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Chapter 4
Psychiatry
Questions
Each of the following questions or incomplete statements is
followed by suggested answers or completions. Select the
ONE BEST ANSWER in each case.
1. Cognitive therapy involves
A) repetition of negative thoughts that eventually dissipate
B) changing a thought that involves a situation that leads to a
change of mood, behavior, or reaction
C) repeated acts of fearful situations that allow adaptation
D) negative reinforcement of harmful activities
E) none of the above
View Answer
Answer and Discussion
The answer is B. Cognitive therapy is a psychological treatment
method that helps patients correct false self-beliefs that
contribute to certain moods and behaviors. The basic principle
behind cognitive therapy is that a thought precedes a mood, and
that both are interrelated with a person's environment, physical
reaction, and subsequent behavior. Therefore, changing a thought
that arises in a given situation changes mood, behavior, and
physical reaction. Although it is unclear who benefits most from
cognitive therapy, motivated patients who have an internal center
of control and the capacity for introspection likely would benefit
most.
Ramana R, Paykel ES, Cooper Z, et al. Remission and relapse in
major depression: a two-year prospective follow-up study. Psychol
Med. 1995;25:11611170.
.
,
9. Domestic violence
A) is higher in gay and lesbian relationships
B) affects males and females equally
C) rarely affects the elderly
D) increases during pregnancy
E) is rarely associated with a spouse
View Answer
Answer and Discussion
The answer is D. Studies show that women are much more likely
than men to be the victims of chronic physical abuse. Domestic
violence in gay and lesbian relationships appears to be as common
as in heterosexual relationships. Domestic violence is also a
significant problem among the elderly. Elder abuse is associated
with an increase in reports of chronic pain, depression, number of
health conditions, and an increased mortality. The abuser is most
commonly a relative (usually the spouse). Domestic violence often
begins or, if already present, increases during pregnancy and the
postpartum period.
Hillard PJ. Physical abuse in pregnancy. Obstet Gynecol.
1985;66:185.
Sillman JS. Diagnosing, screening and counseling for domestic
violence. Up to Date, version 14.1. Accessed 3/6/06.
.
,
Studies show that women are much more likely than men to
.
.
C) compulsion
D) obsession
E) transference
View Answer
Answer and Discussion
The answer is C. Obsessions are persistent thoughts, ideas, and
images that invade into conscious awareness, are recognized as a
product of one's mind, and are perceived as senseless and
intrusive. In many cases these obsessions have a theme that an
insignificant oversight will result in tremendous catastrophe.
Other common themes are contamination, a need for ordering
things, aggressive impulses, and sexual imagery. Compulsions are
urges or impulses for repetitive intentional behavior performed in
a stereotyped manner (e.g., touching, counting, arranging) in an
attempt to alleviate the anxiety that most frequently results from
the obsessions. Often these behaviors are believed to help defend
the patient and others from potential harm.
Ciechanowski P, Katon W. Overview of obsessive-compulsive
disorder. Up to Date, version 14.1. Accessed 3/8/06.
View Answer
Answer and Discussion
The answer is C. Symptoms and signs of bulimia include reflux
esophagitis, abdominal cramping, diarrhea, and rectal bleeding.
Electrolyte abnormalities and metabolic alkalosis signal extreme
purging habits in a bulimic patient. Patients with anorexia
generally have laboratory test results within normal limits until
the very late stage of the condition.
Mehler PS. Diagnosis and care of patients with anorexia nervosa in
the primary care setting. Ann Intern Med. 2001;134:10481059.
21. A 42-year-old man is seen in your office. He has recently
seen a psychiatrist and is being treated for severe
depression. The patient cannot recall the medication that he
is taking, but he remembers that the psychiatrist told him
not to eat cheeses or aged meats. Which of the following
agents is this patient most likely taking?
A) Tricyclic antidepressant
B) Selective serotonin release inhibitor
C) Monoamine oxidase (MAO) inhibitor
D) Neuroleptic
E) Anxiolytic
View Answer
Answer and Discussion
The answer is C. Antidepressant medications fall into three basic
categories:
Beers MH, Porter RS, eds. The Merck manual of diagnosis and
therapy, Merck Research Laboratories, 18th ed. Whitehouse
Station, NJ: Merck & Co.; 2006:17081709.
Shortness of breath
Dizziness, fainting
Palpitations or tachycardia
Shaking
Diaphoresis
Choking
Nausea or abdominal discomfort
Depersonalization
Paresthesia
Flushing or chills
Chest discomfort
Fear of dying
Fear of insanity or doing something uncontrolled
Panic disorder is divided into panic disorder with or without
agoraphobia. Criteria consist of
Appetite changes
Sleep disturbances
Fatigue
Low self-esteem
Poor concentration
Feelings of hopelessness
The symptoms must not have an organic cause and must never be
interrupted for more than 2 months. Major depression has many of
the same symptoms, but they are more severe. Cyclothymia is
dysthymia followed by episodes of mild mania. The diagnosis of
dysthymia requires that the patient has no history of substance
abuse, mania, hypomania, major depression, or psychotic
disorders.
American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, 4th ed. Washington, DC: American
Psychiatric Association; 2000:327, 332.
View Answer
Answer and Discussion
The answer is E. Sexual side effects, usually delayed ejaculation
or anorgasmia, may occur in both men and women who are taking
SSRIs and venlafaxine (Effexor). Treatment consists of several
options: reducing the dosage, switching to another agent, or
adding another agent to overcome the sexual side effects. Sexual
dysfunction typically resolves within 1 to 3 days after
discontinuation of the antidepressant and returns on
reintroduction. Recovery after withdrawal from fluoxetine (Prozac)
may occur within 1 to 3 weeks. Studies suggest that the addition
of bupropion (Wellbutrin) may decrease sexual side effects.
Ables AZ, Baughman AO III. Antidepressants: update on new
agents and indications. Am Fam Physician. 2003;67:547554.
P.239
D) short-acting benzodiazepines
E) strict discipline
View Answer
Answer and Discussion
The answer is B. Attention deficit disorder, also known as
hyperactivity, is a condition characterized by a short attention
span or distractibility that persists for longer than 6 months.
Other symptoms include fidgeting or squirming in one's seat,
restlessness, inability to remain seated when required to do so,
difficulty in awaiting one's turn, blurting out answers to questions
before they are completed, difficulty in completing cognitive tasks
(not related to oppositional behavior or lack of comprehension),
and excessive talking. Affected children often interrupt others,
frequently lose objects, do not listen to instructions, and engage
in dangerous activities without consideration of the consequences.
Boys are more commonly affected, and the onset typically occurs
before 7 years of age. The clinical history is usually all that is
needed to determine the diagnosis, although psychological and
educational testing may help to support the diagnosis. Treatment
is accomplished with stimulants, such as methylphenidate and
dextroamphetamine, which have a paradoxical calming effect on
young patients. Atomoxetine (Staterra) is a selective
norepinephrine reuptake inhibitor that is approved for use in
children over age 6. Most children show improvement with
medication; drug holidays (at least 2 weeks/year) are important
during chronic therapy to see if further medication is necessary.
Behavior modification for the child and family counseling may also
be helpful.
Ferri FF. Ferri's Clinical Advisor, Instant Diagnosis and Treatment.
Philadelphia: Elsevier/Mosby; 2006:107108.
View Answer
Answer and Discussion
The answer is D. Bipolar disorder is characterized by episodes of
mania (e.g., flight of ideas, excessive spending, aggressive and
grandiose behavior, little sleep, activities that are later regretted)
followed by major depressive attacks (e.g., anhedonia, inability to
concentrate, withdrawal from activities, chronic fatigue, loss of
sexual drive, insomnia, anorexia with weight loss). Bipolar I
disorder is typically diagnosed when patients are in their early
20s. Manic symptoms can rapidly escalate over a period of days
and frequently follow psychosocial stressors. Some patients
initially seek treatment for depression. Others may appear
irritable, disorganized, or psychotic. Differentiating true mania
from mania that results from secondary causes can be
challenging. Initially, during the manic phase, these behaviors
may attract other people; however, in the long term, they lead to
significant interpersonal difficulties and conflicts. The episodes,
which begin abruptly and are often precipitated by life stresses,
may last for up to several months; manic episodes are typically
shorter in duration. Bipolar II disorder typically is brought to
medical attention when the patient is depressed. A careful history
usually illuminates the diagnosis. Some depressed patients exhibit
hypomania when given antidepressants. This variation is
sometimes referred to as bipolar III disorder. Spring and summer
months tend to be peak times for the development of symptoms.
The condition may occur at any age but is most common in the
second or third decade of life. The treatment for bipolar disorder
is accomplished with lithium (Eskalith). It is important to
remember that lithium levels need to be followed, and
abnormalities associated with the kidneys and thyroid can be
induced with medication. Valproic acid (Depakene) can also be
used to treat the manic symptoms. If the patient is psychotic, a
neuroleptic medication is also given. Long-acting benzodiazepines
can be used for treating agitation. However, in patients with a
substance abuse history, benzodiazepines should be used with
caution because of the addictive potential of these agents. When
the patient with bipolar disorder becomes depressed, an SSRI or
bupropion is recommended. The use of tricyclic antidepressants
should be avoided because of the possibility of inducing rapid
cycling of symptoms.
Griswold KS, Pessar LF. Management of bipolar disorder. Am Fam
Physician. 2000;62:13431353, 13571358.
P.243
P.244
View Answer
Answer and Discussion
The answer is E. Tourette's syndrome is a genetically
transmitted disorder that begins in childhood as a simple tic,
progressing to multiple tics as the patient ages. Tics may begin as
grunts or barks and progress to involuntary compulsive utterances
called coprolalia. These outbursts may become severe and
significantly disable the patient from a physical or social
standpoint. Tics tend to be more complex than myoclonus but less
flowing than choreic movements, from which they must be
differentiated. The patient may voluntarily suppress them for
seconds or minutes. Simple tics may respond to benzodiazepines.
For simple and complex tics, clonidine is effective in some
patients. Long-term use of clonidine does not cause tardive
dyskinesia; its limiting adverse effect is hypotension.
Intermediate-acting benzodiazepines (e.g., lorazepam) may be
useful as adjuvant treatment. For more severe cases,
antipsychotics, such as haloperidol, olanzapine, resperidone or
pimozide, may be required. Side effects of dysphoria,
parkinsonism, akathisia, and tardive dyskinesia may limit their
use. Antipsychotics should be started cautiously, and patients
should be told about potential adverse outcomes.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and
therapy, Merck Research Laboratories, 18th ed. Whitehouse
Station, NJ: Merck & Co.; 2006:2379.
D) Paroxetine (Paxil)
E) Citalopram (Celexa)
View Answer
Answer and Discussion
The answer is C. Bupropion appears to have no or only a limited
effect on sexual function.
Zajecka J. Strategies for the treatment of antidepressant-related
sexual dysfunction. J Clin Psychiatry. 2001;62 (Suppl) 3:35.
77. A 41 year old presents with feelings of being choked
up. The symptoms are rather constant and are not made
worse with swallowing. He denies that food is stuck in the
throat, and he has had no recent weight change. Eating and
drinking help to relieve symptoms. The most likely diagnosis
is
A) globus hystericus
B) panic attacks
C) Barrett's esophagus
D) reflux esophagitis
E) Zenker's diverticulum
View Answer
Answer and Discussion
The answer is A. Globus hystericus is defined as the subjective
sensation of a lump or mass in the throat. No specific cause or
mechanism has been determined, although there is some evidence
to suggest that increased cricopharyngeal (upper esophageal
sphincter) pressures or abnormal hypopharyngeal motility exist
during the time of symptoms. The sensation may result from
gastroesophageal reflux or from frequent swallowing and drying of
the throat associated with anxiety or other emotional states.
Although not related to a specific psychiatric disorder, globus may
be a symptom of certain mood states. Suppression of sadness is
most often implicated. Symptoms resemble the normal sensation
of being choked up. With globus, symptoms do not become
worse during swallowing, food does not stick in the throat, and
eating or drinking often provides relief. No pain or weight loss
occurs. Chronic symptoms may be experienced during grief
reactions and may be relieved by crying. The diagnosis is based
on the history and physical examination and is a diagnosis of
exclusion. The treatment involves treating the underlying
psychological condition.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and
therapy, Merck Research Laboratories, 18th ed. Whitehouse
Station, NJ: Merck & Co.; 2006:6970.
C) poorer self-concept
D) more maladjustment problems
E) all of the above
View Answer
Answer and Discussion
The answer is E. Marital conflict and divorce are prevalent in our
society. Women who divorce during middle age face age-specific
stresses, including loss of long-held social position, the possibility
of overdependence on young adult children, a shrinking
remarriage pool, socially denigrated body changes, and unfair
labor market conditions. In assisting women who are going
through divorce, family physicians need to focus initially on the
patient's grief and mourning and then emphasize behavior
modification and improved coping skills, which can be
accomplished with the aid of a therapist. As a group, children
(especially boys) of parents who are going through a high-conflict
divorce are two to four times more likely to have clinical
emotional and behavioral disturbances compared with national
norms. Court-ordered joint physical custody and a frequent
visitation arrangement in high-conflict divorce tend to be
associated with poorer outcomes in children, especially girls.
Thus, a child's ultimate adjustment to divorce depends on several
factors, including the following:
The level of interparental conflict that precedes and follows
divorce. The number of stressful life events that accompany
and follow divorce
The custodial parent's psychological adjustment and
parenting skills
The amount and quality of contact with the noncustodial
parent
The degree of economic hardship to which children are
exposed
View Answer
Answer and Discussion
The answer is C. Attention deficit hyperactivity disorder is the
most common pediatric psychiatric disorder, involving 1 of every
20 children. It is often a disabling condition and is frequently
accompanied by high levels of frustration and comorbidity.
Diagnosis of attention deficit hyperactivity disorder requires a
detailed history from the family and use of rating scales to collect
observations from two or more settings. Effective treatment,
including behavior management, appropriate educational
placement, and stimulant medication, improves academic
performance and behavior in most patients. Children in whom
initial management fails or for whom the diagnosis is unclear or
complicated should be referred to appropriate mental health
professionals. Medications that are used for treatment include
methylphenidate, dextroamphetamine, and pemoline. Although
these medicines have a stimulating effect in most, they have a
calming effect in children and adults with attention deficit
hyperactivity disorder. Other medications include atomoxetine,
clonidine, desipramine, imipramine, and bupropion. Side effects
include headaches, gastrointestinal symptoms, anorexia and
weight loss, insomnia, and palpitations. Pemoline has been
associated with hepatotoxicity and is no longer used. Dosing of
medications should be 30 to 45 minutes before meals (breakfast
and lunch). Lunchtime doses can be given at school for some
children. An alternative is the use of longer-acting preparations.
The long-acting form of these medications should not be crushed,
broken, or chewed before swallowing. The long-acting forms are
dosed (usually) once a day, before breakfast.
Guevara J, Paquin A, Payton K. Attention deficit hyperactivity
disorder. West J Med. 2001;175:189192.
Hunt RD, et al. An update on assessment and treatment of
complex attention-deficit hyperactivity disorder. Pediatr Ann.
2001;30(3):162172.
View Answer
Answer and Discussion
The answer is B. In patients affected with mental retardation,
many of the most challenging behaviors are caused by the same
neuropsychiatric disorders that affect the general population and
most respond to the same treatments. One notable exception is
benzodiazepine therapy, which can precipitate paradoxical
reactions of increased irritability and aggression in 10% to 15% of
patients with mental retardation.
Kalachnik JE, Hanzel TE, Sevenich R, et al. Benzodiazepine
behavioral side effects: review and implications for individuals
with mental retardation. Am J Ment Retard. 2002;107:376410.
D) Memory impairment
E) Feelings of hopelessness
View Answer
Answer and Discussion
The answer is B. Specific signs and symptoms can assist
physicians in distinguishing between delirium and a preexisting
psychiatric disorder. Visual hallucinations are an indicator of an
underlying metabolic disturbance or adverse effect of medication
or substance abuse. Although visual hallucinations can occur in
patients with primary psychiatric illnesses such as schizophrenia,
they are much less common than auditory hallucinations. In
primary psychiatric disorders, visual hallucinations are associated
with other, more characteristic signs and symptoms of the
disorders. Visual hallucinations that occur in patients with delirium
can be formed (e.g., people, animals) or unformed (e.g., spots,
flashes of light). Electroencephalography (EEG) can be useful in
differentiating delirium from other conditions. In patients with
delirium, the EEG displays a diffuse slowing of the background
rhythm. An exception is patients with delirium tremens, where the
EEG shows fast activity. EEGs are also useful in detecting ictal and
postictal seizure activity, as well as nonconvulsive status
epilepticus, all of which can present as delirium. Abnormal EEG
readings would not be expected in patients with psychotic
disorders or depression. However, slowing may occur in patients
with dementia. Additionally, the acute onset and fluctuating
nature of delirium are hallmark features in distinguishing it from
primary psychiatric disorders. Patients are often unable to provide
an adequate history. It is important to interview family members
and caregivers to determine the time of onset of symptoms and
other pertinent medical and psychiatric information, including a
review of medications and a history of substance abuse. It is also
important to know how patients are currently different from their
normal cognitive state. Psychiatric symptoms that arise in persons
50 years and older without a prior psychiatric history or the
development of new symptoms in patients with preexisting
psychiatric illness should undergo a thorough medical work-up.
Gleason OC. Delirium. Am Fam Physician. 2003;67:10271034.
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