in agoraphobia); objects or situations related to obsessions (as in obsessive- compulsive disorder); reminders of traumatic events ( as in posttraumatic stress disorder) ; separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).
100
Which of the following is used to differentiate between a manic and hypomanic episode? a. In hypomania there is no involvement in activities that have a high potential for painful consequences b. The diagnosis of hypomania only requires inflated self-esteem or grandiosity c. In hypomania the period of abnormally and persistently elevated, expansive, or irritable mood with increased goal-directed activity or energy lasts at least 4 consecutive days d. A hypomanic episode cannot be induced by a substance
What is Answer: c In determining whether a mood episode is hypomanic versus manic, one must consider the length of time the symptoms have occurred. To meet criteria for a manic episode, the symptoms must have lasted for at least 7 days versus hypomania where the symptoms have only lasted at least 4 days.
100
Approximately what percentage of women will experience the onset of a major depressive episode during pregnancy or postpartum? A. 5% B. 15% C. 30% D. 50%
What is Answer A. Mood episodes can have their onset either during pregnancy or postpartum. Although estimates differ according to the period of follow-up after delivery, 3-6 percent of women will experience the onset of a major depressive episode during pregnancy or in the weeks or months after delivery (Gaynes et al. 2005). Note: 50% of “postpartum” major depressive episodes actually begin prior to delivery.
100
Which of the following is NOT a symptom of caffeine withdrawal according to the DSM-5? A. Headache B. Difficulty concentrating C. Flu-like symptoms D. Depressed mood E. Auditory hallucinations
What is Answer E: DSM-5 specifies caffeine withdrawal as characterized by 3 or more of the following symptoms in a patient with prolonged daily caffeine use: headache, marked fatigue or drowsiness, dysphoric mood, depressed mood, or irritability, difficulty concentrating, and flu-like symptoms. Auditory hallucinations are not a symptom of caffeine withdrawal.
100
A 20 year old Caucasian male was brought by his mother, who was concern because her son has spent long hours isolated in his room for the last 4 months. He is no longer active and enthusiastic as he used to. He has not hang out with his friends. He has not taken a shower in weeks. More recently, he stopped eating, when he is offered food he examines it and asks mother to try it first. With the information presented above, which is the first diagnosis that you may consider in your differential? A. Delusional Disorder B. Schizoid Personality Disorder C. Brief Psychotic Disorder D. Schizophreniform Disorder E. Schizophrenia
Correct answer is d- Schizophreniform Disorder This patient presented with delusions and negative symptoms, avolition, decrease emotional expression that lasted more than a month and less than 6 months. Considering the time frame, helps to rule out Brief Psychotic Disorder and Schizophrenia. Diagnosis may qualified as “provisional “if diagnosis has to be done without waiting for recovery. Delusional Disorder is not the first diagnosis to consider due to this patient presented also negative symptoms and significant acute impairment in social and productive areas. Finally personality disorder is also less likely as patient’s presentation is acute, there is an abrupt change in functioning, and the case did not describe a pervasive pattern of detachment from social relationships.
200
A 9 year-old Caucasian girl with no past psychiatric history and appropriate developmental milestones presents with a consistent failure to speak at school for the past 2 months. She is talkative at home and interacts well with her siblings. This recent change in behavior has been affecting her performance at school. Which of the following is the most accurate diagnosis? A. Specific phobia B. Autism spectrum disorder C. Selective mutism D. Social anxiety disorder E. Psychotic disorder NOS
What is Correct answer: C Diagnostic criteria for Selective Mutism include: A. Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations B. The disturbance interferes with educational or occupational achievement or with social communication. C. The duration of the disturbance is at least 1 month (not limited to the first month of school). D. The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation. E. The disturbance is not better accounted for by a Communication Disorder (e.g., Stuttering) and does not occur exclusively during the course of a Persuasive Developmental Disorder.
200
What is the most common comorbidity in Bipolar I Disorder? A. ADHD B. Substance Use Disorder C. Anxiety Disorder D. Impulse-Control Disorder E. Conduct Disorder
What is Answer C: Any anxiety disorder, such as panic attacks, social phobia, or a specific phobia, occurs in approximately 75% of individuals with bipolar disorder. The other answer choices listed above occur in over half of individuals with bipolar I disorder. Note: Adults with bipolar disorder also have higher rates of co-occurring medical conditions. Metabolic syndrome and migraines are more common in individuals with bipolar disorder than in the general population.
200
In distinguishing grief from a major depressive episode, it is useful to consider that in grief the predominant affect is: A. Persistent depressed mood and the inability to anticipate happiness and pleasure. B. Feelings of emptiness and loss. C. Severe recurrent temper outbursts with irritable mood. D. Elated mood with grandiose delusions. E. Self critical or pessimistic ruminations.
What is Answer B. Symptoms of Grief include: Feelings of emptiness and loss. Other differentiating features between grief and MDD include: The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves. The pain in grief may be accompanied by positive emotions and humor. The thought content features a preoccupation with thoughts and memories of the deceased. In grief, self esteem is generally preserved. Persistent depressed mood and the inability to anticipate happiness or pleasure. The depressed mood of an MDE is more persistent and not tied to specific thoughts or preoccupations. Self-critical and pessimistic ruminations. Feelings of worthlessness and self loathing. Suicidal thoughts because of feeling worthless, undeserving life or unable to cope with the pain of depression.
200
Which of the following is the only non-substance-related addictive disorder to be recognized in the DSM-5 chapter on addictive disorders? A. Gambling disorder
 B. Internet gaming disorder C. Electronic communication addiction disorder
 (e.g. Facebook, Twitter) D. Compulsive computer gaming E. Compulsive shopping
What is Answer A: No other excessive behavioral condition, such as those that
 are related to computer use or the internet, has sufficient research evidence to be included in this chapter. Internet gaming disorder has been included in the Appendix of DSM-5 to encourage further research.
200
Why were subtypes of schizophrenia (i.e. paranoid, disorganized, catatonic, undifferentiated, residual) removed from DSM-V? A. Poor validity B. Low reliability C. Limited diagnostic stability D. All of the above E. None of the above
What is Answer D: The subtypes of schizophrenia (paranoid, disorganized, catatonic, undifferentiated, residual) were removed from DSM-V because they were found to have poor validity and low reliability. They also have limited diagnostic stability—they have not been shown to exhibit distinctive patterns with respect to longitudinal course. Also, the subtypes were not found helpful in predicting treatment response or providing targeted treatment.
300
Selective Mutism occurs before what age? A. 4 B. 5 C. 6 D. 3 E. 8
What is Answer E The onset of the selective mutism is usually before the age of 5 years, but the disturbance may not come to clinical attention until entry into school, where there is an increase in social interaction and performance task such as reading aloud. It is associated with social anxiety.
300
Which of the following is NOT a symptom of mania: a. Grandiosity b. Racing thoughts c. Auditory hallucinations d. Pressured speech e. Increased goal-directed activity
What is Explanation: A manic episode is characterized by a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy lasting at least 1 week. During this period, 3 or more (4 if the mood is irritable) of the following symptoms are present: inflated self esteem or grandiosity, decreased need for sleep, increased talkativeness or pressured speech, flight of ideas or racing thoughts, distractibility, increased goal-directed activity, excessive involvement in activities with a propensity for dangerous consequences.
300
Which of the following is not consistent with a diagnosis of disruptive mood dysregulation disorder? A. Severe, recurrent temper outbursts manifested verbally and/or behaviorally out of proportion to the provocation. B. The temper outbursts are appropriate for the patient’s developmental level. C. Outbursts occur 3 or more times per week. D. Outbursts occur for at least 12 months. E. The diagnosis cannot be made before age 6 or after age 18.
What is Answer (B): Disruptive mood dysregulation disorder consists of temper tantrums that last for 12 months and occur at least 3 times per week. These outbursts occur out of proportion to the stimulus. The diagnosis cannot be made before age 6 or after age 18. The temper tantrums are NOT appropriate for the patient’s developmental level.
300
For the past year, an 80-year-old woman has made frequent visits to the ED and doctor offices complaining of abdominal pain. She has been hospitalized several times with negative workup for a significant medical illness. Also, it has been observed that the intensity of pain is much less than the patient reports. During each visit, the patient does not obtain relief from any pain medication other than Dilaudid. Her niece reports that she has been isolating herself, eating less, taking more Dilaudid than prescribed, and starts to complain of pain once her prescription runs out. Rate the severity of her opioid use disorder: A. Mild B. Moderate C. Severe
What is Answer B: The patient meets criteria for an opioid use disorder. Severity is based on the number of symptoms present: mild (2-3), moderate (4-5), and severe (6 or more). Since the patient consumes her time in activities to obtain a prescription (multiple ED visits and doctor shopping), isolates herself (thus reducing social, occupational, recreational activities), takes more than prescribed, and has the constant urge to use Dilaudid, she presents with an opioid use disorder, and by definition moderate in severity (4 symptoms). Note: In DSM-IV, dependence was defined as a maladaptive pattern of drug use, leading to clinically significant impairment or distress with three or more symptoms over a 12 month period. In DSM-V, elements of both substance abuse and substance dependence have been lumped together to describe the new term, ‘substance use disorder’: criteria from abuse + 2 from dependence, with legal consequences removed, and craving added, equals a substance use disorder. Diagnosis of substance use disorder requires the presence of only 2 or more of the aforementioned combined symptoms.
300
Which of the following is required for the diagnosis of brief psychotic disorder? A. Symptoms last for more than a few days and resolve within one month. B. Symptom last at least one day and resolve within one month. C. Symptoms last 7 days and resolve within 3 weeks. D. Symptoms last for 1 week and resolve within one month.
What is Answer B. symptoms must last for at least one day and resolve within one month and patient return to full functioning status within one month for one to be diagnosed with brief psychotic disorder.
400
Ataque de nervios which appears in DSM-IV-TR as a culture-bound syndrome most likely fits the criteria in DSM-5 for which of the following disorders: A. Other specified anxiety disorder B. Unspecified anxiety disorder C. Anxiety disorder due to another medical condition D. Generalized anxiety disorder E. Major depressive disorder with anxious distress
What is Answer: A Ataque de nervios is a psychological syndrome most associated with Spanish-speaking people from the Caribbean. Ataque de nervios translates into English as 'attack of nerves'. The condition appears in Appendix I of DSM-IV-TR as a culture-bound syndrome. Aspects of the syndrome include uncontrollable screaming or shouting, crying, trembling, sensations of heat rising in the chest and head, dissociative experiences, and verbal or physical aggression. Other specified anxiety disorder applies to presentations in which symptoms characteristic of an anxiety disorder that cause clinically significant distress or impairment in social, occupational or other important areas of functioning predominate but do not meet the full criteria for any other disorder in the anxiety disorders diagnostic class. Examples include: limited-symptom attacks, generalized anxiety not occurring more days than not, Khyal Cap, Ataque de nervios.
400
A 20 year old college sophomore presents to the counseling center. She reports that her parents complained about her fast talking and say she is behaving "manic" like her uncle Charlie who has a gambling problem. She reports feeling great and mentions only coming in today as her parents threatened to stop her emergency credit card unless she complies. She has maintained good grades, is full of energy only requiring 3 hours of sleep, finishes her homework quickly so that she can focus on some new projects like painting her dorm room. She says everything was going well until she started to buy some extra clothes online with her parents' credit card. In this scenario, the presence of which of the following would help distinguish between bipolar I and bipolar II? A. The patient's symptoms have lasted 7 days. B. The patient's friends notice a change in behavior from baseline. C. The patient does not feel anything is wrong with her. D. The patient is paranoid about others stealing her brilliant ideas. E. The patient's uncle has a history of bipolar I disorder.
What is Answer D. Psychosis is not a criteria for Bipolar I disorder or Bipolar II disorder. Psychotic symptoms may be present. All other answers do not distinguish between bipolar I or II and can be present in both.
400
Compared to individuals with major depressive disorder, those with persistent depressive disorder (dysthymia) are at higher risk for which of the following co-morbidities? A. Psychiatric co-morbidity in general B. Anxiety disorders C. Substance use disorders D. Cluster B and C personality disorders E. All of the above
What is answer E. Compared to individuals with major depressive disorder, those with persistent depressive disorder (dysthymia) are at higher risk for psychiatric co-morbidity in general, and for anxiety disorders and substance use disorders in particular. Early-onset persistent depressive disorder is strongly associated with Cluster B and C personality disorders.
400
Which two of the following develops within several hours to a few days after cessation of alcohol to indicate alcohol withdrawal? A. Nystagmus and incoordination B. Dysphoric mood and rhinorrhea C. Headache and flu-like symptoms D. Aggression and decreased appetite E. Insomnia and nausea/vomiting
What is Answer E: Insomnia and nausea/vomiting are two of the alcohol withdrawal symptoms. Nystagmus and incoordination are symptoms of alcohol intoxication. Headache and flu-like symptoms are typically present in caffeine withdrawal. Dysphoric mood and rhinorrhea are usually seen in the opioid withdrawal. Aggression and decreased appetite are related to cannabis withdrawal.
400
A 25 year old medical student was brought in by his parents to the ED with c/o bizarre behavior. As per his parents, patient has been making statements that, “ I am a prophet and the chosen one”. Patient has been isolative and also reported to his that he hears the God’s voice talking to him. Parents reported that these started approximately two weeks ago. Parents also pointed that the patient was going to take his USMLE step 2 exam in a month’s time and has been studying hard for it. Patient is a stellar student otherwise before this period. He has no history of substance abuse. No h/o other medical problems. What is the most appropriate diagnosis? A. Schizophreniform disorder B. Brief reactive psychosis C. Schizophrenia D. Schizoaffective disorder E. Delusional disorder with bizarre content
Correct Answer is B: Brief reactive psychosis or Brief psychotic disorder with marked stressor has the following criteria as per the DSM V: The presence of one or more of the following symptoms, one of these must include 1,2 or 3. 1. Delusions, 2. Hallucinations, 3. Disorganized speech and 4. Grossly disorganized or catatonic behavior, For at least 1 day but less than one month, which eventual full term return to premorbid level of functioning. Schizophreniform disorder- at least for 1 month but less than 6 months Schizophrenia- duration of symptoms for at least one month. Schizoaffective disorder-No mood symptoms present in the patient Delusional disorder with bizarre content- symptoms present for at least one month or longer.
500
A 26 year old female actress with no past psychiatric history and medical history of mitral valve prolapse, presents to the emergency room complaining of palpitations, sweating, shortness of breath, nausea, dizziness, chills alternating with sensations of heat, numbness from her fingertips to all of her body and face, along with feelings that she is watching herself from the outside. She reports that everything happened very quickly, minutes before the last dress rehearsal where she is playing a very demanding, challenging role that she always wanted. The patient denies having similar experience in the past, but she admits that she tends to stress greatly prior to her first performance. Which of the following should be included in the differential diagnosis? a. Major depressive disorder b. Agoraphobia c. Panic disorder d. Social anxiety disorder, performance only e. Generalized anxiety disorder
What is The correct answer is D. Explanation: Single episode, panic attack; does not meet the criteria for panic disorder. The context should make the physician include social anxiety disorder, performance only in the differential.
500
Which of the following specifiers may apply to Bipolar I disorder, Bipolar II disorder and Cyclothymic disorder: A. With peripartum onset B. With seasonal pattern C. With rapid cycling D. With anxious distress E. With mixed features
What is Answer D: Cyclothymic disorder may specify if with anxious distress. Specifiers for Bipolar I disorder and Bipolar II disorder are with anxious distress, with mixed features, with rapid cycling, with melancholic features, with atypical features, with mood-congruent/incongruent psychotic features, with peripartum onset, and with seasonal pattern.
500
Which of the following types of mood disorder episodes require the symptom duration of at least 2 weeks? A. Major Depressive Episode B. Manic episode C. Hypomanic episode D. All of the above E. None of the above
What is Answer A Neither of the core criterion symptoms applied to the diagnosis of major depressive episode nor the requisite duration of at least 2 weeks has changed from DSM IV. Hypomania is still 4 days and to fulfill manic episode one must have manic symptoms for a week.
500
A 27 yo man is brought to the ED by his best friend. As per his friend the patient was found this morning wandering the streets and appeared to have been robbed. Friend states patient seems very odd, and at times appears to be "listening to something". You evaluate the patient and observe a drowsy disoriented man with a BP of 110/80 Pulse 89 bpm pupils are mildly dilated, mucous membranes appear to be dry. During your evaluation you notice that the patient is very subdued and follows all the instructions that you give him without any opposition, even uncomfortable aspects of the exam are followed without questioning, you find this interesting and decide to ask the patient to get one one leg and jump, patient immediately does this, you attribute this odd finding to his current condition and begin supportive treatment. A few hours later the patient is reevaluated he is now appearing to be normal and states he does not remember anything from the previous night or earlier this morning, he does however state he can remember getting ready to go out for drinks with some friends the night before. With this information which is the best diagnosis you can give at this time? a. Cannabis intoxication b. Opioid intoxication c. Other (or unknown) substance intoxication d. Stimulant intoxication e. Hallucinogen intoxication
What is Answer is C. In order to answer this question you must go through a process of elimination. Cannabis intoxication: you can see motor impairment, euphoria and anxiety, on physical exam you may see conjunctival injection and tachycardia which our patient does not have, and you can find dry mouth, cannabis would not explain the lack of “free will” that our patient shows and it would not impair memory. Opioid intoxication you would see myosis, rarely mydriasis, drowsiness and slurred speech. You may see impairment in memory and rarely hallucinations. In stimulant intoxication: psychomotor agitation, nausea or vomiting, bradycardia or tachycardia, elevated or low blood pressure, you may see confusion but again not behavior as presented by this patient. Hallucinogen intoxication you can appreciate anxiety, paranoia, pupillary dilation, tachycardia tremors and incoordination. The patient from our case presents with some anticholinergic symptoms, impaired memory, questionable hallucinations and odd behavior, the diagnosis is Scopolamine intoxication. Scopolamine is not a well known substance in US, it has medical indications for Nausea and is available by transdermal patches. In South America specially in Colombia Scopolamine is used as a drug to commit crime and is usually either blown to a persons face or administered in their drinks. It is a drug of choice for robbery as patients present total lack of free will and obey every command that is given, facilitating crime. Scopolamine intoxication may present also with some anticholinergic side effects and at large doses these will be more prominent. Hallucinations may also occur. As this substance is not well known and not part of the substances listed in DSM 5 the correct answer will be Other (or unknown) substance intoxication. The importance of this question is to be aware of some of the most popular drug intoxication side effects but at the same time be cognizant of the possibility of rare or unknown drugs.
500
Which of the following statements is true in the delusional disorder? A. The presence of delusions with a duration must be 1 week or longer. B. Patient can have more than 5 delusions at the same time. C. No hallucinations present. D. No manic or major depressive episodes present. E. Delusions must be non-bizarre in content.
What is ANSWER: B 1. The presence of delusions with a duration of 1 month or longer, not 1 week or longer 2. Patient can have one or more delusions with the duration of 1 month or longer 3. Non-prominent, delusional theme-related hallucinations my present 4. Can have manic or major depressive episodes which are relative to delusional periods 5. Delusions can be bizarre in content