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CAQ-Psychiatry study materials
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CAQ-Psychiatry practice questions

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Question 1Psychiatry (content domains not enumerated in source)

A 28-year-old man is brought to the emergency department with agitation, dilated pupils, sweating, and a heart rate of 128. He reports using a stimulant hours earlier. Which finding most specifically suggests a sympathomimetic toxidrome rather than anticholinergic toxicity?

  1. Presence of piloerection and diaphoresis Correct answer.
  2. Presence of dry mucous membranes
  3. Presence of flushed skin
  4. Presence of bowel sounds on auscultation

Explanation

Sympathomimetic toxicity produces adrenergic excess with diaphoresis, piloerection, mydriasis, and tachycardia. Anticholinergic toxicity classically causes dry skin and absent bowel sounds because muscarinic receptors are blocked. Sweating is the practical discriminator at the bedside.

Question 2Psychiatry (content domains not enumerated in source)

Which medication is a first-line treatment for alcohol withdrawal in a hospitalized patient with intact liver function?

  1. Clonidine
  2. Naltrexone
  3. Haloperidol
  4. Chlordiazepoxide Correct answer.

Explanation

Benzodiazepines such as chlordiazepoxide are first-line for alcohol withdrawal because they restore GABA-A activity and reduce seizure and delirium risk. Symptom-triggered dosing is preferred over fixed schedules in most protocols. Haloperidol and clonidine treat associated symptoms but do not prevent withdrawal seizures.

Question 3Psychiatry (content domains not enumerated in source)

A patient with schizophrenia develops a high fever, muscle rigidity, confusion, and a creatine kinase of 4,000 U/L several days after starting an antipsychotic. Which condition is most likely?

  1. Neuroleptic malignant syndrome Correct answer.
  2. Acute dystonia
  3. Serotonin syndrome
  4. Tardive dyskinesia

Explanation

Neuroleptic malignant syndrome presents with the tetrad of hyperthermia, severe rigidity, autonomic instability, and altered mental status, with markedly elevated creatine kinase. It develops over days after dopamine antagonist exposure. Serotonin syndrome instead features hyperreflexia and clonus with a usually milder CK rise.

Question 4Psychiatry (content domains not enumerated in source)

Which feature best distinguishes delirium from dementia in an older hospitalized patient?

  1. Presence of cortical atrophy on imaging
  2. Acute onset with fluctuating attention Correct answer.
  3. Presence of behavioral disturbance
  4. Presence of memory impairment

Explanation

Delirium is defined by an acute onset with a fluctuating course and impaired attention, whereas dementia has an insidious, progressive course with relatively preserved attention until late. Memory impairment and behavioral problems can occur in both. The acuity and fluctuation are the key discriminators.

Question 5Psychiatry (content domains not enumerated in source)

A 24-year-old woman has recurrent intrusive thoughts of contamination and washes her hands until they bleed, recognizing the thoughts as her own. Which diagnosis fits best?

  1. Obsessive-compulsive disorder Correct answer.
  2. Generalized anxiety disorder
  3. Body dysmorphic disorder
  4. Schizophrenia

Explanation

OCD requires obsessions or compulsions that are time-consuming and cause distress, with insight often preserved. The content here is contamination obsessions with washing compulsions. The patient recognizes the thoughts as her own, distinguishing them from delusional beliefs.

Question 6Psychiatry (content domains not enumerated in source)

Which finding is most consistent with a manic episode?

  1. Decreased need for sleep with increased goal-directed activity Correct answer.
  2. Persistent worry about multiple life domains
  3. Anhedonia with weight gain
  4. Hypersomnia with psychomotor retardation

Explanation

Mania is marked by elevated or irritable mood with increased energy, decreased need for sleep, pressured speech, and goal-directed activity. Reduced sleep while remaining energetic is characteristic. The other options describe depressive or anxiety presentations.

Question 7Psychiatry (content domains not enumerated in source)

A patient on lithium for bipolar disorder presents with coarse tremor, ataxia, vomiting, and confusion. Which action is most appropriate first?

  1. Start an SSRI
  2. Increase the lithium dose
  3. Hold lithium and arrange urgent dialysis evaluation Correct answer.
  4. Add a benzodiazepine and continue lithium

Explanation

These signs indicate lithium toxicity, which requires stopping the drug and urgent assessment of renal function and lithium level. Hemodialysis is indicated for severe toxicity with levels generally above 2.5 mEq/L or significant neurologic or renal impairment. Continuing or increasing lithium would worsen the toxicity.

Question 8Psychiatry (content domains not enumerated in source)

Which statement about clozapine monitoring is correct?

  1. Absolute neutrophil count monitoring is required because of agranulocytosis risk Correct answer.
  2. Clozapine is first-line for treatment-naive psychosis
  3. Weekly complete blood counts are required for the first six months
  4. Clozapine does not require ECG monitoring

Explanation

Clozapine carries a risk of agranulocytosis, so ANC monitoring is mandated under a risk evaluation program. In the United States, weekly ANC checks are required for six months, then every two weeks for six months, then monthly. Clozapine is reserved for treatment-resistant illness because of these risks.

Question 9Psychiatry (content domains not enumerated in source)

A 19-year-old presents with three weeks of bizarre behavior, disorganized speech, and auditory hallucinations with clear functional decline. What is the minimum duration of continuous signs required for a schizophrenia diagnosis?

  1. One month
  2. Six months Correct answer.
  3. One week
  4. Two weeks

Explanation

Schizophrenia requires continuous signs of disturbance for at least six months, including at least one month of active-phase symptoms. The six-month threshold distinguishes schizophrenia from schizophreniform disorder, which lasts one to six months. Brief psychotic disorder lasts less than one month.

Question 10Psychiatry (content domains not enumerated in source)

Which agent is most appropriate for maintenance treatment of opioid use disorder in a patient who wants to avoid daily clinic visits?

  1. Acamprosate
  2. Disulfiram
  3. Varenicline
  4. Extended-release injectable naltrexone Correct answer.

Explanation

Extended-release injectable naltrexone provides monthly dosing and blocks opioid effects, making it suitable for patients seeking infrequent administration. It requires an opioid-free interval and adequate liver function. The other agents treat alcohol or nicotine use disorders.

Question 11Psychiatry (content domains not enumerated in source)

A 32-year-old woman reports depressed mood in the week before menses for the past year, with symptoms resolving after menses. Which diagnosis is most appropriate?

  1. Persistent depressive disorder
  2. Premenstrual dysphoric disorder Correct answer.
  3. Bipolar II disorder
  4. Cyclothymic disorder

Explanation

Premenstrual dysphoric disorder requires symptoms in the final week before menses that improve within days of onset and are minimal postmenstrually, confirmed prospectively over at least two cycles. The cyclical luteal pattern is the defining feature. Other mood disorders would not be tied so tightly to the menstrual cycle.

Question 12Psychiatry (content domains not enumerated in source)

Which feature suggests a diagnosis of antisocial personality disorder rather than borderline personality disorder?

  1. Fear of abandonment with unstable relationships
  2. Recurrent self-harm for emotional relief
  3. Identity disturbance with chronic emptiness
  4. Pervasive disregard for the rights of others beginning in childhood Correct answer.

Explanation

Antisocial personality disorder requires a pervasive pattern of disregard for and violation of others' rights with evidence of conduct disorder before age 15. Borderline personality disorder instead centers on instability of relationships, identity, and affect with abandonment fears. The childhood conduct history is the key differentiator.

Question 13Psychiatry (content domains not enumerated in source)

A child has school refusal, separation-related distress, and physical complaints every morning before school. Which diagnosis should be considered first?

  1. Autism spectrum disorder
  2. Attention-deficit/hyperactivity disorder
  3. Conduct disorder
  4. Separation anxiety disorder Correct answer.

Explanation

Separation anxiety disorder involves developmentally inappropriate fear of separation from attachment figures, often manifesting as school refusal and somatic complaints. Distress tied specifically to leaving caregivers is the core feature. The other conditions present with different primary symptoms.

Question 14Psychiatry (content domains not enumerated in source)

Which finding is characteristic of serotonin syndrome?

  1. Clonus and hyperreflexia Correct answer.
  2. Dry skin with absent bowel sounds
  3. Lead-pipe rigidity with bradyreflexia
  4. Pinpoint pupils with respiratory depression

Explanation

Serotonin syndrome is characterized by neuromuscular hyperactivity, including clonus, hyperreflexia, and tremor, along with autonomic instability and altered mental status. Clonus is the most specific finding. Neuroleptic malignant syndrome instead shows rigidity and hyporeflexia.

Question 15Psychiatry (content domains not enumerated in source)

A patient with major depression has not responded to two adequate trials of different antidepressants. Which medication is most supported for treatment-resistant depression with a rapid-acting effect?

  1. Mirtazapine monotherapy
  2. Intravenous ketamine or esketamine Correct answer.
  3. Bupropion augmentation
  4. Buspirone monotherapy

Explanation

Ketamine and esketamine produce rapid antidepressant effects in treatment-resistant depression, with esketamine approved as an intranasal adjunct. They act via NMDA receptor antagonism. Standard oral antidepressants typically require weeks and have failed in this patient.

Question 16Psychiatry (content domains not enumerated in source)

Which criterion is required for a diagnosis of post-traumatic stress disorder?

  1. Symptoms limited to the first 48 hours
  2. Symptoms lasting at least one week after a stressful event
  3. Presence of a manic episode after trauma
  4. Symptoms lasting at least one month after exposure to a traumatic event Correct answer.

Explanation

PTSD requires exposure to actual or threatened death, serious injury, or violence, followed by intrusion, avoidance, negative cognitions, and arousal symptoms lasting more than one month. Symptoms lasting three days to one month constitute acute stress disorder. The one-month threshold separates the two.

Question 17Psychiatry (content domains not enumerated in source)

A 70-year-old with new-onset psychosis and cognitive decline is evaluated. Which feature most suggests dementia with Lewy bodies rather than Alzheimer disease?

  1. Early prominent aphasia
  2. Family history of early-onset Alzheimer disease
  3. Prominent early visual hallucinations with parkinsonism Correct answer.
  4. Gradual memory loss with preserved gait

Explanation

Dementia with Lewy bodies features fluctuating cognition, visual hallucinations, and spontaneous parkinsonism, often with REM sleep behavior disorder and neuroleptic sensitivity. Alzheimer disease typically begins with progressive memory loss without early hallucinations or parkinsonism. The core features are the differentiator.

Question 18Psychiatry (content domains not enumerated in source)

Which medication is most appropriate for acute cessation of severe alcohol withdrawal seizures in the emergency setting?

  1. Propranolol
  2. Gabapentin
  3. Thiamine
  4. Lorazepam Correct answer.

Explanation

Benzodiazepines such as lorazepam are first-line for terminating alcohol withdrawal seizures because they enhance GABA-A activity. They also prevent progression to delirium tremens. Propranolol masks autonomic signs without treating seizures, and thiamine prevents Wernicke encephalopathy rather than seizures.

Question 19Psychiatry (content domains not enumerated in source)

A patient with bipolar I disorder on lithium has a creatinine rise and reports tremor and vomiting. Which laboratory test is most important to obtain urgently?

  1. Serum lithium level Correct answer.
  2. Serum amylase
  3. Serum ferritin
  4. Urine catecholamines

Explanation

A serum lithium level is essential to confirm and grade toxicity, especially with renal impairment that reduces lithium clearance. Levels above 1.5 mEq/L are generally toxic, and severe symptoms warrant dialysis evaluation. The other tests are unrelated to lithium toxicity.

Question 20Psychiatry (content domains not enumerated in source)

Which statement about the mechanism of action of selective serotonin reuptake inhibitors is correct?

  1. They directly antagonize dopamine D2 receptors
  2. They inhibit monoamine oxidase
  3. They block presynaptic serotonin reuptake transporters Correct answer.
  4. They block postsynaptic serotonin receptors

Explanation

SSRIs inhibit the serotonin transporter on the presynaptic neuron, increasing synaptic serotonin availability. Clinical benefit follows adaptive changes over weeks, not immediate receptor effects. They do not act on dopamine receptors or monoamine oxidase.

Question 21Psychiatry (content domains not enumerated in source)

An adolescent with first-episode psychosis is started on an antipsychotic. Which metabolic monitoring parameter should be checked at baseline before treatment?

  1. Fasting glucose and lipid panel Correct answer.
  2. Urine porphobilinogen
  3. Serum ceruloplasmin
  4. Serum ammonia

Explanation

Second-generation antipsychotics carry metabolic risk, so baseline weight, BMI, waist circumference, blood pressure, fasting glucose, and lipids should be obtained. This establishes a reference for later monitoring. The other tests relate to uncommon metabolic or hepatic disorders and are not part of antipsychotic monitoring.

Question 22Psychiatry (content domains not enumerated in source)

A patient with borderline personality disorder engages in recurrent self-harm. Which psychotherapy has the strongest evidence for reducing self-harm in this population?

  1. Electroconvulsive therapy
  2. Cognitive remediation therapy
  3. Dialectical behavior therapy Correct answer.
  4. Psychoanalysis

Explanation

Dialectical behavior therapy combines skills training in distress tolerance and emotion regulation with validation and problem-solving, and it reduces self-harm and suicidal behavior in borderline personality disorder. It is the most studied structured treatment for this indication. The other options lack comparable evidence.

Question 23Psychiatry (content domains not enumerated in source)

Which finding suggests that a patient's depressed mood is due to hypothyroidism rather than a primary depressive disorder?

  1. Cyclical mood changes with menses
  2. Mood elevation alternating with depression
  3. Weight gain with cold intolerance and bradycardia Correct answer.
  4. Insomnia with weight loss and tachycardia

Explanation

Hypothyroidism can mimic depression and characteristically produces cold intolerance, weight gain, constipation, bradycardia, and fatigue. Screening with TSH is appropriate when such features are present. The other patterns suggest primary mood or endocrine conditions other than hypothyroidism.

Question 24Psychiatry (content domains not enumerated in source)

A patient with schizophrenia on haloperidol develops sustained neck muscle spasm and upward eye deviation. Which treatment is most appropriate?

  1. Adding an SSRI
  2. Intramuscular diphenhydramine or benztropine Correct answer.
  3. Increasing the haloperidol dose
  4. Starting lithium

Explanation

Acute dystonia is an extrapyramidal reaction caused by dopamine blockade and responds rapidly to anticholinergic agents such as benztropine or antihistamines such as diphenhydramine. Oculogyric crisis and torticollis are classic presentations. Increasing the antipsychotic would worsen the reaction.

Question 25Psychiatry (content domains not enumerated in source)

A 45-year-old with alcohol use disorder has confusion, ataxia, and ophthalmoplegia. Which treatment is indicated immediately?

  1. Oral naltrexone
  2. Oral disulfiram
  3. Intravenous thiamine Correct answer.
  4. Intravenous haloperidol

Explanation

The triad of confusion, ataxia, and ophthalmoplegia indicates Wernicke encephalopathy, a thiamine deficiency emergency. Prompt intravenous thiamine prevents progression to Korsakoff syndrome and death. Glucose should be given with or after thiamine to avoid precipitating the syndrome.

Question 26Psychiatry (content domains not enumerated in source)

A 24-year-old graduate student is brought to the emergency department by her roommate. For the past five days she has slept only two hours per night, speaks rapidly, and claims she has been chosen to lead a global peace initiative. She has also maxed out her credit cards buying supplies for this mission. She has no history of manic episodes, and her symptoms are not due to substance use or a medical condition. Which diagnosis is most appropriate?

  1. Bipolar II disorder, current episode hypomanic
  2. Major depressive disorder with mixed features
  3. Cyclothymic disorder
  4. Bipolar I disorder, current episode manic Correct answer.

Explanation

A manic episode requires a distinct period of abnormally elevated, expansive, or irritable mood lasting at least one week (or requiring hospitalization) with marked impairment, and grandiosity, decreased need for sleep, and reckless spending are classic features. A first manic episode establishes bipolar I disorder regardless of whether depression has occurred. Hypomania does not cause marked impairment or require hospitalization, and cyclothymia involves chronic subsyndromal mood fluctuations rather than a full manic episode.

Question 27Psychiatry (content domains not enumerated in source)

A 28-year-old woman with schizophrenia has been stable on risperidone for two years. She reports that her menses have stopped and she has begun producing breast milk. Which mechanism best explains these findings?

  1. Serotonin reuptake inhibition in the tuberoinfundibular pathway
  2. Histamine H1 blockade in the chemoreceptor trigger zone
  3. Dopamine D2 blockade in the tuberoinfundibular pathway Correct answer.
  4. Muscarinic M1 blockade in the basal ganglia

Explanation

Atypical antipsychotics such as risperidone block dopamine D2 receptors in the tuberoinfundibular pathway, removing tonic inhibition of prolactin secretion and producing hyperprolactinemia. This causes amenorrhea, galactorrhea, and sexual dysfunction. Serotonin reuptake inhibition does not directly disinhibit prolactin to this degree, and H1 or M1 blockade do not cause hyperprolactinemia.

Question 28Psychiatry (content domains not enumerated in source)

A 62-year-old man with treatment-resistant schizophrenia is admitted with fever, muscle rigidity, confusion, and autonomic instability. His creatine kinase is markedly elevated. Which medication is the most appropriate specific treatment?

  1. Propranolol
  2. Bromocriptine
  3. Lorazepam
  4. Dantrolene Correct answer.

Explanation

This presentation is neuroleptic malignant syndrome, a life-threatening reaction to dopamine antagonists characterized by rigidity, hyperthermia, autonomic instability, and elevated creatine kinase. Dantrolene, a muscle relaxant that inhibits ryanodine receptor–mediated calcium release, is a specific treatment along with supportive care and discontinuation of the offending agent. Bromocriptine is also used but is not the best single answer here because dantrolene directly addresses the rigidity and hyperthermia.

Question 29Psychiatry (content domains not enumerated in source)

A 34-year-old woman with major depressive disorder has not responded to an adequate trial of sertraline. Her psychiatrist considers augmenting with aripiprazole. Which statement about this augmentation strategy is correct?

  1. It is contraindicated because atypical antipsychotics worsen depression.
  2. It is effective only when the patient has psychotic features.
  3. It should replace the antidepressant rather than be added to it.
  4. It is supported by evidence for treatment-resistant depression and can reduce depressive symptoms when added to an antidepressant. Correct answer.

Explanation

Aripiprazole is one of the best-studied augmentation agents for treatment-resistant major depression, with randomized trials showing improved response and remission when added to an antidepressant. It is not contraindicated in depression and is used in nonpsychotic depression. Augmentation means adding to, not replacing, the antidepressant.

Question 30Psychiatry (content domains not enumerated in source)

A 19-year-old college student is brought to the clinic after a two-month history of hearing voices commenting on his actions and believing that his thoughts are being broadcast to others. He has stopped attending classes but has no history of mania or substance use. Which diagnosis is most appropriate?

  1. Brief psychotic disorder
  2. Delusional disorder
  3. Schizophreniform disorder
  4. Schizophrenia Correct answer.

Explanation

Schizophrenia requires at least two of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms, with continuous signs persisting for at least six months. This patient has auditory hallucinations and delusions of thought broadcasting for two months, with functional decline, but the total duration is less than six months, so schizophreniform disorder is the more accurate diagnosis at this point.

Question 31Psychiatry (content domains not enumerated in source)

A 45-year-old man with alcohol use disorder is admitted with confusion, ataxia, and ophthalmoplegia. He is given intravenous thiamine. Which additional treatment is most important to prevent worsening of his condition?

  1. Intravenous haloperidol
  2. Intravenous lorazepam
  3. Intravenous glucose Correct answer.
  4. Oral naltrexone

Explanation

This presentation is Wernicke encephalopathy, a thiamine deficiency syndrome. Thiamine must be given before or with glucose because glucose administration without thiamine can precipitate or worsen Wernicke encephalopathy. Naltrexone is for maintenance of alcohol use disorder, lorazepam is for withdrawal, and haloperidol is for agitation or psychosis, none of which address the acute thiamine deficiency.

Question 32Psychiatry (content domains not enumerated in source)

A 30-year-old woman with a history of childhood sexual abuse presents with intrusive memories, nightmares, and avoidance of reminders of the trauma for eight months. She also reports feeling detached from others and having a persistently negative view of herself. Which diagnosis is most appropriate?

  1. Acute stress disorder
  2. Generalized anxiety disorder
  3. Post-traumatic stress disorder Correct answer.
  4. Adjustment disorder

Explanation

Post-traumatic stress disorder requires exposure to actual or threatened death, serious injury, or sexual violence, followed by intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity lasting more than one month. This patient has all four symptom clusters for eight months. Acute stress disorder lasts from three days to one month, adjustment disorder does not require a Criterion A trauma, and generalized anxiety disorder does not include intrusive trauma memories.

Question 33Psychiatry (content domains not enumerated in source)

A 26-year-old man with schizophrenia is started on clozapine after failing two other antipsychotics. Which adverse effect requires immediate discontinuation and is the reason for mandatory monitoring?

  1. Hypersalivation
  2. Neutropenia Correct answer.
  3. Weight gain
  4. Sedation

Explanation

Clozapine carries a risk of severe neutropenia and agranulocytosis, which can be fatal, so absolute neutrophil count monitoring is mandatory and the drug must be stopped if neutropenia develops. Weight gain, hypersalivation, and sedation are common but do not require immediate discontinuation. The monitoring program is specifically designed to detect neutropenia early.

Question 34Psychiatry (content domains not enumerated in source)

A 38-year-old woman with bipolar I disorder on lithium presents with coarse tremor, ataxia, vomiting, and confusion. Her lithium level is 2.5 mEq/L. Which action is most appropriate?

  1. Hold lithium, provide supportive care, and consider hemodialysis Correct answer.
  2. Continue lithium at a reduced dose and recheck the level in one week
  3. Add a thiazide diuretic to enhance lithium excretion
  4. Administer intravenous sodium bicarbonate

Explanation

A lithium level of 2.5 mEq/L with neurologic and gastrointestinal toxicity indicates moderate to severe lithium toxicity. Management includes stopping lithium, supportive care, and hemodialysis for severe toxicity, especially with renal impairment or levels above 2.5 mEq/L. Thiazides increase lithium reabsorption and worsen toxicity, and sodium bicarbonate is not a treatment for lithium toxicity.

Question 35Psychiatry (content domains not enumerated in source)

A 52-year-old man with alcohol use disorder is admitted for detoxification. Twelve hours after his last drink he develops tremor, sweating, and a heart rate of 120 beats per minute. Which medication is first-line for preventing progression to severe withdrawal?

  1. Clonidine
  2. Haloperidol
  3. Diphenhydramine
  4. Chlordiazepoxide Correct answer.

Explanation

Benzodiazepines such as chlordiazepoxide are first-line for alcohol withdrawal because they reduce central nervous system excitability and prevent seizures and delirium tremens. Haloperidol may lower the seizure threshold and is not first-line. Clonidine and diphenhydramine are adjuncts for autonomic symptoms but do not prevent seizures or delirium.

Question 36Psychiatry (content domains not enumerated in source)

A 24-year-old woman with borderline personality disorder reports recurrent suicidal gestures and intense fear of abandonment. Which psychotherapy has the strongest evidence for reducing self-harm in borderline personality disorder?

  1. Supportive psychotherapy
  2. Cognitive behavioral therapy
  3. Dialectical behavior therapy Correct answer.
  4. Psychodynamic psychotherapy

Explanation

Dialectical behavior therapy is the most extensively studied psychotherapy for borderline personality disorder and has the strongest evidence for reducing self-harm and suicidal behavior. It combines individual therapy, skills training, phone coaching, and consultation team meetings. The other therapies may be helpful but have less consistent evidence for self-harm reduction.

Question 37Psychiatry (content domains not enumerated in source)

A 16-year-old boy is brought by his parents because of a two-year history of persistent irritability, temper outbursts, and argumentative behavior at home and school. He does not have episodes of elevated mood or grandiosity. Which diagnosis is most appropriate?

  1. Oppositional defiant disorder
  2. Intermittent explosive disorder
  3. Disruptive mood dysregulation disorder Correct answer.
  4. Bipolar I disorder

Explanation

Disruptive mood dysregulation disorder is characterized by severe recurrent temper outbursts that are grossly out of proportion to the situation, occurring three or more times per week, with persistently irritable or angry mood between outbursts for at least twelve months. It is diagnosed in children and adolescents and is distinguished from bipolar disorder by the absence of distinct manic episodes. Oppositional defiant disorder involves a pattern of angry/irritable mood and argumentative behavior without the severe, frequent temper outbursts required for DMDD.

Question 38Psychiatry (content domains not enumerated in source)

A 70-year-old man with major depressive disorder and no psychotic symptoms is started on an antidepressant. Which medication is most appropriate given his age and the need to minimize anticholinergic and orthostatic effects?

  1. Paroxetine
  2. Nortriptyline
  3. Amitriptyline
  4. Sertraline Correct answer.

Explanation

Sertraline is an SSRI with a favorable side-effect profile in older adults and is often preferred because it has less anticholinergic and orthostatic burden than tricyclics. Amitriptyline and nortriptyline are tricyclics associated with anticholinergic effects, orthostasis, and cardiac conduction changes. Paroxetine is an SSRI but is more anticholinergic than sertraline and has more drug interactions.

Question 39Psychiatry (content domains not enumerated in source)

A 28-year-old woman with schizophrenia on olanzapine for six months has gained 12 kg and has a fasting glucose of 126 mg/dL. Which monitoring parameter should be checked regularly to detect this adverse effect early?

  1. Serum prolactin
  2. Fasting glucose and lipids Correct answer.
  3. Thyroid-stimulating hormone
  4. Serum lithium

Explanation

Second-generation antipsychotics, especially olanzapine and clozapine, are associated with metabolic syndrome, including weight gain, hyperglycemia, and dyslipidemia. Baseline and periodic monitoring of fasting glucose, lipids, and weight is recommended to detect these effects early. Prolactin, lithium, and TSH are not the primary monitoring parameters for olanzapine-induced metabolic effects.

Question 40Psychiatry (content domains not enumerated in source)

A 32-year-old woman reports depressed mood, anhedonia, and fatigue that began two months after starting a new job. She also has a history of recurrent panic attacks. Which feature would most suggest that her depression is due to bipolar disorder rather than major depressive disorder?

  1. A history of at least one hypomanic or manic episode Correct answer.
  2. A family history of depression
  3. Onset after a stressful life event
  4. Presence of comorbid anxiety

Explanation

The key distinction between bipolar and unipolar depression is the presence of a manic or hypomanic episode. A history of such an episode establishes bipolar disorder and has major treatment implications, because antidepressants alone can precipitate mood switching. Family history of depression, stressful onset, and comorbid anxiety are common in both conditions and do not distinguish them.

Question 41Psychiatry (content domains not enumerated in source)

A 60-year-old man with alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which treatment is indicated immediately?

  1. Oral disulfiram
  2. Intramuscular haloperidol
  3. Intravenous lorazepam
  4. Intravenous thiamine Correct answer.

Explanation

The triad of confusion, ataxia, and ophthalmoplegia indicates Wernicke encephalopathy, a thiamine deficiency disorder that is a medical emergency. Immediate intravenous thiamine is required to prevent irreversible Korsakoff syndrome and death. Disulfiram is for maintenance of abstinence, lorazepam is for withdrawal, and haloperidol is for agitation or psychosis, none of which treat the underlying thiamine deficiency.

Question 42Psychiatry (content domains not enumerated in source)

A 22-year-old man is brought to the emergency department after being found agitated and confused at a party. He has a temperature of 39°C, dilated pupils, and muscle rigidity. He reports taking an unknown pill. Which condition is most likely?

  1. Serotonin syndrome Correct answer.
  2. Anticholinergic toxicity
  3. Malignant hyperthermia
  4. Neuroleptic malignant syndrome

Explanation

Serotonin syndrome presents with the triad of mental status changes, autonomic instability, and neuromuscular hyperactivity, often after combining serotonergic agents. Hyperthermia, agitation, dilated pupils, and rigidity are consistent with serotonin syndrome. Neuroleptic malignant syndrome also causes rigidity and hyperthermia but typically develops over days on dopamine antagonists and features lead-pipe rigidity and elevated creatine kinase. Anticholinergic toxicity causes dry skin and flushing without rigidity, and malignant hyperthermia follows anesthetic exposure.

Question 43Psychiatry (content domains not enumerated in source)

A 45-year-old woman with treatment-resistant schizophrenia is being considered for clozapine. Which baseline test is mandatory before starting clozapine?

  1. Absolute neutrophil count Correct answer.
  2. Serum lithium level
  3. Serum prolactin
  4. Thyroid-stimulating hormone

Explanation

Clozapine can cause severe neutropenia and agranulocytosis, so a baseline absolute neutrophil count is required before initiation, followed by regular monitoring. Lithium levels, TSH, and prolactin are not mandatory baseline tests for clozapine, although other baseline tests such as metabolic panel and ECG may be obtained.

Question 44Psychiatry (content domains not enumerated in source)

A 30-year-old woman with major depressive disorder has not responded to an adequate trial of escitalopram. Her psychiatrist considers adding bupropion. Which statement about this strategy is correct?

  1. Bupropion is effective only for psychotic depression.
  2. Bupropion augmentation can improve depressive symptoms and may reduce sexual side effects from the SSRI. Correct answer.
  3. Bupropion should replace the SSRI rather than be added.
  4. Bupropion is contraindicated with SSRIs because of serotonin syndrome risk.

Explanation

Bupropion is a reasonable augmentation agent for treatment-resistant depression; it acts on norepinephrine and dopamine and can offset SSRI-related sexual dysfunction. It has minimal serotonergic activity, so combining it with an SSRI does not carry the same serotonin syndrome risk as combining two serotonergic drugs. Augmentation means adding bupropion to the SSRI, not replacing it.

Question 45Psychiatry (content domains not enumerated in source)

A 25-year-old man with schizophrenia is started on haloperidol. Two days later he develops a sustained neck spasm and upward deviation of the eyes. Which treatment is most appropriate?

  1. Intravenous lithium
  2. Oral haloperidol at a higher dose
  3. Oral clozapine
  4. Intramuscular diphenhydramine Correct answer.

Explanation

This is acute dystonia, an extrapyramidal reaction caused by dopamine blockade. Treatment is with an anticholinergic or antihistaminergic agent such as diphenhydramine or benztropine, given intramuscularly or intravenously for rapid relief. Increasing haloperidol would worsen the dystonia, and lithium and clozapine are not treatments for acute dystonia.

Question 46Psychiatry (content domains not enumerated in source)

A 68-year-old woman with major depressive disorder and mild cognitive impairment is started on an antidepressant. Which medication is most appropriate to minimize anticholinergic burden?

  1. Sertraline Correct answer.
  2. Amitriptyline
  3. Paroxetine
  4. Nortriptyline

Explanation

Sertraline is an SSRI with low anticholinergic activity and is generally preferred in older adults with cognitive concerns. Amitriptyline and nortriptyline are tricyclics with significant anticholinergic effects that can worsen cognition. Paroxetine is an SSRI but has more anticholinergic activity than sertraline.

Question 47Psychiatry (content domains not enumerated in source)

A 40-year-old man with bipolar I disorder on lithium has a creatinine rise and reports tremor and vomiting. Which laboratory test is most important to check to assess for lithium toxicity?

  1. Serum lithium level Correct answer.
  2. Serum prolactin
  3. Serum ceruloplasmin
  4. Serum amylase

Explanation

Lithium toxicity is diagnosed by measuring the serum lithium level in the context of clinical symptoms such as tremor, vomiting, and renal impairment. Amylase, prolactin, and ceruloplasmin are not used to assess lithium toxicity; ceruloplasmin is associated with Wilson disease, and prolactin with antipsychotics.

Question 48Psychiatry (content domains not enumerated in source)

A 29-year-old woman with schizophrenia has been stable on risperidone for one year. She now reports amenorrhea and galactorrhea. Which mechanism best explains these findings?

  1. Dopamine D2 blockade in the tuberoinfundibular pathway Correct answer.
  2. Serotonin reuptake inhibition in the tuberoinfundibular pathway
  3. Histamine H1 blockade in the chemoreceptor trigger zone
  4. Muscarinic M1 blockade in the basal ganglia

Explanation

Risperidone blocks dopamine D2 receptors in the tuberoinfundibular pathway, which removes tonic inhibition of prolactin release and causes hyperprolactinemia. This leads to amenorrhea and galactorrhea. Serotonin reuptake inhibition, H1 blockade, and M1 blockade do not produce this effect.

Question 49Psychiatry (content domains not enumerated in source)

A 35-year-old man with alcohol use disorder has been abstinent for two weeks and asks about medication to reduce craving. Which medication is most appropriate?

  1. Haloperidol
  2. Naltrexone Correct answer.
  3. Chlordiazepoxide
  4. Disulfiram

Explanation

Naltrexone, an opioid antagonist, reduces alcohol craving and heavy drinking and is approved for alcohol use disorder. Disulfiram is an aversive agent that discourages drinking but does not reduce craving and requires abstinence. Chlordiazepoxide is used for acute withdrawal, and haloperidol is not a treatment for alcohol use disorder.

Question 50Psychiatry (content domains not enumerated in source)

A 55-year-old man with schizophrenia has been on haloperidol for years. He now has involuntary chewing movements and facial grimacing. Which condition is most likely?

  1. Tardive dyskinesia Correct answer.
  2. Neuroleptic malignant syndrome
  3. Akathisia
  4. Acute dystonia

Explanation

Tardive dyskinesia is a late-onset extrapyramidal syndrome characterized by involuntary choreoathetoid movements, especially of the mouth, tongue, and face, after prolonged dopamine antagonist exposure. Acute dystonia occurs early with sustained muscle contractions, akathisia is restlessness, and neuroleptic malignant syndrome is an acute life-threatening reaction with rigidity and hyperthermia.