PANCE Exam: Psychiatry/Behavioral Science Review Questions & Answers

ANXIETY DISORDERS

Question: What are the two most common behavior problems seen by general practitioners?
Anxiety and depression.

Question: What are the eight common medical causes of anxiety or anxiety attacks?

1. Alcohol withdrawal
2. Thyrotoxicosis
3. Caffeine
4. Stroke
5. Cardiopulmonary emergencies
6. Hypoglycemia
7. Psychosensory/psychomotor epilepsy
8. Pheochromocytoma

Question: What age is the average onset of separation anxiety?
Age 9. Children with separation anxiety fear leaving home, going to sleep, being alone, going to school, and losing their parents; 75% develop somatic complaints in order to avoid attending school.

Question: Do patients with mild anxiety attacks require medication?
In general, no. Patients who experience greater frequency of events and/or impairment normal function may require medication. Tricyclic antidepressants are a first-line treatment but are reserved due to their side effects.

Question: A 24-year-old man presents complaining of pleuritic pain, palpitations, dyspnea, dizziness, and tingling in his arms, legs, and lips. What is the potential diagnosis?
Hyperventilation syndrome. This is frequently associated with anxiety. Decreased carbonate levels in the blood cause the tingling. This should always be a diagnosis of exclusion.

A 20-year-old woman complains of sudden episodes of palpitations, diaphoresis, lightheadedness, a fear of losing control, a sense of being choked, tremors, and paresthesias. What is the diagnosis?
Panic disorder. Panic disorders need not be linked to any events, although they are commonly associated with agoraphobia, social phobia, mitral prolapse, and late nonmelancholic depression.

Question: Which gender is more likely to suffer from panic attacks?
Women are twice as more likely than men. Median onset is in the mid-twenties.

Question: What percentage of patients with panic disorder also suffer from major depression?
50%. Patients who suffer from panic attacks generally have a low self-esteem as well.

Question: Describe a patient with generalized anxiety disorder:
Patients afflicted with this disorder appear apprehensive, restless, irritable, and are easily distracted. Patients can also experience muscle tension and fatigue, as well as various autonomic symptoms, such as palpitations, shortness of breath, chest tightness, nausea, or diffuse weakness and numbness.

Question: Name a few substances that might mimic generalized anxiety when ingested:
Nicotine, caffeine, amphetamines, cocaine, and anticholinergics. Alcohol and sedative withdrawal can also mimic this disorder.

Question: What are some risk factors for PTSD?
Women (twice compared to men), prior history of trauma, and a family history of anxiety disorder.

Question: What is the most common symptom of a patient with PTSD?
Reexperiencing the traumatic event by either flashback, nightmares, or intrusive memories. Other symptoms can be avoidance and hyperarousal. Insomnia is also a major problem.

Question: John has just come back from the war in Iraq and has been diagnosed with PTSD. What would be the first-line medication for John?
Selective serotonin reuptake inhibitors (SSRIs), particularly sertraline and paroxetine.

Question: Can a person acquire posttraumatic stress disorder (PTSD) if he/she did not actually witness a disturbing event?
Yes. According to the DSM-IV, one can experience PTSD if an event, such as a violent personal assault, a serious accident, or the serious injury of a close friend or family member, is learned of indirectly. PTSD can also occur after a person hears of a life-threatening disease affecting a friend or family member.

Question: A 28-year-old woman who was raped 6 months ago has been psychologically sound thus far. She now suddenly develops recurrent flashbacks of the rape, nightmares, intense fear, avoidance of all men, a diminished memory of the rape, and an exaggerated startle response. Is this woman experiencing PTSD?
Yes. This is delayed onset PTSD. The onset of symptoms occurs at least 6 months after the provoking event.

What is the most common phobia in men?
Social phobia.

Question: What is social phobia?
It is a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others.

Question: What is the most common specific phobia in children?
Animal phobia.

Question: What is the most common nonpharmacologic treatment for most phobias?
Behavioral or cognitive-behavioral psychotherapy.


ATTENTION-DEFICIT DISORDERS

Question: What is the most common behavioral, emotional, and cognitive disorder in the youth population?
Attention-deficit/hyperactivity disorder (ADHD).

Question: What are some of the signs and symptoms of ADHD?
Inattentiveness, distractibility, impulsivity, and hyperactivity that is out of the reasonable boundaries for patients within their developmental stage.

Question: What comorbid diseases could you also find in a patient with ADHD?
Oppositional defiant disorder, conduct disorder (greater severity), mood disorders, and childhood anxiety are some of the more common diseases.

Question: The sibling to a female patient with ADHD is at a higher risk for what other disorders?
Conduct, mood, anxiety, and antisocial disorders, substance abuse, and, of course, ADHD. Relatives of women with ADHD are at a higher risk for these disorders compared to relatives of men.

Question: What class of drugs is commonly prescribed for the treatment of ADHD?
Stimulants, specifically methylphenidate.
 

ADHD (causes or associations) (Mnemonic: DEFICIT):
Diet (malnutrition)
Exposed to toxin (lead poisoning)
Fetal alcohol syndrome
Iron deficiency
Congenital (genetics or metabolic)
Infection (brain or ears)
Traumatic brain injuries

What accounts for the most referrals to child psychiatrists?
Attention-deficit/hyperactivity disorder (ADHD). ADHD accounts for 30% to 50% of child psychiatric outpatient cases.


AUTISTIC DISORDERS

Question: Which gender has a greater prevalence of autism?
Men are three to four times more likely.

Question: What are some early signs of autism?
In early stages of childhood, the children are often mute (50%). In later stages, the child has social deficits and difficulty with social interaction, eye contact, and defective imitation.

Question: What percentage of autistic children will be able to function independently?
20%.

Question: What is this percentage in adults?
Only 1% to 2%.

Question: What chromosomal abnormality do autistic patients commonly have?
A fragile X syndrome (8%).


EATING DISORDERS

Question: What are the two types of anorexia nervosa?
1. Restriction
2. Binge/purging

Question: What percentage of patients with anorexia are women?
90%.

Question: Besides vomiting (purging), what are the other methods for weight loss that patient’s with anorexia use?
Use of laxatives and diuretics.

Question: What are some signs on examination that may be present in anorexia?
Emaciated appearance, hypotension (orthostatic sometimes), bradycardia, lanugo, salivary gland hypertrophy, peripheral edema, and dental enamel erosion.

What are some commonly seen laboratory abnormalities in anorexia?
- Hematology—Leukopenia
- Chemistry
- Elevated—liver functions, HCO3, carotene, and cholesterol
- Lower—chloride, potassium, zinc, estrogen, T3, and T4

Question: What is the most common psychiatric comorbidity in anorexia?
Anxiety disorders.

Question: What are the two types of bulimia?
1. Purging type
2. Non-purging—associated with fasting and/or excessive exercising; without the use of laxatives or diuretics

Question: What is the most common age of onset for bulimia?
18 to 20 years; 98% to 100% are women.

Question: What is the only medication that is approved for the treatment of bulimia nervosa?
Fluoxetine 60 mg daily.

Question: What are some of the more common physical examination and laboratory abnormalities associated with bulimia?
Physical examination—dehydration appearance, dental erosion, oropharyngeal irritation, gastrointestinal bleeding
Laboratory—electrolyte abnormalities, metabolic alkalosis, decreased serum chloride and potassium; metabolic acidosis in patients taking laxatives

Question: What findings in a female patient who presents with parotid gland swelling and eroding tooth enamel might you expect?
Bulimia, which is associated with elevated serum amylase and hypokalemia. The enlarged parotid is referred to as the “chipmunk appearance.”


MOOD DISORDERS

Question: What is an adjustment disorder?
It is the development of emotional or behavioral symptoms in response to stressors, which occur within 3 months of the onset of stressors.

Question: What are some risk factors for individuals with adjustment disorder?
Prior stress, childhood experience that was stressful and mood or eating disorders. Any family unity disruption (divorce, death [especially the father], living with in-laws) and prior exposure to war without PTSD.

What is the behavioral and pharmacologic therapy for a patient with an adjustment disorder?
Psychodynamic psychotherapy and antidepressants (SSRIs).

Question: What are the two required symptoms for the diagnosis of depression?
Depressed mood and loss of interest or pleasure for at least a 2-week period of time.

Question: What are some risk factors for depression?
A family history of depression, or alcoholism, a recent negative life experience, personality disorder, early childhood trauma, and postpartum depressive states.

Question: What are some signs and symptoms of a major depressive event?
Depressed mood, anhedonia, change in appetite and sleep, change in energy, body activity, feelings of worthlessness, decreased concentration, and suicidal ideation.

Question: A patient is being evaluated for depression. Would there be any reason to evaluate the patient’s thyroid?
Yes. Up to 40% of patients with depression will have lower T4 levels on initial evaluation. Most of these patients benefit with thyroid supplementation.

Question: Is there a correlation with the number of depressive episodes and prediction for future episodes?
Yes. The more major depressive episodes a patient has, the more likely they are to have more. In an average lifetime, most patients will suffer about five major depressive events.

Question: Which class of drugs is commonly used as a first-line treatment for depression?
Selective serotonin reuptake inhibitors (SSRIs).

Question: What are some second-line treatment options for depression?
Monoamine oxidase inhibitors (MAO) and TCAs. Be careful as these medications have several side effects.

Question: When would electroconvulsive therapy (ECT) be considered for treatment of depression?
During an urgent need, when the risk of ECT outweighs pharmacological therapy, when ECT has been beneficial in the past, and strong patient preference.

Question: What are the eight common medical causes of depression?

1. Stroke
2. Viral syndromes
3. Corticosteroids
4. Cushing disease
5. Antihypertensive medication
6. SLE
7. Multiple sclerosis
8. Subcortical dementias, such as Huntington and Parkinson diseases, and HIV encephalopathy

Major depression and bipolar affective disorders account for what percentage of suicides?
50%. Another 25% are due to substance abuse and another 10% are attributed to schizophrenia.

Question: Name some symptoms of major depression:
IN SAD CAGES:
 

Interest
Sleep
Appetite
Depressed mood
Concentration
Activity
Guilt
Energy
Suicide

Question: What is dysthymia?
Dysthymia is a chronic disorder that lasts for more than 2 years. The severe symptoms of depression, such as delusions and hallucinations, are absent. Patients with dysthymia have some good days; they react to their environment and they have no vegetative signs; 10% of patients with dysthymia develop major depression.

Question: Who is at a greater risk for mood disorders, men or women?
Women (7:3).

Question: What are some risk factors for dysthymia?
More common in first-degree relatives or in those with history of major depression; age of onset before 45 years.

Question: What are some of the symptoms of dysthymia?
Low self-esteem, low self-confidence, social withdrawal, loss of pleasure or interest, chronic fatigue or tiredness, feelings of guilt, difficulty thinking, and decreased activity.

Question: What is the common class of drugs that are given for dysthymia?
SSRIs.

Question: What percentage of patients with dysthymia recovers after 2 years?
40%.

Question: Which has an earlier onset, bipolar disorder or unipolar disorder?
Bipolar. Onset of bipolar disorder is usually in the patient’s twenties or thirties; onset of unipolar disorder is usually between ages 35 to 50 years.

Differentiate between bipolar I, bipolar II, and hypomania:
Bipolar I: Mania and major depression
Bipolar II: Hypomania and major depression
Cyclothymic: Hypomania and mania without severe impairment or psychotic features

Question: Are the majority of affective disorder patients bipolar or unipolar?
Unipolar (80%).

Question: Which is most commonly the first episode of bipolar disease, mania or depression?
Mania. Depression is rarely the first symptom. In fact, only 5% to 10% of patients who develop depression first go on to have manic episodes.

Question: First-degree relatives of bipolar patients have a greater risk for which mental illnesses?
Unipolar disorders and alcoholism.

Question: Are bipolar patients at risk for suicide?
Yes. In fact, they are two to three times more likely to commit suicide compared to general population.

Question: Other than classic mania, what can lithium be used to treat?
Bulimia, anorexia nervosa, alcoholism in patients with mood disorders, leucocytosis in patients on antineoplastic medication, cluster headaches, and migraine headaches.

Question: Postural tremor is a major side effect of lithium. How is this side effect controlled?
Minimize the dose during the workday and give small doses of β-blockers.

Question: Should people who are physically active have their lithium dosage increased or decreased?
Increased. Lithium, a salt, is excreted more than sodium in sweat.

Question: True/False: A patient starting lithium will be expected to gain weight:
True. All psychotropic medications cause weight gain, hence, lithium’s usefulness in combating anorexia nervosa.

Question: What is the potential complication associated with treating manic depression and congestive heart failure simultaneously?
Lithium toxicity. A low-salt diet and/or sodium-losing diuretics can cause lithium retention and toxicity.

Question: Lithium toxicity begins at what level?
14 mg/L. Above this level, nausea, diarrhea, vomiting, rigidity, tremor, ataxia, seizures, delirium, coma, and death can occur.

Question: Name some vegetative symptoms:
Loss of appetite, lack of concentration, chronic fatigue, agitation, restlessness, inability to sleep, and weight loss.


PERSONALITY DISORDERS

Question: Is there a genetic link to patients with antisocial personality disorder?
Yes. Patients who have a father with an antisocial disorder or alcoholism are more likely to have it even if the father wasn’t around to raise the child.

Question: True/False: patients with antisocial personality disorders have a higher rate of substance abuse:
True.

Question: A 24-year-old man who has a history of antisocial personality disorder along with a substance abuse history. Provided he stops his addiction, what can you tell the patient about his long-term prognosis?
Most patients will have some improvement and 30% to 40% will significantly improve their symptoms as they reach the mid-thirties and forties age.

Question: A 30-year-old patient that you are seeing in your clinic. She has expressed that she does not interact in social situations because of a fear of not being liked. In addition, she is obsessed with thoughts of wondering if people like her. This causes the patient to feel socially inept and inferior. What is her diagnosis?
Avoidant personality disorder.

Question: Which gender is more likely to have avoidant personality disorder?
Women.

Question: Are patients with avoidant personality disorders able to function in a normal environment?
It depends. Some patients are able to survive if they are able to control the conditions in which they exist. Others who are not able to keep control of these external factors will have more problems and this will directly impact their ability to function normally.

Question: Which personality disorder accounts for up to 30% of all personality disorders?
Borderline personality disorder.

Question: What is the most common clinical symptom of a patient with a borderline personality disorder?
Chronic boredom. Other symptoms include severe mood swings, volatile relationships, continuous and uncontrollable anger, and impulsiveness.

Question: What is a commonly reported historical fact that most patients with borderline personality disorder admit to in their childhood?
Sexual, physical, and/or emotional abuse.

Question: Are suicidal gestures common in borderline personality patients?
Yes. In fact, the more that they occur, the more serious they become with 10% of these cases becoming successful.

A 27-year-old woman who is a controlling individual. She will ask friends to do things that she herself thinks are unpleasant, and tries to draw attention toward herself with superficial sexuality–type behaviors. When rejected, she will display disappointment to the point of throwing a childish temper tantrum. What is the patient’s diagnosis?
Histrionic personality disorder.

Question: True/False: Histrionic patients are often introverts:
False. They are quite extroverted and at times neurotic.

Question: What are some other psychiatric disorders that accompany patients with histrionic personalities?
Depression and anxiety can be common diagnoses.

Question: What is a narcissistic personality disorder?
It is a pattern of behavior that exhibits grandiosity, a feeling of being greater than what is reality, requires excessive admiration, and is critical of others who challenge the patient. There is also a lack of empathy toward others.

Question: Which gender is more common in a narcissistic personality?
Men.

Question: Which diagnoses can be confused with narcissistic personality disorder?
Hypomania can often mimic this as well as antisocial personality.

Question: Is psychopharmacologic therapy beneficial in a narcissistic personality?
No.

Question: What is the prognosis for a narcissistic patient?
Many of the patients will actually worsen as they get older, typically in their forties. Depression is also common.

Question: Obsessive-compulsive disorders (OCD) generally begin before what age?
25 years.

Question: What gender does obsessive-compulsive disorders predominate?
Men.

Question: What are some common obsessions?
Dirt and contamination, order and symmetry, religion and philosophy, daily decisions. Unfortunately, compulsion does not relieve the anxiety of the obsession. Serotonin reuptake inhibitors and exposure therapy can be helpful.

Question: Have medications been effective in treating OCD?
No.

Is there a familial relationship in patients with paranoid personality disorder?
There seems to be a relationship with family members who have a history of schizophrenia and/or delusional disorders.

Question: A patient who is unable to express his anger, has few close friends, is indifferent to praise from others, is absentminded, and is emotionally cold and aloof probably has which kind of personality disorder?
Schizoidia.

Question: Are first-degree relatives of schizophrenics more likely to have schizoidia or schizophrenia?
Schizoidia, at a ratio of 3:1.

Question: What is a differentiating characteristic of schizoid when compared to schizophrenia?
Schizoid patients do not have a need or behavior that dangers or involves others, while schizophrenia does.

Question: Tom is a 14-year-old adolescent who has been exhibiting behavior that is unusual, along with odd beliefs and feels that he possesses magical abilities. What is the most likely diagnosis for Tom?
Schizotypal personality disorder.

Question: What are some more common disorders in patients with schizotypal disorders?
Anxiety and substance abuse are common problems.

Question: Which class of medications can be helpful in managing a patient with schizotypal disorder?
Antipsychotics.


PSYCHOSES

Question: Can patients with delusional disorder have hallucinations?
Yes, tactile and olfactory hallucinations can be present in these patients.

Question: What are some types of delusions?
Erotomanic, grandiose, jealous, persecutory, somatic, and mixed.

Question: What are some differential diagnoses with delusional disorder?
Schizophrenia, schizoaffective, mood disorders, psychoses, and substance abuse.

Question: Which classes of drugs are used to help control delusions?
Antipsychotics.

Question: What percentage of melancholic episodes are associated with hallucinations and/or delusions?
20%.

Cite an example for each of the following perceptual disturbances: illusion, complete auditory hallucination, functional hallucination, and extracampine hallucination:

Illusion: A kitten is perceived as a dragon. (The patient misinterprets reality.)

Complete auditory hallucination: The patient claims to hear people talking when no one is around. (Clear voices are reportedly heard. They are perceived as being external to the patient.)

Functional hallucination: The patient hears voices only when cars honk their horns. (Hallucinations occur only after sensory stimulus in the same category as the hallucination.)

Extracampine hallucination: The patient can see people waving from the top of the Eiffel Tower, even though she is in Chicago. (Hallucinations are external to the patient’s normal range of senses.)

Question: What is the difference between schizophrenia and schizophreniform disorder?
Schizophreniform disorder implies the same signs and symptoms as schizophrenia, yet these symptoms have been present for less than 6 months. The impaired functioning in schizophreniform disorder is not consistent. Schizophreniform disorder is generally a provisional diagnosis with schizophrenia following.

Question: What are some characteristics of schizophrenia?
Delusional disorder, hallucinations (usually auditory), disorganized thinking, loosening of associations, disheveled appearance, and the inability to realize thoughts and behavior are abnormal.

Question: What are the five first schizophrenia rank symptoms according to Schneider?
1. Experiences of influence
2. Thought broadcasting
3. Experiences of alienation
4. Complete auditory hallucinations
5. Delusional perceptions
First-rank symptoms occur in 60% to 75% of schizophrenics. They also develop in patients with affective disorder, more commonly during manic stages.

Question: What are the five criteria for diagnosing schizophrenia?
1. Psychosis
2. Emotional blunting
3. Absence of affective features or episodes
4. Clear consciousness
5. Absence of coarse brain disease, systemic illness, and drug abuse

Question: What percentage of patients with schizophrenia become chronically ill?
60% to 80%. Men are at a greater risk for chronic illness.

Question: The onset of schizophrenia generally occurs by what age?
80% of schizophrenics develop the disease before their early twenties. The disease is very rare after age 40.

What are the five causes of schizophrenia?
1. Viral infection in the CNS
2. Problem during pregnancy that affects the neuronal development
3. Head injury
4. Seizure disorder
5. Street drugs

Question: What psychiatric problems are associated with violence?
Acute schizophrenia, paranoid ideation, catatonic excitation, mania, borderline and antisocial personality disorders, delusional depression, posttraumatic stress disorder, and decompensating obsessive-compulsive disorder.

Question: What is the average age of onset for schizophrenia?
Men: 18 to 25 years
Women: 25 to 35 years

Question: What are the ages that are considered late and very late for the onset of schizophrenia?
Late: after age 45
Very late: after age 65

Question: What percentage of schizophrenics is successful at suicide?
10% to 13%.

Question: What are some secondary reasons for acute psychosis?
Viral and bacterial infections, CNS infections, parasites, medications, anticholinergics drugs, hallucinogens, and over-the-counter stimulants.

Question: What are some hallmark signs and symptoms of schizophrenia?
Delusions, hallucinations, disorganized speech and thoughts, and negative symptoms (deficits of normal function but not psychotic).

Question: What class of medications are the first-line treatment of schizophrenia?
Antipsychotics.

Question: What are the five criteria for brief reactive psychosis?
1. Precipitating stressful event
2. Rapid onset of the psychosis
3. Affective lability and mood intensity
4. Symptoms that match the stressful event
5. Resolution of symptoms once the stressor is removed, generally within 2 weeks

What brain lesions sites are most commonly associated with psychosis?
The temporolimbic system, caudate nucleus, and frontal lobes.

Question: List some life-threatening causes of acute psychosis:
WHHHIMP:

Wernicke encephalopathy
Hypoxia
Hypoglycemia
Hypertensive encephalopathy
Intracerebral hemorrhage
Meningitis/encephalitis
Poisoning

Question: What signs and symptoms suggest an organic source for psychosis?
Acute onset, disorientation, visual or tactile hallucinations, age under 10 or over 60 years, and any evidence suggesting overdose or acute ingestion, such as abnormal vital signs, pupil size and reactivity, or nystagmus.

Question: When are women at the greatest risk for psychiatric illness?
The first few weeks postpartum. A psychiatric illness most often occurs in patients who are primiparous, have poor social support, or have a history of depression.

Question: When does postpartum psychosis begin?
Within a week to 10 days following childbirth. A second, smaller peak occurs 5 to 7 months later, correlating with the first menses postpartum. The risk of psychosis is lowest during pregnancy.


SOMATOFORM DISORDER

Question: A 30-year-old woman complains of calf pain, headache, shooting pain when flexing her right wrist, random epigastric pain, bloating, and irregular menses, all of which cannot be explained after medical examination. What is the diagnosis?
Somatization disorder, many unexplained medical symptoms involving multiple systems. In order to diagnose a patient with somatization disorder, one must have four or more unexplained pain symptoms. Symptoms generally begin in childhood and are fully developed by age 30. This is more common in women than in men.

Question: What percentage of primary care patients exhibits some form of somatizations in clinic visits?
25%.

Question: What is a classic type of patient that presents with somatoform disorder?
Young, unmarried, non-white woman from a rural area and who is uneducated.

What is the treatment of somatoform disorder?
It is extremely difficult. First, you have to detect the disorder and then convince the patient that they have this problem. Second is to have the patient exhibit more than two to three office visits that are legitimate problems. Make sure to examine all symptoms and orders tests as needed, and lastly prescribe any medications that may help the said illness and monitor for improvement.

Question: What are some criteria to meet in a acute stress disorder (ASD)?
Primary—Patient has to be witness to a traumatic event or involved. The event has to involve the patient’s fear or helplessness.
Secondary—While during this event, the patient has a sense of detachment, will be in a daze and not able to function normally, and have a detachment from memory about the event. This may also cause the patient to have recall of the event, flashbacks, and reminders of the trauma. This experience will create a significant impairment for the patient.

Question: If a patient has an ASD from an event, what is he/she likely to develop?
Up to 80% of these patients will later be diagnosed with PTSD.

Question: What are the three categories of child maltreatment?
Child neglect, physical abuse, and sexual abuse.

Question: How many children die each year as a result of abuse?

1500.

Question: What are some parental factors that lend to child abuse?
Lower parental education, mental illness, alcoholism, and substance abuse.

Question: In what percentage of child sexual abuse cases is the abuser known by the child?
90%. In 50% of such cases, the mother is also abused.

Question: In addition to the history, physical examination, laboratory tests, and collection of physical evidence, what needs to be done in cases of child sexual abuse?
File a report with child protective services and law enforcement agencies. Provide emotional support to the child and family. Give a return appointment for follow-up of STD cultures and testing for pregnancy, HIV, or syphilis as indicated. Assure follow-up for psychological counseling by connecting the child/family to the appropriate services in your area.

Question: Is violence more likely between family members or nonfamily members?
Family members: 20% to 50% of the murders in the United States are committed by members of the victims’ families. Spouse abuse is as high as 16% in the United States.


OTHER BEHAVIORAL DISORDERS

What is the epidemiology of domestic violence?
95% of the victims are women. An estimated 4 million women are battered each year. Domestic abuse is the number one cause of injuries to women. More than half of all women murdered in the United States are killed by their intimate partner.

Question: What are the clinical clues for domestic violence?
Any evidence of injury during pregnancy or late entry into prenatal care. Injuries presenting after significant delay or in various stages of healing; especially to the head, neck, breasts, abdomen, or areas suggesting a defensive posture, such as bruises on the forearms. Vague complaints or unusual injuries, such as bites, scratches, burns, or rope marks.

Question: What is the standard of care for victims of domestic violence currently recommended by JCAHO, the AMA, and the CDC?
- Establish a confidential system to identify DV victims
- Document the abuse
- Collect physical evidence
- Evaluate safety issues and potential for lethality or suicide
- Formulate a safety plan with the victim
- Advise the victim of all his/her options and resources
- Refer for counseling and other services, including legal assistance
- Coordinate with law enforcement
- Transport to a shelter if desired or needed
- Follow-up with a domestic violence advocate

Question: What are the prodromes of violent behavior?
Anxiety, defensiveness, volatility, and physical aggression.

Question: What are the only reliable indicators of a potentially violent patient?
Male gender, history of violence, and history of substance abuse. Cultural, educational, economic, and language barriers to effective patient/staff communication can increase the patient’s frustration and lower his or her threshold for violence as can trivialization of the patient or the family’s concerns.

Question: Bereavement generally lasts how long?
6 months. Full melancholic syndrome, hallucinations, and suicidal ideation are not common in bereavement.

Question: When do you medically treat uncomplicated bereavement?
When the symptoms mimic depression and last for more than 13 months. This would be the expected time that uncomplicated bereavement should subside.

Question: Who is more successful at suicide, men or women?
Men (a 3:1 men-to-women ratio). However, women attempt suicide three times as often as men.

Question: True/False: Fantasies frequently precede suicidal acts:
True.

What percentage of patients with melancholia attempt suicide?
15%.

Question: What is the number one cause of death for African American men between the ages of 10 and 24 years?
Firearm injury. The overall homicide rate for young men in the United States is more than seven times that of the next developed country.

Question: Do intentional or unintentional causes account for more firearm-related deaths?
Intentional causes account for 94% of firearm deaths, suicide for 48%, and homicide for 46%. Unintentional firearm injuries account for about 4%. Only 1% of firearm deaths occur as a result of legal intervention. The number of firearm-related fatalities has more than doubled in the last 30 years.

Question: What are risk factors for homicide?
Most homicide victims are killed by someone they know, someone of the same race, and usually during an argument or fight. Drugs and alcohol are important cofactors as is the presence of a handgun.

Question: What are the relative risks for suicide and homicide if a gun is kept in the home?
Suicide is five times more likely. Homicide is three times more likely. The victim is 43% more likely to be a member of the family than an intruder. In the case of domestic violence, a gun at home increases the risk of homicide 20-fold.


SUBSTANCE USE DISORDERS

Question: What is the prevalence of alcoholism in the United States?
10% to 15% is the lifetime prevalence, and 10% of men and 3.5% of women are alcoholic.

Question: What age range has the highest prevalence of drinking problems?
18 to 29 year olds have the greatest prevalence.

Question: What laboratory changes are suggestive of alcoholism?
Look for an increase in ALT, AST, alkaline phosphatase, amylase, bilirubin, cholesterol, GGT, LDH, MCV, prothrombin time, triglycerides, and uric acid and a decrease in BUN, calcium, coagulopathy, hematocrit, magnesium, phosphorus, platelet count, and protein.

Question: Describe the symptoms of alcohol withdrawal and their temporal relations:
Autonomic hyperactivity: Tachycardia, hypertension, tremors, anxiety, and agitation occur 6 to 8 hours after patient’s last drink
Hallucinations: Auditory, visual, and tactile occur 24 hours after patient’s last drink.
Global confusion: Occurs 1 to 3 days after patient’s last drink.

What is the difference in the treatment methods between alcohol withdrawal compared to sedative hypnotic withdrawal?
Alcohol withdrawal is treated with benzodiazepine, carbamazepine, or paraldehyde. Sedative hypnotic withdrawal is treated with the substitution of a long-acting barbiturate.

Question: What is the most effective long-term treatment program for alcoholism?
Alcoholics Anonymous.

Question: What should you do when handling intoxicated, violent, psychotic, or threatening patients?
Conduct careful histories and physicals with attention to mental status. Look for evidence of trauma, toxic ingestion, or metabolic derangement. Historical sources (e.g., family, paramedics, mental health workers, police, or medical records) may need to be accessed. Patients may need to be physically or chemically restrained in order to obtain an adequate examination and to ensure the safety of the patient and hospital staff.

Question: What is the most common mental illness in large cities?
Substance abuse. Substance abuse is prevalent in rural communities as well but the addiction percentages are lower. Incidentally, opiates are predominantly a city drug, while marijuana, alcohol, and amphetamines are found in both the rural and urban settings.

Question: A patient presents with tearing eyes, a runny nose, tachycardia, hair on end, abdominal pains, nausea, vomiting, diarrhea, insomnia, pupillary dilation, and leukocytosis. What is the diagnosis?
Opiate and/or opioid withdrawal. Treat with methadone or Dolophine. Clonidine may blunt some of the side effects.

Question: Wild and abundant dreams may result from the withdrawal of what drugs?
Antidepressants. Other side effects of withdrawal are anxiety, akathisia, bradykinesia, mania, and malaise.

Question: What percentage of deaths has been associated with tobacco use?
25%.

Question: What are some of the more common diseases associated with tobacco use?
Coronary heart disease, oral cancers, dental disease, emphysema, lung cancer, and low birth weight in pregnant women.

Question: What are the components of the multiaxial diagnostic system?
Axis I: Symptoms and syndromes comprising a mental disorder, including substance abuse/addiction
Axis II: Personality and developmental disorders underlying the axis I diagnosis
Axis III: Physical medical problems/conditions that may or may not contribute to the axis I diagnosis
Axis IV: Psychosocial factors
Axis V: Adaptive ability/disability

What is the most common cause of catatonia?
Affective disorder.

Question: What is a previously healthy patient most likely suffering from when he becomes suddenly and intensely excited, goes into a delirious mania, develops catatonic features, and a high fever.
Lethal catatonia. Such patients have a 50% death rate without treatment. Treat these patients with ECT.

Question: How is lethal catatonia differentiated from neuroleptic malignant syndrome?
By the timing of the hyperthermia. In lethal catatonia, severe hyperthermia occurs during the excitement phase before catatonic features develop. In neuroleptic malignant syndrome, hyperthermia develops later in the course of the disease with the onset of stupor.

Question: In infancy, simple repetitive reactions like nail-biting, thumb-sucking, masturbation, or temper tantrums are manifestations of what psychological reaction?
Adjustment reactions. These are responses to separation from the caregiver and are often associated with developmental delay.

Question: What is the prevalence of conduct disorder?
10%. It is more common in boys and is hereditary.

Question: Children with conduct disorders will probably develop what adult disorder?
Antisocial personality disorder. About 40% will have some pathology as adults.

Question: What is conversion disorder?
An internal psychological conflict that manifests itself through somatic symptoms. Voluntary motor or sensory functions are affected. Examples include weakness, imbalance, dysphagia, and changes in vision, hearing, or sensation. These symptoms are not feigned or intentionally produced. They are also not fully explained by medical conditions.

Question: What are the five Kübler-Ross stages of dying?

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
Patients may undergo either all or only a few of these stages.

Question: What psychiatric disease is the most hereditary?
Idiopathic enuresis. If one parent has enuresis, there is a 44% chance that the child will also have the disease. If both parents have it, the likelihood increases to 77%.

What is an extreme case of factitious disorder?
Munchausen syndrome. These patients may actually try to cause harm to themselves (e.g., by injecting feces into their veins) and are very accepting/seeking of invasive procedures. Munchausen by proxy is another example. In this disease, the patient seeks medical care for another, usually a child.

Question: Give examples of the following thought disorders: perseveration, nonsequiturs, derailment, tangential speech, neologism, private word usage, and verbigeration:

Perseveration—“I’ve been wondering if the mechanical mechanisms of this machine are mechanically sound. Mechanically speaking, I must understand the mechanisms.” (A repetition of certain words or phrases is found in the natural flow of speech.)

Nonsequiturs—Q: “Are you nervous about the upcoming boards?” A: “Why no, the king of France is an excellent king.” (The patient’s answers are unrelated to the questions asked.)

Derailment—“I first became interested in the study of medicine after mom bought me a toy ambulance. Toys can be very dangerous, especially if they are very small and can be swallowed. I’ve been having difficulty swallowing lately.” (The patient suddenly switches lines of thought, though the second follows the first.)

Tangential speech—A: “Those are nice clothes you’re wearing today.” B: “Of course I’m wearing clothes today.” A: “I mean, I like the outfit you have on.” B: “I think everyone should wear clothes, except on Friday, because Friday is casual day at my office.” (Conversations are on the right subject matter; however, the responses are inappropriate to the previous questions or comments.)

Neologism—“I’m going to explaphrase (explain by paraphrasing) the meaning of agnonoctaudiophobia (things that go bump in the night).” (Neologisms are meaningless combinations of two or more words to invent a new word.)

Private word usage—“I can’t believe the loquacious way he is formicating those tripods.” (Words and or phrases used in unique ways.)

Verbigeration—“I have been studying, have been studying, have been studying, for hours for hours hours hours.” (The patient repeats words, especially at the end of thoughts, thoughts, thoughts, thoughts.)

Question: Matching:

Answers: (1) b, (2) c, (3) a, (4) d, and (5) e.

Question: A patient is brought in because she believes butterflies are landing all around her. The butterflies talk to her and tell her to love everyone. She denies suicidal ideation and any desire to harm herself or others. She has no record of harming people in the past. Can this person be institutionalized against her will?
No. Unless the patient is a danger to herself or others, she cannot be confined to an institution despite questionable mental status.

What is the difference between a malingering and a factitious disorder?
A malingerer’s incentive is external, such as workman’s compensation. The goal of someone with a factitious disorder is to enter into the sick role. Both involve feigning illness.

Question: According to Holmes and Rahe, what are life’s top 10 most stressful events?

1. Death of spouse or child
2. Divorce
3. Separation
4. Institutional detention
5. Death of close family member
6. Major personal injury or illness
7. Marriage
8. Job loss
9. Marital reconciliation
10. Retirement


REFERENCES
Brunton Laurence L, L J. Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 11th ed. New York, NY: McGraw-Hill; 2006.
Ebert ML, Nurcombe B, Leckman JF. Current Diagnosis and Treatment, Psychiatry. 2nd ed. New York, NY: McGraw-Hill; 2008.
Fauci Anthony S., B. E. (2008, 7 1). Harrisons Online. New York, NY.
McPhee Stephen J, PM. Current Medical Diagnosis and Treatment 2009. New York, NY: McGraw-Hill; 2009.