(BQ) Part 1 book BRS Behavioral science presents the following contents: The beginning of life - Pregnancy through preschool; school age, adolescence, special issues of development, and adulthood; aging, death and bereavement; genetics, anatomy and biochemistry of behavior; biological assessment of patients with psychiatric symptoms;... and other contents.
Behavioral Science Behavioral Science Barbara Fadem, PhD Professor Department of Psychiatry University of Medicine and Dentistry of New Jersey New Jersey Medical School Newark, New Jersey Acquisitions Editor: Crystal Taylor Product Manager: Catherine Noonan Marketing Manager: Joy Fisher-Williams Designer: Holly Reid McLaughlin Compositor: Aptara, Inc Sixth Edition Copyright © 2014, 2009, 2005 Lippincott Williams & Wilkins, a Wolters Kluwer business 351 West Camden Street Baltimore, MD 21201 Two Commerce Square 2001 Market Street Philadelphia, PA 19103 Printed in China All rights reserved This book is protected by copyright No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright To request permission, please contact Lippincott Williams & Wilkins at 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via website at lww.com (products and services) Library of Congress Cataloging-in-Publication Data Fadem, Barbara Behavioral science / Barbara Fadem.—6th ed p ; cm.—(Board review series) Includes bibliographical references and index ISBN 978-1-4511-3210-6 I Title II Series: Board review series [DNLM: Behavioral Sciences—Examination Questions Behavioral Sciences–Outlines Behavior—Examination Questions Behavior—Outlines WM 18.2] 616.890076—dc23 2012042579 DISCLAIMER Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320 International customers should call (301) 223-2300 Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST I lovingly dedicate the 6th edition of this book to Daniel, Jonathan, Terri, Sarah and Joseph Fadem and Tom and Fifi Chenal Preface The function and state of the mind are of significant importance to the physical health of an individual The United States Medical Licensing Examination (USMLE) is closely attuned to the substantial power of the mind–body relationship and extensively tests this area on all three steps of the examination This review book was prepared as a learning tool to help the students rapidly recall information that they learned in the first two years of medical school in behavioral science, psychiatry, epidemiology, and related courses The sixth edition of BRS Behavioral Science contains 26 chapters All chapters start with a “Typical Board Question,” which serves as an example for the manner in which the subject matter of that chapter is tested on the USMLE Each chapter has been updated to include the most current information A total of more than 700 USMLE-style questions (about 70 more than in the fifth edition) and answers with detailed explanations are presented after each chapter, as well as in the Comprehensive Examination A significant number of these questions were written expressly for this sixth edition and reflect USMLE style, using clinical vignettes in the stem Many tables are included in the book to provide quick access to essential information vii Chapter 11 Which of the following symptoms of schizophrenia is likely to respond best to antipsychotic medication? Schizophrenia and Other Psychotic Disorders 115 11 A 35-year-old man who lives in a group When compared to traditional antipsychotic medication, atypical antipsychotic medication is more likely to be helpful for which of the following symptoms? home says that his roommates are spying on him by listening to him through the electrical outlets For this reason, he has changed roommates a number of times over the last years He dresses strangely, is dirty with unkempt hair, and seems preoccupied He reports that he has trouble paying attention to the doctor’s questions because “I am listening to my leader giving me instructions in my head.” Neuropsychological evaluation of this patient when he is not hearing voices is most likely to reveal (A) (B) (C) (D) (E) (A) (B) (C) (D) (E) (A) (B) (C) (D) (E) Delusions Flattening of affect Poor speech content Lack of motivation Social withdrawal Hallucinations Delusions Agitation Over-talkativeness Social withdrawal A 20-year-old woman tells the physician that sometimes she becomes frightened when her room is dark because her computer looks like a lion lurking in the corner This is an example of (A) (B) (C) (D) (E) an illusion a neologism a hallucination a delusion an idea of reference 10 A 53-year-old hospitalized patient with schizophrenia tells the physician that a newscaster was talking about her when he said on television, “A woman was found shoplifting today.” This patient’s statement is an example of (A) (B) (C) (D) (E) an illusion a neologism a hallucination a delusion an idea of reference memory impairment inability to state his name mental retardation frontal lobe dysfunction lack of orientation to place 12 A 20-year-old man reports that he just found out that his mother (whom he believed had died when he was a child) has been in an institution for the past 15 years with schizophrenia He asks what the chances are that he will develop schizophrenia over the course of his life The most correct answer is approximately (A) (B) (C) (D) (E) 1% 5% 10% 50% 80% 13 A patient reports that his 19-year-old identical twin brother has just been diagnosed with schizophrenia and wants to know what the likelihood is that he will develop this disorder The most correct answer is approximately (A) (B) (C) (D) (E) 1% 5% 10% 50% 80% 116 Behavioral Science 14 The percentage of patients with schizo- 18 A 68-year-old patient tells the physician phrenia who attempt suicide is approximately that for the last years his neighbor has been trying to get him evicted from his apartment by telling lies about him to the landlord The patient is married and is working full time in a job, which he has held for over 30 years What is the most appropriate diagnosis for this patient? (A) (B) (C) (D) (E) 1% 5% 12% 50% 80% 15 Which of the following is most closely associated with a good prognosis in schizophrenia? (A) (B) (C) (D) (E) Younger age of onset Catatonic symptoms Negative symptoms Many relapses Mood symptoms 16 The most common type of hallucination seen in schizophrenia is (A) (B) (C) (D) (E) visual gustatory auditory olfactory hypnagogic 17 A 45-year-old man with a 20-year history of severe depression and psychotic symptoms has held different jobs, but none of them for more than months He is successfully treated for his severe depressive symptoms, but he remains withdrawn and odd and expresses the belief that he has been “chosen” for a special mission on earth What is the most appropriate diagnosis for this patient? (A) (B) (C) (D) (E) (F) (G) Schizophrenia Schizoaffective disorder Schizophreniform disorder Brief psychotic disorder Delusional disorder Shared psychotic disorder Psychosis due to a general medical condition (A) (B) (C) (D) (E) (F) (G) Schizophrenia Schizoaffective disorder Schizophreniform disorder Brief psychotic disorder Delusional disorder Shared psychotic disorder Psychosis due to a general medical condition 19 A 60-year-old woman whose husband believes (in the absence of any evidence) that their house is filled with radioactive dust worries about her ability to clear the house of the dust when he is hospitalized What is the most appropriate diagnosis for this woman? (A) (B) (C) (D) (E) (F) (G) Schizophrenia Schizoaffective disorder Schizophreniform disorder Brief psychotic disorder Delusional disorder Shared psychotic disorder Psychosis due to a general medical condition 20 In a 50-year-old patient with schizophrenia, the size of the cerebral ventricles, glucose utilization in the frontal lobes, and size of limbic structures are most likely to be, respectively (A) (B) (C) (D) (E) (F) increased, decreased, decreased increased, decreased, increased increased, increased, decreased decreased, decreased, decreased decreased, increased, decreased decreased, increased, increased Answers and Explanations Typical Board Question The answer is G This patient is showing evidence of psychosis due to a general medical condition The abnormal gait, age of the patient, and family history strongly suggest Huntington disease, which often presents with psychiatric symptoms such as psychosis and depression (see also answer to Question 1) The answer is D This patient is showing evidence of brief psychotic disorder This disorder is characterized by psychotic symptoms lasting >1 day, but 5% of body weight) (3) A – Anhedonia (loss of pleasure or interest in usually pleasurable activities) (4) G – Guilt (feelings of responsibility for negative life events when little or none exists) b These and other symptoms of depression are listed and described in Table 12.1 t a b l e 12.1 Signs and Symptoms of Depression and Mania Depression Likelihood of Occurrence ++++ ++++ ++++ ++++ ++++ +++ +++ +++ ++ ++ ++ + + SWAG (suicidality, weight loss, anhedonia, guilt) symptom Sadness, hopelessness, helplessness, low self-esteem Reduced energy and motivation Anxiety (is apprehensive about imagined dangers) Sleep problems (wakes frequently at night and too early in the morning) Cognitive problems (has difficulty with memory and concentration) Change in physical activity (psychomotor retardation or agitation) Decreased or increased (in atypical depression) appetite for food and sex Poor grooming Diurnal variation in symptoms (worse in the morning, better in the evening) Suicidal ideation (has thoughts of killing oneself) Suicide (takes one’s own life) Psychotic symptoms (has delusions of destruction and fatal illness) Mania Likelihood of Occurrence Elevated mood (has strong feelings of happiness and physical well-being) Grandiosity and expansiveness (has feelings of self-importance) Irritability and impulsivity (is easily bothered and quick to anger) Disinhibition (shows uncharacteristic lack of modesty in dress or behavior) Assaultiveness (cannot control aggressive impulses; causes legal problems) Distractibility (cannot concentrate on relevant stimuli) Flight of ideas (thoughts move rapidly from one to the other) Pressured speech (seems compelled to speak quickly) Impaired judgment (provides unusual responses to hypothetical questions, [e.g., says she would buy a blood bank if she inherited money]) Psychotic symptoms (has delusions of power and influence) Approximate percentage of patients in which the sign or symptom is seen: + 70% ++++ ++++ ++++ ++++ ++++ ++++ ++++ ++++ ++++ +++ Chapter 12 Mood Disorders 121 Masked depression a As many as 50% of depressed patients seem unaware of or deny depression and thus are said to have “masked depression.” b Patients with masked depression often visit primary care doctors complaining of vague physical symptoms c In contrast to patients who have somatoform disorders (physical symptoms resulting from psychological factors; see Chapter 14) depressed patients show at least one SWAG symptom in addition to their physical complaints Seasonal affective disorder (SAD) a SAD is a subtype of major depressive disorder associated with the winter season and short days b SAD is characterized by atypical symptoms of depression (e.g., oversleeping and overeating) and a heavy feeling in the limbs (“leaden paralysis”) c Many SAD patients improve in response to full-spectrum light exposure Suicide risk a Patients with mood disorders are at increased risk for suicide b Certain demographic, psychosocial, and physical factors affect this risk (Table 12.2) c The top five risk factors for suicide from higher to lower risk are (1) serious prior suicide attempt (2) age older than 45 years (3) alcohol dependence (4) history of rage and violent behavior (5) male sex B Bipolar disorder In bipolar disorder, there are episodes of both mania and depression (bipolar I disorder) or both hypomania and depression (bipolar II disorder) There is no simple manic disorder because depressive symptoms eventually occur Therefore, one episode of symptoms of mania (Table 12.1) alone or hypomania plus one episode of major depression defines bipolar disorder Psychotic symptoms, such as delusions, can occur in depression (depression with psychotic features) as well as in mania a In some patients (e.g., poor patients with low access to health care), a mood disorder with psychotic symptoms can become severe enough to be misdiagnosed as schizophrenia b In contrast to schizophrenia and schizoaffective disorder, in which patients are chronically impaired, in mood disorders the patient’s mood and functioning usually return to normal between episodes C Dysthymic disorder and cyclothymic disorder In contrast to major depressive disorder and bipolar disorder, respectively, dysthymic disorder and cyclothymic disorder are less severe nonepisodic chronic not associated with psychosis or suicide III ETIOLOGY A The biologic etiology of mood disorders includes Altered neurotransmitter activity (see Chapter 4) A genetic component, strongest in bipolar disorder (Table 12.3) Physical illness and related factors (Table 12.4) Abnormalities of the limbic–hypothalamic–pituitary–adrenal axis (see Chapter 5) 122 Behavioral Science t a b l e Category 12.2 Risk Factors for Suicide Factor Increased Risk Serious suicide attempt (about 30% of people who attempt suicide try again and 10% succeed) 3 mos since previous attempt Rescue was very likely No family history of suicide Intact family throughout childhood Dysthymia or no depressive symptoms No psychotic symptoms Some hopefulness Thinks things out The depth of severe depression; patients rarely have the clarity of thought or energy needed to plan and commit suicide Little or no substance use Good health No recent visit to a physician Married Strong social support Has children Lives with others Elderly (persons age 65 and older, especially men) Middle-aged (over age 55 yrs in women and age 45 yrs in men) Adolescents (suicide is the third leading cause of death in those 15–24 yrs of age; rates increase after neighborhood suicide of a teen or when media depict teenage suicide) Male sex (men successfully commit suicide three times more often than women) Professionals Physicians (especially women and psychiatrists) Dentists and veterinarians Police officers Attorneys Musicians Unemployed Caucasian Not religious Jewish Protestant Economic recession or depression Children (up to age 15 yrs) A plan for suicide (e.g., decision to stockpile pills) A means of committing suicide (e.g., access to a gun) Sudden appearance of peacefulness in an agitated, depressed patient (he has reached an internal decision to kill himself and is now calm) Shooting oneself Crashing one’s vehicle Hanging oneself Jumping from a high place No plan for suicide Young adults (age 25–40 yrs) Female sex (although women attempt suicide three times more often than men) Non-professionals Employed Non-Caucasian Religious Catholic Muslim Strong economy No means of suicide Taking pills or poison Slashing one’s wrists Chapter 12 t a b l e 12.3 Mood Disorders 123 The Genetics of Bipolar Disorder Group Approximate Occurrence (%) General population Person who has one parent or sibling (or dizygotic twin) with bipolar disorder 20 Person who has two parents with bipolar disorder Monozygotic twin of a person with bipolar disorder 60 75 B The psychosocial etiology of depression and dysthymia can include Loss of a parent in childhood Loss of a spouse or child in adulthood Loss of health Low self-esteem and negative interpretation of life events “Learned helplessness” (i.e., because attempts to escape bad situations in the past have proven futile, the person now feels helpless) (see Chapter 7) C Psychosocial factors are not directly involved in the etiology of mania or hypomania IV MANAGEMENT A Overview Depression is successfully managed in most patients Only about 25% of patients with depression seek and receive treatment a Patients not seek treatment in part because Americans often believe that mental illness indicates personal failure or weakness b As in other illnesses, women are more likely than men to seek treatment Untreated episodes of depression and mania are usually self-limiting and last approximately 6–12 months and months, respectively The most effective management of the mood disorders is pharmacologic B Pharmacologic management (see Chapter 16) Treatment for depression and dysthymia includes antidepressant agents (e.g., heterocyclics, selective serotonin and selective serotonin and norepinephrine reuptake inhibitors [SSRIs and SNRIs], monoamine oxidase inhibitors [MAOIs], and stimulants) t a b l e 12.4 Differential Diagnosis of Depression Medical Conditions Psychiatric and Related Conditions Cancer, particularly pancreatic and other gastrointestinal tumors Viral illness (e.g., pneumonia, influenza, acquired immune deficiency syndrome [AIDS]) Endocrinologic abnormality (e.g., hypothyroidism, diabetes, Cushing’s syndrome) Neurologic illness (e.g., Parkinson disease, multiple sclerosis, Huntington disease, dementia, stroke [particularly left frontal]) Nutritional deficiency (e.g., folic acid, B12) Renal or cardiopulmonary disease Schizophrenia (particularly after an acute psychotic episode) Adjustment disorder Anxiety disorder Normal reaction to a life loss, e.g., bereavement Somatoform disorder Eating disorder Drug and alcohol abuse (particularly use of sedatives and withdrawal from stimulants) Prescription drug use (e.g., reserpine, steroids, antihypertensives, antineoplastics) 124 Behavioral Science Mood stabilizers a Lithium and anticonvulsants such as carbamazepine (Tegretol) and divalproex (Depakote) are used to manage bipolar disorder b Mood stabilizers in doses similar to those used to manage bipolar disorder are the primary treatment for cyclothymic disorder c Atypical antipsychotics such as olanzapine (Zyprexa) and risperidone (Risperdal) d Sedative agents such as lorazepam (Ativan) are used to manage acute manic episodes because they resolve symptoms quickly C Psychological management Psychological management for depression and dysthymia includes psychoanalytic, interpersonal, family, behavioral, and cognitive therapies (see Chapter 17) Psychological management in conjunction with medication is more effective than either type of management alone D Electroconvulsive therapy (ECT) (see Chapter 16) The primary indication for ECT is major depressive disorder It is used when The symptoms not respond to antidepressant medications Antidepressants are too dangerous or have intolerable side effects Thus, ECT may be particularly useful for elderly patients Rapid resolution of symptoms is necessary (e.g., the patient is acutely suicidal or psychotic) Review Test Directions: Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement Select the one lettered answer or completion that is best in each case A 65-year-old woman, who was diagnosed with advanced lung cancer months ago, has lost 18 pounds, wakes frequently during the night, and has very little energy Over the past month she has been preoccupied with feelings of guilt about “people I have hurt in my life” and expresses concern that she will die in pain The sign or symptom most likely to indicate that this patient is experiencing a major depressive episode rather than a normal reaction to life-limiting illness is This college student has two brothers The first is his monozygotic twin; the second is years younger The risks that his first and second brothers will develop bipolar disorder are respectively about (A) (B) (C) (D) (E) Questions and weight loss decreased energy difficulty sleeping preoccupation with feelings of guilt concern about dying in pain Questions 2–4 A 20-year-old male college student is taken to the emergency department by police because he tried to enter a state office building to “have a conference with the governor” about conducting a fund drive to “finance my cure for cancer.” When police prevent him from entering the building, he becomes irritable and hostile and resists attempts to restrain him The most appropriate diagnosis for this patient is (A) (B) (C) (D) (E) dysthymic disorder major depressive disorder bipolar disorder hypochondriasis cyclothymic disorder The most effective long-term management (A) (B) (C) (D) (E) 75% and 60% 75% and 20% 60% and 10% 50% and 10% 10% and 1% For the past few months, a 28-year-old woman has seemed full of energy and optimism for no obvious reason Although she gets only about hours of sleep a night, she has been very productive at work She is talkative and gregarious and relates that she belongs to four clubs and two different sports teams A few years previously, friends say she was often pessimistic and seemed tired and “washed out.” During that period, she continued to work but did not seek out social activities and had little interest in sex There is no evidence of a thought disorder and the patient denies suicidality or hopelessness Physical examination including body weight is normal This patient shows evidence of (A) dysthymic disorder (B) major depressive disorder (C) bipolar disorder (D) hypochondriasis (E) cyclothymic disorder for this patient is The most effective long-term management for this patient is (A) (B) (C) (D) (E) (A) (B) (C) (D) (E) a heterocyclic antidepressant lithium electroconvulsive therapy psychotherapy a monoamine oxidase inhibitor a heterocyclic antidepressant lithium electroconvulsive therapy psychotherapy a monoamine oxidase inhibitor 125 126 Behavioral Science Questions and A 62-year-old woman whose husband died months ago tells her physician that she believes killing herself would end her suffering Physical examination is unremarkable Of the following signs and symptoms, which is most likely to be seen in this patient? (A) (B) (C) (D) Weight gain Flight of ideas Auditory hallucinations Feeling better in the morning than in the evening (E) Poor grooming Analysis of neurotransmitter availability in the brain of this patient is most likely to reveal (A) (B) (C) (D) (E) increased dopamine decreased histamine increased acetylcholine decreased acetylcholine decreased serotonin A 25-year-old male patient who is slow moving and has a flat affect is put on fluoxetine (Prozac) Within weeks, the patient is showing greatly increased activity level, flight of ideas, and pressured speech In this patient, the medication has (A) (B) (C) (D) (E) precipitated a manic episode had a toxic effect had a delayed effect increased anxiety increased depression 10 A 35-year-old physician tells his internist that he has lost interest in playing in the hospital string quartet, an activity he formerly enjoyed He reports that over the past months he commonly wakes up a few hours before his alarm goes off and cannot fall back to sleep, and has lost 12 pounds without dieting He states “maybe my family would be better off without me.” He says that although he has lots of aches and pains and often feels tired, he feels somewhat better as the day progresses Physical examination and laboratory studies are unremarkable The most appropriate diagnosis for this patient is (A) (B) (C) (D) (E) (F) (G) dysthymic disorder major depressive disorder masked depression hypochondriasis cyclothymic disorder malingering bipolar disorder 11 A 28-year-old man comes in complaining of headaches and a variety of other aches and pains that have been present for the past months He denies that he is sad or hopeless After a 4-week trial of antidepressant medication, the patient’s physical complaints have disappeared The most appropriate diagnosis for this patient is (A) (B) (C) (D) (E) (F) (G) dysthymic disorder major depressive disorder masked depression hypochondriasis cyclothymic disorder malingering bipolar disorder Questions 12–14 A 65-year-old Catholic male patient has been abusing alcohol for the past 15 years His history reveals that his wife recently asked him for a separation 12 Which of the following characteristics is this patient’s greatest risk factor for suicide? (A) (B) (C) (D) (E) Alcoholism Male sex Marital separation Religion Age 13 This man is at the lowest risk for suicide if he works as a (A) (B) (C) (D) (E) messenger policeman physician lawyer dentist 14 If this patient tries to commit suicide, the method most likely to fail is (A) (B) (C) (D) (E) shooting himself with a gun crashing his car slashing his wrists jumping from a high place hanging himself 15 The percentage of depressed patients who seek treatment for their symptoms is about (A) (B) (C) (D) (E) 1% 5% 25% 50% 75% Chapter 12 16 A 15-year-old girl is brought to the emergency room after ingesting 20 acetaminophen tablets She tells the physician that she tried to commit suicide because she was not admitted to an honors English class The girl is the president of her grade in school and always tries to be perfect The most important factor in whether this girl tries to kill herself again is (A) (B) (C) (D) (E) that she is female the method of the suicide attempt that she has major depressive disorder that she tried to commit suicide once her need to be perfect (A) (B) (C) (D) (E) (F) (G) higher, higher, equal higher, higher, lower higher, equal, higher higher, higher, higher equal, higher, equal equal, higher, lower equal, equal, equal 18 A 30-year-old financial consultant tells her doctor that over the past years she has felt “down” most of the time She relates that when colleagues ask her to dinner or to a 127 get-together she usually says “yes” but then rarely feels like going when the time comes and does not have a good time when she does go There are no significant physical findings While the patient denies suicidality, she notes that she never feels really excited or happy about anything The best diagnosis for this patient at this time is (A) (B) (C) (D) (E) (F) (G) 17 When compared with a man, the chances that a woman will develop major depressive disorder, dysthymic disorder, or bipolar disorder over the course of her lifetime are, respectively Mood Disorders major depressive disorder bipolar I disorder bipolar II disorder dysthymic disorder cyclothymic disorder substance-induced mood disorder mood disorder due to a general medical condition 19 A 45-year-old man with bipolar disorder tells his doctor that he has remarried and would like to have a child with his new wife He is concerned because the 19-year-old daughter that he had with his first wife has just been diagnosed with bipolar disorder Neither of the patient’s wives has bipolar disorder What is the probability that this patient will have another child with bipolar disorder? (A) (B) (C) (D) (E) 1% 10% 20% 50% 70% Answers and Explanations Typical Board Question The answer is G The most likely diagnosis at this time is mood disorder due to a general medical condition This patient is showing symptoms of hypothyroidism, for example, slowing of cognition, gravelly voice, constipation, dry skin, hair loss, and lag in the relaxation phase of the ankle jerk reflex, in addition to symptoms of major depression (e.g., suicidality) Other mood disorders are diagnosed when there are no medical findings to explain the mood symptoms For example, major depressive disorder involves at least one SWAG symptom most of the time for a period of at least weeks Dysthymic disorder involves mild or moderate depression most of the time, occurring over a 2-year period with no discrete episodes of symptoms Bipolar disorder involves episodes of both mania and depression (bipolar I) or hypomania and depression (bipolar II) Cyclothymic disorder involves episodes of hypomania and dysthymia occurring over a 2-year period with no discrete episodes of symptoms The answer is D The sign or symptom most likely to indicate that this patient is experiencing a major depressive episode rather than a normal reaction to serious illness is her preoccupation with feelings of guilt Such feelings are more characteristic of depression than sadness about being very ill The other symptoms that the patient shows (e.g., weight loss, decreased energy, and sleep problems) are characteristic of patients with advanced cancer Fear of dying in pain is realistic and commonly seen in patients with life-limiting illnesses The answer is C The answer is B The answer is B This patient is most likely to have bipolar I disorder While this disorder involves episodes of both mania and depression, a single episode of mania defines the illness The beliefs that one is important enough to demand a conference with the governor and cure cancer are grandiose delusions Schizophrenic delusions are commonly paranoid in nature Irritability and hostility are also common in a manic episode Of the listed treatments, the one most effective for bipolar disorder is lithium Heterocyclic antidepressants, electroconvulsive therapy, monoamine oxidase inhibitors, and psychotherapy are used primarily to manage depression Antidepressants and psychotherapy are used to manage dysthymia The chances of the monozygotic twin and first-degree relative (e.g., brother) of this bipolar patient developing the disorder are about 75% and 20%, respectively The answer is E The answer is B This patient shows evidence of cyclothymic disorder This disorder involves periods of both hypomania (energy and optimism) and dysthymia (pessimism and feeling “washed out”) occurring over a 2-year period with no discrete episodes of illness Of the listed treatments, the one most effective for cyclothymic disorder, as for bipolar disorder, is lithium Heterocyclic antidepressants, electroconvulsive therapy, monoamine oxidase inhibitors, and psychotherapy are primarily used to manage depression Antidepressants and psychotherapy are used to manage dysthymia The answer is E The answer is E This woman is showing evidence of major depression (note: Suicidality is not characteristic of a normal grief reaction) Depressed people typically show poor grooming She is also more likely to show weight loss, and to feel better in the evening than in the morning Auditory hallucinations are common in schizophrenia but uncommon in depression Flight of ideas is characteristic of mania Analysis of neurotransmitter availability in this patient is most likely to reveal decreased serotonin, commonly reflected in decreased plasma levels of its major metabolite 5-HIAA Increased dopamine is seen in schizophrenia, and decreased acetylcholine is seen in Alzheimer disease 128 Chapter 12 Mood Disorders 129 The answer is A In this depressed patient, the antidepressant fluoxetine has precipitated a manic episode (i.e., greatly increased activity level, flight of ideas, and pressured speech) This indicates that the patient has bipolar disorder rather than major depressive disorder There is no evidence of increased depression, increased anxiety, or a delayed or toxic effect in this patient 10 The answer is B This patient is most likely to have major depressive disorder Evidence for this is that, while there are no physical findings, he has lost interest in his usual activities, wakes up too early in the morning, has vague physical symptoms, shows diurnal variation in symptoms (worse in the morning), has lost a significant amount of weight, and is showing suicidal ideation (e.g., “maybe my family would be better off without me”) Also, his symptoms have been present for a discrete, identified amount of time Dysthymic disorder involves mild or moderate depression most of the time, occurring over a 2-year period with no discrete episodes of illness Bipolar disorder involves episodes of both mania and depression Cyclothymic disorder involves episodes of hypomania and dysthymia occurring over a 2-year period with no discrete episodes of illness In hypochondriasis, patients believe that normal body functions or minor illnesses are serious or life threatening People who are malingering fabricate symptoms for obvious gain (e.g., to win a lawsuit) (see Chapter 13) 11 The answer is C This patient’s physical complaints (i.e., headaches and other aches and pains) were relieved by antidepressant medication This indicates that these symptoms were manifestations of masked (hidden) depression rather than hypochondriasis There is no evidence in this patient of bipolar disorder, dysthymic disorder, cyclothymic disorder, or malingering (see also answer to Question 10) 12 The answer is E 13 The answer is A 14 The answer is C Although male sex, alcohol abuse, and marital separation all are risk factors for suicide, the highest risk factor of those mentioned is his advanced age Catholic religion is associated with a reduced risk of suicide Nonprofessionals are at a lower suicide risk than professionals Among professionals, those at the highest risk for suicide are police officers, physicians, lawyers, and dentists The method of suicide most likely to fail is slashing the wrists or taking pills Shooting, crashing a car, jumping from a high place, and hanging are more lethal methods of committing suicide 15 The answer is C Only about 25% of depressed patients seek treatment, although management (antidepressants, psychotherapy, electroconvulsive therapy) is effective in most depressed patients 16 The answer is D This girl shows a number of risk factors for depression and attempted suicide, including female sex and her excessive need to be perfect However, the most important factor in whether she tries to kill herself again is that she tried to commit suicide once Taking pills such as aspirin or acetaminophen is less lethal than other methods, but young people such as this teenager may not know this Thus, this girl has made a serious suicide attempt (See also answers to Questions 12–14.) 17 The answer is A When compared with a man, a woman is twice as likely to develop major depressive disorder, and three times as likely to develop dysthymic disorder Bipolar disorder and cyclothymic disorder occur equally in men and women 18 The answer is D This best diagnosis for this patient is dysthymic disorder The patient has had a low mood for years, but although she is never really happy or excited about what should be pleasant experiences, because she is functional For example, she is working and is not suicidal, it is less likely that she has major depressive disorder (and see also answer to Question 10) 19 The answer is C The likelihood that this man with bipolar disorder will have a child with bipolar disorder is about 20% The fact that his older child has bipolar disorder is not relevant to the chances that his next child will have the disorder (and see also answer to Question 2) ... 7 11 months 12 15 months 16 –30 months 0–3 months 4–6 months 7 11 months 12 15 months 16 –30 months 0–3 months 4–6 months 7 11 months 12 15 months 16 –30 months 0–3 months 4–6 months 7 11 months 12 15 ... Narcolepsy 10 0 Management of Sleep Disorders 10 1 Review Test 11 90 I Schizophrenia 10 9 II Other Psychotic Disorders 12 11 4 Overview 11 9 Classification of Mood Disorders Etiology 12 1 Management 12 3 Review... Etiology 12 1 Management 12 3 Review Test 10 9 11 2 MOOD DISORDERS I II III IV 10 0 10 2 SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS Review Test 96 12 5 11 9 12 0 xiv 13 Contents ANXIETY DISORDERS, SOMATOFORM